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Editorials |

Teach a Man to Fish and You Have Fed Him for a Lifetime FREE TO VIEW

Jennifer J. Davis, MD; William C. Bailey, MD
Author and Funding Information

Affiliations: Birmingham, AL
 ,  Drs. Davis and Bailey are affiliated with the University of Alabama-Birmingham Medical Center.

Correspondence to: Jennifer J. Davis, MD, Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama-Birmingham, 1530 Third Ave South, LHRB 321, Birmingham, AL 35294-0007; e-mail: jrdavis@uab.edu



Chest. 2006;129(2):220-221. doi:10.1378/chest.129.2.220
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Published online

Over the last 20 years, the literature has increasingly demonstrated that racial and ethnic disparities in health exist.1As a result, more African Americans are seeking care at emergency departments (EDs). In 2002, the rate of ED visits for blacks was 380% higher when compared to whites. Similarly, there were 484,000 hospitalizations for asthma in 2002, with a rate for blacks that was 225% higher than that for whites.2

The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report includes recommendations on close primary care follow-up after an ED visit. In this issue of CHEST (see page 257), Baren et al3report on a study that was designed to examine the likelihood of patient follow-up in a primary care setting following an ED visit for asthma. They demonstrate two simple facts. First, compliance rates of follow-up appointments are better if the appointment is made on behalf of the patient. Second, getting patients to the primary care providers is not enough. The results of the study fail to show any impact on secondary outcomes, such as the number of ED visits, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year. In busy practices, physicians and health-care providers are not equipped to give the time necessary for the proper education and teaching of self-management. The reality is that there are other obstacles besides lack of time and resources that make obtaining good asthma control an achievable goal. Cultural beliefs impact the management of asthma as well. In fact, two pediatric studies, one in African Americans4and one in Navajo Indians,5 have proven that caregivers of children with asthma have cultural beliefs about asthma medications that provide the rationale for limiting or discontinuing the use of medications.

Lower socioeconomic status and minority group affiliations are generally associated with increased asthma morbidity among children and adults. While the documentation of these associations is informative, it must be noted that health-care providers are not equipped to effectuate changes in behavior without both the awareness of diverse cultural beliefs and the tools to deal with these beliefs. However, even in those areas where providers can impact asthma outcomes, disparities persist. For example, in a study examining adherence to treatment guidelines among providers serving the Medicaid population of Florida, caregiver adherence to treatment with prescribed medications remained low despite an almost doubling in the proportion of children receiving prescriptions for medications.6We can conclude that even providing the medicines for patients is not enough to impact asthma outcomes. So, what do we do? We know that the key to impacting the morbidity associated with asthma is self-management of the disease. Patient education alone is not enough to impact outcomes, such as hospitalization from asthma, the number of visits to the doctor, medication usage, or lung function.7Several studies89 have demonstrated the utility of self-management, along with regular review by the practitioners as having an impact on days lost from work, hospitalizations, ED visits, unscheduled visits to the doctor, nocturnal symptoms, and quality of life. In a study by Lahdensuo et al,9 in Finland, the group of patients with mild-to-moderate asthma in the interventional group (guided self-management) had outcome variables that were sustained even at 1 year, which had not been demonstrated in other studies.

The episodic nature of asthma as a chronic disease presents challenges for self-management as patients lose interest in their condition once they are asymptomatic. An important consideration in educational programs is to have a sustained effort by personnel who maintain frequent contact and provide reassurance, comfort, and consistency to the patient.9However, self-management is complicated by the health-care system as it currently exists. Our system does not provide the financial support for self-management to be effective. We need to find the means of making asthma education and self-management10with reinforcement by providers a priority. Employing examples, such as the chronic care model recently described in the American College of Physicians article11and Wagner et al12is essential. A significant advance toward this goal is the recent development of the National Asthma Educator Certification Board, which is similar to the well-established National Certification Board of Diabetes Educators and its Certified Diabetes Educator.13 Future challenges should include the utilization of certified asthma educators in the primary care setting with the goal of impacting the success of self-management.

References

Betancourt, JR, Maina, AW (2004) The Institute of Medicine report “Unequal Treatment”: implications for academic health centers.Mt Sinai J Med71,314-321. [PubMed]
 
Centers for Disease Control and Prevention... Asthma prevalence, health care use, and mortality 2000–2001. 2002; Centers for Disease Control and Prevention. Hyattsville, MD:.
 
