P&S Journal: Spring 1995, Vol.15, No.2
A Multidisciplinary Approach to Asthma
By Robin Eisner
On a Wednesday afternoon in early January, 12 asthma inpatients sat in a semicircle in an Allen Pavilion day room to learn about their disease. A physical therapist, Stephanie Burke, with the help of flip charts and handouts, explained in Spanish and English how roaches, humidity, pollution, cold weather, dust, cigarettes, automobile fumes, detergents, colds, and paint can precipitate asthmatic attacks. And she offered suggestions for avoiding these things.
"I work in a haircutting store and hair spray makes me sick," one asthmatic woman said.
"Try to cover your mouth when you're spraying," Ms. Burke responded.
Ms. Burke also described proper usage of bronchodilators. Many asthmatics do not know how to use them: Some pump too many times into their mouths and get overdosed; others spray the drug into the air and try to inhale the aerosol.
The death rates and the severity of the disease for inner city and minority adult asthmatic patients in New York are among the highest in the nation. In an effort to improve the situation, CPMC started the weekly asthma education program in 1991 within the asthma unit at the Allen Pavilion. The asthma unit, opened in 1990, has seen 2,000 patients pass through the 12-bed inpatient unit. The multidisciplinary care from the unit's three attending physicians, nurses with asthma expertise, physical therapists, nutritionists, and allergists is not available elsewhere in the city.
Approximately 13 million people in the United States, about 5 percent of the population, suffer from asthma, according to the Centers for Disease Control and Prevention. In the 1980s, asthma prevalence in the United States rose by 30 percent. Since the 1970s, hospitalizations for asthma have doubled in adults to a level of 500,000 annually. Between 1982 and 1991, the death rate rose 40.2 percent. It is five times higher for blacks than whites. Experts point to higher poverty and drug and alcohol abuse rates among blacks as one explanation for the difference.
Asthma is an inflammation of the airways causing wheezing and shortness of breath. The bronchial tubes in the lungs narrow, and mucus builds up. Although asthma cannot be cured, it can be controlled with drugs that either open up the passageways or reduce the inflammation. Since asthma patients are often sensitive to environmental agents, knowledge about specific causes in individuals helps prevent attacks.
"Key to the success of the care and the management of our asthma patients is education," says Dr. Manuel Cabrera, assistant professor of clinical medicine and director of the asthma unit. Surveys of the Allen patients reveal that classes give them a better understanding of their disease, their drugs, and self-management techniques. They also become more self-confident about their disease. Physicians also report improved compliance with medications and clinic follow-up visits.
Besides benefiting patients, the unit also has helped Presbyterian Hospital, says Dr. Cabrera. Before the unit existed, he explains, asthma patients having an acute attack would go to the Presbyterian Hospital emergency room, be treated, remain under observation for a prolonged time, and then get admitted to the hospital. But ER facilities are costly and beds not always readily available.
"The unit relieved some of the overcrowding in the emergency room," says Dr. Cabrera. "And because of the specialized care in the unit, hospital stays for patients got shorter and cut costs."
To further improve patient access to care for the less acute phases of the disease, Dr. Cabrera plans to expand the unit to include an outpatient component. Since not all patients need to be admitted, an on-call nurse practitioner could provide 24-hour service to patients.
One of the problems with asthmatics who are poor is that they do not come to follow-up visits at clinics, says Dr. Cabrera. If their disease progresses for some reason, it does not get monitored until an emergency arises.
"The clinic system does not work for asthmatics. Appointments are made too far in advance and if patients come they never see the same doctor," says Dr. Cabrera. The nurse practitioner, he suggests, would provide better continuity of care.
Dr. Cabrera also would like to track patients after they leave the hospital, develop a regional culturally sensitive resource center, and build a clinical research program. "We want to create a structure that would allow us to fulfill our mission as an academic medical center-to provide the best care and advance knowledge about asthma," says Dr. Cabrera.