SECHENOV MSCOW MEDICAL ACADEMY The Department Of Public Health Medical Care Organizations And Economics

Nurul Husna Asmaa Binti Yahaya Group 9 Ms Ekkert Natalia Vladimirovna

The Role Of A Doctor In The Treatment Of Asthma In The America

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How can we improve community and institutional surveillance of asthma to measure the impact of the disease on our patient population? How hard or easy is it for you to get spirometry on a patient for diagnosis and follow-up of a patient with asthma? Are providers in your clinic and hospital checking spirometry in patients with asthma? How difficult is it for you to get a pulmonary and/or allergy consultation when needed? Do you use the Asthma Register System at your facility and have you used the asthma action plans that are available through this program? If not, do you have a method of providing written action plans for your patients that is usable? Is there any role for remote/telemetric monitoring of peak flows, home spirometry, and use of MDI’s where providers can keep tabs on a patient’s status?

Asthma is chronic inflammatory lung disease characterized by obstruction of airflow and at least partial reversibility of this obstruction. Although asthma can begin at any age, a previous discussion explored childhood asthma. Here, adult asthma will be mainly discussed. Unfortunately, the burden of asthma on American Indians/Alaska Natives (AI/AN) is largely unknown except to the providers in clinics and emergency departments, and to the patients and families who suffer with the disease on a daily basis. In 1964, Herxheimer concluded that there were strikingly few cases among Indians of the Southwest and Northern Plains1. In 1975, a review of 9,000 consecutive visits to the IHS clinic at Lame Deer, MA found only 1 patient with asthma2. Attempts to look for asthma were made by mortality reviews from 19691977 in New Mexico where only one fatal case was found3. Another review of mortality from asthma, this time national, found no fatal cases from 1980 to 1986. More recently, the prevalence of asthma in AI/AN people has become clearer. In 1995, Clark found 12.3% prevalence of asthma or reactive airway disease in children 3 to 13 years old in a Pueblo in New Mexico4. In 1999, Stout identified a 7.06% incidence of parent reported asthma in 2288 children aged 1-17 years old5, and this year a report from the Yukon-Kuskokwim delta region of western Alaska identified 7.4% of students selfreporting that they had received a diagnosis of asthma from a physician6. Even though all of the recent data is performed in children, it does give us an idea that asthma is at least as significant a problem as the general U.S. population and possibly an emerging illness for AI/AN people. There are difficulties inherent in general asthma surveillance. First, it may be difficult to accurately identify cases of asthma since there is no definitive clinical test for asthma. Because of this, some health care providers tend to accept diagnoses of asthma by history, physical exam, and subjective response to bronchodilators. Although there is no data in the literature to support this assertion, it is seen in this first hand on a daily basis. Of the patients in the clinic in 2001 who carried a diagnosis of “asthma,” roughly half of the patients had never had a spirometry performed. Second, asthma is episodic by definition and the objective measurements that might aid in diagnosis are not always helpful. Once again in the clinic, only a quarter of patients carrying a diagnosis of asthma had their diagnosis confirmed by spirometry, while the other quarter had spirometry that was not consistent with asthma. This highlights the importance of performing spirometry when the patient is symptomatic so that the episodic obstruction can be confirmed. Even though surveillance of asthma can be difficult and time consuming, there are important reasons to take a closer look at asthma. This monitoring would allow us to follow trends in asthma prevalence, asthma severity,


our success in managing this chronic disease, as well as its overall costs7. One push to improve surveillance of asthma comes from the goals established by “The Healthy People 2010” initiatives. Some of the general U.S. Data for asthma goals is known, but there is essentially no baseline data for AI/AN people in regards to the different targets. Surveillance for some of these asthma related targets kick-off as part of one upcoming GPRA indicator; “baseline rates for asthma visits broken out by age groups.” While GPRA indicators will push us to follow asthma outcomes, a public health approach to improvement in asthma treatment is the more important reason. The National Asthma Education and Prevention Program (NAEPP) developed an Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma (EPR-1) in 1991 and then revised/updated this report in 2002 (EPR-2)8. Under these guidelines, the treatment of asthma was organized around the following key components of effective asthma management: ➢ ➢ ➢ ➢ “Use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy Environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or exacerbations. Comprehensive pharmacologic therapy for long-term management designed to reverse and prevent the airway inflammation characteristic of asthma as well as pharmacologic therapy to manage asthma exacerbations. Patient education that fosters a partnership among the patient, his or her family, and clinicians.”

