The healthcare industry deals with various medical and managerial issues, the number and complexity of which is always increasing. In this context, chronic diseases occupy a distinctive niche since they require specific approaches of investigation, control, prediction, and treatment. This paper aims at examining the chronic disease process, namely, asthma, with a detailed description of its pathophysiology, the standard of practice, pharmacological treatments, and clinical guidelines for assessment, diagnosis, and patient education.
In addition, the paper will discuss characteristics and resources related to the patients who manage the given condition, three factors contributing to disease management, and analyze asthma’s impact on patients, families, and populations. Finally, the paper will discuss three strategies for the evaluation and implementation of best practices for managing asthma.
The Pathophysiology of Asthma
Asthma refers to a long-term pulmonary disease characterized by chronic inflammation of respiratory airways, and spasm of smooth muscle, which consequently leads to airflow obstruction. According to National Heart, Lung, and Blood Institute (US), airflow limitation during asthma is recurrent and caused by different alterations in the airways, including bronchoconstriction, airway edema, immune hyperresponsiveness, and airway remodeling (“National Asthma Education,” 2007).
Many risk factors contribute to the occurrence and development of bronchial asthma in specific individuals, including heredity, ecology, nutrition, overweight, and microorganisms.
Many cells, such as dendritic cells, T-helper 2, lymphocytes, neutrophils, eosinophils, and others, play a significant role in the steady inflammation of the bronchial mucosa and the airways’ hyperresponsiveness (McCance & Huether, 2014). In particular, bronchoconstriction induced by the trigger is connected with mediators released from mast cells, including leukotrienes, histamine, prostaglandins, and tryptase that intermediately impact airway smooth muscle.
Triggers, that is, factors that cause attacks of suffocation and exacerbation of the disease, are allergens of chemical or natural origin, as well as cold, pungent odors, sudden fright, laugh, significant nervous, or physical stress.
Additionally, there are early asthmatic reaction and late response, the first of which reaches its maximum magnitude in the first 30 minutes and continues three or four hours. During this phase, dendritic cells capture allergens from the surface of the bronchial mucosa and bring them to the regional lymph nodes, where, interacting with regulatory T-cells, they activate the differentiation of T-lymphocytes into Th2 cells (McCance & Huether, 2014).
This process leads to vasodilation, bronchospasm, mucosal edema, and considerable mucus secretion from mucosal goblet cells. The delayed asthmatic response starts 4 to 8 hours after the early response with a more severe reaction of the immune system. Chemotactic recruitment of eosinophils, lymphocytes, basophils neutrophils, and lymphocytes during the acute response results in a latent release of inflammatory mediators and additional production of mediators (McCance & Huether, 2014).
During this phase, there is a direct tissue injury, scarring of the respiratory tract, and impaired mucociliary function with the accumulation of mucus and cell debris.
Standard of Practice for Asthma
The most recent clinical guideline for the management of asthma, called Global Strategy for Asthma Management and Prevention, was published by The Global Initiative for Asthma (GINA) in 2020. The initiative is lead and supported by the National Institutes of Health, the US, the National Heart, Lung, and Blood Institute, as well as the World Health Organization (“About us,” n.d.). The given Standards of Practice provide the entire spectrum of recommendations regarding the definition, description, assessment, diagnosis, and control of symptoms and future risks of asthma.
Special attention is paid to the determination of long term goals of asthma management, up-to-date asthma medication and therapies, treatment steps, and the management of exacerbations of symptoms. Furthermore, a separate chapter is selected for diagnosing and management of asthma in children aged five years and younger (“Global Strategy for Asthma Management,” 2020).
This section offers advice concerning inhaler choice, medication for symptoms control and risk-minimizing, as well as education of patients regarding main and possible factors, and first aid. Finally, the publication discusses the implementation process of asthma management strategy into clinical practice and the healthcare system overall.
The Evidence-Based Pharmacological Treatments in Minnesota State
Regarding asthma, the pharmacological treatment in Minnesota state adheres to the contemporary requirements of WHO. Before treatment, a doctor considers various factors to determine the most appropriate medicine in terms of dose and active substance. Mostly, drugs are taken through a device known as an inhaler, but it also can be given in the form of pills. In this regard, the pharmacological treatment is divided into two types, namely, long-term control medicines and quick-relief medicines.
In particular, long-term control medicines imply the use of various drugs that directly reduce airway inflammation and help to prevent symptoms from starting. It worth noting that this type of medication cannot relieve symptoms instantly or stop an asthma attack but can reduce the frequency and severity of such attacks considerably.
