Arizona Comprehensive Asthma Control Plan ...........
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The Arizona Department of Health Services sponsored the development of this plan with the intent to set priorities and suggest strategies to address asthma as a serious chronic disease and public health issue.
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Letter From Our Director
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Dear Arizona Residents:
Asthma is a major public health issue of growing concern in Arizona. Within the past decade statewide prevalence rates have continued to increase and are much higher than the national average. Asthma is one of our states most common and costly diseases. More than 600,000 Arizonans suffer from asthma, of which 100,000 are children. Nationally, direct and indirect costs exceed $14 billion annually. The direct impact of asthma includes hospitalizations, emergency department visits, and deaths. The indirect effects of asthma reach well beyond asthmatics themselves and include missed school and workdays, and quality of life issues. For people impacted by asthma, quality of life decreases as daily activities are disrupted due to symptoms associated with the disease. The Arizona Department of Health Services has developed this Arizona Comprehensive Asthma Control Plan. This plan sets priorities, objectives, and strategies to reduce deaths attributable to asthma in our state, reduce the proportion of Arizonans who are burdened by the disease, and attempts to reduce the direct and indirect costs associated with the disease. The plan promotes improvements in the treatment and management of the disease, as well as promoting patient education and secondary prevention. The exact causes of asthma have not yet been determined, but research indicates that both environmental and genetic factors contribute to the disease. Risk factors for asthma include a family history of the disease, low socioeconomic status, and living in an inner-city environment. This plan is designed to assist stakeholders, policymakers, healthcare professionals, educators, and public health workers to develop and coordinate approaches to address asthma among their constituents. The plan is an important step in raising awareness of the serious public health problem of asthma and provides a framework for action to reduce the impact of asthma in Arizona.
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Sincerely,
Susan Gerard Director
Arizona Comprehensive Asthma Control Plan
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Ta b l e o f C o n t e n t s
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Ta b l e o f C o n t e n t s
I. Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
II. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 III. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Def inition of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Prevalence of Asthma Nationwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Economic Impact of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 An Asthma Attack/Episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Diagnosis of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Treatment of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Burden of Asthma in Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
3
IV. Objective Sections: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Epidemiology and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Treatment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 School/Childcare Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Collaborative Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Public Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
V. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Arizona Comprehensive Asthma Control Plan
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Acknowledgements
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Acknowledgements
TRUST Commission
The Arizona Department of Health Services would like to thank the Advisory Council of the Tobacco Revenue Use, Spending and Tracking (TRUST) Commission for supporting the development of the Arizona Comprehensive Asthma Control Plan. Donna Bryson, R.N. American Lung Association of Arizona Nancy Cohrs, R.R.T., R.C.P. American Lung Association of Arizona
Special Thanks
Janet Bourbouse, M.A. Arizona Department of Health Services
Arizona Asthma Coalition
We would like to thank the Arizona Asthma Coalition for providing input for the development of the plan.
Dilia Loe, M.T.S. Arizona Department of Health Services William Pfeifer, President/CEO American Lung Association of Arizona/New Mexico Patricia Tarango, M.S. Arizona Department of Health Services Margaret Tate, M.S., R.D. Arizona Department of Health Services
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Authors
Rhonda Kay Follman, M.S. American Lung Association of Arizona Meryl S. Salit, R.R.T., R.C.P., M.B.A. Arizona Department of Health Services
Arizona Comprehensive Asthma Control Plan
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Executive Summary
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Executive Summary
Asthma is one of the nation's most common and costly diseases,1 affecting over 31 million Americans,2 with direct and indirect costs exceeding $14 billion annually.3 Asthma is a chronic respiratory
disease characterized by inflammation of the airways, tightening of the muscles surrounding the airways, and an increase in mucus production.
4
While the exact causes of asthma have not yet been determined, research indicates that both environmental and genetic factors contribute to the disease.5 Risk factors for asthma include a family history of the disease, low socioeconomic status, living in an inner-city environment, and race (Hispanic and African American).6 The Arizona Department of Health Services sponsored the development of this plan with the intent to set priorities and suggest strategies to address asthma as a serious chronic disease and public health issue. The plan continues the focus placed on asthma in the Healthy People 2010 report. The plan is meant to serve as an ambitious and comprehensive approach to improving the health and quality of life for those with asthma living in Arizona. This plan should be seen as a fluid framework for stakeholders to further develop and identify objectives and strategies to address the issues. Due to the complexity of the disease, it is important that a comprehensive approach be taken and that community stakeholders work collaboratively to implement the plan.
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Although there is no cure for asthma, proper disease management strategies including pharmacological treatments, effective asthma education, and the elimination of triggers from the environment are essential to ensure quality of life for those with the disease. The direct effects of asthma include hospitalizations, emergency department visits, and death. The indirect effects of asthma are widespread and reach far beyond asthmatics themselves. Indirect effects include missed days from school and work, and quality of life issues. For many people with asthma and their families, quality of life decreases as daily activities are disrupted due to symptoms associated with the disease.
Arizona Comprehensive Asthma Control Plan
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TA B L E
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Overriding Goals:
� Reduce asthma deaths in Arizona. � Reduce asthma-related hospitalizations and emergency department visits in Arizona. � Reduce the number of asthma-related missed school and work days.
