Asthma Management Guidelines Research Articles

An evaluation of a community pharmacy‐based rural asthma management service

To compare the effect of a pharmacist-delivered rural asthma management service (RAMS) on health outcomes for people with asthma in a rural/regional area with 'standard care' delivered through community pharmacies. A parallel group controlled repeated measures study. Community pharmacies in Central West New South Wales. Standardised protocols and resources based on national asthma management guidelines, delivered by specially trained community pharmacists. Patients visited the pharmacy at baseline and 1, 3 and 6 months after baseline in the intervention group and at baseline plus 6 months after baseline in the control group. The intervention pharmacists (n = 12) were trained to deliver the RAMS model, while control pharmacists (n = 8) provided standard asthma care to their recruited patients. Fifty-one and 39 patients were recruited by intervention and control pharmacists. Asthma severity score which was a composite score based on recency, frequency and severity of asthma symptoms, and asthma history. Data compared at the final visit between groups indicated that the RAMS patient group demonstrated a significant reduction in the asthma severity scores (7.9 +/- 2.6 versus 10.4 +/- 2.6, P < 0.001); a reduction in the risk of non-adherence to medication scores (1.6 +/- 0.7 versus 2.3 +/- 1.1, P < 0.001); and an increase in the proportion of patients owning a written action plan (50% versus 23%, P = 0.04). These results indicated that the community pharmacy-based RAMS model can improve asthma outcomes for patients in rural settings, and similar models for asthma and other chronic diseases should be tested rigorously and adopted in rural primary care practice.

New Guidelines for Diagnosis and Management of Asthma

In an effort to improve healthcare and quality of life for every asthmatic, the National Heart, Lung and Blood Institute (NHLBI) of the U.S. Department of Health and Human Services has recently revised its guidelines for diagnosis and management of asthma. Initially published in 1991, these guidelin

What Color is Your Yellow Zone? Is There a Role for Escalation of Anti-inflammatory Therapy Short of an Oral Corticosteroid Burst?

ABSTRACT Current asthma management guidelines advise management of mild asthma exacerbations with short-acting beta agonists, followed by consideration of a short course of systemic corticosteroids. Problems with this approach include lack of effect of beta agonists on flareup progression, and the toxicity of systemic corticosteroids. There is a need for a management strategy for mild exacerbations intermediate between beta agonist only and addition of systemic corticosteroids. Randomized controlled clinical trials on doubling doses of inhaled corticosteroid AFTER an asthma exacerbation is established have shown no benefit; however, this strategy may be too little, too late. Other randomized controlled clinical trials have examined either escalation from low- to high-dose inhaled corticosteroid (quadrupling dose) or escalation of the inhaled corticosteroid concurrently with the beta agonist in an inhaler that combines both medications (i.e., one combination inhaled steroid + rapid acting beta agonist inha...

Knowledge of and Attitudes and Adherence to the Spanish Guidelines for Asthma Management (GEMA) Among Spanish Health Care Professionals: The GEMA TEST Project

Health care professionals' adherence to asthma guidelines is believed to be low. The aim of the present study was to determine the knowledge, attitudes, and adherence of Spanish health care professionals with respect to the Spanish Guidelines for Asthma Management (GEMA). A multiple choice test with 15 questions was constructed. Items assessed knowledge of and opinions and adherence to asthma guidelines in general and the GEMA in particular. Test completion was voluntary, individual, and anonymous. A total of 1,066 physicians and nurses took the test. The sample consisted of 241 (22.6%) respiratory medicine specialists and 244 (22.9%) nurses from the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), 221 (20.7%) pediatric pulmonologists from the Spanish Society of Pediatric Pulmonology (SENP), 220 (20.6%) general practitioners from the Spanish Society of Family and Community Medicine (semFYC), 181 (17%) general practitioners from the Spanish Society of Rural and General Medicine (SEMERGEN), and 38 (3.6%) others. Asthma guidelines were considered useful or very useful by 805 (76%), and 771 (72%) stated they were familiar with the GEMA. However, 388 (36%) admitted that they followed guidelines seldom or never. The level of adherence to the GEMA was poor for 243 (30.3%) respondents. The multivariate analysis revealed that low adherence was associated with the following characteristics: coming from the geographic center or south of Spain; being a primary care physician, unfamiliar with guidelines, or unconvinced of their utility; and not being a user of spirometry. Even though the majority of Spanish health care professionals surveyed seem to know of the GEMA, their adherence to those guidelines is very low. Educational programs that seek to improve knowledge of asthma guidelines should consider the profile of professionals with low adherence to the GEMA so as to include educational strategies that target them specifically.

