SECHENOV MSCOW MEDICAL ACADEMY

COURSE
MOSCOW
WORK PART
The Department Of Public Health Medical
Care Organizations And Economics
2 2008
The Role Of A Doctor In The Treatment
Of Asthma In The America
Nurul Husna Asmaa Binti Yahaya
Group 9
Ms Ekkert Natalia
Vladimirovna
QUESTIONS FOR DISCUSSION: _____________________
1. How can we improve community and institutional surveillance of asthma to measure the impact of the
disease on our patient population?
2. How hard or easy is it for you to get spirometry on a patient for diagnosis and follow-up of a patient
with asthma? Are providers in your clinic and hospital checking spirometry in patients with asthma?
3. How difficult is it for you to get a pulmonary and/or allergy consultation when needed?
4. Do you use the Asthma Register System at your facility and have you used the asthma action plans that
are available through this program? If not, do you have a method of providing written action plans for
your patients that is usable?
5. Is there any role for remote/telemetric monitoring of peak flows, home spirometry, and use of MDI’s
where providers can keep tabs on a patient’s status?

Introduction_________________________________________
Asthma is chronic inflammatory lung disease characterized by obstruction of airflow and at least partial
reversibility of this obstruction. Although asthma can begin at any age, a previous discussion explored
childhood asthma. Here, adult asthma will be mainly discussed.

Unfortunately, the burden of asthma on American Indians/Alaska Natives (AI/AN) is largely unknown except to
the providers in clinics and emergency departments, and to the patients and families who suffer with the disease
on a daily basis. In 1964, Herxheimer concluded that there were strikingly few cases among Indians of the
Southwest and Northern Plains1. In 1975, a review of 9,000 consecutive visits to the IHS clinic at Lame Deer,
MA found only 1 patient with asthma2. Attempts to look for asthma were made by mortality reviews from 1969-
1977 in New Mexico where only one fatal case was found3. Another review of mortality from asthma, this time
national, found no fatal cases from 1980 to 1986.

More recently, the prevalence of asthma in AI/AN people has become clearer. In 1995, Clark found 12.3%
prevalence of asthma or reactive airway disease in children 3 to 13 years old in a Pueblo in New Mexico4. In
1999, Stout identified a 7.06% incidence of parent reported asthma in 2288 children aged 1-17 years old5, and
this year a report from the Yukon-Kuskokwim delta region of western Alaska identified 7.4% of students self-
reporting that they had received a diagnosis of asthma from a physician6. Even though all of the recent data is
performed in children, it does give us an idea that asthma is at least as significant a problem as the general U.S.
population and possibly an emerging illness for AI/AN people.

There are difficulties inherent in general asthma surveillance. First, it may be difficult to accurately identify
cases of asthma since there is no definitive clinical test for asthma. Because of this, some health care providers
tend to accept diagnoses of asthma by history, physical exam, and subjective response to bronchodilators.
Although there is no data in the literature to support this assertion, it is seen in this first hand on a daily basis.

Of the patients in the clinic in 2001 who carried a diagnosis of “asthma,” roughly half of the patients had never
had a spirometry performed. Second, asthma is episodic by definition and the objective measurements that
might aid in diagnosis are not always helpful. Once again in the clinic, only a quarter of patients carrying a
diagnosis of asthma had their diagnosis confirmed by spirometry, while the other quarter had spirometry that was
not consistent with asthma. This highlights the importance of performing spirometry when the patient is
symptomatic so that the episodic obstruction can be confirmed.

Even though surveillance of asthma can be difficult and time consuming, there are important reasons to take a
closer look at asthma. This monitoring would allow us to follow trends in asthma prevalence, asthma severity,

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our success in managing this chronic disease, as well as its overall costs7. One push to improve surveillance of
asthma comes from the goals established by “The Healthy People 2010” initiatives.

Some of the general U.S. Data for asthma goals is known, but there is essentially no baseline data for AI/AN
people in regards to the different targets. Surveillance for some of these asthma related targets kick-off as part of
one upcoming GPRA indicator; “baseline rates for asthma visits broken out by age groups.” While GPRA
indicators will push us to follow asthma outcomes, a public health approach to improvement in asthma treatment
is the more important reason.

