Recom ommendati tion ons t to I Improve A e Asthma Ou Outcom - - PowerPoint PPT Presentation

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Recom ommendati tion ons t to I Improve A e Asthma Ou Outcom - - PowerPoint PPT Presentation

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Recom ommendati tion ons t to I Improve A e Asthma Ou Outcom omes: Work Gr Group C Call t to Action Barbara P. Yawn, MD, MSc FAAFP February 22, 2019 Fort Myers, FL Objectives Define the importance of allergy evaluation in asthma

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SLIDE 1

Recom

  • mmendati

tion

  • ns t

to I Improve A e Asthma Ou Outcom

  • mes:

Work Gr Group C Call t to Action

Barbara P. Yawn, MD, MSc FAAFP February 22, 2019 Fort Myers, FL

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SLIDE 2

Objectives

  • Define the importance of allergy evaluation in asthma management.
  • Discuss the 3 high risk groups appropriate for immediate allergy

evaluation.

  • Define the 2 methods for assessing specific allergen sensitizations.
  • Discuss the need to include the ACT or the Asthma APGAR as part of

asthma and allergy evaluation visits.

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SLIDE 3

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.

2.1M

Annual ER visits

479K

Annual hospitalizations

2 2

14.2M

Lost work days

3

$50B

Annual direct costs

  • f care

3

$3,300

Annual cost per person (medical expenses)4

Increase in the asthma population from 2001-09

4.3M

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SLIDE 4
  • Adults with moderate or severe

persistent asthma

  • Prior to study patients were considered

controlled by their clinicians

  • Study results: 55% of patients were

found to be uncontrolled

  • Incomplete adherence
  • Inadequate inhaler technique
  • Unaddressed triggers

Most Asthma not Controlled

Peters SP, et al. J Allergy Clin Immunol. 2007;119:1454-1461.

55%

uncontrolled

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SLIDE 5

Care Gap

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Published Workgroup Recommendations

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Multi Disciplinary Work Group

Name Specialty Randall Brown, MD MPH Allergist, educator Michael Cabana, MD MPH Pediatrician Steve Clark Optum quality VP Ivor Emmanuel, MD ENT Len Frommer, MD Family Physician Andrew Liu, MD Pediatric Allergist Allan Luskin, MD Allergist Brad Lucas, MD MBA OB/Gyn Suzanne Madison, PhD Patient Christine Wagner, APRN, MSN, AE-C Allergy Nurse Practitioner Barbara Yawn, MD MSc MSPH Family Physician

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SLIDE 8

Predominance of Allergic Risk Factors

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SLIDE 9

Allergic Sensitization in 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%

  • f adult patients with asthma1

90%

  • f children with persistent asthma
  • 2. Høst A, et al. Allergy. 2000;55:600-608.

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

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SLIDE 10

Asthma Burden and Allergy

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SLIDE 11

Predictive in Children

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Core Components of Asthma Care

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 of environmental triggers Pharmacologic therapy Education

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SLIDE 13

From the Guidelines…

  • NIH. Guidelines for the Diagnosis and Management of Asthma, 2007. NIH publication p 167

For successful long-term management of asthma, it is essential to identify and reduce exposure to relevant allergens.

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SLIDE 14

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 asthma

Persistent 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 medication

Consult 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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SLIDE 15

Workgroup Recommended Priorities

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You can identify from EMR or claims data

819K – 215K = 704K Not 2.2 M

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History is not be enough

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Diagnostics are important and available

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Interpretation

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Not just immunoRx---Education

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Control tool that includes trigger questions

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Al Algori rith thm

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ED/urgent care/hospitalizations

Control 15.9% to 20.9%, p =.006 Intervention 17.5% to 10.6%, p = .001

Rates of “in control asthma” by ACT

Control 42.0% to 46.0%, p =.086 Intervention 40.8% to 54.3%, p = .001 p=.004 p=.06

Yawn BP, et al. Ann Fam Med. 2017; 87 (1):230-237. Yawn BP. Abstract presented at the AAAAI Annual Meeting; March 6, 2017; Atlanta, Georgia.

