3/7/2018. Making the Most Out of Your Asthma Visit. Disclosures And Conflicts Of Interest. Outline. Michael Zacharisen, MD Allergy/Immunology

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1 Making the Most Out of Your Asthma Visit Michael Zacharisen, MD Allergy/Immunology Disclosures And Conflicts Of Interest Green Bay Packer fan I drive a Jeep Information today: Published studies Personal experience (25 years) and still working on it Outline Asthma Care in the Office Setting What are the roadblocks? What are the solutions? 1

2 Case Study: Asthma Follow Up Mrs. Jones brings in Bridger (7 yrs old) 6 month follow up visit: 10 min late to the visit (icy roads) Younger twin siblings with her (sick with colds and dirty diapers) Front desk: collect updated information etc. How do you make this visit work effectively and efficiently? Asthma Care Visit: Roadblocks Time (or lack of) Establishing asthma severity and control What tools to use? Treatment Using National Guidelines (out of date?) Medications Adherence Inhalers: which one? Formularies and Prior authorizations During an average day, is physician time well spent? 27%: direct clinical face-to-face time with pts 49.2%: time spent on EHRs and other work (reviewing tests, logging info, med orders) Communication with pts Portals, , fax, phone 1%: insurance and scheduling ORIGINAL RESEARCH 6 DECEMBER 2016 Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties Ann Int Med

3 Asthma Visit Roadblocks: Time Average time a doctor spends with pts? 13 to 16 min* Female physicians spend more time than male doctors 52.9%: In the exam room talking with pts 37%: time spent on EHR/desk work Recording/documentation Ordering Providers: spend up to 2 hrs of personal time every night "catching up" on additional clerical work *Medscape (owned by WebMD) released 2016 Physician Compensation Report, self reported data from >19,200 doctors in 26 specialties. Time is relative! Primary care appts last <5 minutes in 18 countries that represent half the world s population In India, average visit with primary care doctor lasts: 2 minutes In Bangladesh: average visit: 48 seconds International variations in primary care physician consultation time: a systematic review of 67 countries. Irving et al. BMJ Open So much to do, so little time! Multiple tasks to accomplish: Assess severity (first visit) & control (follow up) Examination Assess co-morbidities Document lung function (>5 yrs old) Develop or change treatment plan Educate: inhaler technique, action plan Answer questions Pts may have different: beliefs, concerns and goals about treatment plan 3

4 Obtaining information: History Severe symptoms? ER, urgent care Hospitalizations Prednisone Day, night or exercise? Interfere with activity Albuterol use Controller use Other: colds Influenza vaccine Physical Exam: Weight/Growth VS with pulse ox ENT (thrush) Respiratory Skin Inhaler technique Asthma Control Test (ACT) Spirometry ( 5 yr) Annual, med changes Components of Severity Impairment Symptoms Nighttime awakenings SABA for symptom control (not prevention of EIB) Intermittent 2 days/wk Classification of Asthma Severity (0 4 years of age) Persistent Mild Moderate Severe >2 days/wk but not daily Daily Throughout the day 0 1 2x/month 3 4x/month >1x/week 2 days/wk >2 days/wk but not daily Daily Several times per day Risk Interference with normal activity None Minor limitation Exacerbations (consider frequency and severity) Recommended Step for Initiating Therapy (See figure 4-1a for treatment steps.) 0 1/year Some limitation Extremely limited 2 exacerbations in 6 months requiring oral steroids, or 4 wheezing episodes/1 year lasting >1 day AND risk factors for persistent asthma Frequency and severity may fluctuate over time Exacerbations of any severity may occur in patients in any severity category Step 1 Step 2 Step 3 and consider short course of oral steroids In 2 6 weeks, depending on severity, evaluate level of asthma control achieved. If no clear benefit in 4 6 weeks, consider adjusting therapy or alternative diagnoses. Components of Control Classification of Asthma Control (0 4 years of age) Well Controlled Not Well Controlled Very Poorly Controlled Symptoms 2 days/week >2 days/week Throughout the day Nighttime awakenings 1/month >1x/month >1x/week Impairment Interference with normal activity Short-acting beta 2-agonist use for symptom control (not prevention of EIB) None Some limitation Extremely limited 2 days/week >2 days/week Several times per day Risk Exacerbations 0 1 per year 2 3 per year >3 per year Treatment-related adverse effects Recommended Action for Treatment (See figure 4-1a for treatment steps.) Med side effects can vary in intensity from none to very troublesome. Level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Maintain current treatment. Regular followup every 3 6 months. Consider step down if well controlled for at least 3 months. Step up (1 step) and Reevaluate in 2 6 weeks. If no clear benefit in 4 6 weeks, consider alternative diagnoses or adjusting therapy. For side effects, consider alternative treatment options. Consider short course of oral corticosteroids, Step up (1 2 steps), and Reevaluate in 2 wks, If no clear benefit in 4 6 wks, consider alternative diagnoses or adjusting Tx For side effects, consider alternative Rx options. 4

