1. Managing the Child with Asthma: Don’t Forget Environmental Controls James R. Roberts MD, MPH Associate Professor of Pediatrics Medical University of South Carolina

2. Financial Relationships As it pertains to CME, I need to disclose that I have no relevant financial relationships with any commercial interest to disclose.

3. Learning Objectives Be familiar with the epidemiology and medical management of pediatric asthma in the US Be familiar with the epidemiology and medical management of pediatric asthma in the US Be aware of the scientific evidence Be aware of the scientific evidence – demonstrating that environmental exposures impact asthma incidence and prevalence – demonstrating that environmental controls can reduce asthma morbidity Be able to provide specific guidance about controlling environmental exposures Be able to provide specific guidance about controlling environmental exposures

4. Pediatric Asthma Most prevalent chronic medical condition in childhood Most prevalent chronic medical condition in childhood > 6 million US children > 6 million US children Low income children are: Low income children are: – More likely to have increased morbidity from asthma – Less likely to receive preventive care

5. Current Asthma Prevalence by Race/Ethnicity: United States, 2005 Race/ Ethnicity:* Current Asthma Prevalence *CDC Health Data for All Ages (age-adjusted) (HDAA) 2003-2005

6. Variation in Asthma Care by Race/Ethnicity African-American children less likely to have made office visit for asthma (OR 0.48) African-American children less likely to have made office visit for asthma (OR 0.48) – P Lozano, FA Connell, TD Koepsell. Use of health services by African- American children with asthma on Medicaid. JAMA 1995; 274 (6); pages. African-American and Latino children less likely to use inhaled corticosteroids (OR 0.69 and 0.58 respectively) African-American and Latino children less likely to use inhaled corticosteroids (OR 0.69 and 0.58 respectively) – TA Lieu, et al. Racial/Ethnic Variations in Asthma Status and Management Practices in Managed Medicaid. Pediatrics 2002; 109(5):857-865.

7. This is not good African-American children as compared to white children African-American children as compared to white children – >3 times as likely to be hospitalized – >4 times as likely to die from asthma LJ Akinbami, KC Schoendorf.Pediatrics 2002: 110; 315-322.

8. Barriers to Asthma Care Health Care System Health Care System – Lack of health insurance, primary care, coordination of care – High cost of medications and services Health care providers Health care providers – Lack of recognition and severity – Suboptimal compliance with guidelines Family Family – Confusion about symptoms and therapies

9. Pediatric Asthma Care 1997 NAEPP Asthma Guidelines Stepwise approach to managing asthma Stepwise approach to managing asthma – Gaining control – Maintaining control Classifying asthma severity Classifying asthma severity – Controller medication for persistent asthma Provide WRITTEN asthma action plan Provide WRITTEN asthma action plan Control of factors contributing to severity Control of factors contributing to severity National Institutes of Health. Practical Guide for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program (NAEPP) 1997

10. National Asthma Education and Prevention Program Expert Panel Report-3: Guidelines for the Diagnosis and Management of Asthma EPR-3 slides courtesy of: James P. Kiley, M.S., Ph.D. American College of Chest Physicians October 25, 2007

11. Monitoring Asthma Control New framework for measuring control: New framework for measuring control: – Impairment: current experience with symptoms, low lung function, or activity limitation – Risk: likelihood of future exacerbations, progressive loss of lung function or, for children, lung growth, or medication side effects Both domains are important: Both domains are important: – Treatment may affect impairment or risk differently – Patients may have low day-to-day impairment but high risk of frequent exacerbations

12. Control of Environmental Factors New recommendation: comprehensive approaches are necessary (single steps are not sufficient) New recommendation: comprehensive approaches are necessary (single steps are not sufficient) Emphasis on avoidance of tobacco smoke Emphasis on avoidance of tobacco smoke New consideration of specific immunotherapy for selected allergic pts. New consideration of specific immunotherapy for selected allergic pts.

