Assessing the importance of asthma education using outcomes data is a primary concern among the staff at the Little Rock Allergy & Asthma Clinic.
Asthma is a chronic inflammatory disease of the large and small airways marked by hyper responsiveness and by reversible airflow limitation. The degree of reversibility can vary spontaneously or in response to treatment. Symptoms of asthma include wheezing, breathlessness, cough, and chest tightness. The impact of asthma (both on health care costs and on the patient’s quality of life) has pushed the health care industry to look at outcomes data in order to help guide practitioners in choosing patient education techniques and patterns of treatment.
The prevalence, morbidity rate, and mortality rate of asthma continue to worsen despite advances in treatment. In the United States, there are now an estimated 17 million people affected by asthma.1 The self-reported prevalence of asthma increased 75 percent from 1980 to 1994. From 1975 to 1995, the estimated annual number of office visits for asthma more than doubled; in 1995, 1.8 million people visited a US emergency department for asthma. Hospital admissions for asthma increased from 386,000 to 466,000 between 1980 and 1994,2 and the number of deaths due to asthma continues to rise each year.
The total US cost of asthma care in 1994 reached $6 billion. Direct costs, which include ambulatory care visits, emergency department visits, hospital services, and physician services, as well as medications, accounted for 88 percent of the total. Indirect costs (which include missed workdays, restriction from normal work activities, and missed school days) make up the other 12 percent.3
Increasing Asthma Morbidity
Why worsening morbidity and mortality rates for asthma continue to be seen is unclear. It has been theorized that it may be due to the fact that people spend much more time indoors in energy-efficient, airtight buildings than they once did. Indoor allergens such as house dust mites, domestic pets, cockroaches, and molds all play a role in the development of asthma. It has been estimated that 60 percent to 80 percent of children and young adults with asthma have allergies that act as triggers for their asthma.4
Indoor pollutants, such as nitrogen dioxide, could also be contributing to asthma morbidity. Nitrogen dioxide is generated by the combustion of hydrocarbons. Gas stoves and space heaters generate this gas in our homes. It is an important component of urban smog, possibly contributing to asthma morbidity (especially in inner cities).4 Urban pollution in general has been thought to be a contributing factor to asthma, but the outdoor environment has become cleaner while asthma prevalence, morbidity rates, and mortality rates have increased.4
Tobacco smoke has been closely linked with increased asthma prevalence. A 1993 study5 surveyed urine levels of cotinine (a metabolite of nicotine) and reviewed parental reports to determine the significance of exposure to cigarette smoke undergone by children with asthma. Data showed that as exposure to environmental tobacco smoke increased, acute exacerbations of asthma increased and pulmonary function decreased.
Evidence suggests that asthma education can affect asthma morbidity and mortality rates in a positive way.6 The asthma education program at the Little Rock Allergy & Asthma Clinic (LRAAC), Little Rock, Ark, has an RCP that gives one-on-one instruction to the patient and family on the physiology of asthma, and the use of daily asthma medications to control symptoms. Patients are given detailed instruction in the use of inhalers, spacers, and peak flow meters. Individualized asthma care plans are developed to help the patient determine when to step up or step down therapy on the basis of symptoms. Written medication instructions are given to all patients.
Getting Patients Involved
Health care providers must encourage patients to take an active role in the management of their disease. They must be cognizant of any psychosocial or financial barriers to therapy; they must ask the right questions in order to ascertain whether the patient has the resources needed to purchase asthma medications, peak flow meters, and spacer devices. It is also important to know whether the parents of a child with asthma live apart, for example, because the child who spends time in two households may need inhalers, peak flow meters, and asthma care plans for both homes. Clinicians must be able to speak at a level that the patient can understand if the patient is to feel comfortable communicating with them.
Educational sessions work best if they are spread out over several visits, giving the patient time to assimilate and put into practice the information and techniques that are being taught. Consistent educational follow-up allows the health care team to review and observe previously taught techniques. Those patients who display good inhaler and peak flow techniques over time tend to be the patients who adhere to their treatment plan and do well. The 4 Rs noted in the 1991 National Heart, Lung, and Blood Institute (NHLBI) guidelines present an effective way of teaching that has been helpful for us at the LRAAC (Table 1).7
Given the high cost of asthma care and the effect of the disease on quality of life, outcomes data have become very important in asthma management. David Tinkelman, MD, past president of the Joint Council of Allergy, Asthma and Immunology (JCAAI), has stated, “Expertise and excellence must be demonstrated through objective outcomes measurements, rather than testimonials or self-proclaimed directives.”8 Providers must be able to measure the effectiveness of asthma education techniques and to monitor patients’ progress over time. Outcomes data benefit both patient and health care provider. If patients perceive that they are getting the best asthma care, they will be motivated to adhere to therapy. Communication between patient and physician will improve, thus creating a win-win situation. Physicians and RCPs involved in asthma care can use outcomes information to improve their understanding not only of the physical limitations of asthma, but also of the mental strain of chronic disease. For asthma specialists who are board-certified allergists, asthma outcomes are important in proving the value of specialized care. Allergists must be able to prove to managed care organizations that they can improve the quality of life for patients with asthma and hold down health care costs at the same time.
