Office Asthma Care: Practical Elements of Asthma Management. Learning Objectives. Diagnosis

Transcription

1 Office Asthma Care: Practical Elements of Asthma Management Pri-Med West Annual Conference March 29, 2014 Anaheim, CA Sande Okelo, MD, PhD, University of California Los Angeles Learning Objectives 1. Describe the 3 clinical criteria for establishing a diagnosis of asthma according to NIH asthma guidelines. 2. Utilize an asthma questionnaire to classify asthma control/severity. 3. Describe the differential diagnosis of uncontrolled asthma in children 4. Identify strategies to assess inhaler technique and medication adherence Diagnosis What are the NIH diagnostic criteria for asthma? Assessment What is the goal of every clinical encounter with an asthma patient?

2 Uncontrolled asthma common despite type of visit (n = 2, 429 children at 29 practices) 100% 90% Is Asthma Controlled? 80% 70% 60% 50% 40% 30% 20% 10% 0% 46% 54% Uncontrolled asthma (ACT <19) 35% All Visits Resp. Visit Non-Resp Visit AH Liu J Peds 2010;157: Many Children with Persistent Asthma Symptoms Asthma Control/Severity NIH Severity Level % of Children (n=721) Severe Persistent 11.6% Moderate Persistent 14.3% Mild Persistent 20.5% Mild Intermittent 53.6% What clinical symptoms are used to classify asthma control/severity? Base: All respondents (unweighted N=2509). JS Halterman Arch Pediatr Adolesc Med. 2002;156: Components of Severity/Control: Impairment & Risk Impairment Daytime symptoms Night-time awakenings Short acting beta 2 agonist (albuterol) use for symptom control Interference with normal activity Lung function ( 5 years of age) Validated measures of control ( 12 years of age) Risk Exacerbations requiring systemic steroids How can we reliably completely assess patients for asthma control/severity?

3 Scoring of PACCI Control Domain Use validated asthma questionnaires When? At every clinical encounter (e.g., well child care, sick visit) Why? Better information Consistent approach Efficient retrieval of information Reimbursement (HPI elements; time counseling) Focus on other important tasks 1. Sum Score: = 10 higher scores = worse control uncontrolled 3 2. Problem Index: = 4 higher count = worse control uncontrolled 2 3. NHLBI severity categories severe persistent asthma 4. Controlled/Not Controlled not controlled Is Asthma Controlled? Yes do nothing or step-down treatment Follow-up in 1 6 months No work through causes of uncontrolled asthma Follow-up in 2 6 weeks What is the ddx of uncontrolled asthma? What is the ddx of uncontrolled asthma? Non-adherence Poor inhaler technique Environmental exposures Tobacco smoke Co-morbidities Allergic rhinitis Obesity Sinusitis Under-treatment (need to step-up treatment) Mistaken Assumptions of Adherence in Health Outcomes Adherence = Good Health Outcomes Medication efficacy (e.g., oral albuterol) Disease severity Metabolism/pharmacokinetics Pharmacodynamics Prescriber adherence to practice guidelines

4 Adherence Solutions What can the clinician do? Mistaken Nonadherence Provide & review written treatment plan at each visit Ask patient to repeat dosing instructions Review device technique Provide asthma education Encourage accessing social support Erratic Adherence Query barriers & problem-solve Simplify & tailor regimen Behavioral strategies Self-monitoring (e.g. diaries) Cueing (e.g. toothbrush, pillbox) Reminders (e.g., cell phone) Linking to established habits or pleasurable activities Reinforcement Intentional Nonadherence Include patient in decisionmaking Provide personalized feedback on relationship between adherence and health outcomes Provide asthma education Link therapy with personal goals Summary Consider systematic ways of evaluating for nonadherence Query patient adherence every visit be skeptical of self-report, but remember a report of any nonadherence is true Inhaler Technique Match counseling strategies to identified barriers

5 Poor MDI/DPI Technique Tight fitting facemask and quiet breathing increase delivery of aerosol to lungs % good technique Patients 32-68% House staff 43-65% Physicians 57% Nurses 4-47% Respiratory Therapists 85-92% Pharmacists 62% Fink & Rubin 2005 Interiano & Guntupalli 1993 Guidry et al Kesten et al Loose fitting facemask during MDI/spacer delivery Tight fitting facemask and child breathing quietly during MDI/spacer delivery Erzinger S, et al. J. Aerosol Medicine 2007; 20 (suppl 1):S78-S84. Tight fitting facemask and child screaming during nebulizer delivery Tight fitting face mask and child breathing quietly during nebulizer delivery IF ASTHMA IS NOT CONTROLLED, ALSO CONSIDER EACH OF THE FOLLOWING: Don t actuate multiple times before inhaling Don t delay inhaling after actuation Acute Respiratory Infection: patient may benefit from regular use of Albuterol (4 times a day) during the acute illness Inhaler technique: is patient using spacer with MDI? have patient demonstrate inhaler technique Medication adherence: review patient response to PACCI adherence question review pharmacy record of filled medications Environmental allergies and exposures: has patient been allergy tested? is there secondhand smoke exposure? Comorbid conditions: allergic rhinitis sinusitis obesity gastro esophageal reflux Asthma specialist referral: systemic steroids 2 times/year intubation/icu admit uncontrolled asthma on high dose ICS and LABA Newman SP. Clin Pharmacokinet 2004;43: Summary 1. Diagnosis of asthma: episodic symptoms of airflow obstruction or bronchospasm: cough, wheeze, dyspnea. 2. The goal of every encounter with an asthma patient: is asthma controlled? A) yes: do nothing or step down B) no: review adherence and inhaler technique if good, then step-up controller therapy 3. Identify the differential diagnosis of uncontrolled asthma in children environmental exposures (tobacco smoke); co-morbidities (allergic rhinitis; obesity); under-treatment 4. Become familiar with strategies to assess inhaler technique and medication adherence Further Thoughts Asthma care is a team sport Plan improvements in asthma care based on the health system you work in (office, HMO, etc.) EHRs may be means of sustainably providing high quality asthma care Automation Decision support Feedback on performance