It is essential that every effort be made to make the correct diagnosis when evaluating a patient with dyspnea. The EPR-2 reiterates “to establish the diagnosis of asthma, the clinician must determine that: • • Episodic symptoms of airflow obstruction are present. Airflow obstruction is at least partially reversible. Alternative diagnoses are excluded.”8

Because of this definition, spirometry is required (if the patient can coordinate it) to prove airflow obstruction before making the diagnosis of asthma. Reversibility can be proven by spirometry or by peak flow monitoring. The last bullet above is one point that should not be ignored so that contributing/exacerbating diagnoses can be ruled-out. Once the diagnosis of asthma is firm, the severity should be classified on the basis of the patient’s daytime and nighttime symptoms and their lung function. Once the diagnosis of asthma is firm, the severity should be classified on the basis of the patient’s daytime and nighttime symptoms and their lung function. Cherokee Indian Hospital has created an excellent handout/tool that summarizes the NAEPP recommendations in this regard. One of the most useful tables in these handouts is as follows: Mild Intermittent Step 1 Symptom ≤ 2 per week Frequency Nocturnal ≤ 2 per month Symptoms* PEF Max ≥80% ≥80% >60 and < 80% ≤60% >2 per month >1 per week Frequent > 2 per week Every day Continuous Mild Persistent Stage 2 Mod. Persistent Stage 3 Severe Persistent Step 4


PEF Variabiltiy Bronchodilator use Activity Post attack pulmonary function

<20% <1 per week

20-30% ≤8 puffs / day May be limited

>30% 10 puffs / day Limited May not return to normal Flunisolide (Aerobid) MDI with spacer 4 puffs BID OR Budesonide (Pulmicort) MDI 2-3 inhalations QD AND Salmeterol (Serevent) Discus** 1 inhalation QDBID AND

>30% >10 puffs / day Limited May not return to normal Budesonide (Pulmicort) MDI >3 inhalations QD



Flunisolide (Aerobid) MDI with spacer 2 puffs BID OR Chronic control medication (Daily) Triamcinolone (Azmacort) MDI 4 puffs BID Alternative Nedocromil (Tilade) MDI with spacer 2 puffs QID Acute rescue medication *** Acute viral respiratory infections ****


Salmeterol (Serevent) Discus** 1 inhalation QDBID

Albuterol MDI with spacer 2-4 puffs q 4-6 hr PRN or 0.5 ml via nebulizer q 4-6 hr +/- Ipratropium (Atrovent) 500mcg (1 vial) via nebulizer q 6 hr – may mix with albuterol Albuterol q 4-6 hr up to 24 hours (longer with MD consult) For severe exacerbations: short course “burst” of prednisone 40-60 mg per day as a single or two divided doses for 3-10 days.

* Theophylline 10mg/kg/day up to 300mg HS may be helpful with nocturnal symptoms. Monitor serum levels (Goal levels: 10-20 mcg/mL) (> 20 mcg/mL = increased toxicity). ** Avoid use of salmeterol without concomitant inhaled steroids. Overuse of salmeterol has been associated with worsening asthma and increased mortality in a retrospective report. *** Use of albuterol >2 times per week in intermittent asthma (daily or increasing use in persistent asthma) may indicate the need to initiate or increase long-term control medications. ****Hi Dose Taper: 60mg day 1, 60mg day 2, 40mg day 3, 40mg day 4, 20mg day 5, 20mg day 6, 10mg day 7, 10mg day 8 Low Dose Taper: 40mg day 1, 35mg day 2, 30mg day 3, 25mg day 4, 20mg day 5, 15mg day 6, 10mg day 7, 5mg day 8