Long-term control medicines include inhaled corticosteroids, omalizumab, cromolyn, inhaled long-acting beta2-agonists, leukotriene modifiers, theophylline (“Managing Your Asthma,” n.d.) (“Asthma”). Among them, the most preferred and effective drug is inhaled corticosteroids that lead to long-term relief of the inflammation and swelling. By alleviating inflammation, they avert the chain reaction of the immune system, which ultimately hinders asthma development.
Sometimes, to enhance the effect of corticosteroids, inhaled long-acting beta2-agonists are added to them, the purpose of which is to open the airways (“Managing Your Asthma,” n.d.). At the same time, all people suffering from asthma require quick-relief medicines that can alleviate the symptoms immediately. Anticholinergics and inhaled short-acting beta2-agonists, including Albuterol, Levalbuterol, Metaproterenol, and Terbutaline, are referred to such types of medicine, the role of which is to relax smooth bronchial muscles that are tight during asthma attacks.
|Long-term Medicine||Quick-relief Medicine|
|Inhaled long-acting beta2-agonists||Metaproterenol|
Clinical Guidelines for Assessment, Diagnosis, and Patient Education
Diagnosis and Assessment
The accurate initial diagnostics, follow-up, and patient awareness play an integral part in the quick and successful management of the disease and prevention of its relapses. In particular, if the patient has complaints of recurrent dry coughing at night or 10-20 minutes after exercise, along with episodes of shortness of breath, wheezing, and chest tightness, asthma can be suspected (Horak et al., 2016).
To check for the availability of an allergic reaction in a patient, an allergy diagnosis should be conducted, which comprises the review of medical history, specific Immunoglobulin group E test, and skin test (Horak et al., 2016). Besides, for the precise diagnosis of asthma, the therapist should perform other tests, including pulmonary function testing, that is, spirometry measurements, and the identification of comorbidities and risk factors.
In particular, pulmonary function testing is fundamental for the diagnostic of asthma. Basic spirometry takes around 15 minutes to determine measures, such as PEFR, MMEFR, and FEV1, and can be conducted for individuals from 6 years of age in the clinic (Tarasidis & Wilson, 2015). For example, “the peak expiratory flow rate (PEFR) is a measure of the maximum velocity of expired air” (Tarasidis, & Wilson, 2015, p. 25).
These measurements facilitate defining the availability of airflow obstruction, its severity, and the possibility of recurrence over the short-term. However, it is worth noting that spirometry findings regarding many children with asthma are inclined to at a healthy level and, in seldom cases, indicate FEV1 limitations during complications (Horak et al., 2016).
Regarding comorbidities, it should be specified that tobacco smoke, obesity, atopy, allergic rhinitis, and family predispose are the most prominent risk factors among asthmatics. Finally, there is a differential diagnosis of asthma in adults over the age of 40 years, which should consider the availability of decease, including pulmonary embolism, chronic bronchitis, or emphysema congestive heart failure, among others.
Finally, it is worth adding that the primary objectives of assessment and monitoring are directly related to the notion of control, severity, and responsiveness to treatment. In particular, the assessment of control includes the evaluation of symptoms control and future risks of adverse treatment results, while severity assessment implies the level of treatment needed to manage complications and symptoms (“Global Strategy for Asthma Management,” 2020). Overall, the assessment process continues from three to six months and includes the application of spirometry procedure and peak flow monitoring.
Asthma is a chronic variable disease that is not amenable to complete recovery, and the manifestations of which significantly complicate the wellbeing of patients. Moreover, asthma epidemic burden on patient and state budgets since its exacerbations result in frequent time off and poor performance at work and school, and its overall management is rather expensive. In this regard, to alleviate the consequences of the disease, the Global Initiative for Management and Prevention of Asthma (GINA) developed guidelines to enhance the care and control of asthma, called an asthma action plan.
Many healthcare organizations, including BTS, SIGN, Irish Department of Health, among others, joined to GINA’s initiative regarding an asthma action plan. The plan includes a list and rules of medications, information about the ways of care for asthma with mild symptoms, during exacerbations, asthma attacks, and emergency contacts (“Asthma Action Plan,” n.d.). Besides, the guidelines consist of simple but practical and useful advice for the patients, which allows for preventing asthma attacks.
