Asthma Prevalence and
Management: Addressing the
Barriers to Ideal Asthma Care
National Tribal Forum
Camlesh Nirmul, MD, FAAP
Phoenix Indian Medical Center, Indian Health Service
May 2, 2013
Disclaimer: The views expressed in this lecture do not
necessarily represent the view of the Phoenix Indian
Medical Center or the Indian Health Service.
The Asthma “Challenge”
• There are a lot of people suffering from asthma
– The burden of asthma is increasing among all
populations
– Etiology of asthma is multi-factorial, with definite
disparities in the asthma prevalence between different
racial/ethnic groups
• We know how to manage it successfully
– National guidelines for the diagnosis and management
of asthma have existed for over a decade
– Newer/more effective treatment and devices
• Yet we have not eliminated the burden of asthma!
The Burden of Asthma
• Increasing prevalence (8-13%) in last decade
– Involves up to 1 in 8 children
– Rate is increased in certain groups (inner city, some
minorities)
• Adult CDC BRFSS 2009 data
– National prevalence rate (current asthma): 8.8%
– Arizona rate (current asthma): 10.8%
– Pediatric AZ rate (17yr and younger): 13.5%
• NC Asthma Program 2010: lifetime asthma
– American Indian/Alaska Native – 16%
– African-America – 15.5%
– Non-Hispanic White – 12.2%
The Burden of Asthma
• Pediatric asthma prevalence
– Disparities exist in the burden of asthma in
different subgroups but little is known about
the AI/AN community
– AI/AN data limited but some suggestion that
may be much higher than national average
• NE Montana 1999 study at Ft. Peck IHS Unit – 15.5%
children had a diagnosis of asthma
• Jemez Pueblo 1995 study in NM found rate twice
the national average - 12.3%
• Washington State 2012 data – 12 graders reported
twice the rate of general population – 17%
AI/AN Data – DHHS: Office of Minority Health
•
•
“American Indian/Alaska Native adults are 30% more likely to have asthma as nonHispanic Whites. Data on asthma conditions for American Indian/Alaska Natives is
limited. “
Percentage of asthma among persons 18 years of age and over, ever being told
they had asthma, 2010
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–
•
American Indian/Alaska Native – 12.3%
Non-Hispanic White – 12.9%
Percent of current asthma prevalence, 2010
–
–
American Indian/Alaska Native – 10.5%
Non-Hispanic White – 8%
•
Source: CDC 2012. Summary Health Statistics for U.S. Adults: 2010. Table 4
•
Percentage of adults 18 years of age and over with asthma, 2004-2008
–
–
•
American Indian/Alaska Native – 14.2%
Non-Hispanic White – 11.6%
Source: CDC 2010. Health characteristics of the American Indian or Alaska Native adult
population: United States, 2004–2008, Table 4.
The Burden of Asthma
• Increasing morbidity/mortality from asthma
– ED visits and hospitalization rates are increasing,
especially in young
• 25% of children with asthma visited ED in last year
(Washington data: AI/AN rate, same as national rate)
• 39% of pediatric asthma hospitalizations were under age 5 yrs
(2003)
• Washington study found hospitalization rate 2-3x higher in
AI/AN children under 1 year age
– Death from asthma remains rare in pediatrics
• However the death rate increased 30% in the last decade
• Fatal asthma not just in severe asthma – 1/3 have mild asthma
Effect of Asthma on Quality of Life
• Childhood asthma is leading cause of missed
school days (loss of 14 million school days)
– 52% missed school or day care at least once
• Over 60% of kids have some limitation in their
lives from asthma (sleeping through the night,
playing sports/exercising, etc)
• Over 1/3 of kids and parents avoid activities
because of the child’s asthma
• Over 1/3 of parents miss work because of their
child’s asthma
Management of asthma
• While there is no cure for asthma, asthma
can be managed successfully
• Because of advances made in
understanding the causes and management
of asthma, asthma is now treatable and
controllable
– IF providers use and follow national asthma
guidelines to treat asthma optimally
– IF patients/families adhere to this prescribed
management
Management of asthma
• Guidelines from the NIH’s National Asthma
Education and Prevention Program outline how to
achieve symptom-free days and normal quality of
life through a multi-modal approach
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–
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Pharmacotherapy
Control of the environment and elimination of triggers
Treatment of associated conditions
Education and encouraging adherance
• Do these guidelines apply to and work across
racial and ethnic lines?
