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Asthma can have a significant impact on a patient’s quality of life. The development of a comprehensive High-Risk Asthma Program can alleviate this impact by allowing targeted interventions designed to improve control and reduce the patient’s risk of adverse asthma outcomes and mortality. 1

TEACHING POINT 1: Identify Key Personnel

 

The identification of key personal within your organization is the first step in developing a successful program. The task force should include dedicated, interested professionals that represent different departments within your facility to develop and implement your program. You should include representation from physicians, nurses, respiratory therapists and medical assistants. You might even consider involving someone from the operational side of the practice to ensure that any policies that are made regarding scheduling or electronic records are able to be implemented within your current system.

Once identified, this task force should meet on a regular basis and share their progress with the group as whole at regular intervals. Accountability and transparency throughout the program development process will make it easier to sustain forward momentum and assure that the group is meeting the practice’s needs.

It is also critical to develop achievable program goals which should serve as your guide for each step of program development and should be revisited frequently throughout the process.

The National Heart, Lung, and Blood Institute (NHLBI) Guidelines 2 state that the goals for successful management of asthma are:

  • Achieve and maintain control of symptoms
  • Maintain normal activity levels, including exercise
  • Maintain pulmonary function as close to normal as possible
  • Prevent asthma exacerbations
  • Avoid adverse effects from asthma medications
  • Prevent asthma mortality

These are the goals we use for all of our patients with asthma, yet it is important to establish the goals of your High-Risk Asthma program as they relate to your unique patient population. Some questions you may want to ask yourself are: Are you interested in maintaining data that could be useful for research purposes? Is the intent of the program to add consistency to the medical management of the identified patients? Are you aiming for increasing asthma control? Or is your practice interested in meeting more than one or all of these goals?

Which of the following criteria is not part of the Health Plan Employer Data and Information Set (HEDIS) definition of high-risk asthma?

a) ≥1 emergency department visits
b) ≥1 hospitalizations for asthma
c) ≥1 oral steroid prescriptions for asthma
d) ≥5 ambulatory visits for asthma plus 2 prescriptions
 

TEACHING POINT 2 / Discussion: Identify Patients

 

Identifying patients with high-risk asthma can be one of the most challenging aspects of your program. The Health Plan Employer Data and Information Set (HEDIS) definition of high-risk asthma is one method that can be used to identify patients. Published in 2006 and revised in in 2007 in order to reduce the amount of misclassification, the definition requires patients to meet at least one of the utilization criteria in a 12-month period for two consecutive 12-month periods and the criteria met in each period do not need to be the same ones. 3

Other tools are available to assist practitioners in patient identification as well. Another option would be the Asthma Control Test. Practitioners should decide if they are going to use a screening form, a check list or rely on clinicians to select patients from their asthmatic patients.

When a patient is identified as having high-risk asthma, it is important to let the patient or parent know of the designation. This message needs to be delivered in a clear and confident manner in order to prevent heightening the patient’s anxiety regarding their disease. It is important to convey that by including the patient in the High-Risk Asthma Program you are taking extra measures to reduce the burden of their disease and minimize risk for mortality.

True/False: For clinicians, classification of asthma severity is typically based on the severity of the underlying disease and responsiveness to treatment. Severity is a varying feature and can change over months to years.

a) True
b) False
 

Discussion:

 

When determining which patients in your practice are at risk, it is helpful to consider disease severity as well as asthma control. The NHLBI Asthma Guidelines 2 outline the following asthma history items risk factors for death from asthma:

  • Previous severe exacerbation requiring intubation or intensive care unit (ICU) admission
  • > 2 hospitalizations for asthma in the past year
  • > 3 Emergency Department (ED) visits for asthma in the past year
  • A hospitalization or ED visit for asthma in the past month
  • Using > 2 canisters of a short acting beta agonist per year
  • Difficulty perceiving asthma symptoms or severity of flare-ups
  • Not having a written asthma action plan
  • Sensitivity to Alternaria

TEACHING POINT 3: Tools

 

A comprehensive High-Risk Asthma Program should work toward reducing risk from adverse asthma outcomes and mortality. This approach typically involves most if not all of the following components:

Case Management

  • Patients are seen or contacted at least 3 to 4 times a year for “well” asthma care in addition to any acute asthma care visits that are required
  • Scheduled contact by telephone or text
  • Close follow-up for any missed or cancelled appointments

Medical Management

  • Consistent application of standard asthma guidelines working through stepwise asthma care
  • Monitoring indicators of slipping asthma control such as increased frequency of refills for short-acting beta agonists
  • Identifying and treating asthma co-morbidities such as allergies, gastroesophageal reflux disease and sinus disease

Self-Management

  • Every patient has a written asthma action plan that outlines steps for early warning signs as well as escalating symptoms
  • Consideration of a small supply of oral corticosteroids at home
  • Patient specific asthma education
  • Access to written asthma education materials

TEACHING POINT 4: Monitoring Interventions

 

At regular intervals, it is important to track progress with the pre-determined goals or endpoints of your program. There are a variety of outcomes measures you can select to track your progress. For example: The Singapore National Asthma Program followed over 3400 high-risk asthma patients from August 2001 to January 2010 and monitored school absence, parents lost days of work, symptomatic days, symptomatic nights and interruption in activity. Additionally they tracked healthcare utilization and found that emergency department usage dropped from 66% on the first visit to 11% on the 6th visit. 4

Conclusion:

 

We know that asthma is a chronic, variable disease that is associated with significant morbidity and mortality. The development of a comprehensive High-Risk Asthma Program can help us help our patients and reduce their burden of disease.

References:

 

1.  Greineder DK, Loane KC, Parks P. Reduction in Resource Utilization by an Asthma Outreach Program. Arch Pediatr Adolesc Med. 1995 Apr; 149(4):415-20.

2.  National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug; Available: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

3.  Bennett AV, Lozano P, Richardson LP, et al., Identifying high-risk asthma with utilization data: a revised HEDIS definition. Am J Manag Care. 2008 Jul; 14(7):450-6.

4.  KK Women’s and Children’s Hospital. Clinical Outcome on High Risk Asthma Patients. Available: http://www.kkh.com.sg/AboutUs/ClinicalOutcomes/Pages/HighRiskAsthmaOutcomes.aspx Accessed: March 12, 2012.

Comments and Discussion:

 

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