To the editor,

The Australian Institute of Health and Welfare (AIHW) recently released a report regarding Asthma in Australia, including trends over the past 5 years, and pediatric-specific data.¹ It used national data sets to assess prevalence, disease burden, and the state of asthma care against a set of predetermined “National Asthma Indicators.” Unfortunately, the report highlights several worrying results regarding pediatric asthma in Australia. While these results are specific to the Australian context, they may parallel issues with the management of childhood asthma seen in other countries.

Like previous reports, asthma remains highly prevalent affecting 8.5% of all children aged between 0 and 14 years old. It also remains the leading cause of disease burden in the 1- to 4-, 5-to 9-, and 10- to 14-year-old age groups.¹ Pleasingly the rate of hospital admissions for asthma in those aged 0–14 years has fallen over the past decade.¹ Despite this, there are several areas of concern.

A basic tenet of asthma management is an asthma action plan, and yet 31% of children with asthma did not have an action plan.¹

Further, the harms of reliance on short-acting beta agonist (SABA) therapy and suboptimal use of inhaled corticosteroids (ICS) are well documented with a systematic review identifying both as risk factors for severe asthma exacerbation in children.² The AIHW report shows that 10% of children who were dispensed SABA inhalers, were dispensed three or more in 12-month period.¹ This indicator is used as a surrogate of poor asthma control and shows that approximately one in 10 children who had SABA dispensed through the pharmaceutical benefits scheme, have poor control and are reliant on SABA therapy. This indicator likely significantly underestimates the problem of poor control, as it does not include over-the-counter SABA sales. Another quality-of-care indicator is the analysis of the dispensing of asthma-preventer medication such as ICS. For these medications to be effective they typically need to be used regularly and hence should be dispensed multiple times per year. Of children who were dispensed at least 1 asthma preventer, only 29% were dispensed three or more preventers within 12 months. This shows that when a child's doctor thought a preventer was indicated, only one in three children used it regularly.¹ Neither indicator has shown improvement over the last 5 years, highlighting that overreliance on SABAs and underuse of ICS are enduring problems in Australian childhood asthma.

There are further concerns regarding childhood asthma care in Australia, arising from more granular data. For example, while AIHW data suggest hospital admission rates are declining, in a study of three hospitals, spanning tertiary and mixed adult-pediatric hospitals in metropolitan and regional settings, the 12-month readmission rates for asthma increased. Last decade, one in five children were readmitted to hospital over 12-month period but this figure was one in three children in the recent study.³ In keeping with the AIHW findings of under-utilization of ICS, a recent study spanning three states showed that in children with persistent asthma, 30.5% were not prescribed ICS.⁴ Further data show that only 16.2% of children admitted to the hospital due to asthma were prescribed ICS before admission, and of those who were not on a preventer at the time of admission only 12.2% were commenced during the admission.^{3, 5} Concerningly, when examining the dispensing records of those prescribed a preventer, only 45.6% of the prescriptions were dispensed.⁵ Likewise, of those children already on a preventer at the time of admission, only 45.1% had an active prescription or had the medication recently dispensed.⁵ With regard to asthma action plans, one study showed that while children admitted to hospital frequently received an action plan (91.5%), for those managed in the community the rate was much lower (46.5%).⁴ Other key aspects of asthma management include asthma self-management education and assessment of inhaler technique. A recent study reported only 25.6% of children admitted to the hospital with asthma received asthma education³ and only one-third of children had an assessment of their inhaler technique during their admission.³ In addition, a study spanning general practice (GP, the Australian term for primary care), pediatrician outpatient clinics, emergency departments, and inpatient admissions in three states reported only 25.3%–27.8% of children had their inhaler technique assessed.⁴

