Asthma Management Guidelines: Updates, Advances, and New Options

BACKGROUND: Asthma still poses a substantial and unacceptable health and economic burden. The National Asthma Education and Prevention Program (NAEPP) guidelines for the management of asthma continue to evolve based on emerging clinical data, improving the understanding of asthma and approaches to its management. OBJECTIVES: To examine the clinical implications of current NAEPP guidelines for the diagnosis and treatment of asthma and the potential impact of the proposed 2007 guidelines update on asthma management. To examine the role of managed care organizations in fostering evidence-based asthma management. SUMMARY: Current NAEPP guidelines recognize symptom control as the chief therapeutic target in the management of asthma. The proposed update to NAEPP guidelines places greater emphasis on symptom control by expanding its definition to not only include measures of impairment but also the risk for deteriorating pulmonary function, asthma exacerbations, and controller medication side effects. Although inhaled corticosteroids remain central to achieving long-term asthma control in both current and proposed guidelines, the latter offers greater treatment flexibility and recognizes combination therapy as a preferred choice for achieving control in many patients with moderate persistent asthma. Managed care organizations, primarily using disease management programs, provide impetus for the widespread adoption of evidence based asthma treatment guidelines. CONCLUSIONS: Widespread adoption of evidence-based asthma management programs offers the opportunity for achieving and maintaining asthma control.

primaryc arer egional sales manager for McKesson General Medical and general manager of NMC Homecare. At HMSS, Inc., Rice assumed several positions of increasing responsibility,i ncluding branch management field trainer,o perations facilities manager, generalm anager of the Comprehensive CareCenter,and director of operations and business development. As director,h ei nitiated and developed operations for 7a mbulatoryi nfusion centers and several multimillion dollar management services agreements with physician practices.
Rice earned ab achelor of science degree in pharmacy from the Massachusetts College of Pharmacy and Allied Health Sciences in Boston. He received amaster of science degree in pharmacy from the University of Houston and completed apharmacy residency program accredited by the American Societyo fH ealth-System Pharmacists at the Veterans Administration Medical Center in Houston. He has authored numerous articles and publications pertaining to both clinical and managerial topics.
Kenneth L. Schaecher,M D, FACP, is medical director of utilization management, SelectHealth, Salt Lake City,U tah. He has direct responsibilities in the oversight and direction of physician review services as part of the utilization management and customer service/appeals processes for the health plan. Additional responsibilities include oversight and direction for the new technologies assessment process and as ac linical resource to the coding, clinical auditing, and pharmacy services department. He also maintains an active independent internal medicine practice, seeing patients 12 hours per week. This provides unique insight into issues that arise from both the payer and provider perspective and allows for decision making that can be awin-win proposition for all parties.
He is currently an active participant in awide array of academic/ community involvement activities, including serving as an adjunct associate professor of medicine at the University of Utah School of Medicine, member of the Utah Medical Association and adelegate to its annual convention, member of the American College of Physicians, and president-elect of the Salt Lake County Medical Society.H is previous experience includes serving as chief of staffo fal ocal community hospital, president of the largest independent multispecialty clinic in the Salt Lake Valley,m edical director of an independent medical services organization, chairman of the utilization management (UM) review committee for al ocal physician hospital organization, and member of Intermountain HealthcareUrban Central Region UM Review Committee.
Schaecher received his bachelor of science degree in biology at South Dakota State University and medical degree from the University of South Dakota Medical School. He completed his internal medicine residency at the University of Utah. He is acurrent member of Phi Kappa Phi.

