Canadian Asthma Consensus Guidelines Research Articles

Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE): 2011 national forum proceedings.

In a novel knowledge translation initiative, the Government of Ontario's Asthma Plan of Action funded the development of an Asthma Care Map to enable adherence with the Canadian Asthma Consensus Guidelines developed under the auspices of the Canadian Thoracic Society (CTS). Following its successful evaluation within the Primary Care Asthma Pilot Project, respiratory clinicians from the Asthma Research Unit, Queen's University (Kingston, Ontario) are leading an initiative to incorporate standardized Asthma Care Map data elements into electronic health records in primary care in Ontario. Acknowledging that the issue of data standards affects all respiratory conditions, and all provinces and territories, the Government of Ontario approached the CTS Respiratory Guidelines Committee. At its meeting in September 2010, the CTS Respiratory Guidelines Committee agreed that developing and standardizing respiratory data elements for electronic health records are strategically important. In follow-up to that commitment, representatives from the CTS, the Lung Association, the Government of Ontario, the National Lung Health Framework and Canada Health Infoway came together to form a planning committee. The planning committee proposed a phased approach to inform stakeholders about the issue, and engage them in the development, implementation and evaluation of a standardized dataset. An environmental scan was completed in July 2011, which identified data definitions and standards currently available for clinical variables that are likely to be included in electronic medical records in primary care for diagnosis, management and patient education related to asthma and COPD. The scan, sponsored by the Government of Ontario, includes compliance with clinical nomenclatures such as SNOMED-CT® and LOINC®. To help launch and create momentum for this initiative, a national forum was convened on October 2 and 3, 2011, in Toronto, Ontario. The forum was designed to bring together key stakeholders across the spectrum of respiratory care, including clinicians, researchers, health informaticists and administrators to explore and recommend a potential scope, approach and governance structure for this important project. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) goal is to recommend respiratory data elements and standards for use in electronic medical records across Canada that meet the needs of providers, administrators, researchers and policy makers to facilitate evidence-based clinical care, monitoring, surveillance, benchmarking and policy development. The focus initially is expected to include asthma, chronic obstructive pulmonary disease and pulmonary function standards elements that are applicable to many respiratory conditions. The present article summarizes the process and findings of the forum deliberations.

How are guidelines on allergic respiratory diseases implemented in primary care in Canada?

Asthma is still not optimally controlled in Canada, as in other countries [1,2]. As an effort to determine what could be optimal care of this chronic condition, Clinical Practice Guidelines (CPGs) have been produced and revised regularly in the last two decades, although recent reports suggest that they are not still sufficiently implemented, particularly into primary care [1-4]. Cabana et al. had reported, following a systematic literature review of studies on barriers to adherence to CPGs, that more than half of physicians were not aware of the exact content of current guidelines; common barriers to guidelines implementation included a lack of agreement and/or motivation to change, a lack of self-efficacy, inertia of previous practice, and external factors, such as lack of time and insufficient resources [4]. In regard to asthma, we previously reported data from questionnaires completed by 2,605 Canadian practitioners [5]; we observed that Canadian Asthma Consensus Guidelines (CACG) were considered well known only by a minority of Primary care Physicians (PCP) and that significant discrepancies existed between this Guideline’s recommendations and current care, such as a low use of objective measures of airflow limitation to assist with diagnosis, difficulties with proper assessment of medication needs, a low provision of written action plans for patients and an infrequent referral to other health professionals for asthma education. In keeping with this initial study, following a recent Canadian survey, we proposed that an insufficient use of objective measures for the diagnosis of asthma explained the over-diagnosis of asthma observed [6]. More recently, using a sample of patients treated in primary care in Canada, we confirmed that many patients still do not enjoy adequate guideline-defined asthma control, particularly women, current smokers, older patients and those who lack a written action plan for exacerbation management [1]. However, primary care physicians recognized a lack of control among most asthma patients and were likely to recommend appropriate medication changes and aftercare to patients who fail to achieve guideline targets for asthma control. This, therefore, suggests that although there have been improvements in guideline implementation, some care gaps still persist. In order to better understand how Canadian guidelines are implemented and to develop targeted strategies to improve their translation into current care, we developed a new tool, the Physicians’ Practice Assessment Questionnaire (PPAQ) [7]. As an initial assessment of this tool, implementation of fourteen key-recommendations on asthma management from the most recent CACG was evaluated in a group of 47 general practitioners7. Validation of the questionnaire showed good internal consistency and good test-retest, and revealed that the lowest self-reported rates of implementation were for: 1) referral for patient education; 2) provision of a written action plan; 3) regular assessment of inhaler technique; and 4) referral to a specialist for difficult to control asthma or uncertain diagnosis. This suggests that in order to improve asthma control, these specific behaviors should be addressed and translation of these recommendations facilitated. Finally, in regard to rhinitis, under-diagnosis and under-treatment of rhinitis seems common and although international guidelines are available, we need to better understand how physicians integrate their recommendations into care [8]. Barriers and facilitators of guidelines’ translation into current care should be further addressed.

