Widespread use of the Guidelines is essential for reducing fatalities, emergency room visits and hospital stays, and for improving day to day quality of life for people with asthma (58). Despite the existence of the Guidelines, a substantial gap remains between their recommendations and the actual practices of many clinicians, people with asthma, and their families. Expanded investment in two areas can help close this gap: 1) promot ing widespread use of current scientific knowledge through public health activities , and 2) encouraging research to continually improve means of managing asthma.
Promote Wider Use of Current Knowledge to Diagnose and Manage Asthma: Public Health Actions
All segments of the health community have vital roles to play in improving the management of asthma. Medical professional societies can promote the use of best practices by their members and improve patient education. State and local health departments can sponsor education programs to promote improvements in managing asthma by health care providers, patients, families and the broader community. At the local level, coalitions among health care providers, public health planners, managed care organizations, school personnel, housing and environmental officials, and community outreach workers can promote improved asthma care in their community.
Current DHHS Activities: Promote Wider Use of Current Knowledge to Diagnose and Manage Asthma
DHHS support s an array of public health activities designed to promote broad dissemination and application of scientific knowledge to improve the diagnosis and management of asthma. These activities includ e clinician education and the promotion of improved quality in health care delivery, family and patient education, facilitation of community-based asthma programs and public education, and support for public health activities at the state level .
NHBLI supports clinician education through the translation of research on asthma into clinical practice guidelines and practical health education materials and tools. The first set of the Guidelines was widely distributed to physicians, medical schools and other health professionals and organizations, as well as to asthma patients. To promote broad use by other key health care professionals, targeted companion documents were developed for nurses, emergency department personnel, pharmacists, and school personnel. NHLBI also produced specialized reports on asthma during pregnancy, asthma in the elderly and asthma in minority children.
Research to Improve Quality of Care
The Agency for Healthcare Research and Quality is investigating whether several approaches to improve the quality of asthma care are effective in helping clinicians better manage the disease in accordance with the Guidelines.
Several programs are conducting research designed to understand which strategies are most effective in promoting the actual implementation of the Guidelines by health care providers. The Agency for Healthcare Research and Quality (AHRQ) has supported research on the factors that cause providers to not use the Guidelines. AHRQ is sponsoring several research projects to assess whether specific quality improvement approaches, being implemented in various clinical settings, are effective in helping clinicians better manage childhood and adult asthma in accordance with the Guidelines. Cost-effectiveness is being examined in several studies which are also testing health outcome measures such as symptom-free days to identify how treatments affect children's daily lives.
NHLBI sponsors a wide range of education and outreach activities through the National Asthma Education and Prevention Program (NAEPP), which is guided by a Coordinating Committee composed of diverse public and private sector organizations (7) . These groups have worked together and in partnerships with other organizations on outreach activities. Examples include: a national conference on "Managing Asthma in Managed Care;" a school-based asthma education program (implemented in partnership with EPA and the American Lung Association); and a bilingual asthma awareness program ("Sesame Street: A is for Asthma") with the Children's Television Workshop. The NAEPP has explored how best to convey strategies for asthma management not only to patients, but also to clinicians, family members, school personnel and caregivers.
Asthma Management Model System
The National Asthma Education and Prevention Program designed a model web-based system to improve the diagnosis and management of asthma. The site provides virtually all the scientific literature on chronic asthma that has ever been published, as well as practical information for clinicians, patients, and public health professionals. See www.nhlbi.nih.gov.
The National Institute of Nursing Research (NINR) evaluates the effectiveness of routine education in a clinic setting reinforced by nurse home visits which include a computer-based asthma instructional program on self-management. Another NINR program is instructing parents and caretakers to learn signs of pending asthma attacks in children living in rural areas. NIAID- and NHLBI-sponsored Demonstration and Education projects focus on improving management of asthma in under-served areas. The Inner-City Asthma study, (described more fully in the following section on research), has evaluated the impact of various types of outreach and education, including intervention with an asthma counselor tailored to the needs of each family.
Recently, DHHS has expanded efforts to address asthma in community settings, including collaborat ion with community-based coalitions that directly address asthma in a comprehensive manner at the local level. These coalitions are composed of community groups, health care providers, and other private and public sector organizations to foster better quality of care for asthma sufferers. For example, the NAEPP facilitates collaborative activities at the local level, has established a consortium of over 40 coalitions, and maintains an Asthma Coalition Exchange on the NHLBI website. CDC's National Center for Environmental Health has worked with DHHS Region IV and seventeen other organizations on a public health program known as "ZAP Asthma," a collaborative program to reduce the adverse impacts of asthma in the Atlanta Empowerment Zone neighborhoods.