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SLIDE 24

Adherence to elements of asthma guidelines:

Intervention N = 632 Control N = 208 Transistion N = 226 Change in % of assessment from baseline to 12-months Adherence to 3 or more elements 20.7%

  • 1.9%

10.2% P < .001 Specific elements: Control assessed 55.2% 0.5% 19.5% P < .0001 Allergies assessed 15.8%

  • 11.1%
  • .05%

P < .0001 Inhaler technique

  • bserved

1.2%

  • 5.2%

1.7% P = 0.3 Asthma action plan completed 3.6% 1.4% 4.0% P = .51 Medication adherence assessed 32.3% 25.4% 37.6% P = .13

Yawn BP, et al. Ann Fam Med. 2017; 87 (1):230-237. Yawn BP. Abstract presented at the AAAAI Annual Meeting; March 6, 2017; Atlanta, Georgia.

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Barriers and facilitators for practice change and staff comments

Barriers Staff comments regarding barriers

Time Limited physician buy in Limited staff acceptance Lack of centralized mandate Unsure of need

“It takes time to try something new—we don’t have time” “Some physicians are just not willing to try anything new.” “Some of the nursing staff only do what is required by their physicians.” “Our patients are doing OK”

Facilitators Staff comments regarding facilitators

Feedback from patients Asthma as quality site target Case reports Ease of use of tools Tools from primary care

“[With the Asthma APGAR] we actually knew what the patient was doing and thinking”. “I got more information than I have ever had and…. it improved care.” “Using the system definitely improved the asthma care and the patients liked it.”

Yawn BP, et al. Ann Fam Med. 2017; 87 (1):230-237. Yawn BP. Abstract presented at the AAAAI Annual Meeting; March 6, 2017; Atlanta, Georgia.

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SLIDE 26

Presentation

  • Persistent cough w/periodic wheeze &

dyspnea x 1 yr

  • Persistent nasal congestion x 1 yr
  • Asthma APGAR = 4
  • Marked several triggers

Past Medical History

  • Episodic “bronchitis” & “sinusitis”.

Treatment w/antibiotics/NSA

  • Frequent unscheduled visits
  • 2 steroid bursts in past yr for respiratory Sx

Rhys, age 9 years

Family History

Mother has allergic rhinitis & asthma

Social History

  • Lives w/parents, brother & dog
  • Mother confirms ambivalence about meds
  • No smokers @ home

Meds

  • Fluticasone propionate metered dose

inhaler 88 mcg BID

  • Montelukast 5 mg qd
  • Albuterol prn (using almost daily)
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Rhys continued

Physical Exam

  • PEF = 195 L/min (nl = 214)
  • BP 74/52, 88, 16, afebrile, pulse ox 96%
  • HEENT: Pale, swollen nasal mucosa, Dennie’s lines
  • Lungs: Clear to auscultation w/prolonged expiration
  • Skin: Clear—no eczema

Other

  • Inhaler technique with spacer—adequate
  • Meds refilled X10 past year

Poorly controlled asthma, several exacerbations and 2 oral steroid bursts

Now what?

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SLIDE 28

Sensitization may or may not = clinical allergy

Allergen Testing

=

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SLIDE 29
  • Authors concluded that specific IgE blood test & SPT

both exhibited similar and excellent efficiency

Predictive Value vs. Skin Prick Testing (SPT)

Performance Parameters

In Vitro

SPT

Sensitivity (%) 87.2 93.8 Specificity (%) 90.5 80.1 PPV (%) 91.1 90.1 NPV (%) 86.4 87.1 Clinical Efficiency (%) 88.8 89.2

Wood RA, et al. J Allergy Clin Immunol. 1999;103:733-779.

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SLIDE 30
  • FDA-cleared quantitative measure of specific IgE
  • Most widely used specific IgE blood test, documented in

> 4,000 peer-reviewed publications

  • Interchangeable with skin prick testing

ImmunoCAP as an Allergy Diagnostic Tool

Johansson SGO. Expert Rev Mol Diagn. 2004;4:273-279. Hamilton RG. Pediatric Allergy: Principles & Practice. St Louis, MO: Mosby-Year Book,Inc; 2003:233-242.