How much do health care providers value a community-based asthma care program? A survey to collect their opinions on the utilities of and barriers to its uptake.

BackgroundA comprehensive asthma care program (ACP) based on Canadian Asthma Consensus Guidelines was implemented in 8 primary care sites in Ontario, Canada. A survey was distributed to health care providers' (HCPs) to collect their opinions on the utilities of and barriers to the uptake of the ACP.MethodsA 39-item self-administered survey was mailed to 184 HCPs and support staff involved in delivering the ACP at the end of implementation. The items were presented in mixed formats with most items requiring responses on a five-point Likert scale. Distributions of responses were analyzed and compared across types of HCPs and sites.ResultsOf the 184 surveys distributed, 108 (59%) were returned, and of that, 83 were completed by HCPs who had clinical contact with the patients. Overall, 95% of the HCPs considered the ACP useful for improving asthma care management. Most HCPs favored using the asthma care map (72%), believed it decreased uncertainties and variations in patient management (91%), and considered it a convenient and reliable source of information (86%). The most commonly reported barrier was time required to complete the asthma care map. Over half of the HCPs reported challenges to using spirometry, while almost 40% identified barriers to using the asthma action plan.ConclusionContrary to the notion that physicians believe that guidelines foster cookbook medicine, our study showed that HCPs believed that the ACP offered an effective and reliable approach for enhancing asthma care and management in primary care.

Montelukast as Add-On Therapy with Inhaled Corticosteroids Alone or Inhaled Corticosteroids and Long-Acting Beta-2-Agonists in the Management of Patients Diagnosed with Asthma and Concurrent Allergic Rhinitis (the RADAR Trial)

OBJECTIVE: To evaluate the effectiveness of montelukast as add-on therapy for patients diagnosed with asthma and concurrent allergic rhinitis who remain uncontrolled while receiving inhaled corticosteroid (ICS) monotherapy or ICS/long-acting beta-2-agonist (LABA) therapy in a community practice setting.DESIGN: An eight-week, multicentre, open-label, observational study. Patients were 15 years of age or older and, while treated with an ICS or ICS/LABA, had allergic rhinitis and uncontrolled asthma symptoms by at least two criteria as per the Canadian Asthma Consensus Guidelines. The primary outcome measure was the percentage of patients with controlled asthma symptoms after eight weeks of treatment with montelukast 10 mg once daily added to ICS or ICS/LABA therapy.RESULTS: In total, 1004 patients participated in the survey phase of the study. Of these patients, 319 continued in the treatment phase and 301 (94.4%) completed the eight-week assessment. At baseline, all patients had uncontrolled asthma symptoms based on the Canadian Asthma Consensus Guidelines; at the eight-week assessment, 229 patients (76.1%) achieved asthma control. According to the Asthma Control Questionnaire (as determined by scores of 0.75 or less), 164 patients (54.7%) achieved well-controlled asthma at week 8. The mean (± SD) Asthma Control Questionnaire score decreased from 2.03±0.80 to 0.92±0.80 (P<0.001) for all patients, representing a clinically significant improvement. A statistically and clinically significant reduction in the overall Mini Rhinitis Quality of Life Questionnaire score was achieved with a decrease from 2.57±1.20 to 1.12±1.00 (–1.45±1.35; P<0.001). Patient and physician satisfaction rates with montelukast add-on therapy were also significantly increased when compared with baseline treatment.CONCLUSION: Montelukast add-on therapy is effective for managing asthma and allergic rhinitis symptoms in patients who were previously uncontrolled with ICS or ICS/LABA treatment.