Addressing the Challenge in the Native
American (NA) Community
• What is known about the burden of asthma in the
AI/AN population?
• If a disparity exists compared to national data and
other groups, how can we overcome it to achieve
optimal asthma care?
• What are the barriers that need to be addressed
to improve asthma care and eliminate any
disparity?
The Phoenix Native American
Community
• The Phoenix Area IHS oversees delivery of health care to
>140,000 AI/ANs in Arizona, Nevada and Utah
– Includes over 40 tribal groups and 10 service units, the largest of
which is the Phoenix Service Unit
• Over 62% of the AI/AN population in Arizona lives in
primarily urban areas
– The majority of the population is Navajo, with significant
percentages from the Yaqui Pima and Apache nations
– Estimated >80,000 children under age 15 in Arizona who may
receive care through the HIS
– Found over 21% of patients under age 15 with physician diagnosis
of asthma
Burden of Asthma in the Phoenix Area
• Maricopa county/Phoenix urban environment with high
levels of pollution, know trigger for asthma
– Ozone high in the valley, leads to inflammation in airways and
triggers asthma
– Particulates alerts are frequent (PM 2.5, PM 10)
• ADEQ 2008 report: Study of 5000 asthma events in 5-18yr olds in
Maricopa County found 14% increase in asthma events when PM10
increased from 25% to 75%
• PM 10 large particulates stick to airways, leading to increased mucus
in efforts to expel them
• PM 2.5 goes deep into the airways, where difficult to expel
– High construction areas – stir up mold/fungal spores in the dirt
leading to increased asthma events in those sensitive to these
molds
Barriers to successful asthma care
• Paradigm shift over last decade
– Goal was to aggressively treat symptoms of asthma
– Current goal is long-term control of asthma
•
•
•
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Focus on asthma as a chronic disease
Aggressively treat airway inflammation
Control the environment and work on prevention
Teach self-management of asthma (asthma action plan)
• Goal of controlling asthma is difficult to meet
– Definition of “control” is complex and involves
• Decreasing asthma symptoms
• Improving lung function
• Improving quality of life and maintaining normal activity
– Asthma control changes over time and needs to be
measured at every visit
Barriers to successful asthma care
• Measuring asthma control is difficult
– Measures of control correlate poorly with each other
• Symptom review, pulmonary function (spirometry), and patient
questionnaires are various measures available
• Relying on just one measure does not give a complete picture
of the patient’s asthma
– May be difficult to perform all measures at each visit
• Cost and availability may prohibit performing PFTs/spirometry
• Patient questionnaires may take time and effort to administer
• Poor adherence to guideline recommendations
– While the guidelines are widely endorsed and
disseminated, they have not been effectively
implemented and followed
– Involves providers, patients, and the health care system
Provider Adherence Factors
• Adherence to guidelines themselves
– Inertia of previous practice - change is always difficult!
– Guidelines have become more complicated
– Problem is that poor adherence leads to underdiagnosis and under-treatment of asthma
• Visit time constraints and poor reimbursement
– Creates less time and incentive for effective education
– Does not allow environment conducive to asking
questions
• Communication barriers
– Language barriers for verbal but also written education
– Lack of awareness of “medical speak” in talking with
families
Patient/Family Adherence Factors
• Poor adherence to treatment regimen
– Medication issues
• Confusion over the difference in daily controller vs rescue
medications
• Fears about side effects - “steroid phobia”
• Poor technique in using medication delivery devices leading to
less efficacy
– Environmental control is complicated, especially for
indoor allergens
• Literacy barriers
– May not understand verbal or written instructions because of
language itself as well as literacy level of instructions
Patient/Family Adherence Factors
• Cultural barriers
– May not trust medical system fully
– Beliefs/perceptions about asthma and chronic disease
• Expectation that asthma can be “cured”
• Variable disease makes it more difficult to get adherence
• Socioeconomic - limited access/resources
– Can lead to overuse of ED/urgent care and lack of
continuity
– May affect adherence to medications due to cost of
medications and access to delivery devices
– Barrier for purchasing items important in home control
of allergens/asthma triggers (covers, HEPA filters, etc.)
