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Can Fam Physician
Vol. 53, No. 4, April 2007, pp.672 - 677
Copyright © 2007 by The College of Family Physicians of Canada
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Research

Asthma control in Canada

No improvement since we last looked in 1999

R. Andrew McIvor, MD MSc FRCPC
Professor of Medicine at McMaster University and a Respirologist in the Firestone Institute for Respiratory Health at St Joseph’s Healthcare in Hamilton, Ont

Louis-Philippe Boulet, MD FRCPC
Professor of Medicine at Laval University and a Respirologist in the Institut de cardiologie et de pneumologie de l’Université Laval at the Hôpital Laval in Quebec city, Que

J. Mark FitzGerald, MB FRCPI FRCPC
Professor of Medicine at the University of British Columbia in Vancouver and Director of the Centre for Clinical Epidemiology and Evaluation at the Vancouver Health Sciences Centre

Sabrina Zimmerman
Product Manager at AstraZeneca Canada Inc in Mississauga, Ont, when this study was conducted

Kenneth R. Chapman, MD FACP FRCPC
Professor of Medicine at the University of Toronto and Director of the Asthma and Airway Centre in the University Health Network–Toronto Western Hospital in Ontario

Correspondence to: Dr Andrew McIvor, Room T2127, Firestone Institute for Respiratory Health, St Joseph’s Healthcare, 50 Charlton Ave E, Hamilton, ON L8N 4A6; telephone 905 522–1155, extension 4330; fax 905 521–6183; e-mail amcivor{at}stjosham.on.ca

Studies conducted in Canada,1,2 the United States,3 Europe,4 and the Asia-Pacific area5 suggest that asthma is not well enough controlled around the world. This situation exists despite the availability of effective medications and several national, evidence-based asthma treatment guidelines,6–8 including versions published during the past 15 years in Canada.9–13

To improve the situation, a Quebec group proposed a model of automatic referral to asthma education centres for patients who came to emergency departments for acute asthma.14 This model significantly increased the number of patients who could benefit from educational intervention. In a British Columbia study,15 a health coordinator made follow-up appointments with patients’ family physicians after these patients had been to emergency departments for asthma. This strategy resulted in significantly more follow-up office visits, produced more written action plans, and improved quality of life for patients 6 months after the intervention compared with patients who received usual care. Because increased use of guidelines might improve asthma care, efforts to disseminate Canadian guidelines were stepped up with the 2001 update.12 Dissemination strategies included mailing the guidelines to physicians and maintaining a website that had the guidelines, information for patients, and other downloads.16

Our survey, The Reality of Asthma Control (TRAC),17 was designed to update 2 earlier Canadian surveys of patients1,2 to see whether new medications and guideline-implementation strategies had had any effect. It was also designed to enrol a larger patient sample than either of the previous studies,1,2 and unlike the survey conducted in 1999,2 it enrolled only adults. The null hypothesis was that the degree of asthma control had not changed in the last years despite efforts to improve care. This article reports on our findings regarding asthma control, knowledge about asthma, and use of health care resources when asthma worsens.


   METHODS
TOP
 METHODS
RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgments
 References
 
Patient telephone survey
An independent consumer-research company (ICOM Information & Communications Inc, Toronto, Ont) provided the national patient sample frame. In April 2004, trained survey staff from Environics Research Group in Toronto telephoned 26 210 Canadian households that contained at least 1 person with asthma. Patients eligible for inclusion were 18 to 54 years old, had been diagnosed with asthma by a physician at least 6 months previously, did not have chronic obstructive pulmonary disease, and had a smoking history of fewer than 20 pack-years. Identification of cases that met these inclusion criteria depended solely on patients’ self-reports. At least 5 telephone calls were made to a household before it was classified as "no answer." When a household had more than 1 qualified person, the subject was chosen according to the most recent birthday method. Interviews were allocated according to flexible regional quotas, which were raised in the field to increase the number of completed surveys in regions with smaller populations. A companion paper provides additional details on sample-size determination and regional quotas.17

We developed a telephone survey questionnaire, which took about 35 minutes to complete, in conjunction with the research company. The patient survey was pretested on 14 patients and was further refined after the completion of 89 interviews. There was no further measurement of the survey’s validity and reliability.

