Implementation of Asthma Guideline in TaiwanThe Management in Medical Centers

ABSTRACT The asthma guideline was published in Taiwan in 1995. In order to understand the implementation of the guidelines and patients attitudes to inhaled corticosteroid (ICS), in 1999, we conducted two studies: one by reviewing medical records of 230 stable asthmatic patients cared for by 23 pulmonologists in four medical centers and another through a face-to-face questionnaire survey for 246 asthmatic patients at the outpatient clinics. The results revealed that oral bronchodilators were prescribed to 85.7% (197/230) of the patients, while inhaled B2 agonists were prescribed to 66.1% (152/230) of the patients. Inhaled corticosteroids and oral corticosteroids were prescribed to 120 (52.2%) and 64 (27.8%) patients, respectively. Twenty-three (10%) patients were treated with oral corticosteroids without prescription of ICS. Only 25 (10.9%) patients had records of peak expiratory flow (PEF) every month. Thirty-eight (16.5%) patients sometimes measured PEF. The remaining 167 (72.6%) patients never measured PEF. The face-to-face questionnaire survey revealed that 56.5% (139/246) of the patients worried about adverse reactions of corticosteroids. Among them 40 (16.3%) patients were very worried about it. Only 101 of 189 (53.4%) patients currently using ICS took the daily doses according to doctors orders. Seventy-four (39.2%) patients decreased the dose and 14 (7.4%) patients actually did not take ICS. In the 57 patients not treated with ICS, 13 (22.8%) patients answered that they would refuse to take ICS. In conclusion, the adherence to asthma guidelines is suboptimal for pulmonologists in the medical center. Poor adherence to asthma guidelines may be due to doctors behavior and patients attitudes. INTRODUCTION The socioeconomic conditions in Taiwan have markedly improved in the last two decades. The prevalence of asthma in school children has also increased markedly during the past 20 years, from 1.3% in 1974 to 10.2% in 1995 (an eightfold increase). In the same period, death caused by asthma has shown a slight decrease, from 7.8/100,000 in 1977 to 5.9/100,000 in 1997. Guidelines on asthma management have been published in many countries in the last 10 years. The first edition asthma guideline was issued in Taiwan in 1995. The principles of asthma management in this guideline were similar to GINA guidelines, namely severity classification, stepwise management, b2 agonist inhaler on an as-needed basis, inhaled corticosteroid (ICS) for persistent cases, monitoring with peak expiratory flow (PEF), and patient education. In Taiwan, a series of workshops about asthma management for health care personnel were held across the whole country after the guidelines were issued. A questionnaire survey for the evaluation of adherence to the guideline was conducted by 268 physicians who had received the asthma guideline in 1997. The results revealed that the adherence to guidelines seemed to be better in pulmonologists in medical center s (unpublished). Therefore, this study to understand the adherence to asthma guidelines was conducted by reviewing the medical records of asthma patients cared for by pulmonologists in four medical centers. MATERIALS AND METHODS Evaluation of Asthma Management in Medical Centers The management of asthma was evaluated by auditing the medical records of 230 chronic asthma patients cared for by 23 pulmonologists (10 patients per physician) in four medical centers in October 1999. The auditing was done by fellows of pulmonary medicine in each hospital. The main items for evaluation included prescriptions of bronchodilators and corticosteroids, as well as monitoring with PEF. The management and treatment of asthma in six months (from April through September 1999) were reviewed. Questionnaire Survey of Patients Attitudes to Corticosteroids A face-to-face questionnaire survey was carried out by nurses or clinic assistants for evaluation of patients attitudes to corticosteroids. This study enrolled 246 asthma patients at the out-patient clinic of 12 hospitals in 11 cities in September 1999. They included 189 patients currently prescribed with

