# Presentation: 229271

## Key Clinical Activities for Quality Asthma Care 

**Seymour Williams****1****, Diana Schmidt****2****, Stephen Redd****1**
**1****National Center for Environmental Health, CDC**
**2****National Asthma Education Prevention Program NHLBI/NIH**

## Acknowledgments

**Members of the Document Development Working Group **
**American College of Allergy, Asthma and Immunology, **_**William Storms**_**, M.D., Colorado Springs, Colorado, (Chair); **
**American Academy of Family Physicians, **_**Barbara Yawn**_**, M.D., Rochester, Minnesota; **
**American College of Chest Physicians, **_**John P. Mitchell**_**, M.D., Davis, California; **
**American Society of Health System Pharmacists, **_**Leslie Hendeles**_**, Pharm.D., Gainesville, Florida; **
**National Institutes of Health, **_**Diana Schmidt**_**, M.P.H., **_**Virginia Taggart**_**, M.P.H., Bethesda, Maryland; **
**Environmental Protection Agency, **_**Tracey Mitchell**_**, Washington**
**Society for Academic Emergency Medicine, **_**Carlos Camargo**_**, M.D., Dr.P.H., Boston, Massachusetts**
**Centers for Disease Control and Prevention, **_**Stephen Redd**_**, M.D., Atlanta, Georgia; **

**Members of the Professional and Patient/Public Education Subcommittee of the National Asthma Education and Prevention Program**

## Essential Elements of the Asthma Guidelines

**What: Key activities of the components of the asthma guidelines that define quality care**
**Why: Provide tool and simplify lengthy detailed guideline document**
**Who: Health benefits managers and planners**
**How: Detailed review, in light of current measures and goals**
**When: Spring 2003**

## Publication of Key Clinical Activities for Quality Asthma Care: Recommendations of the National Asthma  Education and Prevention Program

**Publication of ****Key Clinical Activities for Quality Asthma Care: Recommendations of the National Asthma  Education and Prevention Program**

- MMWR Recommendations and Reports, Volume 52, Number RR-6,.
- Adobe PDF format: _[http://www.cdc.gov/mmwr/PDF/rr/rr5206.pdf](http://www.cdc.gov/mmwr/PDF/rr/rr5206.pdf)_
- HTML (web) format: _[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5206a1.htm](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5206a1.htm)_

## Why Is the Document Useful ?

**Provide template of minimum standards**
**Attempt to bring some uniformity**
**Increase implementation and compliance**

## Components of Care, Key Clinical Activities and Actions Steps for Providing Quality Asthma Care

| Components of Care | Key Clinical Activities | Action Steps |
| --- | --- | --- |
| Assessment and Monitoring | 1.  Establish Asthma Diagnosis | Establish a pattern of symptoms and history of recurrent episodes.
Document reversible airflow using spirometry
Rule out other conditions. |
|  | 2. Classify Severity of Asthma | Follow the NAEPP classification system and recheck at every visit |
|  | 3. Schedule Routine Follow up Care | See patients at least every 1 to 6 months according to  severity
Perform spirometry at least every 1-- 2 years for the stable patient, more often in the unstable patient.
Review medication use, care plan, and self-management skills at every visit.	 |
|  | 4. Assess for Referral to Specialty Care | Refer to specialty care when referral criteria are met as listed in the text.	 |
| Control of Factors Contributing to Asthma Severity | 5. Recommend Measures to Control Asthma Triggers | Determine exposures and sensitivities, including environmental and occupational triggers.
Review ways to reduce exposure to allergens and irritants that provoke asthma symptoms.
Discuss smoking avoidance with every patient who smokes or who is exposed to ETS.
Assess for EIB if symptoms occur during exercise and provide medication and advice to enable physical activity. |
|  | 6. Treat/Prevent Comorbid Conditions | Consider, particularly, rhinitis, sinusitis, GERD, COPD.
Provide annual influenza vaccination for patients with persistent asthma. |

- COPD- Chronic Obstructive Pulmonary Disease 		GERD- Gastro-Esophageal Reflux Disease
- EIB- Exercise Induced Bronchoconstriction 		NAEPP- National Asthma Education and Prevention Program
- ETS- Environmental Tobacco Smoke