Outcomes data should also be used to continue to refine established practice guidelines. In 1997, an NHLBI expert panel9 revised the asthma guidelines that had originally been published in 1991.7 The new guidelines stressed the early and aggressive treatment of inflammation in asthma. The classification of asthma severity was also changed to better define the continuum of severity (Table 2). The new categories of asthma are mild intermittent, mild persistent, moderate persistent, and severe persistent; each category has specific guidelines for the stepwise use of asthma medications (Table 3).
LRAAC, a private practice clinic staffed by four board-certified allergists, began monitoring asthma outcomes in May 1997. An RCP had been added to the staff (in 1995). With the expertise of the RCP, LRAAC has been able to give detailed instruction and education to asthma patients. Since its asthma education program was solidly in place, LRAAC decided to look objectively at its activities in order to make sure that its patients were benefiting from its care.
LRAAC elected to begin its outcomes monitoring with newly diagnosed asthma patients of all ages. An initial group of 39 patients was monitored using a 12-item health survey10 and a 20-item, asthma-specific questionnaire.11 The 12-item survey is a general health status survey used to elicit physical and mental summary scales and compare them with those of the general population of the United States. The 20-item questionnaire measures breathlessness, mood disturbance, social disruptions, and concerns for health. Patients were also asked questions about specific asthma symptoms.
At the initial visit and after the diagnosis of asthma was made (based on history and physical examination, as well as on spirometry results), questionnaires were given to each patient to complete. Questionnaires were also distributed at quarterly follow-up visits for a year. The initial visit consisted of:
- an allergy workup;
- baseline prebronchodilator and postbronchodilator spirometry;
- instruction in proper inhaler techniques;
- provision of medication education, including written instructions;
- training in the use of a peak flow meter;
- creation of an individualized asthma care plan; and
- provision of information on asthma triggers.
Patients were asked to return a month later for an appointment with the RCP to review inhaler technique and proper use of medications, to evaluate peak flow monitoring results, and to make adjustments to the patient’s asthma care plan, if necessary. If patients could not be followed up at scheduled visits, LRAAC tried to reach them by telephone and mailed questionnaires to them quarterly (with stamped, self-addressed envelopes).
Of the initial group of 39 patients, 18 completed a year of outcomes monitoring. Patients dropped out for various reasons; some stated that they felt better and did not need to be seen, others moved, and follow-up care could not be established for some.
Outcomes data were analyzed at the Office of Health Care Research, Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock. In comparing results from patients’ baseline questionnaire to the results from their 12-month questionnaire (Figures 1 through 5), LRAAC saw a significant change in daytime wheezing and nighttime awakening due to wheezing. This improvement in quality of life is reflected as a significant change in symptoms between those reported initially and those reported a year later. Because of the limitations of the data collected, this outcomes evaluation did not cover the economic impact of the asthma education program on patients. One can reason, however, that if diurnal and nocturnal wheezing drastically improve, patients will subsequently spend less time in emergency departments and hospitals for asthma care.
LRAAC is currently taking part in the Asthma Outcomes Monitoring System started by the JCAAI; the American College of Allergy, Asthma, and Immunology; the American Academy of Allergy, Asthma, and Immunology; and QualityMetric, an outcomes monitoring company. The system has been designed to collect asthma outcomes data from board-certified allergists throughout the United States in order to determine whether this specialty achieves better outcomes in asthma care, at less cost, than other specialties achieve. Data such as these will help shape the future treatment of asthma in the new millennium.
Deanna N. Ruddell, MD, is an allergist; Donna G. Dayer, RRT, is a staff RCP, both at the Little Rock Allergy & Asthma Clinic, Little Rock, Ark.
1. Forecasted state-specific estimates of self-reported asthma prevalence: United States, 1998. MMWR Morb Mortal Wkly Rep. 1998;47:1022-1025.
2. Surveillance for asthma: United States, 1960-1995. MMWR Morb Mortal Wkly Rep. 1998;47:1-28.
3. Smith DH, Malone DC, Lawson KA, et al. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med. 1997;156:787-793.
4. Eggleston PA. Urban children and asthma: morbidity and mortality. Immunology and Allergy Clinics of North America. 1998;18:75-84.
