Patients with asthma account for 9.5 percent of all emergency room visits in the U.S. annually, with the highest percentage for children aged 5–17, according to the Centers for Disease Control and Prevention. With three-quarters of people with asthma receiving care in a primary care practice, much of the burden is preventable if primary care physicians take a more proactive stance towards asthma care.
Unscheduled or emergency office visits often focus on addressing acute symptoms, and little time or attention goes toward ways to prevent the next exacerbation or understand the origin of the ongoing symptoms. But this information, especially a patient’s known and unknown allergic triggers and possible medication non-adherence—including adequacy of inhaler technique, is critical to reducing disease burden.
Identifying Patients with Allergic Components of Asthma
Asthma treatment guidelines, including those from the National Asthma Education and Prevention Program (NAEPP), call for supplementing existing pharmacotherapy with the identification of environmental triggers including both indoor and outdoor allergens. These allergens can exacerbate an asthma attack by causing increased symptoms and decreased lung function, and those with multiple inhaled allergen sensitizations are at an increased risk of requiring a non-scheduled doctor visit or urgent care.
Introducing assessment tools into primary care practices, such as the Asthma APGAR tool, is an excellent first step in improving the allergen evaluation process. The Asthma APGAR tool includes a history assessment and a patient query regarding allergies and triggers, which often leads to further allergy evaluation once it’s determined that a patient has persistent asthma.
Understanding New Diagnostic Techniques and Incorporating them into Daily Practice
Asthma patients who’ve undergone allergy testing are more likely to use preventative strategies such as developing an asthma plan, practicing trigger avoidance and improving medication adherence. But, according to data published in the Mayo Clinic Proceedings, physicians discussed allergy evaluation in only 33 percent of office visits for asthma, and respondents documented allergy testing in just two percent of cases over a year. Limited time, costs and patient burdens are often cited as reasons for failure to evaluate and test, but the long-term costs to patients should be reason enough to overcome these traditional barriers.
Identification of allergen triggers for asthma, especially in high-risk patients, is key to allergy avoidance, abatement and treatment. But the ranks of those qualified to administer and interpret skin prick testing, a common form of allergy testing, are steadily shrinking in the U.S.
The testing gap left by fewer skin prick testing specialists can be filled by primary care physicians who simply need to draw blood. In vitro testing is, in fact, a proven solution for assessing allergen-specific immunoglobulin E (IgE) sensitization. These easy to administer tests are accurate and can be ordered routinely by primary care physicians.
Equipping Primary Care Practices with Tools for Success
For primary care physicians who do not receive in-depth instruction in allergy during training, tools exist to support them. The Asthma APGAR system uses an algorithm that suggests next steps, and many practices report time savings and better patient outcomes after using it. And, after attending the interactive Physician Asthma Care Education (PACE) program, already validated by two rigorous studies, physicians report their patients have fewer days affected by asthma symptoms and fewer emergency room visits – and these physicians spend no more time with patients, just more effective time.
Additionally, teaching, observing and regularly reassessing proper inhaler technique can enhance drug delivery and improve unintentional nonadherence. Even an extra two minutes of observation and instruction can improve medication adherence and avoid a future emergency room visit.
Boosting Patient Engagement
Given the limited time for patient clinic visits in primary care settings, healthcare providers must develop more efficient ways to interact with patients and counsel them on avoiding allergen exposure. Patient engagement starts with input derived from evaluation and testing. It also includes the following:
- Personalized materials – Many of the available patient materials for asthma trigger management are not culturally appropriate or available at the required reading level. They also can be lengthy and require an extremely high health-literacy level to be fully understood by the average patient. Primary care practices need to assess their materials and personalize them for each patient.
- Patient education – Patient education will be difficult and unsuccessful if primary care team members are not well versed and comfortable providing evidence-based recommendations for trigger avoidance. Straightforward, concise educational modules on avoidance counseling should be available. For example, if testing reveals dust mites are a trigger allergen, the provider should educate the patient on ways to reduce his/her asthma symptoms to that trigger.
- New technologies – Apps, videos and other data-driven technologies are emerging in healthcare and have tremendous potential. But more work must be done to understand how technology can improve allergen control and asthma outcomes.
Primary care physicians must take the initiative to better educate themselves on allergy guidelines, allergen testing and trigger management. By focusing on preventative care, proper allergy evaluation and improved patient counseling, patient outcomes can and should improve. Time spent being proactive will have much more impact, and at far lower cost, than time spending attending to patients in the ER.
