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Practice - New guidance to improve asthma control: putting patients at the centre of care

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Asthma is a long-term respiratory disorder affecting around five million people of all ages and social backgrounds (National Asthma Campaign, 2001). There have been major improvements in the management of asthma in recent years, as shown by declining hospitalisation and death rates. However, significant issues still need to be addressed.

Asthma is a long-term respiratory disorder affecting around five million people of all ages and social backgrounds (National Asthma Campaign, 2001). There have been major improvements in the management of asthma in recent years, as shown by declining hospitalisation and death rates. However, significant issues still need to be addressed.Around half of patients have unacceptable symptoms and lifestyle limitation, despite the availability of a range of suitable treatment options (Rabe, et al 2000; Price, et al 1999, Smith, 2000). Part of this problem is thought to lie with the high non-compliance rates for asthma medication. A recent analysis of data from UK asthma patients over five years revealed that 25% of patients have compliance rates estimated at 30% or less (Das Gupta and Guest, 2003). Indeed, non-compliance contributes to between 18% and 48% of asthma deaths (National Asthma Campaign, 2001).The reasons for non-compliance are complex. A variety of factors have been cited by research.

Better compliance
The literature suggests that there are two main components to improving compliance. The first is a simple treatment regimen.Patients on once-daily dosing tend to be ‘high-compliers’ compared to those on more frequent dosing (Das Gupta and Guest, 2003). The number of inhalers patients need to use has also been cited as a factor that influences compliance (Haughney et al, 2004) and, against this background, combination treatments (inhaled corticosteroid and beta2-agonists) have been one of a number of developments to simplify treatment regimens.The second factor is a better patient understanding of their illness and treatment.It has been recognised that the quality of the interaction between prescriber and patient during a consultation impacts on compliance by influencing patient understanding of asthma and treatment.The Medicines Partnership, an initiative supported by the Department of Health, recommends that consultations between patients and health-care professionals should seek to achieve concordance (Medicines Partnership, 2003).The potential for patients to take their medicines is maximised because they have a good understanding of why treatment matters and what a difference it can make.This new approach to prescribing and taking medicines sees the patient and the health-care professional participate as partners to reach an agreement on the illness and treatment, during which the patients’ experiences, beliefs and wishes are considered.

Latest policy
In February 2003, the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) together published a new British guideline on the management of asthma, which was published as a supplement to the journal Thorax.This guideline is also available from the British Thoracic website (www.brit-thoracic. org.uk/) and from the SIGN website (www.sign.ac.uk/). These guidelines are intended to be a comprehensive resource for those caring for those with asthma, whether in the community or within hospitals.So that patients benefit from the latest research, SIGN and BTS intend to update the guideline regularly. The first update occurred in April, and key changes were published on the BTS and SIGN websites.In the absence of a national service framework for asthma, the national evidence-based guidelines provide the best direction for the treatment and care of people with asthma.The recently revised BTS/SIGN guidelines are in keeping with the shift towards an emphasis on patient-focused care, with patients trained to manage their own treatment.

