An Expert Interview With Michael Schatz, MD, MS
An Expert Interview With Michael Schatz, MD, MS
Editor's Note:
A study in the December 2005 issue of the Journal of Allergy & Clinical Immunology (JACI) reported that asthma patients receiving care from an allergist had significantly better controlled asthma and fewer severe symptoms when compared with patients seeing a primary care professional. The article is available on the JACI Web site: http://www.jacionline.org. Michael Schatz, MD, MS, Chief of the Department of Allergy at Kaiser Permanente in San Diego and senior investigator on this study, spoke to us about these data.
Medscape: Welcome, Dr. Schatz.
Michael Schatz, MD, MS: Hi.
Medscape: Your study noted differences in the care of patients with asthma seen by allergists and those patients seen by primary care physicians. What were some of those differences?
Dr. Schatz: The patients of allergists reported better control of their symptoms, less need for rescue therapy, improved quality of life, fewer hospitalizations and other unscheduled visits, and greater satisfaction with care.
Medscape: Why do you think these differences occurred?
Dr. Schatz: The study identified 2 differences that could contribute to the improved outcomes in the patients of allergists. First, we found that the patients who were seeing allergists were dispensed more inhaled steroids and that presumably means that both the doctors were appropriately prescribing them and, probably more importantly, that the patients were taking them. Other studies have also shown that patients of allergists are more adherent to inhaled steroids than patients of nonspecialists.
Second, patients of allergists scored better on a validated self-management education and behavior scale. This would suggest that the other underlying reason for the differences in outcomes that at least we looked at directly was better self-management education, leading to better self-management skills.
There are a number of other elements of care that the allergist brings to the patient with asthma, including identification and control of triggers, sometimes immunotherapy, and more frequent and comprehensive follow up (including spirometry). These elements certainly could have contributed as well, but we didn't look at those directly.
Medscape: Were there differences in the use of beta-agonists?
Dr. Schatz: There definitely were. We looked at computerized pharmacy data, and the patients of allergists definitely were dispensed less beta-agonists.
Medscape: Patients under the care of an allergist were less likely to have required hospitalization or to have unscheduled physician visits during the year. Can you comment on this?
Dr. Schatz: Yes. Not all emergency department visits or hospitalizations are absolutely preventable. But it is felt that most are with a combination of good prophylactic care, so people just don't get that sick, and then good self-management education, so people recognize the early signs of getting worse and know what to do about it.
There is a well established relationship between chronic control and fewer exacerbations. The better chronic asthma control achieved by patients of allergists presumably contributed to reduced exacerbations requiring unscheduled care.
And then, as I say, better self-management education and action plans, which prior studies show are more likely to be provided by asthma specialists, are associated with reduced emergency department visits and hospitalizations as well.
The only other point I would make on this subject is that there have been a number of other studies that have also shown that patients of allergists and other asthma specialists are less likely overall to require emergency department visits, hospitalizations, or other unscheduled visits than patients not being seen in a specialty environment.
Medscape: Were either group of physicians likely to use an asthma management plan for their patients?
Dr. Schatz: We didn't assess that directly in our study. But there have been other studies that have studied this and showed that patients of allergists are more likely to receive an action plan or an asthma management plan than patients of nonspecialists.
Medscape: What does this study mean from a patient's perspective?
Dr. Schatz: It doesn't mean that every patient with asthma should see an allergist. That wouldn't be possible. But what I think it means is that if a patient is really not achieving the goals of therapy, then they really should think in terms of seeing a specialist. That also means they have to know what the goals of therapy are.
They should have infrequent symptoms; not have trouble at night; not have missed work or school or limitation with exercise. They shouldn't be having acute exacerbations. And they shouldn't be having side effects from medicine.
And if all that's happening, and they're not seeing a specialist, then they probably don't need to. But if that isn't happening, then patients need to know that they probably could be doing better. And our study suggests that a specialist might be better able to get them on that road to better control.
The other big reason why a patient might want to see an allergy specialist, even if they're already well controlled on medicines, would be to better understand the triggers of their asthma, particularly allergic triggers, and things they might be able to do to reduce their asthma triggers that would lessen their need for medicines. That's the other main role that the allergy specialist could play for them.
Medscape: What is the take-home message of this study?
Dr. Schatz: I think the take-home message is that patients of allergists have better managed asthma. And while it's certainly not necessary for all patients to see an allergist, patients who want to identify triggers and particularly patients who are not adequately controlled should take advantage of allergy specialist care.
Another point to make is that referral to a specialist doesn't necessarily mean that the specialist is going to take over the care. There are other models where the allergist has a one-time visit to help with triggers and make some recommendations or comanagement, where the allergist sees the patient intermittently and the patient is still followed by a primary care provider. We really didn't get into those models in our study. The patients were just asked who was the main provider of their asthma care. But there's a role here for single consultations or comanagement, not just specialty management.
Medscape: Thank you, Dr. Schatz.
