Running on Empty: The Crisis in Asthma Control
Many patients are like Adrienne Smith – they won’t use their controller inhalers regularly because they don’t like the idea of taking drugs every day. “I wait until it’s too late before I start taking the [controller], and I rely more on my [reliever],” she admits. To her, doing otherwise doesn’t make sense: “It would be like taking an aspirin every day if you didn’t have a headache.”
These patients aren’t fully aware of how the medication works. To be effective, the controller puffer must be used every day; otherwise, the inflammation returns. Because the controller reduces inflammation, rather than simply dilating bronchial tubes like the reliever, it takes a few days of use before there’s an improvement in symptoms.
Kaplan notes that, “if you don’t understand what you’re taking, you’ll say, ‘why do I want to take that orange [controller] inhaler when the blue one is the one that makes me feel better?’”
Efforts have been made to improve patient education. For instance, Canada has a program to educate and certify asthma educators, health professionals who can help patients manage their chronic illness. There are 630 certified asthma educators in Canada, but the system is far short of perfect, and many asthmatics never meet a CAE.
Funding often isn’t available for them so, although most will do asthma education as part of another job (nursing, for example), many are not employed as “asthma educators.” Even where there are full-time CAEs, they are often not accessible to patients, either because they work in a hospital (if you don’t land in emergency, you won’t see one) or because they work in the clinic of an allergist or respirologist, and you need to be referred there.
Asthma educators work with patients to teach them how to use their medication properly, and to explain that asthma shouldn’t be limiting. They often assist patients with implementing the asthma action plan – a document drawn up by the physician that helps the patient to cope with the condition between doctor visits.
For instance, if you get a cold, and your asthma flares up, the plan tells you how to increase the dose of your medication to prevent a severe attack. All asthma patients are supposed to have an action plan. Yet, only between 3 and 15 per cent do. “Education is not always considered an integral part of health care,” notes Haffner.
There is, however, a movement to get asthma education out of the hospitals and into the community. The problem? “There aren’t the resources to pick up the salaries of the asthma educators in the community,” says Cheryl Connors, executive director of the Canadian Network for Asthma Care, which certifies CAEs.
Certainly in some centres, the formula is working better than others. In Calgary, asthma educators are financed by the Calgary Health Region, and they travel to doctors’ offices and pharmacies to work with patients. “I don’t think there’s another place in Canada where such a broad coverage of respiratory educators is available,” says Dr. Robert Cowie, vice-president of CNAC.
In Ontario, changes are underway that will see health-care delivered in more of a team approach, where physicians can hire other health professionals, such as asthma educators, nurse practitioners, diabetes educators, and dietitians, to work with them.
In British Columbia, Jo-Anna Gillespie, a nurse, and her husband, Dr. Michael Mandel, see asthma patients in their Vancouver clinic. The pair also take education to rural communities in the northern part of the province. Gillespie, who has been an asthma educator since 1993, thinks the whole system needs to change.
“It’s totally not patient-centred, it’s doctor-centred,” she says. In her view, asthma management should be done in a clean, comfortable clinic that emphasizes wellness rather than sickness. “I think it should be simple, non-referred, but encouraged and supported by physicians.”
Next page: The road to a national asthma plan