Psychological and Societal Dimensions of Asthma Asthma ... care in resource poor...
Transcript of Psychological and Societal Dimensions of Asthma Asthma ... care in resource poor...
Psychological and Societal Dimensions of Asthma
Asthma Care in Resource-Poor
Settings
Mario Sánchez-Borges, M.D.
sanchezbmario @gmail.com
WAO InternationalScientific Conference
Dubai, UAEDecember 7 th, 2010
Disclosure of conflicts of interest
The author has no conflicts of interest related
to the contents of this educational
presentation.
Educational Objective
To describe the influence of
socioeconomic factors on the
prevalence and management of
asthma
>10.1%
7.6-10%
5.1-7.5%
2.5-5%
0-2.5%
No standardized data
Masoli M et al. Allergy 2004: 59: 469–478
World Map of Prevalence of Clinical Asthma
GINA GOALS OF ASTHMA TREATMENT
1 Symptom control Absence/minimisation of chronic
symptoms
2 Exacerbations Minimal exacerbations
3 Health care utilisation Avoidance of asthma-related visits to
emergency care facilities
4 Reliever medication Minimal or no requirement for quick
relief, rapid-acting ββββ2 agonists
5 Physical activity No asthma-related limitation of
physical activity
6 Lung function Near normal lung function as measured
by peak flow
7 Diurnal variation Reduction in peak flow circadian
variation < 20%
8 Asthma medications Minimal or no adverse effects from
asthma medications
Asthma control in diverse regions of the world acco rding to GINA goals for asthma treatment
GINA-specified goal for asthma treatment
Minimal chronic
symptoms
No ED
visits
Minimal
need for
ββββ2 agonists
No activity
limitations
Normal/
near
normal
LF
Study Region n 1xweek ED last
year %
PRN last
month %
Work
absences
last year %
Never
had LF
AIRE
(1999)
7
European
countries
2050 50 27.9 63.6 17.1 45
AIA
(1998)
USA 2509 71 19 NA 25 65
AIRAP
(2002)
Urban
centres in
8 areas
2323 51.4 43.6 56.3 26.5 60.3
AIRLA
(2003)
11 LA
countries
1376 56 52 55 30 49
Lallou UG, McIvor RA. Int J Tuberc Lung Dis 2006; 10: 474-83
CONCLUSIONS OF ASTHMA CONTROL STUDIES
IN VARIOUS REGIONS
• Poor standard of care in all regions
• Resource-poor countries fared no worst than rich countries
• Both, patients and care providers, underestimated asthma severity and the use of ICS
• Improve access and affordability of ICS
• Patient education and management plans social, cultural and politically relevant
Comparative prevalence of actual asthma diagnosed in the population (%) in 2003
012345678
Arg
entin
a
Bra
zil
Chi
le
Col
ombi
a
Cos
taR
ica
Ecu
ador
Mex
ico
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agua
y
Per
ù
Uru
guay
Ven
ezue
la
AIR
LAT
otal
National representative sample , N= 46275
PROBLEMS IN ASTHMA CARE
• Asthma is a complex
disease
• Lack of public
education
• Prevention generally
not possible
• Lack of substitute for
corticosteroids
• Guidelines too
complicated
• Lack of ownership of
guidelines by care
communities
• Poor acces to effective
health care by the
majority
Lallou UG, McIvor RA. Int J Tuberc Lung Dis 2006; 10: 474-83
OTHER THREATS IN ASTHMA CARE
• Corticophobia
• Cultural barriers
• Weak
infrastructures in
resource poor
settings
• High priority for
other diseases (TB,
HIV)
• Rising incidence of
asthma
• High costs of drugs
• High costs of new
medications
Lallou UG, McIvor RA. Int J Tuberc Lung Dis 2006; 10: 474-83
NONADHERENCE IN ASTHMA: CONTRIBUTING
AND CONFUSING FACTORS
• Underdiagnosis
• Misdiagnosis
• Comorbid conditions
• Concomitant medications
• Aggravating factors
• Environmental/workplace exposures
• Incorrect inhaler technique
WHO Access to Essential Drugs
<50%
50-80%
81-95%
>95%No standardized data
No. (%) of locations where drugs were available and No. of places where drugs were prescribed with different frequencies
Frequency prescribed
Drugs Locally
available
Usually often Rarely Never Not available
Oral salbutamol 40 (98) 35 4 0 1
Theophyllines 41 (100) 30 8 1 0
SR theophyllines 11 (27) 5 2 3 30
Inhaled ββββ agonist 34 (83) 12 18 4 7
Inhaled
anticholinergic
2 (5) 1 0 0 39
Inhaled steroid 15 (37) 2 8 3 26
Cromoglycate 7 (17) 2 1 3 34
Admitted patients
Nebulized
salbutamol
19 (46) 12 2 5 22
Nebulized
ipratropium
1 (2) 1 0 0 40
Watson JP, Lewis RA. Thorax 1997; 52: 605-7
Conclusions – Many asthma patients in
developing countries are not receiving adequate
treatment because the required
drugs are not available in their area or are
prohibitively expensive.