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Executive Summary
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TA B L E
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P l a n O b j e c t i v e s b y To p i c
Epidemiology and Research
1. Establish a surveillance system for accurately tracking asthma deaths, illness, disability, and financial burden in Arizona. 2. Support research investigating causes, triggers, and management of asthma as well as healthcare policies and outcomes particularly as the activities relate to state issues.
Treatment and Management
3. Increase the accuracy of diagnosing asthma in the pediatric and adult population by educating healthcare providers about methods and criteria for diagnosis. 4. Increase the proportion of persons in Arizona who receive appropriate care according to established guidelines. 5. Educate healthcare providers/professionals in Arizona to provide individuals with asthma and their families with the best practice of care, education and resources to effectively manage their condition. 6. Increase the number of Arizonans with asthma who receives written management plans from their healthcare provider.
Patient Education
7. Improve self-management knowledge and behavior in people with asthma, their families and other caregivers.
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Secondary Prevention
8. Reduce exposure to asthma triggers (allergens and irritants) in the home, preschool, school, workplace and outdoor environment to prevent asthma episodes or reduce their severity.
School/Childcare Issues
9. Maximize good asthma management practices in the school setting. 10. Maximize good asthma management practices in the childcare setting.
Disparity
11. Identify and eliminate disparities in asthma prevention, diagnosis, and management throughout the state.
Collaborative Efforts
12. Foster communication, collaboration and networking opportunities among patients, caregivers, healthcare professionals, public health officials and other stakeholders.
Advocacy
13. Advocate and support policies that promote asthma friendly communities.
Public Awareness
14. Improve public awareness and sensitivity to the needs of persons with asthma.
Arizona Comprehensive Asthma Control Plan
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Introduction
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Introduction
Definition of Asthma
Asthma is a chronic respiratory disease where the small airways in the lungs become inflamed and nar rowed in response to triggers. Common triggers that initiate an asthma attack or episode include
allergens, airway irritants (e.g. smoke), sharp changes in weather, exercise, and infections. Asthma attacks may involve shortness of breath, cough, wheezing, chest pain, chest tightening, or any combination of these symptoms. Asthma is a serious public health issue. It is one of the nation's most common and costly chronic diseases.8 The burden of asthma is widespread and includes direct and indirect impacts encompassing medical, economic, and quality of life issues.9 Medically, the disease is responsible for emergency department visits, hospitalizations, and death.10 The economic impact of the disease is derived from the direct and indirect costs associated with medical care and missed work and school days. Quality of life components of the disease include activity limitations and access to care.
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Prevalence of Asthma Nationwide
It is estimated that more than 31 million people nationwide (111 people per 1,000) have at some point in their lifetime been diagnosed with asthma, of which over 8 million are children.11 This is a prevalence rate of 11% for adults and 12% for children. Current asthma prevalence rates are based on the number of people who have been diagnosed with asthma by a healthcare provider and still currently have asthma. In 2002, more than 20 million people (72 people per 1,000) nationwide self-reported currently having asthma (14 million adults and 6.1 million children). More than 12 million people who self-reported currently having asthma also reported having an asthma episode or attack during the previous year (approximately 60%). Asthma is more prevalent among African Americans (12% for persons age 14 years and younger, 9% for persons 15 years and older) of all age ranges than White non-Hispanics (7% for persons age 14 years and younger, 7% for persons
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Arizona Comprehensive Asthma Control Plan
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age 15 years and older) and Hispanics (8% for persons age 14 years and younger, 5% for persons age 15 years and older).12 Nationally, for persons age 14 years and younger, asthma is more prevalent in males (10%) than females (6%). However, for persons age 15 years and older, asthma is more prevalent in females (8 %) than males (5 - 6%).
become inflamed, and the muscles around the airways tighten, thus causing the airways to narrow. Asthma attacks or episodes can range from severe attacks or episodes characterized by chest tightness, severe wheezing, inability to breathe, and blue lips and fingertips to mild attacks or episodes characterized by chest tightness, wheezing, mucus emission, and trouble sleeping at night.14 Asthma attacks or episodes are brought on by triggers.15 Triggers are irritants or allergens that can be found either indoors or outdoors. Common triggers include cold air, tobacco smoke, perfume, paint, hair spray, allergens (particles that cause allergies) such as dust mites, pollen, molds, pollution, animal dander, the common cold, influenza, and other respiratory illnesses. Eliminating and controlling triggers are the most effective way to prevent asthma exacerbations.
Economic Impact of Asthma
Nationally the economic burden of asthma is substantial with more than $14 billion annually (2002 estimates) attributed to direct and indirect costs associated with the disease.
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National
estimates for direct medical costs due to asthma totaled more than $9.4 billion in 2002. Inpatient hospitalizations were the biggest direct medical expenditure totaling more than $4 billion. Indirect
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costs associated with the disease are estimated to be over $4.6 billion. Indirect costs include loss of productivity due to missed school and work days. Missed school days represent the largest indirect expenditure with an estimated value of $1.4 billion of lost productivity annually.