In this regard, not only should asthmatic focus on managing the disease but also considering and avoiding factors causing asthma complications, namely dust mites, tobacco smoke, pollutants, and other allergens. Finally, organizations recommend maintaining regular physical activity and participating in sports events since this improves organism adaptation to stressful situations as well as the physical and biological quality of the lungs.
Comparison of the Standards of Practice
Standard practices for asthma in Mayo Clinic follows the contemporary standards of international guidelines. In particular, every patient undergoes a careful examination, during which they are recommended to pass the appropriate tests, including IgE test, spirometry, Peak flow, Sputum eosinophils, to assess allergic reaction and lung functionality (“Asthma,” n.d.).
Besides, the physician learns a patient’s medical history, symptoms, and complaints and, based on the gathered information, makes a conclusion regarding the disease, its severity degree, and possible comorbidities. After diagnosis, patients can be prescribed medicines recommended by GINA, namely, inhaled corticosteroids, leukotriene modifiers, combination inhalers, theophylline, short-acting beta-agonists, and anticholinergic agents (“Asthma,” n.d.).
Additionally, a doctor develops a detailed asthma action plan in which a patient can find information on doses and time of medication needed during both remission and complication (“Asthma in adults: Creating an asthma action plan,” n.d). Furthermore, an asthmatic is given recommendations regarding triggers and factors related to allergy and asthma, as well as other non-medical measures allowing for preventing asthma attacks, namely, healthy nutrition, sports exercises, etcetera. Last, the patient is recommended to perform examinations in due time for monitoring the course of the disease and adjusting asthma treatment.
Characteristics of and Resources for a Patient Managing Asthma
First, patients who successfully manage asthma have significantly increased life expectancy since its manifestations and symptoms become less life-threatening and can be relieved quickly. In addition, the quality of life becomes also considerably improved because individuals can go in for sports, participate in different events or activities, and sleep better. Overall, they have improved lung functionality, a decreased occurrence of asthma attacks, and a reduced need in the use of inhalers, bronchodilators, and even corticosteroids.
To achieve excellent results in managing asthma, patients primarily should possess access to healthcare centers where they can find help regarding treatment and control of the disease and consultation concerning any disturbing question. In this regard, patients always have nurses and physicians who can advise and, in need, adjust their management programs.
Additionally, those who manage the asthmatic condition well have better access to information about factors causing exacerbations or, on the contrary, relieving the symptoms and measures necessary to prevent or stop the asthma complication. According to Mishra et al. (2017), individuals educated about asthma and its management have fewer emergency room (ER) visits and cases of hospitalization. Moreover, a patient who feels well has a greater variety of options and tools of diagnostic, control, and treatment.
Disparities between Asthma Management on a National and International Level
When comparing the management of asthma on the national and international levels, it worth noting that mainly, guidelines in different countries are similar. Nevertheless, disparities are conditioned by not only the economic and technological capacities of specific countries but also patients’ awareness of the disease.
For example, in the US, the asthma mortality rate is notably higher than in Europen countries; namely, while in the US, this rate is 6-7 deaths per million population, in the EU, this rate account for 2-3 deaths (“The Global Asthma Report 2018,” 2018). This is because Europen countries give much priority to national education of patients about asthma and preventive measures, including physical activities and sports.
Moreover, in Europe, the treatment approach to acute asthma partly differs from the US methods; namely, along with corticosteroid and β2-agonists, European physicians offer taking mepolizumab or reslizumab that has weaker adverse effects compared to corticosteroid (Holguin et al., 2020). Thus, the US government should enhance the distribution of medical service and awareness of people concerning asthma among the population to provide appropriate asthma management.
Four Factors Contributing to the Management
The availability of financial resources is an essential contributor to the management of asthma since the asthma treatment costs expensively. Nurmagambetov et al. (2018) indicate that only the average cost of prescription medication amounts to $1,830 per year, which is perceptible even for a middle-income family. Generally, an individual who has sufficient financial means can afford more effective options of control and medication, more precise diagnostic, and detailed consultation compared to asthmatics who are experiencing financial difficulties.
Medicaid and Medicare
Different healthcare insurance programs, including Medicare and Medicaid, play a substantial role in the management of the disease since they help individuals who strain financially receive adequate medical service. In particular, Medicaid is an insurance program delivering free or low-cost coverage to those in need, especially poor peoples, pregnant women, people with disabilities, and the elderly (“Medicaid”).
At the same time, Medicare is the US National Health Insurance Program for people 65 years of age or older as well as disabled people or individuals with persistent renal failure (“Medicare”). Overall, these programs allow low-income asthmatics to obtain appropriate medical support to manage the disease.
