High Quality Care in Childhood Asthma

1. High Quality Care in Childhood Asthma Floyd Livingston M.D. Division Chief, Pediatric Pulmonology & Sleep Medicine Nemours Children’s Clinic Orlando

2. Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

3. 20.3 million people affected Prevalence increased 75% from 1980 to 1994 111 per 1000 people Per year 10.4 million asthma-related outpatient visits 1.8 million emergency room (ER) visits 5000 deaths >$9.4 billion in direct costs; $4.6 billion in indirect costs Impact on Children 9 million children have been diagnosed with asthma >4 million children had an asthma attack in the past year Prevalence 122 per 1000 people ≤18 years of age 14 million missed school days per year 40% of children whose parents have asthma will develop asthma AsthmaImpact in the United States AAAAI. Asthma Statistics. 2005. Available online at http://www.aaaai.org/media/resources/media_kit/asthma_statistics.stm. Accessed January 16, 2005. Asthma Prevalence Health Care Use and Mortality, 2002;1-6. CDC.

4. And Has Increased in the US* Revision of NHIS Number of People With Asthma Rate per 1000 Persons * With the revision of the National Health Interview Survey in 1997, the question “During the past 12 months, did anyone in the family have asthma?” was eliminated and was replaced with 2 questions: “Have you ever been told by a doctor or other health professional that you had asthma?” and “During the past 12 months, have you had an episode of asthma or asthma attack?”. Realizing the information gap resulting with the revised questions, “Do you still have asthma?” was added in 2001, reinstating a measure of current prevalence. However, data between 1982 and 1996 should not be compared to 2001-2004 estimates. American Lung Association Epidemiology & Statistics Unit Research Program Services. Trends in Asthma Morbidity and Mortality. July 2006. Available at: www.lungusa.org. Accessed November 2, 2006.

5. Epithelial injury Inflammatory cell infiltration of the mucosal layer Thickened sub-epithelial basement membrane Hypertrophy of bronchial smooth muscle Persistent Inflammation

6. Environmental Exposures: Allergens, Infections, Tobacco Smoke “Triggers” Normal Lung Function Inception of Asthma Mild Asthma Severe Asthma Genetic Factors: Atopy Airways Hyperreactivity Interaction of Environmental and Genetic Factors in the Inception of Asthma

7. All Patients Medical history Family history Physical examination findings Rule out differential diagnosis Spirometry tests Selected Patients Chest x-ray Blood tests Sputum studies Allergy tests Challenge tests Diagnosis of Asthma

8. Office Spirometry • A good quality portable spirometer • A dedicated area to perform the test • Dedicated personnel to perform the testNot full time, but consistently available • Enthusiasm and willingness to learn • A good understanding of what the results mean!For primary care: • What is normal, what is obstruction, what to refer. • Training is essential

9. Office Spirometry • To help in initial diagnosis of asthma • Document bronchodilator responsive airway obstruction • Document recurrent episodes • To help evaluate efficacy of therapy • To help evaluate effects of medication adjustments • To identify obstruction in the absence of wheezing or symptoms

10. Obstructive Changes in Lung Function Pre Post FVC 93 99 FEV15977 Response to albuterol: % of predicted

11. Pitfalls of Office Spirometry • Spirometer is malfunctioning or not well calibrated • Different testers evoke different degrees of effort from patients • The correct predictive scale is not applied • Trained personnel are not regularly available • Too few tests are performed to maintain expertise • Interpretation issues

12. Considerations in Pediatric PatientsWhen Should Wheezing Be Called Asthma? • Recurrent • Other wheezing conditions have been excluded • Known risk factors for asthma are present • Child responds to asthma therapy Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics 2002. National Asthma Education and Prevention Program. June 2003. NIH Publication No. 02-5074. Available online at http://www.nhlbi.nih.gov/guidelines/asthma/. Accessed January 16, 2005.

13. Pediatric Patients Distinguish chronic cough from acute cough, which may correspond to viral infections1 Congenital abnormalities1 Cystic fibrosis1,2,3 Gastroesophageal reflux1,3 Airway obstruction2,3 Bronchopulmonary dysplasia2 Upper airway noise3 Immunodeficiency3 Congenital heart disease3 Vocal cord dysfunction3 Adult Patients Chronic obstructive pulmonary disease2 Congestive heart failure2 Gastroesophageal reflux2 Mechanical obstruction2 Medication2 Vocal cord dysfunction2 Differential Diagnosis • Smith L. J Allergy Clin Immunol. 1998;101:S370-S372. • Environmental Triggers of Asthma. Case Studies in Environmental Medicine. April 2002. US Department of Health and Human Services Agency for Toxic Substances and Disease Registry. Division of Health Education and Promotion. Available online at http://www.atsdr.cdc.gov/HEC/CSEM/asthma/. Accessed January 17, 2005. • Pediatric Asthma: Promoting Best Practice. Guide for Managing Asthma in Children. AAAAI. Available at http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm. Accessed January 16, 2005.