Children with asthma may present to GPs, specialist clinics, emergency departments, and inpatient wards, and it is important that care is not fragmented between these settings. Unfortunately, data shows there is poor communication between hospitals and GP, with GPs often unaware that their patients have presented to hospital, and hence follow-up appointments frequently fail to occur.^{3, 6, 7} Information on asthma management activity in GP has been recently hampered by the cessation of funding of the bettering the evaluation and care of health study and the removal of incentive payments for comprehensive cycles of asthma care.^{8, 9} Regardless of where a child presents, they should receive high-quality guideline-concordant care. However, several studies from across Australia highlight guideline-discordant care across many settings (including pediatricians).^{4, 6} Guideline-discordant care is a known risk factor for hospital readmissions.⁶

Despite these challenges, we know what needs to be done to improve asthma care and outcomes for children in Australia. A lack of standardized management and asthma action plans, inadequate systems to allow for timely follow-up with GPs, inadequate asthma education for parents/carers, and lack of integrated asthma care between GPs and hospitals⁷ are some of the barriers to optimal asthma management in Australian children. Multidimensional interventions have been shown to improve asthma control and reduce hospitalization.¹⁰ Multidimensional interventions include asthma self-management education, home environmental assessment regarding potential asthma triggers and supporting families to deliver asthma care at home, care coordination between primary and tertiary care, and school involvement to support the administration of asthma medications. Such an approach has been demonstrated to be beneficial at a single metropolitan tertiary hospital,¹¹ and is currently being introduced in the Inner-West of Melbourne.¹²

Unless we address our current modifiable failings, an unacceptably high number of children in Australia will continue to have poorly controlled asthma. While these data are Australian-specific, they may highlight issues with childhood asthma management also seen in other settings. These issues also affect the management of adults, opening the door to a combined approach to address these failings.¹³ We must urgently tackle these issues, so that in the next AIHW report in 5 year's time, we can see improvements for our children with asthma.

对编辑来说，

澳大利亚健康与福利研究所 (AIHW) 最近发布了一份有关澳大利亚哮喘的报告，包括过去 5 年的趋势以及儿科特定数据。¹它使用国家数据集根据一组预先确定的“国家哮喘指标”来评估患病率、疾病负担和哮喘护理状况。不幸的是，该报告强调了澳大利亚儿童哮喘的一些令人担忧的结果。虽然这些结果是针对澳大利亚的具体情况，但它们可能与其他国家的儿童哮喘管理问题相似。

与之前的报告一样，哮喘仍然非常流行，影响 0 至 14 岁儿童的 8.5%。它还仍然是 1 至 4 岁、5 至 9 岁和 10 至 14 岁年龄组疾病负担的主要原因。¹令人欣喜的是，过去十年中 0-14 岁儿童因哮喘入院的比例有所下降。¹尽管如此，仍有几个方面值得关注。

哮喘管理的基本原则是哮喘行动计划，但 31% 的哮喘儿童没有行动计划。¹

此外，依赖短效β受体激动剂（SABA）治疗和吸入皮质类固醇（ICS）次优使用的危害已得到充分记录，系统评价将两者确定为儿童严重哮喘恶化的危险因素。² AIHW 报告显示，10% 的被配发 SABA 吸入器的儿童在 12 个月内被配发了 3 次或更多。¹该指标用作哮喘控制不良的替代指标，显示通过药物福利计划发放 SABA 的儿童中约有十分之一的哮喘控制不佳且依赖 SABA 治疗。该指标可能大大低估了控制不善的问题，因为它不包括场外 SABA 销售。另一个护理质量指标是对 ICS 等哮喘预防药物的配发分析。为了使这些药物有效，通常需要定期使用，因此每年应分配多次。在至少配发 1 种哮喘预防药物的儿童中，只有 29% 在 12 个月内配发 3 种或更多预防药物。这表明，当儿童医生认为需要使用预防剂时，只有三分之一的儿童定期使用它。¹这两项指标在过去 5 年中都没有显示出改善，这突显了对 SABA 的过度依赖和 ICS 使用不足是澳大利亚儿童哮喘的长期问题。

