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ACT TrainingSAFTINet Partner Engagement Community

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ACT Training

SAFTINet Partner Engagement Community

Outline

1. Clinical Use of the Asthma Control Test (ACT)

2. Workflow for Using the ACT

+1. Clinical Use of the Asthma Control Test (ACT)A. BackgroundB. Guideline-based context for the ACTC. The ACT

+Asthma Epidemiology

Up to 18% diagnosed by high school graduation

More common in males before age 12 and in females after age 12

Over 3,900 deaths (14/day)

Disproportionately affectschildren and African Americans

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2 million ED visits

500,000 hospitalizations

Costs of asthma $16 billion American Lung Association Fact Sheet: Asthma in Adults, June 2004. Available at: http://www.lungusa.org/site/.

National Institute of Allergy and Infectious Disease. Focus on Asthma. Available at: http://www3.niaid.nih.gov/news.American Medical Association. Clinical Performance Measures – Asthma, 2005.

Asthma-Related Annual Utilization

+NIH Guidelines

National Institutes of Health, National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007).

Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.

EPR-3

+Guidelines: Ambulatory Asthma Care

Diagnose asthma

Identify precipitating factors and co-morbidities

Classify asthma severity

Assess patient’s knowledge/skills for self-management

Provide an asthma action plan

Monitor asthma control

Administer influenza vaccine to all with asthma

+Guidelines: Ambulatory Asthma Care

Diagnose asthma

Identify precipitating factors and co-morbidities

Classify asthma severity

Assess patient’s knowledge/skills for self-management

Provide an asthma action plan

Monitor asthma control

Administer influenza vaccine to all with asthma

ACT helps here

+ Assessment/Monitoring: Control vs. Severity

Used for evaluating disease activity and initiating therapy

Categories: Intermittent Persistent (mild,

moderate, severe)

Is not what the ACT measures

Used for monitoring and adjusting therapy

ACT score can be used to measure part of control (impairment)

Severity Control

+Control

Includes two domains Impairment is the present: effects on quality of

life and functional capacity Risk refers to the future: exacerbations and

progressive loss of pulmonary function

Well controlled vs. not well controlled/very poorly controlled

Should be measured at least every 6 months

Use control rating to step up or step down therapy after assessing compliance, device technique and environment

+Assessing Control

+Assessing Control

+ Assessment of Control Using Standardized Tools: ACT (Asthma Control Test)

Simple assessment and easy-to-use scoring method

Assesses asthma control over the past 4 weeks: activity limitations daytime symptoms nighttime symptoms short-acting beta-agonist (SABA) use self-assessment of level of control

Available in >12 languages

+Childhood ACT

Child questions

Parent questions

Instructions

+Childhood ACT: Instructions

Suggested changes for SAFTINet Change “Asthma Control Test” to “Breathing Survey” Change “asthma” to “breathing” Remove the instructions that include the parent adding

up the score and bringing the test to their child’s doctor

+Childhood ACT: Child Questions

+Childhood ACT: Parent Questions

+ACT: Teen/Adult Version

+ACT: Scoring< 19 suggests poor control

Childhood version Validated in children 4-11 years 4 child questions, scored 0 (worst) to 3 3 parent questions, scored 0 to 5 Score range 0 to 27

Teen/Adult versionFor patients >12 years5 questions, scored 1 to 5Score range 0 to 25

+Assessing Control and Adjusting Therapy in Teens and Adults

+Assessing Control and Adjusting Therapy in Children 5–11

• Consider short course of systemic oral corticosteroids,

• Step up 1 2 steps, and• Reevaluate in 2 weeks.• For side effects: consider

alternative treatment options.

• Step up at least 1 step and

• Reevaluate in 2 6 weeks.

• For side effects: consider alternative treatment options.

• Maintain current step.

• Regular followupevery 3 6 months.

• Consider step down if well controlled for at least 3 months.

Recommended Actionfor Treatment

(See figure 4-1b fortreatment steps.)

Lung function

<60% predicted/personal best

60 80% predicted/personal best

>80% predicted/personal best

• FEV1 or peak flow

Evaluation requires long-term followup.

Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

Treatment-related adverse effects

>3 per year2 3 per year0 1 per yearExacerbations

Risk

Several times per day>2 days/week2 days/week

Short-actingbeta2-agonist use

for symptom control(not prevention of EIB)

Extremely limitedSome limitationNoneInterference with normal activity

Classification of Asthma Control (5 11 years of age)

Impairment

Components of Control

Reduction inlung growth

<75% predicted75 80% predicted>80% predicted• FEV1/FVC

2x/week2x/month1x/monthNighttimeawakenings

Throughout the day>2 days/week or multiple times on

2 days/week

2 days/week but not more than once on

each daySymptoms

Very Poorly ControlledNot Well

ControlledWell

Controlled

+Assessing Control and Adjusting Therapy

Components of Control

Classification of Asthma Control

Well Controlled Not Well Controlled

Very Poorly Controlled

Age 5-11

ACT >20 13-19 <12

Age >12

ACT >20 16-19 <15

Recommended Action for Treatment

• Regular followups every 1-6 months to maintain control

• Consider step down if well controlled for at least 3 months

• Step up 1 step and

• Reevaluate in 2-6 weeks

• Consider short course of oral systemic corticosteroids

• Step up 1-2 steps, and

• Reevaluate in 2 weeks

+Stepwise Approach for Managing Asthma in Teens and Adults Intermittent

Asthma

Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 care or higher is required.

