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328. Sampson AP, Cowburn AS, Sladek K, Adamek L, Nizankowska

342. Boulet LP. Perception of the role and potential side effects of

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inhaled corticosteroids among asthmaticChestpatients.

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patientsInt.Arch Allergy Immunol 1997;113 (1-3):355-7.

343. Bhogal S, Zemek R, Ducharme FM. Written action plans for

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asthma in childrenCochrane.

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2006 Jul

asthma.Am J Respir Crit Care Med 2000;161(2 Pt 2):S142-6.

19;3:CD005306

330. Slepian IK, Mathews KP, McLean JA. Aspirin-sensitive asthma.

344. Bateman ED, Bousquet J, Keech ML, Busse WW, Clark TJ,

Chest 1985;87(3):386-91.

Pedersen SE. The correlation between asthma control and

331. Nizankowska E, Bestynska-Krypel A, Cmiel A, Szczeklik A. Oral

health status: the GOAL studyr Respir. 2007J Jan;29(1):56-62

and bronchial provocation tests with aspirin for diagnosis345. Pearlmanof DS, van Adelsberg J, Philip G, Tilles SA, Busse W,

aspirin-induced asthmaEur .Respir2000;15(5):863J

-9.

Hendeles L, Loeys T, Dass SB, Reiss TF.

nset and duration of

332. Szczeklik A, Stevenson DD. Aspirin-induced asthma: advances

protection against exercise-induced bronchoconstriction by

single oral dose of montelukastAnn Allergy. Asthma Immunol

in pathogenesis and managementJ Allergy.

Clin Immunol

2006 Jul;97(1):98-104.

1999;104(1):5-13.

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346. American Lung Association Asthma Clinical Research Centers.

Clinical trial of low-dose theophylline and montelukast in p

provocation test with lysine-aspirin for diagnosis of aspirin-

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with poorly controlled asthmaAm J Respir.

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sensitive asthmaJ Allergy.

Clin Immunol 1998;101(5):581-6.

Feb 1;175(3):235-42.

OR

334. Szczeklik A, Nizankowska E, Czerniawska-Mysik G, Sek S.

347. Bisgaard H, Le oux P, Bjamer D, Dymek A, Vermeulen JH,

Hydrocortisone and airflow impairment in aspirin-induced

Hultquist C. Budesonide/formoterol maintenance plus relie

asthma.J Allergy Clin Immunol 1985;76(4):530-6.

therapy: a new strategy in pediatricChestasthma2006.

335. Dahlen SE, Malmstrom K, Nizankowska E, Dahlen B, Kuna P,

Dec;130(6):1733-43.

Kowalski M, et al.Improvement of aspirin-intolerant asthma by

348. Smith JR, Mugford M, Holland R, Noble MJ, Harrison BD.

montelukast, a leukotriene antagonist: a randomized, double-

ALTER

Psycho-educational interventions for adults with severe or

blind, placebo-controlled trialAm J Respir.

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difficult asthma: a systematicJ Asthmareview2007.

2002;165(1):9-14.

Apr;44(3):219-41.

NOT

336. Drazen JM. Asthma therapy with agents preventing leukotriene

synthesis or actionProc Assoc. Am Physicians

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349. Miller MK, Lee JH, Blanc PD, Pasta DJ, Gujrathi S, Barron H,

Wenzel SE, Weiss ST; TENOR Study Group. TENOR risk

1999;111(6):547-59.

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M, Zeiger RS. Aspirin desensitization in aspirin-sensitive

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asthmatic patients: clinical manifestations and characterization

of the refractory periodJ Allergy. Clin Immunol 1982;69(1 Pt 1):

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351. Rahimi R, Nikfar S, Abdollahi M. Meta-analysis finds use of

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inhaled corticosteroids during pregnancy safe: a systemati

meta-analysis reviewHum.Exp Toxicol 2006 Aug;25(8):447-52.

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340. Chan DS, Callahan CW, Hatch-Pigott VB, Lawless A, Proffitt HL,

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ASTHMA MANAGEMENT AND PREVENTION

85

REPRODUCE!

stakeholders, and take into account local culturalImplementation of asthma guidelines should begin w

and economic conditions.

setting of goals and development of strategies for as

care through collaboration among diverse professional

groups including both primary and secondary health car

• An important part of the implementation process is

professionals, public health officials, patients, as

to establish a system to evaluate the effectiveness

and quality of care.

advocacy groups, and the general public. Goals and

implementation strategies will vary from country to

country–and within countries–for reasons of economi

• Those involved in the adaptation and implementation

culture, and environment. However, common issues are

of asthma guidelines require an understanding of the

OR

ALTER

shown inFigure 5-1 .

cost and cost effectiveness of various management

recommendations in asthma care.

