Asthma Prevalence and Management: Addressing the Barriers to Ideal Asthma Care

1
Asthma Prevalence and Management Addressing the
Barriers to Ideal Asthma Care

• National Tribal Forum
• Camlesh Nirmul, MD, FAAP
• Phoenix Indian Medical Center, Indian Health
  Service
• May 2, 2013
• Disclaimer The views expressed in this lecture
  do not necessarily represent the view of the
  Phoenix Indian Medical Center or the Indian
  Health Service.

2
The Asthma Challenge

• There are a lot of people suffering from asthma
• The burden of asthma is increasing among all
  populations
• Etiology of asthma is multi-factorial, with
  definite disparities in the asthma prevalence
  between different racial/ethnic groups
• We know how to manage it successfully
• National guidelines for the diagnosis and
  management of asthma have existed for over a
  decade
• Newer/more effective treatment and devices
• Yet we have not eliminated the burden of asthma!

3
The Burden of Asthma

• Increasing prevalence (8-13) in last decade
• Involves up to 1 in 8 children
• Rate is increased in certain groups (inner city,
  some minorities)
• Adult CDC BRFSS 2009 data
• National prevalence rate (current asthma) 8.8
• Arizona rate (current asthma) 10.8
• Pediatric AZ rate (17yr and younger) 13.5
• NC Asthma Program 2010 lifetime asthma
• American Indian/Alaska Native 16
• African-America 15.5
• Non-Hispanic White 12.2

4
The Burden of Asthma

• Pediatric asthma prevalence
• Disparities exist in the burden of asthma in
  different subgroups but little is known about the
  AI/AN community
• AI/AN data limited but some suggestion that may
  be much higher than national average
• NE Montana 1999 study at Ft. Peck IHS Unit
  15.5 children had a diagnosis of asthma
• Jemez Pueblo 1995 study in NM found rate twice
  the national average - 12.3
• Washington State 2012 data 12 graders reported
  twice the rate of general population 17

5
AI/AN Data DHHS Office of Minority Health

• American Indian/Alaska Native adults are 30
  more likely to have asthma as non-Hispanic
  Whites. Data on asthma conditions for American
  Indian/Alaska Natives is limited.
• Percentage of asthma among persons 18 years of
  age and over, ever being told they had asthma,
  2010
• American Indian/Alaska Native 12.3
• Non-Hispanic White 12.9
• Percent of current asthma prevalence, 2010
• American Indian/Alaska Native 10.5
• Non-Hispanic White 8
• Source  CDC 2012. Summary Health Statistics for
  U.S. Adults 2010. Table 4
• Percentage of adults 18 years of age and over
  with asthma, 2004-2008
• American Indian/Alaska Native 14.2
• Non-Hispanic White 11.6
• Source  CDC 2010. Health characteristics of the
  American Indian or Alaska Native adult
  population United States, 20042008, Table 4.

6
The Burden of Asthma

• Increasing morbidity/mortality from asthma
• ED visits and hospitalization rates are
  increasing, especially in young
• 25 of children with asthma visited ED in last
  year (Washington data AI/AN rate, same as
  national rate)
• 39 of pediatric asthma hospitalizations were
  under age 5 yrs (2003)
• Washington study found hospitalization rate 2-3x
  higher in AI/AN children under 1 year age
• Death from asthma remains rare in pediatrics
• However the death rate increased 30 in the last
  decade
• Fatal asthma not just in severe asthma 1/3 have
  mild asthma

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Effect of Asthma on Quality of Life

• Childhood asthma is leading cause of missed
  school days (loss of 14 million school days)
• 52 missed school or day care at least once
• Over 60 of kids have some limitation in their
  lives from asthma (sleeping through the night,
  playing sports/exercising, etc)
• Over 1/3 of kids and parents avoid activities
  because of the childs asthma
• Over 1/3 of parents miss work because of their
  childs asthma

8
Management of asthma

• While there is no cure for asthma, asthma can be
  managed successfully
• Because of advances made in understanding the
  causes and management of asthma, asthma is now
  treatable and controllable
• IF providers use and follow national asthma
  guidelines to treat asthma optimally
• IF patients/families adhere to this prescribed
  management

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Management of asthma

• Guidelines from the NIHs National Asthma
  Education and Prevention Program outline how to
  achieve symptom-free days and normal quality of
  life through a multi-modal approach
• Pharmacotherapy
• Control of the environment and elimination of
  triggers
• Treatment of associated conditions
• Education and encouraging adherance
• Do these guidelines apply to and work across
  racial and ethnic lines?