13. Childhood Asthma New distinction of 3 age groups to reflect new evidence on children New distinction of 3 age groups to reflect new evidence on children – 0-4 years – 5-11 years – 12 years and adult Children may respond differently to asthma medications Children may respond differently to asthma medications – (e.g. more children may do well on ICS alone rather than combination therapy)

14. Six Key Messages Inhaled corticosteroids are the most effective anti- inflammatory medication for long term management of persistent asthma Inhaled corticosteroids are the most effective anti- inflammatory medication for long term management of persistent asthma All patients should receive: Written asthma action plan Written asthma action plan Initial assessment of asthma severity Initial assessment of asthma severity Review of the level of asthma control (impairment and risk) at all follow up visits Review of the level of asthma control (impairment and risk) at all follow up visits Periodic, follow up visits (at least every 6 months) Periodic, follow up visits (at least every 6 months) Assessment of exposure and sensitivity to [environmental] allergens and irritants and recommendation to reduce relevant exposures Assessment of exposure and sensitivity to [environmental] allergens and irritants and recommendation to reduce relevant exposures

15. Asthma Case This patient is a 3 yo AA female This patient is a 3 yo AA female Presents with respiratory distress and wheezing after staying with grandmother for the weekend Presents with respiratory distress and wheezing after staying with grandmother for the weekend Also has had rhinorrhea and cough for months Also has had rhinorrhea and cough for months Further hx Further hx – Coughs at night at least 3-4 nights per week – ER visits on two other occasions (1 month ago and 3 months ago) for breathing difficulties: Rx albuterol only Rx albuterol only – Past Medical Hx of atopic dermatitis and “allergies” – Grandmother smokes outside

16. Your Treatment Plan? Classify her asthma & educate Classify her asthma & educate Acute control-- various Acute control-- various Controller medication Controller medication – Inhaled corticosteroid – Inhaled steroid/salmeterol – Second line– montelukast sodium Continued monitoring– peak flow Continued monitoring– peak flow Environmental management of triggers Environmental management of triggers

17. Acute Management ED or Office Setting Bronchodilator treatment Bronchodilator treatment – *Albuterol 2.5- 5 mg inhaled q 30-60 min – Albuterol MDI with spacer 4-8 puffs – Albuterol continuous 0.5 mg/kg/hour (15 mg) – Ipatropium bromide 250-500 micrograms Oral steroids 1-2 mg/kg Oral steroids 1-2 mg/kg – IV if necessary (can’t take PO) Magnesium sulfate 40-50 mg/kg iv (ED) Magnesium sulfate 40-50 mg/kg iv (ED) *Others: Pirbuterol, levalbuterol

18. Criteria for Admission Third treatment in our office Third treatment in our office O2 requirement O2 requirement Late afternoon and unable to observe several hours Late afternoon and unable to observe several hours Social concerns Social concerns

19. Use Steroids when Necessary Acute exacerbation Acute exacerbation – Prednisolone 1-2 mg/kg/day – Syrup is 15 mg/5mL – Effect within 4 hours Controller/ Preventive Controller/ Preventive – Fluticasone 44 mcg 110, and 220 mcg – Fluticasone/salmeterol 100/50; 250/50; 500/50 – Alternatives: beclamethasone (40 and 80 mcg/puff), budesinide (Dry powder inhaler 90,180 and 200 mcg/dose), several others National Institutes of Health. Practical Guide for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program (NAEPP) 1997 Reiterated in 2007 Report.

20. Other Controllers Cromolyn MDI 1 mg/puff 1-2 qid Cromolyn MDI 1 mg/puff 1-2 qid Salmeterol (suggest using only in combination with fluticasone) Salmeterol (suggest using only in combination with fluticasone) Montelukast Sodium 4, 5, and 10 mg tabs Montelukast Sodium 4, 5, and 10 mg tabs – FDA approved for asthma ≥ 12 months – < 5 years old: 4 mg qHS – 5-11 years: 5 mg – 12 years or older: 10 mg National Institutes of Health. Practical Guide for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program (NAEPP) 1997 Reiterated in 2007 Report.

