achieving optimal outcomes for the asthmatic patient ... · 2007 nih asthma management guidelines1...

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Achieving Optimal Outcomes for the Asthmatic Patient –

Addressing Disparities by Utilizing the Entire Healthcare Team

Gary Falcetano, PA-C, AE-C

Clinical Educator

[email protected]

609-577-5351

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Disclosure

It is my obligation to disclose to you (the audience) that I am an employee of Thermo Fisher Scientific,

maker of the ImmunoCAP Specific IgE in vitro diagnostic test. However, I acknowledge that today’s

activity is certified for CE credit and thus cannot be promotional. I will give a balanced presentation

using the best available evidence to support my conclusions and recommendations. I do not intend to

discuss an unapproved or investigative use of a commercial product in my presentation.

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• 1. Describe the current burden of asthma in the US.

• 2. Understand and utilize current NIH guidelines concerning asthma and

allergic disease

• 3. Explore non-traditional approaches to implementing guidelines to

encourage adoption that is more widespread, and that helps in addressing

disparities of care.

• 4. Understand specific IgE blood allergy testing including advantages,

disadvantages and interpretation.

• 5. Describe how Targeted Exposure Reduction (TER) can decrease

symptoms and enhance pharmacologic management of asthma.

• 6. Understand the clinical and economic value of primary care adoption of

evidenced based guidelines to improve patient care and optimize

appropriate specialist referral.

Program Objectives

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18.9 million adults

7.1 million children

Asthma: Clinical and Economic Burden1

1. Asthma in the US. http://www.cdc.gov/nchs/fastats/asthma.htm Accessed Feb 12, 2013.

2. cdc.gov/asthma/asthmadata.htm. National Surveillance of Asthma: United States, 2001–2010, Series 3, Number 35 Novem 2012 Accessed March 7, 2013.

3. Amer. Lung Assoc. Asthma in Adults. www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-in-adults.html. Accessed March 7, 2013.

4. http://www.cdc.gov/vitalsigns/asthma. Accessed March 7, 2013.

2.1MAnnual ER visits

479KAnnual

hospitalizations

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2

14.2MLost work days

3 $50BAnnual direct costs

of care

3

$3,300Annual cost per person (medical expenses)4

Increase in the asthma

population from 2001-09

4.3M

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• Most patients with asthma are managed by primary care

Your Role in Asthma Care

1. Kwong KYC, Eghrari-Sabet JS, Mendoza GR, et al. The benefits of specific Immunoglobulin e testing in the primary care setting. Am Manag Care. 2011;17:S447-S459.

76%of asthma patients are managed

by primary care1

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• Asthma prevalence rate among blacks was 47% greater than among

whites in 2011

• Asthma attack prevalence rate in blacks is 45% higher than the rate in

whites

• Asthma in Latinos

oPuerto Ricans are twice as likely as non-Hispanic Whites to be

diagnosed with asthma (15.7% vs. 7.5% of children and adults

diagnosed with asthma)

oMexican immigrants by contrast have some of the lowest rates of

diagnosed asthma.

• Prevalence is greater in boys than girls, but greater in women than men

Prevalence and Disparities in the U.S.

Trends in Asthma Morbidity and Mortality. American Lung Association, Epidemiology and Statistics Unit, Research and Program Services Division. September, 2012.

Luchando por el Aire: The Burden of Asthma in Hispanics ©2011

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Asthma Prevalence by Age in U.S.

Trends in Asthma Morbidity and Mortality. American Lung Association, Epidemiology and Statistics Unit, Research and Program Services Division. September, 2012.

Luchando por el Aire: The Burden of Asthma in Hispanics ©2011

68.5

105.5

94.9

79.986.7

79.4

0

20

40

60

80

100

120

Under 5 5-17 <18 18-44 45-64 65+

CU

RR

ENT

PR

EVA

LEN

CE

RA

TE P

ER 1

,00

0

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Health disparities are pervasive in the United States. Health and health care

disparities are the differences or gaps in health (eg, life expectancy, morbidity, risk

factors, and quality of life) and health care access and quality between segments of

the United States population as related to race/ethnicity and socioeconomic status

(eg, income, education). Multiple factors are associated with such disparities in

asthma management and education.

