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Improving care, quality and outcomes.
The Asthma APGAR Project
Olmsted Medical Center
Rochester, MN
Chatfield, MN
Pine Island, MN
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Assumption:
Quality Outcomes
Patient-Centered Focus
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Objectives:
Relate care and outcomes Identify quality related outcomes Suggest quality indicators Suggest process to assess indicators Develop 5 easy questions Review cases
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Quality should focus on:
Outcomes that matter to patients Outcomes that matter to families Outcomes that matter to clinicians Outcomes that matter to quality monitors
In that order
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WorkAbsenteeismPresenteeism
Promotion
Outcomes that matter:
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PlayFocus on Fun
Person centeredNot disease centered
Outcomes that matter:
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Sleep EnoughNot interrupted
Outcomes that matter:
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$,$,$ Not consumed by asthma
Outcomes that matter:
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Outcomes that matter to patients:
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Appropriate diagnosis and management
Less Morbidity, Better Quality of Life:
Fewer ED visits– Follow-up after ED
Fewer school/work absences– Medication appropriate to severity
No hospitalizations– Immediate care
More symptom free days
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Outcomes that matter to families:
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More normal lifestyle:
Simple treatment plans– ?? Long acting medications– Step down therapy
Fewer urgent visits– Schedule regular visits– Have a plan for regular visits
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More “normal” lifestyle (con’t):
No hospitalizations Less stress and less obsession with
asthma– Knowing what to do to help
More “asthma-free” days
Education
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Outcomes that matter to the practice:
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Practice outcomes:
Fewer unscheduled visits Fewer phone calls Shorter phone calls
Better self management
Written plans or any plans
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Outcomes that matter to quality monitors:
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Meeting Quotas:
Correct drug ratios “Appropriate” use of medications Fewer ED and urgent care visits Fewer hospitalizations Patient satisfaction
HEDIS
JCAOH
AMA
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First priority is to meet patient and family needs
Understand disease from their perspective Affirm their concerns Negotiate a common ground Provide environment for communication
and education Control symptoms
Patient Centered Focus
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Make sure it is asthma:
Correct diagnosis and uniform terminology
RAD, chronic bronchitis,
wheezy bronchitis
Symptoms
PFT
Allergies
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Assess Severity:
Severity
Baseline
Attacks
Frequency
Intensity
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Asthma Severity
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Do they need steroids?
Classify severity
Baseline or treated
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NHLBI EPR – 2 Severity Classification
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Classify severity:
Simplify to 5 easy questions: How many days of the week do you have
symptoms? All day or most of the day? How many nights a week (month) do you
have symptoms? Do you have long periods of no
symptoms? FEV1
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Translating symptoms to severity
Intermittent -- long periods with no symptoms
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Translating symptoms to severity
Persistent -- no long periods without symptoms– Mild --- symptoms only once or twice a
week, short duration and not intense, rarely at night
– Moderate --- symptoms almost daily + 1 or 2 nights a week, hours to days and varying intensity
– Severe --- symptoms daily and nightly, almost continuous and varying intensity
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Classify severity:
Need to ask about:– Symptoms for 2 to 4 weeks not just 2 to 4 days– Go beyond the “attack”– Be specific
CoughSOB, DOEAwakening
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Assessing symptoms:
Don’t ask --- Don’t tell --- Don’t Document
Has never worked for anything!!!!!
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The severity score addresses the baseline symptom
assessment:
Does not address the exacerbations or attacks
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Add attacks:
60-80% of children who die of asthma have mild asthma.
Frequency
Intensity
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When to use Spirometry
Initial assessment – diagnosis After symptoms and peak flow stabilize Every 1 to 2 years
– Polgar children– Crapp adults
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Components of Spirometry
What do they mean? FVC – forced vital capacity
<75% obstruction FEV1 – forced expir vol, 1 second
<75% obstruction FEV1/FVC - <.7 obstruction
FEF25-75 - forced expiratory flow
<65% obstruction
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Peak Flow as Diagnostic Tool
Less accurate than diagnostic instruments Cannot be calibrated or checked to assure
their performance No graphical display to evaluate effort,
quality Current PEF standards of + 10 percent
allow models of instruments to vary by up to 20 percent
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Who needs steroids?
1. Do they have asthma?<5 years and >45 yearsSymptomsPFTs/ Spirometry-low reversibleOther causes
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Who needs steroids?
