Transcript 6/18 at WRNMMC - AMSUS | Meetings

Control Asthma
Ryan Gottfredson, DO, FAAP, Maj, USAF, MC
Preventive Medicine Resident
Uniformed Services University of the Health Sciences
Disclosures
• The presenter has no financial relationships to disclose.
• This continuing education activity is managed and
accredited by Professional Education Services Group in
cooperation with AMSUS.
• Neither PESG, AMSUS, nor any accrediting organization
support or endorse any product or service mentioned
in this activity.
• PESG and AMSUS staff has no financial interest to
disclose.
• Commercial support was not received for this activity.
Disclaimer
• The content of this presentation is the sole
responsibility of the author and does not necessarily
reflect the views or policies of the Uniformed Services
University of the Health Sciences (USUHS), the
Department of Defense (DoD), or the Departments of
the Army, Navy or Air Force.
• Mention of trade names, commercial products, or
organizations does not imply endorsement by the U.S.
Government.
Learning Objectives
At the conclusion of this activity, the participant will be
able to:
•List the 6/18 recommendations related to asthma
management
•Relate the Community Guide recommendations to the
6/18 goals
•Understand the current epidemiology of asthma
morbidity in the Military Health System (MHS)
•Explore potential interventions at a military treatment
facility that would support 6/18 recommendations
Overview
• 6/18 CDC Recommendations
• 6/18 Cost Evidence
• 2015 USPSTF
• 2007 Clinical Practice Guidelines
• 6/18 Cost Evidence
• Asthma in the Military
• Implementing 6/18 at WRNMMC
6/18
Recommendations
1. Follow 1997 National Asthma Education and
Prevention Program guidelines (NAEPP Guidelines)
2. Improve access and adherence to asthma
medications and devices
3. Intensive self-management education for
individuals whose asthma is not well-controlled with
NAEPP Guidelines based medical management alone
6/18
Recommendations
4. Home visits to improve self-management education
and reduce home asthma triggers for individuals whose
asthma is not well-controlled with NAEPP Guidelines
based medical management and intensive selfmanagement education
NAEPP Guidelines
• NAEPP convened expert panel in 2007, reviewed
literature and established evidence-based guidelines
• Two domains:
• Accurately classifying current impairment
• Future risk
• These two domains are considered for diagnosing asthma
severity (intermittent or persistent) and level of control
(well controlled or not well controlled)
• Tailors therapy in a step-wise fashion – increasing therapy
if not well controlled, and decreasing therapy if overtime
pattern of well control is demonstrated.
NAEPP Guidelines
NAEPP Guidelines
6/18 Evidence
Summary:
Promoting NAEPP
asthma management
• N=3,298 children; when NAEPP Guidelines were
followed, 19.5% fewer symptom days, 13% fewer ED
visits, ROI $3.58 per $1.00 spent
• Study of inner city asthma patients, RCT, doubleblinded showed following NAEPP significantly reduced
sympts days and asthma exacerbations
6/18 Evidence
Summary: Access
and Adherence
• Greater adherence associated with lower ED visits in
adults and children
• First fill rate of ICS was lower if copay at pharmacy was
higher that $12
• Increasing copays resulting in decline in average
annual days of medication supplied; increased copays
were associated with increased asthma-related
outpatient and ED visits.
6/18 Evidence
Summary: Intensive
self-management
education
• 310 low-income asthmatic urban children: randomized,
prospective trial showed decreased ED visits, reduced
health costs (saved $11.22 for every $1 spent on
education)
• 212 inner-city asthmatic children, randomized trial:
reinforced asthma education and case management
reduced costs significantly compared to controls.
6/18 Evidence
Summary: Home
Visits
• Benefits from home-based, multi-trigger, multicomponent
interventions with and environmental focus can match or
even exceed their program costs – based on systematic
review of 13 studies
• RCT: increased asthma-symptom-free days, improved
quality of life, greater decrease in visits to the healthcare
system. ROI was $1.90
The Community Guide: 2008
recommendations
• Systematic review found sufficient evidence to
recommend Home-based, Multi-trigger,
Multicomponent, Environmental Intervention – for
children but not adults
• Intervention is a home visit by trained personnel to:
• Assess the home environment
• Change the indoor home environment to reduce exposure to
triggers
• Educate about the home environment
• Educate and train to improve self-management
• Help provide social services and support
• Coordinate care
Asthma in the Military
• An investigation, comprising the years 1995–1998,
recorded 3,699 EPTS discharges (13.5% of all) because of
asthma
• From 1998 through 2002, approximately 17% of EPTS
discharges among U.S. Army active duty enlistees was for
asthma
• Nontraumatic military-related death because of asthma is
rare with only 1 reported case detected among relatively
healthy young military recruits not exercising
• According to a 2014 VA report, 6% of Veterans serving in
Iraq or Afghanistan received VA care between 2002 and
2011 and met one of the criteria for obstructive lung
disease (i.e., asthma, bronchitis, or emphysema)
Costs of Asthma in the DoD
• No current studies of cost of Asthma
• As of 2011, about $13.2 billion was directly spent on
Veterans’ medical care.
• Another $18.1 billion was paid out in disability
compensation and other benefits, signifying a $31.3
billion total expenditure.
• A 2008 estimate suggested that the long-term cost of
providing medical care and paying disability
compensation for Veterans of the Iraq and Afghanistan
Wars may be between $400 billion and $700 billion.
6/18 at WRNMMC
Current Programs
• Engage Pulm and Allergy at WRNMMC to discuss
programs
• Contact tricare to see what is currently covered (home
visits)
• Nurse educators, extent of role and how well they are
engaged
• Contact Tricare and pharmacy to see if there are any
barriers to access to medication
• Get prescribing trends from Carepoint and pharmacy
data to assess how well patient population is doing
6/18 at WRNMMC
• Program to improve NAEPP Guideline adherence by
providers
• Initiatives to lower barriers to medications and devices for
patients
• Initiative to improve availability of assets for intensive
education and training for self-management for patients
who are not well controlled
• Initiative to provide Tricare coverage for home nursing visit
to do home assessment and home-based trigger control and
education
• Care to be coordinated by case management
References
• Brooks, S. M. (2015). Occupational Medicine Model and
Asthma Military Recruitment. Mil Med, 180(11), 11401146. doi:10.7205/milmed-d-14-00443
• NAEPP Guidelines ref
• Community Guide ref
• CDC 6/18 evidence ref
Obtaining CME/CE Credit
If you would like to receive continuing education credit for
this activity, please visit:
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