Annual healthcare costs due to asthma has been estimated to be US$12.7 billion per year with lost productivity estimated to be US$4.6 billion.²

Asthma is also associated with troubling mortality rates. About 4,261 deaths were related to asthma in 2002. There was an increase in the death rates from asthma during 1980 through 1995, with a slightly decreased trend from 1996 to 1999. The death rates are higher among African-Americans, women, and adults aged 65 and older.^1–3

Practice Guidelines
In response to this public health issue, the National Institutes of Health (NIH) convened an expert panel that produced the National Asthma Education Program (NAEP) in 1991, with updates in 1997 and 2002.⁴ These guidelines focused on several important components of asthma care:

• the role of inflammation in the pathogenesis of asthma;
• the importance of monitoring asthma not only by patient symptoms but also objectively with spirometry;
• recognizing the importance of long-term controller medication including inhaled corticosteroids in the management of persistent asthma;
• the importance of individualized written action plans for daily self-management and exacerbation management;
• the role of patient education during each visit with additional emphasis on reinforcement; and
• setting appropriate treatment goals in collaboration with the patient.

These goals and guidelines have also been adopted internationally with the Global Initiative on Asthma (GINA).⁵ Over 10 years after the introduction of the guidelines, asthma management remains poor.⁶ The Asthma in America survey in 1998 showed that:

• forty-nine per cent of children and 25% adults with asthma missed school or work due to asthma the previous year;
• thrity per cent had night-time symptoms at least once a week;
• forty-eight per cent had limited participation in sports, 36% had to limit normal physical activity, 25% said that it interfered with their social life;
• seventy per cent of physicians said they used spirometry on a regular basis, but only 35% of the patients confirmed this;
• ninety per cent of physicians said that antiinflammatory medication was essential in asthma management; however, only 18% of asthma patients reported using them in the previous four weeks;
• eighty-three per cent of doctors said they prescribed peak-flow meters; however, only 28% of the patients had one and only 9% reported using it at least once a week; and
• seventy per cent of doctors said they prepared an action plan; however, only 27% of the patients confirmed this.

The Asthma Insights and Reality in Europe (AIRE) study done in Europe in 1999 showed a similarly alarming record of sub-optimal asthma management in many Western European countries.⁷

Several factors influence asthma care and compliance with guideline recommendations – socioeconomic issues, patient and family beliefs, and physician understanding and comfort with the guidelines.