Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey

Past asthma surveys have shown suboptimal management and control of asthma in the United States. No major survey of asthma management has been conducted since the Third Expert Panel Report for the National Asthma Education and Prevention Program (NAEPP) guidelines on diagnosis and treatment of asthma (August 2007). This study was designed to report asthma management and control results from the Asthma Insight and Management survey of U.S. patients and physicians. A telephone-based survey was conducted during 2009 in 2500 patients with asthma, aged ≥12 years, and 309 physicians (104 allergists, 54 pulmonologists, 101 family practitioners, and 50 internists). Patients' asthma control perceptions (71% "completely controlled" or "well controlled") were inconsistent with their NAEPP control level as determined by self-reported symptoms (29% well controlled). Patients and physicians had low expectations for effective asthma management; patients considered asthma well managed if rescue medication was used three times per week (46%), urgent care visits occurred twice per year (67%), or emergency department visits occurred once per year (60%). Asthma-related syncope, seizure, intensive care unit admission, and intubation were associated with uncontrolled asthma based on NAEPP guidelines. Respiratory specialists (allergists/pulmonologists) implemented asthma management recommendations more than other physicians surveyed. However, only 22% of patients visited a specialist for usual asthma care and 48% had never visited a specialist. Despite detailed NAEPP guidance, asthma management and control in U.S. patients is unsatisfactory. Improved asthma control assessment (impairment and risk) and implementation of NAEPP management recommendations are needed to improve asthma control and outcomes.     

Improving pediatric asthma care: A partnership between pediatric primary care clinics and a free-standing Children's Hospital

Background: Asthma is a common chronic disease of childhood. Providers’ adherence to asthma guidelines is still less than optimal. Objectives: To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program. Methods: Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of National Asthma Education and Prevention Program (NAEPP) asthma quality indicators by blinded random review of patient charts. Results: In the EI group, 6-, 12-, and 18-month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms, and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12-month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators. Conclusion: In-office training of non-physician asthma providers improves the quality of asthma care.     

Peak expiratory flow meters (PEFMs) – who uses them and how and does education affect the pattern of utilisation?

Background: Asthma control may be assisted by educating patients to use peak expiratory flow meters (PEFMs). Aims: To find out the sociodemographic and clinical characteristics of asthmatics attending an Emergency Room (ER) who owned PEFMs. Methods: We undertook a study of 352 asthmatics aged seven to 55 years who attended an ER. The following were analysed: their pattern of peak flow monitoring (PFM), the factors associated with ‘appropriate’ or daily PFM on entry to the study and then prospectively; whether asthma education influenced utilisation and whether there was a reduction in ER use or admissions in those who acquired a PEFM. Results: Those owning a PEFM at entry to the study (54%) had more asthma morbidity (p= 0.0001), had had asthma for longer (p = 0.0001), had seen their medical practitioners more often in the previous nine months (p = 0.0001), were on more asthma medications (p= 0.0001) and were more likely to have been to an Asthma Clinic (p = 0.0001). Those not owning a PEFM were more likely to be of lower social class (p = 0.016) and of Pacific Island origin (p= 0.0001) suggesting that distribution is not ideal and is influenced by disease severity, amount of health care use and sociodemographics. Patients with a self-management plan (35% of PEFM owners) and those receiving ‘good care’ or management, were more likely to use PFM ‘appropriately’ and to mention PFM in a scenario evaluating their response to worsening asthma control and argues for PEFMs to be distributed only in conjunction with a self-management plan, and therefore in close association with the patients' medical practitioners. Most patients (75%) appeared to prefer making management decisions based on symptoms rather than on their peak expiratory flow (PEF) and few (16%) performed daily PFM at entry to the study and fewer (6%) nine months later. There was an improvement in the pattern of PFM after education, but the acquisition of a PEFM made no difference to the frequency of ER use or admission, Conclusion: More realistic goals need to be defined in relationship to PFM which may improve patients' acceptance of the strategy, and therefore, hopefully their compliance. Such strategies need to be consistently reinforced over time for them to have an impact on asthma morbidity. (Aust NZ J Med 1994; 24: 521–529.)     

