DE LOS ESPEJOS DE ARQUÍMEDES A LOS HORNOS SOLARES

While the drug treatments used in the management of asthma have proven efficacy, effective management strategies are imperative to ensure their appropriate use and reduce morbidly and mortality of the disease. To achieve and maintain asthma control for prolonged periods, recommendations for asthma management have been laid out in a

• Identifying and reducing exposure to risk factors, monitoring control through assessment of symptoms and medication use; and

• Establishing individual plans for disease management and for managing exacerbations.16,65

Several barriers have been shown to reduce the availability, affordability, dissemination and efficacy of optimal asthma therapies. As well as the patient barriers identified (such as poor education, culture differences and low income), the lack of symptom-based guidelines and low public health priority have been recognised as barriers to reducing the burden of asthma.28,29 In 1989, the GINA program was initiated in an effort to raise awareness among public health and government officials, healthcare professionals and the general public that morbidity due to asthma was on the increase.28 GINA works with health professionals around the world in an attempt to reduce asthma prevalence, morbidity and mortality through resources such as evidence-based guidelines for asthma management. The management of asthma has improved considerably over the past decade; the World Health Organisation states “asthma management plans have reduced mortality and severity in countries where they have been applied.”29

In Australia, the NAC was launched in 1989, with the major objective of improving asthma management in Australia through an educational strategy and the implementation of an Australian Asthma Management Plan.66 The NAC was an initiative of the stakeholders in asthma care (Thoracic Society of Australia and New Zealand, Royal Australian College of General Practitioners, Pharmaceutical Society of Australia and the Asthma Foundations Australia) with support from the pharmaceutical industry to promote common approaches to asthma management.66 The Australian Asthma Management Plan provided guidance and recommendations for health professionals in the management of asthma according to a Six Step Plan (Table 3).

Table 3. The Australian Six Step Asthma Management Plan59 1. Assess asthma severity

Assess overall severity when the patient is stable, not during an acute attack

2. Achieve best lung function

Treat with intensive asthma therapy until ‘best’ lung function is achieved

Back-titrate to lowest dose that maintains good symptom control and best lung function

3. Maintain best lung function: identify and avoid trigger factors

Identify and avoid trigger factors and inappropriate medication

4. Maintain best lung function: optimise medication program

Treat with the least number of medications and use the minimum doses necessary

Ensure the patient understands the difference between ‘preventer,’ ‘reliever,’ and ‘symptom controller’ medications

Take active steps to reduce the risk of adverse effects from medication

5. Develop an action plan

Discuss and write down an individualised care plan for the management of exacerbations

Detail the increase in medication doses and include when and how to gain rapid access to medical care

6. Educate and review regularly

Ensure patients and their families understand the disease, the rationale for their treatment and how to implement their action plan

Review inhaler technique at each consultation Review adherence at each consultation

After the implementation of these consensus-based guidelines, there was evidence to suggest that the NAC may have contributed to increased awareness and improved management of asthma in Australia.67 However, during the late 1990s it became clear that a higher level of activity was needed to maintain the progress of the NAC, as asthma management was still suboptimal.49,50,68

In recognition of the significant burden that asthma places on the Australian community in terms of health, social, economic and emotional costs, Australian Health Ministers announced asthma as a National Health Priority Area in 1999.69 Subsequently, the Commonwealth Government announced the $48.4 million National GP Asthma Initiative in the 2001 National Health Budget to improve health outcomes of people with moderate-to-severe asthma. The GP Asthma Initiative promotes the use of the Asthma Cycle of Care (formerly the Asthma 3+ Visit Plan), which utilises a structured

Management Plan in general practice. Currently, the two most important resources for asthma management in Australia are the Asthma Cycle of Care and the Asthma Management Handbook.70

The Asthma Cycle of Care encourages partnerships in proactive asthma care between the patient and their health professionals, and involves at least two asthma-related consultations within 12 months for a patient with moderate-to-severe asthma. The visits include an assessment of asthma severity and level of asthma control, a review of the patient’s use of asthma-related medication and devices, and asthma self-management education. An integral part of the Asthma Cycle of Care is the development of a written Asthma Action Plan (AAP), which helps the patient or carer recognise worsening asthma and adjust asthma therapy accordingly, in an attempt to prevent severe exacerbations.

At a minimum, the Asthma Cycle of Care must include:

• At least two asthma related consultations within 12 months for a patient with moderate-to-severe asthma;

• At least one of these consultations (the review consultation) to have been planned at a previous consultation;

• Documentation of diagnosis and assessment of asthma severity and level of asthma control;

• Review of the patient’s use of, and access to, asthma related medication and devices;

• A written asthma action plan (or documented alternative if the patient is unable to use a written action plan);

• Provision of asthma self-management education; and

• Review of the written or documented asthma action plan.70,71

Ongoing patient education is vital to creating a partnership between patients and healthcare professionals, which can then contribute to successful asthma care.65 However, it has been shown that the acquisition of knowledge by patients does not necessarily translate into effective self-management behaviour.72,73 It is therefore imperative that the patient not only understands their condition, including the purpose of

medication and inhalation technique, but also the importance and value of self- monitoring and self-management of their asthma. Overall, four main components of asthma education programs have been identified:

• Information about asthma;

• Self-monitoring;

• Regular medical review; and

• A written action plan.74

The NAC also publishes the Asthma Management Handbook, which is revised every 3- 4 years. It comprises guidelines for delivery of best-practice asthma care in general practice plus practical strategies for implementation.70

The Asthma Management Handbook aims to help clinicians and other health professionals make changes in their practice based on sound evidence, and where evidence is lacking, the consensus opinion of Australian experts has been incorporated. The Handbook acknowledges the difficulties of providing organised care in the primary care setting and tries to provide practical strategies that will assist with diagnosis, ongoing management and patient education. While primarily aimed at GPs, the Handbook is also intended as a resource and teaching tool for community pharmacists, nurses, asthma educators, ambulance officers, consumer representatives and healthcare students, emphasising a team approach to asthma care. The latest (2006) edition contains:

• Updated diagnostic, management and prescribing guidelines;

• Expanded material on asthma and allergy, exercise-induced asthma, occupational asthma, asthma in pregnancy and in older people and co-morbidities;

• More detail on diet and complementary medicine;

• New chapters on smoking cessation and asthma prevention; and

• Practical advice on providing structured asthma care in the primary care setting.59

with asthma still do not have a written AAP,3,31,46-48 have poorly controlled asthma, and do not regard asthma as a chronic disease, but rather an intermittent problem requiring emergency management.75-77 It is unclear whether incomplete implementation of the NAC guidelines is the result of time shortage or lack of interest on the part of the GP or the patient. There is evidence to suggest that even extensive educational strategies have limited impact on clinical care and outcomes.78 There are clearly barriers to the implementation of certain components of the guidelines, particularly in light of the evidence for low rates of AAP possession and use of ICS, which need to be overcome.