This framework is very helpful for management in primary care. It avoids classifying asthma as mild, moderate, and severe, emphasizing the fact that asthma of any severity can have mild, moderate, or severe exacerbations that may even result in death. The recommended classification of asthma allows for more aggressive treatment of inflammation and preventive medications for patients with stage 2 through 4. As asthma surveillance becomes more of a priority from a public health/system approach, this classification will also provide a framework that will enhance this surveillance. The Asthma Register System employs the recommendations of the EPR and has been added to the IHS Resource and Patient Management System. This resource “provides Indian Health Service/Tribal/Urban (I/T/U) healthcare providers with another tool for improving the care and management of patients with asthma9.” It allows for the creation of a registry, a health summary supplement, asthma related health reminders, and a patient self-management printout.

5 questions or issues asked to an Internal Medicine Chief Clinical Consultant,
1. How can we improve community and institutional surveillance of asthma to measure the impact of the disease on our patient population? Asthma has chronically been under-diagnosed among Native American populations in the primary literature. It was believed that Native Americans suffered very little from asthma based upon data from the 1970s and early 80s - possibly asthma is a new epidemic among Native American populations, or it has not been well documented or inappropriately documented in the past. I think that we need to increase provider awareness of asthma and extinguish the fear of "labeling" persons with asthma. Asthma diagnosis can be active or moved to an inactive status in RPMS over time under the problem list/purpose of visit area of the PCC/PCC+/EHR. Appropriate diagnostic codes should be used - and lackluster codes such as RAD should not be encouraged. What ICD-9-CM codes are providers using most commonly for documentation of asthma? Community screening or education could help raise personal awareness of asthma and asthma screening could be incorporated into school activities. 2. How hard or easy is it for you to get spirometry on a patient for diagnosis and follow-up of a patient with asthma? Are providers in your clinic and hospital checking spirometry in patients with asthma? Cherokee Indian hospital recently received a spirometer and we are still working on the logistics of using it. Initially, it was thought that clinic nurses could perform the spirometry; however we quickly realized that this is an unreasonable request considering the amount of work and responsibility already placed upon our clinic nursing staff. We are in the process of evaluating the potential of getting a respiratory therapist to manage the spiromety. What has worked best at other sites? How many places have RTs? If you have an RT, how large is your facility and what is their role? 3. How difficult is it for you to get a pulmonary and/or allergy consultation when needed? 4. Do you use the Asthma Register System at your facility and have you used the asthma action plans that are available through this program? If not, do you have a method of providing written action plans for your patients that is usable? We are in the process of updating the ARS (Asthma Registry System) registry. We have not provided written action plans for the past for our patients, but that is changing as we work with the system. Currently the package is not functional for entering asthma related data but if this functionality is added, it will be very nice for ensuring that asthma related data gets entered into the system and for printing patient specific education forms. Currently the system if great for running reports, displaying important information on the health summary and raising awareness of asthma as a chronic disease that requires continuous monitoring and management. It is important for us to test out the system and determine what aspects of the application we would like to change or could improve.


5. Is there any role for remote/telemetric monitoring of peak flows, home spirometry, and use of MDI’s where providers can keep tabs on a patient’s status? Home peak flow monitoring has been advocated by the NHLBI as a monitoring tool to assess asthma status. I am aware of some patients (not many) who have been willing to bring in their PF monitoring sheets in for review, but again - very few. Remote monitoring or even PF meters with memory would be interesting tools that could help increase usage and benefit of this type of monitoring and patient education

The State data presented above raise several questions for anyone involved in quality improvement. • • • What does a State's position on the continuum of quality measures mean? What factors influence that position and the variability among the States? What factors can be influenced through State policy change and local efforts?

