1. Asthma 2009: Overview of Asthma Prevalence & Mortality Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma Network of West Michigan April 21, 2009

2. Prevalence of Asthma Among Michigan Children (<18 Years), 2007 MI BRFS, 2007

3. Prevalence of Asthma Among Michigan Adults (  18 Years), 2007 MI BRFS, 2007

4. Prevalence of Asthma for Adults (  18 Years) by Indicators of Socioeconomic Status, Michigan, 2007 MI BRFS, 2007 EducationIncome

5. Prevalence of Asthma Among Michigan Adults (  18 Years) by County, 2005 MI BRFS, 2005

6. Percent of Children with Persistent Asthma by County of Residence, Medicaid, Michigan, 2005 1.Source: Data Warehouse, 2005, MDCH 2.Persistent asthma and asthma medications defined according to NCQA HEDIS 3.Age-adjusted to 2000 US Std Population 4.Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

7. Rates of Hospitalization due to Asthma by Sex, by Race and by Age Group, Michigan, 2004-2006 *Age adjusted to the 2000 US standard population. Sources: 2004-2006 Michigan Inpatient Database & 2005 MI population estimates, MDCH

8. Rates* of Hospitalization due to Asthma by Race and Income, Michigan, 2000-2002 *Uses 2000 MI population and is age adjusted to the 2000 US standard population. Source: 2000-2002 Michigan Inpatient Database, MDCH Rate per 10,000

9. Asthma Hospitalization Rates * by Age-Race Group and Year, All Ages, Michigan, 1990-2006 *Uses MI population estimates, 1990-2006 and is age adjusted to the 2000 US standard population. Source: 1990-2006 Michigan Inpatient Database, MDCH. Rate per 10,000

10. *Insufficient data to compute a stable rate,  20 Events or < 5000 Population **Uses 2005 MI population estimates and is age adjusted to the 2000 US standard population. Source: 2004-2006 Michigan Inpatient Database, MDCH WhiteBlack Asthma Hospitalization Rates ** by Race and County of Residence, All Ages, Michigan, 2004-2006

11. Emergency Department Reliance Methodological Notes:  All asthma outpatient visits (office, urgent care, and Emergency Department), ICD-CM-9 493.xx  Among these, the percent of asthma visits that occurred in the emergency department Interpretation of the Indicator  X% of outpatient asthma visits that occurred in the emergency department for children in Medicaid with persistent asthma

12. Percent Reliance on Emergency Department by Race among Children with Persistent Asthma, Medicaid, Michigan, 2001-2005 1.Source: Data Warehouse, 2001-2005, MDCH 2.Persistent asthma and asthma medications defined according to NCQA HEDIS 3.Age-adjusted to 2000 US Std Population 4.Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

13. Percent Reliance on Emergency Department by Race among Children with Persistent Asthma, Medicaid, Michigan, 2005 1.Source: Data Warehouse, 2005, MDCH 2.Persistent asthma and asthma medications defined according to NCQA HEDIS 3.Age-adjusted to 2000 US Std Population 4.Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

14. Proportion with Overuse of SABA Medication Methodological Notes:  SABA medications defined by NCQA HEDIS list of asthma medications  Overuse defined as >6 filled prescriptions of SABA filled in 12 months Interpretation of the Indicator  X% of children in Medicaid with persistent asthma filled >6 prescriptions for SABA medication

15. Percent of Overuse of Short-Acting  -Agonist Medication among Children with Persistent Asthma, Medicaid, Michigan, 2001-2005 1.Source: Data Warehouse, 2001-2005, MDCH 2.Persistent asthma and asthma medications defined according to NCQA HEDIS 3.Age-adjusted to 2000 US Std Population 4.Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

16. Proportion taking Inhaled Corticosteroid Medication Methodological Notes:  Inhaled corticosteroid (ICS) medications defined by NCQA HEDIS list of asthma medications  ICS use defined as  1 filled prescriptions of ICS filled in 12 months  ICS includes bronchodilator combination therapy Interpretation of the Indicator  X% of children in Medicaid with persistent asthma filled  1 prescriptions for ICS medication

17. Percent of Children with Persistent Asthma with  1 Inhaled Corticosteroid or Bronchodilator Combination by Race, Medicaid, Michigan, 2001-2005 1.Source: Data Warehouse, 2001-2005, MDCH 2.Persistent asthma and asthma medications defined according to NCQA HEDIS 3.Age-adjusted to 2000 US Std Population 4.Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months) in Medicaid with full coverage and no other insurance.

18. Rates of Mortality due to Asthma by Sex, by Race and by Age Group, Michigan, 2004-2006 *Age adjusted to the 2000 US standard population. Data Source: Michigan Resident Death Files & 2005 MI population estimates, MDCH.