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Addressing the Challenge in the Native American
(NA) Community

• What is known about the burden of asthma in the
  AI/AN population?
• If a disparity exists compared to national data
  and other groups, how can we overcome it to
  achieve optimal asthma care?
• What are the barriers that need to be addressed
  to improve asthma care and eliminate any
  disparity?

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The Phoenix Native American Community

• The Phoenix Area IHS oversees delivery of health
  care to gt140,000 AI/ANs in Arizona, Nevada and
  Utah
• Includes over 40 tribal groups and 10 service
  units, the largest of which is the Phoenix
  Service Unit
• Over 62 of the AI/AN population in Arizona lives
  in primarily urban areas
• The majority of the population is Navajo, with
  significant percentages from the Yaqui Pima and
  Apache nations
• Estimated gt80,000 children under age 15 in
  Arizona who may receive care through the HIS
• Found over 21 of patients under age 15 with
  physician diagnosis of asthma

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Burden of Asthma in the Phoenix Area

• Maricopa county/Phoenix urban environment with
  high levels of pollution, know trigger for asthma
• Ozone high in the valley, leads to inflammation
  in airways and triggers asthma
• Particulates alerts are frequent (PM 2.5, PM 10)
• ADEQ 2008 report Study of 5000 asthma events in
  5-18yr olds in Maricopa County found 14 increase
  in asthma events when PM10 increased from 25 to
  75
• PM 10 large particulates stick to airways,
  leading to increased mucus in efforts to expel
  them
• PM 2.5 goes deep into the airways, where
  difficult to expel
• High construction areas stir up mold/fungal
  spores in the dirt leading to increased asthma
  events in those sensitive to these molds

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Barriers to successful asthma care

• Paradigm shift over last decade
• Goal was to aggressively treat symptoms of asthma
• Current goal is long-term control of asthma
• Focus on asthma as a chronic disease
• Aggressively treat airway inflammation
• Control the environment and work on prevention
• Teach self-management of asthma (asthma action
  plan)
• Goal of controlling asthma is difficult to meet
• Definition of control is complex and involves
• Decreasing asthma symptoms
• Improving lung function
• Improving quality of life and maintaining normal
  activity
• Asthma control changes over time and needs to be
  measured at every visit

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Barriers to successful asthma care

• Measuring asthma control is difficult
• Measures of control correlate poorly with each
  other
• Symptom review, pulmonary function (spirometry),
  and patient questionnaires are various measures
  available
• Relying on just one measure does not give a
  complete picture of the patients asthma
• May be difficult to perform all measures at each
  visit
• Cost and availability may prohibit performing
  PFTs/spirometry
• Patient questionnaires may take time and effort
  to administer
• Poor adherence to guideline recommendations
• While the guidelines are widely endorsed and
  disseminated, they have not been effectively
  implemented and followed
• Involves providers, patients, and the health care
  system

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Provider Adherence Factors

• Adherence to guidelines themselves
• Inertia of previous practice - change is always
  difficult!
• Guidelines have become more complicated
• Problem is that poor adherence leads to
  under-diagnosis and under-treatment of asthma
• Visit time constraints and poor reimbursement
• Creates less time and incentive for effective
  education
• Does not allow environment conducive to asking
  questions
• Communication barriers
• Language barriers for verbal but also written
  education
• Lack of awareness of medical speak in talking
  with families

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Patient/Family Adherence Factors

• Poor adherence to treatment regimen
• Medication issues
• Confusion over the difference in daily controller
  vs rescue medications
• Fears about side effects - steroid phobia
• Poor technique in using medication delivery
  devices leading to less efficacy
• Environmental control is complicated, especially
  for indoor allergens
• Literacy barriers
• May not understand verbal or written instructions
  because of language itself as well as literacy
  level of instructions

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Patient/Family Adherence Factors

• Cultural barriers
• May not trust medical system fully
• Beliefs/perceptions about asthma and chronic
  disease
• Expectation that asthma can be cured
• Variable disease makes it more difficult to get
  adherence
• Socioeconomic - limited access/resources
• Can lead to overuse of ED/urgent care and lack of
  continuity
• May affect adherence to medications due to cost
  of medications and access to delivery devices
• Barrier for purchasing items important in home
  control of allergens/asthma triggers (covers,
  HEPA filters, etc.)

