3Opening Remarks We will cover: Definition of Asthma & COPD Evidence based guidelines for diagnosis, evaluation, and management of asthmaEvidence based guidelines for diagnosis, evaluation, and management of adult with COPDCodingBC/BS services available to assist your practices
4What is Asthma? Obstructive lung disease with characteristics of: Airway obstruction; reversible in most patientsChronic airway inflammation (eosinophils)Increased airway responsivenessOnset of symptoms can occur at any age
5Asthma 34 million people in the U.S. currently diagnosed with asthma 7.1 million children are diagnosed with asthma1.3 million visits to hospital outpatient departments with asthma as a primary diagnosisAsthma costs exceed $30 billion/yearAsthma in the U.S. is growing every yearU.S Department of Health and Human Resources Center for CDC: 12/2012
6What is COPD? A common, preventable, and treatable disease: Characterized by persistent airflow limitationUsually progressiveAssociated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.Exacerbations and comorbidities contribute to the overall severity in individual patients.
7COPD 16 million U.S. adults have been diagnosed with COPD 15 million or more U.S. adults have COPD that have not been diagnosed4th leading cause of death in the U.S.Annual direct & indirect COPD Medical Costs $42.6 billionU.S Department of Health and Human Resources Center for CDC: 2007
9Asthma vs. COPDSpirometry is required pre- and post- bronchodilator to help differentiate between Asthma and COPDAsthma = ReversibilityCOPD = No/partial reversibilityChest Xray – to order or not?Vaccinate for flu and pneumonia
10Case Study45 year old female presents to the office with complaints of shortness of breath and wheezing. She has a history of asthma.
11History – Questions to ask Symptoms (wheezing, dyspnea, cough)Timing and FrequencyTriggersWork environment: dust, fumes, chemicalsHome environment: heating, mold, pets, dust, roaches, cigarette/cigar smokeExerciseUpper Respiratory InfectionsMedications – inhalers, steroids and other medicationsSmoking historyFamily history
12Findings Smoker – 1 ppd X 10 years, quit age 30 SOB and wheezing – dailyUses albuterol inhaler 1x per dayWakes at least 1 night per week with a coughBecomes SOB with exerciseWorks at Chevy plant Monday – Friday2 courses of oral systemic corticosteroids last 6 months
21Next Steps Education: Review Medications Review inhaler technique + compliance at each visitReducing exposure to triggersReview asthma action plan each follow-up visitSmoking cessation assistanceVaccinate for flu and pneumonia
23Follow-up: 2-6 weeks after initial visit ACT test – patient completesAssess level of symptom control with current medication regimeMedication compliance and techniqueStep up or step down, according to signs and symptomsPatient educationReferral to pulmonologist or allergist, if neededReview and update Asthma action planEncourage compliancePatient case study- s/s are better- symptoms less than 2 x week, has not woken up at night, no shortness of breath w activity, used short acting beta 1 x w in 3 weeks; spirometry performed and results show FEV1 is > 80% of the predicted. Review meds- no change at this time. Smoking cessation discussed- Member states she has called quit line.
25Case study follow-up ACT test – review SOB 1X in 3 weeks No nighttime awakeningNo SOB while exercisingUse albuterol inhaler 1X in 3 weeksRepeat spirometry showed FEV1 > 80% predictedNext follow up appointment in 1-6 monthsWell controlledConsider step down if well controlled for at least 3 months
27Case Study45 year old female presents to the office with complaints of shortness of breath and wheezing.
28History – Questions to ask Symptoms (SOB, cough, wheezing, phlegm production, color, amount)Timing and FrequencySmoking historyMedications – inhalers, steroids, other medicationsFamily history
29Findings Smoker 2ppd since age 20 Dyspnea and wheezing Uses albuterol inhaler 1x per dayExperiences cough and some dyspnea with exerciseProductive cough with white sputumWorks at Chevy plant Monday – FridayHas been treated with 2 courses of Prednisone in the past 6 months
30Spirometry MUST be performed! Is this COPD?Spirometry MUST be performed!Within 180 days from initial diagnosisPulse oximetry – to do or not?Chest Xray – to do or not?Discuss if needs Chest Xray
34Medications for Asthma & COPD Pharmacy FormularyType ofMedicationCommercial/Child Health Plus/Healthy New YorkMedicaid/Family Health PlusMedicareSABAProAir HFAProventil HFAVentolin HFAXopenex HFALABAForadil, Serevent DiskusSerevent DiskusArcapta, Foradil, Perforomist, Severent DiskusICSAsmanex, Flovent Diskus/HFA, Pulmicort, QVARAlvesco, Flovent Diskus HFA, Pulmicort Flexhaler, QVARAlvesco, Asmanex, Flovent Diskus/HFA, QVARLABA/ICS combosAdvair, SymbicortAdvair, Dulera, SymbicortAnticholinergicsSpiriva, AtroventMiscellaneousCombivent, montelukast, zafirlukastCombivent, Daliresp, montelukast, zafirlukast* Included medications are tier 1 (generics) and tier 2 (brands) for commercial/HNY/CHP.*Included medications are covered for Medicaid on generic or brand tier.*Included medications are tier 2 (non-preferred generic) and tier 3 (preferred brand) for Medicare
35Next Steps Review medications Review inhaler technique & compliance at each visitReview care plan each follow up visitSmoking cessation assistanceVaccinate for flu and pneumonia
36Follow upFollow up Q 6 months or sooner if hospitalized or in ED for COPDReview symptoms at each visitReview MedicationsSpirometry every yearReview HEDIS measures related to ED or In Pt stay / medications -
44How we can help youOne on one health coaching with a registered nurse available to assist our BCBS membersEducate about disease processMedication managementAddress gaps in careCoordinate servicesReinforce treatment plan
45How we can help youWe also have a team of social workers, dieticians and outreach workersCommunity classes:Smoking cessationNutritionWeight managementExercise programsStress management