Physician survey
In May 2004, the research company sent letters of invitation to a random sample of family physicians and general practitioners. The sample was taken from a list of 4363 physicians who had previously identified themselves as physicians treating adults with asthma. Physicians were excluded from the sample if they had reported that more than 90% of their patients were younger than 18 years. The letter invited physicians to complete the survey by telephone but, due to the low response rate, questionnaires were mailed out in 3 waves during July, and completed questionnaires were accepted until August 31. This survey took about 25 minutes to complete and did not undergo pilot testing or measurement of its validity and reliability.

Definitions
Patients were classified as having controlled or uncontrolled asthma according to their answers to specific questions about the 6 symptom-based criteria of control outlined in the Canadian Asthma Consensus Guidelines.11–13 The guidelines specify good control as daytime symptoms fewer than 4 times a week, nighttime symptoms less than 1 night a week, no limitations on physical activity, mild and infrequent exacerbations, no absences from work or school, and fewer than 4 doses a week of short-acting β2-agonists. Patients were asked about control during the past year. Patients who had failed to meet 2 or more of the criteria at any time during the past year were classified as having uncontrolled asthma.

The survey defined asthma "worsening" as a time when asthma was at its worst (most out of control) or when symptoms worsened substantially. Asthma "exacerbation" was defined as an episode that required acute care (unscheduled physician visit, emergency department visit, or overnight hospitalization).

Analysis and ethics approval
The research company analyzed the data using SPSS and simple descriptive statistics. Student’s t test was used for comparisons between groups. The 95% confidence limits were ±3.35%. The final patient sample was weighted by sex to reflect the breakdown among asthma patients in the Canadian population: 58% women and 42% men.18 An independent company, Institutional Review Board Services of Toronto, gave ethics approval through its Ethics Review Board.


   RESULTS
TOP
 METHODS
 RESULTS
DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgments
 References
 
Table 1 lists the number of patients at each stage of the recruitment and interview process. The effective completion rate for the telephone interviews was 7%, and the actual completion rate was 13% (Table 1). Table 2 presents demographic information.


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  		Table 1 Number of subjects at each stage of the recruitment and interview process

 

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  		Table 2 Characteristics of the 893 respondents: Mean age of respondents was 39.2 years.

 
Asthma control
According to the objective criteria of the Canadian Asthma Consensus Guidelines,11–13 474 of the 893 patients (53%) had uncontrolled asthma, and 418 (47%) had controlled asthma. (The number of patients adds to 1 less than the total of 893 patients; 1 patient could not be classified because of "don’t know" responses or no answers to questions on asthma control.) Only 3% of patients thought they had uncontrolled asthma (Table 3).


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  		Table 3 Asthma worsening and exacerbation during the past year by asthma control status

 
Among patients who claimed their asthma was well controlled, few could describe aspects of good control. According to 45% of patients, making 1 or 2 visits to an emergency department was an expected part of having asthma.

Worsenings and exacerbations
Almost all patients with asthma (82%) had times when their symptoms became worse during the previous year. For patients with uncontrolled asthma, these periods lasted longer and exacerbations required substantially more health care resources than for patients with controlled asthma (Table 3).

Asthma education
One third of patients thought they had not been taught to recognize the early signs of asthma worsening, and one quarter claimed they had received no instruction on what to do when asthma symptoms became worse (Figure 1). Up to one third of patients had never heard of the distinction between reliever and controller medications, were confused about the differences between the 2, or did not know whether to use them regularly or as needed.


Figure 10530672
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  		Figure 1 Patients’ concerns about asthma medications and education issues: N = 893.