Barriers to successful asthma care:
Health Care System
• Limited access/resources
– Decreased ability to schedule and receive appropriate follow-up
care
• May lead to overuse of ED/urgent care and lack of continuity
• Less access to specialized tests or providers (especially allergists,
allergy testing to identify specific triggers)
– Restricted access to medications and asthma equipment
(especially spacers and peak flow meters)
• Communication/continuity of care issues
– Lack of feedback loops between all the involved players (ED primary care provider - school - pharmacy) results in fragmented
care for asthma in the system
Individual Barriers to Care in the
NA Community
• Socioeconomic
– Limited health insurance coverage is experienced by
60% of the population
– Low income, single caregivers
• Over 35% of children live in single parent households
• Over 30% live below the poverty line
– Housing options often limited and may not be able to
control environment adequately (especially to limit
indoor trigger exposure)
– Leads to limited resources and less ability to maintain
adherence with daily meds and frequent visits
Individual Barriers to Care in the
NA Community
• Environmental triggers – allergens and irritants
– Tobacco smoke (Washington study)
• Higher rates of adult smoking
– AI/AN adult smoking rate 2x general population
– 1/3 AI/AN adults with asthma smoke
• High rates of secondhand tobacco smoke exposure
– 1/7 non-smoking adults are exposed to secondhand tobacco smoke
– Indoor allergens (Washington study)
• Carpets/rugs - 95% of AI/AN houses had carpets/rugs
• Inside pets – 72% houses
– Wood burning – indoor and outdoor
• Cultural events and ceremonies
• Community events
Individual Barriers to Care in the
NA Community
• Cultural/Psychosocial
– Beliefs/perceptions about asthma and asthma
medications
– Beliefs/perceptions about chronic disease
– Lack of trust in provider/system may prevent optimal
asthma education and care
– Health care practices with overuse of acute care vs
preventive (<10% of visits are for preventive screening)
– Mobile/transient population (urban to reservation)
– Multiple households (as well as caretakers)
Individual Barriers to Care in the
NA Community
• Problems with adherence
– Lack of understanding of the chronicity of asthma
– Medications are often not taken appropriately
• Confusion over the difference in daily controller vs rescue
medications
• Reluctance to use daily meds - “steroid phobia”
• Poor technique in using medication delivery devices leading to
less efficacy
– Reliance on child when still young to be responsible for
his/her asthma
– Primary use of unscheduled/acute care visits instead of
regular follow-up
How can we meet this challenge and achieve
optimal asthma care?
• Identify the individual and specific barriers
to adherence
– Include provider, patient/family, and health
system barriers
• Address these barriers systematically
– Improve education
– Improve communication
– Attempt behavior change
Meeting the challenge: Providers
• Read and know the guidelines!
– Most providers have seen the guidelines, yet adherence is low
• How closely do you follow the guidelines?
– Do you diagnose asthma correctly?
– Do you assess both impairment and risk?
– Are you prescribing the correct medications for each classification
of asthma?
– Are you educating patients and families on the differences in
medications, use of asthma delivery devices, and selfmanagement of asthma (Asthma Action Plans, environmental
control of triggers)?
– Are you seeing patients for regular follow-up and assessing
asthma control on these visits? (And if asthma is uncontrolled, do
you adjust treatment appropriately?)
Meeting the challenge: Providers
• Tools/Teaching aides to increase awareness of and use of
guidelines
– Pocket cards, posters of step classifications, medications charts,
and sample devices - “Toolkit” in every room
– Patient encounter forms or worksheets specific for asthma
• Prompt providers to ask right questions so that reach right diagnosis
• Guide providers to use preferred treatment
• Involve other personnel to help share the asthma care
burden and overcome time constraints
– Nursing/pharmacy/RT can assist with teaching use of
devices/meds
– PHN can help with allergy/trigger avoidance, self-management
plans (asthma action plans) and adherence
– Enlist someone to be an asthma champion or train to be a
certified asthma educator
– Use school programs like ALA “Open Airways” program
Meeting the challenge:
Communication/Education
• Administer asthma questionnaires to quickly assess
control
– Asthma Control Test (A.C.T.)
– Asthma Therapy Assessment Questionnaire (ATAQ)
• Practice “active listening”
– Elicit concerns and fears of families and patients
– Create environment where questions are freely asked
• Make education more effective
– Use non-medical language
– Choose appropriate education materials
• Multilingual handouts, appropriate literacy level
• Non-written education (video, CD, web-based, etc.)
