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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
gary@falcetano.com
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.
Assessment& monitoring
Control ofenvironmental
triggers
Pharmacologictherapy
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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631939Mayo 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
www.mayoclinicproceedings.org n ª 2016 Mayo Foundation for Medical Education and Research
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Asthma Workflow
• Asthma Control Test
• Spirometry
• History and physical exam
Assessment& monitoring
Control ofenvironmental
triggers
Pharmacologictherapy
Education
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Asthma Workflow
• Identify Non-Allergic Triggers
• Allergic Trigger Identification with
testing
• Review of specific IgE test results
Assessment& monitoring
Control ofenvironmental
triggers
Pharmacologictherapy
Education
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• Medication review
• Complete Asthma Action Plan
Asthma Workflow
Assessment& monitoring
Control ofenvironmental
triggers
Pharmacologictherapy
Education
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• Review of proper medication usage/techniques
• Environmental interventions and progress
• Self-Management skills
Asthma Workflow
Assessment& monitoring
Control ofenvironmental
triggers
Pharmacologictherapy
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
Control ofenvironmental
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
Control ofenvironmental
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
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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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0
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
gary@falcetano.com
609-577-5351
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