1. Improving care, quality and outcomes. The Asthma APGAR Project Olmsted Medical Center Rochester, MN Chatfield, MN Pine Island, MN

2. Assumption: QualityOutcomes Patient-Centered Focus

3. Objectives: Relate care and outcomes Identify quality related outcomes Suggest quality indicators Suggest process to assess indicators Develop 5 easy questions Review cases

4. Quality should focus on: Outcomes that matter to patients Outcomes that matter to families Outcomes that matter to clinicians Outcomes that matter to quality monitors In that order

5. Work Absenteeism Presenteeism Promotion Outcomes that matter:

6. Play Focus on Fun Person centered Not disease centered Outcomes that matter:

7. Sleep Enough Not interrupted Outcomes that matter:

8. $,$,$ Not consumed by asthma Outcomes that matter:

9. Outcomes that matter to patients:

10. Appropriate diagnosis and management Less Morbidity, Better Quality of Life: Fewer ED visits –Follow-up after ED Fewer school/work absences –Medication appropriate to severity No hospitalizations –Immediate care More symptom free days

11. Outcomes that matter to families:

12. More normal lifestyle: Simple treatment plans –?? Long acting medications –Step down therapy Fewer urgent visits –Schedule regular visits –Have a plan for regular visits

13. More normal lifestyle (cont): No hospitalizations Less stress and less obsession with asthma –Knowing what to do to help More asthma-free days Education

14. Outcomes that matter to the practice:

15. Practice outcomes: Fewer unscheduled visits Fewer phone calls Shorter phone calls Better self management Written plans or any plans

16. Outcomes that matter to quality monitors:

17. Meeting Quotas: Correct drug ratios Appropriate use of medications Fewer ED and urgent care visits Fewer hospitalizations Patient satisfaction HEDIS JCAOH AMA

18. First priority is to meet patient and family needs Understand disease from their perspective Affirm their concerns Negotiate a common ground Provide environment for communication and education Control symptoms Patient Centered Focus

19. Make sure it is asthma: Correct diagnosis and uniform terminology RAD, chronic bronchitis, wheezy bronchitis Symptoms PFT Allergies

20. Assess Severity: Severity Baseline Attacks Frequency Intensity

21. Asthma Severity

22. Do they need steroids? Classify severity Baseline or treated

23. NHLBI EPR – 2 Severity Classification

24. Classify severity: Simplify to 5 easy questions: How many days of the week do you have symptoms? All day or most of the day? How many nights a week (month) do you have symptoms? Do you have long periods of no symptoms? FEV 1

25. Translating symptoms to severity Intermittent -- long periods with no symptoms

26. Translating symptoms to severity Persistent -- no long periods without symptoms –Mild --- symptoms only once or twice a week, short duration and not intense, rarely at night –Moderate --- symptoms almost daily + 1 or 2 nights a week, hours to days and varying intensity –Severe --- symptoms daily and nightly, almost continuous and varying intensity

27. Classify severity: Need to ask about: –Symptoms for 2 to 4 weeks not just 2 to 4 days –Go beyond the attack –Be specific Cough SOB, DOE Awakening

28. Assessing symptoms: Dont ask --- Dont tell --- Dont Document Has never worked for anything!!!!!

29. The severity score addresses the baseline symptom assessment: Does not address the exacerbations or attacks

30. Add attacks: 60-80% of children who die of asthma have mild asthma. Frequency Intensity

31. When to use Spirometry Initial assessment – diagnosis After symptoms and peak flow stabilize Every 1 to 2 years –Polgar children –Crapp adults

32. Components of Spirometry What do they mean? FVC – forced vital capacity <75% obstruction FEV 1 – forced expir vol, 1 second <75% obstruction FEV 1 /FVC - <.7 obstruction FEF 25-75 - forced expiratory flow <65% obstruction

33. Peak Flow as Diagnostic Tool Less accurate than diagnostic instruments Cannot be calibrated or checked to assure their performance No graphical display to evaluate effort, quality Current PEF standards of + 10 percent allow models of instruments to vary by up to 20 percent