Health Disparities

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• HEALTH CARE ACCESS AND QUALITY

• ASTHMA EDUCATION

• ENVIRONMENT

Asthma Disparities – Specifically….

Disparities in Asthma Care, Management, and Education Among Children With Asthma

Holsey, Chanda N. DrPH, MPH, AE-C*; Collins, Pamela MPA, MSA†; Zahran, Hatice S. MD, MPH†

Clinical Pulmonary Medicine: July 2013 - Volume 20 - Issue 4 - p 172–177

doi: 10.1097/CPM.0b013e3182991146

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Breathmobile

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1. Liao, et al. Journal of School Health. 2006; 76(6):313-319.

N = 205, p < 0.001

0

5

10

15

20

25

30

35

40

Pre Post

22.9%

14.6%

10.2%

5.9%

Two or more ER Visits

One ER Visit

• Pre- vs. Post-year Comparison of ER Visits

Guideline-Based Care Improves Care and Reduces Cost

1. Liao, et al. The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children. Journal of School Health. 2006;

76(6):313-319.

57%Reduction

in

ER Visits

% P

atie

nts

Vis

ite

d th

e E

R

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0

2

4

6

8

10

12

14

16

18

20

Pre Post

Two or more

hospitalizations

One hospitalization

1. Liao, et al. Journal of School Health. 2006; 76(6):313-319.

% P

atie

nts

Vis

ite

d th

e E

R

• Pre- vs. Post-Year Comparison of Hospitalizations

Guideline-Based Care Improves Care and Reduces Cost

1. Liao, et al. The Breathmobile: a novel comprehensive school-based mobile asthma care clinic for urban underprivileged children. Journal of School Health. 2006;

76(6):313-319.

85%Reduction

in

Hospitalizations

10.2%

8.3%

2.4%

0.5%

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Core Components of Asthma Care1

1. National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed May 3, 2013.

Assessment& monitoring

Control ofenvironmental

triggers

Pharmacologictherapy

Education

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Core Components of Asthma Care1

1. National Heart Lung and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Full Report 2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed May 3, 2013.



triggers


Education

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• 1176 Persistent Asthmatics (285 children, 211 tweens, and

680 adults)

• 16 Family Medicine and 6 Pediatric practices across the

United States

• Adherence was highest for prescription of medications

(88.0% for short-acting b-agonists and 70.4% for

maintenance medications)

Adherence to Guidelines in Primary Care – Overall (2009-2014)

Mayo Clin Proc. n April 2016;91(4):411-421 n http://dx.doi.org/10.1016/j.mayocp.2016.01.010

www.mayoclinicproceedings.org n ª 2016 Mayo Foundation for Medical Education and Research

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• Conclusion and Relevance:

Adherence to asthma guidelines is

poor in primary care practices, leaving

many opportunities for improvement.

Adherence to Guidelines

Mayo Clin Proc. n April 2016;91(4):411-421 n http://dx.doi.org/10.1016/j.mayocp.2016.01.010


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Asthma Workflow

• Asthma Control Test

• Spirometry

• History and physical exam



triggers


Education

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Asthma Workflow

• Identify Non-Allergic Triggers

• Allergic Trigger Identification with

testing

• Review of specific IgE test results



triggers


Education

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• Medication review

• Complete Asthma Action Plan

Asthma Workflow



triggers


Education

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• Review of proper medication usage/techniques

• Environmental interventions and progress

• Self-Management skills

Asthma Workflow



triggers


Education

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Allergic Asthma

1. Characteristics of allergic sensitization among asthmatic adults older than 55 years: results from the National Health and Nutrition Examination Survey, 2005-2006

Original Research Article Annals of Allergy, Asthma & Immunology, Volume 110, Issue 4, April 2013, Pages 247-252

Image retrieved from: https://www.hopepaige.com/how-to-properly-use-your-asthma-inhaler.aspx