19. Thirty-Two Deaths from Asthma in Michigan 2002, Age 2 - 34 Demographics Age <19 38% Male 59% African-American 56% High School Graduate 70% Wayne County 44% Pronounced Dead Prior to Hospitalization 84% Medical Insurance 78%

20. Thirty-Two Deaths from Asthma in Michigan 2002, Age 2 - 34 Tox/Alcohol Screen  0% Steroids 50% Prior Intubation 13% Prior Hospitalization 48% Treated in ED 80% Allergist 38% Pulmonologist 40% PFTs 33% Peak Flow Meter 63% Used Regularly 13% Asthma Management Plan 0% BMI > 30 37% Type 2 – 18% Medical History

21. Causal Factors Based on 18 Deaths Reviewed for Adults (ages 19-34), Michigan 2002 Doctor Inadequate prescription of steroids11 Needed referral or inadequate diagnosis for high risk patients5 Patient Compliance9 Inadequate use of steroids7 Obesity3 Lack of prior diagnosis2 Depression1 Allergic reaction1 Aspirin sensitivity1 Society Lack of insurance5 Health insurance would not pay for referral1 Job/heat1

22. Suggested Intervention Based on 18 Deaths Reviewed for Adults (ages 19-34), Michigan 2002 Educate Health Care Providers Steroids8 Referrals3 Pulmonary function tests2 Educate Patients Steroids6 Provide education in ED3 Aspirin1 Society Case manager5 Insurance5 Public awareness2 Regulation insurance companies on referrals Labeling aspirin products1 Medical Examiners Criteria for asthma deaths4

23. Issues Not Found to be Important Previously Reported in Literature Issues Consistent with Factors Previously Reported in Literature Substance abuse Psychological problems Lack of peak flow meter African American Low income Lack of steroids

24. Summary of Risk Factors for Fatal and Near-Fatal Asthma from Medical Literature Risk Factors Reported with Fatal Asthma Risk Factors Reported With Near-Fatal Asthma Lack of steroid inhalers Diagnosis of asthma < 5 years African-American Stress Low income Hx intubation Lack of peak flow meter Hx previous hospital admission Blunted perception of dyspnea Hx allergy and atopy > 90% on steroids Blunted perception of dyspnea Symptoms of wakening at night Air conditioning at home

25. Risk Factors for Death from Asthma – EPR-3 Asthma History  Previous Severe Exacerbation (i.e., intubation or ICU admission)  2 or more hospitalizations within the past year  3 or more ED visits in the past year  Hospitalization or ED visit in the last month  Using > 2 canisters of SABA in the last month  Poor perception of symptoms or severity of exacerbation  Lack of a written asthma action plan  Sensitivity to Alternaria

26. Summary Asthma deaths – relatively rare Death occurring prior to hospitalization Generally preventable MORE INHALED STEROIDS

27. Questions? Karen Meyerson, MSN, RN, FNP-C, AE-C  Phone:616-685-1432  E-mail:meyersok@trinity-health.orgmeyersok@trinity-health.org  Websites: www.asthmanetworkwm.org www.GetAsthmaHelp.org

28. Asthma 2009: Asthma Guidelines and Goals of Therapy Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma Network of West Michigan April 21, 2009 Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA Allan T. Luskin, MD, Madison, WI

29. 1997…

30. 2002…

31. Guidelines For The Diagnosis and Management of Asthma (EPR-3) Expert Panel Report 3 National Heart, Lung and Blood Institute (NHLBI) National Asthma Education and Prevention Program (NAEPP) August 29, 2007 …2007

32. Asthma Assessment and Monitoring: Key Differences from 1997 and 2002 Key elements of assessment and monitoring  Severity  Control  Responsiveness to treatment Severity emphasized for initiating therapy Control emphasized for monitoring and adjusting therapy Severity and control defined by 2 domains:  Impairment  Risk

33. Severity & Control are assessed based on 2 domains: Impairment (present)  frequency and intensity of symptoms  functional limitations (quality of life) Risk (future)  asthma exacerbations (utilization)  progressive loss of pulmonary function (lung growth)  risk of adverse reaction from medication NAEPP Draft Report, ERP 2007 EPR-3, p38-80, 277-345

34. Domain: Impairment What the patient tells US in terms of frequency and intensity of symptoms. This is the disruption of their ability to function or current limitations in their lives due to asthma. Impairment is the burden of illness.

35. Goals of Asthma Therapy Reducing Impairment Prevent chronic and troublesome symptoms Require infrequent (<2x/week) use of rescue therapy Maintain (near) normal lung function Maintain normal activity levels Meet patients’ and families’ expectation of and satisfaction with asthma care

36. Domain: Risk What we tell PATIENTS This is the likelihood of asthma exacerbations, progressive decline in lung function or risk of adverse effects from medications - examples:  LABA may decrease impairment but may increase risk  ICS may decrease impairment but also decrease risk

37. Goals of Asthma Therapy Reducing Risk Reduce recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations Prevent progressive loss of lung function; for children, prevent reduction of lung growth Provide pharmacotherapy with minimal or no adverse effects

38. Asthma: Establishing and Maintaining Control Periodic Assessment and Monitoring Monitor signs and symptoms of asthma Monitor pulmonary function  Spirometry  Peak Flow Monitoring Monitoring quality of life Monitoring history of asthma exacerbations Monitoring pharmacotherapy for adherence and side effects

39. Questions?  Download the Guidelines at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf  Download the Summary Report at: http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf