Como ReducirHospitalizaciones por

AsmaAsmaMark A Brown, MD

Professor of PediatricsUniversity of ArizonaUniversity of Arizona

brown6@email.arizona.edu

Guideline-based Treatment Results in Rapid Asthma Controlin Rapid Asthma Control

Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide in addition to guideline based treatment for inner-city adolescents and young adults: a randomized controlled trial. Lancet 2008;372:1065-72.

Guideline-based Treatment Results in Rapid Asthma Controlp

Busse WW, Morgan WJ, M.D., Gergen PJ, et al. Randomized trial of omalizumab(anti-IgE) for asthma in inner-city children. N Engl J Med 2011; 364:1005-1015.

AAP Ch t Q lit N t kChapter Quality Network Works with state/regional chapters through disease-specific g p g p

initiatives (Asthma, ADHD, Adolescent Substance use)

Dual focus Develop QI training capacity at the chapter level Train individual providers to incorporate best practices and QI

into individual clinical practiceso d dua c ca p ac ces

Uses face-to-face and distance learning technologies, coaching

Utilizes a registry to track key metrics (“key drivers”)

CQN Optimal asthma carep

100%Asthma Action Plans

91%

85%85%

78%70%80%90%100%

nt le

ft of

fice

actio

n pl

an

49%

57%

49%

40%50%60%70%

whe

re p

atie

nat

e as

thm

a a

48%

20%30%40%

enco

unte

r w

an u

p-to

-da

Goal Pilot 2010 Phase 2 2012 Phase 3 2013 Phase 4 2015

0%10%

1 2 3 4 5 6 7 8 9 10 11 12

% o

f w

ith

Months of participation

Goal Pilot, 2010 Phase 2, 2012 Phase 3, 2013 Phase 4, 2015

Months of participation

CQN Optimal asthma carepGoal CQN2, 2012 CQN3, 2013 CQN4, 2015

81% 87%

93%

80%90%

100%

crib

ed

74%

50%60%70%80%

Wer

e Pr

esc

Med

icat

ion

20%30%40%50%

ere

Patie

nts

Con

trol

ler M

0%10%20%

1 2 3 4 5 6 7 8 9 10 11 12

% W

he

1 2 3 4 5 6 7 8 9 10 11 12Months of participation

CQN Optimal asthma carepGoal Pilot, 2010 Phase 2, 2012 Phase 3, 2013 Phase 4, 2015

83%

99%89%

97%85%

98%

80%

90%

100%

epw

ise

50%

60%

70%

80%

rs W

here

Ste

h w

as U

sed

20%

30%

40%

50%

f Enc

ount

erA

ppro

ac

0%

10%

20%

1 2 3 4 5 6 7 8 9 10 11 12

% o

f

1 2 3 4 5 6 7 8 9 10 11 12Months of participation

CQN Optimal asthma care

85% 81%

90%

100%

p

81%

82%

67%71%

74%

81%

70%

80%

48%

44% 49% 52%

60% 64%

67%

40%

50%

60%

35%

38%

20%

30%

0%

10%

month 1 month 2 month 3 month 4 month 5 month 6 month 7 month 8 month 9 month 10 month 11 month 12

Goal Pilot, 2010 Phase 2, 2012 Phase 3, 2013 Phase 4, 2015

Optimal Asthma Care = % of encounters with all of the following: assessment of asthma control, stepwise approach used to adjust treatment, written asthma action plan and children with persistent asthma on a controller medication

The Inner City Asthma Study (ICAS) Multi-center, randomized, controlled trial of

Comprehensive environmental remediation

Physician feedback on participant asthma status

937 children aged 5 to 12 years with moderate 937 children aged 5 to 12 years with moderate asthma enrolled from inner-city census tracts

Boston, Bronx, Chicago, Dallas, New York, SSeattle, and Tucson

Positive skin test to > 1 indoor allergen

One year of intervention followed by one year of observation

Morgan WJ, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351:1068-80.

