Part 1

ASTHMA IN AUSTRALIA - THE CURRENT SITUATION

Asthma is a major public health problem in Australia. It affects 2,041,400 Australians¹ and costs an annual $585 to $720 million.² Asthma is a major cause of school absenteeism³ and of child admission to hospital.⁴ Asthma drugs cost the government $170,000,000 in 1995-1996 and are the third highest drug-group cost.⁵ Asthma is one of the ten most common reasons for seeing a general practitioner.

Prevalence is increasing in Australia as in other countries with a western lifestyle.⁶ Various theories are proposed for this increase⁷ but the complicated interaction of factors responsible has yet to be defined. There also appears to be an increased
severity of asthma.

The causes of asthma are not yet known and there is still no cure. However, in most people with asthma, the condition can be successfully managed. The fall in deaths from 964 in 1989 to 715 in 1997⁸ may indicate that some of Australia's strategies for asthma management are effective. The 1990 and 1993 national surveys of 22,000 adults and 16,000 children conducted by the National Asthma Campaign showed improved asthma management practices in the three year period. ⁹

The third national epidemiological survey of the asthma management practices of children and adults is being conducted at the time of writing (1999). This third survey will indicate developments since 1993 and set the baseline for the Implementation Plan.

The 1990 and 1993 results are as follows:

CHILDREN

SYMPTOMS (%)
	1990	1993	P Value
Wheeze past 12 months	19.5	20.7	<0.05
Diagnosed as asthma	17.2	17.1	ns

MANAGEMENT PRACTICES (%)
	1990	1993	P value
Dr meas lung fn	27.7	38.8	<0.001
Has PFM	15.4	26.5	<0.001
Has action plan	16.7	21.7	<0.001
Both AP & PFM	6.2	12.1	<0.001

REGULAR THERAPY (%)
	1990	1993	P value
Inh b/dilator	48.4	30.2	<0.001
Theophylline	5.3	1.2	<0.001
Inh c/ster	18.1	21.5	<0.05
Cromoglycate	8.9	7.0	<0.05

Dr meas lung fn = doctor measured lung function
Has PFM = has peak flow meter
Both AP & PFM = both action plan and peak flow meter
Inh b/dilator = inhaled brochodilator

ADULTS

SYMPTOMS (%)
	1990	1993	P Value
Wheeze past 12 months	19.1	18.4	ns
Diagnosed as asthma	7.1	7.2	ns

MANAGEMENT PRACTICES (%)
	1990	1993	P value
Dr meas lung fn	40.2	44.2	ns
A & E meas lung fn	11.1	7.7	ns
Has PFM	18.7	29.8	<0.001
Has action plan	14.0	19.8	<0.001
Both AP & PFM	7.1	12.9	<0.001

REGULAR THERAPY (%)
	1990	1993	P value
Inh b/dilator	89.7	89.5	ns
Theophylline	20.5	3.9	<0.001
Inh c/ster	33.4	39.1	<0.01
Cromoglycate	4.6	3.9	ns

Better asthma management means improved health outcomes and quality of life for people with asthma, and reduced costs to the community.² More general practitioner consultations may be incurred initially but, with the implementation of appropriate management plans involving a multidisciplinary team, fewer hospital admissions and specialist visits are likely.

A RECENT HISTORY - A Collaborative Approach to a Serious Problem

The problem of asthma in Australia is well documented. The first government report on this was the 1988 Report of the NHMRC Working Party on Asthma Associated Deaths.

Then, in response to the serious concerns about the death rate and the undermanagement of asthma by health professionals and people with asthma, The Thoracic Society of Australia and New Zealand developed the Asthma Management Plan, ¹⁰ the guidelines to assist doctors to manage asthma. By the time these guidelines were published, the major bodies concerned with asthma, The Thoracic Society of Australia and New Zealand, The Royal Australian College of General Practitioners, the Pharmaceutical Society of Australia and the Asthma Foundations, had conducted and evaluated the first national public education campaign, Could it be asthma?, using advertising and media to reach patients and doctors.¹¹

This led to the formation of the National Asthma Campaign (NAC) in 1990. The NAC was given the tasks of promoting the Asthma Management Plan to health professionals and people with asthma, undertaking epidemiological surveys on asthma, developing policy on asthma issues and conducting national public education campaigns. These national campaigns complemented the local activities of the seven Asthma Foundations and also stimulated asthma education activities in settings such as schools.

In 1995 the NHMRC National Health Advisory Committee Working Party on Asthma issued the report Asthma: Management, Education and Research.¹² This report acknowledged the valuable work being carried out in asthma, advising it be continued and expanded. It acknowledged the NAC as the leading agency in the field of asthma and recommended that it continue to provide a unifying direction for all forms of endeavour in asthma.

The strong intersectoral coalition of interests surrounding asthma has continued to examine issues, develop policies and improve practice. The NAC coordinated the development of the National Asthma Strategy, Goals and Targets and the National Asthma Strategy, Strategies and Implementation with other major shareholders. The National Asthma Strategy Implementation Plan, which follows these reports, examines current asthma activity and indicates areas for future action.