What patients think
Research suggests that meeting the needs of patients and improving communication between health-care professionals and patients is likely to achieve better adherence to treatment (Partridge, 2000; Gibson, 1998).A recent patient survey, The Living and Breathing Study (Haughney et al, 2004) further underlines the need for improved communication between asthma patients and health-care professionals so that patients have a better understanding of their condition. This study gives some insight into patients’ perceptions of their asthma, what they think of its management and on their expectations for asthma control. It was based on a patient survey involving 517 people with mild to moderate asthma.It reported that 91% thought their asthma was under control, yet two-thirds experienced symptoms at least two to three times a week. Initially, 58% of patients questioned said they were satisfied with their asthma care but this fell to 33% when they were shown asthma guidelines.A recent report from Asthma UK, Living on a Knife Edge (2004), highlighted the huge impact of severe asthma on patients. One in six said that at least once a week they have an attack so severe they cannot speak. One in five were seriously concerned the next asthma attack might kill them and 65% expected no improvements in how the NHS manages asthma.Compliance - In the Living and Breathing survey, patient practice varied significantly. A third of patients said they took a dose of reliever medication every day, whether they needed it or not, and 11% reported they did not take any reliever medication even when they experienced symptoms. A third of patients also reported missing a dose of preventer inhaler. Younger people were more compliant than older patients.What patients want - The new asthma guidelines acknowledge that meeting the individual needs of patients is an important goal in a patient-centred management strategy.The Living and Breathing study shed some light on aspects of treatment and management that patients would find appealing. Simplicity of management and treatment was identified as key to improving asthma treatment regimens.Four-fifths found fewer inhalers either appealing or very appealing. Also, 68% of patients reported they would feel comfortable being able to adjust the dose of their inhaler themselves after discussions with their health-care professional and in line with a personal, asthma action plan that showed them how to make changes to their regimen when their asthma improved.The Living and Breathing study suggested that patients were keen on simplified treatment regimens such as combination treatments, which offer a convenient option for patients who are poorly controlled on an inhaled steroid alone.Currently available combination treatments offer a choice of adjustable or fixed dosing.A recent study (Aalbers, et al, 2004) showed that an adjustable dosing regimen with the budesonide/formoterol combination reduced severe asthma exacerbations by 40% compared to a fixed dosing regimen of salmeterol/fluticasone. Patients in the adjustable dosing arm of the study also used significantly less reliever medication than those on a fixed dosing regimen.Many patients in the survey wished for a more constructive relationship with their health-care professional and a more personalised approach to asthma management.More than 80% of respondents said they had never been provided with a written asthma action plan, though over half said they would find one helpful and be comfortable using it. There was also a high level of enthusiasm for alternative methods of communication with health-care experts, such as telephone consultations.In the Living and Breathing study discussion, a number of implications for practice were highlighted (see Box, below).

Conclusion
The move towards patient-focused care sits comfortably with the belief of the Royal College of Nursing (RCN) that partnerships with patients are key to the future of the NHS.The updated BTS/SIGN guideline, like its predecessor, recognises that if outcomes in asthma management are to improve, patients need to be better engaged and involved in treatment plans geared to self-management.The guideline emphasises the need for patient education and the implementation of personal asthma action plans.It also recommends that inhaled steroids should be considered in milder cases than previously advised.

Latest Policy
BTS/SIGN guidance on asthma managementThe April 2004 update to the British Thoracic Society/Scottish Intercollegiate Guidelines Network contains the following new advice for practitioners. The guidelines will be updated on a regular basis.

MEDICATION
Inhaled steroids should be considered in milder cases than previously recommended. They are advised for patients:- With exacerbation of asthma in the last two years- Using inhaled beta-2 agonists three times a week or more- With symptoms three times a week or more- Waking one night a week.The revised guideline also recommends titration of the dose of inhaled steroids to the lowest dose at which effective control of asthma is maintained.

HELPING PATIENTS HELP THEMSELVES
People with asthma should be offered education and written asthma action plans that focus on their individual needs - this is a reinforcement of earlier advice.Before discharge from hospital, patients with severe asthma should be given a personal asthma action plan by someone with expertise in asthma management. This should contain advice about recognising loss of asthma control - assessed by symptoms, peak-flow recording or both - and action to take if asthma deteriorates, including seeking emergency help, starting steroid tablets, restarting or temporarily increasing inhaled steroids as appropriate to clinical severity.

PRIMARY CARE MANAGEMENT
Primary care services delivered by clinicians trained in asthma management improve diagnosis, prescribing, education, monitoring and continuity of care.Regular structured review by health professionals with particular expertise in asthma management is recommended. Health professionals should consider using telephone consultations for routine clinical review of those with asthma. The special needs of ethnic minority groups and those with social disadvantage and communication difficulty is again stressed.

SECONDARY CARE MANAGEMENT
Those admitted into hospitals should be managed as inpatients in specialist rather than general units.People attending hospitals with acute exacerbations of asthma should be reviewed by clinicians with particular expertise in asthma management, preferably within 30 days.

