The impact of guidelines on long-term asthma care: a study of hospitalised patients in Malta • Antonella Tonna, Dorothy J. McCaig and Joseph M. Cacciottolo Pharm World Sci 2004; 26: 208–213. © 2004 Kluwer Academic Publishers. Printed in the Netherlands. A. Tonna (correspondence, e-mail: antonellatonna@hotmail.com): Department of Pharmacy, St. Luke’s Hospital, Malta D.J. McCaig: School of Pharmacy, Robert Gordon University, Aberdeen, UK J.M. Cacciottolo: Department of Medicine, St. Luke’s Hospital, Malta Key words Asthma Guideline adherence Inhaled steroids Malta Patients Self management Undertreatment Abstract Objective: To compare actual practice to that recommended in asthma guidelines, published in Malta in February 1998, with respect to the management of asthma. These were the first national clinical guidelines to be published locally. Method: A piloted, structured interview was conducted with patients between 14–59 years who were hospitalised with an admission diagnosis of acute asthma. In the case of repeated admissions, only the first interview was considered. All interviews were carried out by either of two clinical pharmacists and lasted about 30 min. The four-year prospective study started in February 1997 (one year before publication of guidelines and aimed at collecting baseline data) and finished in January 2001 (three years after publication of the local guidelines). Main outcome measures: Inhaled steroids on admission. Patient partnership: use of a written self-management plan and home peak flow monitoring. Patient compliance with inhaled steroids. Results: 304 patients (68% females; mean population age 33.9 years SD ± 13.41) were interviewed over the four-year period. The difference in proportions test (Z-test) was used to analyse the data comparing years 2, 3 and 4 with year 1. No statistical differences were found when comparing the groups for inhaled steroid treatment on admission or availability of a home peak flow meter. Similarly, no differences were found between groups when comparing compliance with inhaled steroids. A statistically significant increase in availability of a self-management plan was found over the study period (3% in year 1; 1% in year 2; 11% in year 3; 9% in year 4), but the overall use of such plans remains disappointingly low. Conclusion: With the exception of an increased use of self-management plans, there appears to be lack of adherence to guidelines with consequent undertreatment of asthma, despite the fact that guidelines were published three years ago. This indicates a need to ensure better dissemination and implementation strategies to promote adherence. It is suggested that the clinical pharmacist is well-placed to promote adherence to guidelines. Accepted September 2003 Introduction Malta is a Mediterranean island lying 93 km south of Sicily and 288 km away from North Africa. The popu- lation for 2000 was 382,500 1 . There is no data on prevalence of asthma in adults in Malta, though there is a general impression among physicians that incidence of asthma is increasing 2 . Mortality rates have remained low with 8 deaths in 2001 3 . Asthma falls under the list of chronic diseases and patients are entitled to a free-of-charge health care at primary, secondary and tertiary levels of care. Emergency care and hospitalisation are offered at St. Luke’s Hospital, the only acute hospital in Malta. Patients below the age of 14, are admitted to paediat- ric wards, while those between the ages of 14–59 are admitted to medical wards under the care of one of three consultants in respiratory medicine. Worldwide, asthma guidelines have been devel- oped in an effort to reduce asthma morbidity and mor- tality 4–12 . The Maltese asthma guidelines, based mainly on the National Lung, Heart and Blood Institute (NHLBI) publication, were published in February 1998 and were the first local therapeutic guidelines for the management of a chronic condition 13, 14 . Prior to their development, the British Thoracic Society (BTS) guide- lines were the most readily available guidelines 15 . The local development group was made up of respiratory specialists, family doctors, researchers, health planners and policy makers. Initial dissemination took the form of a launch whereby all stakeholders were invited. A copy of the guidelines was mailed to doctors and phar- macists then registered. Since the launch in February 1998, there has been no other initiative to disseminate the guidelines. As described by the authors, the aim of the guidelines is ‘to optimise long term care of asthma, reduce morbidity and improve quality of life.’ Inter- ventions recommended include use of inhaled steroids early in disease onset, development of a partnership with patients including self-management, home peak- flow monitoring and compliance with medication pre- scribed and regular patient follow up. All these inter- ventions have been shown to improve asthma health outcomes 16–28 . There are relatively few studies measuring adher- ence to guidelines and impact of non compliance with guidelines on patient outcomes. There appears to be a lack of compliance to both BTS and NHLBI guidelines with underutilization of inhaled steroids, overutiliza- tion of short-acting bronchodilators, poor inhaler technique, underutilization of a spacer device, lack of availability of peak-flow meters and action plans and overall lack of patient self-management know- ledge 29–33 . A major success has been achieved by the health system in New Zealand where implementation of asthma management policies reduced asthma mor- bidity and mortality 6 . The aim of this study was to compare actual prac- tice to that recommended in the Malta guidelines with respect to management of chronic asthma. Method Study population Inclusion criteria were: • Patients admitted through the Accident and Emer- gency (A&E) Department. • Patients between the ages of 14–59 years. Research article 208