2. Do they have daily symptoms?
(>2 x / week)
or
nightly symptoms
(>2 x / month)
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Who needs steroids?
3. Do they have PFT with FEV1 <75% predicted?
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Who needs steroids?
4. Can you remove the trigger(s)?
Allergens
Irritants
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Who needs steroids?
5. Do they have life threatening exacerbations?
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Triggers/Allergies
Doesn’t have to be overwhelming Few people have more than 2 or 3
major triggers Triggers may change (additive
effects)
Unlikely to gain control without knowing triggers
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Allergies:
Symptoms– Running or stuffy nose– Itchy nose or eyes– Eczema– Sneezing
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Allergies:
Family history Known triggers Seasonal vs. persistent Related to location
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Irritants:
Almost everyone with asthma reacts to some irritant.– Smoke– Fragrance– URI– Formaldehyde
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Case #1:
John, 25 year-old computer programmer Mid-August-yearly Stuffy, runny nose Itchy eyes, nose, throat Regular jogger 3 x /week Shortness of breath and coughing with jogging
June & August Night-time awakening OTC meds only
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Exam:
Nasal voice Swollen, boggy mucosa No polyps Lungs clear
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Question A:
Based on the history so far, the most likely diagnosis is:
Card
• Summer cold with bronchitis #1• Seasonal allergic rhinitis (hay fever) #2• Seasonal allergic rhinitis with
post-nasal-drip induced cough #3• Seasonal allergic rhinitis with seasonal asthma #4
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Answer:
Seasonal allergy and asthma #4
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Question B:
How would you rate asthma severity?– Mild intermittent #1– Mild persistent #2– Moderate persistent #3– Severe persistent #4
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Answer:
Mild persistent #2– Daily symptoms > 2 x / week– Nightly symptoms > 2 x / month– ? PFTs
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Question C:
What is your next test?
Total IgE #1 Spirometry #2 Skin test #3 CT of sinuses #4
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Answer:
Spirometry #2
FVC 4.3 L 110%
FEV1 3.4 L 100%
FVC/FEV1 .79 86%
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Question D:
Does this man need steroids? No #1 Inhaled low dose #2 Inhalded moderate dose #3 Oral burst #4
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Treatment:
Asthma – mild persistent– Inhaled steroids – low dose #2– Pre-med for exercise
Allergies– Antihistamine
Re-check 2 weeks
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Case 2:
16 year old girl – feels fine Asthma diagnosed age 8 Trouble in 1st hour class-sleepy Stays up late talking on phone Awakened by coughing Meds - prn
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Question A:
What are her asthma symptoms?– None #1– Fatigue #2– Coughing #3– School problems #4
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Answer:
At least coughing #3 Probably fatigue #2 Probably school problems #4
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Exam:
HEENT-neg Lungs-difuse wheezes FEV1 –72%
Slender Otherwise normal
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Question B:
What is asthma severity level?
– Mild intermittent #1– Mild persistent #2– Moderate Persistent #3– Severe Persistent #4
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Answer:
At least moderate #3
and
probably severe persistent. #4
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Question C:
Does this girl need steroids?
– No #1– Inhaled low dose #2– Inhaled moderate/high dose #3– Oral #4
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Treatment:
Inhaled moderate/high dose steroids #3 Long-acting ß agonist Rescuer ? More
See back 2 weeks
Consider spirometry
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Treatment:
Inhaler technique Written action plan Education
– Goal setting (collaborative)
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Case 3:
8 year old boy Coughing and wheezing 4 days this week Increased symptoms with cat Increased symptoms with running Mother won’t let him play soccer ß agonist BID x 2 years
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Question A:
Asthma severity?– Mild intermittent #1– Mild persistent #2– Moderate persistent #3– Severe persistent #4
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Answer:
At least mild persistent #2– >2 x / week– No soccer
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Can you remove triggers?
Cat - ? Exercise - ?
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Question B:
What is the next test?
– Spirometry #1– Cat RAST #2– Exercise challenge #3– Methacholine challenge #4
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Answer:
Spirometry #1
FEV1 70%
After ß agonist FEV1 90%
>15% improvement
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Question C:
Does he need steroids?
