Asthma management in five European countries: doctors' knowledge, attitudes and prescribing behaviour. Drug Education Project (DEP) group.

The aim of the study was to examine the relationship between guideline recommendations on asthma management, and the performance of doctors in five different European health care contexts. Knowledge, attitudes and prescribing behaviour of doctors recruited to an educational project was investigated. A total of 698 general practitioners from Germany, The Netherlands, Norway and Sweden, and 94 specialists from the Slovak Republic participated. A questionnaire was used to assess their knowledge and attitudes. Antiasthmatic drugs dispensed to their patients reflected their prescribing behaviour. In response to questions on how to treat chronic asthma, most doctors were in agreement with guideline recommendations. In practice, however, the proportion of asthma patients receiving inhaled steroids varied almost twofold, ranging 31% in Germany to 58% in The Netherlands. On questions related to exacerbation of asthma, German and Slovakian doctors often preferred treatment with antibiotics to steroids. They also more often associated yellow-green sputum with bacterial infection. In conclusion, although many doctors in different health care contexts have accepted the recommendations given in guidelines, the proportion of their patients treated accordingly differed. German and Slovakian doctors seem to attach less importance to the inflammatory features of asthma than the doctors from the other three European countries.     

Inhaled corticosteroids and mortality in COPD

STUDY OBJECTIVES: To assess the influence of inhaled corticosteroids (ICSs) on mortality in COPD patients, which is currently a controversial topic. SETTING: Manitoba Health maintains a population-wide research database that includes pharmaceutical information. Design and patients: We examined mortality in people 90 to 365 days after hospital discharge for COPD, comparing those persons who received inhaled steroids within 90 days of hospital discharge with those who did not. Cox proportional hazards models were used with adjustments for other respiratory drugs, comorbidities, and physician visits before and after hospital discharge. We also compared mortality in patients who received inhaled steroids with those who received other respiratory drugs, but not inhaled steroids, and those who received neither. Using nested case control analysis, we examined the time of receipt of inhaled steroids in relation to fatal events. RESULTS: In people > 65 years of age, inhaled steroids were associated with a 25% reduction in mortality between 90 and 365 days after hospital discharge, while mortality increased with bronchodilator use, physician visits, age, and comorbidities. The exclusion of people who had also received a diagnosis of asthma or had received inhaled steroids before hospitalization did not change the result. Inhaled steroids were associated with an even larger mortality reduction in people aged 35 to 64 years. People who received bronchodilators but no steroids had higher mortality than people who received no bronchodilators or received both bronchodilators and inhaled steroids. The reduction in all-cause mortality was largely due to the decreased number of cardiovascular deaths. The receipt of inhaled steroids within 30 days of death was protective, but this was not the case for greater time intervals. CONCLUSIONS: Therapy with ICSs reduced mortality in COPD patients; the effect was particularly notable for cardiovascular death and was short term in that it was dependent on recent exposure.     

Underuse of inhaled steroid therapy in elderly patients with asthma

STUDY OBJECTIVES: Despite their proven efficacy, inhaled steroids may be underused in the elderly asthmatic population. The objectives of this study were to determine if inhaled steroids are underused in the elderly asthmatic population, who are at a high risk for rehospitalization and mortality, and to identify certain risk factors that predict lower use of inhaled steroids in this group of patients. DESIGN: Population-based, retrospective, cohort study using linked data from hospital discharge and outpatient drug databases. PARTICIPANTS: All people > or = 65 years old in Ontario, Canada, who survived an acute exacerbation of asthma between April 1992 and March 1997. MEASUREMENTS AND RESULTS: Of the 6,254 patients, 2,495 patients (40%) did not receive inhaled steroid therapy within 90 days of discharge from their initial hospitalization for asthma. Patients > 80 years old were at a greater risk of not receiving inhaled steroid therapy, compared to those 65 to 70 years of age (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.05 to 1.47). Patients with a Charlson comorbidity index of > or = 3 were also at an increased risk of not receiving inhaled steroid therapy, compared to those having no comorbidities (adjusted OR, 3.45; 95% CI, 1.56 to 7.69). Moreover, receipt of care from a primary-care physician was independently associated with an elevated risk of not receiving inhaled steroid therapy, compared to receipt of care from respirologists/allergists (adjusted OR, 1.35; 95% CI, 1.10 to 1.61). INTERPRETATION: Forty percent of Ontario patients > or = 65 years old who experienced a recent acute exacerbation of asthma did not receive inhaled steroid therapy near discharge from their initial hospitalization for asthma. Nonreceipt of inhaled steroid therapy was particularly prominent in the older patients with multiple comorbidities. Moreover, those who received care from primary-care physicians were also less likely to receive inhaled steroid therapy, compared to those who received care from specialists.     

