As the medical community celebrates Asthma and Allergy Awareness Month this May, the American College of Allergy, Asthma & Immunology reminds clinicians and patients alike that allergists are key to successful asthma treatment.
“Allergists are board certified asthma specialists,” Jonathan L. Bayuk, DO, vice chair of the ACAAI Payer and Managed Care Committee and president of Allergy & Immunology Associates of New England in Springfield, Massachusetts, told Healio.
According to a report from ACAAI titled Asthma Management and the Allergist: Better Outcomes at Lower Cost, allergist management of asthma improves patient outcomes while reducing treatment costs for payers and indirect costs for society. It also leads to fewer hospitalizations and other emergency interventions, fewer missed days of work and school and significantly better health and quality of life.
Jonathan L. Bayuk
“Nine percent of people in Massachusetts have asthma, and that bears out across the country,” said Bayuk, who also is the division chief of allergy and immunology at Baystate Medical Center and assistant professor of medicine at UMass Chan Medical School.
The 25 million people with asthma in the United States — or 7.9% of the nation’s population — include 6.1 million aged younger than 18 years and account for an average of 3,168 deaths per year. But despite scientific advances, ACAAI said, asthma’s prevalence has increased.
“If you look at all the changes in medication that we’ve had, we’re still not further along, and that’s frustrating,” Bayuk said. “At some point, it’s not just about creating new drugs. It’s really about changing the way that health care looks at asthma.”
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Changing the approach
Guidelines encourage clinicians to diagnose asthma as early as possible and aggressively treat it when it is still mild to achieve control. Allergists are best equipped to provide these diagnoses and courses of treatment, according to ACAAI’s report.
Guidelines from the National Heart, Lung and Blood Institute and Global Initiative for Asthma as well as other national organizations recommend referral to specialists in many cases, although some health care plans make these referrals difficult.
“An allergist will focus on identifying the triggers, as much of asthma and asthmatic disease is allergic,” Bayuk said, adding that unlike many primary care providers, allergists often respond with biologics.
“Most patients in my area do not want to be on any medication, so we use immunotherapy or allergy shots, which could be extremely effective in reducing asthma symptoms and, in some cases, remove them from having any problems at all,” he said.
Patient education is a significant part of this process as well, as Bayuk said that allergists are especially good at explaining the immunology behind asthmatic reactions.
“Identify the triggers, try to eliminate as much as you can, optimize the medication and then educate the patient — what the problem is, why it happens, what can be done about it, how the patient can participate, which is vital to their own care, and have regular follow-up,” Bayuk said.
A preventive approach to asthma is preferable to waiting for exacerbations to occur and then sending the patient to the ED for oral steroids, Bayuk said, which may have side effects including weight gain, permanent changes to bones, increased fat in unsafe areas such as organs, increased diabetes risks and possibly even psychosis.
“That’s just a very poor way to manage it,” Bayuk said. “Steroids work. I certainly use them if I have to. But they’re definitely overused in settings where someone isn’t being managed properly. That’s not a good approach, and we know that to be true.”
Beyond the office
Outside the examination room, allergists can play a role in educating the community.
“I’ve been involved in many asthma awareness days, programs and fairs over the years, a lot of times focusing on children so they get education as early as possible,” Bayuk said. “Those efforts can be helpful because they educate in a way that is not just sitting in a doctor’s office.”
Though these events no longer use spirometry as part of their screening processes due to the COVID-19 pandemic, Bayuk said, he has incorporated breathing instruction into his presentations.
“It’s an obstructive disease, meaning that you can get air out but it still feels like you can’t breathe,” he said. “There are some breathing techniques that can be taught that can help people get through their asthma problems and strengthen their lungs as well.”
Despite these efforts, challenges remain at the system level.
“There’s a tremendous shortage of staffing in health care right now — nursing staff, medical assistant staff, ancillary health and physicians. In the last year, I would say at least 10% to 15% of our primary care service in this area has retired,” Bayuk said.
When patients do connect with PCPs, Bayuk continued, they often are dealing with other physical issues such as diabetes and hypertension or mental disorders such as depression or anxiety, in addition to other problems.
“At the end of the visit, the doctor may ask, ‘How’s your asthma?’ And the patient will say ‘It’s fine,’ and that’s it,” Bayuk said. “Patients definitely underestimate their asthma. They don’t necessarily know that the way that they feel is abnormal and that they need to address it.”
Furthermore, patients often get treatment for asthma exacerbations at urgent care centers and EDs, which then refer patients back to their primary care doctors instead of to an allergist.
“They just don’t have that direct connection,” Bayuk said. “That’s a big obstacle. So, I spend time in emergency rooms educating emergency department providers but, again, the system is overloaded, and there are other priorities that take precedence over asthma.”
Plus, regardless of their level of insurance coverage, patients struggle with affording medication.
“If their options are fighting through it with whatever they can get until they have an exacerbation or going to an emergency room vs. spending several hundred dollars a month for preventive medicines that work, they will often choose the former,” Bayuk said.
Environment plays a role in these asthma cases too, as Bayuk noted many residents of Springfield who live in apartment buildings that contend with dust mites, cockroaches, mold, mice and other triggers that are beyond his patients’ control.
“Their asthma is taken care of by community centers and urgent care centers and sometimes not taken care of at all,” he said. “So, they end up having a lot of asthma exacerbations. Hospitals, as hard as they try, sometimes are unable to look at that preventive piece, and that’s across the country.”
The role of collaboration
Bayuk believes that hospitals and outpatient providers need to collaborate and that primary care doctors should understand the role of allergists and what they can do in providing asthma care.
“Many patients tell me ‘I can’t believe I haven’t come here before. I was never told this was an option,’” Bayuk said.
Patients with asthma who are managed by specialists report significantly higher general physical and asthma-specific quality of life, according to ACAAI. But in addition to achieving better patient care, these referrals improve the bottom line too.
Each dollar invested in asthma control programs could save $71 in health care expenses as care shifts from costly hospital and ED settings to doctor’s offices and outpatient clinics, according to data from ACAAI.
Additionally, managed care leads to higher ratings for quality of care, fewer restrictions in activities, improved physical function, fewer unscheduled visits for asthma care and less overuse of beta agonist medications, among other personal and systemic improvements.
Now, Bayuk is working with colleagues at Baystate Medical Center in Northampton, Massachusetts to identify patients who are frequently treated for asthma at the center and connect them with allergist care.
“We’re trying to find a way to make it relatively easy for the emergency room provider or the urgent care provider to identify these patients and then have them referred to get further evaluations,” he said.
“If we could find a way for that to be much more efficient, how we take care of these folks, once they land in the hands of a well-trained person who understands how to take care of asthma, it could change their life,” he said.
These efforts should not stop with one collaborative program at one hospital either, Bayuk said.
“The way that America looks at chronic disease needs to change so we can help people live healthier, happier lives,” he said. “It’s better not just for them, but the health care system can save resources, make people’s lives better and prevent morbidity and mortality.”
For more information:
Jonathan L. Bayuk, DO, can be reached at [email protected].