lowest utilization of inhaled steroid therapy was among patients with advanced age and multiple comorbidities. Although neither the American nor Canadian consensus guideline statements has indicated that the use of inhaled steroid therapy should be modified by age or comorbidities, our findings are consistent with previous reports that asthma is underdiagnosed and undertreated in the elderly population. In the Cardiovascular Health Study, for instance, only 30% of asthma patients ≥ 65 years old were prescribed inhaled steroids In another community-based survey, only 22% of eligible elderly patients with asthma were receiving inhaled steroids. Paradoxically, however, a majority of asthma-related deaths occurs in the elderly population with multiple comorbidities. Although our study was not designed to tell us why this is occurring in the community, several plausible explanations exist. Previous studies showing the efficacy of inhaled steroid therapy in asthma have excluded elderly patients, which may make clinicians more hesitant in prescribing these medications for older patients. Physicians may also believe that inhaled steroid therapy may be unsafe for elderly asthmatic patients. Furthermore, elderly patients may be undertreated for their asthma because they have multiple comorbidities. Whatever the cause, our findings highlight age and comorbidities as important barriers to inhaled steroid therapy in the asthmatic population.
We also found that patients treated by specialists were approximately 50% more likely to have received inhaled steroid therapy, compared to those treated by family physicians/general practitioners. This finding is consistent with a previous report that showed that patients receiving their asthma care from specialists were considerably more likely to report using both inhaled steroid therapy and having higher health-related quality of life. These observations have been supported by other studies. Differences in disease severity of the patients and lack of familiarity of primary-care providers with these medications may partly explain this disparity. Primary-care providers also face numerous resource and time constraints that hinder optimal delivery of asthma care. Although various asthma consensus guidelines have been promulgated widely over the past decade, there remains a substantial gap between recommended and actual practices regarding inhaled steroid therapy, particularly among primary-care physicians. Our findings are consistent with the prevailing paradigm that information dissemination by itself is ineffectual in modifying practice patterns; more research is needed to identify various physician, patient, and structural barriers present within the current health-care system.
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