Symptomatic asthma: attendance and prescribing in general practice

Under-prescribing and low attendance continue to be cited as reasons for ongoing asthma symptoms in primary care despite marked increases in prescribing and structured care for asthma over the past 10 years. The objective of this study was to determine the relationship between continuing asthma morbidity and the attendance of and prescribing for symptomatic asthmatic patients in primary care. A random sample of 402 subjects from 801 who reported at least one of six symptoms in the previous month on most or every day were identified from responses to a validated morbidity questionnaire. An analysis of their care over a 2-year period (1 year before and 1 year after the questionnaire) was carried out from their general practice case-notes. Data on 308 patients was available for analysis. Ninety-four per cent of these symptomatic asthma patients attended over the 2-year period, with 77% attending for an asthma related consultation. Most patients were managed exclusively in primary care. Inhaled steroids were prescribed for 78% of patients and high dose inhaled steroids (> or = 800 mcg of beclomethasone or equivalent per day) were prescribed for 38%. Patients with most symptoms were more likely to be prescribed inhaled steroids. Rescue courses of oral steroids were prescribed for 29% of patients. Changes in asthma medications were recorded for 31% during the study period. Metered dose inhalers (MDI) were prescribed for 86% with more than half prescribed MDIs combined with some other delivery device. Elements of structured care were more frequently recorded in patients who reported most symptoms. In conclusion the asthma management of the majority of patients in this study was active with high levels of steroid prescribing. There appeared to be room to increase prescribing and to improve the structure of care.While patients who were 'symptomatic on steroids' should have had their medications, delivery devices and structured care reviewed regularly many were already on maximal treatment and were therefore likely to remain symptomatic. It is unclear how practitioners could improve morbidity in many of these patients as under-treatment and low attendance seem unlikely to be the principal causes of continuing symptoms.     

Asthma care practicing among general practitioners in Lebanon: a cross-sectional study

Objectives: The aim of this study was to characterize the current practice of asthma among general practitioners (GPs) in Lebanon. Methods: Out of 2450 Lebanese registered GPs, a representative sample of 330 were stratified by region to fill out the questionnaire constructed on the basis of surveys developed mainly by the Chicago Asthma Surveillance Initiative Report Team in newly moderate persistent asthma patients aged 5 years and above. The questionnaire included information about ascertaining diagnostic techniques, pharmacotherapeutic approaches, formal patient education program; asthma related continuing medical education and asthma practice guidelines. Results: Totally, 302 completed the questionnaire achieving a response rate of 91.5%. Chest radiography was the most commonly used diagnostic test (98%), while stain for eosinophilia was the less commonly used (7.9%). For clinical monitoring, cough and wheezing (98.7%) were mostly assessed. Short acting inhaled β₂-agonists were often the most prescribed (94.3%) followed by inhaled corticosteroids (87.4%) then by long acting β-agonist (LABA) and theophylline (27.5% and 20.9%, respectively). Moreover, 10% of GPs provided formal asthma education program, 72.2% attended professional education and 65% adopted guidelines. Conclusion: Based on current international guidelines, the overall Lebanese GPs practice of asthma management is not at an acceptable standard. Therefore, it is recommended to improve monitoring parameters, implement the asthma guidelines nationally and improve patient education.     

A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial

OBJECTIVES: to investigate the effectiveness of a pharmacy discharge plan in elderly hospitalized patients. DESIGN: randomized controlled trial. SUBJECTS AND SETTINGS: we randomized patients aged 75 years and older on four or more medicines who had been discharged from three acute general and one long-stay hospital to a pharmacy intervention or usual care. INTERVENTIONS: the hospital pharmacist developed discharge plans which gave details of medication and support required by the patient. A copy was given to the patient and to all relevant professionals and carers. This was followed by a domiciliary assessment by a community pharmacist. In the control group, patients were discharged from hospital following standard procedures that included a discharge letter to the general practitioner listing current medications. OUTCOMES: the primary outcome was re-admission to hospital within 6 months. Secondary outcomes included the number of deaths, attendance at hospital outpatient clinics and general practice and proportion of days in hospital over the follow-up period, together with patients' general well-being, satisfaction with the service and knowledge of and adherence to prescribed medication. RESULTS: we recruited 362 patients, of whom 181 were randomized to each group. We collected hospital and general practice data on at least 91 and 72% of patients respectively at each follow-up point and interviewed between 43 and 90% of the study subjects. There were no significant differences between the groups in the proportion of patients re-admitted to hospital between baseline and 3 months or 3 and 6 months. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: we found no evidence to suggest that the co-ordinated hospital and community pharmacy care discharge plans in elderly patients in this study influence outcomes.     

