Delivering asthma education to special high risk groups

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Abstract

Patients at high risk from their asthma and therefore worthy of more focused asthma education are those at risk of fatal and near fatal asthma(NFA). In recent years the characteristics of these patients have been better defined. The most important risk factor appears to be a prior history of NFA. Other important features include prior emergency room visits or hospitalization for asthma. Excess use of beta-agonists, especially in the absence of inhaled corticosteroids, also confers increased risk. High risk groups also share similar psychosocial barriers as well as economic deprivation. The benefits of asthma education in these groups have been assessed in a number of studies. In general, asthma education has been shown to have an impact on these patients. Greater effects have been achieved where there has been consistent follow-up by the same physician. Patients require frequent reinforcement of their asthma management, especially regarding their response to acute exacerbations. A sub-group of patients with more severe asthma appear to have a problem perceiving dyspnoea and may therefore benefit from peak flow monitoring but the problem of compliance with this intervention is significant. Behaviour modification plays an important role as does ensuring the patient has adequate resources to purchase medications especially the more expensive anti-inflammatory therapy. Future studies should focus on optimizing the potential benefits of educating high risk patients as they are not only those at greatest risk of death but also consume a disproportionate amount of health care resources.

Introduction

In recent years there has been concern regarding rising rates of asthma [1]and in addition asthma mortality [2]and near fatal asthma(NFA) [3]. Although rates of asthma mortality are declining in many Western countries 4, 5much still needs to be done. Along with the changing epidemiology of asthma the role of inflammation in the pathogenesis of asthma has been recognized and has focused our attention on the therapeutic importance of anti-inflammatory therapy [6]. Recent evidence based asthma guidelines have highlighted the importance of such therapy [7].

A better awareness of the chronic nature of asthma has also led to greater emphasis on the role of asthma education in its management [8]. In this article we will outline the characteristics of those at increased risk from their asthma i.e. those who have risk factors for NFA and fatal asthma; outline the barriers to the delivery of asthma education to such groups and finally review studies that have targeted these groups. We outlined future research needs in this area.

Section snippets

High risk groups

Characteristics of patients at high risk of asthma morbidity and mortality are outlined in Table 1. The single greatest risk factor for NFA is a prior history of intubation [9]. In a prospective study we have shown that patients with such a history have a twenty seven times higher risk of NFA than hospitalized controls [9]. Similarly a prior history of hospitalization or visit to the emergency room in the prior twelve months has been associated with an increased risk of fatal asthma [10]. In a

Delivering asthma education

Intuitively the delivery of an effective educational and therapeutic intervention to a high risk group should be more cost-effective than offering similar programs to less severe asthmatics. The objective is to reduce severe attacks that may be fatal or require hospitalization, subsequently improving quality of life and decreasing the utilization of the more expensive hospital based asthma resources. A 1992 study estimated that direct and indirect health care costs for asthma in the United

Future directions

In this brief review we have identified patients at increased risk from their asthma and by definition patients who should be candidates for focused asthma education. There is a need for further research into improving the delivery of asthma education to these high risk patients (Table 5). In addition, their management will only become optimal if the physicians and allied health care workers caring for them provide an integrated approach based on evidenced based principles [52]. Although

References (55)

  • T.V. Hartert et al.

    Inadequate outpatient medical therapy for asthma patients admitted to two urban hospitals

    Am J Med

    (1996)
  • M.R. Sears

    Epidemiologic trends in asthma

    Can Respir J

    (1996)
  • J.M. FitzGerald et al.

    Fatal asthma

    Annu Rev Med

    (1996)
  • J.M. FitzGerald et al.

    Proceedings of a workshop on near fatal asthma

    Can Respir J

    (1995)
  • M.J. Campbell et al.

    Age specific trends in asthma mortality in England and Wales, 1983–95: results of an observational study

    Br Med J

    (1997)
  • J. Garrett et al.

    Major reduction in asthma morbidity and continued reduction in asthma mortality in New Zealand: what lessons have we learned?

    Thorax

    (1995)
  • FitzGerald JM, editor. Report of the working groups for the Canadian Consensus Conference. Can Respir J...
  • P. Ernst et al.

    Canadian Asthma Guidelines. Report from a consensus workshop

    Can Respir J

    (1996)
  • L.P. Boulet et al.

    Asthma education

    Chest

    (1995)
  • M.O. Turner et al.

    A prospective study of risk factors for near fatal asthma (NFA)

    Am J Respir Crit Care Med

    (1994)
  • H. Rea et al.

    A case control study of deaths from asthma

    Thorax

    (1986)
  • W.O. Spitzer et al.

    The use of B-agonists and the risk of sudden death and near death from asthma

    New Engl J Med

    (1992)
  • S. Suissa et al.

    Patterns of increasing beta-agonist use and risk of fatal and near fatal asthma

    Eur Respir J

    (1994)
  • J.E. Garrett et al.

    Risk of severe life-threatening asthma (SLTA) and type of prescribed beta-agonist: an example of confounding by severity

    Aust New Zealand J Med

    (1994)
  • P. Ernst et al.

    Risk of fatal and near-fatal asthma in relation to inhaled corticosteroid use

    J Am Med Assoc

    (1992)
  • W. Carr et al.

    Variations in asthma hospitalizations and deaths in New York City

    Am J Public Health

    (1994)
  • G.M.F. Gardens et al.

    Psychiatric and social aspects of brittle asthma

    Thorax

    (1993)
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