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
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.

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:

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:

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. 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

21. 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.

22. 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

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:

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