ICS and 57 patients currently not treated with ICS. The question to all patients was, Do you worry about the side-effects of corticosteroids? The question to the patients currently prescribed with ICS was, Do you follow the doctors orders to use ICS? The question to those currently not treated with ICS was, Would you like to take ICS if your doctor prescribed it? RESULTS Evaluation of Asthma Management in Medical Centers The auditing of medical records of 230 chronic asthma patients disclosed that the adherence to the principles of treatment guidelines was suboptimal. Oral bronchodilators were more frequently prescribed than inhaled b2 agonists (85.7% vs. 66.1%) (Table 1). Sixty-six patients (28.7%) were treated with oral bronchodilators without prescription of b2 inhalants. Inhaled corticosteroids were prescribed in 52.1% (120/230) of the patients. Oral corticosteroids were prescribed for 64 (27.8%) patients. Among them, 10% (23/230) of the patients were treated with oral corticosteroids without prescription of inhaled corticosteroids (Table 2). Only 27.4% (63/230) of chronic asthma patients were monitored with PEF measurements. Among them, only 25 (10.9%) patients had records of PEF every month, 38 (16.5%) patients recorded PEF sometimes. The remaining 167 (72.6%) patients never had peak flow meters. Questionnaire Survey of Patients Attitudes to Corticosteroids The questionnaire revealed that 56.5% (139/246) of the patients worry about the side-effects of corticosteroids (Table 3). Of the 189 asthma patients currently treated with ICS, 101 (53.4%) patients took the dose as prescribed by the doctor, 14 (7.4%) patients actually did not use ICS, and 74 (39.2%) patients decreased the dose by themselves (Table 4). In 57 asthma patients currently not treated with ICS, only 29 (50.9%) patients would accept a doctors prescription for ICS. The remaining 15 (26.3%) patients were reluctant to accept ICS if their doctors insisted; 22.8% (13/57) would refuse to use ICS (Table 5). DISCUSSION The purposes of introducing the asthma guidelines are to improve the management of asthma and to reduce the medical cost. The implementation of guidelines is influenced by a lot of factors, such as knowledge and attitudes of health care personnel and patients, as well as socioeconomic status. The adherence to guidelines was reported to be suboptimal in both children and adults. In our previous unpublished study of the questionnaire, the adherence seemed to be good, particularly for pulmonologists in medical centers, i.e., in accordance with previous observations. In reality, however, the adherence to guidelines was suboptimal in terms of prescriptions of bronchodilators and ICS, as well as monitoring with PEF. In auditing the medical records, oral bronchodilators were more frequently (85.7%) prescribed for patients with asthma than inhaled agonists (66.1%). Twenty-nine percent of the patients were treated with oral bronchodilators without prescriptions of short-acting b2 agonists. That indicated overuse of oral bronchodilators. Ten percent of the asthma patients were treated with oral corticosteroids without prescription of ICS. That also indicated overuse of oral corticosteroids. In this study, the severity of asthma was not evaluated. The percentage of patients not treated with corticosteroids was 37.8%, which was relatively low as compared with 85.7% of patients treated with regular oral bronchodilators. The preferred use of oral corticosteroids rather than ICS was thought to be more commonly seen in district hospitals and private clinics in Taiwan. But, from this study we found the situation is also common in medical centers. This study revealed that the non-adherence to guidelines may partly be caused by the patients attitude, especially in the corticosteroid treatment. About half of the patients worried about the side effects of corticosteroids (Table 3). The refusal rate of ICS was 7.4% and 22.8% in the patients currently treated with and those without ICS, respectively (Tables 4, 5). This result indicated that the patients education and understanding of the underlying inflammatory process of asthma and the reassurance of the safety of ICS is very important. In Taiwan, most patients can afford to buy a peak flow meter. More than 70% of asthma patients in the medical centers never had a peak flow meter. The low applicability of PEF was most likely a physician factor, which indicates that health care personnel education is equally important for patients. The real adherence to asthma guidelines was lower than that found in the written questionnaire. However, the adherence rate was actually much lower, caused by patients incompliance. The suboptimal compliance of patients has been reported to be one of the important causes of poor asthma control.