Thorax 1997;52:605–607
Is asthma treatment affordable in developing
countries?
John P Watson, Richard A Lewis
AVAILABILITY OF RESOURCES AND MEDICATIONS IN RESOURCE
POOR REGIONS
24 developing countries in Africa and Asia
• Oxygen 50 %
• Electricity 25/41 centres
• PFMs 3 sites, 26/41 doctors
• Rapid acting BDs in all
• ICS 50 % (too expensive)
• Patient education lacking
Edwards PE. Case Manager 2004; 15: 59-61
DEPRIVATION AND ASTHMA
• Deprivation is consistently associated with
increased severity of asthma but not with
higher prevalence. (Rona RJ. Asthma and poverty. Thorax 2000; 55:
239-44)
• Commitment of public health officials is low
and there is a large diversity of care systems,
availability of medications and resource
limitations.
• Especially in resource-poor countries lack of
access to basic therapy (ICS)
LOGISTIC REGRESSION ANALYSIS OF ASTHMA SEVERITY SHO WING SIGNIFICANT ASSOCIATIONS WITH DEPRIVATION AND CLINI C PROVISION
Predictor
variables
Odds ratio P value 95% CI
Age 45-64 n.s. n.s.
Age 65-74 n.s. n.s.
Age 75+ 1.91 0.020 (1.11, 3.28)
Female n.s. n.s.
Rented housing 1.68 0.009 (1.14, 2.48)
Clinic 0.61 0.028 (0.39, 0.94)
Baker D et al. J Public Health Med 2003; 25: 258-60
• As an aetiological factor.
• As a contributor to exacerbations
• As a determinant of the quality of care
• As a contributor of psychosocial behaviour
which impacts on the management and
prognosis
Possible effects of poverty on asthma
Rona RJ. Thorax 2000;55:239–244
DEPRIVATION AND ASTHMA
• Steroids and LABAs are not universally available
• New drugs, devices and formulations expensive
• Poor adherence
• Alternatives: cheaper, older ICS, SR theophylline,
increased doses of ICS, oral ccs and BDs
• Non-physician educators
• Provide global access to medications at affordable
prices, and to encourage education
CULTURAL vs SOCIOECONOMIC FACTORS
• In a study carried out in East London, South Asians showed less confidence in controlling asthma, were unfamiliar with preventive medication, and expressed less confidence in their GPs
• They managed exacerbations with family advocacy, without changes in prophylaxis and without systemic corticosteroids
• Attended practices with weak strategies for asthma care
• Increased risk of hospital admission
Griffiths C et al. BMJ 2001; 323: 1-7
CULTURAL vs SOCIOECONOMIC FACTORS
• This could reflect either an intrinsic cultural characteristic or the difficulties of coping with asthma in deprived circumstances
• Good access to primary care is associated with reduced risk of hospital admission
• A behavioural intervention for doctors that promoted a partnership style of consulting increased patient’s confidence and reduced their use of health services
Griffiths C et al. BMJ 2001; 323: 1-7
Conclusions—The management of both
ethnic groups centred on drug prescription,
delivery techniques and compliance, but was
deficient, particularly in the ISC group, in
developing understanding of the disease and
self management.
