Barriers to managing asthma

Nov 10 2008

Barriers to managing asthma include access to appropriate care, patient adherence, distrust of the medical profession, delayed asthma diagnosis, culture, lifestyle choices and genetic discrepancies according to experts at the annual meeting of the American College of Allergy, Asthma and Immunology (ACAAI) in Seattle.

"Lack of access to high quality care contributes to disparities in asthma care, especially for vulnerable populations," said Michael B. Foggs, M.D., chief of Allergy, Asthma & Immunology, Advocate Health Centers of Advocate Health Care in Chicago. "Uninsured individuals do worse than privately insured individuals on almost 90 percent of quality measures and on all access measures."

"A combination of poor patient understanding of asthma management and inadequate physician monitoring may contribute to disparities in asthma care," he said.

African Americans, Hispanics/Latinos and uninsured are more likely to receive asthma care by a hospital provider, or in poorer facilities with irregular follow-up, and receive treatment for asthma in emergency departments. Minorities are less likely to be seen by an asthma specialist. Fewer than half were found to use NIH-recommended anti-inflammatory medication, and a majority managed symptoms with an inhaled bronchodilator medication.

Health care disparity exists for asthma care even among the insured. Among adults in managed care organizations, fewer blacks than whites reported care consistent with the 2007 NHLBI/NAEPP Asthma Guidelines.

Delays in diagnosis in asthma occur with significant frequency according to Phillip L. Lieberman, clinical professor of medicine & pediatrics at the University of Tennessee Health Science Center in Memphis. "These delays can have a deleterious effect on outcomes including causing fatalities, increasing days with symptoms, and resulting in a rapid decline in lung function. Timely diagnosis will result in appropriate treatment, which can prevent these undesirable effects," he said.

Patient Adherence

For optimal treatment outcomes, patients must be involved in all aspects of care, from defining the problem to determining therapy said Alan T. Luskin, M.D., associate professor of medicine at the University of Wisconsin in Madison.

"Half the time patients and physicians disagree on what the problem is, and two-thirds of the time patients and physicians disagree on what the goals of treatment are," said Dr. Luskin. "We must be able to assess our patient's beliefs and expectations, and consider what features of the available therapies meet their needs."

Factors limiting adherence to a patient's asthma management plan are low health literacy; financial and economic barriers; environmental factors at home; customs, cultural or religious beliefs that impact use of health care services. Non-adherence likely accounts for up to 60 percent of hospitalizations.

According to Dr. Luskin, risks for non adherence include:

• More than one medication, or more than one medication per day
• Worry about medication side effects
• Multiple asthma care givers
• Takes medication for other problems
• Worries about too much or too little medication
• Has problems using the medicine or child refuses
• Feels medication is only somewhat effective
• Has trouble getting an appointment
• Doesn't have medication in the house if needed

Comparing physician estimates of compliance with actual pharmacy refill rates, physicians identified only 21 of 43 patients whose controller medication rate was less than 50 percent prescribed.

"Patients generally only see their physician when symptoms interfere with daily life. They adapt to their disease and lower their expectations, often viewing asthma episodes as facts of life," Dr. Luskin said.

Culture and Life Style

When considering true barriers to asthma care, the role of obesity, food and smoking have a significant impact in effecting asthma outcomes said Michael S. Blaiss, M.D., clinical professor of pediatrics and medicine at the University of Tennessee Health Science Center in Memphis.

"As a group, subjects with asthma are heavier than subjects without asthma, and studies show obesity may worsen asthma control," he said.

Prospective studies have shown: (1) greater initial weight and greater weight change in adults increases the risk of development of asthma later in life; and (2) the effect of overweight and obesity in children increases the risk of development of asthma.

"Asthma and obesity in children are common chronic conditions and both disorders have been increasing in the last 2 to 3 decades. The changes of dietary habits and a sedentary life style could have played a role in increasing the prevalence of both conditions," Dr. Blaiss said.

The consumption of fast food has been shown to be a risk factor for asthma. As part o the International Study of Asthma and Allergies in Childhood (ISAAC), a cross-sectional prevalence study of 1,321 children, investigators in New Zealand found an independent risk of hamburger consumption on having a history of wheeze or asthma if ingestion of one or more per week compared to less than one per week.

Smoking is also a known risk factor for asthma. According to the CDC (November 2007), 21 percent of the U.S. adult population smokes.

"Current smoking has been associated with increased severity of asthma, worse asthma-specific quality of life, worse mental health status, and a greater risk of hospitalization for asthma. Smoking is also associated with poor asthma control, and new evidence suggests that smoking reduces the benefits of inhaled corticosteroids. Exposure to passive smoke at home may delay recovery from an acute attack," said Dr. Blaiss.

Cultural factors, such as language limitations and parental beliefs are also barriers to asthma care. Patients with a language barrier are more likely to have less access to a usual source of medical care, receive preventative care at a lower rate and have increased risk of non-adherence to medication. Parents with strong beliefs against use of medication, or preferences for holistic approaches to treatment may present obstacles to a child's asthma care.

Patient information on allergic diseases including the brochure titled Take Control: A Guide for People with Asthma is available by calling the ACAAI toll free number at (800) 842-7777 or visiting its Web site at www.acaai.org.

About ACAAI

The American College of Allergy, Asthma and Immunology (ACAAI) is a professional medical organization headquartered in Arlington Heights, Ill., that promotes excellence in the practice of the subspecialty of allergy and immunology. The College, comprising more than 5,000 allergists-immunologists and related health care professionals, fosters a culture of collaboration and congeniality in which its members work together and with others toward the common goals of patient care, education, advocacy and research.