No #1 Inhaled low dose #2 Inhaled moderate dose #3 Oral burst #4
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Answer:
Inhaled moderate dose #3
Pre-treat exercise – next week Inhaler technique Action plan Return 2 weeks ? Peak flow meter
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Diagnosis:
Recurrent symptoms PFT Consistent terminology
% of 493 that are RAD or wheezy bronchitis in children and adults > 3 years
old
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Classify severity:
Symptoms, Symptoms, SymptomsSpirometry
% with daytime symptoms documented
% with nighttime symptoms documented
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Self-management skills:
Education Monitoring medication use
% of persistent asthmatic with education
% of asthmatic with inhaler technique documented
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Triggers:
When and what
% of charts with triggers or allergies
mentioned or evaluated
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Follow-up:
Regular care Post ED Post hospitalization
% of patients with non-urgent visit in a year
% of patients with f/u visit after ED
% of patients with f/u visit after hospitalization
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Referral:
Not all but when appropriate Must communicate
% of patients with f/u letter after referral
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Quality indicators:
% of 493 that are RAD or wheezy bronchitis in children and adults > 3 years old?
% with daytime symptoms documented?
% with nighttime symptoms documented?
% of charts with triggers or allergies mentioned or evaluated?
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Quality indicators:
% of patients with non-urgent visit in a year?
% of patients with f/u visit after ED?
% of patients with f/u visit after hospitalization?
% of patients with f/u letter after referral?
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POOM
If zones are red
and patients are blue
you need to take better
care of asthma, too!
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Case 1A 15 y.o. female comes in for a sports physical. Complains of chest
tightness during cheerleading practice, which she does every day after school. Uses Albuterol MDI (refills about once a month). Reports “hay-fever” every May and June, uses Allegra during these months only.
Spirometry:FVC: 102% predicted
FEV1: 89% predicted (6% increase after Albuterol)
FEF25-75%: 78% predicted PEFR: 93% predicted
What is your assessment of her asthma severity, and your proposed treatment plan?
Is there any other information that would be helpful to your management decision-making?
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Case 2A 6 y.o. girl in for a well child check. Occasional night cough (keeps
younger sister up –same bedroom). She has no history/diagnosis of asthma, but hospitalized once for bronchiolitis at 11 months old, and seen in ED once for RAD at “about” 2 years old.
Spirometry:FVC: 96% predicted
FEV1: 75% predicted (15% increase after Albuterol)
FEF25-75%: 52% predictedPEFR: 92% predicted
Does she have asthma?
If so, what is your assessment of her asthma severity, and your proposed treatment plan?
Is there any other information that would be helpful to your management decision-making?
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Case 3A 17 y.o. male in for planned asthma visit. Your patient for 2 years, since he
moved to your city from Hawaii. Diagnosed with asthma as an infant there. Says he feels fine today. Uses Albuterol several times a day, typically on way to school bus and before Phys. Ed. Usual medications
-Advair 250/50 1 puff b.i.d. -Singulair 10 mg q.h.s.-Rhinocort 2 puffs b.i.d. -Albuterol p.r.n.Reports good adherence; you believe himSpirometry:FVC: 93% predicted
FEV1: 64% predicted (10% increase after Albuterol)
FEF25-75%: 38% predictedPEFR: 82% predicted
What is your assessment of his asthma severity, and your proposed treatment plan?
Is there any other information that would be helpful to your management decision making?
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Case 4A 56 y. o. woman presents to your office with dry cough, dyspnea on
exertion. She says that she had had episodes of “bronchitis” with yellow sputum production in the spring and in the fall, for as long as she can remember. She takes an antibiotic and the symptoms go away in a month, or so.
Spirometry:
FVC: 65% predicted
FEV1: 62% predicted (24% improvement after Albuterol)
FEF25-75%: 40% predicted
PEFR: 60% predicted
Does she have asthma? How would you treat her?
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Case 5
A 56 y.o. man presents to your office with chronic cough, productive of usually clear sputum. He has dyspnea on mild exertion, e.g. walking up on flight of stairs. He has a 65 pack year smoking history, but quit 2 years ago. He has chronic sinus drainage that exacerbates in the late summer and early fall.
Spirometry:
FVC: 55% predicted
FEV1: 52% predicted (24% improvement after Albuterol)
FEF25-75%: 37% predictedPEFR: 50% predicted
Does he have asthma? How would you treat him?