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Table of Contents
Asthma Management Guidelines: Updates, Advances, and New Options This supplement was funded by an educational grant from AstraZeneca Pharmaceuticals. This supplement is based on the proceedings of an independent symposium held April 11, 2007, in San Diego, California. The symposium was supported by an educational grant from AstraZeneca Pharmaceuticals. *A total of 0.15 CEU (1.5 contact hours) will be awarded for successful completion of this continuing education activity (ACPE Universal Program No. 404-000-07-005-H01). For faculty disclosures, please see page S11. For accreditation information, please see page S12.
The articles published in this supplement represent the opinions of the authors and do not reflect the official policy or views of the Academy of Managed CarePharmacy,the authors' institutions, or AstraZeneca Pharmaceutical unless so specified. The authors have disclosed if any unlabeled use of products is mentioned in their articles. Beforeprescribing any medicine, clinicians should consult primaryr eferences and full prescribing information.

Target Audience
Pharmacists, physicians, and other managed health careproviders involved in asthma management

Learning Objectives
Upon completion of this activity,participants will be able to 1. define the burden imposed by uncontrolled asthma, 2. describe the National Asthma Education and Prevention Program (NAEPP) definition of asthma severity and issues that surround the diagnosis of asthma, U ncontrolled asthma continues to pose as ubstantial health careand financial burden. In the United States, asthma prevalence, hospitalizations, and mortality increased for morethan 2decades, beforeplateauing or slightly declining in 2000. 1 From 1979 to 1999, the asthma-associated death rates per 100,000 people almost doubled from 0.9 to 1.7, beforedeclining slightly to 1.5 in 2002. The most recent estimates revealed that, in the United States, almost 20 million people wered iagnosed with asthma in 2003, including approximately 6.2 million children under the age of 18 years. 1 Asthma prevalence spikes in children between the ages of 5and 17 years, increasing during adulthood in females (50% higher than males), and in blacks (28% higher than whites). Uncontrolled asthma still engenders nearly 500,000 hospitalizations and morethan 4,000 deaths annually. 1 Disconcertingly,a lmost 40% of the asthmarelated hospitalizations occur in children under the age of 15 years. In addition, the direct and indirect costs associated with asthma treatment now total about $16 billion annually,with the costs associated with uncontrolled asthma about twice that for controlled asthma. 1,2 Because uncontrolled asthma continues to be ap revalent and sometimes debilitating and potentially life-threatening disorder, optimal asthma management aimed at maintaining consistent control remains aparamount treatment goal. The National Asthma Education and Prevention Program (NAEPP) asthma guidelines focus on symptom control as acentral featureofoptimal management; the implementation of the most recent guidelines (2002) and the proposed 2007 updates, when finalized, will offer managed health careorganizations an opportunity to optimize the treatment of asthma for their enrollees.
In April 2007, as ymposium was held in San Diego, California, to examine the implications of current and proposed NAEPP asthma treatment guidelines for improving asthma outcomes. The symposium' se xpert participants provided valuable data and perspectives on the potential role of NAEPP proposed guidelines in asthma diagnosis and treatment as well as the role of managed careo rganizations in fostering their use among health carep roviders. The faculty included Robert P. Navarro, PharmD, president, NavarroPharma, LLC, cofounder of the Academy of Managed CareP harmacy; GaryK .R ice, RPh, MS, MBA, vice president, Pharmaceutical Services, Kelsey-Seybold Clinic, Houston, Texas; and Kenneth L. Schaecher,M D, medical director,S electHealth, Salt Lake City,U tah. This manuscript is based on the content of that symposium and includes current published clinical findings and expert opinions relevant to best practices in asthma management. SUMMARY: Current NAEPP guidelines recognize symptom control as the chief therapeutic target in the management of asthma. The proposed update to NAEPP guidelines places greater emphasis on symptom control by expanding its definition to not only include measures of impairment but also the risk for deteriorating pulmonaryfunction, asthma exacerbations, and controller medication side effects. Although inhaled corticosteroids remain central to achieving long-termasthma control in both current and proposed guidelines, the latter offers greater treatment flexibility and recognizes combination therapy as apreferred choice for achieving control in many patients with moderate persistent asthma. Managed careorganizations, primarily using disease management programs, provide impetus for the widespread adoption of evidencebased asthma treatment guidelines.
CONCLUSION: Widespread adoption of evidence-based asthma management programs offers the opportunity for achieving and maintaining asthma control.