34. Who needs steroids? 1. Do they have asthma? 45 years Symptoms PFTs/ Spirometry-low reversible Other causes

35. Who needs steroids? 2. Do they have daily symptoms? (>2 x / week) or nightly symptoms (>2 x / month)

36. Who needs steroids? 3. Do they have PFT with FEV 1 <75% predicted?

37. Who needs steroids? 4. Can you remove the trigger(s)? Allergens Irritants

38. Who needs steroids? 5. Do they have life threatening exacerbations?

39. Triggers/Allergies Doesnt have to be overwhelming Few people have more than 2 or 3 major triggers Triggers may change (additive effects) Unlikely to gain control without knowing triggers

40. Allergies: Symptoms –Running or stuffy nose –Itchy nose or eyes –Eczema –Sneezing

41. Allergies: Family history Known triggers Seasonal vs. persistent Related to location

43. Irritants: Almost everyone with asthma reacts to some irritant. –Smoke –Fragrance –URI –Formaldehyde

44. Case #1: John, 25 year-old computer programmer Mid-August-yearly Stuffy, runny nose Itchy eyes, nose, throat Regular jogger 3 x /week Shortness of breath and coughing with jogging June & August Night-time awakening OTC meds only

45. Exam: Nasal voice Swollen, boggy mucosa No polyps Lungs clear

46. Question A: Based on the history so far, the most likely diagnosis is: Card Summer cold with bronchitis#1 Seasonal allergic rhinitis (hay fever) #2 Seasonal allergic rhinitis with post-nasal-drip induced cough #3 Seasonal allergic rhinitis with seasonal asthma #4

47. Answer: Seasonal allergy and asthma #4

48. Question B: How would you rate asthma severity? –Mild intermittent #1 –Mild persistent #2 –Moderate persistent #3 –Severe persistent #4

49. Answer: Mild persistent #2 –Daily symptoms > 2 x / week –Nightly symptoms > 2 x / month –? PFTs

50. Question C: What is your next test? Total IgE #1 Spirometry #2 Skin test #3 CT of sinuses #4

51. Answer: Spirometry #2 FVC 4.3 L 110% FEV 1 3.4 L 100% FVC/FEV 1.79 86%

52. Question D: Does this man need steroids? No #1 Inhaled low dose #2 Inhalded moderate dose #3 Oral burst #4

53. Treatment: Asthma – mild persistent –Inhaled steroids – low dose #2 –Pre-med for exercise Allergies –Antihistamine Re-check 2 weeks

54. Case 2: 16 year old girl – feels fine Asthma diagnosed age 8 Trouble in 1 st hour class-sleepy Stays up late talking on phone Awakened by coughing Meds - prn

55. Question A: What are her asthma symptoms? –None #1 –Fatigue #2 –Coughing #3 –School problems #4

56. Answer: At least coughing #3 Probably fatigue #2 Probably school problems #4

57. Exam: HEENT-neg Lungs-difuse wheezes FEV 1 –72% Slender Otherwise normal

58. Question B: What is asthma severity level? –Mild intermittent #1 –Mild persistent #2 –Moderate Persistent #3 –Severe Persistent #4

59. Answer: At least moderate #3 and probably severe persistent. #4

60. Question C: Does this girl need steroids? –No #1 –Inhaled low dose #2 –Inhaled moderate/high dose #3 –Oral #4

61. Treatment: Inhaled moderate/high dose steroids #3 Long-acting ß agonist Rescuer ? More See back 2 weeks Consider spirometry

62. Treatment: Inhaler technique Written action plan Education –Goal setting (collaborative)

63. Case 3: 8 year old boy Coughing and wheezing 4 days this week Increased symptoms with cat Increased symptoms with running Mother wont let him play soccer ß agonist BID x 2 years

64. Question A: Asthma severity? –Mild intermittent #1 –Mild persistent #2 –Moderate persistent #3 –Severe persistent #4

65. Answer: At least mild persistent #2 –>2 x / week –No soccer

66. Can you remove triggers? Cat - ? Exercise - ?

67. Question B: What is the next test? –Spirometry #1 –Cat RAST #2 –Exercise challenge #3 –Methacholine challenge #4

68. Answer: Spirometry #1 FEV 1 70% After ß agonist FEV 1 90% >15% improvement

69. Question C: Does he need steroids? No #1 Inhaled low dose #2 Inhaled moderate dose #3 Oral burst #4

70. Answer: Inhaled moderate dose #3 Pre-treat exercise – next week Inhaler technique Action plan Return 2 weeks ? Peak flow meter