 

   DISCUSSION
TOP
 METHODS
 RESULTS
 DISCUSSION
Limitations
 Conclusion
 Footnotes
 Acknowledgments
 References
 
Hospitalization rates and asthma mortality rates among adults with asthma declined substantially in Canada between 1987 and 2000.19 Nevertheless, TRAC demonstrates that asthma control remained suboptimal in Canada 5 years after the last large national survey. The 53% of patients who reported they had uncontrolled asthma in TRAC is consistent with results of earlier Canadian studies. In 1999, 57% were uncontrolled (measured by the same criteria as in TRAC),2 and in 1996, 55% of patients reported daily symptoms.1

The TRAC results suggest that patients, physicians, or both fail to recognize the potential seriousness of exacerbations and emergency department visits for acute asthma. These episodes increase the risk of severe asthma events (including death) for patients who have had repeated or recent periods of worsening asthma,20 decrease quality of life,21 and increase the burden on the health care system. 22


   Limitations
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
Conclusion
 Footnotes
 Acknowledgments
 References
 
The key limitation of the TRAC study is that data were collected retrospectively, so could be subject to recall bias. In addition, the survey’s definition of "asthma exacerbation" was somewhat arbitrary, because patients might have treated exacerbations according to their asthma action plan instructions and not gone to see physicians. The high prevalence of emergency department visits suggests that these episodes of worsening asthma were in fact real, serious events, so our study limitations would be more likely to lead to under reporting of worsening asthma than over reporting.

Another potential bias stems from the low response rate to the survey, which took about half an hour to complete. We speculate that the length of the survey largely accounted for this. Because respondents who did make the time to answer the survey might have been more knowledgeable or interested than most patients about asthma, the results might not accurately reflect the state of asthma control in Canada.


   Conclusion
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
Footnotes
 Acknowledgments
 References
 
Little has changed in control of asthma over the last decade in Canada according to results of community surveys and to public health experts. As part of its ongoing effort to change the situation, the Canadian Thoracic Society’s Asthma Committee is planning to update the Canadian asthma guidelines. We suggest that TRAC results are as important for review and reflection as is efficacy data from clinical trials.

In partnership with community-based family physicians and urgent care providers, the committee hopes to develop such things as asthma care maps and standing orders to foster changes in community practice based on evidence. These initiatives, researching best practices in continuing medical education, and encouraging patients to adhere to their prescribed treatment regimens (pharmacotherapy and routine follow up) might help improve asthma control. By fostering partnerships and improving control, we believe we can reduce urgent care visits and improve asthma control in Canada.



   EDITOR’S KEY POINTS
 
  • Since the last update of the Canadian Asthma Consensus Guidelines in 2001, much effort has been put into their dissemination, including mailing them to physicians and maintaining a website. Has this made a difference? The Reality of Asthma Control study suggests not.
  • More than half the patients surveyed in 2004 had uncontrolled asthma that resulted in an increased number of hospitalizations and emergency room visits.
  • This article suggests that a further update of the guidelines should include practical methods for incorporating them into physicians’ practices.

 


   Acknowledgments
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgments
References
 
Environics Research Group developed the survey instruments in conjunction with the authors, conducted the surveys, and analyzed the results. IntraMed provided editorial assistance for this manuscript. A grant from AstraZeneca Canada funded the survey.


   Footnotes
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
Acknowledgments
 References
 
This article has been peer reviewed.

Contributors

Dr McIvor, Dr Boulet, Dr FitzGerald, Ms Zimmerman, and Dr Chapman contributed to study concept and design, analysis and interpretation of data, and preparing the article for submission.

Competing interests

Dr Boulet has received honoraria, lecture fees, research sponsorship, funding for participating in asthma treatment studies, or support for producing educational materials from 3M, Altana, Asthmatx, AstraZeneca, Boehringer-Ingelheim, Dynavax, Genentech, GlaxoSmithKline, IVAX, Merck Frosst, Novartis, Roche, Schering, and Topigen. Dr FitzGerald has received funding from AstraZeneca for research, for participating on advisory boards, and for presenting continuing health education seminars.


   References
TOP
 METHODS
 RESULTS
 DISCUSSION
 Limitations
 Conclusion
 Footnotes
 Acknowledgments
 References
 