Diagnosis of Asthma
The requirements for diagnosis of asthma include an evaluation of the patient's history of variable respiratory symptoms, physical examination, in addition to objective measures of pulmonary function.16 This history should include the patients past and current medical history, social and environmental history, and family history. Physical examination and testing for airflow obstruction, as well as reversibility and exercise testing are also used to determine a diagnosis of asthma. Elimination of alternative diagnoses (i.e., croup, congestive heart failure, cystic fibrosis, etc.) is also required. Once the diagnosis for asthma has been made, a statement about the level of severity
An Asthma Attack/Episode
According to the American Lung Association, the exact cause of asthma has yet to be determined. However, factors leading to an asthma
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attack or episode and what happens to the lungs during an attack or episode are well understood. During an asthma attack or episode the cells in the airways increase in mucus production, the airways
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Introduction
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should be included. Classification of asthma severity is based on frequency of daytime symptoms, frequency of nighttime symptoms, impact on daily life, lung function measurements, and diurnal variability. There are four levels of severity, which include severe persistent, moderate persistent, mild persistent, and mild intermittent. Severe persistent asthma is characterized by continual symptoms with frequent nighttime symptoms along with pulmonary function below 60% of predicted. Moderate persistent asthma is characterized by daily symptoms and nighttime symptoms occurring more than five times per month along with pulmonary function below 60% of predicted. Mild persistent asthma is characterized by symptoms occurring three to six times per week and nighttime symptoms occurring three to four times per month with pulmonary function at or above 80% of predicted. Mild intermittent asthma is characterized by occasional symptoms (twice or less per week) and occasional nighttime symptoms (twice or less per month) with pulmonary function at or above 80% of predicted.
faceted approach and include pharmacological treatments, patient and family education, and attempts to eliminate and control triggers.18 Common pharmacological treatments for asthma include anti-inflammatory medications, fast-acting bronchodilators, and leukotriene receptor antagonist medications. Anti-inflammatory medications prevent and reduce inflammation and swelling in the lungs.19 These medications are considered to be long-term, controller medications that take several days to become fully active. In all but one of the asthma severity classifications, (Mild Intermittent), controller medications should be the first line drugs of choice. Inhaled steroids are the most effective anti-inflammatory medications currently available. Although extremely critical to the prevention of asthma attacks, anti-inflammatory medications are not useful in stopping an acute exacerbation. Leukotrienes mediate airflow obstruction, hyperresponsiveness and inflammation through multiple channels.20 The leukotriene receptor antagonist medications help to prevent those effects. This class of medication is included in the controller category. Fast acting bronchodilators, which help to relax the muscles around the airways and reduce bronchoconstriction, are useful in helping to relieve an acute exacerbation.21 They are also used to reduce symptoms in exercise-induced asthma, when they are used to pre-treat before activity. Fast acting
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Treatment of Asthma
According to the National Institute of Health (NIH), the goals of asthma treatment should include: the prevention of chronic asthma symptoms and exacerbations, the maintenance of normal activity levels, normal or near-normal lung function, minimal side effects, and patient satisfaction with the care received.17 To obtain these goals, effective treatment of asthma should consist of a multi-
Arizona Comprehensive Asthma Control Plan
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bronchodilators should not be used as a regular every day treatment for asthma. According to NIH guidelines, if they are used more than twice a week, the patient should be strongly considered for controller therapy.22
12%.25 More than 390,000 Arizona adults, or approximately 12% were told by a doctor or health care professional they currently have asthma. In addition, more than 230,000 Arizona adults who currently have asthma reported having an episode or attack within the past year (approximately 59%). An average of 80 deaths occur each year in Arizona due to asthma.26 Currently, there is no statewide survey to accurately determine the number of children in Arizona with asthma. However, according to the nationwide survey (NHIS) utilizing U.S. Census data, it is estimated that more than 79,000 Arizona children have had an asthma episode in the past 12 months and that more than 120,000 Arizona children have been diagnosed with asthma at some time in their life.27 Table 3 below illustrates
Burden of Asthma in Arizona
Prevalence
In the past decade, asthma prevalence and mortality rates in Arizona have exceeded national averages in nine out of 10 years.23 The prevalence for asthma statewide increased from 11% in 200024 to 12% in 2003. More than 600,000 Arizonans have, at some time in their life, been diagnosed with asthma. In 2003, the prevalence rate for asthma among Arizona adults (persons 18 years of age or older) who have been diagnosed with asthma at
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some point in their lifetime was approximately
TA B L E
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Estimated Prevalence Rates For Most Arizona Counties Based On The NHIS For Pediatric Asthma And The Arizona BRFS For Adults
County COCHISE COCONINO GILA MARICOPA NAVAJO PIMA PINAL SANTA CRUZ YAVAPAI YUMA TOTAL:
Total Pop 120,439 120,295 51,565 3,303,876 102,202 881,221 196,275 40,035 179,057 167,407 5,162,372
14 & Under 26,629 28,495 10,531 774,314 28,993 184,249 41,032 11,099 30,548 41,136 1,177,026
65 & Over 18,250 8,561 10,410 374,333 10,340 124,925 31,649 4,376 39,073 28,799 650,716
Pediatric Asthma 2,683 2,869 1,072 75,751 2,936 18,303 4,106 1,109 3,123 4,083 116,035
Adult Asthma 7,698 7,913 3,260 216,543 6,009 58,660 12,893 2,379 11,921 10,329 337,605
Introduction
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estimated prevalence rates for most Arizona counties based on the NHIS for pediatric asthma and the Arizona BRFS for adults.28
White/Caucasian Arizonans followed by Hispanics/Latinos, and African Americans (65%, 16%, and 6% respectively). For persons under 21 years of age, Arizona Hospitalization Discharge Data show a total of 2,952 hospitalizations due to asthma as a primary complication.30 Approximately 39% of this group was between one and four years of age, 46% were between five and 14 years of age, and 9% were between 15 and 21 years of age. The average length of stay for this group was approximately 2.5 days with a total of 7,250 days for all hospitalizations. An average of $8,153 was spent per hospitalization with a total healthcare expenditure of $24 million.