The National Asthma Education and Prevention Program (NAEPP) developed an Expert Panel Report:
Guidelines for the Diagnosis and Management of Asthma (EPR-1) in 1991 and then revised/updated this report
in 2002 (EPR-2)8. Under these guidelines, the treatment of asthma was organized around the following key
components of effective asthma management:

➢ “Use of objective measures of lung function to assess the severity of asthma and to monitor the course
of therapy
➢ Environmental control measures to avoid or eliminate factors that precipitate asthma symptoms or
exacerbations.
➢ Comprehensive pharmacologic therapy for long-term management designed to reverse and prevent the
airway inflammation characteristic of asthma as well as pharmacologic therapy to manage asthma
exacerbations.
➢ Patient education that fosters a partnership among the patient, his or her family, and clinicians.”

It is essential that every effort be made to make the correct diagnosis when evaluating a patient with dyspnea.
The EPR-2 reiterates “to establish the diagnosis of asthma, the clinician must determine that:

• Episodic symptoms of airflow obstruction are present.

• Airflow obstruction is at least partially reversible.
• Alternative diagnoses are excluded.”8

Because of this definition, spirometry is required (if the patient can coordinate it) to prove airflow obstruction
before making the diagnosis of asthma. Reversibility can be proven by spirometry or by peak flow monitoring.
The last bullet above is one point that should not be ignored so that contributing/exacerbating diagnoses can be
ruled-out.

Once the diagnosis of asthma is firm, the severity should be classified on the basis of the patient’s daytime and
nighttime symptoms and their lung function.

Once the diagnosis of asthma is firm, the severity should be classified on the basis of the patient’s daytime and
nighttime symptoms and their lung function. Cherokee Indian Hospital has created an excellent handout/tool
that summarizes the NAEPP recommendations in this regard. One of the most useful tables in these handouts is
as follows:

Mild Intermittent Mild Persistent Mod. Persistent Severe Persistent

Step 1 Stage 2 Stage 3 Step 4

Symptom
≤ 2 per week > 2 per week Every day Continuous
Frequency

Nocturnal
≤ 2 per month >2 per month >1 per week Frequent
Symptoms*

PEF Max ≥80% ≥80% >60 and < 80% ≤60%

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PEF
<20% 20-30% >30% >30%
Variabiltiy

Broncho-
<1 per week ≤8 puffs / day 10 puffs / day >10 puffs / day
dilator use

Activity May be limited Limited Limited

Post attack
May not return to May not return to
pulmonary Normal Normal
normal normal
function

Flunisolide Budesonide
Flunisolide
(Aerobid) MDI (Pulmicort) MDI
(Aerobid) MDI
with spacer
with spacer >3 inhalations QD
4 puffs BID
2 puffs BID
OR
OR
Budesonide
Chronic Triamcinolone
(Pulmicort) MDI
control (Azmacort) MDI
None
medication 2-3 inhalations QD
(Daily) 4 puffs BID
AND AND
Alternative
Salmeterol Salmeterol
Nedocromil
(Serevent) (Serevent)
(Tilade) MDI with
Discus** Discus**
spacer
1 inhalation QD- 1 inhalation QD-
2 puffs QID
BID BID

Acute rescue
Albuterol MDI with spacer 2-4 puffs q 4-6 hr PRN or 0.5 ml via nebulizer q 4-6 hr
medication
+/- Ipratropium (Atrovent) 500mcg (1 vial) via nebulizer q 6 hr – may mix with albuterol
***

Acute viral Albuterol q 4-6 hr up to 24 hours (longer with MD consult)

respiratory
infections For severe exacerbations: short course “burst” of prednisone 40-60 mg per day as a

**** single or two divided doses for 3-10 days.

* Theophylline 10mg/kg/day up to 300mg HS may be helpful with nocturnal symptoms.