21. Your Treatment Plan? Classify her (or His!) asthma Classify her (or His!) asthma Acute control-- various Acute control-- various Controller medication Controller medication – Inhaled corticosteroid – Inhaled steroid/salmeterol – Second line– montelukast Continued monitoring– peak flow Continued monitoring– peak flow – Written asthma care plan Environmental management of triggers Environmental management of triggers National Institutes of Health. Practical Guide for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program (NAEPP) 1997 Reiterated in 2007 Report.

22. Peak Flow Monitoring Find out predicted based on height Find out predicted based on height Green Zone: 80% of predicted or > Green Zone: 80% of predicted or > Yellow Zone: 50-80% of predicted Yellow Zone: 50-80% of predicted Red Zone: 50% of predicted or less Red Zone: 50% of predicted or less Write it Down! Written plans help keep kids out of the hospital

23. Your Treatment Plan? Classify her asthma and educate Classify her asthma and educate Acute control-- various Acute control-- various Controller medication Controller medication – Inhaled corticosteroid – Inhaled steroid/salmeterol – Second line– montelukast Continued monitoring– peak flow Continued monitoring– peak flow Environmental management of triggers Environmental management of triggers

24. National Survey on Environmental Management of Asthma Assessed public’s knowledge of environmental asthma triggers and their actions to manage environmental triggers People from low income, low education households are more likely to have asthma People from low income, low education households are more likely to have asthma Thirty percent of people with asthma have a written asthma management plan Thirty percent of people with asthma have a written asthma management plan Thirty percent of people with asthma are taking essential actions to manage their environmental triggers Thirty percent of people with asthma are taking essential actions to manage their environmental triggers Children with asthma are nearly twice as likely as other children (19% vs 11%) to be regularly exposed to secondhand smoke in their homes Children with asthma are nearly twice as likely as other children (19% vs 11%) to be regularly exposed to secondhand smoke in their homes Some Key Findings: US Environmental Protection Agency 2003

25. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Released by the National Environmental Education Foundation in August 2005 http://www.neefusa.org/health/asthma/index.htm

26. Overview of Asthma Guidelines Developed for children 0-18 years, already diagnosed with asthma Developed for children 0-18 years, already diagnosed with asthma Applies to all settings where children spend time Applies to all settings where children spend time – Homes, schools, and daycare centers – Cars, school buses – Camps, relatives’/friends’ homes, other recreational or housing settings – Occupational environments Available online, in hard copy, and on CD-ROM Available online, in hard copy, and on CD-ROM http://www.neefusa.org/health/asthma/index.htm

27. Environmental History Form (P. 17) Quick intake form Quick intake form Available online as PDF and Word document Available online as PDF and Word document Copy into electronic medical record template Copy into electronic medical record template Questions in yes/no format Questions in yes/no format – Follow up yes answer with in-depth questions on Intervention Guidelines Fact Sheets

28. Indoor vs. Outdoor Exposures Indoor Indoor – Animal Dander – Dust Mites – Roaches – Mold – Solvents – Second Hand Smoke (SHS) Outdoor Air Pollution Outdoor Air Pollution – Particulate Matter – Ozone – VOCs (Solvents) – Metals Chromium, Cadmium, Cobalt, Nickel – Sulfur and Nitrogen Dioxides – Carbon Monoxide

29. Clearing the Air Institute of Medicine Sufficient evidence of Causal Relationship Sufficient evidence of Causal Relationship – Cat CockroachETS (preschooler) – House dust mite Sufficient evidence of an Association Sufficient evidence of an Association – – Dogmolds rhinovirus NO 2 & Ozone Limited evidence of Association Limited evidence of Association – FormaldehydeVOCs(solvents) RSV – ETS (school-aged and older children) Committee on the Assessment of Asthma and Indoor Air; Division of Health Promotion and Disease Prevention; Institute of Medicine, 2000.

