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CareAsthma: A partnership in achieving excellence in asthma care
CareAsthma Program
The prevalence of asthma among Oregon children is 7.2%% (2004 BRFSS) and 9.8% among adults (2006 BRFSS). This contrasts to national rates of 8.3% for children and 8.2% among adults for the same reporting periods.
As with many chronic conditions, prevalence rates for asthma are higher among Oregon Health Plan (OHP)/Medicaid enrollees than in the general population. In Oregon, the estimated prevalence of asthma in the OHP population ranged from 18.1% in 2004 to 20.7% in 2005.
CareOregon is committed to developing and promoting a healthcare partnership with our clinician network and our members through innovative programs and outreach.
Program Goals
- Increase the proportion of members, ages 5-56 years, who use appropriate asthma medications as defined by Healthcare Effectiveness Data Information Set (HEDIS®)
- Increase the proportion of members, ages 4-55 years, with persistent asthma who have a medication ratio greater than or equal to 0.5 as defined by the Oregon Department of Human Services
- Increase the proportion of members, ages 4-55 years, with persistent asthma who have a medication ratio greater than or equal to 0.33 as defined by the Oregon Department of Human Services
- Reduce ED visits, hospital admission and hospital days for members with asthma
- Increase the proportion of members with an ED visit or inpatient stay with a primary discharge of asthma who receives a follow-up outpatient visit within 30 days of discharge
- Increase the percentage of CareOregon clinicians who are aware of and employ a stepwise approach to pharmacologic therapy in the treatment of their asthma patients and adhere to the monitor and follow-up schedules recommended by the National Asthma Education & Prevention Program: Expert Panel Report #3 (2007)
Summary of Interventions
- Asthma Management Report – clinician key
- AIR: Asthma In ContRol
- Telephonic outreach to high-risk asthma members
- Sponsorship of asthma education classes
National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 (EPR-3) 2007: Guidelines for the Diagnosis and Management of Asthma
- The NAEPP, coordinated by the NHLBI, issued the EPR-3 in August 2007. The EPR-3 is the first comprehensive, evidence-based update to the guidelines since 1997.
- The guidelines emphasize the importance of assessing asthma control and individualizing treatment based on this assessment.
Recommendations for the four components of asthma care are below:
- assessment and monitoring
- patient education
- control environmental factors and other conditions that can worsen asthma
- medications
For the full report and summary report click here.
Assessment and Monitoring
Spirometry is the gold standard for diagnosing and monitoring asthma. The term mild intermittent is no longer valid. A patient has either intermittent asthma or persistent asthma in various degrees (from mild to severe).
Classifying Asthma Severity and initiating Treatment according to age:
Children 0-4 Years of Age
Children 5-11 Years of Age
Youths ≥12 Years of Age and Adults
Emphasizes distinction among asthma severity and asthma control.
- Severity = the intrinsic intensity of the disease process. Use to initiate therapy in newly diagnosed patients.
- Control = the degree to which asthma manifestations are minimized by therapeutic interventions and treatment goals are met. Use to adjust therapy.
The goals of therapy are to reduce impairment and risk. Impairment and risk may not correlate with each other and may respond differently to therapy.
- Impairment = frequency and intensity of symptoms and functional limitations currently or recently experienced.
- Risk = the likelihood of asthma exacerbation, decline in lung growth (children) or function, or risk of adverse effects.
- Impairment and risk may not correlate with each other and may respond differently to therapy.
While asthma can be controlled, the condition often changes over time and differs among individuals and age groups. Regular follow-up at one- to six-month intervals, depending on the level of control, is recommended to ensure control is maintained and therapy is appropriately adjusted (e.g. stepped up or stepped down).
Assessing Asthma Control and Adjusting Therapy Summary Chart:
Children 0-4 Years of Age
Children 5-11 Years of Age
Youths ≥ 12 Years of Age and Adults
Routine use of validated quality-of-life questionnaires is recommended to assess control and current level of impairment. The Asthma Control Test (ACT; www.asthmacontrol.com) is quick, easy to use and clinically validated for children and adults. A patient or parent can fill it out before seeing the clinician.
Patient Education
- Encourage the development of joint treatment goals.
- Education should occur at all points of care: clinics, EDs and hospitals, pharmacies, schools and other community settings, and patients’ homes.
- Reinforces the importance of teaching patients skills to self-monitor and manage asthma, including the use of a written asthma action plan.
- Patients should understand 1) the disease process, 2) daily treatment, 3) differences between medications, 4) inhaler technique and 5) how to recognize and handle worsening asthma.
- Patient education tools including written asthma action plans are available in the Oregon Asthma Resource Bank.
Control of Environmental Factors and Other Conditions
- Emphasis on limiting exposure to allergens and other substances that can worsen asthma.
- Single interventions are often ineffective. Environmental control must be continuously evaluated and reinforced.
- More information on common conditions that can exacerbate asthma symptoms such as rhinitis, sinusitis, GERD, obesity, obstructive sleep apnea, stress and depression.
Medications
- Medication types and doses are stepped up as needed and stepped down when possible according to patient’s control level.
- Recommendations reflect current evidence on effectiveness and safety.
- Patients with persistent asthma need both long-term control medications to control asthma and prevent exacerbations, and quick-relief medications for symptoms as needed.
- Inhaled corticosteroids (ICS) are the most effective long-term control medication for all age groups.
- Evidence review on long-acting beta agonists (LABA) and LABA-ICS combination products
- A frequent need for short-acting beta agonists (SABAs) shows inadequate control of asthma. Patients using one SABA canister every one to two months increase their risk of acute exacerbations.
Click here for the Stepwise Approach for Managing Asthma in
Managing Exacerbations
- Early treatment at home is the best strategy.
- Consider the four domains: assessment and monitoring, patient education, environmental control and medications.
- A written asthma action plan should include:
- Early signs of worsening asthma with symptoms and PEF values
- Environmental controls (remove allergens and irritants)
- Guidance on medication adjustments such as increasing SABAs and/or adding a short course of oral steroids
- Increasing inhaled steroids is ineffective.
- MDI plus a valve-holding chamber and appropriate technique is as effective as nebulizer therapy in mild-moderate exacerbations.
- Monitoring response to medication adjustments
- A plan for prompt communication between patient and provider about deterioration, decreased responsiveness to SABAs and when to seek urgent or emergency care.
Click here for Management of Asthma Exacerbations: Home Treatment.
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