DETERMINANTS OF MANAGEMENT ERRORS IN ACUTE SEVERE ASTHMA

Background - It is hypothesised that, despite recent initiatives to im prove asthma self-management including asthma education, derailed inve stigation of the sequence ef events culminating in hospital admission will lead to the identification of important management errors and thu s the likelihood that the majority of severe asthma attacks are preven table by currently available strategies, and that psychological, healt h care and socioeconomic factors are risk factors for such management errors, Methods - A cross sectional study was undertaken of 138 patien ts aged 15-50 years admitted re hospital (general ward or intensive ca re unit) with acute severe asthma who were assessed within 24-72 hours of admission using a number of previously validated instruments, A de tailed history of events of the attack was assessed against predetermi ned criteria for non or delayed use of oral corticosteroids and non or delayed use of emergency ambulance services. Results - Subjects had e vidence of severe chronic asthma and had acute severe asthma at presen tation (n = 90, pH = 7.3 (8.2), PaCO2 = 7.2 (5.0) kPa) but duration of hospital stay was short (3.7 (2.6) days). Serious management errors o ccurred very frequently and most: were deemed to have been made by the patient. Forward stepwise regression revealed that delayed or non-use of oral corticosteroids was predicted independently by lack of paying job (p = 0.02), high total use of inhaled beta agonists in the 24 hou rs before index admission (p = 0.04), loss of a job in the last year ( p = 0.04), Iow frequency of use of oral corticosteroids in the last ye ar (p = 0.06), concerns during the index attack about medical expenses (p = 0.07), and delay in the use of ambulance services (p = 0.05) - t he model being responsible for 23% of the variance. Delayed or non-sum moning of emergency ambulance services was predicted independently by total life events (p = 0.03), having something stolen in the last year (p = 0.003), panic during the index aback (p = 0.01), acid concerns d uring the index attack about taking time off work (p = 0.07) - the mod el being responsible for 21% of the variance. Conclusions - The result s of this study show that, despite recent educational advances, seriou s management errors are common in those admitted to hospital with acut e severe asthma and that mast management errors relate to patient self -management behaviour. Serious management errors are. predicted by a v ariety of socioeconomic and psychological factors. While the results o f this study are consistent with the widely held view that most acute severe attacks are theoretically preventable, the challenge for the fu ture is to change patients' behaviour in the face of considerable adve rse socioeconomic and psychological factors.