Leonard Bielory, MD
Director of the Division of Allergy
and Immunology
UMDNJ-New Jersey Medical School
An estimated 13 million Americans, 5.1 percent of the population, have asthma. It is our most common chronic disease. In recent years asthma has increased in prevalence as well as related morbidity and mortality, particularly among specific populations - African-Americans, Hispanics and young people. Researchers remain uncertain ofthe underlying reasons for asthma's rising prevalence, and they are frustrated by the apparent inability to control the disease and prevent deaths.
The Scope of the Problem
It is not surprising that chronic diseases disproportionately affect those living in poor, inner-city neighborhoods, and asthma is no exception. Morbidity statistics show asthma-associated hospitalizations for all children age 10 to 14 years rose from 2.2 per 1,000 in 1980 to 3.2 per 1,000 in 1984. This same study, a Michigan-based investigation, reported that the prevalence among African-American children of the same or similar age and for the same time period increased from 3.2 per 1,000 to 7.1 per 1,000. That reflects a greater than 100 percent rise in only four years.
Mortality among inner-city African-Americans has also risen. Data based on records from the New Jersey Department of Health death certificates (ICD coded), and compiled by the Asthma and Allergy Research Center at UMDNJ-New Jersey Medical School, indicate that asthma related deaths in the state have more than doubled over a 10-year period, from 63 in 1980 to 137 in 1990. The growth in population does not explain this increase, since the census figures for this period rose only by 5 percent.
These data demonstrate a difference in asthma associated morbidity and mortality between the predominantly poor, minority populations of the inner city of Newark and the middle- and upper-middle-class populations of the suburban parts of Essex County. The death rate attributable to asthma in Newark is 5.8 per 100,000, compared with 2.8 per 100,000 in the suburban/rural areas of the county. Hospital admissions for the treatment of asthma were 110 per 100,000 persons in Newark, but only 46 per 100,000 for the suburban/rural populations.
Recently released data from the National Heart, Lung, and Blood Institute confirm these findings. In 1992, asthma associated mortality for African-Americans was three times higher than for Caucasians. For people between the ages of 15 and 24, the 1993 statistics showed that African-Americans were six times more likely to die of asthma than Caucasians.
Economics and Asthma
In the current cost-conscious environment of medicine, perhaps no greater challenge faces the health care provider than effective management of a chronic illness such as asthma among poor, inner-city populations.
In addition to the direct expenditures - hospitalizations, medications, and emergency and outpatient care - associated with asthma, the indirect costs are also significant. Lost school days account for an estimated $899.7 million; lost work days among men total $134.8 million and among women $211.5 million. The higher costs among women are probably attributable to the fact that more women have asthma, about one and a half times as many as men. Total indirect costs are estimated at $2.5 billion, but the cost of such factors as disrupted learning, psychosocial implications and stigmata, especially among children, are incalculable.
Addressing the Problem
Management of asthma begins with the recognition that many changes must take place before the trends of increasing morbidity and mortality can be reversed. The cornerstones of any program are:
In this era of managed health care, any management program must minimize costs and maximize quality of care.
Designing a Management Program
Several studies have been conducted to analyze problems associated with asthma and to develop possible cost-effective interventions. An integral element of a program is a needs assessment to: identify measures to limit exposure to triggers, incorporate an appropriate pharmacologic regimen, and design motivational tools to enhance adherence to the program.
The program must be individualized to meet the needs of each patient. Findings from one evaluation that used the case management approach, coupled with quality assurance standards, may offer insights into what elements can be implemented into asthma programs in the inner city. Several factors were identified as impediments to quality care: Obtaining medication was an obstacle for 63 percent of the parents of asthmatic patients - 10 percent had no medication in the home and 45 percent of the parents thought their child's wheezing could not be prevented. There were 56 prescribing errors - most commonly lack of medication for acute episodes of wheezing. The dosage of many prescriptions, as well as the dosing schedules, were inadequate in many cases.
Incorporating Pharmacotherapy into the Program
Recent investigation indicates that appropriate use of steroids and other anti-inflammatory medications improve asthma outcomes; yet many asthmatics are not receiving them. Although the reasons for the discrepancy are unknown, African-Americans receive fewer corticosteroids than other children.
In the Newark metropolitan area, monitoring of asthma medication sales, including theophylline, shows that prescribing habits have remained unchanged since the introduction of the National Institutes of Health (NIH) guidelines for diagnosis and management of asthma. In fact, northern New Jersey and the New York-Staten Island regions report the largest sales of bronchodilators in the country. There has been no increase in the use of anti-inflammatory medications for asthma in the Newark population. These findings support those of other investigators. They indicate that the NIH guidelines, which reflect the importance of treating the inflammatory aspect of asthma, have not been incorporated into the day-to-day practice of inner-city primary care physicians.
