Asthma education, control test help lower exacerbations risks

The presence of asthma education and Asthma Control Test (ACT) may prevent exacerbations or at least delay the onset of severe exacerbations, suggests a Singapore study.

ACT consists of five multiple-choice questions and is used as a numerical asthma symptom control tool. Its scores range from 5 to 25, with higher scores indicating better asthma control.

“This emphasizes the importance of ensuring quality care through these quality-of-care indicators (QCIs) in our clinical practice,” the researchers said. “Our findings have the potential to inform clinical guidelines and policy decision-making.”

The research team obtained and analysed data from the SingHealth COPD and Asthma Data Mart, including asthma patients managed in nine SingHealth polyclinics and Singapore General Hospital from January 2015 to December 2020.

Patients were included in the analysis if they received Global Initiative for Asthma (GINA) steps 3‒5 treatment, with at least one QCI recorded, and at least one severe exacerbation within 1 year before the first QCI record. The researchers used multivariate Cox regression and quasi-Poisson regression models to analyse data.

A total of 3,849 patients were included in the study. Those with records of asthma education (adjusted hazard ratio [HR], 0.88; p=0.023) or ACT (adjusted HR, 0.83; p<0.001) showed a longer time to severe exacerbation (TTSE). On the other hand, the adjusted HR is higher for spirometry (adjusted HR, 1.22; p=0.026). [Ann Acad Med Singap 2023;52:497-509]

Multivariate analysis revealed that only asthma education and ACT were associated with a reduction in the number of exacerbations (asthma education estimate, ‒0.181; p<0.001; ACT estimate, ‒0.169; p<0.001).

“No QCI was significant for the number of exacerbations associated with ED/inpatient visits,” the researchers said.

ACT assessment

Previous studies evaluating ACT only assessed the validity of this tool and the association of its scores with asthma control. No other study had examined the performance of ACT in improving patient outcomes, according to the researchers. [Chest 2005;128:1968-1973; Chest 2009;135:904-910; World Allergy Organ J 2010;3:6-8]

“[ACT] can be performed concurrently during the asthma education session by the asthma educator and is offered in multiple languages,” they said.

Of note, QCI implementation meant hiring and training certified asthma educators. Training staff would require time. The additional time spent in clinics could result in longer wait times for patients and greater burden of care by service providers.

“An alternative to in-person ACT assessment would be teleconsultations, preferably before clinical consultation,” the researchers said. “ACT or other asthma symptom control tools (eg, Asthma Control Questionnaire, GINA risk assessment) can be assessed online.” [https://www.asthmasingapore.com/asthma-singapore/asthma-resources/asthma-control-test.html]

Other barriers towards the QCI implementation included language and culture. Language issues could deter the effectiveness of asthma education, and translation services would mean higher costs. [Patient Prefer Adherence 2020;14:1351-1359; Ann Allergy Asthma Immunol 2012;109:179-184]

“The multiracial and cultural make-up of Singapore also has bearing on the beliefs and perceptions of asthma treatment (eg, use of traditional Chinese medication, steroid phobia),” the researchers said. “Hence, more time and resources may be required to convince such groups of the effectiveness of evidence-based asthma treatment.” [Patient Prefer Adherence 2020;14:1351-1359]