New study points to gaps in asthma care across Ontario

By Ana Gajic

A new study led by Dr. Samir Gupta, an associate scientist at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, found that despite certain core asthma management practices that have been recommended for more than 20 years, significant gaps in asthma care persist across the province.

The study, published today in BMJ Open, found that care providers across three large family health teams in Ontario assess asthma control in only five per cent of visits, marking an important and newly identified gap in asthma care in Canada. For patients who did not have good control of their asthma, less than half were on a controller medication for asthma – a standard therapy which enables the majority of patients to achieve good control.

We asked Dr. Gupta about the focus of his team’s study and what he hopes will come next.

Q. What did you set out to study?

In the area of asthma management, there are three key care practices that doctors should follow:

1. Assess a patient’s asthma control level every visit;
2. Adjust medications according to the control level; and
3. Provide patients with a written asthma action plan (AAP), which is a self-management tool that lets patients know how to adjust their medications in case their asthma flares up.

We aimed to measure if these important practices are being followed in real-world primary care settings in Canada, and to understand what factors might be influencing these practices.

Q. Why did you focus in on asthma?

Asthma is one of the most common chronic diseases in Canada, affecting more than eight per cent of our population and costing Canadians over $2-billion per year. The primary goal of asthma management is to obtain good control of the disease.

With the right disease management, we know that most patients can live symptom-free. Unfortunately most patients do not have good asthma control, and we suspected that the reason for this was that best care practices were not always being followed.

Accordingly, we set out to study how patients are actually being managed in real-world, busy Canadian primary care settings, and to identify opportunities for improvement.

Q. What were the key findings of this work?

We followed 884 patients with asthma across three large family health teams in Ontario, over one year.

Our research found that providers assessed asthma control in only five per cent of visits and in 15 per cent of asthma patients over the one-year study period. When providers did attempt to assess control, they asked an average of only 1.6 out of the five recommended control questions.

Also, among patients who did not have good control of their asthma, less than half were on a controller medication for asthma – a standard therapy which enables the majority of patients to achieve good control. Finally, not a single patient received an asthma action plan over the study period. Even among patients who had been seen for a specialist for their asthma in the past, only four per cent had received an asthma action plan from that specialist.

Q. Why are these findings important?

These core asthma management practices have been recommended in Canadian and international asthma guidelines for over 20 years, based on decades of scientific research.

Our study demonstrates that these important practices still aren’t being routinely performed – and as a result, there are gaps in how asthma is being managed in the real world. These gaps represent a lost opportunity to improve the health and quality of life of patients with asthma.

There are many reasons why these gaps may exist, including the challenges of a busy and complex practice environment in Canadian primary care.

Q. What’s next for this research?

We are now using these results to identify strategies to improve care in busy primary care settings.

We have also developed an online electronic health solution that supports clinicians in identifying patients with poor asthma control and provides them with guidance in managing these patients based on best guideline evidence, right at the point of care (through the electronic medical record system).

About St. Michael’s Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in more than 29 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the Hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael’s Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.

About Unity Health Toronto

Unity Health Toronto, comprised of Providence Healthcare, St. Joseph’s Health Centre and St. Michael’s Hospital, works to advance the health of everyone in our urban communities and beyond. Our health network serves patients, residents and clients across the full spectrum of care, spanning primary care, secondary community care, tertiary and quaternary care services to post-acute through rehabilitation, palliative care and long-term care, while investing in world-class research and education. For more information, visit www.unityhealth.to.