Association of Asthma Control with Health Care Utilization and

Quality of Life

Asthma is reversible chronic inflammatory disorder that can be controlled by

compliance in treatment. Asthma control is the degree to which asthma symptoms
are minimized in patients with an established diagnosis of asthma. The degree of
control is used to determine whether a patients medications should be adjusted.
Non-adherence in treatment can cause asthma severity. Older adults with asthma
have worse quality of life, asthma control and increased health care utilization
than do healthy peers. Factors that contribute to this are currently unknown.

PREFACE

A. Asthma

Definition

Asthma is a chronic inflammatory disorder of the airways. It is defined by

the history of respiratory symptoms such as wheezing, shortness of breath, chest
tightness and cough that vary over time and in intensity, together with variable
expiratory airflow limitation (GINA 2014).

Epidemiology

As of 2011, 235330 million people worldwide are affected by asthma, and

approximately 250,000345,000 people die per year from the disease. Rates vary
between countries with prevalences between 1 and 18%. [22] It is more common
indeveloped than developing countries. One thus sees lower rates in Asia, Eastern
Europe and Africa. Within developed countries it is more common in those who
are economically disadvantaged while in contrast in developing countries it is more
common in the affluent. The reason for these differences is not well known. Low
and middle income countries make up more than 80% of the mortality.

While asthma is twice as common in boys as girls, severe asthma occurs at equal
rates. In contrast adult women have a higher rate of asthma than men and it is more
common in the young than the old. In children, asthma was the most common
reason for admission to the hospital following an emergency department visit in
the US in 2011.

Global rates of asthma have increased significantly between the 1960s and
2008 with it being recognized as a major public health problem since the 1970s.
Rates of asthma have plateau in the developed world since the mid-1990s with
recent increases primarily in the developing world. Asthma affects approximately
7% of the population of the United States and 5% of people in the United
Kingdom. Canada, Australia and New Zealand have rates of about 1415%.

Diagnosis

Asthma is a diagnosis of exclusion. It is important to consider the pattern of

symptoms and triggers and to rule out conditions that cause wheezing, coughing,
and dyspnea before making the diagnosis. The evidence for the diagnosis of
asthma should be documented before starting controller treatment, as it is often
more difficult to confirm a diagnosis afterwards. To establish a diagnosis of
asthma:

1. Use history and physical to determine whether symptoms of recurrent episodes

of airflow obstruction or airway hyper-responsiveness are present. Symptoms
include: Wheezing (polyphonic, musical or whistling sounds, predominantly
expiratory), Cough, Chest tightness, Dyspnoe, Worsening of symptoms at night or
in the presence of environmental stimuli

2. Use spirometry in patients 5 years and older to determine whether airflow

obstruction is at least partially reversible after use of a bronchodilator. In patients
of all ages, reversibility is indicated by an increase of at least 12% in FEV1 from
baseline. In adults, an increase in FEV1 of greater than 200 mL from baseline also
constitutes reversibility. Note that having normal lung function does not exclude
the diagnosis of asthma, especially in children.

3. Exclude alternative diagnoses such as pulmonary diseases (e.g., COPD,

pulmonary fibrosis, bronchiectasis), upper airway conditions (e.g., chronic allergic
rhinitis and sinusitis, vocal cord dysfunction, obstructive sleep apnea), congestive
heart failure, and other causes (e.g., foreign body in trachea or bronchus, GERD,
enlarged lymph nodes or tumors, cystic fibrosis, drug-related cough).

Asses Control

Asthma control is the degree to which asthma symptoms are minimized in

patients with an established diagnosis of asthma. The degree of control is used to
determine whether a patients medications should be adjusted. Control is classified
as well controlled, not well controlled, and very poorly controlled. Both asthma
severity and control are evaluated by the degree of impairment (the frequency and
intensity of symptoms and functional limitations) that the patient is experiencing
and by the risk of asthma exacerbation, progressive decline in lung function, or
treatment-related adverse effects.
 B. Healthcare Utilization

Definition

Health Care Utilization is the quantification or description of the use of

services by persons for the purpose of preventing and curing health problems,
promoting maintenance of health and well-being, or obtaining information about
ones health status and prognosis. Health Care Utilization refers to the use of
health care services. People use health care for many reasons including preventing
and curing health problems, promoting maintenance of health and well-being, or
obtaining information about their health status and prognosis.

DISCUSSION

The last 10 year have seen a major shift in the way physicians in the United
States view and treat asthma. Asthma is now seen not as an acute, bronchospastic
disease, but rather as a chronic inflammatory disease of the airways. Coincident
with this, increasing emphasis has been placed on preventive disease management
and on control of the inflammatory process. Current U.S. guidelines recognize four
distinct levels of asthma severity: mild intermittent, mild persistent, moderate
persistent, and severe persistent, and separate treatment protocols are
recommended for each.

Although many attempts have been made to operationalize these and

previous definitions of asthma severity, all have their shortcomings and no
agreement exists on a common standard. We believe the problem is further
complicated by a lack of distinction in the literature between underlying disease
severity and current level of asthma control. The former is a reasonably stable
characteristic of the individual that may change slowly over time, whereas level of
control reflects current functioning and may change markedly over relatively short
time frames, although the objective of management is to maintain a good level of
control.

While measures of both severity and level of control will inevitably be

correlated, both concepts are important and conceptually distinct. For example,
although mild asthmatics have disease that is, by definition, relatively easy to
control (e.g., through as needed use of b-agonists) they will occasionally suffer
from acute exacerbations during which their level of control may be very poor.
Similarly, individuals with moderate to severe asthma require more intensive
pharmacotherapy to control their symptoms, and yet with proper therapy and good
compliance can experience good symptom control. From the perspective of the
practicing clinician, level of control may be the more relevant measure, because
the objective of therapy will be to control symptoms and minimize the impact of
the disease on patient functioning (i.e., to achieve a good level of control). From
the perspective of population-based disease management, asthma control could
also serve as a good barometer of the adequacy of health care being provided to a
population, as well as serving as an indicator of patients who may benefit from
more aggressive management.

Study in Pacific Northwest used The Asthma Therapy Assessment

Questionnaire (ATAQ) which was developed as a disease management (DM) tool
to identify individuals whose asthma management may be suboptimal. This brief,
self-administered questionnaire generates a five level measure of asthma control (0
= no control problems to 4 = four control problems). In addition, the ATAQ is used
to identify possible barriers to good disease management. The conclusion of this
study is there is a correlation of asthma control with healthcare utilization and
quality of life patient.

Asthma severity and level of asthma control are two related, but
conceptually distinct, concepts that are often confused in the literature. Study of
that correlation had reported on an index of asthma control developed for use in
population-based disease management. This index was measured on 5,181 adult
members of a large health maintenance organization (HMO), as were various self-
reported measures of health care utilization (HCU) and quality of life (QOL). A
simple index of number of control problems, ranging from none through four,
exhibited marked and highly significant cross-sectional associations with self-
reported HCU and with both generic and disease-specific QOL instruments,
suggesting that each of the four dimensions of asthma control represented by these
problems correlates with clinically significant impairment. Qualitatively similar
results were found for control problems assessed relative to the past month and
relative to the past year. Asthma control is an important vital sign that may be
useful both for population-based disease management as well as for the
management of individual patients.

Comorbid depression is strongly associated with poorer asthma quality of

life and control in older adults. In addition, worse functional status and living alone
may be associated with poorer outcomes. Screening for these conditions is
important in the care of the elderly asthmatic population.