The next step is adaptation of guidelines on asthma

• GINA has developed a number of resources and

management for local use by teams of local primary and

secondary care health professionals. Many lowand

programs to aid in guideline implementation and

dissemination.

middle income countries do not consider asthma a high-

priority health concern because other, more common

respiratory diseases such as tuberculosis and pneum

are of greater public health importance. Ther fore,

1

INTRODUCTION

DO

NOTpractical asthma guidelines for implementation in lo

income countries should have a simple algorithm for

It has been demonstrated in a variety of settings thatseparating non-infectious from infectious respira

-

illnesses; simple objective measurements for diag

patient care consistent with recommendations in evidence-

2

based asthma guidelines leads to improved outcomes.and management such as peak flow variabil; avaitylable,

Guidelines are designed to ensure that all membersaffordable,of

and low-risk medications recommended for

patientis health care team are aware of the goals of

asthma control; a simple regime for recognizing severe

asthma; and simple diagnosis and management approaches

treatment and of the different ways of achieving these

relevant to the facilities and limited resources avai

goals. They help set standards of clinical care, may serve

as a basis for audit and payment, and act as a starting

Next, adapted guidelines must be widely disseminat

point for the education of health professionals and patients.

MATERIAL

multiple venues and using multiple formats. This

accomplished, for example, by publication in professio

However, in order to effect changes in medical practice

and consequent improvements in patient outcomes, journals, accompanied by multidisciplinary symposia,

COPYRIGHTED

workshops, and conferences involving national and local

evidence-based guidelines must be implemented and

experts with involvement of the professional and ma

disseminated at national and local levels. Dissemination

media to raise awareness of the key messag. Thes

involves educating clinicians to improve their awareness,

3

knowledge, and understanding of guideline

most effective interventions to improve professio

coming to emergency departments.

difficult problem worldwide. Barriers to implementation

22

range from poor infrastructure that hampers delivery of

In some countries, implementation of asthma guideli

medicines to remote parts of a country, to cultural factors

that make patients reluctant to use recommended

has been done at a national level with government health

department collaboration. A model for an implementation

medications (e.g., inhaled preparations), suboptimal use of

21

program that has improved patient outcomes is provided

medications, and lack of physician use of guidelines.

and outcome within different sectors of the health

Figure 5-1. Checklist of Issues for National or Local

system. Each country should determine its own mini

Asthma Implementation

sets of data to audit health outcomes. There are a variet

of assessment tools which provide a consistent and

• What is the size of the problem and burden of asthma in this

country or district?

objective assessment of asthma morbidity or control (

9

10-12

• What arrangements will be made for shared care among

Asthma Control Test, Asthma Control Questionnaire,

13

Asthma Therapy Assessment Questionnaire). Results of

different health care providers (doctors and nurses, hospital

and primary care)?

these assessments should be recorded at each visit,

providing a record of the long-term clinical response o

• How will medical care be linked with community health facilities

and educational initiatives?

patient to treatment. Direct feedback provides several

benefits—a means for the patient/caregiver to become

• What are the major preventable factors in this country or district

that could help prevent asthma from developing or could

familiar with, and sensitized to, satisfactory vers

prevent asthma exacerbations from occurring in those who control of asthma; a reference point from which to eval

already have asthma?

deteriorating asthma; and an indicator of changes in

asthma control in response to changes in treatment. Us

• What preconceived assumptions about asthma and its treatment

and what cultural factors will need special attention?

of administrative datasets (e.g., dispensing records)

• What treatments are currently used?

urgent health care utilization can help to identify a

REPRODUCE!

patients or to audit the quality of23health.The care

• How affordable and accessible are medications and services to

the patient?

strategy of culturally appropriate direct feedback of

OR

• What other treatments are available, cheap enough for

outcomes to physicians about specific health care res

of their patients may be important for general practit

purchase, and stable in local climatic conditions?

who treat many diseases in addition to asthma and thus

• Can inhaler devices and medicines be standardized to reduce

cost/storage/availability problems?

could not be expected to know guidelines in detail and

handle patients accordingly.

• Who will provide emergency care?

ALTER

• Which groups of the population are at special risk (e.g., inner-

MIC VALUE OF

city, poor, teenage, minority)?

EC

• Whom can we enlist to help in education (community health I

TERVENTIONS AND GUIDELINE

NOT

workers/health-promotion facilitators/trained educators currently

working on other programs/self-help support groups)?

IMPLEMENTATION IN ASTHMA

• Who will take responsibility for the education ofDOhealth

care

professionals?