Monitor serum levels (Goal levels: 10-20 mcg/mL) (> 20 mcg/mL = increased toxicity).
** Avoid use of salmeterol without concomitant inhaled steroids. Overuse of salmeterol has been
associated with worsening asthma and increased mortality in a retrospective report.
*** Use of albuterol >2 times per week in intermittent asthma (daily or increasing use in persistent
asthma) may indicate the need to initiate or increase long-term control medications.
****Hi Dose Taper: 60mg day 1, 60mg day 2, 40mg day 3, 40mg day 4, 20mg day 5, 20mg day 6,
10mg day 7, 10mg day 8
Low Dose Taper: 40mg day 1, 35mg day 2, 30mg day 3, 25mg day 4, 20mg day 5, 15mg day 6,
10mg day 7, 5mg day 8

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This framework is very helpful for management in primary care. It avoids classifying asthma as mild, moderate,
and severe, emphasizing the fact that asthma of any severity can have mild, moderate, or severe exacerbations
that may even result in death. The recommended classification of asthma allows for more aggressive treatment
of inflammation and preventive medications for patients with stage 2 through 4. As asthma surveillance
becomes more of a priority from a public health/system approach, this classification will also provide a
framework that will enhance this surveillance.

The Asthma Register System employs the recommendations of the EPR and has been added to the IHS
Resource and Patient Management System. This resource “provides Indian Health Service/Tribal/Urban
(I/T/U) healthcare providers with another tool for improving the care and management of patients with asthma9.”
It allows for the creation of a registry, a health summary supplement, asthma related health reminders, and a
patient self-management printout.

5 questions or issues asked to an Internal Medicine Chief Clinical Consultant,

1. How can we improve community and institutional surveillance of asthma to measure the impact of the
disease on our patient population?

Asthma has chronically been under-diagnosed among Native American populations in the primary literature. It
was believed that Native Americans suffered very little from asthma based upon data from the 1970s and early
80s - possibly asthma is a new epidemic among Native American populations, or it has not been well
documented or inappropriately documented in the past. I think that we need to increase provider awareness of
asthma and extinguish the fear of "labeling" persons with asthma. Asthma diagnosis can be active or moved to
an inactive status in RPMS over time under the problem list/purpose of visit area of the PCC/PCC+/EHR.
Appropriate diagnostic codes should be used - and lackluster codes such as RAD should not be encouraged.
What ICD-9-CM codes are providers using most commonly for documentation of asthma? Community screening
or education could help raise personal awareness of asthma and asthma screening could be incorporated into
school activities.

2. How hard or easy is it for you to get spirometry on a patient for diagnosis and follow-up of a patient
with asthma? Are providers in your clinic and hospital checking spirometry in patients with asthma?

Cherokee Indian hospital recently received a spirometer and we are still working on the logistics of using it.
Initially, it was thought that clinic nurses could perform the spirometry; however we quickly realized that this is
an unreasonable request considering the amount of work and responsibility already placed upon our clinic
nursing staff. We are in the process of evaluating the potential of getting a respiratory therapist to manage the
spiromety. What has worked best at other sites? How many places have RTs? If you have an RT, how large is
your facility and what is their role?

3. How difficult is it for you to get a pulmonary and/or allergy consultation when needed?

4. Do you use the Asthma Register System at your facility and have you used the asthma action plans that
are available through this program? If not, do you have a method of providing written action plans for
your patients that is usable?

We are in the process of updating the ARS (Asthma Registry System) registry. We have not provided written
action plans for the past for our patients, but that is changing as we work with the system. Currently the package
is not functional for entering asthma related data but if this functionality is added, it will be very nice for
ensuring that asthma related data gets entered into the system and for printing patient specific education forms.
Currently the system if great for running reports, displaying important information on the health summary and
raising awareness of asthma as a chronic disease that requires continuous monitoring and management. It is
important for us to test out the system and determine what aspects of the application we would like to change or
could improve.

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5. Is there any role for remote/telemetric monitoring of peak flows, home spirometry, and use of MDI’s
where providers can keep tabs on a patient’s status?

Home peak flow monitoring has been advocated by the NHLBI as a monitoring tool to assess asthma status. I am
aware of some patients (not many) who have been willing to bring in their PF monitoring sheets in for review,
but again - very few. Remote monitoring or even PF meters with memory would be interesting tools that could
help increase usage and benefit of this type of monitoring and patient education