ICAS Environmental Intervention Outcomes

Environmental intervention was associated with significantly reduced asthma morbidity over two years:

Maximum symptom days (P<0.001) Days of wheeze (P<0.001) Nights caretaker woke up (P<0 001) Nights caretaker woke up (P<0.001) Missed school days (P=0.003) Unscheduled visits for asthma (P<0.04)( )

(Morgan et al. NEJM 2004;351:1068-80)

ICAS Primary OutcomeMaximum Symptom Daysy p y

7.0Year 1 = Intervention Year 2 = Follow-up

5 0

6.0

7.0

eks

Control

4.0

5.0

per 2

Wee Environmental Intervention

2.0

3.0

Day

s

1.0B 2 4 6 8 10 12 14 16 18 20 22 24

Study Month

(Morgan et al. NEJM 2004;351:1068-80)

ICAS: Cost EffectivenessICAS: Cost Effectiveness

Study cost was $1,469 per family in 2001 dollars. The ICER gives the cost per additional symptom free day (SFD) gained per child over the 2-year period.

(Kattan, M et al. J Allergy Clin Immunol 2005;116:1058-63.)

ICAS Cost Effectiveness The current estimate likely overestimates potential

cost per symptom-free day Other household members with asthma may have benefited

Duration of the effect would likely have lasted longer than the single observation year

Cost could also have been reduced by using a single remediation counselor instead of two counselors/visit

Missed school days were decreased by the intervention Missed school days were decreased by the intervention and the reduction of these indirect costs alone could have led to a cost savings

The control group had a substantive reduction in symptoms The control group had a substantive reduction in symptoms possibly due to an “attentional” effect leading to an underestimation of real-world savings

(Kattan, M et al. J Allergy Clin Immunol 2005;116:1058-63.)

Boston Community Asthma Initiative

Children 2-18 years from 4 urban zip codes were eligible

Subjects identified through ED & hospital admission records; 283/562 (50.4%) agreed to participate.

55.1% male; 39.6% Black, 52.3% Latino; 72.7% Medicaid; 70.8% household income <$25K

Woods ER, et al. Pediatrics 2012; 129:465-472., ;

Boston Community Asthma Initiative

Home visits in 203/283 (71.7%) families 176 Nurse 145 Community health worker 40 Exterminator

Retention 68% at 6 months, 60% at 12 months

Woods ER, et al. Pediatrics 2012; 129:465-472.

Boston Community Asthma InitiativeInitiative

Woods ER, et al. Pediatrics 2012; 129:465-472.

Boston Community Asthma InitiativeInitiative

ED Visits & Hospitalizations Cost per child over 2 years =

$2529

Savings per child over 2 years =

ED Visits & Hospitalizations

Savings per child over 2 years = $3827

ROI = 1.46

Woods ER et al Pediatrics 2012; 129:465-472Woods ER, et al. Pediatrics 2012; 129:465 472.

Boston Community Asthma InitiativeInitiative

3-year Unadjusted ROI = 2.04

2-year Adjusted ROI = 1.06

3-year Adjusted ROI = 1.33y j

3-year Adjusted SROI = 1.85

Bhaumik U, et al. J Asthma 2013; 50:310-317

Asthma Action Plans Recommended in both NIH and GINA guidelines

Role of peak flow monitoring unclear; symptom-basedRole of peak flow monitoring unclear; symptom based steps may be sufficient Short-term peak flow monitoring Following an exacerbation to monitor recoveryFollowing an exacerbation, to monitor recovery. Following a change in treatment, to help in assessing whether the

patient has responded. If symptoms appear excessive (for objective evidence of degree of

l f ti i i t)lung function impairment). To assist in identification of occupational or domestic triggers for

worsening asthma control Long-term monitoringLong term monitoring For earlier detection of exacerbations, mainly in patients with poor

perception of airflow limitation. For patients with a history of sudden severe exacerbations. For patients who have difficult-to-control or severe asthma

Asthma Action PlansAsthma Action PlansOral corticosteroids as part of homeOral corticosteroids as part of home

asthma action plan Recommended for adults in GINA Require medically astute parents Use should be approved by physician and

noted in medical record for control assessment

ResumenResumen Guideline/Evidence based treatment works Guideline/Evidence-based treatment works

Systematic quality improvement efforts lead to improvements in careimprovements in care

Home visits are both medically effective and cost ff tieffective

Action plans, including home administration of oral ti t id id d t t i itcorticosteroids, can avoid emergency department visits

and hospitalizations