-

Cost is recognized as an important barrier to the delive

of optimal evidence-based health care in almost every

• Who will take responsibility for the education of people with

asthma and their family members/caregivers?

country, although its impact on patientsi access to

treatments varies widely both between and within

• How can asthma education and treatment be integrated into

countries. At the country or local level, health authori

other programs (e.g., child health)?

make resource availability and allocation decisions

MATERIAL

affecting populations of asthma patients by conside

outcomes (benefits and harms), often in relation to

comprehensive, multifaceted public health initiative with

COPYRIGHTED

well-defined targets for asthma guideline implementation.

7,8

competing public health and medical needs. Treatment

costs must also be explicitly considered at each

Public health strategies involving a broad coalition of

consultation between health care provider and patient t

stakeholders in asthma care, including medical societies,

health care professionals, patient support groups,

assure that cost does not present a barrier to achievin

government, and the private sector, have been

asthma control. Thus, those involved in the adaptation

and implementation of asthma guidelines require an

implemented in Australia (Australian National Asthma

Campaign, http://www.nationalasthma.org.au), and the

understanding of the cost and cost effectiveness o

management recommendations in asthma care. To this

United States (National Asthma Education and Prevention

Program, http://www.nhlbi.nih.gov).

end, a short discussion of cost-effectiveness eval

asthma care follows.

An important part of the implementation process is to

Utilization and Cost of Health Care Resources

establish a system to evaluate the effectiveness and

quality of care. Evaluation involves surveillance of

Between 35 and 50% of medical expenditures for asthma

traditional epidemiological parameters, such as morbidity

14

are a consequence of exacerbations, an asthma outcome

IMPLEMENTATION OF ASTHMA GUIDELINES IN HEALTH SYTEMS

89

and use of rescue medication comprise the majority Asthmaof

exacerbation-related treatment costs. In clinical trials of

asthma treatments, exacerbations are customarily

Economic evaluations require the selection of three m

characterized by use of health care resources, alone or in

combination with symptom and lung function data,

outcome parameters–estimates of treatment-related hea

benefits, treatment-related risks, and treatment-relat

especially when the primary study outcome is reduction in

These parameters can be determined directly from clin

exacerbation-related treatment in precise and valid terms.

REPRODUCE!

the exacerbation frequency or time to an exacerbation

event. Routine collection of health care resource

studies or through the application of modeling studi

Local evidence requirements for economic evaluations

consumption data can be undertaken in the field through

determine the choices of health benefit measures. W

patient or caregiver self-report. In some circumstances,

automated data from clinical or billing records can

the decision to be considered is at the macro-level, for

13,15

example the inclusion of a new treatment in a governm

substitute for self-report and are more reliable. and valid

sponsored health care program or the benefits package of

16,17

a health insurer, economic evaluations require the us

Composite definitions of asthma controlmayinclude

common metric such as life years gained, improvement

one or more health care utilization items. These items

generic quality of life, or quality-adjusted life ye

typically describe the presence of an exacerbation or an

OR

gained. These outcomes support comparison of cost-

18

treatment data, such as unscheduled or urgent care visitsdifficultor

to measure, particularly in children wher

use of nebulized-agonists and/or oral glucocorticosteroids.

17

preference measures are not available. Some have

2

Although health care utilization elements are essential to any

advocated the use of clinical measures such as

pragmatic definition of asthma control, as yet unanswered

symptom-free days or asthma control as the denominator

in the literature is which of the number of possible health

19

in economic evaluations. A unified definition of asthm

NOT

care options (single items or combinations of items) can ALTER

control would substantially improve the acceptance of

contribute to an acceptable definition of control, and the

non-QALY economic evaluations among those interested

values of each that might be viewed as acceptable control.

DO

in their design and application.

For studies to evaluate the cost impact of guideline

GINA DISSEMINATION AND

implementation or of specific asthma interventions, data on

costs of implementation (e.g., costs related to dissemination

-

IMPLEMENTATION RESOURCES

MATERIAL

reviewed literature on asthma management and updates

and publication of guidelines, costs of health professional

education), preventive pharmacotherapy, diagnostic and

Educational materials based onGlobalthisStrategy for

follow-up spirometry, use of devices (spacers, peak flow

are available in

Asthma Management and Prevention

meters), and routine office visits are required to supplement

COPYRIGHTED

medical information. Although it is still not widel

Once data on use of health care resources are collected,various GINA documents. A report of a GINA Working

costs can be determined by assigning local currency price

Group

20

provides a blueprint for implementation strate

weights to health care resources consumed. Unit price

weights are normally collected from government reports,

Other activities to assist with implementation of a

price audits of local payers, billing records, claims

databases, and patient surveys.

management recommendations through the GINA

program include:

Assessment of patient and caregiver travel and waiting

The Internet is

GINA Website - www.ginasthma.org.

time for medical visits, as well as absences from and

creating a conduit for the access, sharing, and exchang

productivity while at school or work, comprise additional

and important outcome measures in asthma. These

of information and permits the global distribution o

indirect costs of asthma are substantial, in estimated to be

roughly 50% of the overall disease burden. However,

available, especially in low-income countries, the globa

14

there are no standardized, validated, and culturally

trend is for increasing use of the Internet for med

adapted instruments for assessing these measureseducationin

by asthma patients and their health care

variety of populations.

providers. Thus, to facilitate communication with he

public as well as updates of activities and informatheionInternationalabout

Union Against Tuberculosis and Lun

collaborating groups and contacts throughout the worldDiseases. (IUATLD).

