AAAAI plans seminars on using asthma guidelines
AAAAI plans seminars on using asthma guidelines
The American Academy of Allergy, Asthma and Immunology (AAAAI) announced in March that it will join forces with nine other groups to teach physicians how to use treatment guidelines published by the National Heart, Lung and Blood Institute (NHLBI).
AAAAI officials say the program is designed to improve the way primary care physicians and other providers diagnose and manage their patients with asthma, by promoting adoption of the recently published 52-page Practical Guide for the Diagnosis and Management of Asthma. The Practical Guide is intended to be a user-friendly version of the NHLBI’s lengthier 1997 Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma.
Increasing awareness
Trouble is, many providers aren’t using them.
"The core guidelines currently exist, but we know many physicians don’t reference them," says William Busse, MD, president-elect of the AAAAI and a chairman of the advisory committee overseeing the campaign. "This initiative will increase awareness and use of the guidelines, and promote better patient care for asthma."
For instance, the 1997 guideline report underscores the need to treat asthma as a chronic illness that requires ongoing medication and monitoring. Most providers, however, don’t use the guidelines because they continue to treat asthma as an episodic illness.
"They have all seen the guidelines; I don’t think that’s the issue. Asthma still isn’t appreciated as a chronic disease," says Busse, who also is professor of medicine and head of allergy and immunology at the University of Wisconsin School of Medicine in Madison.
Busse says the guidelines also help doctors get their patients to think about how asthma affects their everyday lives. Because they often become accustomed to a style of life that is not normal, many people don’t realize the quality of their lives can be improved. Patients tell their doctors they are feeling well, but if the caregiver learns to push a bit, the physician may find patients aren’t living normally and their lung function remains a problem.
The guidelines also strongly recommend using anti-inflammatory drugs for long-term control. These medications should be started early in asthma treatment. But corticosteroids remain under-used, even though the report calls them the most potent and consistently effective long-term control medication for asthma. Despite that, Busse says, "It’s not clear prescription habits have changed widely."
There’s a reluctance to use long-term corticosteroids in the United States even though this approach is more accepted in other countries that have used and studied them longer.
"They don’t have the phobia of steroids we have," says Colleen Lum Lung, RN, MSN, CPNP, who runs Health Care Innovations, a Denver-based asthma education business.
Generalists main guideline target
Primary care clinicians will be the major focus of the education campaign because they see patients earlier in the development of the disease and are in a better position to diagnose the condition and follow up with the right treatment plan.
Lung, who is vice chairman of the AAAAI advisory committee running the education campaign, says she hopes the program will help doctors accept the guidelines.
Providers may be reluctant to stick an asthma "label" on patients, she says, especially younger ones who may "grow out of it." Instead, doctors may diagnose patients with pneumonia, for instance, and treat them with rounds of antibiotics rather than try bronchodilator medications to see if symptoms improve.
Doctors also may be concerned that following the guidelines will cause a rise in the costs to treat asthma. The authors of the guidelines counter this concern, however, by noting the recommendations actually will cut costs in the long term. Although some costs will rise due to patients getting more doctor visits, equipment, and medication to control their disease, they will miss fewer days of work or school and require fewer hospitalizations and emergency department visits.
Now the AAAAI group is faced with how to get the message out. Reaching busy medical professionals is no easy feat.
"It’s not clear what the most effective way to do this is," Busse says. "There have been a lot of attempts to do this and they haven’t been particularly successful."
But the effort has a range of professional groups on board that can promote the guidelines to their members. Along with the AAAAI, other groups involved in the campaign include:
• American Academy of Family Physicians;
• American Academy of Pediatrics;
• American College of Allergy, Asthma and Immunology;
• American College of Physicians/American Society of Internal Medicine;
• American College of Clinical Pharmacy;
• American Pharmaceutical Association;
• American Society of Health Systems Pharmacists;
• American Thoracic Association;
• National Heart, Lung and Blood Institute.
The group plans to use case studies at interactive seminars as one way to reach primary care workers already inundated with information about the range of conditions they treat.
"Primary care physicians don’t only treat asthma," Lung says. "They have a lot of information to keep up with on a daily basis. They really have to be jacks of all trades."
The education campaign will focus on producing national education seminars for primary care physicians, coordinate formal training sessions for seminar presenters, create and disseminate education materials, and develop Internet resources for health care providers. It’s funded by an unrestricted grant from Glaxo Wellcome. The curriculum for the national education seminars, "Practical Approaches to Asthma Using Case Studies," is being finalized.
Seminars will cover current diagnosis, therapeutics and self-care practices such as peak flow meters, use of anti-inflammatory and bronchodilator therapies, proper role of environmental control measures, steroid phobia, patient education, compliance, and management.
The two-hour, interactive seminars will be held in 1999 and 2000 and will feature case studies aimed at audiences of primary care physicians and other primary care professionals, including physician assistants, nurse practitioners, educators, and pharmacists.
The training session is scheduled for spring 1999, with a pilot seminar to be held in June, perhaps in Chicago, Denver or Las Vegas. After the pilot seminar is fine-tuned, the national seminar series will begin in fall 1999. Internet resources will be developed throughout the year.
The effort also includes trying to get patients to read the Practical Guide so they understand the importance of ongoing therapy, avoiding triggers, and complying with medications.
History of the guidelines
Development of the asthma guidelines began in 1989, when the NHLBI and the National Asthma Education Program (NAEP) convened their first panel of experts. The goal was to describe the appropriate use of therapies in managing asthma based on current science.
In 1991, under the auspices of the NAEPP, the first guidelines were published in the Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma.
This report outlined four components of effective asthma management:
• use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy;
• environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or cause exacerbations;
• comprehensive pharmacological therapy for long-term management, designed to reverse and prevent the airway inflammation characteristic of asthma, as well as pharmacological therapy to manage exacerbations;
• patient education that fosters a partnership among the patient, the family, and clinicians.
The NHLBI funded the development of a new report in 1991. It convened a second group of 22 volunteer experts including health professionals in general medicine, family practice, pediatrics, emergency medicine, allergy, pulmonary medicine, nursing, pharmacy, and health education. Representatives from several federal agencies also participated.
The group reviewed more than 5,000 abstracts of all relevant literature on asthma in human subjects published in English between 1991 and 1995.
In July 1997, this group released the Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. It’s divided into four components:
• Measures of Assessment and Monitoring;
• Control of Factors Contributing to Asthma Severity;
• Pharmacologic Therapy;
• Education for a Partnership in Asthma Care.
[The 1997 guidelines are available on-line at www.nhlbisupport.com/asthma/guides.html. Photocopies are available for $20 from the National Heart, Lung and Blood Institute Information Center, P.O. Box 30105, Bethesda, MD 20824-0105.
The Practical Guide is not yet available on-line but should be this fall. It is available for $5 at (301) 251-1222.]
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