Issues at the interface between primary and secondary care in the management of common respiratory disease. 3: Providing better asthma care: what is there left to do?

Knowledge and Attitudes of GPs in Saxony-Anhalt concerning the Psychological Aspects of Bronchial Asthma: A Questionnaire Study

Bronchial Asthma is a worldwide condition with particularly high prevalence in first world countries. The reasons are multifactorial but a neglected area is the psychological domain. It is well known that heavy emotions can trigger attacks and that depression negatively affects treatment outcomes. It is also known that personality type has a greater effect on disease prevalence than in many other conditions. However, many potential psychological treatments are hardly considered, neither in treatment guidelines nor in reviews by asthma specialists. Moreover, there is very little research concerning the beliefs and practices of doctors regarding psychological treatments. Using a questionnaire survey we ascertained that local GPs in Saxony-Anhalt have reasonably good knowledge about the psychological elements of asthma; a third consider it to be some of the influence (20-40% aetiology) and a further third consider it to be even more important than that (at least 40% total aetiology). Our GPs use psychosomatic counseling sometimes or usually in the areas of sport and smoking (circa 85% GPs), although less so regarding breathing techniques and relaxation (c40% usually or sometimes do this) However despite this knowledge they refer to the relevant clinicians very rarely (98% sometimes, usually or always refer to a respiratory physician compared with only 11% referring for psychological help).

Global Initiative for Asthma (GINA) guidelines: 15 years of application

The Global Initiative for Asthma (GINA), founded in 1993, embodies a network of public health organizations and medical societies, as well as other individuals concerned with asthma. Its first report, published in 1995 and entitled 'A Global Strategy for Asthma Management and Prevention', has been widely adopted, providing the foundation for asthma guidelines in many nations across the world. To this effect, the report has not only been translated into several languages but has also been frequently updated. Since its establishment 15 years ago, GINA has undergone two major paradigm shifts. The first was the change in the late 1990s from an opinion- to an evidence-based approach for the management of asthma severity. The second, an even more radical shift, was seen in 2006, when the revised GINA guidelines involved the classification of asthma severity according to the level of control as a guide to treatment. In order to classify asthma control, elements such as the significance of the partnership between the patient and caregiver, patient education, guided self-management and treatment goals were introduced. In addition to compiling guidelines and reports for the management of asthma, GINA is actively involved in organizing and coordinating the World Asthma Day, regional initiatives and GINA symposia. On the whole, during the 15 years since their original publication in 1995, the GINA guidelines have provided the basis for many national asthma strategies around the world. This course is most likely to continue in the future. In this paper, the history of the development of the guidelines and other issues regarding the GINA project will be addressed.

History of guidelines for the diagnosis and management of asthma: from opinion to control

The Global Initiative on Asthma (GINA) was launched in 1993 in collaboration with the National Heart, Lung, and Blood Institute, the National Institutes of Health (USA) and the WHO. Its first effort was the production of a consensus report on asthma treatment, which aimed to bridge the gap between the various treatment options and the incorporation and implementation of innovative treatment forms into daily clinical practice. The first report published in 1995, A Global Strategy for Asthma Management and Prevention, has been translated into several languages, widely adopted and provided the foundation for several asthma guidelines worldwide. The GINA and other guidelines were primarily based on consensus of expert opinion in order to employ a severity-based classification system as a guide to treatment. However, in the late 1990s, guidelines underwent a major paradigm shift from opinion- to evidence-based classification as the foundation for asthma management. A second major shift involved the classification of asthma according to the level of disease control as a guide to treatment, which was realized for the first time in the revised 2006 GINA guidelines. Since their first appearance, asthma guidelines have played a leading role in disseminating information about asthma. In addition, they have had a substantial impact on standardizing asthma care around the world, which is likely to continue in the future. This article addresses the history of guideline development and issues related to asthma guidelines, with particular emphasis on the GINA guidelines.

Effect of clinical pathways on the management of acute asthma in the emergency department: five years of evaluation

There is a wide variability in clinical practice for treating acute asthma (AA) in the emergency department (ED), interfering in the quality of care. The purpose of this study was to evaluate the impact of a clinical pathway on the management of AA in the ED. We conducted a prospective before-after study of patients presenting with AA to the adult ED, during five separate periods (from January to March): in 2001 (pre-protocol group), 2002, 2003, 2004, and 2005 (6 months without educational reinforcement). We evaluated the effects of the recommendations on objective assessment of severity, diagnostic resource utilization, use of recommended and non-recommended therapy, and outcomes. The 2001, 2002, 2003, 2004, and 2005 groups comprised, respectively: 108, 96, 97, 98, and 101 patients. There was a significant increase in the use of pulse oximetry (8.3%, 77.1%, 88.7%, 95.9%, and 97.0%, respectively; p < 0.001). There was an increase in the use of peak expiratory flow rate from 2001 to 2004 (4.6%, 20.8%, 28.9%, and 48.0%) and a decrease after a period without educational efforts (29.7%, p < 0.001). Although the overall use of systemic corticosteroids was not changed, there was a significant increase in the use of oral steroids (p < 0.001). There was a decrease in aminophylline utilization (p = 0.005). Length of stay in the ED was significantly reduced (p = 0.04). There was no effect on hospital admission or emergency discharge (p = 0.193). The AA clinical pathway applied in the ED was associated with a positive effect on improving the quality of care.