Hospitalizations
Arizona Hospitalization Discharge Data show a total of 32,171 asthma-related hospitalizations for Arizona residents. The average length of stay was
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approximately four days with a total of 132,479 days for all asthma-related hospitalizations. An average of $20,185 was spent per hospitalization with a total healthcare expenditure of $650 million for all hospitalizations. Additionally, a greater number of females were hospitalized for asthma-related complications (66% females vs. 34% males). The majority of hospitalizations were among Non-Hispanic
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TA B L E
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Arizona Asthma Hospitalization Discharge Rates, 1999-2003
120 115 114 . 2 10 6 . 7 114 . 9
R AT E PER 100,000
110 105 100 95 90 85 80
98.2
89.4
19 9 9
2000
2001
2002
2003
YEAR
Arizona Comprehensive Asthma Control Plan
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Objectives
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Objectives
Epidemiology and Research
Objectives
1. Establish a surveillance system for accurately tracking asthma deaths, illness, disability, and f inancial burden in Arizona. 2. Support research investigating causes, triggers, and management of asthma as well as healthcare policies and outcomes particularly as the activities relate to state issues. adults living in Arizona. The BRFSS is not utilized to obtain data about participant family members. In addition to these two survey sources, the Arizona Department of Health Services, Bureau of Public Health Statistics maintains the Arizona Hospital Discharge Database. Hospital discharge data are available from this source for persons hospitalized with asthma as the primary diagnosis. This source does not include data from federal or Native American facilities and does not include emergency
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Rationale
Systematic asthma surveillance is essential as the f irst step in determining asthma's impact in Arizona. Asthma is not a condition reportable to the Arizona Department of Health Services, therefore obtaining asthma data from one centralized source is difficult. Currently, prevalence rate data for the disease are obtained from two sources: the NHIS and the BRFSS. The NHIS collects national asthma prevalence data from across the U.S. for survey participants and their families. State prevalence rates are then extrapolated from U.S. Census data utilizing Centers for Disease Control and Prevention (CDC) configured weights. The Arizona BFRSS collects data from selected
room data unless the person was admitted to the hospital. A surveillance system, which includes statespecif ic data for adults and children in addition to emergency room data from all medical institutions, is needed to more accurately assess the burden of asthma throughout Arizona. Currently pediatric prevalence rates are determined utilizing the NHIS data obtained from a national sample. A system to obtain more accurate state-specific data pertaining to pediatric asthma is needed to assess the burden of asthma for children in Arizona. Until emergency room data and hospitalization data from all medical
Arizona Comprehensive Asthma Control Plan
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facilities statewide are obtained, the true economic impact of the disease cannot be determined. A more comprehensive understanding of the distribution of the morbidity and mortality of asthma statewide will assist local efforts in the development, planning, implementation, and evaluation of programs for the disease. Although there is no cure for asthma and the cause of the disease has not been identified, scientif ic advances in the understanding of the disease have led to new and better techniques to manage the disease. Research findings about the role of airway inflammation have led to pharmacological treatments that have been key to successful disease management. In addition, a better understanding of environmental conditions and triggers related to asthma exacerbations has
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Develop
new surveys or utilize existing surveys
to collect data not available through existing data sources.
Expand
the Arizona BRFSS to include children
of survey participants.
Create
an infrastructure for emergency
department and hospitalization data to be obtained from all medical facilities statewide including federal and Native American institutions.
Conduct
special studies to assess the burden of
asthma among disparate populations.
Disseminate
reports based on acquired data to
community stakeholders.
Objective
2. Support research investigating causes, triggers, and management of asthma as well as healthcare policies and outcomes particularly as the activities relate to state issues.
evolved due in part from research findings. More research is needed to address issues pertaining to disease onset, progression, increases in prevalence rates, and potential cures for the disease.
Strategies
Increase
awareness for the need of asthma
research.
Objective
1. Establish a surveillance system for accurately tracking asthma deaths, illness, disability, and f inancial burden in Arizona.
Conduct
research studies on the link between
environmental triggers and asthma exacerbations.
Conduct Conduct Conduct
etiological studies on asthma. studies focusing on a cure for asthma. research on the increase of morbidity
Strategies
Establish
a standardized case definition of
asthma and establish criteria for the measurement of asthma morbidity and mortality.
Ensure
and mortality of asthma in Arizona, with an emphasis on disparate populations.
adequate resources to develop and
maintain new and existing surveillance systems.
Treatment and Management
Objectives
3. Increase the accuracy of diagnosing asthma in the pediatric and adult population by educating healthcare providers about methods and criteria for diagnosis. 4. Increase the proportion of persons in Arizona who receive appropriate care according to established guidelines. 5. Educate healthcare providers/professionals in Arizona to provide individuals with asthma and their families with the best practice of care, education and resources to effectively manage their condition.