30. Allergy Referral? In vitro testing for allergens can be considered, but false positives occur In vitro testing for allergens can be considered, but false positives occur – Should focus on allergens identified in history – Should not replace timely allergy referral Low cost environmental interventions are reasonable, especially where wide spread exposure occurs (i.e. dust mites in SE) Low cost environmental interventions are reasonable, especially where wide spread exposure occurs (i.e. dust mites in SE) – Costly interventions should be done after you have referred patient for skin testing

31. Dust Mite Control Randomized controlled trial Randomized controlled trial – Group 1-- polyurethane casings for bedding, tannic acid on the carpets – Group 2-- Benzyl benzoate on mattresses and carpets at time 0, and 4 & 8 months – Group 3-- Placebo foam on the mattresses and carpets at time 0, and 4 & 8 months Decreased mite allergen on Gp 1 mattresses Decreased mite allergen on Gp 1 mattresses Children of Group 1 with reduced airway reactivity Children of Group 1 with reduced airway reactivity Enhert B, et al. Allergy Clin Immunology 1992;90:135-8

32. Dust Mite Control Danish study in children (n= 60) Danish study in children (n= 60) – Allergen impermeable mattress covers Significant reduction in dust mite concentration for intervention group Significant reduction in dust mite concentration for intervention group Significant decrease in effective dose of inhaled steroid Significant decrease in effective dose of inhaled steroid Halken S, et al. J Allergy Clin Immunol 2003;112:220

33. Dust Mites Simple, but Effective Interventions Encase all pillows and mattresses of the beds the child sleeps on with allergen impermeable encasings Encase all pillows and mattresses of the beds the child sleeps on with allergen impermeable encasings Wash bedding weekly to remove allergen Wash bedding weekly to remove allergen Wash in HOT water (130°F) to kill mites Wash in HOT water (130°F) to kill mites Results generally seen in 1 month Results generally seen in 1 month Avoid ozone generators and some ionic air cleaners that produce ozone Avoid ozone generators and some ionic air cleaners that produce ozone P. 20 www.nationalallergy.com

34. Dust Mites Other Interventions Synthetic materials in bedding Synthetic materials in bedding Remove or wash and dry stuffed toys weekly Remove or wash and dry stuffed toys weekly Vacuum with a HEPA-filtered vacuum cleaner Vacuum with a HEPA-filtered vacuum cleaner Avoid humidifiers Avoid humidifiers Additional suggestions in guidelines Additional suggestions in guidelines P. 20

35. Cats Stick with You Classrooms with many (>25% of class) cat owners had cat allergen than other classrooms Classrooms with many (>25% of class) cat owners had cat allergen than other classrooms Allergen levels in non-cat owners’ clothes increased after one day in that classroom Allergen levels in non-cat owners’ clothes increased after one day in that classroom Exposure through school can exacerbate asthma in sensitized children even if they don’t own a cat Exposure through school can exacerbate asthma in sensitized children even if they don’t own a cat Almqvist C. J Allergy Clin Immunol 1999;103:1002-4 Almqvist C et al. Am J Respir Crit Care Med 2001;163:694-8

36. Control of Cat Ag RCT with 35 cat-allergic (and owner) subjects RCT with 35 cat-allergic (and owner) subjects – HEPA room air cleaner – Mattress and pillow covers – Cat exclusion from bedroom Reduced airborne cat allergen levels Reduced airborne cat allergen levels No effect on disease activity No effect on disease activity In cat allergic individuals with asthma, intranasal steroids were effective In cat allergic individuals with asthma, intranasal steroids were effective Wood RA Am J Respir Crit Care Med 1998;158:115-20 Wood RA, Eggleston PA. Am J Respir Crit Care Med 1995;15:315-20

37. Animal Allergens Effective Interventions Find a new home for indoor pets Find a new home for indoor pets Keep pet outside Keep pet outside If these aren’t possible… If these aren’t possible… – Similar interventions as with dust mites – Encasings, HEPA air cleaner, HEPA Vacuum, – Keep pet out of bedroom Takes 24-30 weeks before allergen levels reach those of non-cat households 1 Takes 24-30 weeks before allergen levels reach those of non-cat households 1 P. 21 Wood RA et al. J Allergy Clin Immunol 1989;83:730-4

