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

Par

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


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


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


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


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

psychological and societal dimensions of asthma asthma ... care in resource poor...

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