REPRODUCE!

World Asthma Day.

Initiated in 1998, and held on the REFERENCES

first Tuesday in May, World Asthma Day is organized by

GINA in collaboration with health care groups and asthma

Stewart AW, Mitchell EA, Pearce N, Strachan P, Weilandon

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professionals, and government officials. For patients with

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Higgins BG, Britton JR, Chinn S, Cooper S, Burney PG,

asthma and their relatives, these activities foster an

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expiratory flow variability measurements for epidemiologi

regional, national, and international level. Activities studiesAm Rev. Respir Dis 1992;145(3):588-93.

include sporting events; meetings of people with asthma

3.

Partridge MR, Harrison BD, Rudolph M, Bellamy D, Silverman

and their families with health professionals; meetings with

OR

M. The British Asthma Guidelines--their production,

local health officials to discuss progress in asthma care;

and reports in print media, radio, and television.

dissemination and implementation. British Asthma Guidel

Co-ordinating CommitteeRespir.

Med 1998;92(8):1046-52.

Information about World Asthma Day can be found on the

4.

Davis D , Thomson MA, Oxman AD, Haynes RB. Changing

GINA Website.

physician performance. A systematic review of the effect

ALTER

Regional Initiatives. To examine the formation of

continuing medical education strategiesJAMA 1995;274(9):700.-5.

networks to facilitate the process of guideline

5.

Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD,

implementation, two pilot initiatives have been

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implemented in the Mesoamerica and Mediterranean

NOT

an overview of systematic reviews of interventions to pr

regions. GINA leaders have been identified in each

the implementation of research findings. The Cochrane

country in each region who will supervise collaborationDO

Effective Practice and Organization of Care Review Group.

-

BMJ 1998;317(7156):465-8.

between GINA and local groups and bring the GINA

6.

Sullivan SD, Lee TA, Blough DK, Finkelstein JA, Lozano P, Inui

guidelines into forms that can be readily used by health

care professionals and patients in each region.

TS, et al.A multisite randomized trial of the effects of ph

education and organizational change in chronic asthma care:

GINA Assembly.

To maximize interaction with global

cost-effectiveness analysis of the Pediatric Asthma Care

Patient Outcomes Research Team II (PAC-PORT II). Arch

asthma-care practitioners, a GINA ssembly was initiatedPediatr Adolesc Med 2005;159(5):428-34.

in January 2005. The Assembly provides a forum for

7.

Haahtela T, Klaukka T, Koskela K, Erhola M, Laitinen LA.

dialogue among these health care professionals and

MATERIAL

Asthma programme in Finland: a community problem needs

facilitates sharing of information about scientific advances

and implementation of health education, management,

community solutionsThorax. 2001;56(10):806-14.

and prevention programs for asthma.

8.

Haahtela T, Tuomisto LE, Pietinalho A, Klaukka T, Erhola M,

Kaila M, et al.A 10 year asthma programme in Finland: major

Global Alliance Against Chronic Respiratory Diseases

change for the betterThorax. 2006;61(8):663-70.

(GARD).

GINA is a partner organization of the Global

9.

Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus

Alliance Against Chronic Respiratory Diseases (GARD),

P, et al.Development of the asthma control test: a survey for

a World Health Organization initiative

assessing asthma controlJ Allergy. Clin Immunol

(http://www.who.int/respiratory/gard/en/). The goal of

2004;113(1):59-65.

GARD is to facilitate collaboration among existing

10. Juniper EF, Buist AS, Cox FM, Ferrie PJ, King DR. Validation

governmental and nongovernmental programs interested

of a standardized version of the Asthma Quality of Life

COPYRIGHTED

in chronic respiratory diseases to assure more efficient

QuestionnaireChest. 1999;115(5):1265-70.

utilization of resources and avoid duplication of efforts. The

11. Juniper EF, Bousquet J, Abetz L, Bateman ED. Identifying hwell-

participating organizations will develop a comprehensive

global approach to the prevention and control of chronic

controlledi and hnot well-controlledi asthma using the Asthma

respiratory diseases, with a special emphasis on

Control QuestionnaireR .spir Med 2005.

IMPLEMENTATION OF ASTHMA GUIDELINES IN HEALTH SYTEMS

91