As many as 15 million Americans (more than 5 percent of the population) have asthma. 1 More than 2,500 adults in the United States die of this condition each year. Asthma accounts for more than 500,000 acute care hospitalizations, costing more than $1.6 billion annually. 2 Optimal treatment could reduce the morbidity, mortality, and costs associated with this illness and improve the quality of life of patients and their families.
Early diagnosis, education about the disease and treatment, appropriate pharmacologic balance, and adherence to a recommended self-care regimen are important elements of treatment. Self-care regimens require patients to alter their environment and participate in long-term treatment programs that combine oral and inhaled medications taken on a routine and/or as-needed basis.
Patients are asked to attend to their health by monitoring symptoms and respiratory function, and independently altering their drug regimen or seeking the assistance of their health care provider. Clearly, the successful management of asthma depends on informed and active participation of the patients themselves.
Unfortunately, evidence suggests that fewer than 40 percent of patients with asthma adhere to a recommended therapeutic regimen. 3-5 This may account for a significant portion of the high costs associated with this disease.

Impact of Nonadherence: Personal Costs
At present, evidence indicates that, overall, the problem of nonadherence with asthma treatment is not improving.6 The consequences of nonadherence can be measured in personal and economic costs.
While decreased adherence in some patients may not compromise disease control, the consequence of nonadherence for many patients is illness exacerbation. In clinical trials, children who did not comply with therapy demonstrated significantly more wheezing, greater variability in peak flow rates, and lower asthma control scores,7 while adults whose airway obstruction failed to resolve were markedly less compliant than those who improved.8 More tragically, nonadherence has been associated with asthma-related deaths in children, particularly when psychologic dysfunction has been observed in the patient or the patient’s family.9
Growing evidence reveals that many severely asthmatic patients are dramatically noncompliant. Among those with various chronic diseases, adherence improves as disease severity increases from mild to moderate, but appears to reverse with severe illness.10 Hospitalizations and emergency department visits, it might be assumed, would dramatically boost adherence motivation because they are frequently unpleasant and costly experiences that signal to patient and caregiver that a serious health decline has occurred. Strikingly, this assumption is frequently incorrect.
Nonadherence is often high among patients who appear in the emergency department or hospital, and there is no evidence that such contacts with urgent care increase and sustain subsequent adherence.6 In a 90-day longitudinal study, eight children who required urgent care visits resulting in oral corticosteroid bursts (two of the children required subsequent hospitalization) had been dramatically less compliant with a daily regimen of inhaled cortico-steroids than a group of 16 patients with stable symptom

Impact of Nonadherence: Economic Costs
Asthma is a costly disease. The annual direct and indirect cost of asthma is estimated to be approximately $6.2 billion.12 The $3.6 billion direct medical costs include physician visits and medication, but the largest portion (almost $3 billion) results from emergency department visits and hospitalizations.12
Because only a small proportion of asthmatic patients require hospitalization, much of the cost of asthma is created by a relatively small group of patients. Approximately 5 percent of asthma patients account for more than 70 percent of the total cost of asthma.13 Many of those asthmatic patients who present at the emergency department or hospital have been there before.12
That inadequate health care behavior results in increased cost is evidenced by the finding that a few programs targeting self-management behavior achieved significant subsequent savings through reduced hospitalizations and emergency department use.14-16

Improving Adherence: What Caregivers Can Do
The fact that improving treatment adherence can lead to better asthma control has been widely addressed.17-19 Recent discussions have increasingly recognized that the cost of introducing programs to better educate asthmatic patients in self-management knowledge and skills may be offset multifold by savings realized when patients require less emergent care and fewer hospitalizations.20-22
When programmatic changes include only asthma education classes, however, increased patient knowledge often fails to translate into improved disease outcomes.23,24 The more difficult task of changing patient behavior requires greater awareness of patients’ individual perceptions of their disease and its treatment, and increased commitment from the health care provider to communicate with and teach patients.
The new Guidelines for the Diagnosis and Management of Asthma25 address more comprehensively the caregiver’s role in assessing patient perceptions, and emphasize the need for a “partnership” between caregiver and patient in order to improve treatment adherence and disease outcome.
The relationship between patient and caregiver is the single most powerful tool for changing patient health care behavior. Other attempts to improve adherence are unlikely to succeed if patients do not like and trust their physicians. Patients will not reveal concerns about their illness or reluctance about a proposed treatment if they believe that the caregiver is hurried, disinterested, or impatient. Making direct eye contact, transmitting genuine interest in what the patient has to say, explaining all recommendations thoroughly and in clear language, praising good treatment adherence and problem solving, and expressing willingness to modify the treatment plan in accord with concerns expressed by the patient all enhance adherence.10
The Guidelines for the Diagnosis and Management of Asthma 25 further recommend that caregivers themselves provide patient education at the time of diagnosis; that they repeatedly reinforce the patient’s knowledge and skills; that they give the patient a written, individualized treatment plan; and that they remain sensitive and responsive to patient cultural and language differences.

Role of the RT and the Value of Patient Education
The respiratory therapist is in a unique position to better educate asthma patients about their disease and its management. Education of asthma patients usually leads to better control of the disease, fewer visits to physicians, fewer hospital and emergency department admissions, and fewer days lost from work. 26-28 The use of medication, particularly inhaled corticosteroids, often increases.29 Quality of life improves, and the resultant cost-benefit balance is usually favorable.30
Simply handing out brochures is inadequate, because a substantial number of people are functionally illiterate and can only comprehend text at or below a seventh-grade level. As a result, numerous pamphlets on asthma are beyond the reading skills and comprehension of many in their target audience. The most effective teaching is done in small groups, utilizing verbal presentations, videos, and even electronic multimedia presentations.31 The latter method appeals to all patients, whether they are visual, auditory, or kinesthetic learners. It also results in improved understanding and retention of the information.29
Specific areas of education should include explanation of the illness and the rationale for the use of medication for its treatment and prevention; proper utilization of a metered-dose inhaler (MDI) and spacers; self-assessment of peak flow rates; and the development of plans of action in anticipation of asthma flares. Improved management of asthma will occur only if changes in airflow are recognized early and combined with self-management action plans. Children’s knowledge about asthma can also influence behavior, and education programs designed specifically for children may improve asthma management.32
John D. Zoidis, MD, is a contributing writer for RT.
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