Neil, you asked what are the issues we've found in high income countries through our Asthma Right Care programme about underuse of inhaled steroids and overuse of short-acting beta-agonists; what are the reasons, and to compare the situation in LMICs.
These are the issues so far and what we already know about LMICs. I'd also like to make a general point that whilst I am talking about asthma, many of the issues apply to other NCDs, but it's quite interesting to see the world through a respiratory lens rather than a CVD one for a change, and through a condition that affects children, and adults, and is variable, and highly sensitive to the local environment.
Also, whereas there are non-pharmacological interventions for many NCDs, there really are not for asthma, and there are extremely good pharmacological interventions that are under or misused. In addition, the range of misuse with an inhaled medicine is greater than with a tablet. Therefore the role of primary care is critical in diagnosis, communication of the diagnosis and choice of treatment, and in follow up.
1. The right diagnosis is not made because asthma is a variable disease and needs more than one visit but the clinician only sees the patient once. This might be because:
- Primary care is not incentivised for long term care so only sees the patient once for diagnosis and treatment
- Follow-up and review is not part of normal care so the suggestion to return is considered by the patient to be "upselling" by the clinician (this is mainly a LMIC issue)
- Education and training needs
2. The individual communication of the diagnosis is not accurate:
is bronchoconstriction AND inflammation explained?
- Are the words asthma actually used? Some clinicians avoid it for fear of worrying their patients
- Are there visual tools and models available to help explain?
- Is it described as a chronic/long term condition or episodic?
- Is the treatment linked to the diagnosis?
- Are metaphors used to help describe the problem? We created question and challenge cards to be used with a whole range of patients and clinicians with an example “Using the blue reliever is like dampening down a fire, but to put the embers out, and to stop it flaring up again, you need the ICS controller”
3. Prescribing is not right because:
- The diagnosis is made through a "trial of treatment" which is often still SABA, although it should be ICS. This is never reviewed and the person continues on SABA
- Lack of knowledge by the prescriber about what is right despite MANY educational initiatives and guidelines. This was a really strong signal in HICs - we produced an asthma slide rule using simple maths about how many puffs (normally 200) are in an inhaler, how many would be taken if the person was following best evidence, and how much it was if they did what they thought was OK. People keep being surprised how few puffs a day or week is evidence-based. See https://www.dropbox.com/s/h8xeh87sxkt9a63/Darush%20Video%204.MOV?dl=0
- The intervention happens in the Emergency Department, and is never reviewed in primary care; ED practice may be out of date; ED practice may suit patients - eg episodic use of oral steroids (despite the risks of harm).
- Lack of access to the right medicine (a LMIC issue mainly, but even in UK people with asthma have to pay for their prescriptions but people with diabetes do not have to pay for their diabetes prescriptions so they sometimes choose between, and go for the one they don't want to be without in case of emergencies). WHO has only fairly recently included ICS on the essential medicines list! However, that hasn't yet been picked up in all national formulary.
- The wrong incentives (eg in some LMICs there's a limit on the number of ICS that can be prescribed, but not SABA)
- Inadequate shared decision-making about treatment which affects adherence
4. Dispensing is not right because
There is little investment in pharmacist education
Pharmacists are not incentivised to offer patient support and education
Pharmacists may spot a problem but are not confident to challenge the prescriber (who may provide a supply of business)
Pharmacists are out of date: 30 years ago it used to be taught "first take the SABA to open up the airways, then take the ICS." We now know that's not right.
Pharmacists are able to sell SABA over the counter (normally only "for emergencies") and so they do: it's in their interests to keep customers happy and, they hope, healthy.
1. Patient beliefs about asthma. Assuming they have been given the diagnosis. In some countries it is not seen as a diagnosis to worry about and in others, the reverse. This is perfectly understandable. If only those with severe asthma get diagnosed, then they are at risk of serious consequences, including death, and so asthma is something to worry about, which leads to a range of behaviours. These include not getting diagnosed.
2. Patient beliefs about medicines. You've alluded to these already Neil. This can lead to non-adherence to the right medicine.
3. Practical problems of using medicines:
- Can they use the inhaler?
- Were they prescribed a spacer?
- Has anyone taught them how to use the inhaler?
- Are the inhalers available?
- Are they affordable?
There's much more - all fascinating. But maybe that's enough to get people thinking about their experience?
We will write this up in due course.
HIFA profile: Sian Williams is Executive Officer at the International Primary Care Respiratory Group in the UK. Professional interests: Implementation science, NCDs, primary care, respiratory health, education, evaluation, value, breaking down silos. firstname.lastname@example.org