How to Improve Outcomes for Asthma Patients

Asthma rates have surged in recent years, and many patients are under-treated. But pharmacists are in a key position to help individuals manage this chronic disease.

The statistics are sobering. About 8% of the US population has an asthma diagnosis, with the prevalence of those affected increasing consistently since the 1980s.¹ Asthma-related symptoms increase absenteeism and cut into productivity at both schools and workplaces and costs the US economy $56 billion annually in lost productivity and health care expenses.² Asthma is the most common chronic pediatric condition, the third most common chief complaint of pediatric hospital admissions, and the most cited reason for missed school days.²

Here are some other asthma statistics:

• College graduates are 25% less likely to have asthma than high school dropouts (7.5% and 10%).
• Americans in households with earnings of less than $15,000 per year are 90% more likely to have asthma than those in households with earnings of more than $75,000 per year (13.3% and 7%)
• Healthy weight adults, per BMI measures, are 40% less likely to have asthma than obese adults (7.2% and 12%).³
• Asthma prevalence is higher among women than men (10.5% and 6.3%).
• Multi-race people have almost twice the risk of asthma than Caucasian patients in both adults and children.
• Asthmatic adults are more likely to smoke than the US general population (21% and 16.8%), even though smoking is a common attack trigger. In fact, smoking prevalence among those with asthma in Ohio is greater than 30%.⁴

Both children and adults with asthma use more health care services than the general population. The pediatric/adult rates of multiple emergency and urgent-care visits within 1 year are 22.2%/13.8% and 39.8%/24.1%, respectively.³ Asthma-related death risk increases steadily with age, and African Americans are almost 3 times more likely to die of asthma-related causes. But better outcomes through enhanced self-management can boost individual and societal productivity, improve quality of life, and trim health care expenses. Yet different barriers to care and inadequate disease education cause asthma self-management to fall short of patient goals.

A team of researchers from the United Kingdom examined factors affecting adherence and barriers to care in a recently published qualitative review.⁵

The authors culled nearly 3000 articles, primarily through database searching, to include 56 articles in this review. They included asthma-specific studies with qualitative data on opinions about self-management (ie, disease education, self-monitoring, and asthma plans) from patients, caregivers, and providers.

Respect and trust are crucial in a patient-provider relationship for optimal communication. Developing a relationship with pharmacists benefits patients, though this is difficult in some retail environments, especially busier ones. Mentally competent adults benefit from counseling, but providers regularly overlook children and the disabled. Remember to talk to patients directly, when possible. And consider whether the practice location is equipped to handle and provide patient education to vision, hearing, and mobility-impaired patients.

Patient cultural differences have a profound effect on asthma outcomes. Many patients are unaware that the chronic element of asthma means that symptom management continues even when they are asymptomatic.

Meanwhile, the study's authors reported that low health literate patients perceive pharmacist and emergency department (ED) care as superior in quality, more accessible, and quicker to access than primary care provider consultation. Pharmacists can leverage this trust and preference to keep patients out of the ED. Pharmacists’ role as a safety net has expanded, because pediatric asthma patients have difficulty accessing school nurses. School districts across the United States are overtaxing or even eliminating these positions.

Patients in the studies expressed concerns about adverse effects, both real and perceived, and dependence development. Cited adverse effects included weight gain (steroids), tremors and palpitations (beta agonists), and dry mouth (anticholinergics). These were also reasons given for preferring complementary and alternative medicine products. Some patients neglect their maintenance medication(s) because they feel no short-term symptomatic relief. The most omitted medication class was corticosteroids, so pharmacists should remind patients who take separate inhaled corticosteroid and long-acting beta agonist products to take both medications. These patients benefit from education about how controlling chronic asthma inflammation with maintenance medications reduces the frequency of attacks frequency and the severity of persistent symptoms.

Beyond reliance on rescue inhalers, ineffective ad-hoc regimen changes plague some patients. Patient perception of past experiences may guide their medication adjustments. An inability to identify and avoid triggers may be a prime driver of unsupervised changes in therapy. For example, patients with a seasonal allergy trigger may decrease their medication doses or frequency (possibly with older, expired fixed-dose products) once the specific pollen season ends. The patient may require emergency care following gradual loss of symptom control or unexpected trigger exposure. This phenomenon tends to preferentially affect maintenance medications because of the previously mentioned lack of short-term symptomatic feedback. Patients may rebuff therapy escalation because they associate high doses with severe disease. Ensure that such patients understand their need for a higher dose or more complicated regimens to achieve the desired outcomes. An educated patient with access to a trusted accessible provider is less likely to make ad-hoc changes.

Payers have already intertwined reimbursements and outcome improvements and will implement more outcome-based metrics in the future. Pharmacists can improve asthma outcomes through patient education. Develop a trusted patient-pharmacist relationship, keep cultural differences in mind, clarify concerns about adverse effects, and explain the need for chronic medication use for prophylaxis.

References

• CDC. Data, statistics, and surveillance. cdc.gov/asthma/asthmadata.htm. Updated September 8, 2016. Accessed October 9, 2017.
• Asthma and Allergy Foundation of America. Asthma facts and figures. aafa.org/page/asthma-facts.aspx. Accessed October 9, 2017.
• CDC. Asthma facts. CDC's national asthma control program grantees. cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf. Published July 2013. Accessed October 9, 2017.
• CDC. Percentage of people with asthma who smoke. cdc.gov/asthma/asthma_stats/people_who_smoke.htm. Updated January 31, 2013. Accessed October 9, 2017.
• Miles C, Arden-Close E, Thomas M, et al. Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views. NPJ Primary Care Respir Med. 2017;27(1):57. doi:10.1038/s41533-017-0056-4.