Factors That Determine Quality Of Asthma Care_________________

A number of factors influence quality and outcomes of health care for any disease. Some factors may be difficult to change, such as biologically inherited traits; income, education, and social status; and general population characteristics. Others may be changeable in the medium or long term, but not in the short term, such as the supply of health care professionals, the makeup and mission of health care organizations, and the disease prevalence of the population (which represents ingrained patterns of personal behaviors and health system effectiveness). All of these factors influence the process and outcome of health care. Although State government and community leaders do not have control over all factors, State actions can influence some important factors to promote positive change. These include educating people with asthma about the risks of uncontrolled asthma, raising awareness among professionals about health care processes that can improve outcomes for people with asthma, raising awareness in schools and communities about mitigating risk factors that can trigger asthma attacks, and creating financial incentives to encourage providers to manage diseases with their patients. Some States, for example, target programs to affect patient self-management and other external causes toward minority populations that are disproportionately affected by asthma. Racial, Ethnic, and Socioeconomic Factors The socioeconomic makeup of a State will likely play a role in how it compares to national norms on process and outcome measures. States with a higher proportion of individuals living in poverty, lower average education, and a more diverse racial and ethnic population, for instance, will likely find poorer outcomes for their population compared to the national population. The NHDR summarizes the racial, ethnic, and socioeconomic differences in asthma across the Nation (but not by State). Nationwide, minority or lower socioeconomic status is associated with higher asthma prevalence, higher asthma death rates, higher rates of serious asthma complications, and poorer asthma outcomes. (Blacks, for example, are much more likely than Whites to be hospitalized for asthma) The socioeconomic makeup of a State, thus, should play a role in the strategies that the State uses to improve asthma care quality. For instance, States that target efforts to improve asthma care at population groups particularly at risk for asthma complications should also be able to improve their overall performance on asthma care quality. Biological and Behavioral Factors Understanding biological and behavioral influences on asthma should help in developing assessment tools and interventions for preventing or reducing the burden of asthma. Risk factors for asthma include : • • • Parental history of asthma. Early-life stressors and infections. Obesity.


• •

Exposure to indoor allergens, tobacco smoke, and outdoor pollutants. Work-related exposures.

Socioeconomic factors may be related to underlying biological factors or behavioral factors. The accumulated stress of poverty, low levels of control in jobs and relationships, low job and life satisfaction, and societal discrimination against minority groups can influence health status.

Physical Environment
The physical environment in which asthma patients live is an important contributor to their asthma severity. The presence of poor air quality, dust, pets, cockroaches, and other allergens can affect how well a patient is able to control his or her asthma. A recent study released by the National Institutes of Health shows the connection between decayed bacteria in bedrooms and other rooms of a house and asthma prevalence.

External Environment
In addition to individual characteristics (some of which are amenable to change with personal motivation), each State has a different infrastructure and different environmental factors over which policymakers may or may not have control. These factors include the collective health status of the population, the distribution of health care services within locales, the distribution of wealth and tax resources among communities, and government programs and leadership. State leaders will face different health care system challenges, including:

• • • • • • • • •

Health system infrastructure—Availability of health professionals, emergency rooms, and hospitals beds. Uninsured populations—Presence of vulnerable and uninsured populations and the need for special State programs to cover the cost of health care for them. Safety net infrastructure—Availability of a safety net of health care providers as a last resort for those who cannot afford health insurance and private health care. Provider knowledge—Providers who have sufficient state-of-the-art knowledge to manage asthma effectively and to educate their patients in asthma self-management. Public education—Public education programs that raise patient awareness of the warning signs of the disease, its potential complications, the importance of diet and exercise, and the effectiveness of personal self-management, including knowing when to consult a doctor. Government resources—Funds, in a time of tight State budgets, to stimulate quality improvement activities related to asthma care. Leaders to champion quality improvement—Leaders who can draw attention to the problems associated with asthma and harness the commitment of health professionals to change practices and monitor results. Knowledge of what to do—Identification of effective quality improvement programs that are based on scientific evidence. Adequate data systems to assess progress—Availability of data systems that can provide comparable measures across providers, communities, and States.

