Expert Interview: The Challenge of Asthma Management in Primary Care

By some estimates, nearly two-thirds (60%) of asthma care is provided at the primary care level. Some evidence suggests, however, that care for asthma in these settings is not always in step with recommendations in published guidelines.

Patient Care Online recently spoke with 2 asthma experts for perspective on the challenges primary care clinicians face in the day-to-day management of asthma patients. Drs Michelle Cloutier and Lara Akinbami offer insights and also suggest ways the burden of chronic care management could be lessened.

Michelle M Cloutier, MD, is Professor Emerita of Pediatrics and Medicine at the University of Connecticut School of Medicine and Director of the Asthma Center at Connecticut Children's Medical Center, in Storrs, CT. For 35 years she has been an NIH-funded researcher.

Capt Lara Akinbami, MD, is a medical officer and epidemiologist at the National Center for Health Statistics of the Centers for Disease Control and Prevention and a clinical pediatrician at the Walter Reed National Military Medical Center.

The following transcript has been edited lightly for clarity.

Patient Care Online: So, primary care clinicians are an increasingly overburdened practice group. They're often caring for patients from cradle to grave and are sometimes the initial and often the ongoing care provider for multiple chronic conditions. How are they particularly challenged when juggling asthma patients in this mix, who are often fairly complex themselves?

Michelle Cloutier, MD: Well, I think you hit the nail on the head, Grace, when talk about the overburdening of primary care clinicians. The last time I checked, pediatricians had more than 85 guidelines that they needed to adhere to, in their day to day care management. I've not looked at that statistic for internists, but I would imagine that they have also a very large number. And the problem, I think, is that we, now referring to the subspecialty community, have not sufficiently refined the really important aspects of chronic care management, for clinicians. I think we've put it sort of all out there. And I think that while that works very well, for specialists, I mean, you know, I manage asthma, and that's all I manage. So, I hope I'm good at it. But, really, I didn't have all these other things that I also had to deal with.

So, I think what, what we as a specialty community need to do is 1) identify those aspects of care, that are really the core aspects of care for primary care clinicians. And 2) we need to suggest ways in which they can they can use those core elements and add to them, maybe other things that add small increments or small improvements in care.

PCO: Dr Akinbami, would you like to add to that?

Lara Akinbami, MD: As a primary care pediatrician, also, I, I feel the what Michelle was talking about kind of the overwhelming pressure to adhere to these many things, and really just be the point of responsibility for all things for all your patients. And it can be overwhelming. But I think there's also the variation that has to be recognized, as a great deal of how well clinicians can adhere to any set of recommendations has to do with the settings in which they find themselves. And so, having said that, I still think that the evidence-based strategy that's been used to make the guidelines can be an inspiration to clinicians to be advocates for the asthma-friendly changes in their practices and communities that are needed.

But one of the biggest challenges I think, that are facing providers is time, so time to spend educating patients and their caregivers, or talking to school nurses and teachers or to specialists to coordinate care, or even negotiating with insurance providers to get access to needed medications. There's just so many demands that are needed. But I think there's also hopefully a movement to recognize the need for additional team members, that physicians don't have to do it alone. So there's community health care workers, patient educators, patient advocates, people can share the load and gather information from patients and their families on their own turf. So team approach can be a game changer, especially in the wider environment where things may seem too formidable to change alone, or to even just engage. So, there's tools that can be used by teams and providers, some of those are in this example on the CDC website. So, if you go under asthma and look for under health care professional, there's some tools there. One of them is called EXHALE. I think you can just Google that too, if navigating the website is too difficult. It's a technical package and EXHALE stands for:

• Education on self management
• EXtinguishing tobacco smoke exposure
• Home visits for asthma trigger reduction
• Achievement of guideline based management
• Linkage and coordination of care across settings
• Environmental policies to reduce asthma triggers

And that does sound overwhelming. But again, if you take it as part of a team approach, it may be more digestible and achievable. I think the other part where we don't quite recognize the full burden that we place on providers is that not only do they have to motivate themselves to do that big chunk of stuff I just talked about, but they also have to motivate their patients and families. So asthma is a chronic disease, which means that there's just a continuous level of effort and attention that you need to control it, which can be tiring, everybody, and that's just the reality of chronic disease management. So we're asking the physicians not only to adhere to the guidance, but to motivate their patients and families to do as well. And it's a tough job. So I think, again, we need to be creative and figure out how do we get continued high quality as a standard of asthma care in balancing all these demands.