Asthma Clinics in Primary Healthcare Centres in Oman: Do they make a difference?

OBJECTIVES: This study aimed to determine the effect of newly established asthma clinics (ACs) on asthma management at primary healthcare centres (PHCs) in Oman. METHODS: This retrospective cross-sectional study was conducted between June 2011 and May 2012 in seven PHCs in the Seeb wilayat of Muscat, Oman. All ≥6-year-old asthmatic patients visiting these PHCs during the study period were included. Electronic medical records were reviewed to determine which clinical assessment and management components had been documented. RESULTS: A total of 452 asthmatic patients were included in the study. The mean age was 35 ± 21 years old (range: 6-95 years) and the majority (57%) were female. In total, 288 (64%) cases were managed at ACs and 164 (36%) were managed at general clinics (GCs). Significant differences were noted in the documentation of cases managed at ACs compared to those at GCs, including history-taking information regarding signs and symptoms (91% versus 19%; P <0.001), trigger factors (79% versus 16%; P <0.001) and a history of atopy (81% versus 17%; P <0.001), smoking (61% versus 7%; P <0.001), asthma exacerbations (73% versus 10%; P <0.001) or previous admissions (63% versus 10%; P <0.001). Furthermore, prescription rates of inhaled corticosteroids (72% versus 61%; P = 0.021) and short-acting ß-agonists (93% versus 82%; P = 0.001) were significantly higher at ACs compared to GCs. CONCLUSION: Overall, the findings indicated that ACs have had a positive impact on asthma management at the studied PHCs.

Asthma control: importance of compliance and inhaler technique assessments.

OBJECTIVES: The available assessment tools to determine asthma control do not include components assessing factors that may directly affect control. Our aim was to evaluate the relationship between patient compliance, inhaler technique and the level of asthma control. METHODS: Scores from the Asthma Control Test, individual inhaler device checklists and a novel questionnaire on the patient's medication regimen were used to measure control, inhaler technique and compliance, respectively, in patients with asthma attending Sultan Qaboos University Hospital, Muscat, Oman during a 3-month period. RESULTS: All of the 218 patients were receiving inhaled steroids, either in combination with long-acting beta agonists (86.2%) or alone. Asthma control was good in 92 (42.2%) patients; with 38 males (50%) and 54 females (38%), respectively (p = 0.059). Compliance and inhaler technique were poor in 40.8% (89) and 18.3% (40) of the patients. 60% (36) of the patients with good and 59.4% (41) with partial compliance had good control while 83.1% (74) with poor compliance had poor control (p < 0.001). Of the 92 patients with good control, 86 (93.5%) exhibited good inhaler techniques. In contrast, 85% (34) of the patients with poor inhaler techniques demonstrated poor control (odds ratio [OR] = 5.3; 95% confidence interval [CI]: 2.05-14.8; p < 0.001). A total of 93.3% (56) with good and 89.9% (62) with partial compliance demonstrated good inhaler techniques (p < 0.001). In patients with good control, 35 (38%) exhibited both good inhaler techniques and compliance and 38 (41.3%) had a good technique and partial compliance. CONCLUSION: Patients with good inhaler techniques and compliance have better control of their asthma. Asthma control will remain suboptimal unless the reasons for this lack of control are identified, assessed and eliminated. We recommend that inhaler technique assessment and measurements of patient compliance with their prescribed treatments should be considered for inclusion in the current assessment tools.

Is Clinical Judgment of Asthma Control Adequate?: A prospective survey in a tertiary hospital pulmonary clinic.