GINA guidelines on asthma and beyond

Clinical guidelines are systematically developed statements designed to help practitioners and patients make decisions regarding the appropriate health care for specific circumstances. Guidelines are based on the scientific evidence on therapeutic interventions. The first asthma guidelines were published in the mid 1980s when asthma became a recognized public health problem in many countries. The Global Initiative on Asthma (GINA) was launched in 1995 as a collaborative effort between the NHLBI and the World Health Organization (WHO). The first edition was opinion-based but updates were evidence-based. A new update of the GINA guidelines was recently available and it is based on the control of the disease. Asthma guidelines are prepared to stimulate the implementation of practical guidelines in order to reduce the global burden of asthma. Although asthma guidelines may not be perfect, they appear to be the best vehicle available to assist primary care physicians and patients to receive the best possible care of asthma.

The Finnish national asthma programme: communication in asthma care--quality assessment of asthma referral letters

AIMS AND OBJECTIVES

The Finnish National Asthma Programme, which was launched in year 1994, considered the management of asthma as a community problem. The role of the primary health care in the management of asthma was emphasized. Optimal asthma management includes good communication between health care professionals. Referral letters are an accepted tool for evaluation of the communication process. The aim of this study was to assess the quality of asthma-related referral letters.

METHODS

All non-acute referral letters (n=3176) to three pulmonary departments were screened in 2001 and all those related to asthma were included (n=1289). The 14 previously derived asthma-specific criteria were applied: occupation, smoking, known allergies, current medication, other diseases, onset of symptoms, wheezing, dyspnoea, specified dyspnoea, cough, specified cough, use of asthma medication, peak-flow follow-up or spirometry with bronchodilatation test as an attachment. The study group was prepared to accept the maximum of 30% of the referral letters to be of poor quality.

RESULTS

Twenty-one per cent of the referral letters were graded good, 34% satisfactory and 45% poor. Information on wheezing, smoking habits and current medication was mentioned in 44%, 42% and 41% of asthma letters respectively.

CONCLUSIONS

The Finnish National Asthma Programme calls for optimizing communication between doctors. The proportion of poor letters was 50% higher than the preset standard and clearly indicates a need for improvement. We found several issues, which need to be better communicated (smoking, lung function tests, wheezing, medication) when referring a patient with suspected asthma.

Proactive asthma care in childhood: general practice based randomised controlled trial

OBJECTIVES

To assess the feasibility and effectiveness of a general practice based, proactive system of asthma care in children.

DESIGN

Randomised controlled trial with cluster sampling by general practice.

SETTING

General practices in the northern region of the Australian Capital Territory.

PARTICIPANTS

174 children with moderate to severe asthma who attended 24 general practitioners.

INTERVENTION

System of structured asthma care (the 3+ visit plan), with participating families reminded to attend the general practitioner.

MAIN OUTCOME MEASURES

Process measures: rates for asthma consultations with general practitioner, written asthma plans, completion of the 3+ visit plan; clinical measures: rates for emergency department visits for asthma, days absent from school, symptom-free days, symptoms over the past year, activity limitation over the past year, and asthma drug use over the past year; spirometric lung function measures before and after cold air challenge.

RESULTS

Intervention group children had significantly more asthma related consultations (odds ratio for three or more asthma related consultations 3.8 (95% confidence interval 1.9 to 7.6; P = 0.0001), written asthma plans (2.2 (1.2 to 4.1); P = 0.01), and completed 3+ visit plans (24.2 (5.7 to 103.2); P = 0.0001) than control children and a mean reduction in measurements of forced expiratory volume in one second after cold air challenge of 2.6% (1.7 to 3.5); P = 0.0001) less than control children. The number needed to treat (benefit) for one additional written asthma action plan was 5 (3 to 41) children. Intervention group children had lower emergency department attendance rates for asthma (odds ratio 0.4 (0.2 to 1.04); P = 0.06) and less speech limiting wheeze (0.2 (0.1 to 0.4); P = 0.0001) than control children and were more likely to use a spacer (2.8 (1.6 to 4.7); P = 0.0001). No differences occurred in number of days absent from school or symptom-free day scores.

CONCLUSIONS

Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.