NHLBI supports the development of model programs for improving asthma management in the school setting. NHLBI has also sponsored a number of media campaigns to promote asthma awareness among the general public and to encourage undiagnosed patients to seek care.
In communities where people might be exposed to hazardous substances in the environment, the Agency for Toxic Substances and Disease Registry (ATSDR) recommends actions for safeguarding people's health. The agency has made such recommendations at sites where exposures to substances known or suspected to exacerbate asthma have occurred. It has also supported general health education and promotion activities, including continuing medical education for physicians on the relationship between asthma and the environment.
To protect workers, the National Institute for Occupational Safety and Health (NIOSH) develops and recommends criteria for preventing disease (including asthma) and hazardous conditions in the workplace; the recommendations are transmitted to the U.S. Department of Labor for use in promulgating legal standards. Additionally, NIOSH issues alerts that urgently request assistance from workers, employers, and safety and health professionals in preventing, solving, and controlling newly identified occupational hazards. For example, alerts have been issued on asthma in animal handlers, and asthma from exposure to diisocyanate and natural rubber latex.
To support asthma programs at the state level, in late 1997, CDC established a network of asthma contacts that includes officials from every state, the District of Columbia, two city health departments and two territorial health departments. CDC supports the network through a series of activities, including sponsoring monthly teleconferences and annual meetings, working to identify and document scientifically proved intervention programs, identifying state laws that affect persons with asthma, and drafting model language for asthma to be used by state agencies in writing Medicaid contracts.
DHHS regions have also been involved in collaborative efforts on asthma . For example, in Region I (New England), DHHS, EPA, and the Department of Housing and Urban Development are convening a summit meeting of federal and state public health, environmental, and housing officials to develop a joint strategy to reduce the burden of asthma in New England. Region II (New York, New Jersey and Puerto Rico) awarded grants to the New York and New Jersey State Health Departments to develop community-based partnerships to focus on asthma. Region III (Philadelphia) co-sponsored a conference with EPA and Johns Hopkins University - involving health care providers, health educators, community health advocacy groups, managed care organizations, and others - to begin developing an asthma strategy for the mid-Atlantic region (See Appendix E for additional programs supported by DHHS regions).
Urgent Needs: Promote Wider Use of Current Knowledge to Diagnose and Manage Asthma
Help health care providers practice up-to-date asthma care. Recent evidence indicates that many health care providers do not follow the Guidelines for the diagnosis (8) and management of asthma (61, 62, 63, 69) . Failure to follow clinical guidelines stems in part from factors related to knowledge, attitudes and behavior (70), so multiple approaches will be needed to see improvements. Proactive approaches appear to be the most promising, and include educational outreach visits, interactive educational meetings, and consistent reminders integrated into medical care routines (71, 72, 73). As an example, one asthma study reported that an interactive seminar for physicians resulted in improvements in the prescribing and communications behavior of physicians, more favorable patient responses to physician's actions, and reductions in health care utilization (74). DHHS must expand and sustain partnerships with state and local health agencies, medical professional societies, and other organizations to sponsor education and outreach programs to improve the quality of asthma care available to patients with asthma. Such programs need to be developed for particular settings, and those that have demonstrated effectiveness in both changing health care practices and improving health outcomes need to be expanded.
Educate patients and their families. Asthma management often requires behavioral changes and vigilance on the part of people with asthma. This includes paying careful attention to respiratory symptoms and adhering to complex treatment regimens, which can be difficult for many asthma patients, including young children and the elderly, and for families and caregivers with multiple demands and stresses. To promote adherence to treatment recommendations, patients and their families need to be full participants in the development of the asthma management plan, and health care providers should seek to understand and address factors that can affect adherence. Additionally, some model programs promoting self-management of asthma have resulted in dramatic improvements in functional status and improved school performance for children. Moreover, they have achieved substantial cost reductions, in some cases up to 50 percent, by cutting hospitalizations and acute care visits (75, 76, 77). DHHS, working with state and local health agencies and other organizations, must increase and sustain support for effective and culturally-competent approaches that teach patients and families to control asthma, enhance their ability to communicate with health care providers about asthma, and help sustain progress in managing this chronic disease.