Prevalence of cocaine use and its impact on asthma exacerbation in an urban population

OBJECTIVES: To assess the prevalence of cocaine use, and its impact on severity of presentation, among adults presenting to the emergency department (ED) with asthma. A secondary aim was to assess the use of various asthma treatment modalities, with reference to the 1997 National Asthma Education and Prevention Program (NAEPP) guidelines. METHODS: All adults aged 18 to 55 years who presented to the ED of this institution with an asthma attack, were approached about participating in the study, which required giving informed consent, answering a facilitated questionnaire, and giving a urine sample for drug screening. RESULTS: Patients were enrolled during a 7-month period. A total of 163 patients were approached to enter the study; 116 patients consented to participate in the study, with 103 submitting complete urine samples. Thirty-seven patients refused to participate, and 10 were excluded. Sixty-eight percent of the patients were women, with a mean age of 33 years. African-Americans made up 89% of the total group. Thirty-five percent were cigarette smokers. Urine cocaine tests were positive in 13 of 103 (13%); 6 of 103 (5.8%) were positive for opiates. In the cocaine-positive group, 5 of 13 patients (38%) were admitted to the hospital, including two patients requiring intubation and mechanical ventilation. Of the total group, 23 of 103 patients (22%) were admitted, and 5 of those 23 admitted patients (22%) were cocaine-positive. Length of stay was significantly longer (5 vs 2.5 days, p < 0.05) in the cocaine-positive admitted patients. Forty-six percent of all patients reported using inhaled corticosteroids (ICS), with 39% of admitted patients using them. Thirty-two percent of all patients had obtained three or more refills of their beta(2)-agonist inhaler in the previous month. CONCLUSIONS: The prevalence of cocaine use may be much higher than the 13% shown in this study, because of patients' refusal to participate in the study. Second, the severity of exacerbation appears to be worse in the cocaine-positive group. Finally, the majority of patients presenting did not use ICS in accordance with the NAEPP guidelines.     

Asthma control following initial inhaled corticosteroid monotherapy in mild to moderate asthma: a 4- to 8-week observational study

BACKGROUND: There is an increasing trend for the use of combination therapy of inhaled corticosteroids (ICS) and long-acting beta(2)-agonists as initial treatment for asthma. OBJECTIVE: To assess the efficacy of initial monotherapy with ICS for achieving asthma control in steroid-naive mild to moderate asthmatics. METHOD: During an observational survey, steroid-naive patients received ICS in a dosage of 400-2,000 mug/day. After 4-8 weeks' treatment, achievement of asthma control, defined according to the Global Initiative for Asthma (GINA) guidelines, was assessed and the Asthma Control Questionnaire (ACQ) was completed. RESULTS: Among 537 selected patients, 21 were excluded because of severe asthma and 96 because of inadequate ICS daily dosage. Four hundred and twenty patients were analyzed, 396 (94%) of whom completed the survey. Mean ICS dosage, in equivalent beclomethasone, was 479 +/- 62 mug/day for mild asthma (group A) and 1,115 +/- 306 mug/day for moderate asthma (group B). Asthma control was achieved for 71 and 65% of the patients, mean ACQ score improved from 1.1 +/- 0.6 to 0.5 +/- 0.5 (p < 0.001) and from 2.0 +/- 0.8 to 0.8 +/- 0.7 (p < 0,001), and FEV(1) (% predicted) improved from 93 +/- 9 to 96 +/- 13 (p < 0.05) and from 85 +/- 15 to 91 +/- 15 (p < 0.001) for groups A and B, respectively. CONCLUSION: Asthma control can be achieved by ICS monotherapy for two thirds of steroid-naive patients with mild to moderate asthma. For these patients, we suggest that ICS alone could be started as initial therapy and that additional therapy should be considered after 4-8 weeks for patients who do not achieve control.     