Efficacy of an Outdoor Air Pollution Education Program in a Community at Risk for Asthma Morbidity

Background. Asthma management guidelines recommend avoiding exposure to indoor and outdoor air pollutants. A limitation of such recommendations is that they do not provide information about how the public should obtain and act on air quality information. Although the Air Quality Index (AQI) provides simplified outdoor air quality forecasts, communities with high rates of asthma morbidity tend to have low rates of internet access due to factors such as low socioeconomic status. Assessments of knowledge about air quality among low-income minority communities are lacking, as are community-based programs to educate the public about using the AQI. Methods. An air quality education program and system for disseminating air quality information were developed to promote pollutant avoidance during the reconstruction of a major highway in a low-income minority community on Chicago's South Side. The program, which centered on workshops run by community asthma educators, was evaluated using a pre-test, post-test, and 1-year follow-up questionnaire. Results. A total of 120 community workshop participants completed at least a portion of the evaluation process. At baseline, knowledge about air quality was limited. Following the workshops, substantial increases were noted in rates of correct answers to questions about health effects of air pollution, the availability of air quality information, and the color code for an AQI category. Approximately 1 year after the workshops were held, few participants could recall elements of the training. Few participants have internet access, and alternative means of distributing air quality information were suggested by study participants. Conclusions. Baseline knowledge of air quality information was limited in the community studied. Air quality education workshops conducted by community educators can increase knowledge about outdoor air quality and its impact on health over the short term. Refresher workshops or other efforts to sustain the knowledge increase may be useful. Given the known short-term and long-term effects of air quality on morbidity and mortality, air quality education efforts should be further developed, evaluated, and promoted for the general public, for people with underlying cardiopulmonary disease, and given the documented health disparities within the general population, for low-income and minority communities.

Milestones in asthma management

Background: Asthma is an old and common disorder of respiratory function whose prevalence is increasing everywhere particularly in urban centres. This situation, coupled with the problem of suboptimal management has led to an increase in the morbidity of the disease and enormous economic losses through lost productivity and absenteeism from work and schools. There is therefore a need to review the evolution of the management of this disease with a view to drawing attention to currently recommended management guidelines. This should help to improve the outlook for the asthma patient and hopefully reduce the morbidity and mortality of this rampant disease. Methods: A review of the literature regarding the history of asthma and the evolution of its management was undertaken with the aid of textbooks, journal publications and the Internet via Google Pubmed. The history of asthma and the evolution of the management of asthma was surveyed with emphasis on major and spectacular developments particularly in respect of chronic asthma. Results: Asthma management started from the naming of the disorder, a description of its pathogenesis, pathology and attempts at the therapy of the disease with a variety of agents notably adrenaline, noradrenaline and cortisone. This was followed by the invention of various drug delivery systems and the discovery of salbutamol and cromoglycate. The invention of the bronchoscope led to the development of anti-inflammatory drugs like inhaled corticosteroids and leucotriene antagonists while the discovery of the synergy between salmeterol and fluticasone (an inhaled corticosteroid), made possible the development of combination therapy. Guidelines were devised to ensure the optimal management of the disease through the proper classification of the disease according to severity as well as the efficient utilization of available effective therapies. Conclusion: Although asthma management began in the pre-christian era, the most spectacular and revolutionary developments occurred during the last 55 years and include the discovery of various drug delivery systems, salbutamol, combination therapy and the development of asthma management guidelines. Keywords: Asthma, Management, Developments, Guidelines Port Harcourt Medical Journal Vol. 2 (1) 2007: pp. 13-21

An overview of chronic severe asthma

Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are a few with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regimen. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease and a systematic diagnostic work-up may help to guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma (CSA) should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with CSA. In this review, a diagnostic and therapeutic overview of CSA is provided for the benefit of those who have a specific interest in this problematic condition.

OMALIZUMAB SYMPOSIUM

Nowadays, in many regions of the world, many patients with asthma are well managed because of the availability of effective therapies, such as inhaled corticosteroids, long-acting β adrenoceptor agonists and short-acting bronchodilators. National and international asthma management guidelines, which were initially developed in the early 1990s, have been revised to take account of research findings and new medications. Despite effective therapies and the wide dissemination of useful guidelines, there is still a small proportion of patients with troublesome asthma. It is probable that this asthma, which is poorly responsive to conventional therapy with corticosteroids and β adrenoceptor agonists, has a different pathophysiological basis to the more typical asthma, which is well controlled with available therapies, such as inhaled corticosteroids. Observational studies have established the relationship between allergy, asthma and raised serum concentrations of IgE. With the development of omalizumab, which is an mAb that binds to IgE, it has been possible to investigate the putative causative role of IgE in asthma and to determine the clinical efficacy of this antibody. The papers in this symposium describe the unmet need in asthma therapy, summarize the findings of the clinical trials, which were the basis of registering omalizumab for the treatment of asthma, and propose clinical criteria for its use in severe asthma.

