Cities and urban environments tend to have large gaps in health care accessibility and correspondent health care disparities. Despite the existence of localized public health infrastructure, such infrastructure tends to be fragmented and cannot fully encompass the level of nuance within its patient population as a result. As such, health care inequities are cyclically perpetuated in part through discontinuous health systems. Smarter, patient-centric approaches are needed to move the needle forward and improve at-risk populations’ clinical care and associated outcomes. While technology is often thought of as the proprietor to achieve this goal, low-cost educational interventions and updated guidelines may serve as equally reliable or even better methods to attain this outcome.
Take the case of asthma, a morbidity that is magnified in urban geographies. In St. Louis, asthma is the greatest health care inequity, with African-American children having an incidence rate greater than 10x that of white children. Children in St. Louis are afflicted by rates of asthma 3x higher than that of the national average, and asthma is currently the leading chief complaint at St. Louis Children’s Hospital. Underserved communities face a multitude of issues that exist beyond the medical aspects of health care. And unfortunately, asthma is not only an issue due to its accompanying signs and symptoms, but for its pertinence well beyond its pathology.
While inhalers are often the appropriate standard of care for asthma treatment, inhalers can also be incredibly complex due to their variable prescribed regimens, inadequate patient health literacy, and visual or physical similarity to other inhalers regardless of status as maintenance or rescue inhalers. Furthermore, considerations of high cost and a lack of insurance coverage can pose additional barriers that can significantly affect inhaler adherence when taken together with those outlined above. And the reality is that some patients with asthma may end up only using their rescue inhalers in acute asthma situations, and neglect their maintenance inhaled corticosteroid (ICS) inhaler on days when they are not experiencing symptoms, although the maintenance inhaler is prescribed for daily or repeated use regardless of symptom frequency. With this context in mind, the Global Initiative for Asthma (GINA) presented robust evidence resulting in the updated recommendation of the use of as-needed ICS-formoterol as a viable alternative to a short-acting beta-agonist (SABA) alone or use of a maintenance low-dose ICS with an as-needed SABA.
In essence, this update follows the guidelines of harm reduction in its concession to the matter of inhaler nonadherence. Suppose patients are understood to be nonadherent with regard to their inhaler use. How can a treatment strategy be crafted to maximize benefit to nonadherent patients when they do utilize their inhalers? Thus, this recommendation allows for nonadherent patients to benefit from some inhaled corticosteroid exposure if they only take their inhalers as needed when they are symptomatic and/or experience flare-ups. Additionally, combining an ICS and formoterol into a single inhaler prevents potential confusion between maintenance and rescue inhalers and simplifies accordant treatment regimens. Although GINA’s recommendation may not necessarily solve the underlying multifaceted problem of inhaler adherence, its updated guidelines do recognize the reality of inhaler adherence to effectively meet patients where they are at. It is a step forward and offers primary care, pulmonary, and allergy providers a protocol that might ultimately improve patient outcomes and clinical care.
Tejas Sekhar is a graduate student.
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