Healthcare provider education on the current best practices for asthma is key to the improvement of asthma diagnosis and management as well as continuity of care for patients. Although many practitioners have at some point in their career received education on the diagnosis and management of asthma, keeping current on the latest best practices for the disease can be a challenge. Advances in asthma research and improved treatment strategies make it necessary for providers to continually receive education on current diagnostic methodology and management techniques. Strategies to assess usage barriers, promote guideline utilization, and facilitate provider
6. Increase the number of Arizonans with asthma who receive written management plans from their healthcare provider.
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education are needed to enable healthcare professionals to provide the best care possible for patients.
Rationale
Asthma is a very complex disease requiring continuity of care by all healthcare providers diagnosing, treating, and managing patients with the disease. The National Institutes of Health, National Heart, Lung, and Blood Institute (NIH/NHLBI) publishes a practical guide of best practices for the diagnosis and management of asthma for healthcare providers. Unfortunately, widespread adherence to these established guidelines has not been achieved. Numerous barriers including lack of consensus on best practices, time restraints, and access to educational sessions for rural providers prevent provider knowledge of and adherence to the established guidelines.
Due to the episodic nature of the disease, asthma can be difficult to diagnose. According to the NIH guidelines, establishing a diagnosis of asthma should include a medical history including the presence of symptoms of airway obstruction, objective measures of pulmonary function, and the exclusion of alternative diagnoses. Improved diagnosis of the disease could potentially speed up treatment efforts and eliminate ambiguous diagnoses such as reactive airway disease. According to the NIH guidelines, the goals of asthma treatment and management for patients should be to prevent chronic asthma symptoms including exacerbations, maintain normal activity levels, have normal or near-normal lung function, have no or minimal side effects, and be satisfied with the care received. These goals should be
Objectives
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obtained utilizing a comprehensive management approach including pharmacological interventions, implementation of environmental control measures, and patient education. Strategies need to be developed to enhance patient care and disease management utilizing a comprehensive approach. According to the NIH guidelines all persons with asthma should be provided written instructions on when to increase medications and return for care if symptoms worsen. These set of instructions are known as a written asthma action plan. A written asthma action plan should include: clear instructions on how to follow it; instructions on how to recognize signs of worsening asthma and signs that indicate the need to call the doctor or seek emergency care; and, when to use a fast-acting bronchodilator. The guidelines indicate that all patients with asthma should have a written asthma action plan and know how to use it. Unfortunately many asthmatic patients never receive an asthma action plan or instructions on how to follow the plan if supplied with one. Efforts need to be made to increase provider education on the use of written asthma action plans and techniques to educate patients on asthma action plans. Moreover, coordinated efforts among healthcare providers, school health offices, and parents need to be put into action to disseminate asthma action plans to school health offices for students with asthma.
Objective
3. Increase the accuracy of diagnosing asthma in the pediatric and adult population by educating healthcare providers about methods and criteria for diagnosis.
Strategies
Assess
the use of spirometry in the diagnosis of
asthma.
Improve
asthma diagnosis by utilizing objective
measurements of lung function and ruling out other diagnoses with similar symptoms.
Objective
4. Increase the proportion of persons in Arizona who receive appropriate care according to NIH/NHLBI guidelines.
Strategies
Assess
current provider knowledge of the NIH
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guidelines.
Identify
barriers, systemic and individual, to the
use of NIH guidelines by healthcare providers.
Promote
provider use of the NIH guidelines in
all healthcare settings.
Develop
and utilize protocols for the diagnosis
and treatment of asthma during hospitalization and emergency department visits based on the NIH guidelines.
Objective
5. Educate healthcare providers/professionals in Arizona to provide individuals with asthma and their families with the best practice of care, education and resources to effectively manage their condition.
Arizona Comprehensive Asthma Control Plan
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Strategies
Identify,
Coordinate
efforts with schools, health plans,
update and/or develop asthma
medical providers, government and nongovernment agencies, families, and other stakeholder organizations to promote, develop, use, and disseminate written asthma action plans for all patients with asthma.
Include
education curriculum for healthcare providers based on the NIH guidelines.
Conduct
provider education utilizing interactive
techniques on diagnosis and management of asthma.
Encourage
instructions on how to develop and use
written asthma action plans in healthcare periodic provider education sessions provider education programs.
Include
on NIH guideline updates.
Develop
instructions on the proper techniques
or adopt an asthma education program
and use of peak flow meters as related to written asthma action plans in healthcare provider education programs.
Develop
to certify health educators in Arizona.
Encourage
providers to promote healthy living
practices to patients such as good nutrition, physical activity, and yearly influenza vaccinations.
Create
and make available on-line a standard
asthma action plan.
an incentive program to motivate
Patient Education
Objective
7. Improve self-management knowledge and behavior in people with asthma, their families and other caregivers.
healthcare providers to participate in educational sessions.
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Partner
with non-profit agencies and
community organizations to facilitate provider education.
Develop
and promote standardized education
for pharmacists to facilitate pharmacy consultation with patients, families, and caregivers on the proper use of asthma medications and optimal techniques for peak flow meters and spacers.