71. Diagnosis: Recurrent symptoms PFT Consistent terminology % of 493 that are RAD or wheezy bronchitis in children and adults > 3 years old

72. Classify severity: Symptoms, Symptoms, Symptoms Spirometry % with daytime symptoms documented % with nighttime symptoms documented

73. Self-management skills: Education Monitoring medication use % of persistent asthmatic with education % of asthmatic with inhaler technique documented

74. Triggers: When and what % of charts with triggers or allergies mentioned or evaluated

75. Follow-up: Regular care Post ED Post hospitalization % of patients with non-urgent visit in a year % of patients with f/u visit after ED % of patients with f/u visit after hospitalization

76. Referral: Not all but when appropriate Must communicate % of patients with f/u letter after referral

77. Quality indicators: % of 493 that are RAD or wheezy bronchitis in children and adults > 3 years old? % with daytime symptoms documented? % with nighttime symptoms documented? % of charts with triggers or allergies mentioned or evaluated?

78. Quality indicators: % of patients with non-urgent visit in a year? % of patients with f/u visit after ED? % of patients with f/u visit after hospitalization? % of patients with f/u letter after referral?

79. POOM If zones are red and patients are blue you need to take better care of asthma, too!

80. Case 1 A 15 y.o. female comes in for a sports physical. Complains of chest tightness during cheerleading practice, which she does every day after school. Uses Albuterol MDI (refills about once a month). Reports hay- fever every May and June, uses Allegra during these months only. Spirometry: FVC: 102% predicted FEV 1: 89% predicted (6% increase after Albuterol) FEF 25-75% : 78% predicted PEFR: 93% predicted What is your assessment of her asthma severity, and your proposed treatment plan? Is there any other information that would be helpful to your management decision- making?

81. Case 2 A 6 y.o. girl in for a well child check. Occasional night cough (keeps younger sister up –same bedroom). She has no history/diagnosis of asthma, but hospitalized once for bronchiolitis at 11 months old, and seen in ED once for RAD at about 2 years old. Spirometry: FVC:96% predicted FEV 1 : 75% predicted (15% increase after Albuterol) FEF 25-75% :52% predicted PEFR:92% predicted Does she have asthma? If so, what is your assessment of her asthma severity, and your proposed treatment plan? Is there any other information that would be helpful to your management decision-making?

82. Case 3 A 17 y.o. male in for planned asthma visit. Your patient for 2 years, since he moved to your city from Hawaii. Diagnosed with asthma as an infant there. Says he feels fine today. Uses Albuterol several times a day, typically on way to school bus and before Phys. Ed. Usual medications -Advair 250/50 1 puff b.i.d.-Singulair 10 mg q.h.s. -Rhinocort 2 puffs b.i.d.-Albuterol p.r.n. Reports good adherence; you believe him Spirometry: FVC:93% predicted FEV 1 :64% predicted (10% increase after Albuterol) FEF 25-75% :38% predicted PEFR:82% predicted What is your assessment of his asthma severity, and your proposed treatment plan? Is there any other information that would be helpful to your management decision making?

83. Case 4 A 56 y. o. woman presents to your office with dry cough, dyspnea on exertion. She says that she had had episodes of bronchitis with yellow sputum production in the spring and in the fall, for as long as she can remember. She takes an antibiotic and the symptoms go away in a month, or so. Spirometry: FVC: 65% predicted FEV 1 : 62% predicted (24% improvement after Albuterol) FEF 25-75% :40% predicted PEFR: 60% predicted Does she have asthma? How would you treat her?

84. Case 5 A 56 y.o. man presents to your office with chronic cough, productive of usually clear sputum. He has dyspnea on mild exertion, e.g. walking up on flight of stairs. He has a 65 pack year smoking history, but quit 2 years ago. He has chronic sinus drainage that exacerbates in the late summer and early fall. Spirometry: FVC: 55% predicted FEV 1 : 52% predicted (24% improvement after Albuterol) FEF 25-75% :37% predicted PEFR: 50% predicted Does he have asthma? How would you treat him?