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

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 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.

Asthma: Clinical and Economic Burden 1 2 4.3M 2.1M Annual ER visits Increase in the asthma 18.9 million adults population from 2001-09 7.1 million children $3,300 Annual cost per person (medical expenses) 4 $50B 479K 3 2 14.2M 3 Annual hospitalizations Annual direct costs Lost work days of care 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.

Most Asthma not Controlled • Adults with moderate or severe persistent asthma • Prior to study patients were considered 55% controlled by their clinicians • Study results: 55% of patients were uncontrolled found to be uncontrolled • Incomplete adherence • Inadequate inhaler technique • Unaddressed triggers Peters SP, et al. J Allergy Clin Immunol . 2007;119:1454-1461 .

Care Gap

Published Workgroup Recommendations

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

Predominance of Allergic Risk Factors

Allergic Sensitization in Asthma 90% of children with persistent asthma Over 60% of adult patients with asthma 1 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 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

Asthma Burden and Allergy

Predictive in Children

Core Components of Asthma Care Control of Assessment Pharmacologic environmental Education & monitoring therapy triggers 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.

From the Guidelines… For successful long-term management of asthma, it is essential to identify and reduce exposure to relevant allergens. NIH. Guidelines for the Diagnosis and Management of Asthma, 2007. NIH publication p 167

2007 NIH Asthma Management Guidelines 1 Environmental Persistent asthma: daily medication Intermittent Persistent asthma: daily medication Consult with Asthma Specialist if Step 4 or higher is required asthma Controls Consider consultation at Step 3 Stepwise Approach for Managing Asthma • Indicated across Step 6 all levels of severity Preferred: Step 5 High-dose ICS +LABA Preferred: Step 4 + High-dose Oral systemic ICS +LABA Preferred: Corticosteroids Allergy Testing Step 3 Medium-dose AND ICS +LABA AND Preferred: Step 2 Consider Low-dose ICS Alternative: Consider Omalizumab for • Indicated for at least +LABA Preferred: Medium-dose ICS Omalizumab for Step 1 patients who OR Low-dose + patients who patients with persistent asthma have allergies Medium-dose ICS Either LTRA, have allergies Preferred: ICS Theophylline or SABA PRN Alternative: Alternative: Zileuton • Skin or in vitro tests Low-dose ICS + Cromolyn or Either LTRA, Montelukast may be used Theophylline or Zileuton • Category A evidence Patient education and environmental control at each step Patient education and environmental control at each step 1. NIH. Guidelines for the Diagnosis and Management of Asthma, 2007. NIH publication 08-4051.

Workgroup Recommended Priorities

You can identify from EMR or claims data 819K – 215K = 704K Not 2.2 M

History is not be enough

Diagnostics are important and available

Interpretation

Not just immunoRx---Education

Control tool that includes trigger questions

Al Algori rith thm

ED/urgent care/hospitalizations Control 15.9% to 20.9%, p =.006 Intervention 17.5% to 10.6%, p = .001 p=.004 Rates of “in control asthma” by ACT Control 42.0% to 46.0%, p =.086 Intervention 40.8% to 54.3%, p = .001 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.

Adherence to elements of asthma guidelines: Intervention Control Transistion N = 632 N = 208 N = 226 Change in % of assessment from baseline to 12-months Adherence to 3 or 20.7% -1.9% 10.2% P < .001 more elements Specific elements: Control assessed 55.2% 0.5% 19.5% P < .0001 Allergies assessed 15.8% -11.1% -.05% P < .0001 Inhaler technique 1.2% -5.2% 1.7% P = 0.3 observed Asthma action plan 3.6% 1.4% 4.0% P = .51 completed Medication 32.3% 25.4% 37.6% P = .13 adherence assessed 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.

Barriers and facilitators for practice change and staff comments Barriers Staff comments regarding barriers Time “It takes time to try something new—we don’t have time” Limited physician buy in “Some physicians are just not willing to try anything new.” Limited staff acceptance “Some of the nursing staff only do what is required by their physicians.” Lack of centralized mandate “Our patients are doing OK” Unsure of need Facilitators Staff comments regarding facilitators Feedback from patients “[With the Asthma APGAR] we actually knew what the patient was Asthma as quality site target doing and thinking”. Case reports “I got more information than I have ever had and…. it improved care.” Ease of use of tools “Using the system definitely improved the asthma care and the Tools from primary care 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.

Rhys, age 9 years Family History Presentation Mother has allergic rhinitis & asthma • Persistent cough w/periodic wheeze & dyspnea x 1 yr • Persistent nasal congestion x 1 yr Social History • Lives w/parents, brother & dog • Asthma APGAR = 4 • Mother confirms ambivalence about meds • Marked several triggers • No smokers @ home Past Medical History • Episodic “bronchitis” & “sinusitis”. Meds Treatment w/antibiotics/NSA • Fluticasone propionate metered dose • Frequent unscheduled visits inhaler 88 mcg BID • Montelukast 5 mg qd • 2 steroid bursts in past yr for respiratory Sx • Albuterol prn (using almost daily)

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?

Allergen Testing Sensitization may or may not = clinical allergy =

Predictive Value vs. Skin Prick Testing (SPT) Performance Parameters SPT In Vitro 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 • Authors concluded that specific IgE blood test & SPT both exhibited similar and excellent efficiency Wood RA, et al. J Allergy Clin Immunol . 1999;103:733-779.

ImmunoCAP as an Allergy Diagnostic Tool • 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 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 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.

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