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Barriers to successful asthma care Health Care
System

• Limited access/resources
• Decreased ability to schedule and receive
  appropriate follow-up care
• May lead to overuse of ED/urgent care and lack of
  continuity
• Less access to specialized tests or providers
  (especially allergists, allergy testing to
  identify specific triggers)
• Restricted access to medications and asthma
  equipment (especially spacers and peak flow
  meters)
• Communication/continuity of care issues
• Lack of feedback loops between all the involved
  players (ED - primary care provider - school -
  pharmacy) results in fragmented care for asthma
  in the system

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Individual Barriers to Care in the NA Community

• Socioeconomic
• Limited health insurance coverage is experienced
  by 60 of the population
• Low income, single caregivers
• Over 35 of children live in single parent
  households
• Over 30 live below the poverty line
• Housing options often limited and may not be able
  to control environment adequately (especially to
  limit indoor trigger exposure)
• Leads to limited resources and less ability to
  maintain adherence with daily meds and frequent
  visits

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Individual Barriers to Care in the NA Community

• Environmental triggers allergens and irritants
• Tobacco smoke (Washington study)
• Higher rates of adult smoking
• AI/AN adult smoking rate 2x general population
• 1/3 AI/AN adults with asthma smoke
• High rates of secondhand tobacco smoke exposure
• 1/7 non-smoking adults are exposed to secondhand
  tobacco smoke
• Indoor allergens (Washington study)
• Carpets/rugs - 95 of AI/AN houses had
  carpets/rugs
• Inside pets 72 houses
• Wood burning indoor and outdoor
• Cultural events and ceremonies
• Community events

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Individual Barriers to Care in the NA Community

• Cultural/Psychosocial
• Beliefs/perceptions about asthma and asthma
  medications
• Beliefs/perceptions about chronic disease
• Lack of trust in provider/system may prevent
  optimal asthma education and care
• Health care practices with overuse of acute care
  vs preventive (lt10 of visits are for preventive
  screening)
• Mobile/transient population (urban to
  reservation)
• Multiple households (as well as caretakers)

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Individual Barriers to Care in the NA Community

• Problems with adherence
• Lack of understanding of the chronicity of asthma
• Medications are often not taken appropriately
• Confusion over the difference in daily controller
  vs rescue medications
• Reluctance to use daily meds - steroid phobia
• Poor technique in using medication delivery
  devices leading to less efficacy
• Reliance on child when still young to be
  responsible for his/her asthma
• Primary use of unscheduled/acute care visits
  instead of regular follow-up

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How can we meet this challenge and achieve
optimal asthma care?

• Identify the individual and specific barriers to
  adherence
• Include provider, patient/family, and health
  system barriers
• Address these barriers systematically
• Improve education
• Improve communication
• Attempt behavior change

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Meeting the challenge Providers

• Read and know the guidelines!
• Most providers have seen the guidelines, yet
  adherence is low
• How closely do you follow the guidelines?
• Do you diagnose asthma correctly?
• Do you assess both impairment and risk?
• Are you prescribing the correct medications for
  each classification of asthma?
• Are you educating patients and families on the
  differences in medications, use of asthma
  delivery devices, and self-management of asthma
  (Asthma Action Plans, environmental control of
  triggers)?
• Are you seeing patients for regular follow-up and
  assessing asthma control on these visits? (And if
  asthma is uncontrolled, do you adjust treatment
  appropriately?)

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Meeting the challenge Providers

• Tools/Teaching aides to increase awareness of and
  use of guidelines
• Pocket cards, posters of step classifications,
  medications charts, and sample devices -
  Toolkit in every room
• Patient encounter forms or worksheets specific
  for asthma
• Prompt providers to ask right questions so that
  reach right diagnosis
• Guide providers to use preferred treatment
• Involve other personnel to help share the asthma
  care burden and overcome time constraints
• Nursing/pharmacy/RT can assist with teaching use
  of devices/meds
• PHN can help with allergy/trigger avoidance,
  self-management plans (asthma action plans) and
  adherence
• Enlist someone to be an asthma champion or train
  to be a certified asthma educator
• Use school programs like ALA Open Airways
  program

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Meeting the challenge Communication/Education

• Administer asthma questionnaires to quickly
  assess control
• Asthma Control Test (A.C.T.)
• Asthma Therapy Assessment Questionnaire (ATAQ)
• Practice active listening
• Elicit concerns and fears of families and
  patients
• Create environment where questions are freely
  asked
• Make education more effective
• Use non-medical language
• Choose appropriate education materials
• Multilingual handouts, appropriate literacy level
• Non-written education (video, CD, web-based,
  etc.)
• Visual aides (posters, charts, etc.)
• Practice the teach-back method with patients