Montelukast as Add-On Therapy to Inhaled Corticosteroids in the Management of Asthma (the SAS trial)

AIM: To evaluate the effectiveness of montelukast as add-on therapy for asthmatic patients who remain uncontrolled with low, moderate or high doses of inhaled corticosteroid monotherapy.DESIGN: An eight-week, multicentre, open-label, observational study.RESULTS: Of 320 patients enrolled, 288 (90.0%) completed the study. Of patients who had uncontrolled asthma symptoms (Canadian Asthma Consensus Guidelines Update, 2003) but were controlled according to the Asthma Control Questionnaire (ACQ score of less than 1.5), 93.9% maintained asthma control at week 8. Of patients with uncontrolled asthma at baseline for both definitions, 63.5% achieved asthma control by week 8. The mean ± SD ACQ score decreased from 1.13±0.28 to 0.57±0.50 (P<0.001) for controlled patients at baseline and from 2.38±0.73 to 1.03±0.80 (P<0.001) for patients who were uncontrolled at baseline, each representing a clinically significant improvement.CONCLUSION: Montelukast add-on therapy is an effective alternative to inhaled corticosteroid monotherapy.

Montelukast as Add‐On Therapy to Inhaled Corticosteroids in the Management of Asthma (The SAS Trial)

To evaluate the effectiveness of montelukast as add-on therapy for asthmatic patients who remain uncontrolled with low, moderate or high doses of inhaled corticosteroid monotherapy. An eight-week, multicentre, open-label, observational study. Of 320 patients enrolled, 288 (90.0%) completed the study. Of patients who had uncontrolled asthma symptoms (Canadian Asthma Consensus Guidelines Update, 2003) but were controlled according to the Asthma Control Questionnaire (ACQ score of less than 1.5), 93.9% maintained asthma control at week 8. Of patients with uncontrolled asthma at baseline for both definitions, 63.5% achieved asthma control by week 8. The mean +/- SD ACQ score decreased from 1.13+/-0.28 to 0.57+/-0.50 (P<0.001) for controlled patients at baseline and from 2.38+/-0.73 to 1.03+/-0.80 (P<0.001) for patients who were uncontrolled at baseline, each representing a clinically significant improvement. Montelukast add-on therapy is an effective alternative to inhaled corticosteroid monotherapy.

Can A Community Evidence-based Asthma Care Program Improve Clinical Outcomes?

Asthma is associated with significant morbidity. Previous studies highlight significant variations in asthma management approaches within primary care settings where the adoption of published asthma guidelines is typically suboptimal. To determine whether the implementation of an evidence-based asthma care program in community primary care settings leads to improved clinical outcomes in asthma patients. METHODS, MEASUREMENTS, AND MAIN RESULTS: A community-based participatory research project was implemented at 8 primary care practices across Ontario, Canada, consisting of elements based on the Canadian Asthma Consensus Guidelines (asthma care map, program standards, management flow chart and action plan). A total of 1408 patients aged 2-55 years participated. Conditional logistic regression analyses were used to calculate the odds ratios (OR) comparing baseline to follow-up while adjusting for age, gender, socioeconomic status and other covariates. At 12-month follow-up, there were statistically significant reductions in self-reported asthma exacerbations from 77.8% to 54.5% [OR = 0.35; 95% confidence interval (CI): 0.28-0.43]; emergency room visits due to asthma from 9.9% to 5.5% (OR = 0.47; 95% CI: 0.32-0.62); school absenteeism in children from 19.9% to 10.2% (OR = 0.37; 95% CI: 0.25-0.54); productivity loss in adults from 12.0% to 10.3% (OR = 0.49; 95% CI: 0.34-0.71); uncontrolled daytime asthma symptoms from 62.4% to 41.4% (OR = 0.34; 95% CI: 0.27-0.42); and uncontrolled nighttime asthma symptoms from 46.4% to 25.4% (OR = 0.29; 95% CI: 0.23-0.37). Development and implementation of a community-based primary care asthma care program led to risk reductions in exacerbations, symptoms, urgent health service use and productivity loss related to asthma.

2003 canadian asthma consensus guidelines executive summary.

BackgroundGuidelines for the diagnosis and management of asthma have been published over the last 15 years; however, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian Asthma Consensus Report, important new studies, particularly in children, have highlighted the need to incorporate new information into the asthma guidelines. The objectives of this article are to review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the 1999 Canadian Asthma Consensus Report and its 2001 update, with a major focus on pediatric issues.MethodsThe diagnosis of asthma in young children and prevention strategies, pharmacotherapy, inhalation devices, immunotherapy, and asthma education were selected for review by small expert resource groups. The reviews were discussed in June 2003 at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published through December 2004 were subsequently reviewed by the individual expert resource groups.ResultsThis report evaluates early-life prevention strategies and focuses on treatment of asthma in children, emphasizing the importance of early diagnosis and preventive therapy, the benefits of additional therapy, and the essential role of asthma education.ConclusionWe generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This document is a guide for asthma management based on the best available published data and the opinion of health care professionals, including asthma experts and educators.

