Planned Follow-up of Adult-onset Asthma in Primary Health Care

Adult-onset asthma is the predominant phenotype of asthma with a worse prognosis and lower remission rate than in childhood asthma. Primary health care has the main responsibility for managing adult-onset asthma; however, little is known about conducting a long-term follow-up of asthma in primary health care and how systematically asthma is assessed during the contacts.

The present thesis aims to evaluate how planned asthma follow-up contacts occur in primary health care during a long-term period and how factors affecting asthma are assessed during these contacts. Further aims were to investigate whether there was a difference in evaluating asthma depending on whether the general practitioner (GP), nurse, or both professionals participated in the follow-up and whether possible factors associated with non-participation in follow-up could be identified.

The present thesis investigated the data collected from adult-onset asthma patients in the Seinäjoki Adult Asthma Study (SAAS). The SAAS study is a real-life 12-year follow-up study of 203 patients who were diagnosed with asthma in adulthood in the respiratory department at Seinäjoki Central Hospital. The diagnosis of asthma was made by respiratory specialist based on typical symptoms and objective lung function measurements. Smokers and patients with concomitant chronic obstructive pulmonary disease (COPD) or other comorbidities were not excluded. Thus, this study population well represents the typical primary health care asthma population. In addition to the data gathered from all the asthma-related health care contacts of the 203 patients during the 12-year period, data from the medication purchased was obtained on patients entitled to asthma medication reimbursement from the Finnish Social Insurance Institution.

Most of the asthma patients in the Seinäjoki Adult Asthma Study population had asthma follow-up contacts mainly in primary health care. Based on the results, regular asthma follow-up contacts did not occur according to guidelines in primary health care in the Hospital District of South Ostrobothnia when only a third of patients attended a planned asthma contact per year, and most of the patients had <4 planned contacts during the 12-year period. Overall, 28% of patients in the SAAS -study population had only 0–1 planned asthma follow-up contacts during the study. Heavy alcohol consumption was associated with poorer participation in follow-ups based on our results.

This thesis showed high adherence to performing lung function tests, especially to spirometry, in primary health care. Spirometry, peak flow monitoring, or both were conducted in almost 88% of contacts. Similarly, the documentation of possible respiratory symptoms was found in 79% of planned contacts. Lung function tests and symptoms were screened even more often if the GP and nurse both participated in the visit. Asthma medication names and recommendations for the next planned follow-up contact were found in over 60% of contacts. Instead, the documentation of smoking, pack-years, comorbidities, lifestyle factors, revision of inhalation technique, and asthma action plan (AAP) were poorly carried out during planned contacts, according to recorded patient data. Of all planned asthma contacts smoking status was only documented in 17% of contacts, while the pack-years, comorbidities, revision of inhalation technique, and AAP were assessed based on the recorded patient data under every tenth visit.

The usual division of labor between the nurse and physician can explain some of the differences observed between the GP and nurse in assessing asthma. Significant differences between professionals did not emerge in many respects, and the results emphasized that both professional groups should improve asthma assessment. The results indicated that the co-operation between a nurse and a GP could produce the best outcome in comprehensively evaluating asthma.

To conclude, based on a 12-year real-life follow-up study, this thesis showed that applicating evidence-based asthma guidelines in asthma follow-up has been only partially successful in primary health care. A need exists to improve regular asthma follow-up and systematic assessment and guidance of the patient during the planned contacts. The results may help identify potential health-care practice-related causes for uncontrolled and difficult-to-treat asthma not being controlled, and which areas of asthma assessment and follow-up require more attention in primary health care.