This site is intended for health professionals only

Patient-focused education for asthma control

Medication adherence among patients with chronic diseases is generally poor, but in asthma adherence rates are particularly problematic, ranging from 30% to 70%.(1) Over five million people in the UK are currently receiving treatment for asthma, according to Asthma UK, and the UK has one of the highest rates of asthma in the world. Asthma UK also reports a significant increase in the number of British adults with asthma in recent years.(2)
A predicted further increase in prevalence represents yet more challenges for the healthcare system, especially as evidence suggests there is still a long way to go before most patients achieve asthma control. New unpublished data, presented for the first time at the European Respiratory Society (ERS) Congress in September 2006, suggests that physician-patient communication gaps and asthma medication side-effects are having a severe impact on patient adherence.

Grey areas of education
Unpublished findings from the Global Asthma Physician and Patient (GAPP) Survey - the first-ever global quantitative 16-country survey designed to uncover asthma attitudes and treatment practices among physicians and patients - reveal that there are wide discrepancies when it comes to education.(3) In each of the 10 European countries surveyed, patients and physicians reported very different accounts of the amount of time spent on education during office visits.
Adult patients in Europe reported that 79% of their physicians did not discuss maintaining a symptom diary, 50% did not develop a plan for treating their asthma, and 31% spent no time discussing proper inhaler techniques.(3) Yet most physicians claimed that they do have these conversations, with 97% saying they discussed proper inhaler techniques and 76% claiming they discussed a plan for treating asthma. Nearly three-quarters of physicians said they initiate discussions about asthma medication side-effects, but only 62% of patients reported this conversation.
The GAPP research suggests that there is a link between education - or at least perceived education - and adherence. Patients who say they always take their treatment as prescribed report that double the time (28%) was spent on education during their typical surgery visit, compared with patients who adhere to the treatment regimen half or less of the time (only 14%). Worryingly, it appeared that many patients had a very limited understanding of asthma management and treatment - more than half of patients questioned did not know that asthma attacks can be fatal in mild asthma.
"With education and support, patients can control their condition and improve health outcomes. The use of personal asthma action plans has been demonstrated to improve a wide range of health outcomes for people with asthma, which implicitly suggests improved concordance. The patient should be at the centre of the process and working in partnership with the healthcare professional," comments Martin Dockrell, Asthma UK's assistant director of policy and public affairs.

Less discussion in the UK
It also appears that the UK lags behind other countries when it comes to education. GAPP survey data show that, compared with global findings, adult asthma patients and healthcare providers discuss asthma management less frequently in the UK. Over 40% of patients reported that no time was spent on education during visits, while all physicians and nurses said that at least part of every visit was spent on education. Only 45% of patients said they discussed treatment plans, and just 18% said they discussed keeping a daily symptom/medication diary.(4)
David Price, professor of primary care respiratory medicine at the University of Aberdeen, was not entirely surprised by these findings: "Patients in the UK going to asthma clinics receive a full service and generally get a very good education. But that is only about a third of patients. For the rest, it can be very difficult to fit in this level of education during a seven-minute consultation. Countries that do not have asthma clinics are probably more used to consistently discussing asthma management during routine consultations, and so it is often done that bit better."

Medication side-effect impact
Side-effects from medication constitute another key reason for nonadherence and patients' decisions to change medication. Other GAPP data suggest that side-effects cause patients to switch or consider switching medications (41%/42%), skip/consider skipping doses (31%/36%), stop/consider stopping medications (21%/29%) or change dosage (39%).(5)
Of those patients who switched or discontinued treatment, 19% did so because they experienced side- effects and 17% because of the concern for potential side-effects. In the UK, 39% of patients said they were unaware of the potential short-term side-effects of inhaled corticosteroids and 49% were unaware of the long-term side-effects.(4)
"Side-effects - and fear of side-effects - are key reasons why people do not take their therapy," says Professor Price. "Convenience, or the obtrusiveness of the therapy is also important. People often do not like having to take something three times a day, and local side-effects from inhalers are very common."
Again, there may be patient-healthcare provider discrepancies when it comes to the actual burden of different side-effects. Respiratory nurse consultant Jane Scullion, from the University of Aberdeen, believes that healthcare professionals may sometimes overlook the side-effects that are most important to patients. "Patients worry about the long-term side-effects of their medication and oral thrush may be very problematic for them - yet this is something we tend to gloss over," she says.