ASTHMA CARE QUALITY IMPROVEMENT: A RESOURCE GUIDE FOR

STATE ACTION
Factors That Determine Quality Of Asthma Care_________________
The State data presented above raise several questions for anyone involved in quality improvement.
• What does a State's position on the continuum of quality measures mean?
• What factors influence that position and the variability among the States?
• What factors can be influenced through State policy change and local efforts?
A number of factors influence quality and outcomes of health care for any disease. Some factors may be difficult
to change, such as biologically inherited traits; income, education, and social status; and general population
characteristics. Others may be changeable in the medium or long term, but not in the short term, such as the
supply of health care professionals, the makeup and mission of health care organizations, and the disease
prevalence of the population (which represents ingrained patterns of personal behaviors and health system
effectiveness). All of these factors influence the process and outcome of health care.
Although State government and community leaders do not have control over all factors, State actions can
influence some important factors to promote positive change. These include educating people with asthma about
the risks of uncontrolled asthma, raising awareness among professionals about health care processes that can
improve outcomes for people with asthma, raising awareness in schools and communities about mitigating risk
factors that can trigger asthma attacks, and creating financial incentives to encourage providers to manage
diseases with their patients. Some States, for example, target programs to affect patient self-management and
other external causes toward minority populations that are disproportionately affected by asthma.

Racial, Ethnic, and Socioeconomic Factors

The socioeconomic makeup of a State will likely play a role in how it compares to national norms on process
and outcome measures. States with a higher proportion of individuals living in poverty, lower average education,
and a more diverse racial and ethnic population, for instance, will likely find poorer outcomes for their
population compared to the national population.
The NHDR summarizes the racial, ethnic, and socioeconomic differences in asthma across the Nation (but not
by State). Nationwide, minority or lower socioeconomic status is associated with higher asthma prevalence,
higher asthma death rates, higher rates of serious asthma complications, and poorer asthma outcomes. (Blacks,
for example, are much more likely than Whites to be hospitalized for asthma)
The socioeconomic makeup of a State, thus, should play a role in the strategies that the State uses to improve
asthma care quality. For instance, States that target efforts to improve asthma care at population groups
particularly at risk for asthma complications should also be able to improve their overall performance on asthma
care quality.

Biological and Behavioral Factors

Understanding biological and behavioral influences on asthma should help in developing assessment tools and
interventions for preventing or reducing the burden of asthma. Risk factors for asthma include :
• Parental history of asthma.
• Early-life stressors and infections.
• Obesity.

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 • Exposure to indoor allergens, tobacco smoke, and outdoor pollutants.
• Work-related exposures.
Socioeconomic factors may be related to underlying biological factors or behavioral factors. The accumulated
stress of poverty, low levels of control in jobs and relationships, low job and life satisfaction, and societal
discrimination against minority groups can influence health status.

Physical Environment
The physical environment in which asthma patients live is an important contributor to their asthma severity. The
presence of poor air quality, dust, pets, cockroaches, and other allergens can affect how well a patient is able to
control his or her asthma. A recent study released by the National Institutes of Health shows the connection
between decayed bacteria in bedrooms and other rooms of a house and asthma prevalence.

External Environment
In addition to individual characteristics (some of which are amenable to change with personal motivation), each
State has a different infrastructure and different environmental factors over which policymakers may or may not
have control. These factors include the collective health status of the population, the distribution of health care
services within locales, the distribution of wealth and tax resources among communities, and government
programs and leadership. State leaders will face different health care system challenges, including:
• Health system infrastructure—Availability of health professionals, emergency rooms, and hospitals
beds.
• Uninsured populations—Presence of vulnerable and uninsured populations and the need for special
State programs to cover the cost of health care for them.
• Safety net infrastructure—Availability of a safety net of health care providers as a last resort for those
who cannot afford health insurance and private health care.
• Provider knowledge—Providers who have sufficient state-of-the-art knowledge to manage asthma
effectively and to educate their patients in asthma self-management.
• Public education—Public education programs that raise patient awareness of the warning signs of the
disease, its potential complications, the importance of diet and exercise, and the effectiveness of
personal self-management, including knowing when to consult a doctor.
• Government resources—Funds, in a time of tight State budgets, to stimulate quality improvement
activities related to asthma care.
• Leaders to champion quality improvement—Leaders who can draw attention to the problems
associated with asthma and harness the commitment of health professionals to change practices and
monitor results.
• Knowledge of what to do—Identification of effective quality improvement programs that are based on
scientific evidence.
• Adequate data systems to assess progress—Availability of data systems that can provide comparable
measures across providers, communities, and States.
The inter-relationship among all of the factors in then, affects how a State compares with other States on
measures of asthma care quality. It is difficult to measure all of these factors at the State level. An attempt was
made to analyze the Behavioral Risk Factor Surveillance System (BRFSS) measures in Table 1 against
individual State-level environmental factors—prevalence of asthma, emphysema and chronic bronchitis in the
population, the percent of the population below poverty level, racial/ethnic makeup of the population, the HMO
penetration rate, the supply of hospital beds, and air quality in the State. The findings were not consistent enough
across measures and factors to be believable. Again, the small sample sizes and imprecision of the asthma
estimates themselves may be the limiting factor. Moreover, survey averages (e.g., percent having planned care
visits) related to State aggregates from other sources (e.g., percent of the population that is uninsured) do not
provide a direct test of these relationships.
With large databases, it is possible to assess asthma care quality at not only the State but also local levels for
some measures. For example, HCUP data and the statewide discharge data systems that are the source of HCUP
data (with its hundreds of thousands of discharge records per State per year) support analyses at the county or
other market areas. County-level data related to health care resources are generally available, although county
data on health risk behaviors of the population generally are not. State analysts could use their county-level
databases to compare asthma outcome measures based on HCUP data—e.g., asthma hospitalizations—or on data