38. Animal Allergens Unlikely Interventions Bathing cats MAY be effective at reducing allergen (n = 8 cats) Bathing cats MAY be effective at reducing allergen (n = 8 cats) – The reduction was not maintained by 1 week 1 – Therefore it had been recommended to bathe the cat twice a week… to bathe the cat twice a week… However, A more recent study of 12 However, A more recent study of 12 cats suggests the decrease in cats suggests the decrease in dander after bathing lasts about 1 day 2 dander after bathing lasts about 1 day 2 Avner DB et al. J Allergy Clin Immunol 1997;100:307-12 Ownby D et al. J Allergy Clin Immunol 2006:118:521-2

39. Mouse Ag 18 homes of children with persistent asthma and positive mouse allergen 18 homes of children with persistent asthma and positive mouse allergen Integrated pest management Integrated pest management – Filled holes – Vacuum and cleaning – Low-toxicity pesticides and traps Mouse allergen levels significantly reduced during 5 month period Mouse allergen levels significantly reduced during 5 month period Phipatanakul W et al. Ann Allergy Asthma Immunol 2004;92:420-5

41. Cockroach Ag Control Home extermination– 2 applications Home extermination– 2 applications – Abamectin, Avert (Derived from the soil bacterium Streptomyces avermitilis) Directed education on cockroach allergen removal Directed education on cockroach allergen removal 50% of families followed cleaning instructions, no greater effect was found in these homes 50% of families followed cleaning instructions, no greater effect was found in these homes At 12 months, allergen had returned At 12 months, allergen had returned to or exceeded baseline levels to or exceeded baseline levels Gergen PJ et al. J allergy Clin Immunol 1999;103:501-6

42. Cockroach Ag Control Occupant education, professional cleaning Occupant education, professional cleaning Insecticide bait Insecticide bait Substantial reductions in cockroach allergy levels achieved 1 Substantial reductions in cockroach allergy levels achieved 1 Second Study– Professional cleaning Second Study– Professional cleaning – Bait traps with insecticide – Bait traps without insecticide – Significant reduction in cockroach allergen 2 Arbes SJ et al. J Allergy Clin Immunol 2003;112:339-45 McConnell R et al. Ann Allergy Asthma Immunol 2003;91:546-52

43. Is it the Cleaning? RCT of 150 children with asthma RCT of 150 children with asthma Peer Health Educators Peer Health Educators – Reduce harborage and access to food – Cleaning and applying boric acid – Allergen impermeable covers for bedding 60% decrease in number of cockroaches 60% decrease in number of cockroaches 64% decrease in cockroach Ag from child’s bedding 64% decrease in cockroach Ag from child’s bedding McConnell R et al. Clinical & Experimental Allergy 35(4):426-333, 2005

44. Cockroach Allergen Do’s and Don’ts of Roach Control Integrated pest management (IPM) Integrated pest management (IPM) – Least toxic methods first Clean up food/spills Clean up food/spills Food and trash storage in closed containers Food and trash storage in closed containers Fix water leaks Fix water leaks Clean counter tops daily Clean counter tops daily Boric acid Boric acid Bait stations/ gels Bait stations/ gels Allergen impermeable covers Allergen impermeable covers Don’t!! Don’t!! – Spray liquids in house, especially play and sleep space – Use industrial strength pesticide sprays that require dilution P. 22

45. Mold and Asthma Symptoms Cross sectional study of 2568 children 1 - 6 years old in Helsinki, Finland Cross sectional study of 2568 children 1 - 6 years old in Helsinki, Finland Exposures included histories of water damage, presence of moisture and visible molds and perceived mold odor at home Exposures included histories of water damage, presence of moisture and visible molds and perceived mold odor at home Outcomes included persistent cough, phlegm and wheezing, persistent nasal congestion and excretion during the past 12 months and current asthma Outcomes included persistent cough, phlegm and wheezing, persistent nasal congestion and excretion during the past 12 months and current asthma Mold odor during the past year and water damage over a year ago had the strongest association with the respiratory symptoms. Mold odor during the past year and water damage over a year ago had the strongest association with the respiratory symptoms. Jaakkola et al. J Expo Anal Environ Epidemiol. 1993;3 Suppl 1:129-42.