Rationale
According to the NIH guidelines, the goal of all patient education is to help patients take the actions needed to control their asthma. These actions include: taking daily medications as prescribed,
Objective
6. Increase the number of Arizonans with asthma who receive written management plans from their healthcare provider.
using delivery devices (e.g. spacers, inhalers) correctly, identifying and controlling factors that increase symptoms, using a peak flow meter and monitoring symptoms, and following a written asthma action plan. Effective patient education
Strategies
Promote
should involve a partnership between patients and
the use of asthma management plans
as part of a larger comprehensive asthma education program for medical providers.
26
Objectives
Increase
...............
healthcare professionals with frequent reinforcement of key messages. Patient education should be comprehensive in approach and address patient concerns. In addition, patient education should address disease manifestation, compliance strategies, and quality of life issues. Good disease management should also be coupled with other healthy practices including good nutrition, abstinence from tobacco use, regular exercise, and yearly influenza vaccinations. Patients should be made aware that there is no cure for asthma, but with proper management the disease can be controlled.
funding for asthma education programs
that instill and promote good asthma management skills for youth and adults (e.g. asthma camps, patient workshops).
Establish
asthma support groups for patients,
families, and caregivers.
Develop
a clearinghouse of asthma related
information and resources available on the Internet.
Work
with community organizations to make
asthma education materials available at public libraries statewide.
Secondary Prevention
Objective
Strategies
Encourage
improved patient/provider
8. Reduce exposure to asthma triggers (allergens and irritants) in the home, preschool, school, workplace, and outdoor environment to prevent asthma episodes or reduce their severity.
27
relationships to enhance asthma education and self-management skills.
Educate
patients, families, and caregivers about
asthma and what happens during an asthma attack.
Educate
Rationale
Although there is no known cure for asthma,
patients, families, and caregivers about
environmental triggers and environmental control measures in the home.
Educate
research indicates that environmental triggers may induce asthma exacerbations. Triggers may include air pollutants, chemicals, mold, cockroaches, dust mites, pollen, animal dander, and viral respiratory infections. Attempts to reduce and eliminate asthma triggers from the environment are critical to reduce the impact of asthma in workplaces, schools, homes, and communities.
patients, families, and caregivers about
asthma medications and medical regimen adherence.
Educate
patients, families, and caregivers about
the use of asthma action plans and proper techniques for peak flow use.
Educate
patients, families, and caregivers about
healthy living practices including proper nutrition, exercise, and yearly influenza vaccinations.
Strategies
Promote
public awareness of environmental
factors that contribute to asthma exacerbations.
Arizona Comprehensive Asthma Control Plan
...............
Collaborate
with city neighborhood services to
Promoting asthma-friendly initiatives within the school setting should be approached utilizing a comprehensive design created to maximize school health services and draw upon existing community resources while promoting and fostering internal relationships among school personnel. This comprehensive approach should address issues regarding access to healthcare, student, staff, and family education, healthy school environments
promote environmentally healthy homes.
Educate
patients, families, and caregivers about
triggers and how to eliminate and avoid them.
Develop
and update existing educational
materials on occupational asthma.
Disseminate
educational materials on
occupational asthma to employers, employees, healthcare providers, and health insurance plans.
Promote
indoor air quality management plans
for all public buildings.
Promote
including indoor and outdoor air quality, and the promotion of physical activities.
awareness of secondhand smoke and
its effect on people with asthma.
Asthma-friendly initiatives should also be promoted within the childcare setting. Childcare
School/Childcare Issues
Objectives
9. Maximize good asthma management practices
28
staff should be mandated to acquire education on what asthma is, symptom recognition, and what to do in emergent situations. In addition, childcare facilities should aim to reduce environmental triggers and adopt clean indoor and outdoor air management plans.
in the school setting. 10. Maximize good asthma management practices in the childcare setting.
Objective Rationale
The impact of asthma in the school setting is quite significant. Annually, millions of days of school are missed due to asthma. According to the CDC, asthma is the number one cause of school absenteeism for school-aged children with chronic health conditions. Management of asthma within the school setting is vital for children with the disease to be present and able to learn. School health services should empower students to manage their disease, work to reduce exacerbations, and be able to respond to emergencies when necessary.
Provide Establish
9. Maximize good asthma management practices in the school setting.
Strategies
Promote
comprehensive healthcare for students
with asthma. and promote a standardized asthma
education curriculum for school personnel. age-appropriate asthma education
programs for children with asthma in the school setting.
Objectives
In
...............
partnership with the Arizona Department of
Objective
10. Maximize good asthma management practices in the childcare setting.
Education, establish standardized asthma management protocols, policies, and guidelines for school districts statewide. These policies should address issues such as medication access.
Educate
Strategies
Establish
school personnel, parents, healthcare
and implement standardized asthma
providers, and students about asthma medication "self-carry" policies.
Promote
education curriculum for childcare staff.
Establish
standardized asthma management
indoor air quality and environmental
protocols and policies for childcare centers statewide.
Promote
management plans to school districts statewide.
Promote
that there be one full-time nurse in
indoor air quality and environmental
every school across the state.
Develop
management plans to childcare providers statewide.
Promote
a strategy to assist school nurses in
obtaining written asthma action plans from physicians for all children with asthma.
Enhance
that asthma education be included as
part of childcare provider licensure.
Develop
and encourage school-based asthma
a strategy to assist childcare facilities
surveillance for missed school days and student prevalence rates.
