Asthma Patients Worsen Without Specialist Referral

Are asthma patients being mismanaged when treatment guidelines on specialist referrals are overlooked?

Patients with asthma who are not referred to specialists when indicated by symptom severity and treatment guidelines are likely to have increases in uncontrolled symptoms, emergency department visits, and rescue medications.

A new review of asthma treatment guidelines across several different countries finds multiple factors interfering with adherence to guidelines on when to refer for a specialist consult. Among these, the reviewers indicate, are a lack of awareness about applicable guidelines, “inertia” toward implementing guidelines, and logistical difficulties of doing so within the particular practice setting.

David Price (pictured), FRCGP, of the Centre of Academic Primary Care at the University of Aberdeen, in the UK, commented to MD Magazine that he also faults differences between guidelines and their disparate recommendations on what conditions warrant referral.

“Guidelines need to be more consistent with recommendations on referral, especially with regard to inhaled corticosteroid dose and prior exacerbation threshold,” he said.

Price and colleagues cite studies which have found 20% of patients with asthma have had an exacerbation requiring hospitalization. They point out that exacerbations have a significant impact on quality of life, and their occurrence predicts risk for future occurrences. Further, hospitalizations for exacerbations account for up to 80% of the costs associated with asthma.

Multiple sets of guidelines, including those of the American Academy of Allergy Asthma and Immunology (AAAAI) and the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report-3, agree that referral to a specialist is warranted when patient shave frequent asthma-related health care utilization or a hospitalization/emergency department visitation.

“Specialist care can reduce the number of hospitalizations and the risk of future hospitalizations,” Price and colleagues indicated.

In 1 cited investigation of asthma-related deaths, 20% were related to avoidable factors associated with referrals including delays or failure to make referral, and over 50% of these patients were not under specialist supervision prior to their deaths.

Price and colleagues also suggest that corticosteroid treatment could be more effectively applied and produce less associated morbidity with increased involvement of specialists. In another cited study in the UK in which 90% of asthma patients were receiving inhaled corticosteroid treatment, over 50% were classified as having intermittent asthma which may not have warranted the treatment.

There is also an opportunity for greater instruction on proper use of the inhaled steroids by the primary care provider, as well as identifying and assessing contributing factors, Price indicated. There should be “clarity on the importance of a full review of inhaler technique, adherence, co-morbidities, diagnosis, and smoking before referral,” he said.

Price and colleagues recommend more frequent monitoring of patients with moderate and severe persistent asthma in order to better respond to symptoms and provide timelier referral to specialists. Following hospitalization for a severe asthma attack, they suggest that the respiratory specialist then provide at least 1 year of follow-up. With referral, there is also greater likelihood of appropriate escalation of therapies.

“Ultimately, an improved process of specialist referrals would benefit patients with asthma with unmet needs in improving their asthma control and reducing health care resource utilization,” Price and colleagues conclude.

The review of referrals for asthma treatment specialists was published on-line July 25 in the Journal of Asthma Allergy.

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