Barriers to managing asthma include access to appropriate care, patient adherence, distrust of the medical profession, delayed asthma diagnosis, culture, lifestyle choices and genetic discrepancies according to experts at the annual meeting of the American College of Allergy, Asthma and Immunology (ACAAI) in Seattle.
"Lack of access to high quality care contributes to disparities in asthma care, especially for vulnerable populations," said Michael B. Foggs, M.D., chief of Allergy, Asthma & Immunology, Advocate Health Centers of Advocate Health Care in Chicago. "Uninsured individuals do worse than privately insured individuals on almost 90 percent of quality measures and on all access measures."
"A combination of poor patient understanding of asthma management and inadequate physician monitoring may contribute to disparities in asthma care," he said.
African Americans, Hispanics/Latinos and uninsured are more likely to receive asthma care by a hospital provider, or in poorer facilities with irregular follow-up, and receive treatment for asthma in emergency departments. Minorities are less likely to be seen by an asthma specialist. Fewer than half were found to use NIH-recommended anti-inflammatory medication, and a majority managed symptoms with an inhaled bronchodilator medication.
Health care disparity exists for asthma care even among the insured. Among adults in managed care organizations, fewer blacks than whites reported care consistent with the 2007 NHLBI/NAEPP Asthma Guidelines.
Delays in diagnosis in asthma occur with significant frequency according to Phillip L. Lieberman, clinical professor of medicine & pediatrics at the University of Tennessee Health Science Center in Memphis. "These delays can have a deleterious effect on outcomes including causing fatalities, increasing days with symptoms, and resulting in a rapid decline in lung function. Timely diagnosis will result in appropriate treatment, which can prevent these undesirable effects," he said.
Patient Adherence
For optimal treatment outcomes, patients must be involved in all aspects of care, from defining the problem to determining therapy said Alan T. Luskin, M.D., associate professor of medicine at the University of Wisconsin in Madison.
"Half the time patients and physicians disagree on what the problem is, and two-thirds of the time patients and physicians disagree on what the goals of treatment are," said Dr. Luskin. "We must be able to assess our patient's beliefs and expectations, and consider what features of the available therapies meet their needs."
Factors limiting adherence to a patient's asthma management plan are low health literacy; financial and economic barriers; environmental factors at home; customs, cultural or religious beliefs that impact use of health care services. Non-adherence likely accounts for up to 60 percent of hospitalizations.
According to Dr. Luskin, risks for non adherence include:
- More than one medication, or more than one medication per day
- Worry about medication side effects
- Multiple asthma care givers
- Takes medication for other problems
- Worries about too much or too little medication
- Has problems using the medicine or child refuses
- Feels medication is only somewhat effective
- Has trouble getting an appointment
- Doesn't have medication in the house if needed
Comparing physician estimates of compliance with actual pharmacy refill rates, physicians identified only 21 of 43 patients whose controller medication rate was less than 50 percent prescribed.
"Patients generally only see their physician when symptoms interfere with daily life. They adapt to their disease and lower their expectations, often viewing asthma episodes as facts of life," Dr. Luskin said.
Culture and Life Style
When considering true barriers to asthma care, the role of obesity, food and smoking have a significant impact in effecting asthma outcomes said Michael S. Blaiss, M.D., clinical professor of pediatrics and medicine at the University of Tennessee Health Science Center in Memphis.
"As a group, subjects with asthma are heavier than subjects without asthma, and studies show obesity may worsen asthma control," he said.
Prospective studies have shown: (1) greater initial weight and greater weight change in adults increases the risk of development of asthma later in life; and (2) the effect of overweight and obesity in children increases the risk of development of asthma.