Develop
in obtaining written asthma action plans from physicians for all children with asthma.
Develop
a system to distribute poor air
a system in accordance with HIPAA
29
quality/high ozone warnings to school districts and establish alternative activities for children with respiratory illnesses on these days.
Promote
regulations to share written asthma action plans with appropriate childcare personnel.
Disparities
Objective
11. Identify and eliminate disparities in asthma prevention, diagnosis, and management throughout the state.
physical activity/education and sports
program participation for students with asthma.
Increase
funding to provide asthma-related
resources and education to school nurses and health aides.
Support
student enrollment/utilization of
school-based health clinics.
Develop
Rationale
Asthma does not affect all Arizonans equally. Disparities in the morbidity and mortality for certain groups exist. Among Arizona communities, disparities may be characterized by race, ethnicity, gender, age, income, health status, education, sexual
a system in accordance with HIPAA
regulations to share written asthma action plans with appropriate school personnel.
Arizona Comprehensive Asthma Control Plan
...............
orientation, or geographic location. In Arizona asthma disproportionately affects African Americans and individuals of low socioeconomic status. In addition, females have higher prevalence rates for the disease than males and children under the age of 14 years old are more likely to be hospitalized for the disease than adults. For asthma, health disparities and low socioeconomic status are closely related. According to the U.S. Census Bureau, almost 10% of Arizonans currently live in poverty. Inadequate or lack of insurance coverage, substandard housing conditions, and the lack of resources to effectively control the disease lead to increase hospitalizations and deaths for people of low socioeconomic status. Other factors also contribute to health disparities in Arizona for asthma. These factors include
30
Strategies
Identify
specific populations with increased
rates of asthma and/or with limited access to asthma resources.
Explore
factors contributing to the burden of
asthma in identified disparate populations.
Collaborate
with partners to identify and
promote available asthma-related resources and education to rural and border communities.
Develop,
promote, and disseminate asthma-
related resources that are culturally sensitive.
Develop,
promote, and disseminate asthma-
related resources that meet the needs of all Arizona residents taking into account factors such as socioeconomic status, race, education level, language, and age.
Investigate
the utilization of mobile clinics (e.g.
Breathmobiles) to deliver services to remote communities across the state.
Working
cultural and language barriers, physical distance, lack of transportation in rural areas, and an increase in the geriatric population. In addition, many remote communities in Arizona have difficulty recruiting and retaining healthcare professionals. Improving access to care is critical in eliminating health disparities in Arizona for asthma. Encouraging families to have on-going primary care is essential. Improving access to educational programs, medications, and monitoring devices is also needed. In addition, educational programs curriculum should be culturally and linguistically sensitive and age-appropriate.
in conjunction with the Arizona Health
Care Cost Containment System, develop a system to aid uninsured residents to obtain health insurance coverage.
Identify
emergency assistance programs and
organizations providing free or discounted services, medications, and/or medical equipment statewide.
Assist
healthcare providers and community
healthcare organizations to provide asthma education to all patients diagnosed with asthma in Arizona.
Collaborative Efforts
Objective
12. Foster communication, collaboration, and networking opportunities among patients, caregivers, healthcare professionals, public health officials and other stakeholders.
32
Objectives
...............
Rationale
Partnerships are essential for any successful disease control program. For asthma, local and statewide coalitions and stakeholder workgroups exist. These collaborative efforts among medical organizations, government agencies, patient groups, and policy makers serve to provide a concerted effort in reducing the prevalence and mortality of the disease. By sustaining and expanding strong networks, stakeholders can address barriers to good asthma care, promote unified, consistent messages to raise awareness of asthma, promote established clinical guidelines, create and implement a standardized patient education program, reach undiagnosed patients with information, and create a platform for community advocacy to combat the disease.
Advocacy
Objective
13. Advocate and support policies that promote asthma-friendly communities.
Rationale
Asthma-friendly communities can aid in the overall reduction of disease morbidity and mortality. Educating policymakers about asthma and the issues and barriers surrounding good asthma care in Arizona can provide an infrastructure for future legislative action. Efforts should focus on eliminating disparities in disease treatment and management and promoting healthy living environments for all Arizonans. Moreover, efforts should serve to engage and mobilize community members to take actions in reducing environmental asthma triggers and address indoor and outdoor air quality issues.
33
Strategies
Secure
resources to support a statewide asthma
coalition as an ongoing effort to develop and promote partnerships among stakeholders to address barriers to good asthma care and management.
Encourage
Strategies
Educate
policymakers about the burden of
asthma in Arizona.
Improve
stakeholders to convey clear,
health coverage for uninsured or
consistent messages about asthma-related issues.
Develop
underinsured populations/patients with asthma.
Promote
the delivery of consistent asthma
and disseminate a resource list of
messages and policy recommendations so as to focus efforts on priority issues and concerns.
Promote
on-going statewide resources and educational programs.
clean indoor and outdoor air quality. exposure to environmental asthma
Decrease
triggers.
Support
a statewide smoke-free initiative in all
public buildings.
Arizona Comprehensive Asthma Control Plan
...............
Bring
asthma stakeholders together to
Raise
Arizona residents' awareness about
continually refine, alter, promote and monitor the implementation of the Arizona Comprehensive Asthma Control Plan.
asthma and secondhand smoke.