Dr. Schatz: Thank you.
Editor's Note:
A study in the December 2005 issue of the Journal of Allergy & Clinical Immunology (JACI) reported that asthma patients receiving care from an allergist had significantly better controlled asthma and fewer severe symptoms when compared with patients seeing a primary care professional. The article is available on the JACI Web site: http://www.jacionline.org. Michael Schatz, MD, MS, Chief of the Department of Allergy at Kaiser Permanente in San Diego and senior investigator on this study, spoke to us about these data.
Medscape: Welcome, Dr. Schatz.
Michael Schatz, MD, MS: Hi.
Medscape: Your study noted differences in the care of patients with asthma seen by allergists and those patients seen by primary care physicians. What were some of those differences?
Dr. Schatz: The patients of allergists reported better control of their symptoms, less need for rescue therapy, improved quality of life, fewer hospitalizations and other unscheduled visits, and greater satisfaction with care.
Medscape: Why do you think these differences occurred?
Dr. Schatz: The study identified 2 differences that could contribute to the improved outcomes in the patients of allergists. First, we found that the patients who were seeing allergists were dispensed more inhaled steroids and that presumably means that both the doctors were appropriately prescribing them and, probably more importantly, that the patients were taking them. Other studies have also shown that patients of allergists are more adherent to inhaled steroids than patients of nonspecialists.
Second, patients of allergists scored better on a validated self-management education and behavior scale. This would suggest that the other underlying reason for the differences in outcomes that at least we looked at directly was better self-management education, leading to better self-management skills.
There are a number of other elements of care that the allergist brings to the patient with asthma, including identification and control of triggers, sometimes immunotherapy, and more frequent and comprehensive follow up (including spirometry). These elements certainly could have contributed as well, but we didn't look at those directly.
Medscape: Were there differences in the use of beta-agonists?
Dr. Schatz: There definitely were. We looked at computerized pharmacy data, and the patients of allergists definitely were dispensed less beta-agonists.
Medscape: Patients under the care of an allergist were less likely to have required hospitalization or to have unscheduled physician visits during the year. Can you comment on this?
Dr. Schatz: Yes. Not all emergency department visits or hospitalizations are absolutely preventable. But it is felt that most are with a combination of good prophylactic care, so people just don't get that sick, and then good self-management education, so people recognize the early signs of getting worse and know what to do about it.
There is a well established relationship between chronic control and fewer exacerbations. The better chronic asthma control achieved by patients of allergists presumably contributed to reduced exacerbations requiring unscheduled care.
And then, as I say, better self-management education and action plans, which prior studies show are more likely to be provided by asthma specialists, are associated with reduced emergency department visits and hospitalizations as well.
The only other point I would make on this subject is that there have been a number of other studies that have also shown that patients of allergists and other asthma specialists are less likely overall to require emergency department visits, hospitalizations, or other unscheduled visits than patients not being seen in a specialty environment.
Medscape: Were either group of physicians likely to use an asthma management plan for their patients?
Dr. Schatz: We didn't assess that directly in our study. But there have been other studies that have studied this and showed that patients of allergists are more likely to receive an action plan or an asthma management plan than patients of nonspecialists.
Medscape: What does this study mean from a patient's perspective?
Dr. Schatz: It doesn't mean that every patient with asthma should see an allergist. That wouldn't be possible. But what I think it means is that if a patient is really not achieving the goals of therapy, then they really should think in terms of seeing a specialist. That also means they have to know what the goals of therapy are.
They should have infrequent symptoms; not have trouble at night; not have missed work or school or limitation with exercise. They shouldn't be having acute exacerbations. And they shouldn't be having side effects from medicine.
And if all that's happening, and they're not seeing a specialist, then they probably don't need to. But if that isn't happening, then patients need to know that they probably could be doing better. And our study suggests that a specialist might be better able to get them on that road to better control.
The other big reason why a patient might want to see an allergy specialist, even if they're already well controlled on medicines, would be to better understand the triggers of their asthma, particularly allergic triggers, and things they might be able to do to reduce their asthma triggers that would lessen their need for medicines. That's the other main role that the allergy specialist could play for them.
Medscape: What is the take-home message of this study?
Dr. Schatz: I think the take-home message is that patients of allergists have better managed asthma. And while it's certainly not necessary for all patients to see an allergist, patients who want to identify triggers and particularly patients who are not adequately controlled should take advantage of allergy specialist care.
Another point to make is that referral to a specialist doesn't necessarily mean that the specialist is going to take over the care. There are other models where the allergist has a one-time visit to help with triggers and make some recommendations or comanagement, where the allergist sees the patient intermittently and the patient is still followed by a primary care provider. We really didn't get into those models in our study. The patients were just asked who was the main provider of their asthma care. But there's a role here for single consultations or comanagement, not just specialty management.
Medscape: Thank you, Dr. Schatz.
Dr. Schatz: Thank you.
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