Rapid effects of inhaled corticosteroids in acute asthma: an evidence-based evaluation

BACKGROUND: Current reviews on the use of inhaled corticosteroids (ICS) for acute asthma underestimated their early (minutes) clinical impact and produced conclusions of questionable validity. OBJECTIVE: The analysis of the best evidence available on the early (1 to 4 h) clinical impact of ICS for patients with acute asthma in the emergency department (ED) setting. METHODS: Published (from 1966 to 2006) randomized controlled trials were retrieved using different databases (MEDLINE, EMBASE, Cochrane Controlled Trials Register), bibliographic reviews of primary research, review articles, and citations from texts. Primary outcome measures were admission and ED discharge rates. RESULTS: Seventeen studies met criteria for inclusion in the review (470 adults and 663 children and adolescents). After 2 to 4 h of protocol, a greater reduction in admission rate was observed with trials that used multiple doses of ICS (odds ratio [OR], 0.30; 95% confidence interval [CI], 0.16 to 0.55), especially when they were compared with placebo. Patients treated with ICS also displayed a faster clinical improvement compared with placebo or systemic corticosteroids (SCS), increasing the probability of an early ED discharge (OR, 4.70; 95% CI, 2.97 to 7.42; p = 0.0001). The advantage of the use of ICS was also demonstrated in spirometric and clinical measures as early as 60 min. These benefits were obtained only when patients received multiple doses of ICS along with beta-agonists compared with placebo or SCS. CONCLUSIONS: Data suggests that ICS present early beneficial effects (1 to 2 h) when they were used in multiple doses administered in time intervals < or = 30 min over 90 to 120 min. The nongenomic effect is a possible candidate by covering the link between molecular pathways and the clinical effects of corticosteroids.     

Corticosteroid use after hospital discharge among high-risk adults with asthma

Despite the efficacy of corticosteroid therapy, patients hospitalized for asthma exacerbations are at high risk for re-exacerbation and death after discharge. The objective of this prospective cohort study was to evaluate adherence to inhaled corticosteroids (ICS) and oral corticosteroids (OCS) after discharge in adults hospitalized for asthma exacerbations. ICS and OCS were equipped with electronic medication monitors and were provided at discharge. Adherence (use/prescribed use x 100%) was measured by self-report and canister weight (ICS), pill count (OCS), and electronic medication monitors (both ICS and OCS) 2 weeks after discharge. Poor adherence was defined as adherence of less than 50%. The Asthma Control Questionnaire was used to assess symptom control. Sixty patients were enrolled (age 42.2 years, 98.3% African American, 65.0% female, 46.7% with history of near-fatal asthma). Electronically measured adherence to both corticosteroids dropped to approximately 50% within 7 days of discharge. Poor adherence to both corticosteroids predicted significantly worse symptom control (p = 0.04). Self-report, canister weight, and pill count all had low sensitivity (29.2%, 65.0%, and 7.7%, respectively) for detecting poor adherence. We conclude that adherence to ICS and OCS deteriorates within days of hospital discharge but may not be recognized in a substantial proportion of patients.     

Treatment and evaluation of patients with acute exacerbation of asthma before and during a visit to the ER in Denmark

Background: Acute exacerbation of asthma may be life‐threatening and quite often results in a visit to the emergency room (ER) or admission to a hospital. The aim was to evaluate the treatment and the quality of clinical management of asthma exacerbations, and finally, to identify the factors leading to admission. Material and methods: In a retrospective design, we audited the hospital records of all patients aged 18–40 years admitted to five Danish university hospitals with an acute exacerbation of asthma in 2004. Results: We found records covering 323 asthmatic patients (186 women). Before admission, the mean (standard deviation) duration of the exacerbation was 5.2 (7.5) days. Of those admitted, 14% did not use any medication, 39% used inhaled corticosteroids (ICS) either with a β₂‐agonist or alone, systemic steroids, and 34% used a β₂‐agonist alone. Lung function (peak flow or forced expiratory volume in first second) was measured in 60% on admission, in 58% on discharge and in 47% on both occasions (P < 0.01). Temperature, heart rate and oxygen saturation were measured in 231 of the patients (72%), but the respiratory frequency rate was measured in only 16% of the patients, with some differences between the five hospitals. On discharge, 50% were treated with systemic steroids, and a further 20% had ICS prescribed (P < 0.01, admission vs discharge). In 21% of the cases, inadequate treatment was identified as the most likely reason for their ER visit/admission to a hospital. Conclusions: The assessment and treatment of patients admitted with acute asthma exacerbation was often suboptimal. Under‐treatment with the anti‐asthmatic medication was the main reason for admission. Please cite this paper as: Backer V, Harving H, Søes‐Petersen U, Ulrik CS, Plaschke P and Lange P. Treatment and evaluation of patients with acute exacerbation of asthma before and during a visit to the ER in Denmark. The Clinical Respiratory Journal 2008; 2: 54–59.     