Consider consultation at step 3.

Step 1

Preferred:

SABA PRN

Step 2

Preferred:

Low-dose ICS

Alternative:LTRA Cromolyn, Nedocromil, orTheophylline

Step 3

Preferred:

Medium-dose ICS

OR

Low-dose ICS + either LABA,

LTRA, or Theophylline

Step 5

Preferred:High-dose ICS + LABA

Alternative:

High-dose ICS + either LTRA or Theophylline

ANDOmalizumabmay be considered for patients who have allergies

Step 6

Preferred:High-dose ICS+ LABA + oral corticosteroid

Alternative:High-dose ICS + either LTRA or Theophylline+ oral corticosteroid

ANDOmalizumabmay be considered for patients who have allergies

Step up if needed

(first, check adherence and environmental

control and comorbid

conditions)

Step down if possible

(and asthma is well controlled

at least3 months)

Patient Education and Environmental Control at Each Step

Step 4

Preferred:

Medium-dose ICS + LABA

Alternative:

Medium-dose ICS + either LTRA or Theophylline

Assess control

Quick-Relief Medication for All Patients

• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed.

• Caution: Increasing use of beta-agonist or use >2 times a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

Key: ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist, LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist

+Stepwise Approach for Managing Asthma in Children 5–11

Key: ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist, LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist

+Stepwise Approach for Managing Asthma in Teens and Adults

IntermittentAsthma

Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 care or higher is required.

Consider consultation at step 3.

Step 1

Preferred:

SABA PRN

Step 2

Preferred:

Low-dose ICS

Alternative:LTRA Cromolyn, Nedocromil, orTheophylline

Step 3

Preferred:

Medium-dose ICS

OR

Low-dose ICS + either LABA,

LTRA, or Theophylline

Step 5

Preferred:High-dose ICS + LABA

Alternative:

High-dose ICS + either LTRA or Theophylline

ANDOmalizumabmay be considered for patients who have allergies

Step 6

Preferred:High-dose ICS+ LABA + oral corticosteroid

Alternative:High-dose ICS + either LTRA or Theophylline+ oral corticosteroid

ANDOmalizumabmay be considered for patients who have allergies

Step up if needed

(first, check adherence and environmental

control and comorbid

conditions)

Step down if possible

(and asthma is well controlled

at least3 months)

Patient Education and Environmental Control at Each Step

Step 4

Preferred:

Medium-dose ICS + LABA

Alternative:

Medium-dose ICS + either LTRA or Theophylline

Assess control

Quick-Relief Medication for All Patients

• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed.

• Caution: Increasing use of beta-agonist or use >2 times a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

ACT fits in here

Note the other components in the blue box

+Guidelines: Ambulatory Asthma Care

Identify precipitating factors

Identify comorbidities that may aggravate asthma

Assess patient’s knowledge/skills for self-management

Classify asthma severity

Monitor asthma control

Provide an Asthma Action Plan

Administer influenza vaccine to all patients with asthma

ACT helps here

+ 2. Possible Workflow for Using the ACT

+Identify patients with Asthma

Run reports to yield patient registries based upon ICD9 code 493 (asthma) in the electronic health record

(EHR) Reason for visit: any

Reports run by a clinical analyst the prior day

Medical assistant reviews report and flags patient charts for receiving ACT before the clinic opens in the morning For adolescents and young

men this may be the only way to measure their control

Think like you do for immunizations, missed opportunities

EHR marker flags patient for ACT

+Who can give ACT

Physician or other clinician seeing patient Been shown to miss most patients

Nursing staff putting patient in room Can be combined as a vital sign

Receptionist May allow patient time to complete before in office

+Administering the ACT: An example of patient flow

Several laminated copies of ACT in English and Spanish are available at the front rooms of the office

Receptionist asks about patient’s preferred language and then hands the patient the ACT and erasable marker to flagged patients at check-in

+Administering the ACT: An example of patient flow

Medical assistant or rooming nurse addresses questions about ACT while checking heart rate and blood pressure

Medical assistant or rooming nurse scores and enters ACT result in the asthma worksheet in the EHR

Laminated ACT remains with the patient in the exam room

+Possible script

“Hello, we are starting a new program that will help us take care of patients with asthma/wheeze/breathing problems better. We are asking any patient with asthma etc to fill out this form so that we can figure out the best way to help you get better.”

If the patient is adult, ask them to read the questions and give the answer that describes how they have felt over the last 4 weeks

If you are treating a child under 12, the parent and child should read the first 5 questions and the CHILD should pick the face. The parents then answers the last 3 questions.

Tell them that there is no need to add the numbers up, the provider will review it with them and add up the total in the room

+Clinician Interaction with ACT

Clinician reviews ACT score

Clinician also has available the laminated ACT copy to review specific items

The clinician enters the score in the EHR if not already entered

After encounter, medical assistant or rooming nurse wipes clean the laminated ACT and returns it to the receptionist

+Documenting ACT results in EHR

ACT template has been developed in our EHR

Result entered directly into template (describe where)

+Discussion

No one way is right for everyone

May have several strategies for different types of situations Urgent visits Asthma check ups others

+Potential Barriers Brainstorm on Solutions

Lack of familiarity with the ACT

Time and resource constraints

Patient literacy levels

Fit within the clinical workflow