How much is too much? The treatment of mild asthma

Mild persistent asthmatic patients constitute a significant proportion of patients (up to 70% of all asthmatics) 1. These patients might be considered the “silent majority” of asthmatics. This is because they rarely visit their primary care physician with symptoms of asthma, and are even more rarely seen in a secondary or tertiary healthcare setting, where physicians with a focused interest in asthma management tend to work. It is partly for this reason that, until recently, very little attention has been paid to the morbidity associated with mild persistent asthma and very few studies have evaluated the responses of this patient population to treatment. Asthma management guidelines typically describe mild persistent asthma as patients having: asthma symptoms more than weekly, but less than daily, and nocturnal symptoms less than weekly, with normal lung function (forced expired volume in one second (FEV1) or peak expiratory flow >80%) between asthma episodes 2. However, most studies that claim to have studied patients with “mild-to-moderate asthma” have not included many (or any) patients with mild asthma, as reflected by the mean FEV1, which was usually in the range of 70% predicted normal and/or rescue β2-agonist use of 2–3 puffs·day−1 3–5. This makes these studies of little or no value in deciding on treatment strategies for patients with mild persistent asthma. However, there has been an increase in the number of studies focusing on the optimal management of mild persistent asthma, some of which have been published very recently. Asthma treatment guidelines have been consistent in describing the goals and objectives of asthma treatment. These are to: 1) minimise or eliminate asthma symptoms; 2) achieve the best possible lung function; 3) prevent asthma exacerbations; 4) do the above with the least possible medications; 5) minimise short- and …

‘Evidence‐based implementation’ of paediatric asthma guidelines in a rural emergency department

To determine if an evidence-based implementation (EBI) could lead to improved compliance with guidelines for acute asthma in children aged 1-15 years presenting to a large rural emergency department. Pre-intervention, post-intervention and 12-month follow-up audits were performed to determine the impact of an EBI strategy used to increase compliance with current asthma guidelines. The pre-intervention audit was conducted from 1 April to 30 June 2004, and follow-up data were collected from 1 September to 30 November 2004. The 12-month follow-up audit was conducted from 1 August to 31 October 2005. All audits were chart reviews. The intervention was an EBI strategy that was devised and then used to implement established guidelines for the emergency department management of paediatric asthma. There were 51 presentations pre-intervention, 66 post-intervention and 68 at 12-month follow-up with no differences noted in the severity of asthma between the groups. At 12-month follow-up, there were significant increases in the documentation of asthma severity (45% to 90%, P < 0.001), use of spirometry (32% to 66%, P = 0.012), use of spacers (5% to 53%, P < 0.001) and use of written short-term asthma management plans (16% to 69%, P < 0.001). There was a reduction in the use of ipratropium bromide in mild asthma (31% to 3%, P < 0.001). There was no significant change in the use of systemic steroids (74% to 62%, P = 0.29) or antibiotic use in afebrile patients (15% to 6%, P = 0.175). For the seven clinical indicators (CIs) combined, compliance with the guideline increased from 47% to 79% (P < 0.001). Positive changes in clinical behaviour occurred immediately and compliance with all seven CIs was 83% immediately post intervention before falling, non-significantly, to 79% at 12-month follow-up (P = 0.142). The pre-intervention audit identified a low rate of compliance with current asthma guidelines across seven CIs of asthma care. The intervention significantly increased compliance with five of the CIs and for the seven CIs aggregated. Positive changes in clinical behaviour were immediate and the gains were sustained at 12 months.