Women and Asthma: Lessons from a Gender Analysis of the Asthma in Canada Survey

Objective. To compare the degree of asthma control achieved by men and women with asthma in Canada and to explore differences in patient perspectives, treatments used, and health care resources used between men and women with asthma. Design. Population-based cross-sectional telephone interview survey of Canadians with doctor-diagnosed asthma.Subjects and methods. Random digit dialing was used to identify a representative sample of Canadians with asthma. A total of 801 adults were interviewed over the telephone. Analysis was performed on the data from a subgroup of 20- to 50-year-old patients with asthma who participated in the original survey (329 women and 183 men).Results. Women and men were equally likely to be poorly controlled (58% vs. 56%, p > 0.05) as defined by failing to meet two or more of six symptom-based criteria listed by the 1996 Canadian Asthma Consensus (CAC) Guidelines as appropriate treatment targets. However, there were significant differences in medication used; women were more likely than men to use an inhaled corticosteroid in the treatment of their asthma (59% vs. 45%, p < 0.05) and were more knowledgeable about their appropriate use (62% vs. 46%, p < 0.05), and were more likely to be satisfied with their physicians' care. Despite this, women were more likely than men to have required urgent care for their asthma in the year preceding the survey (50% vs. 36%, p < 0.05).Conclusion. Women report greater need for urgent asthma care despite more frequent use of inhaled corticosteroids and better asthma knowledge scores than men.

2003 Canadian Asthma Consensus Guidelines Executive Summary

2003 Canadian Asthma Consensus Guidelines Executive Summary

Reconcilable Differences: A Cross-sectional Study of the Relationship Between Socioeconomic Status and the Magnitude of Short-Acting β-Agonist Use in Asthma

To assess the association between socioeconomic status (SES) and short-acting (SA) beta-agonist use, controlling for asthma severity. Cross-sectional study. Vancouver, BC, Canada. Two hundred two asthmatics between 19 years and 50 years of age and residing in the greater Vancouver regional district. The quantity of SA beta-agonist used in the previous year was collected by self-report; pulmonary function and beta-receptor genotype were measured on each participant. SES was measured at both the individual and population levels. Five methods of adjustment for asthma severity were used, as follows: the Canadian Asthma Consensus Guidelines, three previously developed asthma-severity scores, and forward stepwise multiple regression modeling. Polychotomous logistic regression was used to assess all relationships. Independent of the method used to measure SES or adjust for asthma severity, lower SES was consistently and significantly associated with the use of greater amounts of SA beta-agonist. Adjusting for severity using the multivariate model explained the most variance of SA beta-agonist use (R(2) adjusted, 0.35 to 0.37). In this model, social assistance recipients were more likely to use greater amounts of SA beta-agonist (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.7 to 6.5). An inverse relationship between SA beta-agonist use and both annual household income (> $50,000; OR, 0.28; 95% CI, 0.13 to 0.60; and $20,000 to $50,000; OR, 0.44; 95% CI, 0.21 to 0.96; relative to <$20,000) and education (completing a bachelor's degree vs no formal education; OR, 0.25; 95% CI, 0.14 to 0.71). Participants living in a neighborhood with higher median household income (OR, 0.91; 95% CI, 0.84 to 0.98 per $1,000 increase) or a higher prevalence of having attained a bachelor's degree (OR, 0.96; 95% CI, 0.84 to 0.98 per 1% increase) were also less likely use greater amounts of SA beta-agonist. Results were consistent for neighborhood unemployment rate. The social gradient in asthma-related outcomes may be at least partially attributable to poorer asthma control in lower-SES asthmatics.

The costs of implementing the 1999 Canadian Asthma Consensus Guidelines recommendation of asthma education and spirometry for the family physician.

National and international asthma guidelines recommend that patients with asthma be provided with asthma education and spirometry as a component of enhanced asthma care. The cost of implementing these interventions in family physician practices is not known. The objective of the present study was to determine the cost of providing recommended asthma care to adult patients in the family practice setting. The present study was conducted using three scenarios of care in family practice. Small, medium and large asthmatic patient populations were used. The incremental costs of implementing enhanced asthma care based on the Canadian Asthma Consensus Guidelines, including the provision of spirometry and asthma education in both group and individual sessions, and the resources required for these interventions were calculated for each scenario. For a physician with 50 asthmatic patients, the cost of providing enhanced asthma care with spirometry and group education sessions was approximately 78 dollars per patient in the first year of implementation. For individual sessions, the cost increased to 100 dollars per patient for the first year. If the physician had 100 asthmatic patients, the per patient cost would decrease; however, the overall cost of the program would be 7,000 dollars. The costs of providing enhanced asthma care are significant. In most cases, physicians are inadequately reimbursed (or not reimbursed) for these interventions. In light of the evidence of the effectiveness of these interventions, health insurance plans should consider adding these services to fee schedules.

