Chronic Disease Management

Mission – To develop sustainable, integrated asthma programs with community partners
Vision - To provide innovative and high-value asthma care to all asthma patients

Asthma is one of the commonest chronic diseases in Singapore; the prevalence is 5% in adults and 20% in children. To reduce the costs and burden of poorly controlled asthma, the Singapore National Asthma Program (SNAP) has been in place since 2001 to reduce the healthcare burden of uncontrolled asthma. Asthma-related healthcare costs were reduced,¹ and asthma mortality in the Singapore population aged 5 to 34 years has fallen from 7 per million population between 1994 and 1998 to 2 per million population between 2006 and 2010.²

However, there is room for improvement. Our asthma-related emergency department visits and hospitalizations are 2-3x higher than other developed countries.³ Preventable asthma deaths in mild asthmatics are still occurring. This is largely because many patients treat asthma, a chronic inflammatory airway disease, as a mild acute viral infection and rely mainly on short-acting beta-agonists (SABA) for temporary symptom relief.⁴ SABA monotherapy is a double-edged sword: though it provides temporary relief, it can paradoxically worsen airway inflammation and thus asthma control.⁵  Excessive SABA use* is strongly associated with asthma deaths.⁶ As concomitant use of ICS can mitigate the side effects of SABA, we hope to work with primary care partners** to change the attitudes and behavior of asthmatics in Singapore, and encourage the use of ICS and self-management for better control.

Since 2018, the SNAP-2 team has extended its work into primary care, to integrate asthma workflows with education efforts via the following initiatives: 

• Integrated asthma quality improvement programs in polyclinics with a view to scaling up to Primary Care Networks (PCNs) and CHAS GPs in future.
• Streamline asthma management processes in the emergency departments, inpatient wards and outpatient clinic of restructured hospitals.
• Multifaceted education strategy with embedment into existing workflows
• Asthma management training programs and accreditation for nurses and clinic assistants (link).
• Equip schools to provide "asthma first aid" to children (link)
• Asthma toolkits and practical asthma courses for GPs (link) 

We hope to continue working with primary care partners to address existing practice gaps. As 80% of asthma cases are managed in primary care, GPs are well placed to contribute to our vision to deliver high value and cost-effective care to all asthmatics in Singapore, in line with their role as the first and continuous line of care for patients. We look forward to working with all our stakeholders to improve asthma care and outcomes.

More Preventor Less Reliever
Zero tolerance to Asthma Deaths

Sincerely,

Dr Lim Hui Fang

Director Singapore National Asthma Program-2

Senior Consultant, National University Hospital, Singapore

Asst. Professor, Yong Loo Lin School of Medicine, National University of Singapore

*Excessive SABA use associated with increased asthma mortality is defined by the usage of 1- canister every month.
** Agency of Integrated Care, College of Family Physicians Singapore, Asthma Allergy Association

References
1.         Tan NC, Nguyen HV, Lye WK, Sankari U, Nadkarni NV. Trends and predictors of asthma costs: results from a 10-year longitudinal study. Eur Respir J 2016; 47:801-9.
2.         Lim TK, Chay OM. Fatal asthma in Singapore. Ann Acad Med Singapore 2012; 41:187-8.
3.         OECD Health Statistics 2015, http://dx.doi.org/10.1787/health-data-en. Accessed 1 Jun 2019.
4.         Thompson PJ, Salvi S, Lin J, Cho YJ, Eng P, Abdul Manap R, et al. Insights, attitudes and perceptions about asthma and its treatment: findings from a multinational survey of patients from 8 Asia-Pacific countries and Hong Kong. Respirology 2013; 18:957-67.
5.         Ameredes BT, Calhoun WJ. (R)-albuterol for asthma: pro [a.k.a. (S)-albuterol for asthma: con]. Am J Respir Crit Care Med 2006; 174:965-9; discussion 72-4.
6.         Levy ML, Andrews R, Buckingham R, Evans H, Francis C, R H. Confidential Enquiry report. London: Royal College of Physicians; 2014. Why asthma still kills: The National Review of Asthma Deaths (NRAD) 2014