Evaluate and address organizational barriers to quality care for asthma. Creating and evaluating cost-effective methods for ensuring implementation of the Guidelines by so many people in so many settings demands continued research. In addition to evaluating education and outreach programs (as indicated in the preceding paragraphs), research should address how other aspects of the health care system affect asthma care. For example, time constraints and payment policies can affect the amount of time a health care provider can spend educating patients. In addition, insurance plans may not reimburse families for equipment used in administering asthma medications (e.g., spacers).
A number of managed care organizations and other types of comprehensive health care organizations are implementing disease management programs for asthma. Disease management is "a systematic, population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical and other outcomes" (78). In one model of disease management, specialized teams work within a health care organization to assist primary care physicians in treating chronic illnesses (79). In another type of program, services are provided through contracts with disease management companies, which stratify patients according to their costs of care, and then target services accordingly (80). Such approaches warrant testing and evaluation to assess their impact on health outcomes, physician practices, and cost-effectiveness.
Expand asthma control activities in community settings. The environment outside the home is beyond the patient's control, and others in those settings may not be trained to recognize symptoms, help support asthma management, or handle an emergency. Apartment buildings and rental housing also create circumstances where the environment inside the home may be out of an individual's control. DHHS must work with state and local health agencies and others to intensify efforts to promote ongoing asthma education in schools, workplaces, public housing, child care and youth programs, job training programs, and other community institutions. This will include outreach to school personnel, workplace supervisors, housing officials, and others, to provide information and to help identify institutional policies that may hamper effective asthma management. For example, o verly rigid policies resulting in inadequate access to and use of medication in school often unnecessarily disrupt classroom learning and make it difficult for children to achieve optimal management of their asthma. In addition to educating people with whom a patient comes into contact and generally expanding public awareness, public health programs should highlight the need to reduce levels of irritants (e.g., environmental tobacco smoke and some air pollutants) and allergens outside of the home environment and otherwise make it easier for patients to follow their treatment plans. DHHS must also increase support for public education campaigns to enhance public awareness about asthma as a serious disease and appropriate asthma management techniques.
Sustain support for State and local public health action. DHHS will seek to equip state health departments, through a grant program, to promote asthma education, prevention, and public health outreach activities in local communities. Activities will target the urgent needs described above and the public health programs described in Priority Area III, including clinician education programs, patient and family education, and training for school personnel. By working with public health and environmental agencies at all levels, as well as organizations outside of the government, scientific advances can be made available to all patients.
Discover and Develop Improved Means of Managing Asthma: Research
While work proceeds to implement state-of-the-art science through public health programs, further research is required to answer remaining questions about asthma care and to explore new ways of improving quality of life for people with asthma. "Secondary prevention" research is designed to identify methods to reduce illness in those who have asthma, but is not directed at preventing the primary onset of the disease.
Current DHHS Activities: Secondary Prevention Research
Discovery of the role that inflammation and allergic sensitization play in asthma led to the development of several new approaches for treating asthma. For example, inhaled corticosteroids reverse the inflammatory process, prevent or reduce severity of symptoms, and reduce emergency room visits, hospitalizations, and deaths due to asthma. Also, two new classes of drugs aimed at reducing asthma severity by inhibiting the inflammatory process have recently been developed - antileukotrienes and anti-IgE therapy.
Managing Childhood Asthma
NHLBI's Childhood Asthma Management Program, a multi-center clinical trial with over 1,000 children enrolled, will provide critical information about the long-term effects and safety of three key therapies for childhood asthma.
NHLBI devotes substantial resources to clinical trials evaluating and assessing treatment strategies. Multiple research investigations are underway to examine the impact and safety of medications at different stages of children's development (e.g., possible effects on bone growth and eye complications later in life) and to discover the best treatment options for children who have different genetic backgrounds or environmental exposures. NHLBI's Childhood Asthma Management Program supports a major multi-center trial to examine and compare the long-term effects of asthma medications on the course of the disease, lung growth and development, and overall physical and psychosocial development of 5-12 year old children. A new Pediatric Clinical Research Network has been established by NHLBI to evaluate clinical asthma treatments, especially in infants and young children. The Asthma and Pregnancy Trial, sponsored jointly by NHLBI and the National Institute of Child Health and Development (NICHD), examines the impact of asthma medication use and effective asthma control on perinatal outcome.
