TulsaAllergyNews

When it comes to medical treatment, there are often times when technology and research have advanced far beyond what was available decades ago. Asthma treatments are no exception, yet many patients – especially children – continue to be prescribed methods of managing their illness that have been in use for more than 30 years. This is very outdated asthma care. Why is this the case? What advancements in asthma treatment could help people better manage the symptoms associated with their condition, and why haven’t they become standard practices yet? In this blog post we will investigate why outdated asthma treatments remain popular despite modern advances and explore what new options may be available to improve care.

Mortimer K, Reddel HK, Pitrez PM, Bateman ED. Asthma management in low and middle income countries: case for change. Eur Respir J. 2022 Sep 15;60(3):2103179. doi: 10.1183/13993003.03179-2021. PMID: 35210321; PMCID: PMC9474897.

Asthma is the most common noncommunicable disease in children, and among the most common in adults. The great majority of people with asthma live in low and middle income countries (LMICs), which have disproportionately high asthma-related morbidity and mortality. Essential inhaled medications, particularly those containing inhaled corticosteroids (ICS), are often unavailable or unaffordable, and this explains much of the global burden of preventable asthma morbidity and mortality. Guidelines developed for LMICs are generally based on the outdated assumption that patients with asthma symptoms <1-3 times per week do not need (or benefit from) ICS. Even when ICS are prescribed, many patients manage their asthma with oral or inhaled short-acting β₂-agonists (SABA) alone, owing to issues of availability and affordability. A single ICS-formoterol inhaler-based approach to asthma management for all severities of asthma, from mild to severe, starting at diagnosis, might overcome SABA overuse/over-reliance and reduce the burden of symptoms and severe exacerbations. However, ICS-formoterol inhalers are currently very poorly available or unaffordable in LMICs. There is a pressing need for pragmatic clinical trial evidence of the feasibility and cost-effectiveness of this and other strategies to improve asthma care in these countries. The global health inequality in asthma care that deprives so many children, adolescents and adults of healthy lives and puts them at increased risk of death, despite the availability of highly effective therapeutic approaches, is unacceptable. A World Health Assembly Resolution on universal access to affordable and effective asthma care is needed to focus attention and investment on addressing this need.

Ring N, Booth H, Wilson C, Hoskins G, Pinnock H, Sheikh A, Jepson R. The ‘vicious cycle’ of personalised asthma action plan implementation in primary care: a qualitative study of patients and health professionals’ views. BMC Fam Pract. 2015 Oct 21;16:145. doi: 10.1186/s12875-015-0352-4. PMID: 26487557; PMCID: PMC4618358.

Background: Personal asthma action plans (PAAPs) have been guideline recommended for years, but consistently under-issued by health professionals and under-utilised by patients. Previous studies have investigated sub-optimal PAAP implementation but more insight is needed into barriers to their use from the perspective of professionals, patients and primary care teams.

Methods: A maximum variation sample of professional and patient participants were recruited from five demographically diverse general practices and another group of primary care professionals in one Scottish region. Interviews were digitally recorded and data thematically analysed using NVivo.

Results: Twenty-nine semi-structured interviews were conducted (11 adults with asthma, seven general practitioners, ten practice nurses, one hospital respiratory nurse). Three over-arching themes emerged: 1) patients generally do not value PAAPs, 2) professionals do not fully value PAAPs and, 3) multiple barriers reduce the value of PAAPs in primary care. Six patients had a PAAP but these were outdated, not reflecting their needs and not used. Patients reported not wanting or needing PAAPs, yet identified circumstances when these could be useful. Fifteen professionals had selectively issued PAAPs with eight having reviewed one. Many professionals did not value PAAPs as they did not see patients using these and lacked awareness of times when patients could have benefited from one. Multi-level compounding barriers emerged. Individual barriers included poor patient awareness and professionals not reinforcing PAAP use. Organizational barriers included professionals having difficulty accessing PAAP templates and fragmented processes including patients not being asked to bring PAAPs to their asthma appointments.