The inter-relationship among all of the factors in then, affects how a State compares with other States on measures of asthma care quality. It is difficult to measure all of these factors at the State level. An attempt was made to analyze the Behavioral Risk Factor Surveillance System (BRFSS) measures in Table 1 against individual State-level environmental factors—prevalence of asthma, emphysema and chronic bronchitis in the population, the percent of the population below poverty level, racial/ethnic makeup of the population, the HMO penetration rate, the supply of hospital beds, and air quality in the State. The findings were not consistent enough across measures and factors to be believable. Again, the small sample sizes and imprecision of the asthma estimates themselves may be the limiting factor. Moreover, survey averages (e.g., percent having planned care visits) related to State aggregates from other sources (e.g., percent of the population that is uninsured) do not provide a direct test of these relationships. With large databases, it is possible to assess asthma care quality at not only the State but also local levels for some measures. For example, HCUP data and the statewide discharge data systems that are the source of HCUP data (with its hundreds of thousands of discharge records per State per year) support analyses at the county or other market areas. County-level data related to health care resources are generally available, although county data on health risk behaviors of the population generally are not. State analysts could use their county-level databases to compare asthma outcome measures based on HCUP data—e.g., asthma hospitalizations—or on data


from their statewide data organization with other county characteristics. AHRQ's Prevention Quality Indicator software can be applied to a State's discharge data to produce county-level statistics.
Table 1. Six Quality Measures for Asthma: National Average, Best-in-class Average, and Poorest Performing Average, 2003 Measure Category Measure Description Process Measures A.2 Medications (in the 71.1 past month) Planned care visits (2 or more in the past 12 months) Smoking (counseling in the past 12 months) Flu shots (in the past 12 months) Outcome Measures C.2 Urgent care visits (in the past 12 months) Emergency room visits (in the past 12 months) 28.1 0.9 19.4 2.0 35.5 1.9 19 82.2 28.3 0.9 75.3 1.8 62.1 2.8 19 National Average Best-in-class average % of People Standard Error Poorest performing average % of People Standard Error Number of States reporting

% of People

Standard Error





























Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2003

SUMMARY AND SYNTHESIS_____________________
Local leaders and health care professionals must see their own data in comparison with other provider data and with State, regional, and national benchmarks in order to appreciate the importance of their work. Assessing State quality of care for asthma begins with identifying quality measures. These fall into two main groups: process measures, which reflect the quality of care delivered, and outcome measures, which reflect patient health status. The former are needed to guide health care providers on how to change, the latter are needed to know whether the changed processes have had the intended effect. Data (whether State, county, municipal, or individual health care provider data) are essential for quality improvement programs to have an impact locally. Ideally, improvements in particular processes yield improvements in the associated outcomes. The National Healthcare Quality Report (NHQR) provides a starting point for accessing consensus-based measures. The NHQR provides estimates for asthma hospitalizations by State. In addition, BRFSS estimates are used to assess asthma care quality by State. Although consensus on a few key measures of asthma care quality has not yet evolved, this Resource Guide provides an inventory of some measures.


Data are essential to improve quality. States need performance data on asthma care to gauge their own performance against national benchmarks and to focus quality improvement efforts by identifying potential problem areas. This Resource Guide provides a list of national, State, and local sources for estimates for asthma, asthma care, and other related information. State-level baseline estimates across all conditions studied in the NHQR afford State leaders a broad view of health care quality in their State. More refined questions about areas within the State will require local data and analysis.




1 Herxheimer H. Asthma in American Indians (correspondence); NEJM 1964;270:1128-9. 2 Slocum, R Rarity of asthma among Cheyenne Indians (letter); Ann Allergy 1975;34:204. 3 Samet, J Respiratory mortality in New Mexico’s American Indians and Hispanics; AJPH 1980; 70(5):492-7. 4 en; Am J Resp Crit Care Med 1995, 1625-1627. 5 Stout, J, Asthma prevalence among American Indian and Alaska Native children; Pub Health Rep 1999; 114(3):25761. 6 7 8 9

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