Over 60%of adult patients with asthma1

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up to 90%

Allergic Asthma

1. Høst A, et al. Allergy. 2000;55:600-608.

Image retrieved from: https://www.hopepaige.com/how-to-properly-use-your-asthma-inhaler.aspx

of pediatric patients with asthma1

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Environmental Controls

• Indicated across

all levels of severity

Allergy Testing

• Indicated for at least

patients with persistent

asthma

• Skin or in vitro tests

may be used

• Category A evidence

2007 NIH Asthma Management Guidelines1

1. NIH. Guidelines for the Diagnosis and Management of Asthma, 2007. NIH publication 08-4051.

Stepwise Approach for Managing Asthma

Intermittent

asthmaPersistent asthma: daily medication

Patient education and environmental control at each step

Step 1

Preferred:

SABA PRN

Step 2

Preferred:

Low-dose

ICS

Alternative:

Cromolyn or

Montelukast

Step 3

Preferred:

Low-dose ICS

+LABA

OR

Medium-dose

ICS

Alternative:

Low-dose ICS

+

Either LTRA,

Theophylline or

Zileuton

Step 4

Preferred:

Medium-dose

ICS +LABA

Alternative:

Medium-dose

ICS +

Either LTRA,

Theophylline or

Zileuton

Step 5

Preferred:

High-dose

ICS +LABA

AND

Consider

Omalizumab

for patients

who have

allergies

Step 6

Preferred:

High-dose

ICS +LABA

+

Oral systemic

Corticosteroids

AND

Consider

Omalizumab

for patients

who have

allergies

Persistent asthma: daily medicationConsult with Asthma Specialist if Step 4 or higher is required

Consider consultation at Step 3

Patient education and environmental control at each step

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No interference from allergy medications

One blood draw any time of day

For adults and children 3 months old or older with allergy-like symptoms1

Lab-designed profiles• Respiratory profile

Simplicity of Ordering Specific IgE Testing

1. Data on file

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Viral

Infections

Viral

InfectionsBirch Pollen

Cumulative Effect of Asthma Triggers 1,2Cumulative Effect of Asthma Triggers1,2

1. Fromer, L. J Family Pract 2004; April: S3-S14

2. Simpson, A et al. J All Clin Immuno 2005;116:744-749.

Symptom Threshold

Mold

Irritants (cigarette smoke)

Dust Mite

MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB

Cumulative Threshold


triggers

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Viral

Infections

Viral

InfectionsBirch Pollen

Cumulative Effect of Asthma Triggers 1,2Reducing Exposure to Allergens Reduces Symptoms1,2

1. Fromer, L. J Family Pract 2004; April: S3-S14

2. Simpson, A et al. J All Clin Immuno 2005;116:744-749.

Symptom Threshold

Mold

Irritants (cigarette smoke)

Dust Mite

MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB

Cumulative Threshold


triggers

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Case Studies

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Case Study:

12 Year Old Male – Multiple Asthma Exacerbations

School Based Health Clinic

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12 y/o male

Presentation – August 20, 2017

12 year old African American, inner city, Medicaid patient. History of seasonal allergies which

exacerbates asthma. Had two recent ED visits. Had to quit playing sports due to complications with

asthma while under primary care supervision.

ACT Score = 11

Past Medical History

• Asthma

• Seasonal Allergic Rhinitis….exacerbate asthma

• Several ED visits and multiple unscheduled office visits

Meds

• Fluticasone propionate (Flovent) 1 Inh BID

• Albuterol prn

• Cetirizine prn

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12 y/o male, continued

Physical Exam

• Spirometry Obstructive Pattern – FEV1 Below Predicted

• VSS, NAD

• HEENT: Pale, swollen nasal mucosa, Dennie’s lines

• Lungs: Clear to Auscultation w/prolonged expiration

• Skin: Clear

Now what?