Access to Care
Access to care is a crucial determinant in managing asthma symptoms since nobody but qualified nurses and clinicians can ensure quality medical assistance that follows the needs of patients and standards of the guidelines. Individuals who have seamless contact with their attending doctors can count on practical solutions to issues related to asthmatic complications. Peoples who have access to clinical facilities can prevent the development of acute asthma and, in the case of exacerbation, save their lives.
Patient’s awareness of threats, consequences, possible measures, and solutions associated with asthma plays an integral role in its management and prevention of the development. In particular, asthmatics who are profoundly informed about their conditions know that they need to change their lifestyle, that is, nutrition, attitude toward physical activity, and different types of stressful situations, substantially.
Furthermore, such people are conscious of the ways and in which cases they should turn to a physician’s help to avert dangerous incidents. The knowledge also helps to avoid high costs as the expenses on medicines and services become lower. Altogether, Knowing information about asthma is vital in saving not only own life but somebody else.
A Lack of the Factors
When individuals have the drawback of financial resources, they cannot afford the quality healthcare services, which leads to poor outcomes in asthma management. Moreover, people in need tend to escape clinical aid and try to overcome the problem alone, which results in avoidable deaths or other adverse consequences to them and their families. The absence of both available and efficient insurance policy only complicates the problem since many people, especially disabled, elderly, and deprived families, cannot afford even primary care. As a result, such patients have increased frequency of asthma attacks, worse symptoms, and reduced wellbeing.
Regarding access to care, it is worth noting that asthma-related deaths mainly occur in developing regions, particularly in Africa, Asia, Latin America, and Indonesia, where people do not have specialized centers for aid. For example, according to the report of the Global Asthma Network 2018 (2018), age-standardized asthma-related deaths per million population in the US and EU account for no more than 10-25 people, while in Africa, it can reach 100-150 people. The central cause of such rates is undoubtedly no access to healthcare facilities.
Finally, concerning patient education, it should be indicated that a patient’s self-management is that strategy without which the successful treatment of this condition is impossible. The absence of knowledge about simple but practical asthma-allied rules and recommendations lead to unsatisfactory and tragic outcomes that can sometimes be easily prevented or addressed.
For instance, the same report displays that in the UK, during 2012-2013, half of 195 asthmatics died because of not seeking medical aid in clinical centers (The Global Asthma Network, 2018). This is the sufficient evidence of human ignorance of those measures required to make to prevent fatal and tragic consequences.
Characteristics of a Patient with Unmanaged Asthma
When asthma is unmanaged, it brings many inconveniences and significant problems in a patients’ life. Such individuals have more considerable frequency and severity of asthma symptoms and attacks as well as considerably worse wellbeing. For example, children with asthma cannot attend school regularly, take part in many entertaining activities and games, consume a particular food, such as citrus fruits or marmalade, and play with pets. Furthermore, such patients often do not have healthy sleep, and they are under constant risk of dying from acute asthma attacks or diseases that can cause exacerbation of asthma.
Effects of Asthma on Patients, Families, and Populations
As has been mentioned above, the lives of patients with a severe form of asthma are unbearable indeed. They have a number of problems that accompany them throughout life. In Minnesota state, adults face difficulties in performing their usual job tasks, while children have a worse performance at school because of frequent attendance at the clinic.
Moreover, many patients have asthma attacks; according to the Minnesota Department of Health, half of all patients experienced such episodes for twelve months (“Asthma in Minnesota,” 2015). Finally, many asthmatics have disrupted sleep, a limited number of permitted activities, and emergency department visits.
Patients’ families also notably suffer from the consequences of asthma due to high year-round expenses on the treatment and troubles related to asthma. There are cases when parents have to leave work responsibilities temporarily to care or arrange their children at the hospital. Besides, relatives have to create a favorable, clean, and safe home environment needed to prevent complications; for example, they should provide appropriate sheets, pillows, mattress, dehumidifier, air cleaner as well as cannot keep pets (“Asthma in Minnesota,” 2015). Such arrangements cause many worries and inconveniences for all members of the patient’s family.
Besides, the local budget, as well as entrepreneurs, incurs losses resulting from different causes. In particular, the Minnesota administration has to allocate a certain amount of financial assistance for treatment. Moreover, many employers face losses because of work absenteeism and sometimes should provide another workplace for asthmatics or an appropriate environment for them.