Disseminate
consistent materials and messages
about asthma to community groups, schools, businesses, and policymakers.
Promote
Public Awareness
Objective
14. Improve public awareness and sensitivity to the needs of persons with asthma.
basic asthma emergency protocols in
f irst aid and emergency care courses.
Future Directions
The ultimate goal of creating a comprehensive asthma control plan should be to coordinate existing services and available resources, identify gaps in services, and provide a guide for future endeavors. In order to achieve this goal, future steps for the Arizona Comprehensive Asthma Control Plan should include stakeholder participation in assessing and modifying the plan as workgroups see f it and continual assessment of strides made in achieving the goals and objectives set forth. In addition, the plan should be updated and revised on a continual basis to ensure the plan is addressing relevant issues and meeting the needs of persons with asthma statewide.
Rationale
Increasing awareness of asthma as a public health concern among the general public can aid efforts in reducing the morbidity and mortality of the disease and increase the quality of life for those afflicted with the disease. Many individuals are unaware of the seriousness of asthma and how
34
debilitating it can be if uncontrolled. Moreover, many Arizonans are unaware of the link between asthma exacerbations and environmental triggers such as secondhand smoke and air pollutants. Concerted efforts should be made to educate and inform the general public about pertinent asthmarelated issues.
Strategies
Raise
Arizona residents' awareness about
asthma as a significant public health issue by promoting asthma-related events, activities and educational opportunities.
Raise
Arizona residents' awareness about
asthma and environmental triggers.
Raise
Arizona residents' awareness about
asthma and indoor and outdoor air quality.
References
...............
References
1 Arizona Department of Health Services, Public Health Prevention Services. Arizona Chronic Disease Surveillance Indicators Report, September 2004. 2 National Center for Health Statistics. Current Estimates from the National Health Interview Survey U.S., 2003. Washington, DC: Department of Health and Human Services, Public Health Services, Vital and Health Statistics. Available from URL: http://www. cdc.gov/nchs/fastats/asthma.htm. 3 American Lung Association, Epidemiology & Statistics Unit, Research and Scientific Affairs. Trends in Asthma Morbidity and Mortality, April 2004. 4 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 5 Arizona Department of Health Services, Bureau of Epidemiology and Disease Control, Office of Environmental Health. Arizona's Children and the Environment, December 2003. 10 American Lung Association. Asthma Fact Sheet, 2004. Available from URL: http://www.lungusa.org/site/pp.asp?c=dvLUK9O 0E&b=22596 6 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 7 National Center for Health Statistics. Current Estimates from the National Health Interview Survey U.S., 2003. Washington, DC: Department of Health and Human Services, Public Health Services, Vital and Health Statistics. Available from URL: http://www. cdc.gov/nchs/fastats/asthma.htm. 8 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 9 National Center for Health Statistics. Asthma Prevalence, Health Care Use and Mortality, 2002. Available from URL: http://www.cdc.gov/nchs/products/pubs/pubd/he stats/astham/astha.htm.
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Arizona Comprehensive Asthma Control Plan
...............
11 National Center for Health Statistics. Asthma Prevalence, Health Care Use and Mortality, 2002. Available from URL: http://www.cdc.gov/nchs/products/pubs/pubd/he stats/ asthma/astha.htm. 12 National Center for Health Statistics. Early Release of Selected Estimates Based on Data From the January-March 2004 National Health Interview Survey, September 2004. 13 American Lung Association, Epidemiology & Statistics Unit, Research and Scientific Affairs. Trends in Asthma Morbidity and Mortality, April 2004. 14 American Lung Association of Arizona. Asthma Fact Sheet, 2004. Available from
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18 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997. 19 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 20 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997. 21 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human
URL:http://www.lungusa.org/site/pp.asp?c=dvL UK9O0E&b=22596 15 American Lung Association of Arizona. Asthma Fact Sheet, 2004. Available from URL:http://www.lungusa.org/site/pp.asp?c=dvL UK9O0E&b=22596 16 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 17 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997.
Services, National Institute of Health. Publication No. 97-4051. July 1997. 22 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997.
23 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997. 24 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 25 Arizona Department of Health Services, Department of Epidemiology. Arizona Behavioral Risk Factor Survey Database, 2000. Available from URL: http://www.azdhs.gov/ plan/hip/for/asthma/index.htm
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28 Centers for Disease Control. National Health Institute Survey Public USe Data Release, 2003. 29 American Lung Association. State of the Air Report, 2004. Available from URL: http://lungaction.org/reports/SOTA04_statesensit ive.html 30 Arizona Department of Health Services. Arizona Hospital Discharge Data, 2003.
26 Arizona Department of Health Services, Department of Epidemiology. Arizona Behavioral Risk Factor Survey Database, 2003. 27 Arizona Department of Health Services. Arizona Vital Statistics, 2003. Available from URL:http://www.azdhs.gov/plan/report/ahs/ahs2 003/toc03.htm
"
Asthma is one of the nation's most common and costly diseases, affecting over 31 million Americans, with direct and indirect costs exceeding $14 billion annually.
"
Arizona Comprehensive Asthma Control Plan
Arizona Department of Health Services Division of Public Health
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To b a c c o E d u c a t i o n a n d P r e v e n t i o n P r o g r a m w w w. a z d h s . g o v