No interference from allergy medications One blood draw any time of day For adults and children 3 months old or older with allergy-like symptoms Lab-designed profiles

  • Respiratory profile
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National Respiratory Regional Profiles

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Rhys’ Report

Maple Tree IgE <0.10 <0.10 kUA/L Elm Tree IgE 0.94 <0.10 kUA/L Oak Tree IgE <0.10 <0.10 kUA/L Ash Tree IgE <0.10 <0.10 kUA/L Birch Tree IgE <0.10 <0.10 kUA/L Alternaria tenule IgE <0.10 <0.10 kUA/L Timothy Grass IgE <0.10 <0.10 kUA/L Dog Dander IgE 6.87 <0.10 kUA/L Bermuda Grass IgE 1.22 <0.10 kUA/L Alternaria alternata IgE 20.01 <0.10 kUA/L June/Kentucky Blue IgE <0.10 <0.10 kUA/L RagweedIgE 23.55 <0.10 kUA/L Orchard Grass IgE 1.23 <0.10 kUA/L Cockroach <0.10 <0.10 kUA/L Dust Mite 5.4 <0.10 kUA/L Mouse Urine <0.10 <0.10 kUA/L Total IgE 76 <100 kU/L Result kUA/L Reference Range

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SLIDE 33

Allergy to: Animals

  • Fantasy--remove pets from inside by finding it a new home or keeping it outside
  • Maybe--Confine pet to a room with a polished floor and wipeable furniture
  • Doable--Restrict furry pets from the bedroom and keep off of furniture
  • $$$--High efficiency particulate air (HEPA) filters in AC/furnace and vacuum cleaners
  • Not sure about this one????---Bathe pet weekly
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SLIDE 34

Control Measures for Mold

INDOOR

  • Doable---Identify and clean moldy areas with fungicide or bleach
  • Maybe--Use a dehumidifier to reduce the humidity in the home
  • Doable--Fix water leaks
  • Doable--Clean furnace, refrigerator and dehumidifier drip pans with bleach
  • Doable—Change furnace filters regularly (not expensive)
  • Doable--Thoroughly dry clothes before storing

OUTDOOR

  • Maybe--Avoid mowing grass, handling mulch, compost or raking leaves
  • Maybe--Avoid using fans that draw in outside air
  • $$$--Use an air conditioner on recirculate
  • Maybe--Keep windows and doors closed

www.EPA.gov/mold/moldresources.gov

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Viral Infections Viral Infections Pollens

Cumulative Effect of Asthma Triggers 1,2

Cumulative 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 of environmental triggers

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SLIDE 36

Viral Infections Viral Infections Pollens

Cumulative Effect of Asthma Triggers 1,2

Reducing Exposure 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 of environmental triggers

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SLIDE 37
  • Make a plan with the patient
  • Rank positive results in order

from high to low IgE measurements

  • Consider reducing exposure

to allergens with the highest IgE levels first

  • Focus on indoor triggers,

since they may be easier to control

Counseling

569728.01

Rhys hys Dus Dust Mi Mite Grass ss Pollen len Weed Pollen llen

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SLIDE 38

Ellen, 45 years old

Presentation

  • Complaint of frequent cough
  • Iced drinks and exercising
  • Nocturnal coughing >3 times/wk
  • Asthma APGAR = 3 (no triggers)

Past Medical History

  • No hx of smoking
  • No other medical hx
  • 3 ED visits in 6 years
  • URIs and exacerbations

Family History

  • Family hx of asthma & allergies

Social History

  • Hardwood floors
  • Cats

Meds

  • NSA, INS & montelukast
  • Good refill hx
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SLIDE 39

Allergen kUA/L (nl <0.10) House dust mite (D. pteronyssinus) <0.10 Cat dander <0.10 Dog dander <0.10 Horse <0.10 Cockroach <0.10 Mold (A. alternata) <0.10 Mold (C. herbarum) <0.10 Common ragweed <0.10 Russian thistle <0.10 Rough marsh elder <0.10 Fire bush <0.10 Oak <0.10 Elm <0.10 Cottonwood <0.10 Box elder <0.10 Redtop grass <0.10 Bermuda grass <0.10 Total IgE 3

Clinical Diagnosis

  • Non-allergic asthma

Treatment

  • Stop NSA, INS and

montelukast

  • Prescribe ICS moderate

dose and Albuterol

Follow-Up:

Asthma APGAR = 1 No more exacerbations Infrequent prn Albuterol

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SLIDE 40

Collaboration is needed

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Summary

  • Most asthma patients have daily symptoms
  • Asthma is a costly disease
  • Specific IgE test results

identify allergic triggers

  • Skin testing is feasible but may be more

costly and harder to obtain

  • Knowing the triggers permits

specific recommendations for control

  • Reducing exposure to triggers

reduces symptoms and costs

  • NIH recommends testing for all patients with

persistent asthma