It is also worth noting that some employers lose workers; for example, the Minnesota Department of Health states that over 30 percent of asthmatics have to change their previous jobs through asthma (“Asthma in Minnesota,” 2015). Finally, asthmatics increase wait times during appointments and take beds in emergency departments.
Financial Costs of Asthma Burden
Patients and their Families
Asthma inflicts immense economic harm both at an individual and national level. In particular, according to Nurmagambetov et al. (2018), as of 2013, the annual total incremental medical cost of asthma per person accounted for over $3,200, $1,800 of which was ascribable to prescription medicine.
Other expenditures, including hospitalizations, office visits, outpatient visits, and emergency room visits, comprise the rest. Regarding patients’ families, they have to spend money on purchasing special equipment, sleeping accessories, and furniture, namely, mattress, dehumidifier, air cleaner, pillows, carpets, and others (“Asthma in Minnesota,” 2015). Besides, there is a need to develop specific nutrition that does not cause allergy for patients, which also requires additional money.
At the state level, it is worth noting that 408,000 Minnesotans have asthma, which notably determines the expenses of the local budget (“Asthma Quick Facts,” n.d.). It was estimated that in 2014, asthma cost accounted for over $650 million, including approximately $615 million of direct medical expenditures along with $54 million for lost workdays (“Asthma Quick Facts,” n.d.).
These expenses were primarily caused by clinical service, including diagnosis, nurse care, and hospitalization, as well as outpatient visits. Finally, the given indicators are significantly underestimated because many patients and medical facilities report only part or no information at all.
Three Strategies for Managing Asthma
Asthma is an issue that requires a complex approach to its resolution. To implement the best practices in the healthcare setting, my tree strategies primarily target at improving the quality of healthcare service, promoting access to care, and supporting affordable care. In particular, medical assistance would be enhanced through promoting current policies, especially patient-centered care that implies stimulating a direct patient’s involvement in the disease management and respect for patient’s values, preferences, and needs.
The patient’s participation in the management process will improve an individual’s literacy that is an integral component of asthma treatment. Additionally, patient-centered care requires reliable cooperation between clinicians, nurses, facility departments, to facilitate appropriate diagnostics and assessment of asthma as well as its successful control. Overall, active patient’s participation and the cooperation between healthcare providers will ensure the cultivation of the best practices in my organization.
Second, to promote the best practices, there is an extreme need for decreasing disparities in providing both access to care and quality care. According to the Agency for Healthcare Research and Quality, every healthcare organization should deliver a necessary set of services for all individuals irrespective of their racial or socio-cultural status (“2015 National Healthcare Quality and Disparities Report,” 2016).
One of the solutions for facilitating access to care is the development of a health insurance system, especially for people in need and disabled. Finally, the third strategy aims at reducing the cost of the medical service to make care affordable for every people. In particular, the Agency recommends designing a healthcare spending model that allocates expenditures more effectively and appropriately (“2015 National Healthcare Quality and Disparities Report,” 2016). The actual spending model will allow for redirecting saved funds on supporting poorer sections of the population.
Appropriate Method to Evaluate the Implementation
The evaluation of the implemented strategies is a challenging process necessitating the participation of all stakeholders, including healthcare providers, patients, and their families, as well as introducing advanced technologies. In particular, to estimate the first strategy, there is a need to conduct and review statistics concerning the results that show the magnitude and frequency of asthma attacks and the manifestation of its symptoms.
Besides, in this regard, the readmission rate would be relevant; less visit frequency of regular patients because of asthma would be a positive feature. Regarding the second strategy, I would observe outcomes associated with reducing disparities; that is, the increased proportion of consumers belonging to minor communities would mean good results. Finally, to evaluate the effectiveness of the spending model, I would focus on accessing the effect of affordable care on the outcomes relevant to the improvement of patients’ wellbeing and health.
In summary, the paper has in-depth examined the primary issues related to asthma, namely, its pathophysiology, pharmacological treatment and approaches of the management, and four factors contributing to the management. In particular, asthma is a chronic pulmonary disease caused by bronchoconstriction, airway edema, immune hyperresponsiveness.
Pharmacological treatment includes the use of long-term drugs that help to prevent the development of asthma and short-term medicine that provide instant alleviation of symptoms. In addition, the paper describes the characteristics of a patient with both managed and unmanaged asthma conditions and the financial and social impact of asthma on patients, families, and populations. Lastly, the paper has offer strategies for the implementation of the best practices, namely, the promotion of better care, affordable care, and collaborative care, as well as the ways of their evaluation.
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