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Meeting the challenge Patients

• Much harder to address - often involves behavior
  change but good education and communication help
• Discuss asthma as a chronic disease
• Lifelong nature, potential for severe disease
  (even death)
• Lack of cure but existence of good treatment
• Variable nature of disease, importance of
  frequent/regular f/up
• Teach families how to recognize asthma control
• Establish an expectation for quality of life
• Rules of 2 (Baylor)
• Address adherence to treatment recommendations
• Discuss difference between medications
• Use medication charts/pictures to ensure patients
  know which medication is being talked about
• Discuss role of daily control medications
• Dispel fears about side effects (especially
  steroids)
• Simplify dosing regimen

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Meeting the challenge Patients

• Make asthma care relevant to each family/patient
• Look for the measure or outcome that matters most
• Identify the specific triggers/allergens that
  they can avoid or control best
• Understand the disease from their perspective
• Ask what is most important to them in treating or
  addressing asthma
• Determine their attitude toward asthma and the
  disease itself
• Identify and directly address any concerns/fears
• Try to find common ground that is acceptable to
  the provider and the family
• Maintain open environment to encourage ongoing
  communication
• Key is to consider all these barriers and
  individualize asthma care plan to each patient
  and family situation

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Meeting the challenge Patients

• Socioeconomic factors
• More aggressive identification of need for extra
  resources
• Most of NA pediatric community qualifies for
  state resources
• Assist with transportation and help advocate for
  housing/environmental changes
• Cultural issues
• Often involves challenge of attempting behavior
  change in a culturally sensitive way
• Establish trust with family/patient
• Listen to their concerns about the disease
• Offer support for traditional practices/beliefs
  but reinforce need to also follow prescribed
  treatment plans
• Involve extended family/all caretakers

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Meeting the challenge Patients

• Environmental control/avoidance
• Indoor triggers
• Aggressively work on tobacco cessation and
  avoidance of second hand smoke
• Individual plan with the family on what allergen
  control measures work best for their housing and
  financial resouces
• Outdoor triggers
• Wood burning/smoke avoidance
• Dry wood, not wet, avoid paper burning, consider
  wood pellets
• Community/school partnership
• Flag programs (Outdoor vs indoor activity days)
• Grass cutting coordination for sport fields

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How can we meet this challenge and achieve
optimal asthma care?

• Identify specific barriers to adherence in your
  own practice and in your patients/families
• Use quality management tools to overcome these
  barriers- work to achieve outcomes that matter
• Patients/Families care about quality of life,
  simple treatment plans, no hospitalization or
  urgent visits, decreased stress and fears about
  asthma and its impact on their lives, low costs
• Clinicians care about increased asthma control
  and quality of life, decreased symptoms,
  decreased rescue medication use, increased lung
  function, decreased unscheduled visits
• Health care systems care about correct drug
  ratios, decreased ED/urgent care visits and
  hospitalizations
• Key to success individualize plans to each
  patient/family situation PATIENT CENTERED
  MEDICINE

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Ultimate Goals

• With the burden of asthma in the NA community,
  how can we meet the challenge to achieve optimal
  asthma care?
• Identify any risk factors contributing to this
  high burden of asthma and target efforts to
  decrease them
• Attempt to eliminate any disparities in the
  burden of disease
• Identify any barriers to care
• Address these barriers in a culturally sensitive
  way

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REFERENCES

• NAEPP of NIH www.nhlbi.nih.gov/guidelines/asthma/
  index.htm - 2007 asthma guidelines.
• 2009 AZ Asthma Burden Report AZ Dept. Health
  Services, November 2011
• 2012 Asthma Among AI/AN in Washington Washington
  Dept. of Health.
• MMWR Key Clinical Activities for Quality Asthma
  Care, March 2003.
• AZ Hospital Discharge Database - 2003 data.
• Regional Differences in Indian Health, 5/03
  publication by the DHHS (of data from FY
  2000-2001).
• Maricopa County Children with Asthma, April
  2005 Community Report by the Health and
  Disability Research Group.
• www.asthmainamerica.com Children and Asthma in
  AZ/NM - subset of the Children and Asthma in
  America study conducted by the Asthma Action
  America campaign in 2004.
• www.gappsurvey.org Global Asthma Physician and
  Patient Survey, 2005.
• www. cdc.gov/health/asthma.htm - links to data
  and surveillence Key Clinical Activities for
  Quality Asthma Care, March 2003. CDC 2009 BRFSS
  Asthma Prevalence Data.