Differences in asthma management between white
European and Indian subcontinent ethnic groups living in
socioeconomically deprived areas in the Birmingham (UK)
conurbation
Moudgil H, Honeybourne D. Thorax 1998;53:490–494
Morbilidad General Registrada en los Establecimientos de Atención Medica. Venezuela Año 2000
Orden
1234
Enfermedades
Sindrome ViralAsmaDiarreasAmigdalitis AgudaOtras
Casos
1.213.772865.738859.797793.584
Tasas
5.021,93.581,93.557,33.283,4
%
6,144,384,354,02
TotalesPor Casos: 19.760,05Por Tasas: 81.755,3Por %: 100.0
MSDS - Enfermedades del Aparato Respiratorio. Venezuela Año 2000
Enfermedades
AsmaAmigdalitis AgudaRinofaringitis AgudaBronquitis AgudaFaringitis AgudaOtras
Casos
865.738793.584346.493270.254184.681
Conc*
1,21,11,11,11,1
%
27,825,411,18,75,9
Tasas**
3.581,93.283,41.238,51.118,2
601,5
TotalesPor Casos: 3.118.729Por Tasas: 12.903,4Por Conc.: 1,1Por %: 100.0(*) Concentración; numero de consultas realizadas por cada paciente por la misma causa.(**) Tasas especificas por 100.000 individuos del grupo correspondiente.Fuente: Dirección de Epidemiologia Regional/D.V.E./D.E.A.E./M.S.D.S. Venezuela 2001
ASTHMA AS A PUBLIC HEALTH PROBLEM in VenezuelaASTHMA AS A PUBLIC HEALTH PROBLEM in Venezuela
((YUPYUP) Asthma shares with Venezuela: ) Asthma shares with Venezuela: YYoung, oung, UUrban and rban and PPooroor
Fluti/Sal1,4%
Formoterol1,6%
Teofilina3,2%
Budesonida1,6%
Formo/Bude0,8%
Otros med control2,5%
Control
14%
Montelukast3,2%
Fuente IMS dic. 2005
Expression of Asthma as a Public Health problemExpression of Asthma as a Public Health problem
Rescue
Asthma Rx is
focused mainly on
exacerbations
Major burden in ED visits
/Hospitalizations
86%
Fuente: Dirección de Vigilancia Epidemiológica. MS
337.669
409.339
470.621
691.839
640.523
713.222
844.327
865.738
711.763
640.376
757.889
753.856
753876
311.158
569.368
1.572,0
1.668,0
1.976,0
2.219,0
2.606,0 3.100,0
2.812,0
3.069,0
2.889,7
2.552,2 2.966,2
2.898,5
2.885,5
3.562,0
3.582,0
0
100.000
200.000
300.000
400.000
500.000
600.000
700.000
800.000
900.000
1.000.000
1991
1992
19931994
1995
1996
1997
199819992000
20012002
2003
2004
2005
CASOS
0,0
500,0
1.000,0
1.500,0
2.000,0
2.500,0
3.000,0
3.500,0
4.000,0
TASAS X 100.000 HAB
CASOS
TASAS
Meds
Asthma Morbidity
Proyecto Venezuela. División de Investigación Sobre la Familia (1981 -1987)
Social level
TotalI+II+II
* IV* V
n66128226407
< 2 yearsn = 11060
%643462
n145789378990
2-6,99 yearsn = 10698
%13.66.125.968.0
n1520350446724
7-13,99 yearsn = 9016
%16.923.029.447.6
n1209227433549
14-19,99 yearsn = 8716
%13.818.735.845.5
Asthma as a disease of the poorAsthma as a disease of the poor
* p < 0.05
Have we tackled this problem ?Have we tackled this problem ?1.National Asthma Program, last revision 1998 ( under GINA guidelines)
2.The Impact from Asthma is on ED visits / Hospitalizations , with direct vs indirect costs on a 1:1 rate .
