Am Fam Physician. 2000 Apr 15;61(8):2328-2330.
Asthma is a serious chronic inflammatory airway disease affecting more than 15 million Americans, one third of whom are children. If managed appropriately, hospitalization is rare, yet over 40 percent of costs are related to emergency services and hospitalizations that result from the failure to effectively use preventive treatment. Studies have found that patients who follow the recommended management program tend to do well clinically; however, objective measures show that fewer than 50 percent of patients with asthma take their inhaled medication as prescribed.1
Growing evidence reveals that many patients with severe asthma do not adhere to their treatment. Across various chronic diseases, including asthma, adherence improves as disease severity increases from mild to moderate but appears to reverse with severe illness.2 We would expect that patients would find emergency department visits and hospitalizations to be unpleasant and costly, and therefore they would improve their adherence; this assumption is often incorrect. Nonadherence is often high among patients who receive their treatment for asthma in the emergency department or hospital. There are no studies in patients with asthma to show that urgent care services increase or sustain subsequent adherence to management programs.
Given this significant problem with nonadherence to recommended asthma management, what can physicians do to improve asthma control for their patients? How do physicians change patients' behavior so they assume responsibility for their disease management?
It used to be called “bedside manner.” It was a term that everyone understood as the warm, reassuring, interpersonal style of good physicians. At the core of the concept was an unstated value: the relationship between physician and patient. The patient and the family knew, liked and trusted the physician, and this bond motivated adherence. This relationship was and still is the single most powerful tool for changing patient health care behavior.
Any attempts to improve adherence are unlikely to succeed if the patient does not like and trust the doctor. Patients will not reveal concerns about their asthma or any other illness if they believe that their doctor is hurried, disinterested or impatient. Adherence is enhanced by making direct eye contact, transmitting genuine interest in what the patient has to say, explaining all recommendations thoroughly and in a language understood by the patient, praising treatment adherence and problem solving, and expressing willingness to modify the treatment plan in accordance with concerns expressed by the patient.3
The central focus of a successful asthma management plan is a “partnership in care,”4 which should begin at the time of diagnosis and is continuously integrated into every step of asthma therapy. Once this relationship is established, other adherence improving changes may be negotiated, including prescribing medications that are less costly or that do not have side effects of concern to the patient or family.
The 1997 National Heart, Lung, and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma4 recommends that the primary physician give the patient a written, individualized treatment plan and indicates that this management plan, as well as all other educational efforts, remain sensitive to the patient's language and cultural differences. When the physician takes the time to provide an individualized, daily self-management plan as part of the overall educational effort for the patient and his or her family, it sends a powerful message about the importance of being knowledgeable in self-management of asthma.
The article by Mellins and colleagues5 in this issue of American Family Physician represents a pharmacologically derived long-term treatment plan for children with asthma. The authors believe that it can also be effective in adults. The chart system described provides the framework for adjusting medications based on changing clinical conditions. Their self-management plan includes recommendations to improve adherence in the management of children with asthma within the framework of a continuous educational effort by the primary physician responsible for the patient's care.
In April 1999, a combined effort of the NHLBI and its European counterpart developed a science base committee to review the world asthma research literature. Using a systematic, evidence-based methodology through the Agency for Healthcare Research and Quality (formerly called the Agency for Health Care Policy and Research) and its 12 evidence-based practice centers, key questions have been identified. One of the questions to be answered through this rigorous process is “What is the evidence that written asthma management plans (either daily asthma management plans or action plans to handle exacerbations) improve patient outcomes?” It is anticipated that a draft report will be available by the middle of this year.
Stuart W. Stoloff, M.D., has a private practice in Carson City, Nev. Dr. Stoloff is also a clinical associate professor of family medicine at the University of Nevada School of Medicine, Reno.
Address correspondence to Stuart W. Stoloff, M.D., 1200 N. Mountain St., Ste. 220, Carson City, NV 89703.
1. Rand CS, Wise RA, Nides M, Simmons MS, Bleecker ER, Kusek JW, et al. Metered-dose inhaler adherence in a clinical trial. Am Rev Respir Dis. 1992;146:1559–64.
2. Bender B, Milgrom H, Rand CS. Nonadherence in asthmatic patients: is there a solution to the problem? Ann Allergy Asthma Immunol. 1997;79:177–86.
3. Stoloff SW, Janson S. Providing asthma education in primary care practice. Am Fam Physician. 1997;56:117–26142.
4. National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute) Guidelines for the diagnosis and management of asthma: expert panel report 2 Bethesda Md: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, 1997. Publication no 97-4051.
5. Mellins RB, Evans D, Clark N, Zimmerman B, Wiesemann S. Developing and communicating a long-term treatment plan for asthma in the primary care setting. Am Fam Physician. 2000;61:2419–28.
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