For Asthma, Exacerbation Control Still Leaves Chronic Care in the Dust

ROCHESTER, Minn., April 30 -- Asthma care remains focused primarily on the short-term chase of acute exacerbations rather than long-term control, researchers here said.

In a retrospective study, primary-care visits for asthma exacerbations were 2.3 times more common than planned visits for evaluation or follow-up, said Barbara P. Yawn, M.D., M.S.P.H., of Olmsted Medical Center, and colleagues.

More than 60% of office visits for asthma were exacerbation related, they reported in the April issue of Mayo Clinic Proceedings.

The study of 397 adults and children was one of the first to monitor community use of the "stepwise" approach to asthma as a chronic disease, recommended in the 2002 National Asthma Education and Prevention Program guidelines.

The findings showed that clinicians have yet to move away from the traditional emphasis on episodic asthma care, Dr. Yawn said.

"People have been talking about it for a while, but it would be a sea change for primary care physicians to really treat it as a chronic disease with regular office visits and regular adjustment of medication," Dr. Yawn said.

The retrospective record review included a random sample of 192 children ages six to 17 and 205 adults ages 18 to 40 who were treated for current or active asthma at any site of care in Olmsted County, Minn., in 2002 and 2003.

The findings:

• Acute symptoms were the cause of more than 60% of all asthma visits and 50% of all office visits in which asthma was addressed.
• 81% of patients had at least one visit for an asthma flare, attack, or exacerbation.
• 33% of patients had at least one evaluation visit.
• 47% of patients had at least one follow-up visit.
• 18% of patients visited their physician for allergy testing.
• 64% of patients had at least one change in medication change during the two-year follow-up (average one per patient per year in those who had a change, 0.75 per year for all patients).
• 52% of medication changes were made during visits for an asthma flare; 25% at evaluation visits, and 15% at follow-up visits, typically after a visit for a flare.

Since patients were predominantly seen for or after an acute exacerbation, it comes as little surprise that medication changes tended to be "step-up" rather than "step-down," the researchers said.

Among the total changes, 64% were dose increases for already prescribed drugs, and 21% were changes to a new medication higher in the National Asthma Education and Prevention Program hierarchy.

"We're treating patients as if their asthma was constantly out of control and that's not a good approach," Dr. Yawn added.

Less than 15% were documented step-down recommendations. Of these, 9% were reductions in dosage and 4% were changes to a less potent drug class. Five percent of patients had step-down changes between visits.

Step-down changes typically occurred at evaluation or follow-up visits or -- in 34 documented and likely many more undocumented cases -- by patients choosing to take a lower dose, discontinuing use, or not refilling a prescription. None were listed as temporary changes.

"If the only time asthma is the focus of care is during exacerbations, it is unlikely that step-down changes in medications as recommended by the National Asthma Education and Prevention Program will occur," Dr. Yawn and colleagues concluded, "and most step-up changes will be in response to short-term changes in symptom burden."

Furthermore, the low rate of medication changes -- once a year or less -- contrasts with clinical trials indicating symptoms can substantially change as often as weekly or monthly.

But the researchers believe that "patients are either stepping up and stepping down their asthma therapy much more frequently than recorded in the medical record or are tolerating either frequent symptoms or overtreatment."

Dr. Yawn said the findings are representative of primary-care practices across the country, although the study was limited by only moderate sample size, a lack of racial and ethnic diversity in the sample (90% of patients were white), and lack of pharmacy refill data.

Dr. Yawn said further study is needed to find ways to improve long-term management.

"The first step is always to identify the problem," she said. "Now we have to go the next step and try to solve the problem."