INFORMATION FROM THE BRITISH THORACIC SOCIETY
The British Thoracic Society website has a wealth of information of use to health professionals dealing with patients with asthma. Log on to www.brit-thoracic.org.uk/sign/index.htm to find the following:- British guidelines on the management of asthma- Update to British guidelines on the management of asthma- Evidence tables- A series of 13 downloadable posters, covering topics such as management of acute severe asthma in A&E and general practice, diagnosis of asthma in adults and children, summary of stepwise management in adults, in children aged less than five years and aged 5-12 years, and so on.- A series of downloadable interactive case histories- Slides, management tools, audit tools and patient information.

Reasons why patients do not comply
with asthma medication regimens- Misunderstanding treatment regimens- Forgetting to take medication- Patients’ erroneous beliefs about the need for medication- Misunderstanding the condition- Denial- Embarrassment- Lack of social support- Fear of side-effects- Complex treatment regimens- Frequent dosing- Method of administrationSource: Medicines Partnership, 2003

PRACTICE IMPLICATIONS OF THE LIVING AND BREATHING STUDY
- Base asthma self-management on treating symptoms in terms of patients’ ability or lack of ability to achieve personal goals rather than using objective lung function measures- Discuss patient-defined goals as a way of raising patient expectations about asthma control- Simplify treatment regimens- Adopt a flexible, patient-centred approach to asthma management.Source: Haughney et al, 2004

Aalbers, R., Backer, V., Kava, T.T.K. et al. (2004)Adjustable maintenance dosing with budesonide/formoterol compared with fixed-dose salmeterol/fluticasone in moderate to severe asthma. Current Medical Research and Opinion 20: 2, 225-240.Asthma UK. (2004)Living on a Knife Edge. London: Asthma UK. Available at: www.asthma.org.uk/news/pdf/WAD summary.pdf (accessed June 2004).British Thoracic Society/Scottish Intercollegiate Guidelines Network. (2003)British guidelines on the management of asthma. Thorax 58: (suppl 1), S1-97. Available at: www.brit-thoracic.org.uk/; www.sign.ac.uk/(accessed 6 June 2004).British Thoracic Society/Scottish Intercollegiate Guidelines Network. (2004)2004 Update to the British guidelines on the management of asthma. Available at: www.brit-thoracic.org.uk (accessed June 2004).Das Gupta, R., Guest, J.F. (2003)Factors affecting UK primary-care costs of managing patients with asthma over 5 years. Pharmacoeconomics 21: 5, 357-369.Gibson, P.G., Coughlan, J., Wilson, A.J. et al. (1998)The effects of self-management education and regular practitioner review in adults with asthma (Cochrane Review). In: Cochrane Library, issue 3. Oxford: Update Software.Haughney, J., Barnes, G., Partridge, M., Cleland, J. (2004)The Living and Breathing Study: a study of patients’ views of asthma and its treatment. Primary Care Respiratory Journal 13: 28-35.Medicines Partnership. (2003)Project Evaluation Toolkit. London: Medicines Partnership.National Asthma Campaign. (2001)National Asthma Campaign Asthma Audit: Out in the Open. A true picture of asthma in the UK today. The Asthma Journal 6: 3 (September), special supplement.Partridge, M.R., Hill, S. (2000)On behalf of the 1998 World Asthma Meeting Education and Delivery of Care Working Group. Enhancing care for people with asthma: the role of communication, education, training and self-management. European Respiratory Journal 16: 333-348.Price, D., Ryan, D., Pearce, L., Bride, F. (1999)The AIR study: asthma in real life. The Asthma Journal 4: 74-78.Rabe, K.F., Vermeire, P.A., Soriano, J.B., Maier, W.C. (2000)Clinical management of asthma in 1999. The Asthma Insights and Realities in Europe (AIRE) study. European Respiratory Journal 16: 802-807.Smith, N.M. (2000)The Needs of People with Asthma survey and initial presentation of data. The Asthma Journal 5:133-137.
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