46. Mold and Mildew Interventions Ways to control moisture and/or decrease humidity to < 50% Ways to control moisture and/or decrease humidity to < 50% – Dehumidifier or central air conditioner – Do not use a humidifier – Vent bathrooms/clothes dryers to outside – Use exhaust fan in bathroom/ other damp areas – Check faucets and pipes for leaks and repair P. 23

47. Mold and Mildew Cleaning up the Mess Items too moldy to clean should be discarded Items too moldy to clean should be discarded An area larger than 3 ft x 3 ft should be professionally cleaned An area larger than 3 ft x 3 ft should be professionally cleaned Chlorine solution 1:10 with water Chlorine solution 1:10 with water is acceptable for smaller areas is acceptable for smaller areas – Don’t mix with cleaners containing ammonia! Quaternary ammonium compounds are also good fungicides if bleach isn’t used Quaternary ammonium compounds are also good fungicides if bleach isn’t used

48. SHS = most important indoor pollutant for child health According to the 2006 Report of the Surgeon General ‘almost 60 percent of children aged 3 through 11 years’ are exposed to SHS. According to the 2006 Report of the Surgeon General ‘almost 60 percent of children aged 3 through 11 years’ are exposed to SHS. Each year, secondhand smoke is associated with an estimated 8,000– 26,000 new asthma cases in children. Each year, secondhand smoke is associated with an estimated 8,000– 26,000 new asthma cases in children. U.S. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington, DC: U.S. Environmental Protection Agency;1992. Pub. No. EPA/600/6-90/006F. Accessed: March 2008.Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. http://www.hhs.gov/surgeongeneral/library/smokingconsequences

49. Second Hand Smoke Possible Interventions Keep home and care smoke free Keep home and care smoke free Encourage support to quit smoking Encourage support to quit smoking – Recommend aids such as nicotine gum/patch – Medication from physician to assist in quitting Choose smoke free social settings Choose smoke free social settings At the very least, do not smoke around your child or in the car! At the very least, do not smoke around your child or in the car! – (This should not keep us from encouraging parents to quit) P. 24

50. Reducing Traffic Reduces Asthma - 1996 Atlanta Olympics The Intervention: The Intervention: – Around-the-clock public transportation – 1,000 buses added – Downtown city streets closed to private cars – Downtown delivery schedules altered – Flexible and telecommuting work schedules encouraged Friedman, M. S. et al. JAMA 2001;285:897-905.

51. Reducing Traffic Reduces Asthma - 1996 Atlanta Olympics The Result: The Result: – Weekday morning traffic counts dropped 22.5% – Peak daily ozone concentrations decreased 27.9% Friedman, M. S. et al. JAMA 2001;285:897-905.

52. Mean Levels of Major Pollutants Before, During, and After the 1996 Summer Olympic Games as a Percentage of the National Ambient Air Quality Standard (NAAQS)

53. Acute Asthma Events During 1996 Olympics - Atlanta Type of claim % change in mean # of Asthma claims per day % change in mean # of Non-Asthma claims per day Medicaid Hosp and ED Visits - 41.6% - 3.1% HMO ED, Urgent Visit, Hosp - 44.1% + 1.3% Friedman, M. S. et al. JAMA 2001;285:897-905.

54. 2002 Summer Asian Games - Korea 2002 Summer Asian Games in Busan, Korea 2002 Summer Asian Games in Busan, Korea – Like Atlanta in 1996, ‘Transportation Controls’ led to a reduction in hazardous air pollutant levels of up to 25% – Relative Risk of Asthma Hospitalization during the reduced pollution period was 73% of baseline (27% decrease) Lee et al. J Air Waste Manag Assoc. 2007 Aug;57(8):968-73.