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REFERENCES

• Asthma burden statistics and barriers to care in
  the PIMC community originate from a planning
  grant funded by the AAP CATCH program. IRB
  protocol number PXR 05.02
• Bukstein, Don, et al. Asthma end points and
  outcomes What have we learned?, Journal of
  Allergy and Clinical Immunology, 2006, 118
  S1-15.
• Clark, Donald, et al. Asthma in Jemez Pueblo
  schoolchildren, American Journal of Respiratory
  and Critical Care Medicine, 1995, 151 1625-1627.
• Fuhlbrigge, Al, et al. The burden of asthma in
  the US, American Journal of Respiratory and
  Critical Care Medicine, 2002, 166 1044-1049.
• Hendrickson, R. et al. High frequency of asthma
  in Native American children among the Assiniboine
  and Sioux tribe of northeast Montana, IHS
  Provider, February 2003, 38-39.
• Kurzius-Spencer, M. et al. The presentation and
  treatment of asthma among Alaska Native children
  in the Yukon-Kuskokwim Delta, preliminary paper
  from Dr. Anne L. Wright, Arizona Respiratory
  Center.

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REFERENCES

• Li, James T., et al. Attaining optimal asthma
  control A practice parameter, Journal of
  Allergy and Clinical Immunology, 2005 draft.
• Liu, LL et al. Asthma and bronchiolitis
  hospitalizations among American Indian children,
  Archives of Pediatric and Adolescent Medicine,
  2000, 154 991-996.
• Peterson, K. et al. A Qualitative Study of the
  Importance and Etiology of Chronic Respiratory
  Disease in Alaska Native Children, Alaska
  Medicine, 2003, 14-20.
• Rose, Diane and Ann Garwick. Urban American
  Indian family caregivers perceptions of barriers
  to management of childhood asthma, Journal of
  Pediatric Nursing, 2003, 18 2-11.
• Schatz, Michael, et al. Asthma Control Test
  Reliability, validity, and responsiveness in
  patients nor previously followed by asthma
  specialists, Journal of Allergy and Clinical
  Immunology, 2006, 117 549-56.
• Van Sickle, David and Anne L. Wright. Navajo
  perceptions of asthma and asthma medications
  Clinical implications, Pediatrics, 2001, 108
  1-7.
• Wind, S. et al. Health, place and childhood
  asthma in southwest Alaska, preliminary paper
  from Dr. Anne L. Wright, Arizona Respiratory
  Center.

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RESOURCES

• www.azasthma.org- AZs asthma coalition website
  links to Provider, Patient/Family, and School
  Toolkits links to 2007 guidelines, STEPS Program
  Quick Guidelines
• www.epa.gov/asthma- Home environmental checklist,
  brochures, Tools for Schools kit, home visiting
  program development, etc.
• www.naecb.org National asthma educator
  certification board website
• www.aafa.org - Asthma and Allergy Foundation of
  America site ACT (Asthma Care Training) CME
  based Asthma Management Program for nurses/RTs
  You can control asthma and validated Wee
  Wheezers education program for patients and
  families
• www.breatherville.org - AANMA (Network of mothers
  of asthmatics) user-friendly site for patients,
  schools and providers
• www.starbright.org - free asthma CD-ROM game for
  kids to learn about triggers and asthma
• www.nhlbi.nih.gov/health/prof/lung/asthma/pace/ind
  ex.htm - link to PACE program and its resources
  and online education seminar

37
RESOURCES

• www.getasthmahelp.org Michigan asthma program
  (AIM) compilation of asthma resources (for
  family and providers)
• www.calasthma.org/resources and
  www.betterasthmacare.org- excellent CA asthma
  sites that compile extensive patient handouts
  (multiple languages), education
  materials/posters, provider tools (under the
  Health Professionals resources tabs), worksheets,
  etc.
• www.oregon.gov/dhs/ph/asthma - Oregons asthma
  site with provider tools like pocket card,
  patient handouts, etc.
• www.ttuhsc.edu/elpaso/som/asthma- print
  Multicolored Simplified Asthma Guidelines
  Reminder asthma worksheets
• www.mainehealth.org/mh_body.cfm?id364 website
  of the Maine AH! Asthma health program go to the
  clinical tools and will find multiple resources
  and performance improvement examples
• www.asthmanow.net - NH asthma site, with great
  toolbox of office resources (chart audit,
  checklists, etc.) as well as section on health
  professional education (multiple powerpoints)
• www.asthma-iAAP.com - Minnesota Asthma Program
  interactive Asthma Action Plan (iAAP).