Conclusions: Primary care PAAP implementation is in a vicious cycle. Professionals infrequently review/update PAAPs with patients; patients with outdated PAAPs do not value or use these; professionals observing patients’ lack of interest in PAAPs do not discuss these. Patients observing this do not refer to their plans and perceive them to be of little value in asthma self-management. Twenty-five years after PAAPs were first recommended, primary care practices are still not ready to support their implementation. Breaking this vicious cycle to create a healthcare context more conducive to PAAP implementation requires a whole systems approach with multi-faceted interventions addressing patient, professional and organizational barriers.

Empowering employees to speak out against workplace misconduct, the Speak Out Act establishes a crucial framework for protecting those who come forward. Beyond merely granting permission to discuss instances of harassment, the Act serves as a shield for employees, safeguarding their rights in doing so. Understanding the full scope of these protections is vital for both employees and employers. So why can’t we use this model to “speak out” against outdated asthma care and explore what new options may be available to improve care?

1. Go on-line….that’s where the people are. Here are some topics that lend themselves to better knowledge of what works for asthma and avoids the old-school way of teaching.
2. Understanding Asthma: Delving into the basics of asthma, what triggers symptoms, and how it affects the airways.
3. Recognizing Symptoms: Identifying common signs of an asthma flare-up and understanding when to seek medical help.
4. What Is Asthma Control? Exploring the meaning of asthma control and the goals of treatment.
5. For Health Professionals:
6. Asthma Pathophysiology: A review of the underlying mechanisms causing asthma and its clinical presentation.
7. Asthma Control Strategies: Implementing guidelines-based management and personalized action plans.
8. Measuring Asthma Control: Utilizing tools such as the Asthma Control Test (ACT) for monitoring patients’ asthma status.

How about advocating for quality asthma care, especially for children!

For Patients:

• Speak Up About Asthma Care: Encouraging patients to communicate openly with healthcare providers about their asthma. Often, patients don’t want to disclose challenges they face with their asthma. Who wants to admit they can’t afford the right ICS (steroid) inhaler for better asthma control? Paradoxically, there are many resources available to help patients get access to the right treatment, but health care providers must know about the need, before we can fill it.
• Understanding Your Rights: Awareness of patients’ rights to access quality asthma care and how to advocate for oneself. It’s very intimidating to be denied a medication from insurance. Why try? Nothing could be further from the truth. If you need a medication for your asthma and it’s denied by your insurance, consider the following:
• Ask your doctor’s office to write an appeal letter to your insurance explaining why you need a particular type of inhaler.
• Hand-written letters sent with a doctor’s appeal letter are very powerful to get your point across. Describe in your letter what uncontrolled asthma means to you: missed work, extra ER visits (and waits of 10-12 hours), inability to exercise and viral infections (which should be the common cold) lasting for weeks with night time wheezing & coughing. Don’t be shy about expressing your frustration with the “system”–it’s real and insurance companies need to know about it.
• Creating an Asthma Action Plan: The importance of having a personalized plan in place and how to develop one with your healthcare team. I’ve already mentioned how uninterested patients and providers alike look at written action plans. Unfortunately, this is an individual decision as to how much effort you choose to place on your asthma care. If we cared for asthma like we care for our favorite sports team, asthma hospital wards would be empty.

For Health Professionals:

• Patient-Centered Communication: Best practices for engaging patients in their care and encouraging self-management start with real listening. What are patient goals for their asthma? How many steroid bursts are too much? Patients will often tell me what they think I want to hear, not their honest opinion. Asking non-judgmental questions about asthma care can be a rare find–patients are shocked when we value their health care goals including what works for them in treating asthma. My best advice: try to be a health care professional that truly listens to asthma patients and let them share in treatment recommendations.
• Advocacy for Patients: Health professionals can support patients’ access to treatments, resources, and education. Writing a letter of appeal to the insurance industry isn’t an easy thing to do and it can become very time-consuming. Patients rely on our expertise and boldness to advocate for asthma medications they simply cannot afford.

I encourage you to leave a review or comment on your experience with controlling your asthma–was it successful or are you lacking the confidence of knowing your asthma is well controlled and “no surprises” with asthma flares is what you expect? I read most of your comments and I enjoy responding to your opinions.

Next time, I’ll address another important aspect of asthma care–Are insurance companies really practicing medicine? Stay tuned, and until next time take care of your physical health–it’s never too late to start.