• Visual aides (posters, charts, etc.)
– Practice the “teach-back” method with patients
Meeting the challenge: Patients
• Much harder to address - often involves behavior change
but good education and communication help
• Discuss asthma as a chronic disease
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Lifelong nature, potential for severe disease (even death)
Lack of cure but existence of good treatment
Variable nature of disease, importance of frequent/regular f/up
Teach families how to recognize asthma control
• Establish an expectation for quality of life
• “Rules of 2” (Baylor)
• Address adherence to treatment recommendations
– Discuss difference between medications
• Use medication charts/pictures to ensure patients know which
medication is being talked about
• Discuss role of daily control medications
– Dispel fears about side effects (especially steroids)
– Simplify dosing regimen
Meeting the challenge: Patients
• Make asthma care relevant to each family/patient
– Look for the measure or outcome that matters most
– Identify the specific triggers/allergens that they can avoid or
control best
– Understand the disease from their perspective
• Ask what is most important to them in treating or addressing asthma
• Determine their attitude toward asthma and the disease itself
• Identify and directly address any concerns/fears
– Try to find common ground that is acceptable to the provider and
the family
– Maintain open environment to encourage ongoing
communication
• Key is to consider all these barriers and individualize
asthma care plan to each patient and family situation
Meeting the challenge: Patients
• Socioeconomic factors
– More aggressive identification of need for extra resources
• Most of NA pediatric community qualifies for state resources
– Assist with transportation and help advocate for
housing/environmental changes
• Cultural issues
– Often involves challenge of attempting behavior change in a
culturally sensitive way
– Establish trust with family/patient
• Listen to their concerns about the disease
• Offer support for traditional practices/beliefs but reinforce need
to also follow prescribed treatment plans
• Involve extended family/all caretakers
Meeting the challenge: Patients
• Environmental control/avoidance
– Indoor triggers
• Aggressively work on tobacco cessation and avoidance of
second hand smoke
• Individual plan with the family on what allergen control
measures work best for their housing and financial resouces
– Outdoor triggers
• Wood burning/smoke avoidance
– Dry wood, not wet, avoid paper burning, consider wood
pellets
• Community/school partnership
– Flag programs (Outdoor vs indoor activity days)
– Grass cutting coordination for sport fields
How can we meet this challenge and achieve
optimal asthma care?
• Identify specific barriers to adherence in your own practice
and in your patients/families
• Use quality management tools to overcome these barrierswork to achieve outcomes that matter
– Patients/Families care about quality of life, simple treatment
plans, no hospitalization or urgent visits, decreased stress and
fears about asthma and its impact on their lives, low costs
– Clinicians care about increased asthma control and quality of life,
decreased symptoms, decreased rescue medication use,
increased lung function, decreased unscheduled visits
– Health care systems care about correct drug ratios, decreased
ED/urgent care visits and hospitalizations
• Key to success: individualize plans to each patient/family
situation = PATIENT CENTERED MEDICINE
Ultimate Goals
• With the burden of asthma in the NA community,
how can we meet the challenge to achieve
optimal asthma care?
– Identify any risk factors contributing to this high
burden of asthma and target efforts to decrease them
– Attempt to eliminate any disparities in the burden of
disease
– Identify any barriers to care
– Address these barriers in a culturally sensitive way
REFERENCES
NAEPP of NIH: www.nhlbi.nih.gov/guidelines/asthma/index.htm - 2007
asthma guidelines.
2009 AZ Asthma Burden Report; AZ Dept. Health Services, November 2011
2012 Asthma Among AI/AN in Washington; Washington Dept. of Health.
MMWR: Key Clinical Activities for Quality Asthma Care, March 2003.
AZ Hospital Discharge Database - 2003 data.
“Regional Differences in Indian Health,” 5/03 publication by the DHHS (of
data from FY 2000-2001).
“Maricopa County Children with Asthma,” April 2005 Community Report by
the Health and Disability Research Group.
www.asthmainamerica.com; “Children and Asthma in AZ/NM” - subset of
the Children and Asthma in America study conducted by the Asthma
Action America campaign in 2004.
www.gappsurvey.org – Global Asthma Physician and Patient Survey, 2005.
www. cdc.gov/health/asthma.htm - links to data and surveillence; “Key
Clinical Activities for Quality Asthma Care,” March 2003. CDC 2009 BRFSS
Asthma Prevalence Data.