Baren, JM, Boudreaux, ED, Brenner, BE, et al Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma.Chest2006;129,257-265. [CrossRef] [PubMed]
 
Van Sickle, D, Wright, AL Navajo perceptions of asthma and asthma medications: clinical implications. Pediatrics. 2001;;108 ,.:E11. [CrossRef] [PubMed]
 
Handelman, L, Rich, M, Bridgemohan, CF, et al Understanding pediatric inner-city asthma: an explanatory model approach.J Asthma2004;41,167-177. [CrossRef] [PubMed]
 
David, C Preventive therapy for asthmatic children under Florida Medicaid: changes during the 1990s.J Asthma2004;41,655-661. [CrossRef] [PubMed]
 
Gibson PG, Powell H, Coughlan J, et al. Limited (information only) patient education programs for adults with asthma. Cochrane Database Syst Rev (database online). Issue 1, 2002.
 
Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev (database online). Issue 3, 2002.
 
Lahdensuo, A, Haahtela, T, Herrala, J, et al Randomised comparison of guided self management and traditional treatment of asthma over one year.BMJ1996;312,748-752. [CrossRef] [PubMed]
 
Creer, TL Self-management of chronic illness. Boekaerts, M Pintrich, PR Zeidner, M eds.Handbook of self-regulation2000,601-626 Academic Press. San Diego, CA:
 
American College of Physicians... Patient-centered, physician-guided care for the chronically ill: the American College of Physicians Prescription for Change. 2004; American College of Physicians. Philadelphia, PA:.
 
Wagner, EH, Austin, BT, Davis, C, et al Improving chronic illness care: translating evidence into action.Health Aff (Millwood)2001;20,64-78. [CrossRef] [PubMed]
 
National Asthma Educator Certification Board. The missions and goals page. Available at: http://www.naecb.org/about/mission_vision.htm. Accessed November 21, 2005.
 

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References

Betancourt, JR, Maina, AW (2004) The Institute of Medicine report “Unequal Treatment”: implications for academic health centers.Mt Sinai J Med71,314-321. [PubMed]
 
Centers for Disease Control and Prevention... Asthma prevalence, health care use, and mortality 2000–2001. 2002; Centers for Disease Control and Prevention. Hyattsville, MD:.
 
Baren, JM, Boudreaux, ED, Brenner, BE, et al Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma.Chest2006;129,257-265. [CrossRef] [PubMed]
 
Van Sickle, D, Wright, AL Navajo perceptions of asthma and asthma medications: clinical implications. Pediatrics. 2001;;108 ,.:E11. [CrossRef] [PubMed]
 
Handelman, L, Rich, M, Bridgemohan, CF, et al Understanding pediatric inner-city asthma: an explanatory model approach.J Asthma2004;41,167-177. [CrossRef] [PubMed]
 
David, C Preventive therapy for asthmatic children under Florida Medicaid: changes during the 1990s.J Asthma2004;41,655-661. [CrossRef] [PubMed]
 
Gibson PG, Powell H, Coughlan J, et al. Limited (information only) patient education programs for adults with asthma. Cochrane Database Syst Rev (database online). Issue 1, 2002.
 
Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev (database online). Issue 3, 2002.
 
Lahdensuo, A, Haahtela, T, Herrala, J, et al Randomised comparison of guided self management and traditional treatment of asthma over one year.BMJ1996;312,748-752. [CrossRef] [PubMed]
 
Creer, TL Self-management of chronic illness. Boekaerts, M Pintrich, PR Zeidner, M eds.Handbook of self-regulation2000,601-626 Academic Press. San Diego, CA:
 
American College of Physicians... Patient-centered, physician-guided care for the chronically ill: the American College of Physicians Prescription for Change. 2004; American College of Physicians. Philadelphia, PA:.
 
Wagner, EH, Austin, BT, Davis, C, et al Improving chronic illness care: translating evidence into action.Health Aff (Millwood)2001;20,64-78. [CrossRef] [PubMed]
 
National Asthma Educator Certification Board. The missions and goals page. Available at: http://www.naecb.org/about/mission_vision.htm. Accessed November 21, 2005.
 
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