Persistent Asthma: Patient Characteristics, Courses of Asthma, and Utility of Salmeterol

Applications of National Asthma and Education and Prevention Program (NAEPP) guidelines for the diagnosis and management of asthma may reduce the morbidity of this disorder. Medical records and questionnaires from a series of 177 outer-city adolescents and adults with persistent asthma were audited according to NAEPP guidelines and for utility of salmeterol (Serevent®). Allergic sensitivity and exposure to indoor allergens house-dust mite (66% of patients), fungi (42%), cat (20%) and/or dog (14%) were of dominant importance to persistent asthma. Patients who continued salmeterol over 1 year had reduced severity of disease, improved forced expiratory flow at 25%-75% of vital capacity, and reduced usage of systemic, but not inhaled, corticosteroid.     

Burden of asthma among patients adherent to ICS/LABA: A real-world study

Objectives: Asthma is a chronic respiratory condition with a U.S. prevalence of 7.4%. Despite numerous treatment options, asthma remains poorly controlled in some patients. Uncontrolled asthma is associated with high healthcare resource utilization (HCRU) and reduced productivity. This study assessed symptoms, productivity, and HCRU of patients adherent to medium/high-dosage inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) treatment, and the relationship of asthma control with these parameters. Methods: Data were collected in the U.S. in 2013–2016 in the Adelphi Respiratory Disease Specific Programme, a cross-sectional survey. Participating physicians (n = 258) each completed a record form for eligible patients, who were receiving medium/high-dosage ICS/LABA treatment with self-reported moderate/high adherence, completed the Asthma Control Test (ACT) and the Work Productivity and Activity Impairment (WPAI) questionnaire, and were included in the analyses. Results: Patients (n = 428) had a mean of 59% symptom-free days in the past month. Wheezing was the most troublesome symptom for 25% of patients. In the previous 12 months, the mean number of exacerbations was 1.3; 15% of exacerbations required emergency room treatment and/or hospitalization. Mean physician visits for asthma was 5.7. Asthma impacted leisure/personal time frequently/constantly for 11% of patients, with 20% overall work impairment. Asthma was poorly controlled (ACT score ≤15) in 18% of patients; poorer asthma control was associated with higher rates of exacerbations, work impairment, and HCRU. Conclusion: Given the substantial burden described, greater attention to asthma monitoring and management is necessary. Identification of novel treatments may be important for patients not responding to medium/high-dosage ICS/LABA treatment.     

Pharmacotherapy of asthma: what do the 2007 NAEPP guidelines say?

The purpose of this article is to review the recommendations for pharmacotherapy in the new National Asthma Education and Prevention Program (NAEPP) guidelines. There are four main changes regarding pharmacotherapy in the updated guidelines. First, the recommendations for three age groups (0-4 years, 5-11 years, and > or =12 years) are presented separately. Second, the steps of therapy have been expanded from 4 steps to 6 steps to simplify the action within each step. Third, medium dose inhaled corticosteroids (ICS) or low-dose ICS plus add-on therapy are recommended for patients 5 years of age and older who are not controlled on low dose ICS. Finally, consideration of omalizumab is recommended for allergic patients 12 years of age and older who are not controlled on medium dose ICS plus long-acting beta agonists. For all age groups, the first step of therapy is inhaled short-acting beta agonists as needed and the second step is low dose ICS. Oral corticosteroids are part of step 6 therapy for all age groups. In patients not already on long-term control medications, the step of initiation of therapy is based on the assessment of severity. In patients on long-term control medications, therapy is adjusted based on the level of asthma control. If the patient is not well controlled, therapy is usually advanced one step. If the patient is very poorly controlled, consider stepping up two steps, a course of oral corticosteroids, or both. It is hoped that the updated NAEPP guidelines will lead to improved quality of life for patients with asthma.     

