A panel of experts comment on primary care vs specialist care for patients with asthma, and when patients should be referred to a specialist.
Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: This is a lot to handle for a single health care professional. With that said, there’s a difference between specialists, primary care physicians, and midlevel providers. Dr Chase, how often are these patients with moderate to severe asthma being managed by the primary care physician vs the specialist who probably has more time, etc? How often are they ending up in the emergency department and urgent care, with or without your knowledge, as you follow them closely? What does that picture look like?
Nicole Chase, MD, FAAP, FAAAAI, FACAAI: Overall, the answer is probably one we all maybe wish was different…. Many patients who have moderate to severe asthma, across the board, are managed by primary care providers. It’s not inherently wrong that they are. But what I think happens, just like Dr White alluded to, is that when patients are feeling good, they may not even complain about any needs from the health care system. They may take their medication either as prescribed or maybe not as prescribed. But realistically, what we see with patients who are managed by primary care providers, there’s a tendency to treat more often with systemic corticosteroids. And that’s one thing specialists do differently—we have a very low threshold for what’s normal as far as baseline levels of control for a patient with asthma. We’re really following the rule of 2s. We don’t want you to be having exacerbations or symptoms twice at night during the month or twice during the week and during the daytime. What ends up happening is patients, when they’re sick and if they’re under the guidance of a primary care provider, often find it easiest to seek care wherever they can. It may be with that provider, but it may also be other places, such as urgent care and the emergency department. I think patients are really not trying to otherwise not take care of their symptoms. It’s just that this is a relapsing remitting disease, so when you’re feeling good, there’s no reason to…see the need for a specialist. But I do think these patients deserve at least the opportunity to be seen by a specialist. What we offer as specialists is not only management but also a review of the diagnosis, making certain that this is asthma. We also offer additional terms of investigational therapies or investigational tools, such as exhaled nitric oxide and spirometry. We can get some objective data, which can be useful in managing patients.
I think the answer to your question about emergencies, visits, or hospitalizations is way too many. Patients are very prone to seek care in the way that they can get it the fastest, especially when there are waits to get in to see specialists. It’s very easy to decide that if you’re feeling bad now, you’ll probably seek care on a more urgent basis. Regarding when patients with asthma should see a specialist, the guidelines state that you can refer a patient at any point to a specialist. That’s really something to keep in mind, that as specialists, we work very commonly with providers. There’s no reason the patient otherwise wouldn’t still be expected to see their primary care doctor, but I think we can take the burden of getting the objective data, making a treatment plan, seeing whether that’s working for the patient, and then otherwise reassessing as time goes on. Then furthermore, offer them long-term options that may be different than what primary care providers are exposed to.
Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: Very well said. After all, it is a small proportion of the patients with asthma who we’re talking about, who need that extra care, handholding, and shepherding through to optimal therapies. And as you said, making sure that, first of all, it is the right diagnosis because there are so many other mimickers, including in the immunologic pathways, that could end up being completely in a different plane. I always say asthma can fool you because it’s like the teapot on the stove: it’s probably bubbling, but it might be too late when it starts wheezing. It’s usually warm. It’s never completely off. It’s a chronic condition. From my colleagues—Dr White and Dr Siri—did you guys ever tell your primary care colleagues that they should refer earlier, sooner, or does it just naturally happen?
Dareen D. Siri, MD, FAAAAI, FACAAI: Do you want to take that, Dr White?
Andrew White, MD: That’s a great question. Honestly, there’s probably a lack of great communication between us and primary care. We probably have a small group we get referrals from, but maybe with the larger group, there’s a lot more room for discussion.
Dr Chase, when you were just talking about potentially referring early, I was thinking that there’s probably many patients out there who really aren’t on controller therapies for asthma, but then they end up with the emergency department visit or maybe even a hospitalization once a year. But the rest of the year, they’re sort of “mild,” but they’re not really a mild asthmatic if that’s happening. That’s a message that might be something we could communicate better as a specialty and work a little more closely with our primary care colleagues.
Dareen D. Siri, MD, FAAAAI, FACAAI: The comments from both of you have really resonated with me as a specialist, allergist, and immunologist. A lot of the patients do shuffle from clinic to clinic, and then we don’t have this full information about what they’re experiencing. Certainly, what you said as far as referring earlier, I think we think about these patients, who are 10% of our patients—the severe asthmatics—but represent 40% of our office visits. If we can catch them earlier—before they’re really symptomatic, before they start to complain and lose lung function when they’re aged 50 or 60—and be more aggressive in that moderate to severe stage in their teens, 20s, or 30s, then perhaps we can prevent some of these atrocious outcomes. That’s really great in terms of encouraging physician to refer earlier.
Nicole Chase, MD, FAAP, FAAAAI, FACAAI: As you said, Dr Siri, regarding the phenotype and endotype, we can be doing that at every single visit. In some sense, we ca almost predict where we think these patients might go. I definitely think we’ve all been surprised before when we’ve seen someone who looked like they were going to be very stable and all of a sudden they had other reasons to be unstable and vice versa. But we should especially be focusing more on the data we can get at every given visit so we can guide who we are watching regarding higher risk turning into moderate or severe asthma.
Transcript edited for clarity