3 . Asthma is 1-2 % of MOH budget
4. MOH 2006 budget: US $ 120 / capita ( for asthma : US $ 67 millions /year )
5. Ambulatory services health costs ( WHO ) : US $ 46.34 per patient ; for aprox. 1 million acute asthma visits /year = US $ 46.34 millions / y
6. If a 10% hospitalization rate / year is assumed ( 4 days) = $ 81.83 / day = US $ 32.73million.
7. Total cost of asthma / year : 78.34 millions / year
ERJ Express. Published on July 30, 2009 as doi: 10. 1183/09031936.00101009
JIACI, 2006
BUD 400 mcgs / single dose / dayBUD 400 mcgs / single dose / day
Can we come up with approaches that are simple, Can we come up with approaches that are simple, cost /effective and within context ??.. cost /effective and within context ??..
Am J Respir Crit Care Med Vol 175. pp 323–329, 2007Originally Published in Press as DOI: 10.1164/rccm.20051 0-1546OC on November 16, 2006Internet address: www.atsjournals.org
Am J Respir Crit Care Med Vol 171. pp 315–322, 2005Originally Published in Press as DOI: 10.1164/rccm.200 407-894OC on November 12, 2004Internet address: www.atsjournals.org
MLK vs BCD ; 10 mg QD vs 200 mcg BID Ages 15-85DBPC MLK n= 387; BCD =251; PBO= 257
Time 3 months Moderate asthma FEV 1 50-85 % of predicted; 5.5 puffs B2 / day
Results : % patients experiencing an asthma attack MLK ( 15.6 % ) , BCD ( 10.1 % ) , PBO (27.3 ) % p < 0.01
ED visits or unscheduled physician visit
Malmstrom K et al. Ann Intern Med 1999; 130 (6): 487-495
Adults x 6 weeks DBPCMLK 10 mg vs BCD 200mcg BID Mixed severity patients
Israel E et al .JACI 2002;110(6): 847-854
Educational (n=22) Control (n=20) P value
Severity
Hospital admissions 0 0.5±±±±0.8 0.08
ER visits 0.7±±±±1.0 2±±±±2 0.03
Nocturnal symptoms
events.day-1
0.3±±±±0.5 0.7±±±±1 0.04
Frequency of the
symptoms score
1.3±±±±1 2±±±±1 0.04
Quality of life
Quality of life
questionnaire score
28±±±±17 50±±±±15 0.0005
Physical limitation 26±±±±23 51±±±±19 0.002
Frequency and severity
of symptoms
37±±±±32 69±±±±25 0.002
Treatment adherence 13±±±±17 34±±±±25 0.007
Socioeconomic domain 33±±±±21 53±±±±20 0.004
Psychosocial domain 32±±±±18 49±±±±24 0.01
Comparison of Asthma Severity, Quality of Life out comes after the intervention between educational and control groups
de Oliveira MA et al. Eur Respir J 1999; 14: 908-14
Educational
(n=22)
Control (n=20) P-value
Skills
Adequate use of MDI 8±±±±3 4±±±±4 0.001
Patients with a score of
10
77 25
Patients with a score of
5 and 0
23 75
Knowledge
rescue/prevention
medication
86 20 <0.05
Triggers/environmental
control
73 35 <0.05
Lung function
PEFR preBD 367±±±±137 323±±±±100 0.3
PEFR postBD 401±±±±114 401±±±±119 0.5
de Oliveira MA et al. Eur Respir J 1999; 14: 908-14
Comparisons of skills, knowledge and lung function outcomes after the intervention between the educational and control gr oups
Educational Control
Before After P-value Before After P-value
Oral ccs 55 50 0.67 35 40 0.50
ICS 41 95 0.0002 50 50 0.65
Methylxanthines 36 41 0.50 30 45 0.22
Oral ββββ2 agonists 14 0 0.12 20 15 0.50
Inhaled ββββ2
agonists
86 100 0.12 85 85 0.68
Inhaled long-
acting ββββ2 agonists
5 5 NA 0 0 NA
de Oliveira MA et al. Eur Respir J 1999; 14: 908-14
Medication used by patients in the educational and control groups
Conclusions• Asthma prevalence in deprived regions is high
(poor, young, urban)
• Increased severity
• Reasons for poor control:
– Low accessibility to controller medications
– Weak infrastructure for the management of chronic
diseases
– Poor adherence to therapy
– Lack of educational approaches
– Social, cultural, and language barriers
Conclusions
• Implementation of improved ways to treat
asthma:
– ICS qd?
– Oral medications?
Educational interventions
with incorporation of modern
technological tools