由于更详细的数据，人们对澳大利亚儿童哮喘护理产生了进一步的担忧。例如，虽然 AIHW 数据显示入院率正在下降，但在对大都市和地区三级医院和成人儿科混合医院的三家医院进行的一项研究中，哮喘 12 个月的再入院率有所上升。过去十年，五分之一的儿童在 12 个月内再次入院，但在最近的研究中，这一数字是三分之一的儿童。³与 AIHW 关于 ICS 使用不足的调查结果一致，最近一项跨越三个州的研究表明，在患有持续性哮喘的儿童中，30.5% 的儿童没有服用 ICS。⁴进一步数据显示，只有 16.2% 因哮喘入院的儿童在入院前服用了 ICS，而在入院时未服用预防剂的儿童中，只有 12.2% 在入院期间开始服用预防药物。^{3, 5}值得关注的是，在检查预防剂处方的配药记录时，只有 45.6% 的处方被配发。⁵同样，在入院时已服用预防药物的儿童中，只有 45.1% 持有有效处方或最近配药。⁵关于哮喘行动计划，一项研究表明，虽然入院儿童经常收到行动计划 (91.5%)，但对于社区管理的儿童来说，这一比例要低得多 (46.5%)。⁴哮喘管理的其他关键方面包括哮喘自我管理教育和吸入器技术评估。最近的一项研究报告称，只有 25.6% 因哮喘入院的儿童接受了哮喘教育³，并且只有三分之一的儿童在入院期间对其吸入器技术进行了评估。³此外，一项涵盖三个州的全科医生（GP，澳大利亚初级保健术语）、儿科门诊、急诊室和住院部的研究报告称，只有 25.3%–27.8% 的儿童接受了吸入器技术评估。⁴

患有哮喘的儿童可能会到全科医生、专科诊所、急诊科和住院病房就诊，重要的是这些机构之间的护理不应分散。不幸的是，数据显示医院和全科医生之间的沟通不畅，全科医生常常不知道他们的患者已经到医院就诊，因此后续预约经常无法进行。^{3, 6, 7}由于停止资助改善健康研究的评估和护理以及取消对哮喘护理综合周期的奖励付款，有关全科医生哮喘管理活动的信息最近受到阻碍。^{8, 9}无论孩子在哪里，他们都应该接受符合指南的高质量护理。然而，澳大利亚各地的几项研究强调了许多环境（包括儿科医生）的护理指南不一致。^{4, 6}与指南不一致的护理是导致再入院的已知风险因素。⁶

尽管存在这些挑战，我们知道需要采取哪些措施来改善澳大利亚儿童的哮喘护理和治疗结果。缺乏标准化管理和哮喘行动计划、无法及时对全科医生进行随访的系统不足、对父母/照顾者的哮喘教育不足以及全科医生和医院之间缺乏一体化的哮喘护理⁷是实现最佳哮喘管理的一些障碍在澳大利亚儿童中。多维干预已被证明可以改善哮喘控制并减少住院治疗。¹⁰多维干预措施包括哮喘自我管理教育、关于潜在哮喘诱因的家庭环境评估和支持家庭在家提供哮喘护理、初级和三级护理之间的护理协调以及学校参与以支持哮喘药物的管理。这种方法已被证明在一家大都市三级医院¹¹中是有益的，目前正在墨尔本内西区推广。¹²

除非我们解决目前可改变的问题，否则澳大利亚仍有大量儿童患有哮喘控制不佳，数量高得令人无法接受。虽然这些数据是针对澳大利亚的，但它们可能突显了其他环境中也存在的儿童哮喘管理问题。这些问题也影响了成年人的管理，为解决这些问题的综合方法打开了大门。¹³我们必须紧急解决这些问题，以便在 5 年后的下一份 AIHW 报告中，我们可以看到哮喘儿童的情况有所改善。