Towards Excellence in Asthma Management (TEAM): A Populational Disease-Management Model

Asthma management is not always optimal, and deficiencies such as inadequate treatment and insufficient patient education are often reported. Towards Excellence in Asthma Management (TEAM) is a four-phase disease management program of the Quebec Asthma Education Network (QAEN), to be carried out over a 5-year period. The program aims to achieve a continuous improvement of asthma management by caregivers and patients. The first phase, completed in January 2000, consisted of determining the actual level of asthma-associated morbidity and mortality in various Quebec regions. The second phase, which began in September 1999, included three parts:Definition of the burden of asthma, taking into account the socioeconomic consequences of the disease and the quality of life of the patientsComparison of current medical practices with the Canadian Asthma Consensus Guidelines for adult and pediatric populationsEvaluation of the level of compliance with medical treatment and with the environmental changes recommended to asthmatic patients.This phase is carried out via a cohort study of physicians, mainly general practitioners and pediatricians, generating a patient cohort study, in addition to substudies evaluating specific aspects of asthma care. Once the care gap is identified, it will be possible to define, apply, and evaluate a series of interventions for physicians, other health professionals, and patients. The interventions will be particularly targeted at regions where asthma incidence and morbidity are higher. We hope that this model of disease management will progressively reduce the burden associated with asthma, and potentially other chronic diseases, and will result in the more effective use of health services.

What is new since the last (1999) Canadian Asthma Consensus Guidelines?

The objective of the present document is to review the impact of new information on the recommendations made in the last (1999) Canadian Asthma Consensus Guidelines. It includes relevant published studies and observations or comments regarding what are considered to be the main issues in asthma management in children and adults in office, emergency department, hospital and clinical settings. Asthma is still insufficiently controlled in a large number of patients, and practice guidelines need to be integrated better with current care. This report re-emphasises the need for the following: objective measures of airflow obstruction to confirm the diagnosis of asthma suggested by the clinical evaluation; identification of contributing factors; and the establishment of a treatment plan to rapidly obtain and maintain optimal asthma control according to specific criteria. Recent publications support the essential role of asthma education and environmental control in asthma management. They further support the role of inhaled corticosteroids as the mainstay of anti-inflammatory therapy of asthma, and of both long acting beta2-agonists and leukotriene antagonists as effective means to improve asthma control when inhaled corticosteroids are insufficient. New developments, such as combination therapy, and recent major trials, such as the Children's Asthma Management Project (CAMP) study, are discussed.

Control of asthma in Canada: failure to achieve guideline targets.

To assess the degree of asthma control achieved by patients with asthma in Canada and to describe the impact of poor asthma control. Population-based, cross-sectional telephone interview survey of Canadians with doctor-diagnosed asthma. Random digit dialing was used to identify a representative sample of Canadians with asthma. A total of 801 adults and 200 parents of children aged four to 15 years were interviewed over the telephone. Telephone interviews were also conducted with 266 physicians. Only 24% of patients achieved disease control by meeting the six symptom-based criteria listed by the 1996 Canadian Asthma Consensus Guidelines as appropriate treatment targets. Fifty-seven per cent of patients failed to meet two or more of the six control criteria and were considered poorly controlled. Fifty-one per cent had required urgent care for out of control asthma at least once in the year before the survey. Nonetheless, 91% of patients thought that their asthma was adequately controlled. Physicians shared this optimism: 77% of family physicians and 90% of respirologists believed that they were usually able to achieve optimal asthma control in their patients. Few physicians gauged asthma control by tracking more than one or two symptoms, and just over one-half (54%) of patients surveyed recalled ever having had a lung function test. One-half (48%) of patients with poorly controlled asthma who used inhaled steroids did not understand the role of inhaled steroids; one-third (32%) of patients with poorly controlled asthma who used short acting bronchodilators misunderstood the action of quick relief bronchodilators. The majority of Canadians with asthma suffer from inadequate control of their disease. Suboptimal control of asthma is associated with excess health care use. Inadequate monitoring by physicians and poor patient education may be factors contributing to this problem.