Avoidance Therapy
Treatment for asthma should be targeted toward the cause, not aimed at just relieving the symptoms. The value of avoidance therapy is confirmed by scientific investigation. For example, when adults with dust mite sensitivity and asthma avoided dust mite exposure by remaining in a controlled environment, their asthma symptoms, pulmonary function, and nonspecific bronchial reactivity improved, and they were able to decrease their daily use of medications.
Avoidance therapy begins with an assessment of the patient's environment, which allows identification of modifiable risk factors and then targets elimination, or at least reduction, of these irritants. By incorporating avoidance therapy into the care plan, the clinician offers the patient an opportunity to take responsibility for one aspect of disease management. This empowerment often leads to enhanced adherence and improved care. Individualizing avoidance therapy to each patient's living situation, irritant exposure and capabilities recognizes the wide gamut of variables associated with asthma.
When patients and/or their families are unable to avoid stimuli, they can take other measures to reduce exposure. If the family cannot part with the cat, frequent bathing and confining the cat to specific areas of the residence may decrease the level of dander. For those who currently are unable to quit smoking, making the residence "off-limits" may help the patient by reducing his or her exposure to allergens and may move the smoker closer to quitting.
Education
It has become apparent that an educational program focusing on the roles of the patient and his family in the long-term management of the disease can have a tremendous impact on improvement of asthma outcomes. The patient, his family, social support, stress, and personal health behaviors affect the level of asthma knowledge, management skills and behavior. These factors have an impact on adherence. Additionally, managed care groups recognize the importance of including education in interventional programs, as asthma management consumes 1 percent of their total health care expenditures. It appears that providing effective care for the asthma patient can offer significant cost savings.
Parental or patient lack of education or knowledge about asthma per se may not be the problem. Investigators have shown that parents of inner-city asthmatic children are very knowledgeable about the disease. Knowing how to apply this information may be the issue: Of the patients who could name irritants, 45 percent thought that their child's wheezing could not be prevented, and at least 75 percent of the parents smoked.
Building a bridge between knowledge and its practical application is a challenging task. Ongoing support, tangible incentives and progress reports may motivate the patient and the parents to continue to be actively involved in the care plan. Periodic lung function testing may provide visible reminders of the effects of good management. Empowering the patient by encouraging her to be a contributing member of the management team enhances educational efforts and improves adherence.
Summary
Just as the etiology of asthma is multifactorial, its management encompasses nonpharmacologic, pharmacologic and educational components.
In order to reverse the increasing trend in asthma morbidity and mortality, many changes must take place. There must be adequate access to care. Action plans must be designed so the patients and/or his parents can respond effectively to increased symptoms. Pharmacotherapy should follow accepted guidelines; parents and caregivers should be monitored to evaluate adherence to the medication plan.
Similarly, parents and patients should receive information on sensitization and the role it plays in asthma, as well as approaches one can take to reduce exposure. In order to be relevant, advice for the patient must be tailored to the economic conditions. Lastly, controlled studies should be conducted regarding the effectiveness of various avoidance measures.
TEST QUESTIONS
1. Each of the following is true except:
2. Indirect costs associated with asthma include all of the following except:
3. The inflammatory infiltrate found in the asthmatic bronchial tissue is directly related to the development of bronchial hyper-responsiveness.
4. In children less than 16 years of age, allergies are the most common cause of asthma.
5. Asthma is triggered by which of the following? (List all that apply.)
6. A simple test that can be performed at home and that correlates well with the FEV1 is
7. Asthma health care costs are about 1% of all health care costs ($6 billion). What percentage of this is due to hospital care that might have been avoided by adequate treatment of the disease?
8. Treatment of asthma includes all of the following except:
9. Common adverse effects of oral B2 agonist include which of the following?
10. Increased theophylline levels are associated with which of the following?
11. Which of the following are considered anti-inflammatory agents in the treatment of asthma?
12. Nocturnal asthma may be controlled with which of the following agents?
According to the National Institutes of Health, asthma patients who depend on more than one canister of an inhaled beta-agonist bronchodilator - such as those listed below - each month to regulate their asthma may be out of control and may need further adjustment of their medications (Proventil, Ventolin, Tornalate, Maxair, Brethaire, Alupent, Primatene Mist, Bronkometer, Metaprel, Serevent).
Take this test to see if your asthma is under control.
1. Are you taking any asthma medications other than those listed above?
2. Are you using more than one canister per month of any of the above medications?
3. Are you using your inhaled bronchodilator more than three or four times a day?
4. Do you experience asthma flares more than once or twice per week?
5. Do you wake up at night with asthma symptoms more than twice a month?
If yes, how often per month?
6. Do you have a hard time breathing or do you cough when you exercise?
If you responded yes to two or more of questions two through six, take this test to your doctor for further consultation on controlling your asthma. For further information on asthma and allergies, call the UMDNJ Asthma & Allergy Research Center's toll-free information telephone line 800-NJ1-ASMA (800-651-2762). References used by the author are available upon request.
To suggest topics or presenters for UMDNJ's Continuing Education programs, contact Paul Novembre by phone at 201-982-5309 or fax to 201-982-7128. The e-mail address is: cce@umdnj.edu