D D i i a a g g n n o o s s t t i i c c C C o o n n s s i i d d e e r r a a t t i i o o n n s s
In the absence of ad efinitive test for asthma, diagnosis relies on the presence of ac onstellation of clinical symptoms, chiefly wheezing, dyspnea, and cough, as well as the patient' spersonal and family history, and the findings from pulmonaryfunction testing. 3,4 NAEPP 2002g uidelinesf urtherr ecommend that beforem aking the diagnosis of asthma, clinicians exclude other conditions that induce asthma-like symptoms, such as allergic rhinosinusitis, cystic fibrosis, chronic obstructive pulmonaryd isease, heart failure, pulmonarye mbolism, and viral bronchiolitis in children and angiotensin-converting enzyme inhibitor-related cough and vocal corddysfunction in adults. 3 Episodic, asthma symptoms frequently occur at night or in the early morning, triggering sleep disruption. Individuals with suspected asthma may also report that their symptoms aresparked by viral upper respiratoryinfection; exposure to specific allergens, including pollens, molds, or pets; or nonallergic triggers, such as weather changes exercise or exposureto irritants such as smoke or smog.

Classification
NAEPP 2002 guidelines advocate the use of spirometry, not just peak expiratoryf low (PEF) testing, for the initial assessment and ongoing evaluation of asthma. It should be noted, however,t hat individuals with asthma may display normal lung function during ag iven testing period. 3 Pulmonaryf unction measurements and asthma symptoms largely determine the level of asthma severity, based on NAEPP guidelines (Table 1).
Several factors complicate the accurate assessment of asthma severity,including the assessment of symptoms beforethe start of treatment, substantial symptom variability,a nd the fact that patients and caregivers often underestimate asthma severity.For instance, for the children diagnosed with moderate asthma (daytime symptoms and/or nighttime symptoms moret han once weekly) in the Children &A sthma in America survey, 46% of caregivers rated their children' sasthma control as good or veryg ood; for the children classified with severea sthma (continual daytime symptoms and frequent nighttime symptoms), 50% of caregivers described asthma control as good or very good (Figure1). 5

Early Identification
Since most cases of asthma begin during the first years of life, the identification of young children at high risk for developing asthma represents an important step in early disease management, providing an opportunity for altering the disease course. Investigators using data from the Tu cson Children' sRespiratoryStudy,alarge, longitudinal assessment of respiratoryillnesses in 1,246 children, starting at birth, developed 2i ndices for the prediction of asthma. 7 The stringent index required children to exhibit frequent wheezing during the first 3years of life and to meet at least 1of2major criteria (parental historyo fa sthma or eczema) or 2o r3m inor   The loose index required children to exhibit any wheezing during the first 3years of life plus the same combination of other risk factorsa st hose described for stringent index. Children with a positive stringent index were4toalmost 10 times morelikely to develop active asthma during their school years when compared with those with an egative index, and children with ap ositive loose index wereabout 3to5times morelikely to develop asthma than children with an egative index. In fact, 50% of the positive loose index and 76% of the positive stringent index children displayed evidence of active asthma during asubsequent school year. The investigators noted that the stringent index displayed arather low sensitivity (14.8% to 27.5%), when compared with the loose index (39.3% to 56.6%), implying the looser index is sufficient to identify many at-risk children destined to develop asthma during their school years. In addition, Guilbert and colleagues assessed the atopic profile of 285 toddler-aged children with recurrent wheezing who wereathigh risk for asthma because of aparental historyofasthma or ap ersonal historyo fa topic dermatitis, or both. 8 In this study,the majority (61%) of these children displayed sensitization to either food or aeroallergens, with eosinophilia and total serum IgE levels correlating strongly with aeroallergen sensitization. Male children weres ignificantly morel ikely to display sensitization to aeroallergens and to manifest blood eosinophil levels of 4% or greater and total serum IgE levels of 100 IU/mL or greater.T his highlights apotentially relevant role for aeroallergen sensitization in the early development of asthma, particularly in males. Overall, these findings suggest that relatively simple, readily available clinical data can be useful in predicting subsequent asthma development in children.
Managed careo rganizations should consider reimbursing for routine spirometrya ssessments in at-risk children and sponsor educational initiatives that would increase the recognition among primarycarephysicians and caregivers of the key signs and symptoms that signal an increased risk for asthma.  9 The guidelines support the addition of a long-acting beta 2 -agonist for patients diagnosed with at least moderate persistent asthma.
The NAEPP 2002 Expert Panel points out that clinical trial data strongly support the use of inhaled corticosteroids (ICSs) for improving asthma control in patients with mild or moderate persistent asthma. 9 When compared with as-needed beta 2 -agonists, ICSs improve prebronchodilator forced expiratoryv olume in 1second (FEV 1 ), dampen airway hyperresponsiveness, attenuate symptoms, and reduce the need for oral corticosteroids and asthma exacerbation-related hospitalizations. 9 Controversy remains, however,a st ow hether long-term ICS use slows disease progression in asthma?

