S

Improving Quality of Care for Asthma in High Risk

PopulationMieko Suzuki, RN, BSN

Augustina Manuzak, MD, MPH, PhD

Defining the Problem

Asthma prevalence US: 25 millions (1 in 12 of the US pop) in 2009 Worldwide: 235 millions in 2011

Disparity

High prevalence in low-and middle-income countries, low SES households. Non-Hispanic blacks

Increased medical expenses Uncontrolled asthma Increased in length of hospital stay, hospitalization, ED

visit

Asthma

Allergic(Atopic) asthma: starts at an early age, associated with family hx of allergies (eczema or rhinitis)

Non-allergic (non-atopic) asthma: often associated with viral respiratory infection

Complex Inflammatory Disease of Asthma

Airway Inflammation

Bronchial Hyper-reactivity Exaggerated bronchoconstrictive response to stimuli Allergens, environmental irritants, cold air

Airflow Limitation Obstruction

Airway Remodeling Increase airway wall thickness Increase mucus gland and muscle mass Increase size & number of blood vessels Increase collagen – scar formation Irreversible airflow obstruction

Disease characteristics

Pathogenesis

Pathophysiology of Asthma

Diagnosis

Hx

Birth, allergies, family, cigarette smoking

Home & occupational environment

Spirometry

FEV1/FVC < 70%

PEF (peak expiratory flow)

Treatment

Step-wise treatment approach (EPR-3)

• Short-acting β2 agonists (SABA)

• Inhaled corticosteroid (ICS)

• Long-acting β2 agonists (LABA) & leukotrience receptor antagonists

• Oral corticosteroids

• Self-management

Epidemiology Triangle

Akinbami, 2012

Asthma in US

Asthma in Hawaii

CDC, 2009

Asthma in Hawaii

CDC, 2009

Asthma in Hawaii

CDC, 2009

Areas for Concern

QOL & productivity• 59% of children, 33% of adults had asthma attack and

missed school or work (2008) Medical expenses• Increased from $48.6 billion in 2002 to $50.1 billion in

2007.• Asthma cost the US $3,300 per person /year Poor self-management • <50% people were taught how to avoid triggers, 50%

of those who were taught did not follow the advice• 44% of adults with asthma have had a routine check-

up in the past• 31% of adults with asthma received asthma

management plan

Primary & Secondary Prevention

Encourage breast-feeding. It protects from asthma development up to 6 yrs.

Avoidance of particular allergens during pregnancy (cow’s milk egg, nuts or cigarette smoking)

Environmental control (removal of allergens)• HDM

- Frequent washing of bed linens in hot water, vacuuming

- Use of allergen-impermeable mattress and pillow encasements

- Humidity < 45%• Pests management (rodents, cockroaches)• Pet removal

Tertiary Prevention

Environmental control

Smoke-free environment

Replacement of gas appliances for cooking (produce higher levels of nitrogen dioxide) with electric systems

Infection control

(vaccination, rhinitis)

Self-management

(monitoring, use of controller)

APRN Roles

Assessment : risk factors, SES, environment, co-morbidity (depression, obesity, rhinitis)Education•Brest-feeding•Environmental control•Medication adherence (proper use of inhaler)•Use of asthma action plan.•Vog: stay indoor during a period of heavy vog, use AC, wash the linens, drink lost of fluids, keep throat and eyes moist

ResourcesAmerican Lung Association Smoking cessation Internet-based or mobile

appsMedicaid & CHIP: flu vaccination, tabaccco cessation Medicare PartB: tobacco cessation, vaccination (flu &pneumonia)Vog helpline (current air condition)Hawaii Department of Health(environmental management division)

Guidelines for the Diagnosis and Management of Asthma

The Expert Panel Report3 (EPR-3), Summary Report 2007, provides key information from the full report on the diagnosis and management of asthma

Summary information is provided on measures of assessment and monitoring, education for a partnership in asthma care, control of environmental factors and comorbid conditions that affect asthma, and medications.

http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/summary-report-2007.htm

Conclusion & Recommendations

Education approach is important for all levels of asthma prevention to decrease asthma burden

Recognizing the risk factors, limitations, and knowing available resources are tasks of APRNs

Asthma action plan for non-English speakers or for those who have low literacy need to be developed

Use of internet/smartphone for self-management needs to be evaluated in further research.

References

Akinbami, L. J., Moorman,J. E., Bailey, C., Zahran, H.S., King, M., Johnson, C. A., & Liu, X. (2012). Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db94.pdf

Ameircan lung Association. (2014). Mobile Apps and asthma mangement. Retrieved from http://www.lung.org/associations/charters/plains-gulf/news/mobile-apps-and-asthma.html

Centers for Disease Control and Prevention. (2009). Asthma in Hawaii. Retrieved from http://www.cdc.gov/asthma/stateprofiles/Asthma_in_HI.pdf

Centers for Disease Control and Prevention. (2011). CDC vitalsigns: Asthma in the US. Retrieved from http://www.cdc.gov/vitalsigns/pdf/2011-05-vitalsigns.pdf

Centers for Disease Control and Prevention. (2012 a). Asthma action plan. Retrieved from http://www.cdc.gov/asthma/actionplan.html

Hawaii Department of Health. (2013). Hawaii asthma plan. Retrieved from http://health.hawaii.gov/asthma/files/2013/06/asthma2012.pdf

Juel, T. C., & Ulric, S. C. (2013). Obesity and asthma: Impact on severity, asthma control, and response to therapy. Respiratory Care, 58. 867-873. doi:10.4187/respcare.02202

Kaufman, G. (2011). Asthma: Pathophysiology, diagnosis and management. Nursing Standard, 26, 48-56. Retrieved from http://nursingstandard.rcnpublishing.co.uk

Silvers, M. K., Frampton, M. C., Wickens, K., Pattemore, K. P., Ingham, T., Fishwick, D…. Epton, J. M. (2012). Breastfeeding protects against current asthma up to 6 years of age. The Journal of Pediatrics,160, 991-996. doi: 10.1016/j.jpeds.2011.11.055