55. Air Pollution Possible Outdoor Air Interventions Monitor air quality index levels Monitor air quality index levels – Ozone, Particulate Matter, NOx, SO2 – Reduce child’s outdoor activities if unhealthy Orange AQI of 101-150 (unhealthy for sensitive groups) Orange AQI of 101-150 (unhealthy for sensitive groups) Red AQI of 151-199 (unhealthy for all) Red AQI of 151-199 (unhealthy for all) Contact health care provider if more albuterol is needed the day after AQI level is high Contact health care provider if more albuterol is needed the day after AQI level is high P. 26 www.epa.gov/airnow

56. Inner City Asthma Study Follows 937 urban children with asthma Follows 937 urban children with asthma – 1 year of intervention, 1 additional year of follow up Evaluation --questionnaire and skin testing Evaluation --questionnaire and skin testing Home sampling --dust, cockroach, cat and dog allergen Home sampling --dust, cockroach, cat and dog allergen Interventions aimed at patient-specific triggers Interventions aimed at patient-specific triggers – Allergen impermeable mattress and pillow covers – HEPA air filters and vacuum cleaners – Professional pest control Morgan WJ, et al. New Engl J Med 2004;351:1068-80

57. Inner City Asthma Study Results and Cost Effectiveness Fewer days with symptoms Fewer days with symptoms Greater decline in level of allergens at home Greater decline in level of allergens at home – Persisted through 2 nd “follow up” year – Dust and cockroach Ag correlated with fewer complications of asthma *Cost Effectiveness analysis *Cost Effectiveness analysis – 38 more symptom free days – Under $30 per symptom free day Morgan WJ, et al. New Engl J Med 2004;351:1068-80 *Kattan M, et al. J allergy Clin Immunol 2005;116:1058-63

58. OK, But who pays for it?! Medications– covered by most insurance and Medicaid Medications– covered by most insurance and Medicaid Spacers and masks– in our office Spacers and masks– in our office Asthma Education? Asthma Education? Environmental trigger assessment? Environmental trigger assessment? – Working on it

59. Role of Health Care Plan Children’s Mercy, KC: Medicaid Managed Care Children’s Mercy, KC: Medicaid Managed Care – Provider education – Developed a disease management program to ASSIST primary care providers – CPT code to reimburse for asthma education Resulted in 60% in ER visits, 50% in hospitalization Resulted in 60% in ER visits, 50% in hospitalization 30% Decrease in cost for asthma claim! 30% Decrease in cost for asthma claim!

60. Kentucky Medicaid managed care plan administered by Amerihealth Medicaid managed care plan administered by Amerihealth – Works with local health department to pay for environmental assessment of patient’s home – Provides summary to primary care provider We’re not in Kentucky, but…. We’re not in Kentucky, but…. – Amerihealth administers a number of state health plans – Health plans see the data on cost savings

61. Who takes the Advice? Seen by Allergists v. Pediatricians Patients seen by an allergist had greater knowledge of environmental allergens Patients seen by an allergist had greater knowledge of environmental allergens – Dust mite knowledge (71% v. 18%) – Need for mattress encasements (61% v. 13%) – Need for pillow encasements (51% v. 11%) Increased knowledge, but not statistically significant Increased knowledge, but not statistically significant – More knowledge about carpet removal (23% v. 11%) – Stuffed animal removal (10% v. 2%) Made some changes in their home Made some changes in their home – Use of mattresses encasements (38% v. 11%)-- 0.001 – Use of pillow encasements (36% v. 16%)– 0.009 – Carpet removal (26% v. 36%)-- NS Callahan KA, et al. Annals Aller Asthma Immunol 2003;90:302-7.

62. Summary Written asthma action plans Written asthma action plans Persistent asthma should be treated with controller medication Persistent asthma should be treated with controller medication Environmental management can and should supplement good medical care Environmental management can and should supplement good medical care

63. Summary (con’t) Ask about environmental exposures and seek ways to intervene Ask about environmental exposures and seek ways to intervene Some low cost interventions may be effective in children Some low cost interventions may be effective in children – Should consider comprehensive approach Consider allergy referral Consider allergy referral – Define exposure risk – Consider immunotherapy