5 Intermittent Asthma Persistent Asthma: Daily Medication Ages 0-4 yrs Consult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2. Step 2 Preferred: Step 1 Low-dose ICS Preferred: SABA PRN Alternative: Step 3 Preferred: Medium-dose ICS Step 6 Step 4 Preferred: Step 5 Preferred: High-dose ICS Preferred: High-dose ICS AND Medium-dose AND Either: ICS Either: Montelukast or AND Montelukast or LABA LABA Either: AND Montelukast or Oral corticosteroids LABA Montelukast or Cromolyn Patient Education and Environmental Control at Each Step Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms. With viral respiratory infection: SABA q 4 6 hours up to 24 hours (longer with physician consult). Consider short course of systemic oral corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations. Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term-control therapy. Step up if needed (first, check adherence and environmental control) Assess control Step down if possible (and asthma is well controlled at least 3 months) Asthma Guidelines Last publication of NHLBI, Guidelines for the Diagnosis & Treatment of Asthma: 2007 Last publication of Global Guidelines: 2017 What is new in the last 12 years? Think Back Over the Last ~12 Yrs! No iphone. Steve Jobs unveiled the first iphone in 2007 No Facebook (unless in college). Opened to public in 2006 No Twitter. Full version launched in 2006 No Instagram. Picture sharing site launched in 2010 No Uber. Company received its seed funding in 2009 No ipad. Apple started the first-gen product in

6 What s new in Asthma Medications in the Last 10 years? 2008 Alvesco (ICS) 2010 Dulera (ICS/LABA) Bronchial thermoplasty 2013 Breo Ellipta (ICS/LABA) 2014 Arnuity Ellipta (ICS) 2015 Spiriva Respimat (LAMA) Mepolizumab (Nucala) SQ 2016 Omalizumab; >6 y/o Reslizumab (Cinqair) IV 2017 AirDuo RespiClick Dupilumab (Dupixent) SQ Benralizumab (Fasenra) SQ New Devices Old Devices Jet Nebulizer Pressurized MDI Dry Powder inhaler Diskus Turbuhaler Rotahaler Ellipta New Devices RespiClick RespiMat New Features Dose counters 6

7 Time Savers! History Differentiating asthma from VCD (vocal cord dysfunction) Trouble breathing IN or OUT? Check inspiratory loop on your spirometry Time Savers! Utilize your team At check-in: Vital signs including pulse oximeter Asthma medication check: How often are you taking? Did you receive your flu shot? Administer: Asthma Control Test (ACT); If >19, normal! Spirometry Check inhaler technique Asthma Action Plan: Asthma Action Plan Green Zone: Take These Controller Medicine(s) Everyday GO Medicine Strength How much to take How often to take Budesonide Respules 1 vial Pulmicort puffs Breathing is normal: Alvesco puffs No cough, wheeze Asmanex puffs or shortness of breath Flovent puffs Can do regular activities QVAR puffs Advair puffs Peak flow more than: Dulera puffs (>80%) Symbicort puffs Montelukast 1 tablet daily Other: Albuterol 2 puffs 20 minutes before gym/activity Yellow Zone: Begin Taking Rescue Medicine(s) Caution Keep taking your controller/green zone medicine(s) Begin taking your rescue medicine as instructed below. Asthma is Uncontrolled: Medicine Strength How much to take How often to take Cough Albuterol MDI puffs Every 20 minutes x 3 Wheeze Albuterol Solution vial then 4-6 hours as needed Shortness of breath Xopenex MDI puffs Chest tightness Xopenex Solution vial Waking up at night Prednisone with food Other: Early with a cold Peak Flow is: to (50-80%) Call: If you are using your rescue medicine more than every 4 hours and symptoms not improving. Red Zone: Go to the emergency room or call 911! STOP Take Immediate Action! DANGER: Medicine How much to take How often to take Albuterol MDI puffs Every 15 minutes Medicine is not helping Albuterol solution vial on the way to the ER Breathing is hard and fast Lev-albuterol (Xopenex MDI) puffs Nasal flaring Lev-albuterol (Xopenex solution) vial Difficult walking/talking Peak flow is less than: (<50%) NHLBI Guidelines for Diagnosis & treatment of Asthma Asthma Action Plan since 1995 (23 years) Narrow window of opportunity! Use Stop Light Colors Patient: DOB: From: M. Zacharisen, MD Phone:

8 Time savers! Education No Black Box warning on ICS/LABA (Breo, Advair, Symbicort, Dulera, AirDuo) Effective Dec 2017 Unnecessary to take 10 min trying to explain why asthma meds trigger fatal asthma attacks! Time Savers! Use Posters Quick relievers vs daily controllers That s it! The red one! SABA LABA ICS ICS/LABA and LABA/LAMA LAMA and SABA/SAMA Biologicals and BT Time Saver! Use Models Review: inflammation and bronchoconstriction and degrees of severity. 8

9 Time Savers! EHR Maximize the EHR Growth charts: children on ICS/prednisone Validated surveys: Asthma Control Test E-prescribing E-order entry: labs, radiology Medical Records with customized templates for asthma notes. Education for Partnership in Asthma Care=Adherence Family will manage asthma on a daily basis Best management plan is not effective if pt doesn t adhere to the regimen Adherence=closely linked to communication and pt educ. Bender et al in ICS Adherence: by child/mother report: 80% by canister weight: 69% by electronic doser: 50% More Efficient Asthma Education During a Short Office Visit: Results from PACE Study. By Michael Cabana, MD, MPH. San Francisco Asthma Network Forum 2016 Medication Adherence: by electronic dose counters N=1394 pts over 8 wks of data for 11,155 pt-wks of data Med adherence improved with age (avg wkly adherence) <12 yr old 47% yr old 40.7% 60 yr old 65% (P<.001) Season: Highest in winter (54%); lowest in summer (35%) Most pts (70%) were Rx bid 56% adhering to both doses and 22% adhering to either am or pm. Avg adherence for ICS/LABA was 15% higher than ICS alone Hock and Szefler, AAAAI abstract #

10 Questions from parents It s not asthma, it s bronchitis/rads Diagnosis Is it hurting his lungs? Necessity It s too expensive Cost He doesn't remember to take it Adherence Will it stunt his growth Steroid concerns Will have to be on them all the time? Duration of med use He takes medications too often Frequency of med use Seems like strong meds for daily use Amount of medication Will it make him hyper? Side effects Education: Not a Time Saver but worth the investment! Lack of pt/family education: Less medication adherence Less asthma control More symptoms, less sleep, less exercise More ER or urgent visits, prednisone, hospitalizations More expensive and more steroids, more side effects Missed school or work Lower quality of life Less pt/family satisfaction Less healthcare provider satisfaction Methods for improving Communication Communication skills: Sit down, listen (non-verbal attentiveness/encouragement) Both parties need to pay attention Key messages Addressing immediate concerns: Eliciting underlying fears (steroid phobia) Reassuring messages Share similar goals of treatment Verbal praise 10

11 Key Educational messages What happens during an asthma attack How to take medicines How to respond to changes in asthma severity Safety of medicines Goals of therapy Criteria for successful treatment Managing asthma at school Identifying and avoiding triggers Sources of additional asthma education Cost and Coverage of Medications Samples: trial before Rx Formulary: constantly changing Prior Authorizations Cover My Meds Manufacturer Coupons (paper vs online) 11

12 On-line resources Dr. Google Montana Dept of Public Health Amer College Allergy, Asthma, Immunol Amer Academy Allergy, Asthma, Immunol American Lung Association Allergy & Asthma Network National Heart Lung, Blood Institute of NIH Asthma & Allergy Foundation of America WebMD Pubmed (National Library of Medicine) Mayo Clinic Grandma know it all answers your questions! Treating Asthma in 2018 Stay calm/yoga Quit smoking/vaping Eat your veggies Treat your GE reflux Avoid allergic triggers Take your meds (correctly) Maintain healthy weight Exercise 30 min Learn inhaler technique twice/week Check: IgE, CBC Take Vitamin D Monitor spirometry Get vaccinated Regular follow-up visits 12

13 Breaking down the 20 min Visit Time Inhaler technique Educ VS ACT Review Plan Spirometry Review Control Exam History Thank You to all who make my work life better! My appreciation to: My tolerant wife and business manager My dedicated medical assistants My friendly, capable medical receptionist 13