Trends in medication use for asthma in school‐entry children in the Australian Capital Territory, 2000–2005

To analyse trends in asthma medications used by school-entry children whose parents report they have asthma. Annual cross-sectional study of all school-entry children (about 4400 each year) in the Australian Capital Territory in 2000-2005, by means of a questionnaire for parents on child health status and medication use; and a cross-sectional study of asthma prescriptions for children aged 5 years obtained from the Medicare Australia database for 2002-2005. All school-entry children in the ACT with parent-reported asthma (numbers in the years 2000-2005 ranged between 435 and 589). Changes in the use of different medications; changes in delivery devices for asthma; changes in the potency of inhaled fluticasone. Response rates to kindergarten health screening were in the range 85%-89% for 2000-2005. Parent-reported asthma prevalence ranged from 11% to 15%. Each year, around 35% of children with asthma (age range, 4-6 years) used inhaled corticosteroids. An increase in the use of fluticasone (from 11% to 33% of children with asthma) was offset by decreases in beclomethasone use (from 14% to 3%) and budesonide (from 14% to 4%). Use of cromoglycate and nedocromil fell from 46% to 16%. Nebuliser use decreased (from 45% to 20%), while the use of spacer devices increased (from 70% to 83%). Use of combined salmeterol/fluticasone increased from 8% (in 2002) to 20% (in 2005) of children with parent-reported asthma. These trends were mirrored in Medicare Australia data for 5-year-old children in the ACT. There was marked volatility in the types of asthma medication used over the 6 years. Reciprocal trends leading to increased use of spacers and decreased use of nebulisers are in accord with national guidelines for better asthma management. The increasing use of products containing a combination of salmeterol and fluticasone requires ongoing monitoring.

Progress in suplatast tosilate research

Progress in suplatast tosilate research

Management of asthma in adults: Do the patients get what they need—and want?

Suboptimal asthma control may be caused by a combination of factors, such as nonadherence to guidelines, lack of compliance, and poor asthma education. The aim was to assess patients' knowledge of asthma and different management strategies, including patients' attitudes toward involvement in treatment decisions. The participants (n=509) were recruited from all parts of Denmark through a web-based panel (Zapera Danmarkspanel). A questionnaire concerning asthma knowledge, compliance, and treatment was fulfilled through the Internet. Among the participating adult asthmatic patients, signs of uncontrolled disease with night asthma (16%), daily symptoms (18%), or exercise-induced asthma (11%) were found. Of 285 participants with persistent asthma, 70% used inhaled corticosteroids. Lung function was measured within the preceding 6 months in 24% of patients, whereas 7% had never had their lung function measured and peak flow monitoring was reported by 5%. Written action plans were provided for 12% of patients and 50% had had their inhaler technique checked. Although 59% of patients were instructed to adjust their controller therapy if needed, only 23% reported that they had done so. In conclusion, this study of adult asthmatic patients revealed an important deficit in patient education, little use of lung function measurements, and poor compliance with guidelines for asthma management. Furthermore, asthmatic patients want more education, although they do not use it when provided by their doctor, indicating that change in educational strategy is needed.

Krankheitskontrolle als Therapieprinzip beim Asthma bronchiale

GINA together with many other national guidelines for the clinical management of asthma recommend a disease severity assessment in order to determine the quantity and frequency of medication. This classification scheme groups patients into one of four categories (intermittent, mild-persistent, moderate-persistent, and severe-persistent). However, it is important to recognise that asthma severity includes both severity of the underlying disease and responsiveness to treatment. In addition, severity is not an unvarying feature in any individual asthma patient and disease severity may change over months or years. Thus, for ongoing asthma management, classification using the level of control may be more relevant and useful in clinical practice. The new version of the GINA guidelines 2006 recognises these limitations of severity assessment and classifies the condition according to the level of control as "controlled", "partly controlled", and "uncontrolled" asthma on the basis of daytime symptoms, restrictions of physical activity, nocturnal symptoms/awakening, need for reliever/rescue medication, lung function (PEF or FEV1) and the frequency of exacerbations. In addition, the patient is assigned to one of five treatment "steps". Each step represents treatment options that are alternatives for controlling asthma. Moreover, steps 1 to 5 provide options of increasing efficacy. In order to maintain asthma control regular monitoring and adjustment is essential. In cases where asthma is not or only partially controlled with the current treatment regimen, step-up treatment is recommended whereas disease control allows a gradual stepping-down to the lowest possible dose of medication necessary to maintain control. This novel asthma management approach based on disease control, may facilitate acceptance and use of asthma guidelines in clinical practice.

