asthma 2009: overview of asthma prevalence & mortality karen meyerson, msn, rn, fnp-c, ae-c...
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Asthma 2009: Overview of Asthma Prevalence & Mortality
Karen Meyerson, MSN, RN, FNP-C, AE-C
Asthma Network of West MichiganApril 21, 2009
Prevalence of Asthma Among Michigan Children (<18 Years), 2007
11.3
7.7
10.6
16.8
11.6
8.1
9.5
0 2 4 6 8 10 12 14 16 18 20
Male
Female
Hispanic
NH Other
NH Black
NH White
Total
Percent
MI BRFS, 2007
Prevalence of Asthma Among Michigan Adults (18 Years), 2007
7.9
11.0
14.5
11.1
12.9
8.7
9.5
0 2 4 6 8 10 12 14 16
Male
Female
Hispanic
NH Other
NH Black
NH White
Total
Percent
MI BRFS, 2007
Prevalence of Asthma for Adults (18 Years) by Indicators of Socioeconomic Status, Michigan, 2007
10.5 11.0 9.3 8.40
4
8
12
16
20
Per
cen
t
< High SchoolHigh School GraduateSome CollegeCollege Graduate
MI BRFS, 2007
8.6 9.9 7.1 8.913.30
4
8
12
16
20
Perc
en
t
<20,00020,000-34,99935,000-49,99950,000-74,99975,000+
Education Income
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. Source: Data Warehouse, 2005, MDCH
2. Persistent asthma and asthma medications defined according to NCQA HEDIS
3. Age-adjusted to 2000 US Std Population
4. 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
*Age adjusted to the 2000 US standard population. Sources: 2004-2006 Michigan Inpatient Database & 2005 MI population estimates, MDCH
13.4
19.3
11.3
46.9
45.6
15.3
7.3
16.2
24.1
16.6
0 10 20 30 40 50
Male*
Female*
White*
Black*
0 to 4
5 to 14
15 to 34
35 to 64
65+
Total*
Rate per 1,000,000
Rates* of Hospitalization due to Asthma by Race and Income, Michigan, 2000-2002
34.7
15.3
56.3
13.6 11.3
36.1
8.4 8.4
19.6
0
10
20
30
40
50
60
Total White Black
Low Income
Middle Income
High Income
*Uses 2000 MI population and is age adjusted to the 2000 US standard population.Source: 2000-2002 Michigan Inpatient Database, MDCH
Rate
per
10,0
00
Asthma Hospitalization Rates* by Age-Race Group and Year, All Ages, Michigan, 1990-2006
0
20
40
60
80
100
90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06
White, Child White, Adult
Black, Child Black, Adult
*Uses MI population estimates, 1990-2006 and is age adjusted to the 2000 US standard population. Source: 1990-2006 Michigan Inpatient Database, MDCH.
Ra
te p
er
10
,00
0
*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
White Black
Asthma Hospitalization Rates** by Race and County of Residence, All Ages, Michigan, 2004-2006
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 IndicatorX% 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
10
20
30
40
50
2001 2002 2003 2004 2005
Total Black White
1. Source: Data Warehouse, 2001-2005, MDCH2. Persistent asthma and asthma medications defined according to NCQA HEDIS 3. Age-adjusted to 2000 US Std Population4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)
in Medicaid with full coverage and no other insurance.
Percent Reliance on Emergency
Department by Race among Children with Persistent Asthma, Medicaid, Michigan,
2005
1. Source: Data Warehouse, 2005, MDCH
2. Persistent asthma and asthma medications defined according to NCQA HEDIS
3. Age-adjusted to 2000 US Std Population
4. 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 medicationsOveruse defined as >6 filled prescriptions of
SABA filled in 12 months
Interpretation of the IndicatorX% 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
10
13
16
2001 2002 2003 2004 2005
Total Black White
1. Source: Data Warehouse, 2001-2005, MDCH2. Persistent asthma and asthma medications defined according to NCQA HEDIS 3. Age-adjusted to 2000 US Std Population4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)
in Medicaid with full coverage and no other insurance.
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
40
50
60
2001 2002 2003 2004 2005
Total Black White
1. Source: Data Warehouse, 2001-2005, MDCH2. Persistent asthma and asthma medications defined according to NCQA HEDIS 3. Age-adjusted to 2000 US Std Population4. Medicaid population restricted to children <=18 Years, continuously enrolled (11+ Months)
in Medicaid with full coverage and no other insurance.
Rates of Mortality due to Asthma by Sex, by Race and by Age Group, Michigan, 2004-2006
*Age adjusted to the 2000 US standard population.Data Source: Michigan Resident Death Files & 2005 MI population estimates, MDCH.
10.3
14.3
9.7
28.7
5.6
6.7
12.4
42.9
12.6
0 10 20 30 40 50
Male*
Female*
White*
Black*
5 to 14
15 to 34
35 to 64
65+
Total*
Rate per 1,000,000
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
Tox/Alcohol Screen 0%
Steroids 50%
Prior Intubation 13%
Prior Hospitalization 48%
Treated in ED 80%
Allergist 38%
Pulmonologist 40%
PFTs 33%
Peak Flow Meter 63% Used Regularly 13%
Asthma Management Plan 0%
BMI > 30 37%
Type 2 – 18%
Medical History
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 8 Referrals 3 Pulmonary function tests 2Educate Patients Steroids 6 Provide education in ED 3 Aspirin 1Society Case manager 5 Insurance 5 Public awareness 2 Regulation insurance companies on referrals Labeling aspirin products 1Medical Examiners Criteria for asthma deaths 4
Issues Not Foundto be ImportantPreviously Reported in Literature
Issues Consistentwith FactorsPreviously Reported in Literature
Substance abuse
Psychological problems
Lack of peak flow meter
African American Low income Lack of steroids
Summary of Risk Factors for Fatal and Near-Fatal Asthma from
Medical Literature
Risk Factors Reportedwith Fatal Asthma
Risk Factors ReportedWith 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: 616-685-1432 E-mail: [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)
August 29, 2007
…2007
Asthma Assessment and Monitoring:Key Differences from 1997 and 2002
Key elements of assessment and monitoringSeverityControlResponsiveness to treatment
Severity emphasized for initiating therapy
Control emphasized for monitoring and adjusting therapy
Severity and control defined by 2 domains:ImpairmentRisk
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
EPR-3, p38-80, 277-345
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 TherapyReducing 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 TherapyReducing 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 ControlPeriodic Assessment and Monitoring
Monitor signs and symptoms of asthma
Monitor pulmonary functionSpirometryPeak 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