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 centers, 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.
Finding a National Approach
At the very least, asthma is on the federal government’s radar. Ottawa is involved in major discussions, led by the Lung Association and including patient groups, the medical community and the pharmaceutical industry, which will be held over the next two to three years.
The intent is to develop a national plan – the Lung Health Framework – that will “stem this impending crisis” in respiratory health in Canada. (The framework will include lung cancer and emphysema as well as asthma).
In the shorter term, there are other projects in the works. Dr. Judah Denburg, the CEO and scientific director of the research network AllerGen, says his organization is working with the government and others on a pilot project that would “make it imperative” that every patient in Canada who is diagnosed with asthma undergoes a lung function test.
When it comes to efforts to improve education and treatment, Chapman of the University Health Network criticizes the slowness to act. “I don’t think there’s been a good application of some of the things we’ve known for years about treating asthma,” he says.
“Somehow, heart disease and cancer always get a lot of attention. And appropriately so. But there certainly is some progress that we can make with asthma that we’ve failed to make.”
The Toll of Poor Control
Poor asthma control isn’t just bad for the patient: in Canada, more than eight million work days are lost each year due to asthma-triggered absenteeism. Respiratory disease as a whole costs the Canadian economy an estimated $15 billion a year. Worldwide, the economic costs associated with asthma are thought to be greater than tuberculosis and HIV/AIDS combined.
Experts hope that as education efforts improve, asthma patients will finally get the message, and spend less time in the emergency room and more time enjoying physical activity and staying healthy.
And there’s even greater incentive to accelerate education and treatment: although the number of deaths caused by asthma has gone down in recent years, more than 200 people still die of it every year in Canada. Almost all of those deaths could have been prevented because, as Boulet puts it, “asthma should really just be a minor nuisance.”
Yet, we all know that person who claims to have “bad asthma,” whether it’s the girl who is always huffing and puffing on your sports team or your friend who refuses to go to the gym because “I can’t.” These people all have one thing in common: they’re being fooled by their condition.
First published in Allergic Living magazine.
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