OBJECTIVES: Asthma control is often difficult to measure. The aim of this study was to compare physicians' personal clinical assessments of asthma control with the Global Initiative for Asthma (GINA) scoring. METHODS: Physicians in the adult pulmonary clinics of a tertiary hospital in Oman first documented their subjective judgment of asthma control on 157 consecutive patients. Immediately after that and in the same proforma, they selected the individual components from the GINA asthma control table as applicable to each patient. RESULTS: The same classification of asthma control was achieved by physicians' clinical judgment and GINA classification in 106 cases (67.5%). In the other 32.5% (n = 51), the degree of control by clinical judgment was one level higher than the GINA classification. The agreement was higher for the pulmonologists (72%) as compared to non-pulmonologists (47%; P = 0.009). Physicians classified 76 patients (48.4%) as well-controlled by clinical judgment compared to 48 (30.6%) using GINA criteria (P <0.001). Conversely, they classified 34 patients (21.7%) as uncontrolled as compared to 57 (36.3%) by GINA criteria (P <0.001). In the 28 patients who were clinically judged as well-controlled but, by GINA criteria, were only partially controlled, low peak expiratory flow rate (PEFR) (46.7%) and limitation of activity (21.4%) were the most frequent parameters for downgrading the level of control. CONCLUSION: Using clinical judgment, physicians overestimated the level of asthma control and underestimated the uncontrolled disease. Since management decisions are based on the perceived level of control, this could potentially lead to under-treatment and therefore sub-optimal asthma control.

Extent of subclinical pulmonary involvement in childhood onset systemic lupus erythematosus in the sultanate of oman.

OBJECTIVES: The aim of this study was to investigate the frequency of pulmonary function abnormalities in clinically asymptomatic children with Systemic Lupus Erythematosus and to determine the relationship of these abnormalities to clinical, laboratory, and immunological parameters as well as to disease activity. METHODS: Forty-two children with childhood onset Systemic Lupus Erythematosus were included in this study. Demographic, clinical, laboratory and immunological parameters, as well as disease activity were assessed. Pulmonary function tests (PFT) were performed routinely to screen for subclinical lung disease. RESULTS: Out of the 42 children, 19% (n=8) had clinical evidence of pulmonary involvement. The patients with no clinical evidence of pulmonary involvement (n=34) represent the study cohort. From our cohort of patients with no clinical evidence of pulmonary involvement 79% (n=27) had PFT abnormality; including 62% (n=21) had reduced FVC, 71% (n=24) had reduced FEV1, and 67% (n=12) had reduced DLCO. Similarly, 56% (n=15) had a restrictive PFT pattern, and 2.6% (n=2) had an obstructive PFT pattern, while 33% (n=7) had an isolated impairment of diffusion capacity. Due to small sample size; it was not possible to find a statistically significant difference between the cohort of asymptomatic SLE patients with abnormal PFT findings (n=27) and those with normal PFT findings (n=7) in terms of clinical, laboratory, immunological or disease activity index score. CONCLUSION: Subclinical lung disease, as demonstrated by abnormal PFT in patients with normal radiographs, may be common but should be interpreted with caution as an early sign of lung disease. Although PFT studies do not correlate well with pulmonary symptoms in patients with childhood onset SLE, they nevertheless provide objective quantification of the type and severity of the functional lesions.

Documentation of the management of asthma exacerbation in adults by primary health care physicians in a teaching hospital in oman.

OBJECTIVES: Asthma exacerbation is a major cause of morbidity and it is usually an indication of poor control. Appropriate management and documentation of the clinical assessment of an exacerbation, its severity, contributing factors and treatment are all essential components of asthma control. The aim of this study was to assess the documentation of the management of asthma exacerbations by primary care physicians (PCPs). METHODS: A retrospective analysis was carried out on patient records from 1 May 2008 to 31 April 2009. We included all acute exacerbation episodes in asthmatic patients aged ≥ 14, who received nebulized bronchodilators in the two family medicine clinics attached to Sultan Qaboos University Hospital (SQUH), Oman. A special form was designed to collect PCP's documented management. RESULTS: A total of 67 patients with 100 episodes were treated by 42 PCPs. Documentation of clinical assessment was low for previous admissions (2%), rescue nebulization (25%), duration of symptoms (57%), trigger factors (19%), compliance (9%), clinical signs (48%), peak flow rate (3%), and inhaler technique (5%). The diagnosis of asthma exacerbation was documented in 77% of the episodes. Documentation of therapy was also low (3% for oxygen therapy and 24% for systemic steroids). Documentation of post-nebulization assessment, follow-up appointment, and referral to asthma clinic were found in 37%, 23% and 11% of cases respectively. No documented evidence was found for referral to chest specialist or spirometry. CONCLUSION: Our study indicates major deficiencies in the documentation of asthma exacerbation management among PCPs. Further research is needed to identify the causes of those deficiencies. Following the standardised management protocol can be helpful.