14. Considerations for Pediatric PatientsBarriers to Effective Treatment • Many treatment options for young children do not provide consistent symptom relief1 • Diagnostic issues2 • Limited access to healthcare2 • Lack of resources2 • Poverty2 • Incorrect use of medication3 • Lack of adherence to treatment regimen4 • Kemp JP, et al. Ann Allergy Asthma Immunol. 1999;83:231-239. • Pediatric Asthma: Promoting Best Practice. Guide for Managing Asthma in Children. AAAAI. Available at http://www.aaaai.org/members/resources/initiatives/pediatricasthma.stm. Accessed January 16, 2005. • Smith L. J Allergy Clin Immunol. 1998;101:S370-S372. • Knorr B, et al. Pediatrics. 2001;108(3). URL: http://www.pediatrics.org/cgi/content/full108/3/e48. Accessed January 16, 2005.

15. Considerations for Pediatric PatientsMedications Properties • Taste • Consistency • Tablet or capsule size (if applicable) • Dosing frequency • Ease of use • Concerns about side effects Smith L. J Allergy Clin Immunol. 1998;101:S370-S372.

16. Inhaled Corticosteroids Beclomethasone, Budesonide, Flunisolide, Fluticasone Propionate, Triamcinolone AAAAI Allergy and Asthma Medication Guide: Quick Reference Guide for Clinicians: Systematic Review of the Evidence Regarding Potential Complications of Inhaled Steroid Use in Asthma. Collaboration of the ACCP, AAAAI, ACAAI. Available online at http://www.aaaai.org/members/resources/quick%20reference%20guide.doc. Accessed January 17, 2005. Communication with Don Bukstein (telephone), January 21, 2005.

17. Are You Confused Too? Nebulizers Dry powder inhalers Spacer Spacer with mask Pulmonary deposition

18. Willingness to Fill an Inhaled Corticosteroid Prescription • 66% of asthma patients report they have • concerns regarding the safety of ICS. • These concerns directly bear on adherence • Most common concerns: • - dependence • - impaired growth • - soft bones • - cosmetic changes Boulet, Chest 1998; 113:587

19. So Lets Get Real….. • We need asthma therapies that are: • effective • safe • easy to take • have no unpleasant side effects • are affordable

20. Defining and Developing Effective Strategies • Importance of early diagnosis and intervention • Identify levels of disease and environmental triggers • Use objective measures of lung function to assess severity and monitor effectiveness of therapy • Define asthma control and monitor variability • Use environmental controls to avoid or remove factors that contribute to disease • Pharmacologic therapy should safely and effectively • Control inflammation • Manage exacerbations • Prevent symptoms • Improve quality of life (QoL) • Provide patient education and promote self-management Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics 2002. National Asthma Education and Prevention Program. June 2003. NIH Publication No. 02-5074. Available online at http://www.nhlbi.nih.gov/guidelines/asthma/. Accessed January 16, 2005.

21. To Achieve Asthma Control… • Patients need to: • Avoid asthma triggers • Use daily medication to reduce lung inflammation • Know what to do if developing increased asthma symptoms • Use quick relievers • Start oral corticosteroids if necessary

22. How do providers help patients achieve asthma control? • NAEPP EPR-3 guidelines recommend: • Use standardized approach • Prescribe daily meds based on symptom severity • Teach patients about different asthma meds • What a controller is and when to take it • What a reliever is and when to take it • Show patients how to use an inhaler • Give patients a written plan for what to do every day, what to in case of distress

23. NAEPP Asthma Guidelines • Most recent release in 2007 (EPR-3) • Lengthy written document • 417 pages of narration & references • Organized by topic rather than workflow • Recommendations difficult to summarize • Lack of usable summary inhibits implementation during patient care

24. e-AAP: Asthma decision support from EHR • Guidelines “translated” into executable code • Launched during patient encounter from EHR • Facilitates & assists: • Focused patient-provider communication • Treatment plan/medication selection • Produces: • Written (English or Spanish) chronic care document (Asthma Action Plan) • Progress note for provider documentation

25. Sample screen: Assessing asthma control Sample screen: Assessing asthma control

26. My Asthma Action Plan

27. Written AAP: Part of the EHR • Important chronic care document • Daily meds for asthma control • Patient actions in response to increased symptoms & respiratory distress • Clinic & provider names & telephone numbers • Follow-up time. • Asthma registry created • Facilitates asthma QI and population management

28. Medical Home in Childhood Asthma Family out of pocket expenses have decreased Emergency Room visits have decreased Inpatient admissions have decreased Overall healthcare costs have decreased Outcomes and Quality of Life have improved

29. Summary • Asthma is the most common chronic disease of childhood • Children with persistent asthma need to placed on and maintained on specific controller therapy • Every asthma patient needs a written “Asthma Treatment Plan” • The Medical Home improves outcomes and family satisfaction which leads to adherence to prescribed treatment plans