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

3. 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

4. Hospitalization Rates

5. Pediatric Hospitalizations

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

9. 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%

11. 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

13. 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

16. 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

17. 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

18. 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

20. Components of Severity Intermittent Persistent MildModerateSevere 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)  2 days/week >2 days/week but not daily Daily Several times per day Activity limits None Minor Limitation Some Limitation 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 Assessing Asthma Severity (0-4)

21. Step 1 Preferred: SABA PRN Step 1 Preferred: SABA PRN Step 2 Preferred: Low-dose ICS Alternative: Cromolyn or Montelukast Step 2 Preferred: Low-dose ICS Alternative: Cromolyn or Montelukast Step 3 Preferred: Medium- dose ICS Step 3 Preferred: Medium- dose ICS Step 5 Preferred: High-dose ICS + either LABA or Montelukast Step 5 Preferred: High-dose ICS + either LABA or Montelukast Step 6 Preferred: High-dose ICS + either LABA or Montelukast OSC Step 6 Preferred: High-dose ICS + either LABA or Montelukast OSC Step 4 Preferred: Medium- dose ICS + either LABA or Montelukast Step 4 Preferred: Medium- dose ICS + either LABA or Montelukast Initial Therapies / Stepwise Approach: Asthma Patients 0-4 Years of Age ICS = inhaled corticosteroid; LABA = long-acting beta 2 -agonist; OSC = Oral Systemic Corticosteroids.; SABA = inhaled short-acting beta 2 -agonist. Consider consult Recommend consult MildModerateSevere A D D D D IntermittentPersistent 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 Step Down If Possible (and asthma is well controlled at least 3 months) Step Up If Needed (first, check adherence, inhaler technique, environmental control) Assess Control

22. Assessing Control (0 – 4) Components of Control Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled Impairment Symptoms  2 days/wk >2 days/wk Throughout the day Nighttime awakenings  1x/month >1x/month>1x/week Activity limits NoneSome limitationExtremely limited B-agonist use (not prevention of EIB)  2 days/week >2 days/week Several times per day Risk Exacerbations requiring OSC 0-1/year2-3/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.

23. 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

24. 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

25. Comprehensive Asthma Care

26. 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

27. 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

28. 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)

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