The National Cooperative Inner City Asthma Study, supported by NIAID since 1991, represents an effort to reduce asthma morbidity in inner-city, predominantly African-American and Hispanic children. The present study, funded by NIAID and NIEHS, tests the effect ivenes s of a comprehensive environmental intervention to reduce levels of indoor allergens such as cockroach, house dust mite and mold, and of environmental tobacco smoke, on asthma morbidity . Also , through a collaborative effort with the U.S. Environmental Protection Agency, a study will evaluate the impact of indoor and outdoor air pollutants on asthma among inner-city children.
The National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC) examines environmental control issues in the workplace. NIOSH conducts studies evaluating the incidence, risk factors, and natural history of asthma in groups of workers employed in settings where substances recognized to exacerbate asthma are present. Exposures of current interest include: health care (natural rubber latex used in medical gloves), aluminum production , wood products manufacturing, and the indoor environmental quality of schools and offices . NIOSH has recently embarked on a multi-center trial to prevent latex sensitization in health care workers.
As the Guidelines assert, regular and effective monitoring of symptoms can help both health care professionals and patients gauge the severity of an asthma attack and react accordingly. NHLBI supports investigations examining the relative merits of different approaches to peak flow or symptom monitoring for guiding day-to-day therapeutic decisions. NINR is testing ways to promote children's use of home peak flow meters. In addition to approving safe and effective drugs for treating asthma, the Food and Drug Administration (FDA) approves medical devices such as peak flow meters and spirometers, as well as serologic tests used in allergy testing.
Urgent Needs: Secondary Prevention Research
Improve understanding of what makes asthma persistent and severe. Some patients, especially those with severe asthma, may have active inflammatory disease without apparent external triggers. Further, some patients may experience long-term, irreversible changes in the lungs. These permanent structural changes (known as airway remodeling) may contribute to the persistence of the disease, often lasting for many years or a lifetime. The mechanisms that induce these irreversible changes, and the methods to prevent them, are largely unknown. Identifying them will lead to effective therapies.
Develop improved means of controlling triggers of asthma and the allergic response to them. Recent research has shown that both the exposure and the allergic immune response to certain indoor allergens are responsible for many exacerbations of asthma. Present methods for modulation of the allergic immune response and for control of levels of certain allergens are of uncertain and possibly limited clinical benefit for asthma. Moreover, some allergens and other agents (in particular, cockroach and mold allergen, and respiratory viruses) are extremely difficult to control. There is a need to identify optimal and cost-effective methods for reducing levels of these asthma triggers in homes, schools and workplaces and for basic research to develop new approaches to modulate the human immune response to those allergens relevant to asthma. Other high priorities include work to identify as yet unknown triggers of asthma and optimal, cost-effective methods for reducing allergen levels.
Investigate the relationship between outdoor air pollutants and asthma. Several ambient air pollutants are known to be respiratory irritants and can exacerbate asthma symptoms (e.g., ozone, sulfur dioxide)(51). DHHS must accelerate efforts to better understand the cellular and molecular mechanisms by which air pollutants perturb the normal functioning of cells, tissues, and organs. In addition to refining understanding of the role of air pollutants in exacerbating asthma, this research will help determine whether they are implicated in the initial onset of the disease. Moreover, some pollutants may act synergistically with other environmental factors to worsen asthma.
Investigate variations in patient response to asthma medications. Not all patients respond favorably or in the same way to the same medications, and some patients experience adverse side effects from asthma medications. P atients would benefit from the development of both new treatments and the means for tailoring therapeutic approaches to the specific genetic and clinical characteristics of the individual's asthma.
Establish causes and risk factors of asthma fatalities. Asthma fatalities should be investigated to identify specific risk factors and to enhance understanding of how events lead to fatal disease. This information can lead to ways to improve patient management and prevent fatalities .
Develop non-invasive methods for diagnosis and disease monitoring. Asthma can be especially difficult to diagnose, monitor, and study in infants, young children, and the elderly. Therefore, new technologies -- such as imaging or biochemical markers of inflammation, and patterns of gene activation - are needed to detect disease and monitor disease progression, particularly in these vulnerable populations.
Expand research on asthma in pregnancy. Work has just begun on evaluating how infants are affected by asthma severity in the mother. Research is particularly needed on women whose asthma is difficult to control, and whose medication could have adverse side effects on the fetus.