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from their statewide data organization with other county characteristics. AHRQ's Prevention Quality Indicator
software can be applied to a State's discharge data to produce county-level statistics.
Table 1. Six Quality Measures for Asthma: National Average, Best-in-class Average, and Poorest Performing
Average, 2003

Measure National Average Best-in-class Poorest performing Number of

Category average average States
reporting
Measure % of Standard % of Standard % of Standard
Description People Error People Error People Error

Process Measures

A.2 Medications (in the 71.1 0.9 75.3 1.8 62.1 2.8 19
past month)

A.5 Planned care 28.3 0.9 40.4 3.0 17.4 1.9 19

visits (2 or more
in the past 12
months)

A.5 Smoking 82.2 1.6 87.9 3.0 75.8 4.1 15

(counseling in the
past 12 months)

Flu shots (in the 40.3 0.6 53.3 1.5 27.9 1.8 54
past 12 months)

Outcome Measures

C.2 Urgent care visits 28.1 0.9 19.4 2.0 35.5 1.9 19
(in the past 12
months)

Emergency room 17.7 0.8 12.2 1.5 22.3 2.1 19

visits (in the past
12 months)

Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System, 2003

SUMMARY AND SYNTHESIS_____________________

Local leaders and health care professionals must see their own data in comparison with other provider data and
with State, regional, and national benchmarks in order to appreciate the importance of their work. Assessing
State quality of care for asthma begins with identifying quality measures. These fall into two main groups:
process measures, which reflect the quality of care delivered, and outcome measures, which reflect patient health
status. The former are needed to guide health care providers on how to change, the latter are needed to know
whether the changed processes have had the intended effect. Data (whether State, county, municipal, or
individual health care provider data) are essential for quality improvement programs to have an impact locally.
Ideally, improvements in particular processes yield improvements in the associated outcomes.
The National Healthcare Quality Report (NHQR) provides a starting point for accessing consensus-based
measures. The NHQR provides estimates for asthma hospitalizations by State. In addition, BRFSS estimates are
used to assess asthma care quality by State. Although consensus on a few key measures of asthma care quality
has not yet evolved, this Resource Guide provides an inventory of some measures.

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Data are essential to improve quality. States need performance data on asthma care to gauge their own
performance against national benchmarks and to focus quality improvement efforts by identifying potential
problem areas. This Resource Guide provides a list of national, State, and local sources for estimates for asthma,
asthma care, and other related information.
State-level baseline estimates across all conditions studied in the NHQR afford State leaders a broad view of
health care quality in their State. More refined questions about areas within the State will require local data and
analysis.

Reference
http://www.ihs.gov/
http://www.ahrq.gov/qual/asthmacare/

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1 Herxheimer H. Asthma in American Indians (correspondence); NEJM 1964;270:1128-9.

2 Slocum, R Rarity of asthma among Cheyenne Indians (letter); Ann Allergy 1975;34:204.

3 Samet, J Respiratory mortality in New Mexico’s American Indians and Hispanics; AJPH 1980; 70(5):492-7.

4 en; Am J Resp Crit Care Med 1995, 1625-1627.

5 Stout, J, Asthma prevalence among American Indian and Alaska Native children; Pub Health Rep 1999; 114(3):257-
61.