Resource utilization in asthma:combined fluticasone propionate/salmeterol compared with inhaled corticosteroids

ABSTRACTBackground: Asthma management guidelines recommend low-dose inhaled corticosteroids (ICS) for initial treatment of mild persistent asthma. Instead, data from primary care practice show that many patients start on combination therapy with fluticasone propionate/salmeterol (FPS) for mild asthma. The consequences of this variance from guideline recommendations are not well described.Objective: Compare healthcare utilization and asthma-related outcomes for patients with mild asthma who began treatment with FPS or ICS alone.Design and data source: A retrospective analysis of asthma-related insurance claims. Patients initially treated with FPS or ICS were identified from an administrative health insurance claims database and followed for 1 year. Analyses of resource utilization 6 months before therapy initiation identified patients with mild asthma. Propensity score matching managed between-group differences in clinical characteristics and controlled for selection bias.Outcome measures: Resource use was determined for asthma-related outpatient visits, emergency room services, hospitalizations, and medications.Results: Demographic characteristics and comorbidities were similar for each group (FPS, n = 1888; ICS, n = 1888). During the 12‑month follow-up period, total asthma-related costs were significantly higher for FPS versus ICS ($1206 vs. $804; p < 0.0001), owing primarily to significantly higher drug costs for FPS versus ICS ($677 vs. $357; p < 0.0001). The percentage of patients experiencing an exacerbation (14.0% FPS, 13.5% ICS) and the average number of exacerbations in each group (0.175 FPS, 0.164 ICS) were similar.Conclusions: Healthcare costs were found to be lower in patients receiving ICS than in those receiving FPS, with similar health outcomes in both groups. Study limitations included the use of claims data and a proxy definition of asthma severity, and potential confounding by unobserved factors.

Effects of nonlinear error correction of measurements obtained by peak flowmeter using the Wright scale to assess asthma attack severity in children

Monitoring of peak expiratory flow (PEF) is recommended in numerous guidelines for management of asthma. Improvements in calibration methods have demonstrated the inaccuracy of original Wright scale of peak flowmeter. A new standard, EN 13826 that was applied to peak flowmeter was adopted on 1st September 2004 by some European countries. Correction of PEF readings obtained with old type devices for measurement is possible by Dr M. Miller's original predictive equation. Assessment of PEF correction effect on the interpretation of measurement results and management decisions. In children with intermittent (35) or stable persistent asthma (75) aged 6-16 years, there were performed 8393 measurements of PEF by Vitalograph normal-range peak flowmeter with traditional Wright scale. Readings were expressed as percentage of individual best values (PB) before and after correction. The effect of correction was analysed based on The British Thoracic Society guidelines for asthma attack treatment. In general, correction reduced the values of PEF (p < 0.01). The highest mean percentage error (20.70%) in the measured values was found in the subgroup in which PB ranged between 250 and 350 l/min. Nevertheless, the interpretation of PEF after the correction in this subgroup changed in only 2.41% of measurements. The lowest mean percentage error (15.72%), and, at the same time, the highest effect of correction on measurement results interpretation (in 22.65% readings) were in children with PB above 450 l/min. In 73 (66.37%) subjects, the correction changed the clinical interpretation of some values of PEF after correction. In 13 (11.8%) patients, some corrected values indicated the absence or a milder degree of airflow obstruction. In 27 (24.54%) children, more than 10%, and in 12 (10.93%), more than 20% of the corrected readings indicated a severe degree of asthma exacerbation that needed more aggressive treatment. Correction of PEF values obtained by peak flowmeters with traditional Wright scale shows a possibility of overtreatment in younger or short stature children and undertreatment in older or taller ones if we use old type of metres. The correction of peak flowmeter for non-linear error is a prerequisite in the application of asthma guidelines in PEF measurements.

Critical appraisal of antileukotriene use in asthma management

Recognition of the importance of leukotrienes in the pathogenesis of asthma has led to the development of leukotriene modifiers, the first new class of drugs for asthma treatment to become available since the introduction of inhaled corticosteroids. Nevertheless, despite their widespread use in clinical practice, the role of leukotriene modifiers in the management of asthma remains controversial. In the present article the clinical applications of this class of drugs have been critically reviewed based on recent evidence. In an effort to try and establish the proper place of antileukotrienes in the management of asthma, important systematic reviews have been carried out over these recent years in three critical areas: antileukotrienes as second choice first line agents after inhaled corticosteroids; antileukotrienes as add-on therapy to inhaled corticosteroids; add-on antileukotrienes versus long acting beta-agonists to patients not controlled by inhaled corticosteroids. In addition, novel and useful clinical targets for this class of drugs have been recently explored and include: patients with severe asthma; aspirin-intolerant asthma; asthmatic patients with allergic rhinitis. Use of antileukotrienes is not recommended as first-line monotherapy in patients with asthma, except those who have aspirin intolerant asthma. Patients with concomitant allergic rhinitis may be a good target population for therapy with antileukotrienes. Addition of leukotriene modifiers to inhaled corticosteroids produces only a modest improvement in the clinical response, and is not greater to that of add-on long acting beta-agonists. The exact role of antileukotrienes in asthma management guidelines still continues to evolve.