I nhaled Corticosteroids and Asthma Progression
One of the potential pathophysiological changes in asthma-airway remodeling, characterized by smooth-muscle hypertrophy,b asement-membrane thickening, epithelial cell destruction, and other deleterious alterations to the lung membrane architecture. This can occur even in patients with mild asthma. 3 Short-term (3 months) ICS therapy has been shown to increase the number of ciliated airway cells and intraepithelial nerves and reduce inflammatorycell infiltrates, restoring the lung membrane architecturedisrupted in patients with untreated asthma (Figure3). 10 Findings such as these led to the hypothesis that ap ossible reversal of airway remodeling in asthma secondarytolong-term ICS therapy would yield beneficial disease modifying effects. Yet, whether sufficient evidence exists to conclude that the early

Bronchial biopsy specimens, clinical symptoms, and lung function wereevaluated in 7patients receiving daily ICS therapy and 7patients receiving adaily beta-agonist. In the figure, bronchial biopsy specimens from apatient with asthma for 9months areshown beforerandomization and after 3months of treatment with an ICS. The pictureonthe left indicates ahighly damaged airway epithelium (E) and evidence of an inflammatoryr eaction, including eosinophils (thick black arrows) and lymphocytes (arrowheads) beneath the basement membrane (BM). Mast cells (thin black arrows) arehighly degranulated. The pictureonthe right shows abronchial biopsy from the same patient after 3months of treatment with an ICS.
Reprinted with permission from Laitinen   mast-cell stabilizer nedocromil, and placebo. 11 All subjects were permitted to use as-needed bronchodilator therapy (albuterol). The results confirmed the role of ICS therapy as first-line therapybudesonide improved airway responsiveness and provided better control of asthma symptoms than either nedocromil or placebo. However,t he CAMP study did not provide evidence of diseasemodifying effects with long-termI CS therapy-progressive declines in lung function did not emerge in any treatment group, and, with treatment discontinuation, airway hyperresponsiveness reemerged. These findings wereb uttressed by data from the Prevention of Early Asthma in Kids (PEAK) study,ar andomized trial that included 285 young children aged 2t o3y ears at high risk for persistent asthma based on the presence of wheezing or allergy. 12 In this study,w hich assessed whether ICSs modify subsequent asthma development, children werer andomized to treatment with either fluticasone propionate (88 µg twice daily) or placebo for 2y ears. During the treatment period, ICS treatment yielded significant increases in episode-free days and lower exacerbation rates as well as significant reductions in the use of supplementaryc ontroller medication. Nonetheless, in these preschool children at high risk for asthma, af ull 2years of ICS therapy did not alter the development of asthma symptoms or alter lung function during at hird, treatment-free year.T hese findings argue that although ICS therapy reduces asthma disease burden, it may not alter disease progression.