## Components of Care, Key Clinical Activities and Actions Steps for Providing Quality Asthma Care

| Components of Care | Key Clinical Activities | Action Steps |
| --- | --- | --- |
| Pharmacotherapy | 7. Prescribe Medications According to Severity | Reduce inflammation in patients with persistent asthma with anti-inflammatory medications.
Increase medications if necessary; decrease  when possible.
Provide appropriate medication delivery and monitoring devices.
Recommend spacers, nebulizers or both if needed and PFM for patients with moderate to severe asthma or a history of severe exacerbations. |
|  | 8. Monitor Use of ß2-Agonist Drugs | Reevaluate patients using more than one canister per month of short-acting ß2-agonist drug. |
| Education for Partnership in Care | 9. Develop a Written Asthma Management Plan | Agree on therapy goals.
Outline daily treatment and monitoring measures.
Prepare an action plan to handle worsening  symptoms/exacerbations. |
|  | 10. Provide Routine Education on Patient Self-Management | Teach/Review
- How and why to take long-term control and quick relief medications
- Correct technique for Inhaler, spacer, PFM and nebulizers as indicated 
- Peak flow/symptom monitoring with patients when appropriate
- Factors that worsen asthma and actions to take |

- PFM- Peak Flow Meter

##  Establish Asthma Diagnosis

**Identify pattern of symptoms and history of recurrent episodes.**
**Document reversible airflow using spirometry.**
**Rule out other conditions**

## Use the NAEPP system
Initially based on day and night symptoms, spirometry and peak flow monitoring
Once patient stable, based on level of medication required to maintain treatment goals
Level determines treatment and management
Perform at every visit

**Initially based on day and night symptoms, spirometry and peak flow monitoring**
**Once patient stable, based on level of medication required to maintain treatment goals**
**Level determines treatment and management**
**Perform at every visit**

**Classify Severity of Asthma**

## Schedule Routine Follow up Care

**See patients at least every 1 to 6 months according to  severity**
**Perform spirometry at least every 1-****-**** 2 years for the stable patient, more often in the unstable patient.**
**Review medication use, care plan, and self-management skills at every visit.****	**

**Notes:**
Review text from slide

## Classification of Asthma Severity

## Recommend Measures to Control Asthma Triggers

**Determine exposures and sensitivities, including environmental and occupational triggers.**
**Review ways to reduce exposure to allergens and irritants that provoke asthma symptoms.**
**Discuss smoking avoidance with every patient who smokes or who is exposed to ETS.**
**Assess for Exercise Induced Bronchospasm if symptoms occur during exercise and provide medication and advice to enable physical activity.**

## Treat/Prevent Comorbid Conditions

**Consider, particularly, rhinitis, sinusitis, GERD, COPD.**
**Provide annual influenza vaccination for patients with persistent asthma.**

## Prescribe Medications According to Severity

**Reduce inflammation in patients with persistent asthma with anti-inflammatory medications.**
**Step up medications, if necessary; step down, when possible.**
**Provide appropriate medication delivery and monitoring devices.**
**Recommend spacers and/or nebulizers if needed and PFM for patients with moderate to severe asthma.**

## Monitor Use of ß2-Agonist Drugs

**Reevaluate patients using more than one canister per month of short-acting ****ß****2-agonist drug.**

## Develop a Written Asthma Management Plan

**Agree on therapy goals.**
**Outline daily treatment and monitoring measures.**
**Prepare an action plan to handle worsening  symptoms/exacerbations.**

## Provide Routine Education on Patient Self-Management

**Teach/Review**
**How and why to take long-term control and quick relief medications**
**Correct technique for Inhaler, spacer, PFM and nebulizers as indicated **
**Peak flow/symptom monitoring with patients when appropriate**
**Factors that worsen asthma and actions to take**

## Key Clinical Activities for Quality Asthma Care 

**Derived from the Expert reports and used to define quality asthma care**
**Address the proper assessment, control, pharmacotherapy and education of the patients with asthma**
**Provides specific ways to accomplish the respective key activity**

## Recommendation

**Use as a minimum standard**
**“****Bill of rights” for patients with asthma**
**Guidance for purchasers (health benefits managers, medical directors, etc.)**
**Use clinical activities to document asthma care in the medical record**