REFERENCES
Asthma burden statistics and barriers to care in the PIMC community
originate from a planning grant funded by the AAP CATCH program.
IRB protocol number PXR 05.02
Bukstein, Don, et al. Asthma end points and outcomes: What have we
learned?,” Journal of Allergy and Clinical Immunology, 2006, 118: S115.
Clark, Donald, et al. “Asthma in Jemez Pueblo schoolchildren,” American
Journal of Respiratory and Critical Care Medicine, 1995, 151: 16251627.
Fuhlbrigge, Al, et al. “The burden of asthma in the US,” American Journal of
Respiratory and Critical Care Medicine, 2002, 166: 1044-1049.
Hendrickson, R. et al. “High frequency of asthma in Native American
children among the Assiniboine and Sioux tribe of northeast Montana,”
IHS Provider, February 2003, 38-39.
Kurzius-Spencer, M. et al. “The presentation and treatment of asthma
among Alaska Native children in the Yukon-Kuskokwim Delta,”
preliminary paper from Dr. Anne L. Wright, Arizona Respiratory Center.
REFERENCES
Li, James T., et al. “Attaining optimal asthma control: A practice parameter,”
Journal of Allergy and Clinical Immunology, 2005 draft.
Liu, LL et al. Asthma and bronchiolitis hospitalizations among American
Indian children,” Archives of Pediatric and Adolescent Medicine, 2000,
154: 991-996.
Peterson, K. et al. “A Qualitative Study of the Importance and Etiology of
Chronic Respiratory Disease in Alaska Native Children,” Alaska Medicine,
2003, 14-20.
Rose, Diane and Ann Garwick. “Urban American Indian family caregivers’
perceptions of barriers to management of childhood asthma,” Journal of
Pediatric Nursing, 2003, 18: 2-11.
Schatz, Michael, et al. Asthma Control Test: Reliability, validity, and
responsiveness in patients nor previously followed by asthma
specialists,” Journal of Allergy and Clinical Immunology, 2006, 117: 54956.
Van Sickle, David and Anne L. Wright. “Navajo perceptions of asthma and
asthma medications: Clinical implications,” Pediatrics, 2001, 108: 1-7.
Wind, S. et al. “Health, place and childhood asthma in southwest Alaska,”
preliminary paper from Dr. Anne L. Wright, Arizona Respiratory Center.
RESOURCES
www.azasthma.org- AZ’s asthma coalition website; links to Provider,
Patient/Family, and School Toolkits; links to 2007 guidelines, STEPS
Program Quick Guidelines
www.epa.gov/asthma- Home environmental checklist, brochures, Tools
for Schools kit, home visiting program development, etc.
www.naecb.org – National asthma educator certification board website
www.aafa.org - Asthma and Allergy Foundation of America site; ACT
(Asthma Care Training); CME based Asthma Management Program for
nurses/RTs; “You can control asthma” and validated “Wee Wheezers”
education program for patients and families
www.breatherville.org - AANMA (Network of mothers of asthmatics) –
user-friendly site for patients, schools and providers
www.starbright.org - free asthma CD-ROM game for kids to learn about
triggers and asthma
www.nhlbi.nih.gov/health/prof/lung/asthma/pace/index.htm - link to
PACE program and it’s resources and online education seminar
RESOURCES
www.getasthmahelp.org – Michigan asthma program (AIM); compilation
of asthma resources (for family and providers)
www.calasthma.org/resources and www.betterasthmacare.org- excellent
CA asthma sites that compile extensive patient handouts (multiple
languages), education materials/posters, provider tools (under the
Health Professionals resources tabs), worksheets, etc.
www.oregon.gov/dhs/ph/asthma - Oregon’s asthma site with provider
tools like pocket card, patient handouts, etc.
www.ttuhsc.edu/elpaso/som/asthma- print “Multicolored Simplified
Asthma Guidelines Reminder” asthma worksheets
www.mainehealth.org/mh_body.cfm?id=364 – website of the Maine AH!
Asthma health program; go to the “clinical tools” and will find multiple
resources and performance improvement examples
www.asthmanow.net - NH asthma site, with great toolbox of office
resources (chart audit, checklists, etc.) as well as section on health
professional education (multiple powerpoints)
www.asthma-iAAP.com - Minnesota Asthma Program interactive Asthma
Action Plan (iAAP).