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Given the significant rise in US asthma prevalence across all age strata, it can be argued that this disease of inflammation is at least equally a disease of communication. Excellence in medical treatment is of no worth if the patient does not take the medication as prescribed. Clinician communication and patient education, therefore, are vital to a patient’s adherence with the clinician's recommendations. Studies consistently show that less than 50% of patients adhere to daily medication regimens. Furthermore, clinicians cannot predict better than chance which patients will be adherent. Adherence is not reliably associated with family income, parental education level, ethnicity, or race. Therefore, all patients require proper education communicated in a manner that builds self-confidence and enables adherence to the asthma treatment plan.1

TEACHING POINT 1: Asthma Diagnosis and Disease Presentation

 

Within the medical community, asthma adherence issues and “compliance” are often ascribed to patient and family failure. Yet perhaps surprisingly, the most common type of prescribed asthma medicine by doctors in the US is antibiotics.2 The responsibility of making a proper diagnosis of the oft-mislabeled asthma—well beyond the wheezy bronchitis, recurrent (touch of) pneumonia, and even reactive airway disease monikers—falls squarely within the hands of the clinician. Historically, doctors have been concerned with “labeling” a patient with chronic illness due to perceived psychosocial impact, (pre-existing condition) insurance coverage interest, and/or military school admission (i.e., The Air Force Academy, West Point, etc.). In fact, these “protective” actions often serve only to limit a patient’s understanding of symptom relevance, severity, outcome, and proper management. Further, physician adoption of asthma clinical guidelines has been sub-optimal and prompted the National Institutes of Health (NIH) to commence implementation strategies to improve clinician adherence that include communication of the proper diagnosis and its management with the patient.3,4,5

True/False: Many studies have shown that it is best that the clinician not label a patient with the asthma diagnosis unless the illness is severe.

a) True
b) False
 

TEACHING POINT 2 / Discussion: Asthma Follow-up and Disease Control

 

As important as medication selection, chronic disease follow-up is critical in maintaining disease control. With asthma in particular, this is especially true no matter the disease severity.6 In fact, symptom perception is known to lessen with advancing severity of disease. Given the lack of an adequate primary bio-measure of disease control (such as the hemoglobin A1-C measure for diabetes management), increased emphasis on quality questioning becomes paramount. With these concerns in mind, the NIH has suggested the use of validated communication strategies such as the asthma control test and asthma control questionnaire in the primary and specialty clinical care of the asthma patient. In most circumstances, these questions (and their answers) add no additional time to the clinical interview and “funnel” the conversation of doctor and patient toward the achievement of desired outcome.7

Discussion:

 

Asthma Medications

Albuterol, the principally prescribed bronchodilating rescue medicine in the US, is ubiquitous. Its use in all aspects of acute and chronic asthma and COPD care exceeds accepted controlled prescriptions by three-fold. The asthma patient, during symptomatic flares, typically trusts this medication to relieve cough, wheeze, chest tightness, or shortness of breath concerns. The reinforcement of this behavior (both psychological and institutional) make the acceptance of other therapies (despite their proven and superior efficacy and safety) less palatable, less convenient, or both. For this reason, the clinician must adopt communication techniques that can paint an accurate and telling picture for the asthma patient. The use of analogies (fire extinguisher, spare tire, etc.), pictures or models (highlighting the inflammation in the asthma lung and resultant small airway pathophysiologic changes), or video vignettes allow for better understanding, appropriate questions, and better adoption of desired management.8,9

The Asthma Road Map

The asthma management plan is a tool that can increase patient/family self-efficacy, which is especially important in an illness that has tremendous variability based upon time of day, environmental exposure, seasonality, physical activity, and other factors. What lies ahead clinically is quite often unknown to patient, family, and doctor. And while the NIH has recently incorporated risk into their disease assessment models for physician, the patient is often clueless until symptoms arise. Helpful to the patient then is a simple management plan that outlines proper steps to follow as the disease course changes. These plans are preferably easy-to-read, one-page documents that carry the specific patient-oriented recommendations of the physician. Most importantly this communication also highlights the expectation of and need for further communication (via phone or clinical visit) as asthma questions or concerns arise.10

