Education and tracking ER use helps patients comply with asthma medications

Dr. Carmen Green-Lee and Lilliana Kraepel

The key to getting patients to take asthma medications regularly is to educate them on how the medication helps them and its proper use, and to schedule follow-up visits to discuss symptom management and asthma triggers, says Dr. Carmen Green‑Lee, a pediatrician who practices at IHA Child Health – Ann Arbor.

Asthma is the most common chronic childhood disease, affecting an estimated 5 million children, according to the National Committee for Quality Assurance. Approximately 20 million people in the United States have asthma. Collectively, people with asthma have more than 100 million days of restricted activity and 5,000 deaths annually.

When patients come in to her office with new symptoms, Dr. Green‑Lee gives patients handouts to help them realize their symptoms are related to asthma. “We try to help them understand the asthma diagnosis and explain how asthma medications work,” says Dr. Green‑Lee. Her office administers a spacer with a mask or nebulizer mist treatment machine for all children who have asthma, and a nurse demonstrates how to use them properly. The office also provides an asthma action plan for all caregivers of the child. Parent education includes reviewing the triggers that can cause asthma symptoms and discussing how to avoid them and treat them once they become apparent.

Follow-up visits are important. “We do a check at yearly physicals for children with mild intermittent asthma,” says Dr. Green‑Lee. “If the children come for any other visits throughout the year, we use those visits as an opportunity to address how they are managing their asthma symptoms.”

Dr. Green‑Lee sees patients with persistent asthma at least every three to six months if the asthma is not well controlled. Usually, they are on inhaled steroids. If the patient’s asthma is not well controlled, the doctor may increase the controller medication or prescribe additional medications. The office also requires frequent follow-up for patients who are stepping down their medication.

Tracking ER visits

Tracking emergency room visits is one way to help asthma patients manage their conditions and check on medication compliance. “We receive a fax within 12 to 24 hours for every patient who has been to the ER,” said Dr. Green‑Lee. “Our quality care coordinator and asthma specialist place phone calls to patients who have visited the ER and make appointments for them to have a follow-up visit in our office,” she said. The nursing staff may spend several hours a day calling patients who have visited the ER.

At the follow-up visit, Dr. Green‑Lee reviews symptoms and triggers and checks to make sure patients are using their medication properly. The office also checks on medication compliance by tracking how often asthma patients get their refills. “If you’re using your controller medicine, you shouldn’t be using albuterol as often,” said Dr. Green‑Lee. “If a patient is calling for albuterol refills too frequently, that’s often a red flag.”

If patients have a lot of emergency room visits, they are referred to a pulmonologist. “Children with asthma should have pulmonary function tests every year or two if they have persistent asthma,” says Dr. Green‑Lee. Parents can see by the lung function whether they have to step up the medications, she noted. “I have had patients who have had lung function tests and have become more compliant.” For example, patients who had required multiple bursts of oral steroids were able to get under better control after becoming more compliant with their inhaled steroids upon seeing their pulmonary function results.

Medication compliance can become an issue when parents are concerned about the side effects of medications, says Dr. Green‑Lee. “Parents may have an overweight child and look for a cause and effect. They may think the inhaled steroid is making the child put on weight,” she says. “But if we put them on the lowest effective dose, most studies show it’s not going to cause weight gain or decrease height. I tell them if you have poorly controlled asthma, the child could end up on oral steroids, which may result in greater side effects.”

Due to the efforts of her office, Dr. Green‑Lee says about 80 percent of her asthma patients have their conditions under control. She attributes that to the asthma education nurses and quality care coordinator who follow up with patients with regular phone calls. “When patients come in, we are not accusatory if they haven’t taken their medication as instructed. We try the compassionate approach and more education,” she says.