  1. Joyce DP, McIvor RA. Use of inhaled medications and urgent care services. Study of Canadian asthma patients. Can Fam Physician 1999;45:1707-13.[Medline]
  2. Chapman KR, Ernst P, Grenville A, Dewland P, Zimmerman S. Control of asthma in Canada: failure to achieve guideline targets. Can Respir J 2001;8(Suppl_A):35-40A.
  3. GlaxoSmithKline. Asthma in AmericaTM: a landmark survey. Update date not given; cited 2005 Apr 7. Research Triangle Park, NC: GlaxoSmithKline; 2005. Available at: http://www.asthmainamerica.com. Accessed 2006 December 12.
  4. Rabe KR, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000;16:802-7.[Abstract]
  5. Lai CK, De Guia TS, Kim YY, Kuo SH, Mukhopadhyay A, Soriano JB, et al. Asthma Insights and Reality in Asia-Pacific Steering Committee. Asthma control in the Asia-Pacific region: the Asthma Insights and Reality in Asia-Pacific Study. J Allergy Clin Immunol 2003;111(2):263-8.[Medline]
  6. National Asthma Education and Prevention Program; National Heart, Lung, and Blood Institute; National Institutes of Health. Expert panel report: guidelines for the diagnosis and management of asthma. Update on selected topics 2002. Ottawa, Ont: National Institutes of Health; 2003. NIH publication no. 02–5074.
  7. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. London, Engl: British Thoracic Society, Scottish Intercollegiate Guidelines Network; 2004. Revised.
  8. Ministry of Health and Welfare, Japan. Asthma prevention and management guidelines. Int Arch Allergy Immunol 2000;121(Suppl 1):i-viii, 1-77.[Medline]
  9. Hargreave FE, Dolovich J, Newhouse MT. The assessment and treatment of asthma: a conference report. J Allergy Clin Immunol 1990;85(6):1098-111.[Medline]
  10. Ernst P, FitzGerald J, Spier S. Canadian Asthma Consensus Conference: summary of recommendations. Can Respir J 1996;3:89-100.
  11. Canadian Asthma Consensus Group. Canadian asthma consensus report, 1999. CMAJ 1999;161(11 Suppl):S1-62.[Medline]
  12. Boulet L-P, Bai TR, Becker A, Bérubé D, Beveridge R, Bowie DM, et al. What is new since the last (1999) Canadian asthma consensus guidelines? Can Respir J 2001;8(Suppl A):3-27A.
  13. Lemière C, Bai T, Balter M, Bayliff C, Becker A, Boulet L-P, et al. Adult asthma consensus guidelines update 2003. Can Resp J 2003;11(Suppl A):9-18A.[Medline]
  14. Robichaud P, Laberge A, Allen MF, Boutin H, Rossi C, Lajoie P, et al. Evaluation of a program aimed at increasing referrals for asthma education of patients consulting at the emergency department for acute asthma. Chest 2004;126:1495-501.[Medline]
  15. Sin DD, Bell NR, Man SF. Effects of increased primary care access on process of care and health outcomes among patients with asthma who frequent emergency departments. Am J Med 2004;117(7):479-83.[Medline]
  16. Canadian Asthma Consensus Guidelines Secretariat. Asthma. [©2000–2003, updated 2003 Jul 28; cited 2006 Jan 31]. Toronto, Ont: Canadian Asthma Consensus Guidelines Secretariat; 2003. Available at: http://www.asthmaguidelines.com. Accessed 2006 December 12.
  17. FitzGerald JM, Boulet L-P, McIvor RA, Zimmerman S, Chapman KR. Asthma control in Canada remains suboptimal: The Reality of Asthma Control (TRAC) study. Can Respir J 2006;13(5):253-9.[Medline]
  18. Statistics Canada. Canadian community health survey, 2003. Ottawa, Ont: Statistics Canada; 2003. Survey no. 3226.
  19. Centre for Chronic Disease Prevention and Control, Chronic Respiratory Diseases, Public Health Agency of Canada. Facts and figures—asthma. Updated 2004 June 16; cited 2005 Jul 12. Ottawa, Ont: Public Health Agency of Canada; 2004. Available at: http://www.phac-aspc.gc.ca/ccdpc-cpcmc/crd-mrc/facts_asthma_e.html. Accessed 2006 December 12.
  20. Magadle R, Berar-Yanay N, Weiner P. The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea. Chest 2002;121:329-33.[Medline]
  21. Juniper EF, Svensson K, Mörk A-C, Stähl E. Measuring health-related quality of life in adults during an acute asthma exacerbation. Chest 2004;125:93-7.[Medline]
  22. Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults. A review. Chest 2004;125:1081-102.[Medline]

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