Transcript The Effect of Inhaled Corticosteroids on Survival in a

Asthma 2009:
Overview of Asthma Prevalence & Mortality
Karen Meyerson, MSN, RN, FNP-C, AE-C
Asthma Network of West Michigan
April 21, 2009
Prevalence of Asthma Among
Michigan Children (<18 Years), 2007
Total
9.5
NH White
8.1
NH Black
11.6
NH Other
16.8
Hispanic
10.6
Female
7.7
Male
11.3
0
2
4
6
8
10
12
Percent
14
16
18
20
MI BRFS, 2007
Prevalence of Asthma Among
Michigan Adults (18 Years), 2007
Total
9.5
NH White
8.7
NH Black
12.9
NH Other
11.1
Hispanic
14.5
11.0
Female
Male
7.9
0
2
4
6
8
Percent
10
12
14
16
MI BRFS, 2007
Prevalence of Asthma for Adults (18 Years) by Indicators
of Socioeconomic Status, Michigan, 2007
Education
20
12
8
4
0
20
< High School
High School Graduate
Some College
College Graduate
16
Percent
Percent
16
Income
<20,000
20,000-34,999
35,000-49,999
50,000-74,999
75,000+
12
8
4
10.5 11.0 9.3
8.4
0
13.3 8.6 9.9 7.1 8.9
MI BRFS, 2007
Prevalence of Asthma
Among Michigan
Adults (18 Years) by
County, 2005
MI BRFS, 2005
Percent of Children
with Persistent
Asthma by County of
Residence, Medicaid,
Michigan, 2005
1.
2.
3.
4.
Source: Data Warehouse, 2005,
MDCH
Persistent asthma and asthma
medications defined according to
NCQA HEDIS
Age-adjusted to 2000 US Std
Population
Medicaid population restricted to
children <=18 Years, continuously
enrolled (11+ Months) in Medicaid
with full coverage and no other
insurance.
Rates of Hospitalization due to Asthma by Sex, by Race
and by Age Group, Michigan, 2004-2006
Total*
16.6
65+
24.1
35 to 64
16.2
15 to 34
7.3
5 to 14
15.3
0 to 4
45.6
Black*
46.9
White*
11.3
Female*
19.3
Male*
13.4
0
10
20
30
40
Rate per 1,000,000
*Age adjusted to the 2000 US standard population.
Sources: 2004-2006 Michigan Inpatient Database & 2005 MI population estimates, MDCH
50
Rates* of Hospitalization due to Asthma by Race and
Income, Michigan, 2000-2002
Low Income
60
56.3
Middle Income
Rate per 10,000
50
40
High Income
36.1
34.7
30
20
15.3
13.6
8.4
10
19.6
11.3
8.4
0
Total
White
Black
*Uses 2000 MI population and is age adjusted to the 2000 US standard population.
Source: 2000-2002 Michigan Inpatient Database, MDCH
Asthma Hospitalization Rates* by Age-Race Group and
Year, All Ages, Michigan, 1990-2006
Rate per 10,000
100
White, Child
Black, Child
White, Adult
Black, Adult
80
60
40
20
0
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06
*Uses MI population estimates, 1990-2006 and is age adjusted to the 2000 US standard population.
Source: 1990-2006 Michigan Inpatient Database, MDCH.
Asthma Hospitalization Rates** by Race and County of
Residence, All Ages, Michigan, 2004-2006
White
*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
Black
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
Percent Reliance on Emergency Department by
Race among Children with Persistent Asthma,
Medicaid, Michigan, 2001-2005
Total
Black
White
2003
2004
50
40
30
20
10
2001
1.
2.
3.
4.
2002
Source: Data Warehouse, 2001-2005, MDCH
Persistent asthma and asthma medications defined according to NCQA HEDIS
Age-adjusted to 2000 US Std Population
Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)
in Medicaid with full coverage and no other insurance.
2005
Percent Reliance on
Emergency
Department by Race
among Children with
Persistent Asthma,
Medicaid, Michigan,
2005
1.
2.
3.
