RI Asthma Control Program: Comprehensive Asthma Care Julian Rodriguez-Drix Program Manager

ASTHMA An estimated 112,000 people in RI currently have asthma. Adults: 15.9% lifetime, 10.8% current Pediatric: 13.1% lifetime, 9.1% current Cause and control related to indoor and outdoor environment Disparities based on age, race, and income So for asthma, why do we care about the environment? People that have asthma experience triggers that exacerbate their asthma. When it comes to the environment, triggers are present all over. Can you all name any environmental asthma triggers? Mold roaches rodents smoke air pollution.

Hospitalization Rates

Pediatric Hospitalizations

Age-Specific Asthma Hospitalization Rates Per 10,000 Population by Race/Ethnicity, 2010-2012

Asthma and Poverty Asthma prevalence significantly higher in adults with an annual income less than $25,000 The highest rates of poverty in RI cluster in urban areas Highest childhood poverty rates up to 79%

Asthma and Housing Housing conditions often linked with poverty Known indoor asthma triggers Mold Smoke Pest (mice and cockroaches) Mildew Neighborhood condition asthma triggers Air quality: ozone, smog, exhaust, particulate matter Stress and intense emotions

Asthma in Schools Chronic absenteeism Missing 10% or more of total school days per year 37% of public school students with asthma were chronically absent from school in either 2010, 2011 or 2012 Highest rates of chronic absenteeism cluster in urban areas May reflect impact of other disadvantages of those with asthma

Asthma Care Guidelines NHBLI’s NAEPP EPR-3 Guidelines: From National Institutes of Health (NIH) National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program: Expert Panel Review Proper diagnosis of severity, medication therapy, and assessment of asthma control Asthma self-management education Control of environmental factors Source: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report

Clinical Guidelines EPR-3: Asthma Care Quick Reference Initial Visit: Diagnose asthma Assess asthma severity Initiate medication and demonstrate use Develop written asthma action plan Schedule follow–up appointment Source: http://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

Clinical Guidelines Follow-up Visit: Assess and monitor asthma control Review medication technique and adherence; assess side effects; review environmental control Maintain, step up, or step down medication Review asthma action plan, revise as needed Schedule next follow–up appointment

Assessing Asthma Severity (0-4) Components of Severity Intermittent Persistent Mild Moderate Severe Impairment Symptoms  2 days/week >2 days/week but not daily Daily Throughout the day Nighttime awakenings None 1-2x/ month 3-4x/month >1x/ week B-agonist use (not prevention of EIB) Several times per day Activity limits Minor Limitation Some Extremely Limited Risk Exacerbations requiring OSC 0-1/yr  2 exacerbations in 6 months requiring oral systemic corticosteroids, or  4 wheezing episodes/ 1 year lasting >1 day AND risk factors for persistent asthma [at the click of the mouse, the slide will highlight two rows (nighttime awakenings and risk for persistent classifications). This helps to distinguish the two age groups under 12.] Note to presenter – there tends to be confusion about severity level, so you may need to spend some time explaining this. Severity level is used to establish a baseline Once severity level is established, then the focus in on assessing asthma control and adjusting therapy accordingly

Preferred: Low-dose ICS Alternative:Cromolyn or Montelukast Initial Therapies / Stepwise Approach: Asthma Patients 0-4 Years of Age D D Step 6 Preferred: High-dose ICS + either LABA or Montelukast OSC Step Up If Needed (first, check adherence, inhaler technique, environmental control) Recommend consult D Step 5 Preferred: High-dose ICS + either LABA or Montelukast D Step 4 Preferred: Medium-dose ICS + either LABA or Montelukast Consider consult Step 3 Preferred: Medium-dose ICS A Step 2 Preferred: Low-dose ICS Alternative:Cromolyn or Montelukast Step 1 Preferred: SABA PRN Assess Control Step Down If Possible (and asthma is well controlled at least 3 months) Step 2: Evidence category A (Randomized controlled trials with a rich body of evidence) Step 3, 4, 5 recommendations for 0-4 yrs are based on consensus opinion (D) distinguished in orange (different for the 5-11 age group) Mild Moderate Severe Intermittent Persistent Each Step: Patient education, environmental control, management of co morbidities If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; OSC = Oral Systemic Corticosteroids.; SABA = inhaled short-acting beta2-agonist.

Classification of Asthma Control Assessing Control (0 – 4) Components of Control Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Impairment Symptoms  2 days/wk >2 days/wk Throughout the day Nighttime awakenings  1x/month >1x/month >1x/week Activity limits None Some limitation Extremely limited B-agonist use (not prevention of EIB)  2 days/week >2 days/week Several times per day Risk Exacerbations requiring OSC 0-1/year 2-3/year >3/year Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. For young children, fewer nighttime symptoms when compared to older age groups signify loss of control If well controlled for at least 3 months, the clinician may consider stepping down

Self-management education Essential to provide patients with the skills necessary to control asthma and improve outcomes Provide all patients with written asthma action plan that includes 2 elements: Daily management How to recognize and handle worsening symptoms Source: http://www.nhlbi.nih.gov/files/docs/guidelines/05_sec3_comp2.pdf

Self-management education Regular review, by an informed clinician, of the status of a patient’s asthma control is an essential part of asthma self-management education Encourage development and evaluation of community-based interventions that provide opportunities to reach a wide population of patients and their families, especially those at high risk

Comprehensive Asthma Care

HARP: Home Asthma Response Program Pediatric asthma home visiting Prior asthma related ED visit / hospitalization Certified Asthma Educator (AE-C) and Community Health Worker (CHW) 3 home visits: asthma self-management education, trigger reduction, environmental supplies Results: improved health outcomes, reduced utilization/costs

BEAH: Breathe Easy at Home Medical referral to code enforcement For extreme situations when provider suspects that a child’s asthma is caused by housing conditions Referral made through KIDSNET Includes educational materials for family and landlord, legal support as needed Currently available in four core cities: Providence, Pawtucket, Central Falls, Woonsocket

Certified Asthma Educators AE-Cs play a critical role in team-based care NAECB: National Asthma Educator Certification Board Prep-courses offered twice per year Encourage Nurse Care Managers, and/or other member of care team to become certified as an AE-C Referrals for AE-Cs will be available through Community Health Network (like CDOEs)

Julian Rodriguez-Drix Program Manager, RI Asthma Control Program 401.222.7742 Julian.Drix@health.ri.gov