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School Based Health Clinics - Cincinatti

Asthma Champs Overview:

http://www.asthmacommunitynetwork.org/sites/default/files/CHAMPS

_Manual.pdf

NIH Guidelines based care:

ACT

PFT

Region 5 Respiratory Profile for all persistent asthmatics

Pharmacologic therapy

Patient Education on asthma action plan including TER sheet

Home Health visits based on positive allergy test to indoor allergens

City Sanitarian visit based off of home health needs assessment

http://www.asthmacommunitynetwork.org/sites/default/files/CHAMPS_Manual.pdf

https://www.wcpo.com/news/our-community/cincinnati-public-schools-partner-with-doctors-to-help-asthmatic-students

https://www.wcpo.com/news/our-community/cincinnati-public-schools-partner-with-doctors-to-help-asthmatic-students

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12 y/o male, continued

Clinical Diagnosis

• Moderate Persistent Allergic Asthma

• Allergic Rhinitis

Treatment –

• Increase fluticasone propionate (Flovent) 2 Inh. BID

• Review Asthma Action Plan every visit

• Targeted Exposure Reduction to Mold, Dust Mites, Dog

• Albuterol prn

• Cetirizine prn

• Refer for home visit.

• Based upon adherence “Sanitarians” not needed.

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12 y/o male

Follow-Up: November 25, 2017

• ACT = 25

• No albuterol use for wks

• Plan to follow closely and decrease medication

• “He doesn’t think he has asthma anymore. Patient and mother credit NP with curing his asthma”

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A Multifaceted Home-based

Environmental Intervention

• 937 inner-city children

• Intervention activities tailored to

child’s sensitization profile

• Targeted allergen exposure reduction

improves asthma control

Inner-City Asthma Study1

1. Morgan WJ, et al. N Engl J Med. 2004;351(11):1068-1080.

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• 2 years with Targeted Exposure

Reduction

• Bedroom-only interventions

• 34 fewer days of wheezing; effect

similar to ICS therapy

Inner-City Asthma Study1

Symptom

days per

year

21.3

1. Morgan WJ, et al. N Engl J Med. 2004;351(11):1068-1080.

Missed

school

days per

Year

4.4

Unscheduled

ED/office

visits per

year

2.1

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Case Study:

8 Year Old Male – Multiple Asthma Exacerbations

Emergency Department Protocol

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• This is the description from the ED Nurse: on 3/5/17:

• Just discharged an asthmatic patient that needs help. This 8yo little boy is having lots of

exacerbations; it sounds like mom is frustrated - they have seen 3 doctors without any progress

and have been seen here 3 times since February 5, plus visits in November and December. Allergy

testing was completed yesterday (Saturday 3/4/17) morning. Has seen pulmonologist as

scheduled. Still no improvement.

• Gave mom some of the materials from our asthma folder. Mom's face lit up when I talked about our

program and showed her the folder. Again, they are connected to a pulmonologist, follow up

appointment is not until late April.

• Follow up: Specific IgE Respiratory panel showed up that the little boy was positive to everything

on the panel. He had never been tested prior to the ED testing him! This led to follow up with

allergist for immunotherapy. Parents were finally relieved that there is a true cause. They were

frustrated because they were doing medications and specialty appointments and everything right!

After education on triggers and making bedroom a safe zone and starting shots, he was only seen

once in the ED for the rest of the year. (Relayed on January 15th, 2018)

Safety Net – Emergency Department Protocol

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10

20

30

40

50

60

70

80

90

100

Given anaction plan

Taught torecognize early

signs/symptomsof an asthma attack

Taught to respond to anasthma attack

Taught how to use a peakflow meter

Given advice onenvironmental control

(Percentage of children age <18 years)

Morbid Mortal Wkly Rpt. 2011;60(17):547-552.

Substantial Number of Patients Lack Information on Self-Management

Gaps in Care

32%49%

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Disparities in Education

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Our experience indicates that

good asthma care management

can prevent up to 99% of

children’s asthma hospitalizations,

and 95% of emergency visits.

This can totally transform the

quality of life for those children.

Pediatric Outcomes

Guillermo Mendoza, MD

Chief, Department of Allergy

Kaiser Permanente

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Asthma: Summary

• Disparities come in many forms

• Solutions – Not “One size fits all”

• First “Do the Right Things”

• Empower patients……..

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Achieving Optimal Outcomes for the Asthmatic Patient –

Addressing Disparities by Utilizing the Entire Healthcare Team

Gary Falcetano, PA-C, AE-C

Clinical Educator

[email protected]

609-577-5351

achieving optimal outcomes for the asthmatic patient ... · 2007 nih asthma management guidelines1...

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