Goals and Principal Strategies

Key strategies which will achieve the stated goals and targets have been identified. They are a combination of

1. doing what is shown by evidence to be effective;

2. testing strategies on which there is currently consensus but no hard evidence;

3. establishing standards of management and practice; and

4. finding out more about interventions which will make a difference.

Goal One - Reduce Asthma Mortality and Morbidity

Potential Cost Reduction
Monitoring
Notes on Goal One

Australian studies demonstrate that asthma mortality and morbidity are associated with a range of preventable factors both environmental and social. Also, underestimation of the severity of the condition is a factor. This delays implementation of appropriate management regimens.

Principal Strategies

Identify best practice for asthma management and its outcomes. In this context evaluate which components of the Asthma Management Plan are effective in reducing morbidity and mortality in people with asthma.

Implement and disseminate proven best practice guidelines for asthma management including strategies for people with asthma and their carers, community education, health services and health professionals.

Conduct effective research to identify the causes of asthma and the mechanisms by which asthma morbidity and mortality can be reduced.

Detailed Strategies

S1.1 Identify best practice for asthma management.

1.1.1 Undertake a thorough evaluation of management practices in different settings including specialist and general practice, Accident & Emergency (A & E) departments, pharmacy practice and hospitals.

1.1.2 Refine and further develop proven components of the Asthma Management Plan in these different settings.

S1.2 Conduct routine audits and set up monitoring and surveillance for the implementation of best practice in the health system.

1.2.1 Develop quality assurance mechanisms to ensure standardised protocols are implemented for monitoring effective asthma management in a range of settings.

1.2.2 Aspects of this will include

- National Asthma Campaign (NAC) continuing its national epidemiological surveys 4 to 5 yearly of the asthma management practices of children and adults;

- establishing a national system to standardise State and Territory measurements of hospital admissions and readmissions;

- putting in place a national system of data collection for asthma related hospital primary care and pharmacist attendance.

S1.3 Develop the structure to facilitate research into reducing asthma morbidity and mortality.

1.3.1 Encourage increased commitment from funding organisations (National Health & Medical Research Council (NHMRC), Asthma Foundations, pharmaceutical companies, general corporate sector) and identify and pursue new sources of funding.

1.3.2 Lobby the Australian Government, NHMRC and State health departments to prioritise asthma as a health issue and to increase financial support for asthma research. This includes basic, clinical and applied research.

1.3.3 Contribute to the NHMRC's initiatives in establishing priorities for best practice guidelines for improved health outcomes.

S1.4 Ensure that age and culturally appropriate medical and education procedures are established for people with asthma.

S1.5 Examine the factors which contribute to school and work absenteeism and develop interventions to address these.

S1.6 Examine the factors which contribute to the risk of life-threatening asthma and develop interventions to manage these.

S1.7 Establish a system for the identification of those at risk of developing life-threatening episodes of asthma,

S1.8 Maintain, refine and develop mechanisms for appropriate classification, recording and analysis of deaths from asthma,

S1.9 Ensure that appropriate medical follow-up procedures are put into place for patients leaving hospital after treatment for asthma,

S1.10 Investigate and determine the most effective means of establishing asthma education programs for patients during and after a hospital stay, including follow-up from the hospital to the GP,

S1.11 Work with health authorities to implement these follow-up procedures on a national basis, using the resources of the General Practice Divisions if appropriate.

S1.12 Ensure that optimum improvements in quality of life are achieved and maintained for people with asthma.

1.12.1 Identify medical, social and psychological barriers to maintaining optimum quality of life for people with asthma.