Asthma in pregnancy.

Asthma, one of the most common serious medical problems to complicate pregnancy, affects 3-8% of pregnancies in the United States. The goals of therapy in the pregnant asthmatic patient do not differ from those in non-pregnant patients. Inhaled corticosteroids (ICS) are preferred in the management of all levels of persistent asthma in pregnant patients, because these agents have been shown to reduce asthma exacerbations during pregnancy. Asthma in pregnancy is often undertreated due to physician and patient concerns over the effects of asthma medications on the fetus. However, undertreatment leads to loss of asthma control and increases in maternal morbidity, perinatal mortality, preeclampsia, preterm birth, and low birth weight infants. Recent prospective clinical cohort studies with active asthma management by NAEPP guidelines show no evidence of increased maternal or fetal morbidity or mortality. Therefore, it is critical for the mother to understand that failure to control asthma during pregnancy may lead to poor outcomes. A case study follows to highlight clinical pearls and pitfalls in the management of asthma in the pregnant patient.     

Health beliefs and compliance with inhaled corticosteroids by asthmatic patients in primary care practices.

The aim of this study was to determine factors associated with regular use of inhaled corticosteroids (ICS) by asthmatic patients in primary care practices. A cross-sectional survey was carried out over 12 family practices in the Philadelphia greater Metropolitan area. A total of 394 patients aged 18–49 years, who received medical care for asthma from their primary care physician and had been prescribed ICS between 1 January 1995 and 31 December 1996, were included.The study measured self-reported demographics, experience with asthma, use of and attitudes about ICS, and health beliefs in six domains.Only 38% of patients reported using ICS at least twice a day almost every day. The most frequently cited reasons for inconsistent or non-use of ICS were related to a belief that ICS were unnecessary during asymptomatic periods and to a general concern about side-effects. By logistic regression, factors associated with regular use of ICS were two patient health beliefs, namely the health belief of ‘Active’ participation in clinical decision-making with their physician (OR=4·6, 95% CI 2·8, 7·5), and the health belief that asthma was a ‘Serious’ health problem (OR=2·3, 95% CI 1·4, 3·7), and hospitalization for asthma within the previous 12 months (OR=2·3, 95% CI 1·6, 4·6).Patients were more likely to report regular use of ICS if they saw themselves as active participants in their treatment planning and conceptualized asthma as a potentially serious illness. These results support the themes of patient education and shared decision-making between patients and physicians that are promoted by the Asthma Guidelines from the National Heart, Lung and Blood Institute (NHLBI).     

The Status of Asthma Control and Asthma Prescribing Practices in the United States: Results of a Large Prospective Asthma Control Survey of Primary Care Practices

Control of asthma symptoms is, unfortunately, not a reality for many people with asthma. Asthma control is an ongoing challenge, requiring a multidisciplinary treatment approach. The National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute published its Guidelines for the Diagnosis and Management of Asthma in 1997, but the extent of implementation of recommendations in physician's practices remains to be determined. We sought to determine if a systematic implementation of the NAEPP practice guidelines would impact physician's treatment decisions for patients with asthma. The Asthma Care Network is a large, national, point-of-care program developed to assist health care providers in the assessment and management of their patients with asthma. Outcome measurements for the program included level of asthma control, activity limitation, sleep disruption, use of rescue medications, use of controller medications, and urgent care services. A total of 4,901 primary care physicians at 2,876 practice sites enrolled more than 60,000 patients. Nearly three fourths of patients reported symptoms consistent with a lack of asthma control (mean 74%, range 69-81%). Approximately 68% of pediatric patients and 78% of adult patients reported limited activities due to asthma in the past week. Sixty-two percent of pediatric patients and 68% of adult patients reported more than two symptomatic days in the past week. Approximately 40% of the patients surveyed were not using controller therapy. The overall percentage of patients reporting uncontrolled asthma who were prescribed a controller medication increased from 60% to 81%, and the use of inhaled corticosteroids containing medications among these patients increased by 52%. As a result of the assessment of the patients' level of asthma control during the office visit, physicians changed their patterns of prescribing controller therapy in patients with uncontrolled asthma.