PRINCIPLES OF ASTHMA CARE

In the development of the National Asthma Strategy, and now of its Implementation Plan, the prime focus has been to improve the quality of life of people with asthma.

The NSW Health Expert Panel on Asthma has agreed principles of care which are:

PRINCIPLES OF ASTHMA CARE ¹³

1. All people with asthma should have access to timely and ongoing care in order to minimise the impact of asthma on their lives and to minimise the risk of premature death.

2. It is a fundamental right of people with asthma to have access to information, education and skills acquisition to enable them to participate in the management of their asthma.

3. All people with asthma should have access to high quality health services regardless of their financial status, cultural backgrounds and place of residence.

4. Asthma care should be appropriate, tailored and made available to groups of people with asthma who have special needs such as children, pregnant women, Aboriginal and Torres Strait Islander people, people from non-English speaking backgrounds and the elderly.

5. Every public hospital should have protocols for the acute management of asthma which conform with accepted guide lines. The protocols must include adequate documentation of assessment of severity, treatment provided and follow-up.

6. The person with asthma is entitled to:

general education about asthma, its effects and self-management skills;

timely and ongoing clinical care;

participate in the management of their asthma;

appropriate psychosocial support.

These excellent principles must continue to be the guiding force as the asthma stakeholders commence the Implementation Plan.

BENEFITS OF IMPLEMENTING THE NATIONAL ASTHMA STRATEGY

Implementation of the National Asthma Strategy will bring certain benefits for the individual and the community in health, social and economic terms. The person with asthma may experience all or some of a range of unpleasant symptoms - cough, wheeze, chest tightness, shortness of breath and disturbed sleep. Symptoms may be occasional, intermittent or persistent - work, school and social activity can be adversely affected by the condition. Even moderate asthma may be life-threatening. It may be difficult for someone with asthma to accept the potential seriousness of the disease. Most asthma can be well managed with medication and avoidance of trigger factors. Adherence to long-term medication is a problem for many people with asthma, as are the costs of medications and devices.

Further improvements in asthma management and positive health outcomes can be achieved through the implementation of those strategies within the National Asthma Strategy which have been identified by stakeholders as being of highest priority.

Tangible effects of a successful strategy would include:

reduced prevalence of asthma symptoms

continued decrease in mortality

fewer hospital admissions

less school and work absenteeism

an increased number of GP visits (good asthma management implies more regular medical review)

systematic asthma education

follow-up after hospital discharge

increased use of correct medications

improved quality of life for people with asthma.

Asthma is a serious problem for Australia, but the work of the NAC and the other organisations in asthma has proved that when resourced and researched adequately, measurable positive health outcomes can be achieved which improve the health and quality of life of people with asthma. The Australian community benefits from this, as well-managed asthma costs less than poorly managed asthma.

Comparison of potential cost impact of changes in asthma control for very severe asthmatics* ($/Asthmatic/Year)²

A reduction in the cost of asthma can only be calculated approximately, owing to increasing prevalence. If good asthma management is maintained, there is potential to reduce the overall cost.

Comparison of 1991 calculations and potential cost reduction for 2010, expressed in $m in 1991 dollars. This is minimal cost saving assuming a 10% change. The cost of asthma education was not included in the 1991 calculations. It could be included under Medical Consultations and Allied Treatments¹⁴

Potential Cost Reduction

If the Optimum Indicative Targets are reached the effect would be:

-	reduced prevalence and mortality
-	fewer hospital admissions
-	less school and work absenteeism
-	the same number of GP visits, as good asthma management implies more regular medical review
-	more asthma education, especially referrals via A&E attendance
-	improved quality of-life for asthmatics
-	increased use of correct medications

The effect on the cost of asthma in Australia can only be calculated approximately but a re-examination of the total cost of asthma in Australia could be:

Total Cost of Asthma in Australia

Comparison of 1991 calculations and potential cost reduction for 2010 if Optimum Indicative Targets reached, expressed in $m in 1991 dollars. This is minimal cost saving assuming a 10% change. The cost of asthma education was not included in the 1991 calculations. It could be included under Medical Consultations and Allied Treatments.

Long-term cost reduction will require some initial investment to implement
sustainable asthma management interventions which result in improved health outcomes for people with asthma.

The preceding companion documents to this Implementation Plan - National Asthma Strategy, Goals and Targets and National Asthma Strategy, Strategies and Implementation - make a clear case for what needs to be done to reduce the incidence and impact of asthma in Australia.

To change the face of asthma in Australia we must ensure that:

those without asthma and who do not have the tendency to asthma remain so. This means raising general awareness of potentially harmful environments and protecting those currently not at risk from situations which may put them at risk. The general strategy is one of environmental control.

those who don't have clinical asthma, but have the potential to do so do not develop the disease. This includes those who are atopic, those with family history of asthma, hay fever or eczema, and others who have had clinical asthma in the past, but in episodes rather than chronically.

ill health is reduced among those who currently have clinical asthma. For those in this category, the possibilities for improving health, quality of life and reducing mortality are to move from severe to mild asthma, persistent to episodic asthma or from episodic to no asthma. This requires education, management and risk control.