Management and control of asthma in patients attending a specialist centre in oman.

OBJECTIVES: The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control. METHODS: All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol. RESULTS: Of the 207 patients, (mean age 40.64 ±14.8), 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E (IgE) was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists (LABA), antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority (40.1%) was receiving medium dose inhaled steroids. Although asthma was controlled in 162 (78.3%), during the previous month 66 (31.9%) patients had visited the emergency department and 31 (15.0%) patients were hospitalised at least once during the previous year. Only 63 (30.4%) patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 (25.6%) patients. CONCLUSION: Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored.

Compliance of physicians with documentation of an asthma management protocol.

BACKGROUND: Studies continue to show poor physician compliance with asthma management guidelines in clinical practice. However, standardized protocols specifically designed to be practical and user-friendly improve patient outcomes. OBJECTIVE: To determine the degree of physicians' compliance with the documentation of an asthma management protocol in a university hospital. METHODS: A simple asthma management protocol was designed and applied in our pulmonary clinic and primary care clinic for asthma. The protocol was based on the 1998 Manual for the Management of Asthma, from the Oman Ministry of Health, which follows internationally recognized guidelines. The protocol consisted of 4 sections: clinical history, peak expiratory flow (PEF) data, medication section, and simplified asthma management guidelines. RESULTS: All 30 physicians scheduled to conduct asthma clinics in the pulmonary clinic (14 physicians) and the primary care clinic (16 physicians) agreed to use the protocol. A total of 282 protocol forms were collected: 130 forms from 6 senior physicians and 152 from 24 junior physicians. Documentation of the entire clinical history was 65%, with the senior physicians scoring significantly higher documentation-completion rates (82%) for all components of the history than the junior physicians (50%). Documentation of all PEF data was poor (26%), despite high documentation of the PEF value itself (95%). There were significant differences in documentation of percent-of-predicted PEF between junior physicians in primary care clinic (70%) and other physicians (19%). Documentation of the entire medication section was only 34%. Although documentation of prescribed medicines was high (92%), compliance (48%) and inhaler technique (49%) documentation was low, with similar patterns demonstrated by all physicians. Documentation of the entire protocol by all physicians was low (9%), with junior physicians in the primary care clinic completing 28% of their forms. CONCLUSIONS: Our protocol enabled us to identify opportunities for improvement in documentation of asthma management in both the pulmonary and primary care clinics. The findings highlight the need for regular asthma education programs for all physicians, with a focus on documentation of performance skills such as monitoring of PEF and inhaler technique.

Metered-dose inhaler technique among healthcare providers practising in Oman.

OBJECTIVE: To evaluate the correctness of metered-dose inhaler (MDI) technique in a sample of healthcare providers practising in Oman, considering that poor inhaler technique is a common problem both in asthma patients and healthcare providers, which contributes to poor asthma control. METHOD: A total of 150 healthcare providers (107 physicians, 33 nurses and 10 pharmacists) who were participants in symposia on asthma management conducted in five regions of Oman, volunteered for the study. After the participants answered a questionnaire aimed at identifying their involvement in MDI prescribing and counselling, a trained observer assessed their MDI technique using a checklist of nine steps. RESULTS: Of the 150 participants, 148 (99%) were involved in teaching inhaler techniques to patients, and 103 of 107 physicians (96%) had prescribed inhaled medications. However only 22 participants (15%) performed all steps correctly. Physicians performed significantly better than non-physicians (20% vs. 2%, p <0.05) Among the physicians, internists performed better (26%) than general practitioners (5%) and accident and emergency doctors (9%). CONCLUSION: The majority of health-care providers responsible for instructing patients on the correct MDI technique were unable to perform this technique correctly indicating the need for regular formal training programmes on inhaler techniques.