Patients' knowledge of drug treatments after hospitalisation: the key role of information

QUESTION UNDER STUDY: Patients often do not know the reasons for taking their medications after hospital discharge. We investigated whether lack of such knowledge was associated with patients' report of not having received information about their medications while hospitalised. METHODS: Patients with at least one long-term drug (ie, prescribed for more than 30 days) discharged from the wards of general internal medicine of a teaching hospital were included in the study. Patients' knowledge of the reasons for taking these drugs and their report of having received information while hospitalised were assessed by phone one week after discharge. RESULTS: 362 (98.6%) of 367 enrolled patients could be interviewed and provided data on 1693/1871 (90.5%) long-term drugs prescribed at discharge. Patients knew the reasons for taking 1382 (81.6%) drugs and reported having received information about 259 (15.3%) of them. In the adjusted analysis, the reason for taking a drug was less likely to be known when introduced during hospitalisation (OR: 0.7; 95%CI: 0.5 to 0.9), among older patients (OR for > or =80 years of age v/s 20-59: 0.41; 95%CI: 0.22 to 0.76) and among those staying longer (OR per additional hospital day: 0.96; 95%CI: 0.94 to 0.99); such knowledge was strongly and positively associated with the report of having received information during hospitalisation (OR: 7.3; 95%CI: 3.2 to 16.1). CONCLUSION: Patients' report of having received information about their long-term drugs during hospitalisation was associated with a significantly higher knowledge of the reasons for taking them. However, receipt of such information was only infrequently reported.     

Emergency Hospital Care for Exacerbation of COPD: Is Inhaled Maintenance Therapy Modified?

Background: The impact of hospital emergency care and inward admission for acute exacerbations of COPD on inhaled maintenance treatment is not well known. Objective: Therefore, we evaluated the impact of short-stay emergency hospital care and inward admission for acute exacerbation of COPD (eCOPD) on inhaled maintenance treatment prescribed at discharge. Design: Prospective observational cohort study of patients presenting with eCOPD at emergency departments in 16 hospitals of the Spanish healthcare system. The ethics committee at each hospital approved the study and patients provided an informed consent before inclusion. We classified the patients according to the severity of COPD: mild/moderate (FEV₁ ≥ 50% predicted) or severe/very severe (FEV₁ < 50% predicted) and need of inward hospitalisation. We analysed changes to maintenance treatment on discharge according to GOLD strategy. Results: 1559 patients, 65% required hospitalisation. The most common maintenance treatment was inhaled corticoids (ICS) (80.9%) followed by long-acting beta-agonists (LABA) (75.4%). The most common combination was triple therapy (LABA+ LAMA+ICS) (56.2%) followed by LABA+ICS dual therapy (18.2%) regardless of the severity of COPD. In more than 60% of patients treatment was not changed at discharge. The most common change in treatment was a reduction when discharge was from emergency care and an increase after hospitalisation (-21.6% and +19.5% in severe/very severe COPD, respectively). Conclusions: Emergency hospital care for eCOPD does not usually induce changes in inhaled maintenance treatment for COPD regardless of the duration of the hospital stay.     

Management of asthma in general practice

An audit of the management of asthma in two large general practices has been undertaken. The overall level of therapy prescribed was, in general, related to both the objective severity of the patients' asthma and the extent of symptoms. However, many individual patients received sub-optimal therapy. Prophylactic inhaled beta agonists were used infrequently. Inhaled steroids were prescribed to only one third of the patients and to less than half of severely affected patients. The results suggest that this group of adult asthmatics were relatively under treated in general practice, but a prospective study with proven compliance is necessary to confirm this.     