Focus Shifts to Asthma Symptom Control
Data demonstrating the failureofcontroller asthma therapy to alter long-term lung remodeling in asthma, principally from results of the CAMP trial, compelled the 2002 NAEPP expert panel to focus on symptom control and quality of life instead of long-term disease remission as reasonable and attainable treatment goals.
The NAEPP guidelines point out that asthma control can be expected to varyover time and should be assessed at everyclinical encounter and that asthma management decisions should be based on the level of control. 13 Asthma control, defined in Table 2, is based on the frequency of asthma symptoms, the need for rescue asthma medication, patient and physician assessments, and lung function testing as well as quality-of-life issues, such as the presence of sleep disturbances and limitations to daily activities.

Measuring Asthma Control
Asthma control can be ac omplex, multidimensional parameter encompassing physiologic assessments and global assessments of functionality,d aytime and nighttime symptoms, health care utilization, and adherence to therapy. 14 Yet, in an active clinical practice with limited time and resources, how can asthma control be efficiently assessed? Easy-to-use questionnaires to evaluate control may include the Asthma Therapy Assessment Questionnaire (ATAQ), the Asthma Control Questionnaire( ACQ) and the Asthma Control Test (ACT). The ACT,for instance, was developed as apatient-based tool to identify individuals with poorly controlled

FIGURE 4 Asthma Control Test for Patients at Least 12 Years Old
asthma. 15 Versions of the ACT weredeveloped for adults (Figure4), children and caregiver ( Figures 5A and 5B). ACT scores have been shown to correlate with asthma-specialist ratings of asthma control and the percent-predicted FEV 1 . 15 As a screening tool, ACT scores have demonstrated an overall agreement with specialist ratings ranging from 71% to 78%. These findings underscorethe potential usefulness of the brief, easy-to-administer ACT as at ool for evaluating asthma control in the physician' s office setting.

Achieving Asthma Control
Asthma control now represents the primarygoal of treatment set by the 2002 NHLBI guidelines-that is, the prevention of chronic and troublesome symptoms during daytime and nighttime and the prevention recurrent exacerbations. Yet, the Children &A sthma in America survey data show that about 20% of children diagnosed with asthma still experience poor asthma control-wheezing, shortness of breath, chest tightness, and coughing at least three time aweek. 5 The financial consequences of poor asthma control ares ubstantial-moret han 80% of the total asthma-related health costs aregenerated by the 20% of patients with the poorest asthma control. 16 Asthma control remains an elusive goal for many patients and clinicians. This leads to the question of whether asthma control, as defined by current guidelines, is realistically achievable in practice. Al arge, one-year,r andomized, double-blind study that included patients with asthma, recruited from general practice and hospital clinics, examined that issue. 17 The study,w hich included 3,400 patients at least 12 years of age, compared inhaled mono-therapy with fluticasone and combination therapy that included salmeterol and fluticasone in achieving rigorous, guideline-based measures of control. In this study,t otally controlled asthma was defined as no daytime symptoms or rescue beta 2agonist use, and morning PEF ≥ 80% of predicted each day.W ellcontrolled asthma was defined as daytime symptoms 2o rf ewer days per week, the need for rescue beta 2-agonist medication on 2o rf ewer days and 4o rf ewer occasion per week, and aP EF ≥ 80% of predicted each day. 17 Both measures of control also required the absence of nighttime awakenings, asthma exacerbations, or emergency visits to the hospital. In the combination therapy group, total control was achieved by 31% of the patients compared with 19% of the patients in the monotherapy group. In addition, asthma was well controlled at the end of the study in 71% and 59% of the combination and monotherapy groups, respectively.T hese results imply that guideline-based persistent asthma control can be achieved for am ajority of patients with asthma, especially with the use of combination therapy,although asignificant proportion of patients still failed to reach guideline-defined control criteria.
Data showing that combination therapy can bolster asthma control led the NAEPP panel to revise the 2002 treatment recommendations for moderate persistent asthma to include longacting inhaled beta 2-agonists along with low-to-medium dose ICS therapy for adults and children older than 5years (Figure2). Although combination therapies have not been well studied in children under the age of 5y ears, the NAEPP 2002 expert panel suggests either monotherapy with medium-dose ICSs or the addition of long-acting inhaled beta 2-agonists to low-dose ICSs, when needed, as prudent treatment options for moderate persistent asthma.  18 Key proposed recommendations from the 2007 draft of NAEPP guidelines ares hown in Table 3. 19 Perhaps the most notable change is the further emphasis on asthma control as the predominant consideration in asthma management. The proposed guidelines link asthma control to two dimensions or domains: the burden of disease or impairment, which can be measured by number of tools including ACT;and risk, which includes not only the risk of asthma exacerbations but also the risk for accelerated decline in pulmonaryf unction with the emergence of airflow obstruction, and the potential risk for side effects associated with long-termcontroller medication use. 18 The 2007 update continues to emphasize anti-inflammatory agents as the most effective medications for long-term asthma therapy,but the guidelines also now note that that these agents do not appear to prevent disease progression. The proposed guidelines maintain the mild, moderate, and severep ersistent asthma  It'saproblem but it'sokay.