Patients' perceptions
Although GAPP is the first-ever major global survey involving patients and healthcare providers, a number of other studies have attempted to explain many asthma patients' nonadherence to treatment.(6-8) One such study found that the "necessity/concerns framework" is a valuable guide in understanding patients' evaluations of the accepted standard - inhaled corticosteroid therapy (ICS).(9) About one-third of patients had major concerns about the adverse effects of ICS, and those with the greatest had the highest rates of nonadherence with their treatment regimen.
This study supports the finding that patients evaluate advice about treatment according to their own understanding of the disease.(1)
These perceptions may be vastly different from the reality, or those views held by healthcare professionals. The Asthma in Real Life (AIR) study was set up to assess the perceptions of patients with asthma and those of GPs and nurses.(10) It found that 79% of patients considered their asthma to be well or completely controlled, yet it was discovered that many patients experience significant symptoms. These symptoms were inadequately acknowledged not only by the patients themselves, but also by the healthcare professionals.
The AIR study found also that patients most commonly focused on their inability to take part in various activities, while doctors and nurses used a medical model and focused on signs and symptoms.

Patient focus
Getting to the core of what information patients need and addressing their individual concerns is key in enhancing education and thus improving adherence. Professor Price says: "If we only talk to patients about peak flow technique, inhaler technique and nighttime waking, then we are missing the plot. There are standard lists to go through, but we need to find out the patient's agenda. What are the breathing problems for that patient, and which symptoms does he or she want to improve?"
All healthcare professionals - and not just prescribers - can help to ensure that patients have a sound understanding of their asthma medication. The UK GAPP data suggested that nurses take a leading role in treating asthma patients and they spent more time on patient education than physicians. Nearly one-third (30%) of nurses said that they spend more than half of the consultation on education, compared with 10% of physicians.(4) Altering the structure of the consultation could have a significant impact: it has been shown that consultations which involve patients in planning their disease management improve outcome and do not need to be long.(11)
Ms Scullion says: "We need to remember that it's the patient's disease and not ours. We have to turn around the consultation so that it is focused on patients' views and what they want to know. We should also avoid using medical terminology."
Using appropriate media - including DVDs, pamphlets and the internet - could also support education. "We need to look at new ways and new technologies to reach people," says Ms Scullion. "It has been suggested that telephone reviews may be effective, or even texting could have a role."
"Asthma has gone forward a lot during the last 30 years and we are doing something right because we have made an impact on asthma-related deaths. But perhaps we are not making as big an impact on day-to-day symptoms as we could. Only some patients are getting the support that they need and we must extend this to all patients."

Conclusion
Data from the GAPP survey highlights variations in  education in patient asthma care. Key implications for practice are:

  • Patients are not gaining a thorough understanding of their disease and their medication, despite healthcare professionals' efforts.
  • Side-effects often cause problems and are not always identified. These should be discussed and the medication changed if necessary.
  • There is a correlation between education and adherence to a medication regimen. All healthcare professionals can help to improve medication concordance.

References

  1. Horne R. Compliance, adherence and concordance: implications for asthma. Chest 2006;130:65-72.
  2. Asthma UK. Where do we stand? Asthma in the UK today. Available from http://www.asthma.org.uk/document.rm?id=92
  3. Dahl R, Kaliner MA, Canonica W, et al. Global Asthma Physician  Patient (GAPP) survey: lack of communication between adult patients physicians in Europe may influence compliance. Presented at the 16th Annual European Respiratory Congress, Munich: 2-6 September 2006.
  4. Baena-Cagnani C, Blaiss MS, Canonica W, et al. Global Asthma Physician Patient (GAPP) survey: patient education and physician - patient communication - UK findings. Presented at the British Thoracic Society Congress Winter Meeting, London: 7-9 December 2005.
  5. Canonica W, Dahl R, Kaliner MA, Valovirta EJ. Global Asthma Physician  Patient (GAPP) survey: satisfaction with current asthma medications in Europe. Adult findings. Presented at the 16th Annual European Respiratory Congress, Munich: 2-6 September 2006.
  6. Rubin, BK. What does it mean when a patient says "My asthma medication is not working?" Chest 2004;126:972-81.
  7. Clark N, Jones P, Keller S, Vermeire P. Patient factors and compliance with asthma therapy. Respir Med 1999;93:856-62.
  8. Gillissen A. Managing asthma in the real world. Int J Clin Pract 2004;58:592-603.    
  9. Horne R, Weinman J. Self regulation and self management in asthma: exploring the role of illness perceptions and treatment beliefs in explaining non-adherence to preventer medication. Psychol Health 2002;17(1):17-32.
  10. Price D, Ryan D, Pearce L, Bride F. The AIR study: asthma in real life. Asthma J 1999;4:74-8.
  11. Jenkins L, Britten N, Barber N, Bradley CP, Stevenson FA. Consultations do not have to be longer. BMJ 2002;325:388.