Analysis of Hospitalizations for COPD Exacerbation: Opportunities for Improving Care

ABSTRACT

Background: Little is known about the actual treatment of patients with chronic obstructive pulmonary disease (COPD), either in the inpatient or outpatient settings. We hypothesized that there are substantial opportunities for improvement in adherence with current guidelines and recommendations. Methods: We reviewed the medical records of all patients hospitalized with acute exacerbation of COPD between January 2005 and December 2006 at 5 New York City hospitals. Results: There were 1285 unique patients with 1653 hospitalizations. Of these 1653, 83% were for patients with a prior history of COPD and 368 (22%) represented repeat admissions during our study period. The majority were treated during their hospitalization with a combination of systemic steroids (85%), bronchodilators (94%) and antibiotics (80%). There were 59 deaths (3.6%). Smoking cessation counseling was offered to 48% of active smokers. Influenza and pneumococcal vaccines were administered to half of eligible patients. On discharge, only 46.0% were prescribed maintenance bronchodilators and 24% were not prescribed any inhaled therapy. Even in the 226 unique patients (17.6%) readmitted at least once during course of the study, on discharge only 44.7% were prescribed maintenance bronchodilators and 23% were not prescribed any regular inhaled therapy. Conclusions: Patients hospitalized with acute exacerbation of COPD generally receive adequate hospital care, but there may be opportunities to improve care pharmacologically and with smoking cessation counseling and vaccination during and after hospitalization.     

Limited treatment adaptation despite poor asthma control in asthma patients treated with inhaled corticosteroids

Objective: Current asthma guidelines recommend use of inhaled corticosteroids (ICS) in patients with persistent disease. This study was designed to investigate (1) the proportion of patients prescribed ICS-containing maintenance treatment who achieve asthma control, (2) determinants of control and (3) how physicians adapt treatment to the level of control. Methods: General practitioners (GPs) and chest physicians (CPs) in France recruited patients consulting for asthma and prescribed an ICS. Over a 2-year follow-up period, asthma symptoms in the previous 3 months and treatments prescribed were documented at each visit. Variables independently associated with asthma control were determined by multiple logistic regression. Results: Data were available for 924 patients recruited by GPs and 455 recruited by CPs. Asthma control was acceptable in only 24% of patients at inclusion, and in 33.6% at the last follow-up visit. Five factors were independently associated with asthma control: age (or time since diagnosis), gender, smoking status, allergic aetiology of asthma and treatment. Most patients (56.3%) were prescribed the same ICS dose regimen at the end of follow-up as at inclusion. The intensity of controller therapy had been increased in only 12.2% of patients unacceptably controlled at inclusion. Conclusions: Asthma was unacceptably controlled in most patients receiving ICS-containing maintenance treatment and remained so during follow-up. Despite this, treatment adaptations by GPs and CPs were very infrequent. This unsatisfactory situation may be improved by adopting a more dynamic approach to tailoring controller therapy to the needs of the patient.     

A survey of Medicaid recipients with asthma: perceptions of self-management, access, and care

STUDY OBJECTIVES: To understand how Medicaid recipients with asthma view their experience with care. DESIGN: Survey sent to Medicaid managed care enrollees. SETTING: A survey designed to assess general health status, access to care, medication-taking behaviors, and overall satisfaction was sent to 25,171 patients with moderate-to-severe asthma. RESULTS: A total of 92% of patients rated their asthma care as good or excellent, 64% of adults reported their health as fair or poor, while only 27% of children reported their health as being fair or poor. Respondents were well-educated regarding their asthma, with 87% reporting knowing what to do for severe asthma attacks, 78% knowing the early warning signs of an asthma attack, and 77% recognizing aggravating factors. Eighty-nine percent of respondents rated the quality of the information given to them by their provider as very good or good. While 75% of patients reported using inhaled steroids, only 38% of those reported using them on a daily basis. Forty percent of patients reported using inhaled steroids only when they have symptoms. Forty-six percent of adults either smoke cigarettes or are exposed to smoking in the home, while 35% of children are exposed to smoke in the home. CONCLUSION: Asthmatic patients rated the quality of the information that their physicians provide very highly and reported that that they understand how to treat exacerbations. However, they do not take prescribed inhaled steroids on a daily basis. In addition, many asthmatic patients reside in homes where cigarette smoking is present.     