4.
Source: Data Warehouse, 2005,
MDCH
Persistent asthma and asthma
medications defined according to
NCQA HEDIS
Age-adjusted to 2000 US Std
Population
Medicaid population restricted to
children <=18 Years, continuously
enrolled (11+ Months) in Medicaid
with full coverage and no other
insurance.
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
Percent of Overuse of Short-Acting -Agonist
Medication among Children with Persistent
Asthma, Medicaid, Michigan, 2001-2005
Total
Black
White
2002
2003
2004
16
13
10
2001
1.
2.
3.
4.
Source: Data Warehouse, 2001-2005, MDCH
Persistent asthma and asthma medications defined according to NCQA HEDIS
Age-adjusted to 2000 US Std Population
Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)
in Medicaid with full coverage and no other insurance.
2005
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
Percent of Children with Persistent Asthma with 1
Inhaled Corticosteroid or Bronchodilator Combination
by Race, Medicaid, Michigan, 2001-2005
Total
Black
White
2002
2003
2004
60
50
40
2001
1.
2.
3.
4.
Source: Data Warehouse, 2001-2005, MDCH
Persistent asthma and asthma medications defined according to NCQA HEDIS
Age-adjusted to 2000 US Std Population
Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)
in Medicaid with full coverage and no other insurance.
2005
Rates of Mortality due to Asthma by Sex, by Race and by
Age Group, Michigan, 2004-2006
Total*
12.6
42.9
65+
35 to 64
12.4
6.7
15 to 34
5 to 14
5.6
Black*
28.7
White*
9.7
Female*
14.3
Male*
10.3
0
10
20
30
40
Rate per 1,000,000
*Age adjusted to the 2000 US standard population.
Data Source: Michigan Resident Death Files & 2005 MI population estimates, MDCH.
50
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%
Thirty-Two Deaths from Asthma in Michigan 2002,
Age 2 - 34
Medical History
 Tox/Alcohol Screen 
0%
 Steroids 50%
 Prior Intubation 13%
 Prior Hospitalization
48%
 Pulmonologist 40%
 PFTs 33%
 Peak Flow Meter 63%
 Used Regularly 13%
 Asthma Management
Plan 0%
 Treated in ED 80%
 BMI > 30 37%
 Allergist 38%
 Type 2 – 18%
Causal Factors Based on 18 Deaths Reviewed for
Adults (ages 19-34), Michigan 2002
Doctor
Inadequate prescription of steroids
11
Needed referral or inadequate diagnosis for high risk patients
5
Patient
Compliance
9
Inadequate use of steroids
7
Obesity
3
Lack of prior diagnosis
2
Depression
1
Allergic reaction
1
Aspirin sensitivity
1
Society
Lack of insurance
5
Health insurance would not pay for referral
1
Job/heat
1
Suggested Intervention Based on 18 Deaths Reviewed
for Adults (ages 19-34), Michigan 2002
Educate Health Care Providers
Steroids
Referrals
Pulmonary function tests
8
3
2
Educate Patients
Steroids
Provide education in ED
Aspirin
6
3
1
Society
Case manager
5
Insurance
5
Public awareness
2
Regulation insurance companies on referrals
Labeling aspirin products
1
Medical Examiners
Criteria for asthma deaths
4
Issues Not Found
to be Important
Previously Reported
in Literature
 Substance
abuse
 Psychological
problems
 Lack of peak
flow meter
Issues Consistent
with Factors
Previously Reported in
Literature
 African American
 Low income
 Lack of steroids
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
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
Summary
 Asthma deaths – relatively rare
 Death occurring prior to hospitalization
 Generally preventable
 MORE INHALED STEROIDS
Questions?
Karen Meyerson, MSN, RN, FNP-C, AE-C
 Phone:
 E-mail:
616-685-1432
[email protected]
 Websites:
www.asthmanetworkwm.org
www.GetAsthmaHelp.org
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
1997…
2002…
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)
…2007
August 29, 2007
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
EPR-3, p38-80, 277-345
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
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.
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
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
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
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
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