Abstract
OBJECTIVE To determine whether asthma control in Canada had improved since the last major survey in 1999 by exploring how well patients’ asthma was controlled, how much they knew about asthma control, and how they used health care resources.
DESIGN National telephone survey of patients between April and August 2004.
SETTING Canada.
PARTICIPANTS Eight hundred ninety-three adults 18 to 54 years old diagnosed with asthma more than 6 months before the survey.
MAIN OUTCOME MEASURES Patients’ control of their asthma, patients’ knowledge about asthma, the frequency and duration of periods of worsening asthma, and patients’ use of health care resources to manage those periods.
RESULTS In total, 26 210 households listed in a consumer database were contacted. Excluding ineligible households and households with a language barrier, a member of 13% of the households completed the 35-minute survey. Based on definitions in Canadian guidelines, 53% of patients had symptomatic uncontrolled asthma. In the previous year, almost all asthma patients had experienced worsening of symptoms that lasted on average 13.6 days for patients with uncontrolled asthma and 8.0 days for patients with controlled asthma (P < .02). Markedly more patients with uncontrolled asthma used health care resources for episodes of asthma than patients with controlled asthma did (72% vs 15% for urgent office visits, P < .01; 32% vs 3% for emergency department visits, P < .01; and 7% vs 0% for hospitalizations, P < .01) in the year before the survey. Patients were confused about the differences between reliever and controller medications. One third of patients claimed that no one had taught them about asthma medications, and one quarter said they had received no training on how to recognize the early signs of asthma worsening.
CONCLUSION Asthma control and management remained suboptimal in Canada and relatively unchanged since the previous major survey in 1999.
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
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
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.
Number of subjects at each stage of the recruitment and interview process
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).
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.
Patients’ concerns about asthma medications and education issues: N = 893.
DISCUSSION
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
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
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.
Acknowledgment
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.
Notes
EDITOR’S KEY POINTS
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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.
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More than half the patients surveyed in 2004 had uncontrolled asthma that resulted in an increased number of hospitalizations and emergency room visits.
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This article suggests that a further update of the guidelines should include practical methods for incorporating them into physicians’ practices.
POINTS DE REPÈRE DU RÉDACTEUR
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Depuis la dernière mise à jour des Principes directeurs du consensus canadien sur l’asthme, en 2001, on a déployé beaucoup d’efforts pour les diffuser, notamment leur envoi par la poste aux médecins et le maintien d’un site web. Ces efforts ont-ils porté fruit? L’étude sur la réalité du contrôle de l’asthme (Reality of Asthma Control) laisse croire le contraire.
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L’asthme n’était pas contrôlé chez plus de la moitié des patients qui ont répondu au sondage en 2004, ce qui a entraîné une hausse du nombre d’hospitalisations et de visites à l’urgence.
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Cet article fait valoir qu’une prochaine mise à jour des Principes directeurs devrait comporter des méthodes pratiques pour que la connaissance de ces principes se traduise par des changements concrets dans la pratique médicale.
Footnotes
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This article has been peer reviewed.
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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.
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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.
- Copyright© the College of Family Physicians of Canada
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