Management of acute asthma: a survey of hospital practice and comparison between thoracic and general physicians in Birmingham and Manchester

The assessment and treatment of 140 randomly selected patients with acute asthma admitted to hospitals in Birmingham and Manchester in 1978 were studied. A detailed history of attack severity was recorded in just over half the case notes on admission (55%) and objective evidence of severity was recorded in a smaller number (measurement of airflow obstruction in 31% and arterial blood gases in 42%). Twenty-one (31%) thoracic patients and 33 (45%) general medical patients received aerosolized bronchodilators from metered-dose inhalers alone and 31% of all patients were given no inhaled bronchodilator drugs. Although the asthma was considered severe enough to require admission to hospital 37% were not given a course of corticosteroid therapy. Response to treatment was monitored by serial peak flow measurements in only 51% overall. Discharge therapy included a bronchodilator inhaler and oral corticosteroids in less than half (43%) of patients. There was no major difference in severity of asthma in patients admitted under the care of 'thoracic' or 'general' physicians but significant differences were found in their assessment and treatment. 'Thoracic' physicians more often measured severity and the response to treatment objectively. They prescribed inhaled (rather than intravenous) bronchodilator drugs more frequently and were more likely to discharge patients with a bronchodilator inhaler, oral corticosteroids, prophylactic therapy and an outpatient follow-up appointment.     

General practitioners' knowledge of childhood asthma in Delhi, India.

OBJECTIVE: To assess knowledge of childhood asthma among general practitioners (GPs) in Delhi, India. DESIGN: In this cross-sectional study, a total of 157 GPs were interviewed using a validated questionnaire, including six questions of local and social relevance. A response rate of 78.5% was obtained. RESULTS: Although the GPs who participated in the study had adequate knowledge of the importance of appropriate treatment, the safety of inhalers/oral steroids and the role of medicines in the prevention of frequent asthma attacks, the majority lacked knowledge of symptomatology, exercise-induced asthma and inhaled corticosteroids. GPs with >5 years of practice were more likely to have significantly less knowledge about preventive drugs, certain aspects of treatment of acute asthma and misconceptions, such as 'drinking milk increases mucus production' or 'children with asthma should not consume dairy products, chilled drinks, sour or chilled food'. On the other hand, GPs with < or =5 of practice had misconceptions such as 'children with asthma have abnormally sensitive airways' and 'asthmatic children develop dependence on inhalers'. CONCLUSIONS: The gaps in knowledge about asthma and its management highlight the need to design well-structured educational strategies for health professionals.     

Socio-economic disadvantage, quality of medical care and admission for acute severe asthma

Background: In asthma, socio-economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality.
Aim: To determine the quality of medical care including the patient perception of the doctor-patient relationship, and the level of socio-economic disadvantage in patients admitted to hospital with acute severe asthma.
Methods: One hundred and thirty-eight patients (15–50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments.
Results: The initial subjects had severe asthma on admission (pH=7.3±0.2, PaCO2=7.1 ±5.0 kPa, n =90) but short hospital stay (3.7±2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%.
Conclusion: Patients admitted to hospital with acute asthma have evidence of good quality on-going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.     

Association between pediatric home management plan of care compliance and asthma readmission

Objectives: In 2007, The Joint Commission implemented three children's asthma care (CAC) measures to help improve the quality of care for patients admitted with asthma. Due to lack of consistent evidence showing a relationship between home management plan of care (HMPC) compliance and readmission rates, CAC-3 was retired in 2016. We aimed to understand the relationship between HMPC compliance and revisits to the hospital, and investigate which components of the HMPC, if any, were driving the effect. Methods: This was a retrospective cohort study at a quaternary care freestanding children's hospital, including patients between 2 and 17 years of age admitted with a primary diagnosis of asthma between January 1, 2006, and July 1, 2013. Bivariate and multiple logistic regression analyses examined effects of HMPC provider compliance on hospital readmission and emergency department utilization for asthma within 180 days of initial discharge, controlling for admission to the intensive care unit, age, gender, ethnicity, insurance type, and whether inhaled corticosteroids were prescribed. Results: A total of 1,176 patients were included. Those discharged with an HMPC (n = 756, of which 84% were fully compliant) were found to have significantly lower readmission rates (7 vs. 11.9%; aOR = 0.63; 95% CI, 0.41–0.95) and ED revisit rates (aOR = 0.73; 95% CI, 0.56–0.96) within 180 days of discharge. Conclusions: Providing an HMPC upon discharge was found to be associated with decreased asthma readmission and ED utilization rates. This suggests that although HMPC is no longer a required measure, there may still be utility in continuing this practice.