3
Yes, all of the time.

0
Yes, most of the time.

1
Yes, some of the time.

2
No, none of the time.

3
Yes, all of the time.

0
Yes, most of the time.

1
Yes, some of the time.

2
No, none of the time. categories but abolish the mild asthma category, replacing it with intermittent asthma to emphasize the point that even patients with milder forms of asthma can have severee xacerbations. In addition, instead of the 2a ge categories used in the previous guidelines ( ≤ 5years and >5 years), the updated guidelines advocate 3s ets of recommendations for managing asthma, based on age: ≤ 4y ears, 5t o1 1y ears, and ≥ 12 years. This change was driven by the growing knowledge that the nature of asthma and the appropriateness of certain asthma treatments and assessments, such as lung function testing, change over the patient's lifetime. The proposed draft also introduced an ew paradigm for pulmonaryfunction testing in children: the addition of FEV 1 /FVC (forced vital capacity) to classify severity. 19 The proposed guideline revisions also emphasize the need to consider the effects of asthma on quality of life and functional capacity separately,o na no ngoing basis, as these domains may respond differently to treatment. Moreover,t hey place greater emphasis on 2a spects of the asthma treatment plan: daily management and the early recognition of asthma exacerbations.

FIGURE 5A Asthma Control Test for Children
Moreover,the proposed guidelines increase the number of treatment steps from 4t o6 ,s upporting greater treatment flexibility.In the proposed treatment paradigm, treatment with as hort-acting beta 2-agonist to achieve symptom control commences on an asneeded basis at the initial diagnosis of intermittent asthma, with an emphasis on patient education and trigger avoidance at all treatment steps. The guidelines also advocate daily therapy for persistent asthma, and combination therapy,p referably with aL ABA, when control cannot be achieved with ICSs alone. It should be noted, however,that the new guidelines discuss the potential for an elevated risk for asthma-related mortality with LABA therapy and that this risk should be weighted against the benefits achieved by their use in patients incompletely controlled by low-to-medium doses of ICSs. In fact, LABA product labeling contains ab oxed warning that indicates these agents should be prescribed only in patients not adequately controlled by low-to-medium doses of ICSs or whose disease severity clearly warrants initiation of treatment with 2m aintenance therapies. 20 Av ariety of agents areo ffered for consideration as alternative therapies, including cromolyn, leukotriene-receptor antagonists, and, in patients with uncontrolled, moderate-to-severeIgE-mediated disease, omalizumab.  patients taking long-acting beta-agonists progression change to intermittent in order to emphasize that even patients with intermittent asthma can have severeexacerbations ≤ 4years, 5to11years, and ≥ 12 years Asthma Management Guidelines: Updates, Advances, and New Options izations typically develop these programs based on the treatment principles established in the NAEPP guidelines published in 1997 and updated in 2002. For instance, SelectHealth, an Intermountain HealthcareC ompany located in Salt Lake City,U tah, provides an array of services to optimize asthma management. For health care providers, it supplies educational materials that focus on the process of asthma careb yu sing guideline-based algorithms for diagnosis and treatment. In addition, SelectHealth routinely provides clinicians with asthma outcome measurement tools, such as ACT.In fact, this managed careorganization emphasizes the importance of outcome measurement based on their axiom, "what you don't measure, you can'tm anage." For patients, SelectHealth also provides educational materials such as newsletters, educational brochures, and notices of community asthma outreach events as well as monitoring tools, such as peak flow meters. When used properly,peak flow monitoring provides objective information on disease status, even in the absence of overt symptoms, and reveals ongoing pulmonaryd ysfunction to the patient. This information may promote continued adherence to the asthma treatment plan.
