February 20, 2019
By Barbara P. Yawn, MD, MSc, FAAFP
People with asthma and their families continue to experience a significant burden caused by the disease, with more than 10.5 million mostly unscheduled office visits a year, according to an assessment that appeared in the Mayo Clinic Proceedings in 2017. These visits, usually in primary care offices, often focus on dealing with acute symptoms or exacerbations, with little time left to discuss the prevention of the next exacerbation, or strategies for dealing with the daily, ongoing burden of asthma symptoms.
For most people with persistent asthma, inflammation of the airways is triggered or maintained by, among other things, exposure to allergens to which they are sensitized. Much of the asthma burden is potentially preventable if sensitization to allergens are identified and personalized care plans are put into action.
If primary care clinicians carefully consider the following steps, they can work together with asthma patients on better outcomes and can move towards closing the current gap that exists in asthma care.
Evaluate and Assess
According to the 2007 National Asthma Education and Prevention Program (NAEPP) Guidelines for the Diagnosis and Management of Asthma, given the importance of allergens to asthma morbidity and asthma management, patients with persistent asthma should be evaluated for the role of allergens as possible contributing factors. Environmental triggers, such as certain indoor and outdoor aeroallergens, can exacerbate an asthma attack by causing increased symptoms and decreased lung function. Those with multiple inhaled allergen sensitizations are at an increased risk of requiring a non-scheduled doctor visit or urgent care. From cockroaches to rodents to dust mites, more than 90 percent of homes have at least three detectable common aeroallergens, and 73 percent have one or more at an elevated level.
Incorporating assessment tools, such as the Asthma APGAR tool, into primary care practices is an excellent first step in improving the allergen evaluation process. The APGAR tool includes history assessment and a patient query regarding allergies and triggers. It’s designed to facilitate discussion including the need for further allergy evaluation once it’s determined that a patient has persistent asthma.
An assessment I participated in a few years ago, which was published in the Mayo Clinic Proceedings, showed that allergy evaluation was only discussed in about 33% of office visits for asthma, and allergy testing was only documented in two percent of cases over the course of a year. Limited time, costs and patient burdens could be some of the reasons why, but these constraints should not stop health care professionals from incorporating advanced diagnostics techniques into their daily practice.
One method is in vitro testing which assesses allergen-specific immunoglobulin E (IgE) sensitization and can be ordered by primary care clinicians during routine visits. Skin testing, either skin prick or intradermal testing, is typically performed by an allergy specialist. While both methods are good,
in vitro testing is a better option for patients who can’t stop their medication during the testing process and for those without access to a specialist.
An interesting note: Patients with asthma who have undergone allergy testing are significantly more likely to employ preventive strategies such as developing an asthma plan, practicing trigger avoidance and improving medication adherence. Additionally, evidence shows that they also have fewer days with allergy symptoms than patients who had not been tested.
Increase Staff Support
Because most patients with asthma will never see an asthma specialist, primary care practices need support and information to become better-versed not only in allergy evaluations, but also in assessing evaluation results and developing strategies for trigger management. Simplifying the process for clinicians to identify patients who will benefit from allergy testing, using an environmental questionnaire, will increase the number of patients receiving allergy testing. By incorporating the Asthma APGAR system, which is linked to a care algorithm that suggests next steps, practices can save time and improve both patient and practice asthma outcomes. Another source of information and training is the Physician Asthma Care Education (PACE) program, available to primary care clinicians and practices throughout the U.S. The PACE has demonstrated that interactive training leads to improved patient outcomes – specifically asthma care plans, frequency of days with asthma symptoms and ED utilization.
Encourage Patient Engagement
A major hurdle to overcome no matter what the ailment or disease might be is limited time for patient clinic visits in primary care settings. With asthma care, there’s a need to develop more efficient ways for health care providers to interact with patients and counsel them on how to avoid allergen exposure. Patient engagement starts with input derived from evaluation and testing. It also includes the following:
Development of personalized materials – Primary care practices need to assess their materials and personalize them for each patient. They must be culturally appropriate, available at the required reading level and not be too lengthy or require an extremely high health-literacy level to be understood.
Patient education – Patient education will be difficult and unsuccessful if primary care team members are not well versed and comfortable providing evidence-based recommendations for trigger avoidance. Straightforward, concise educational modules on avoidance counseling need to be available to patients.
Incorporating new technologies – Apps, videos and other technologies are emerging in health care. There’s still a lot of work to be done to understand how technology can improve allergen control and asthma outcomes, but the ability to access information and data in real-time has the potential to enable a better level of engagement.
Barbara P. Yawn, MD, MSc, FAAFP, is a family physician researcher who currently focuses on respiratory diseases, specifically COPD screening/case finding and implementation of new tools to improve asthma outcomes. She is/was a member of the International Primary Care Respiratory Group; EPR-3 science panel, editor in chief of Respiratory Medicine Case Reviews and Chief Science Officer of the COPD Foundation. She is retired form her position as the director of research at the Olmsted Medical Center and is an Adjunct Professor of Family and Community Health at the University of Minnesota. She serves as a consultant to multiple NIH and PCORI founded studies of asthma and COPD. Dr. Yawn was chair of an Allergy and Asthma Task Force convened and supported by Thermo Fisher Scientific. The Task Force’s recommendations can be found here.