5. Chilmonczyk BA, Salmun LM, Megathlin KN, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. N Engl J Med. 1993;328:1665-1669.
6. Korenblat PE, Korenblat-Hanin M, Gaioni SJ. An asthma center: outcomes validation. J Allergy Clin Immunol. 1995;95:222.
7. National Asthma Education Program Expert Panel. National Asthma Education Expert Report. Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Heart, Lung, and Blood Institute; 1991.
8. Tinkelman D. Interpreting results from the AOMS. Joint Council of Allergy, Asthma and Immunology Newsletter. 1998;22(63):1.
9. National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Washington, DC: Department of Health and Human Services; 1997.
10. Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey. Med Care. 1996;34:220-233.
11. Marks GB, Dunn SM, Woolcock AJ. A scale for the measurement of quality of life in adults with asthma. J Clin Epidemiol. 1992;45:461-472.
The 4 Rs
- Reaching Agreement
- Remember that patients need to be included in developing the written plan. Goals and expectations need to be discussed and agreed upon.
- Once the asthma action plan is developed, discuss it, and encourage the patient to demonstrate learned skills such as correct technique for metered-dose inhalation and peak flow meter use. Walk through the action plan with the patient and discuss what-if scenarios. Encourage problem solving for acute situations.
- At regularly scheduled office visits, review the action plan to ensure that the patient has all of the required medications and is consistently monitoring and recording peak flow values.
- Provide positive feedback for accomplishments. Praise the patient who has instituted environmental control measures, such as removing a pet or prohibiting smoking in the home. Reinforce how such positive steps will help control asthma.
Step 1: Mild intermittent asthma
- Symptoms occur no more than twice per week
- The patient is asymptomatic, with normal peak expiratory flow (PEF) between exacerbations
- Exacerbations are brief (lasting a few hours to a few days), with varying intensity
- Nighttime symptoms occur no more than twice per month
- Forced expiratory volume in 1 second (FEV1)/PEF is 80 percent or more of the predicted value, with variability of less than 20 percent
Step 2: Mild persistent asthma
- Symptoms occur more than twice per week, but less than once per day
- Exacerbations may affect activity
- Nighttime symptoms occur more than twice per month
- FEV1/PEF is 80 percent or more of the predicted value, with variability of 20 percent to 30 percent
Step 3: Moderate persistent asthma
- Symptoms occur daily
- Inhaled, short-acting, 2-agonists are used daily
- Exacerbations affect activity
- Exacerbations occur two or more times per week and may last for days
- Nighttime symptoms occur more than once per week
- FEV1/PEF is between 60 percent and 80 percent of the predicted value, with 30 percent variability.
Step 4: Severe persistent asthma
- Symptoms are continual
- There is limited physical activity
- Exacerbations are frequent
- There are frequent nighttime symptoms
- FEV1/PEF is less than 60 percent of the predicted value, with more than 30 percent variability
Guidelines for Asthma Management
By Anna Chiappetta, BSRT, RRT, RCP
The National Asthma Education and Prevention Program (NAEPP) has recently issued updated guidelines for the management of asthma. This update to the original Expert Panel Report issued in 1991 is entitled Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. These guidelines are subdivided into four sections:
- Measures of Assessment and Monitoring;
- Control of Factors Contributing to Asthma Severity;
- Pharmacologic Therapy; and
- Education for a Partnership in Asthma Care.
Patient education is an essential component of each step of asthma management. Through patient education, RCPs can develop a solid relationship with a patient that begins at diagnosis and is integrated into each step of the patient’s care. At the initial visit, the patient should be taught about asthma, what to do to avoid triggers, and how and why each medication is prescribed and taken. Peak flow monitor use and monitoring should also be taught early in that patient’s care. The patient should be taught his or her personal best peak flow and what values are considered to be in the red, yellow, or green zone. Written reference materials customized to a patient’s particular needs and zone management plan should also be provided. Finally, a copy of these customized patient education materials should be placed in the patient’s permanent record for medical staff reference and follow-up care.
In this article, the authors demonstrate how they have been able to help manage asthma and measure outcomes as verification of their success. By publishing this article, RT, The Journal for Respiratory Care Practitioners, is disseminating valuable information regarding the importance of the RCP’s role as an educator. Unfortunately, this is a role that many payors are reluctant to fund. The measurement, documentation, and publication of outcomes are not only a valuable tool in assessing the efficacy of a particular program, but also a justification of the role of an RCP as an educator.
The complete NAEPP guidelines can be purchased for $7 from: NAEPP, NHLBI Information Center, PO Box 30105, Bethesda, MD 20824-0105. Or contact them on the Web at http:www.hnlbi.nih/lung/asthma/prof/asthc.htm.