1.12.2 Develop and implement ways to improve quality of life for people with asthma and their carers.

Current Situation/Evidence	Performance Indicators	Optimum Indicative Targets for the Year 2010
All-age mortality of 4.4 per 100,000 population¹.	Reduction in all-age mortality rate.	All-age mortality of 3.96 per 100,000.
*Asthma mortality rate in Australians aged 5-34 of 0.8 per 100.000¹.	Reduction in the mortality rate of Australians aged 5-34.	Asthma mortality rate in Australians aged 5-34 of 0.72 per 100,000.
21% of children suffer symptoms of asthma².	Reduction in the number of children experiencing asthma symptoms.	18.9% of children suffer symptoms of asthma.
Prevalence of asthma in adults of 7%^3,4.	Reduction in prevalence amongst adults.	Prevalence of asthma in adults of 6.3%
Impact on quality of life and management of asthma is varied across the community⁵.	Reduction in the factors which impair quality of life in people with asthma and their carers.	Establish baselines for the factors which impair quality of life in people with asthma by the year 2000 and reduce these by IO% by the year 2010.
Average of 8 school days per year lost due to asthma⁶.	Reduction of school absenteeism due to asthma.	Average of 7.2 school days per year lost due to asthma.
Median of 3 days off work per year due to asthma⁴.	Reduction of work absenteeism due to asthma.	Median of 2.7 days off work per year due to asthma.
Facilitated referral of patients to intensive outpatient treatment programs staffed by asthma experts has been shown to improve health and asthma management outcomes for patients with asthma presenting to A & E for acute asthma care^7,8.	An increase in the proportion of people attending A & E who have been referred for asthma education and for medical management.	Baseline established by the year 2000 of the proportion of people attending A & E who have been referred for asthma education and for medical management and a 20%-50% increase achieved by 2010.
Asthma accounts for 3.7% GP encounters⁹.	Reduction in the frequency of exacerbations requiring primary care consultations. Increase in consultations for those with controlled asthma.	Decline of 10% in acute exacerbations attending GPs (baseline to be developed).
3% of asthma admissions to hospital are readmitted for asthma within two weeks¹⁰.	Reduction in preventable asthma readmissions to hospital.	2.7% of asthma admissions to hospital are readmitted for asthma within two weeks.

* As asthma deaths increase with age and Australia's population is ageing, it is particularly important to focus on mortality rates in the 5-34 age group where the impact of preventive strategies can be most readily assessed.

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.

Total Cost of Asthma in Australia	Low Estimate		High Estimate
Total Cost of Asthma in Australia	1991	2010	1991	2010
Travelling time to attend consultations	23	20.7 (-10%)	64	57.6 (-10%)
Reduced effectiveness at work	40	36 (-10%)	96	86.4 (-10%)
Caregiver absenteeism	88	79.2 (-10%)	123	110.7 (-10%)
Direct absenteeism	111	99.9 (-10%)	111	99.9 (-10%)
Ambulance and allied treatments	13	10.4 (-20%)	13	10.4 (-20%)
Indirect medical	34	30.6 (-10%)	58	30.6 (-20%)
Hospitalisation	58	46.4 (-20%)	58	46.4 (-20%)
Medical Consultations*	98	98	98	98
Pharmaceuticals	121	145.2 (+20%)	121	145.2 (+20%)
TOTAL	586	566.4	718	685.2

* unnecessary medical consultations would reduce but regular reviews would increase

Monitoring

Australian Bureau of Statistics and Australian Institute of Health & Welfare data to measure the incidence of asthma
Regular and ongoing population-based surveys to ascertain awareness, knowledge and behaviour changes
Uniform, national, regular and ongoing hospital admissions data to measure the rate of hospital admissions and readmissions and presentations at A & E within one month
Departments of Education records to ascertain school absenteeism due to asthma
Quality of life measures/indicators.

Notes to Goal One

1. Australian Bureau of Statistics, 1994. Causes of Death.

2. Comino EJ, Bauman A, Mitchell C, et al. Serial trends in childhood asthma management in Australia 1990-93. Aust NZJ Med 1994;24-4:462..

3. Bauman AE, Mitchell CA, Henry RL, et al. Asthma mortality in Australia: an epidemiological study. Med J Aust 1992;156:826-31.

4. Abramson M, Kutin J, Rosier M, Bowes G. Morbidity, medical and trigger factors in a community sample of adults with asthma. Med J Aust 1995; 162:7881.

5. Marks GB, Mellis CM, Peat JK, Woolcock AJ, Leeder SR. A profile of asthma and its management in a New South Wales Provincial Centre. Med J Aust 1994, 160:260-8.

6. Robertson CF, Heycock E, Bishop J et al. Prevalence of asthma in Melbourne schoolchildren: changes over 26 years. BM J 1991;302:1116-8.

7. Gibson PG, Talbot PI, Hancock J, Hensley MJ. A prospective audit asthma management following emergency asthma treatment at a hospital. Med J Aust 1993;158:775-8.

8. Allen DH, Allen RM, Jones MP. Referring adults to a special asthma clinic following hospital care for acute asthma improves asthma management and health outcome. Aust N Z J Med 1995;26:453.

9. Bridges-Webb C, Britt H, Miles D, Neary S, Charles J, Traynor V. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust supplement, 19 October 1992.

10. Rushworth RL, Rob MI. Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management. Aust J Public Health, 1995;19:363.

11. National Asthma Campaign. Report on the cost of asthma in Australia, Melbourne 1992.