Insights into Early Treatment of Mild Asthma

Approaches to the management of moderate-to-severe persistent asthma in both children and adults are widely accepted but the treatment of mild persistent asthma remains controversial because of the lack of agreement on what constitutes mild asthma and whether regular treatment is required at all. Recent evidence indicates that 'mild asthma' may not be as benign a condition as was widely believed and should be treated to improve asthma control and to prevent the significant burden of exacerbation and progression of disease. This is supported by compelling evidence from histologic and clinical studies that have attributed irreversible pathologic and functional airway changes to consequences of persistent airway inflammation and under-treated asthma. This article focuses on the rationale of early treatment of mild persistent asthma, and discusses the various findings from the largest randomized, early-intervention trial with inhaled corticosteroids as regular treatment in patients with asthma of recent onset--the START (inhaled Steroid Treatment As Regular Therapy in early asthma) study. A brief review of the background of the natural history of asthma, the findings from key longitudinal epidemiologic studies on disease progression in children and adults, and the effect of inhaled corticosteroids on this progression are included, to provide further insight into the impact of early treatment on asthma management guidelines.

Breaking new ground: challenging existing asthma guidelines.

BackgroundWhile we have international guidelines and various national guidelines for asthma diagnosis and management, asthma remains poorly controlled in many children and adults. In this paper we review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use, particularly in primary care.DiscussionClinical practice guidelines based on evidence from randomized controlled trials are considered the most rigorous and accurate. Current evidence-based guidelines are written predominantly from the perspective of the patient with a clear-cut asthma diagnosis, however, and tend not to consider the heterogeneity of asthma or to accommodate individual patient variations in response to treatment or their needs, differences in practice settings, or local differences in availability and cost of therapies. The results of randomized controlled trials, which are designed to establish efficacy of treatment under ideal conditions, may not apply to 'real-world' clinical practice, where patients are unselected, monitoring is less frequent, and effectiveness – the benefit of treatment in routine clinical practice – is the most relevant outcome. Moreover, most guidelines see asthma in isolation rather than considering other factors that may impact on asthma and response to asthma therapy, particularly age, allergic rhinitis, cigarette smoking, adherence, and genetic factors. When these links are recognized, guidelines rarely provide practical recommendations for treatment in these scenarios. Finally, there is some evidence that general practitioners are not convinced of the applicability of asthma guidelines to their practice settings, especially when those writing the guidelines principally work in specialist practice.ConclusionDeveloping country-specific guidelines or, ideally, local guidelines could provide more practical solutions for asthma care and could account for regional factors that influence patient choice and adherence to therapy. Pragmatic clinical trials and well-designed observational trials are needed in addition to randomized controlled trials to assess real-world effectiveness of therapies, and such evidence needs also to be considered by guideline writers. Finally, practical tools to facilitate the diagnosis and assessment of asthma and factors responsible for poor control, such as associated allergic rhinitis, limited adherence, and smoking behavior, are needed to supplement treatment information provided in clinical practice guidelines for asthma.

Biomedical Informatics Applications for Asthma Care: A Systematic Review

Asthma is a common condition associated with significant patient morbidity and health care costs. Although widely accepted evidence-based guidelines for asthma management exist, unnecessary variation in patient care remains. Application of biomedical informatics techniques is one potential way to improve care for asthmatic patients. We performed a systematic literature review to identify computerized applications for clinical asthma care. Studies were evaluated for their clinical domain, developmental stage and study design. Additionally, prospective trials were identified and analyzed for potential study biases, study effects, and clinical study characteristics. Sixty-four papers were selected for review. Publications described asthma detection or diagnosis (18 papers), asthma monitoring or prevention (13 papers), patient education (13 papers), and asthma guidelines or therapy (20 papers). The majority of publications described projects in early stages of development or with non-prospective study designs. Twenty-one prospective trials were identified, which evaluated both clinical and non-clinical impacts on patient care. Most studies took place in the outpatient clinic environment, with minimal study of the emergency department or inpatient settings. Few studies demonstrated evidence of computerized applications improving clinical outcomes. Further research is needed to prospectively evaluate the impact of using biomedical informatics to improve care of asthmatic patients.