Role of the specialist in the treatment of asthma

The preponderance of literature supports the efficacy of specialist care for asthma. Not every patient with asthma needs to be treated by a specialist, however. An optimal health care delivery model for asthma (i.e. one that provides high quality care that is cost effective) requires some mix of primary and specialty services. A tiered model of care in which the primary care physician acts as the first point of contact and decision-maker with regard to referral and that includes asthma specialists, including allergists, pulmonologists, and other health care professionals with expertise in asthma, appears to be a reasonable solution. The number of studies that compare various models for organizing asthma care is limited, however. Thus, further research is needed to determine how best to align the roles of primary care physicians, allied health professionals, and subspecialists in order to ensure seamless communication and cost-effective care that is targeted to individual patient needs.

Inhaler devices for asthma: do we follow the guidelines?

BACKGROUND

Despite national guidelines for asthma treatment, many children have troublesome symptoms.

AIM

To assess the extent to which the use of inappropriate inhaler devices contributes to this problem.

METHODS

Of 14 813 questionnaires distributed to schoolchildren, 6996 (47%) were returned identifying 1444 children using asthma inhalers. Inhalers were categorised as age appropriate or inappropriate according to national guidelines and were compared with those used by 75 patients attending a hospital clinic.

RESULTS

A total of 35% of "schools" and 4% of "clinic" children reported using an inappropriate inhaler device. Most were using metered dose inhalers alone. Twenty four per cent of "schools" children < or = 5 years old did not use a spacer. Both children and parents overestimated the child's ability to use their inhaler.

CONCLUSIONS

Large numbers of children are given inhalers they cannot use. To improve asthma care we must ensure that prescriptions reflect the age and ability of the child. Recent recommendations by the Department of Health in England and Wales stress the importance of seamless care between primary and secondary services. As the management of childhood asthma is guided primarily by secondary care providers, it is therefore imperative that general paediatricians know the difficulties and issues which are occurring in the community. This will enable them to lead and support necessary change.

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study

PURPOSE

To examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD).

SUBJECTS AND METHODS

We used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days.

RESULTS

There were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income.

CONCLUSION

Although these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.

[Gain, loss and agreement between respiratory specialists and generalists in the diagnosis of asthma]

OBJECTIVE

To determine and analyze the degree of agreement and disagreement in the diagnosis of bronchial asthma (BA) by respiratory disease specialists and generalists in regional hospital and primary care settings.

MATERIAL AND METHODS

Ninety-six outpatients (16 to 70 years of age) were studied; all had been assigned a diagnosis of BA by the referring physician or by the respiratory disease specialist. We recorded 1) clinical symptoms, determining the initial probability of a diagnosis (IPD)of BA to be high, medium or low; 2) results of spirometry and bronchodilator testing (BDT), peak flow variability and methacholine challenge testing; 3) prick test results, eosinophil levels and total serum IgE levels. Three diagnoses were recorded: the initial diagnosis (ID) by the referring physician to whom follow-up data were unavailable; diagnosis by the respiratory disease specialist based only on clinical symptoms (RSS); and the final diagnosis(FD). To arrive at a FD of BA, it was necessary to have a high or medium IPD and a positive BDT. A Kappa test was used to analyze the degree of agreement among the three diagnoses. Group features associated with greater or lesser agreement were analyzed by chi-square tests and analysis of variance.

RESULTS

Agreement was acceptable between RSS and FD (K = 0.63) but very low between ID and RSS and between ID and FD. In the latter two cases, agreement was greatest for patients diagnosed in hospital and for those with high IgE levels (p < 0.05), with high IPD, longer course of disease and a history of asthma (p < 0.01) (odds ratio =59.8). Diagnostic disagreement occurred mainly for patients for whom a BA diagnosis was gained later, the of under-diagnosis being 39%. The patients involved visited the physician only because they had observed an isolated symptom related to asthma (odds ratio = 119) and to arrive at a diagnosis bronchomotor tests other than BDT were required (p < 0.01).

CONCLUSIONS

a) The degree of agreement for a diagnosis of BA is low. b)The functional profile of patients for whom diagnostic agreement exists differs from that of patients for whom diagnosis is gained through testing. c) In the context of this study, a high rate of under-diagnosis is evident.

Qualitative study of views of health professionals and patients on guided self management plans for asthma

OBJECTIVES

To explore the views held by general practitioners, practice nurses, and patients about the role of guided self management plans in asthma care.

DESIGN

Qualitative study using nine focus groups that each met on two occasions.

SETTING

South Wales.

SUBJECTS

13 asthma nurses, 11 general practitioners (six with an interest in asthma), and 32 patients (13 adults compliant with treatment, 12 non-compliant adults, and seven teenagers).

RESULTS

Neither health professionals nor patients were enthusiastic about guided self management plans, and, although for different reasons, almost all participants were ambivalent about their usefulness or relevance. Most professionals opposed their use. Few patients reported sustained use, and most felt that plans were largely irrelevant to them. The attitudes associated with these views reflect the gulf between the professionals' concept of the "responsible asthma patient" and the patients' view.

CONCLUSIONS

Attempts to introduce self guided management plans in primary care are unlikely to be successful. A more patient centred, patient negotiated plan is needed for asthma care in the community.