True/False: Asthma action plans should be easy-to-read, one-page documents that carry specific patient-oriented recommendations of the physician.

a) True
b) False
 

TEACHING POINT 3: Case Presentation

 

Case Presentation

Olivia is a 9-year-old girl who is new to your practice and presents with known asthma. She has daily cough and misses 7-10 days of school per semester. Her symptoms include cough, wheeze, chest tightness, and shortness of breath. Last year, her previous family medicine physician changed her maintenance medication from oral montelukast to moderate dose dry powder inhaled (DPI) corticosteroid plus long-acting beta-agonist (LABA). She has had significant worsening of her symptoms since that time. She requires a refill of albuterol every 2-3 months. She has no nasal allergy symptoms since "allergy-proofing" the home 2 years ago.

Past Medical History: The patient has had 1 hospitalization and 2 emergency department visits in the past year. She has received a total of 5 oral steroid bursts in the past year. She has no known medication allergies. Skin testing conducted 2 years ago revealed positive reaction to dust mite and cat.

Review of Systems: Respiratory symptoms are as described above. The patient also complains of exercise-related shortness of breath, for which albuterol provides relief. She denies heartburn or sinus symptoms and denies food allergy.

Family History: Mother has a history of allergies. Father had asthma as a child. Maternal grandmother died of asthma. Paternal grandfather has chronic obstructive pulmonary disease. There is no history of cystic fibrosis.

Social History: Olivia is in third grade and a good student. Unfortunately, her grades have fallen in the past year due to heightened school absence. She likes to play soccer but has been limited by her asthma. Father is an engineer; mother is a design consultant. The family is of blended race. She has many close friends through school and Girl Scouts.

Environmental History: The patient has hardwood floors in her bedroom and blinds (drapes removed) cover the windows. The family's home is air-conditioned. Olivia's mattress and pillow are encased to reduce dust mite exposure. There are no stuffed animals in the bedroom; the forced hot air furnace filter is changed monthly. There are no smokers and no pets.

Physical Examination: Height and weight are at the 75th percentile for age. Patient is engaging and speaks in full sentences about her asthma symptoms and medications. Heart rate is 80/min (normal); respiratory rate is at 23 breaths per minute. Blood pressure is normal. Oxygen saturation is 98% in room air.

Head, Eyes, Ears, Nose, and Throat: Unremarkable. Nasal examination reveals non-boggy turbinates with pink, non-erythematous mucosa. No posterior pharyngeal mucous drainage or cobblestoning are seen.

Chest: No accessory musculature use.

Lungs: Good aeration without wheeze or crackle.

Cardiovascular: Regular rhythm and rate. Normal S1 and S2. No murmur. Peripheral pulses 2+ and symmetric.

Extremities Warm, normal capillary refill, without clubbing, cyanosis, or edema.

Skin: No rash.

How would you classify this patient’s asthma?

a) Mild intermittent
b) Mild persistent
c) Moderate persistent
d) Severe persistent
 

TEACHING POINT 4:

 

You assess her asthma as severe persistent, which has been refractory to appropriate asthma medicines. You ask and she demonstrates proper DPI device technique. You review her asthma “action plan” with her. You discuss referral to a local pediatric asthma specialist. Lastly, as you suggest increasing her controller medication therapy to include high-dose inhaled corticosteroid plus LABA, you notice both Olivia and her mother have tears in their eyes. Olivia asks her mother, "Am I going to die, too?" Upon hearing this comment, you realize that further discussion is needed.

A family's ability to follow preventive or therapeutic recommendations is based on their health beliefs. These beliefs include (1) the extent to which a patient feels susceptible to asthma; (2) the perceived seriousness to the patient's own health; (3) the personal benefits (vs. the costs) of the recommended treatment plan; and (4) the degree of confidence with which they can carry out the requested actions.

Upon further discussion with Olivia and her mother, you learn Olivia's grandmother was severely restricted by her asthma and heart disease. She died approximately a year and a half ago while using some of the same medication Olivia has been asked to take. Olivia's mother feels inhaled steroids are dangerous and she does not want Olivia to "puff up" and experience other problems as her mother did. Reading the controller medication package insert and black box warning does nothing to dispel her concern. She admits that she and Olivia feel "OK" about her asthma care as long as they have enough albuterol around. Olivia has not regularly used her controller medication since it was prescribed last year.