The SelectHealth asthma management program follows the 2002 NAEPP diagnosis and treatment guidelines and includes disease managers that focus solely on asthma treatment. Disease managers receive plan member health careu tilization data, such as pharmacy data related to the level of controller use, and emergency room or inpatient utilization information. These data permit the identification of members at high risk for asthma exacerbations. Once these at-risk patients arei dentified, case managers work with clinicians to regain symptom control. SelectHealth has also developed an asthma workgroup that examines what changes should be made to their established asthma treatment guidelines to ensurec onsistency with current national guidelines. In addition, on ayearly basis, SelectHealth provides continuing medical education opportunities to physicians in their organizations, so that these professionals can maintain a"state of the art" approach to asthma management. These so-called "Clinical Learning Days" provide SelectHealth with an opportunity to remind clinicians about the current asthma carep rocess models and to introduce any new processes that may have been implemented within the past year.
Since the implementation of SelectHealth' sa sthma disease management program, therehas been anotable decline in asthmarelated emergency room visits (Figure6 ). Moreover,s ince implementation (December 1999), beta 2-agonist use has also declined, with the percentage of patients with 3ormoreshort-acting beta 2agonist prescriptions filled decreasing from 12% (December 1999) to about 5% (September 2006). Controller use, 80% at the start of the program, gradually increased and has plateaued at 90%. These results demonstrate that asthma disease management programs utilized by managed careo rganizations can foster improvements in asthma control, although the gains made so far still fall short of optimal management.
At the Kelsey-Seybold Clinic, an integrated health caresystem that includes moret han 300 physicians providing primarya nd IHC System FIGURE 6 Percentage of Patients With Emergency Room Visits for Asthma Exacerbation Since Implementation of Disease Management Program specialty caretomorethan 300,000 patients at 18 or moreclinic locations throughout Houston, Texas, the pharmaceutical services department, working in conjunction with physicians and their nursing staffs, plays apivotal role in managing asthma with their 12 pharmacies located within the clinics. Kelsey-Seybold emphasizes 4key components of asthma management: objective assessment and monitoring; control of factors contributing to asthma severity,s uch as environmental triggers; pharmacologic therapy with afocus on the use of controller medications versus rescue medications; andpatient and caregiver education. Once finalized, the 2007 changes to the NAEPP guidelines will likely be adopted quickly by managed care organizations nationwide. This will result in amoreaggressive focus on consistent asthma control through the use of educational initiatives to foster early asthma recognition, an increased used of spirometryt o diagnose and classify asthma, and am orea ggressive treatment approach that would encompass short-acting beta-agonist treatment, on an as-needed basis, even in mild, intermittent asthma, and combination therapy to gain and retain control of more severea sthma. Managed carew ill also likely promote the use of patient self-management and self-assessment programs to bolster patient adherence rates and to morereadily identify those patients who experience exacerbations or other signs of uncontrolled asthma between regular physician visits.