Some families resist accepting the diagnosis of asthma because they believe the same crippling fate of a relative may await them or their child. Others may not perceive the disease to be a threat at all (e.g., "it's like a cold"), hindering their ability to follow the treatment plan. Often, families may be too embarrassed to share these beliefs if they feel their disclosure will make them appear foolish or uneducated. In Olivia's case, you communicate via reassuring messages that she can control her asthma rather than it controlling her. You learn her grandmother's medical issues were quite different than and far exceeded the physiologic scope of Olivia's health concerns. Eliciting underlying fears about the diagnosis and/or treatment regimen may be as – if not more – important than prescribing the proper medicine. Furthermore, at each visit you set goals with Olivia, preparing her to carry out a treatment plan at home that highlights patient-centered tangible successes (beyond pulmonary function improvement). Her wishes to improve her school performance and play soccer without limitation are critical marker s of achievement to her.

Specifically, for Olivia and her mother, you discuss the safety profile of her controller medications using as few medical terms as possible. A conversation about inhaled steroid therapy (with or without combination LABAs) and how these and other medications work to keep asthma "under control" can be both useful and reassuring. Frank discussion, too, about the real and perceived risks of these medicines invites families to more openly share the concerns that limit their acceptance and implementation of the treatment plan. Opportunity for questions reinforces the family's belief that the clinician is listening and therefore has the information needed to make a good treatment decision.

Proven educational strategies can be efficiently delivered via effective communication during scheduled primary care office visits. Specific communication techniques are shown to improve long-term asthma patient outcomes without adding extra time to the office visit. Not only did Olivia's subsequent school attendance and report cards improve and her exercise abilities progress, but her pulmonary function also normalized within weeks of her office visit. Just as for this and every family affected by asthma of any severity, enhancing self-confidence is a critical component of the chronic illness patient care plan.

True/False: Discussion of risk concerns about medication-related events is an important part of the asthma clinical visit, as highlighted by the most recent NIH asthma guidelines.

a) True
b) False
 

Conclusion: Case Lessons for the Clinician

 
  1. Clinician communication and patient education are vital to a family's adherence with the clinician's recommendations.
  2. Specific communication techniques and proven educational strategies (such as those discussed in this case) can improve long-term asthma patient outcomes.
  3. Enhancing self-confidence is a critical component of the chronic illness patient care plan.

References:

 

1.  Akinbami, L. National Health Statistics Reports. Asthma Prevalence, Health Care Use, and Mortality: United States, 2005–2009. CDC National Center for Health Statistics, 2011. Available: http://www.cdc.gov/nchs/data/nhsr/nhsr032.pdf Accessed 4-2-2012

2.  Luskin A, Bukstein D, Kocevar VS, et al. Asthma rescue and allergy medication use among asthmatic children with prior allergy prescriptions who initiated asthma controller therapy. Ann Allergy Asthma Immunol. 2005 Aug;95(2):129-36.

3.  Clark NM, Gong M, Schork A, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101:831-836.

4.  National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. Available: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

5.  Cabana MD, Ebel BE, Cooper-Patrick L, et al. Barriers pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med. 2000;154:685-693.

6.  Jones CA. Controlling asthma through disease management. Manage Care. 2005 Aug;14(8 Suppl):18-24; discussion 25-7.

7.  Clark NM, Gong M, Schork MA, et al. Long-term effects of asthma education for physicians on patient satisfaction and use of health services. Eur Respir J. 2000;16:15-21.

8.  Brown R, Bratton SL, Cabana MD, et al. Physician asthma education program improves outcomes for children of low-income families. Chest. 2004;126:369-374.

9.  Clark NM, Nothwehr F, Gong M, et al. Physician-patient partnership in managing chronic illness. Acad Med. 1995;70:957-959.

10.  10. Clark N, Gong M, Schork MA, et al. A scale for assessing health care providers' teaching and communication behavior regarding asthma. Health Educ Behav. 1997;24:245-256.

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