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Medical Home Chapter Champions Program on Asthma, Allergy,
and Anaphylaxis (MHCCPAAA)
Educational and Networking Conference
October 9-10, 2015
DoubleTree Hotel -- Rosemont, Illinois
TABLE OF CONTENTS
General Conference Information
Conference Schedule
Educational Need, Learning Objectives, and Acknowledgement of Support
Faculty
Planning Group
Continuing Medical Education Credit
Disclosures
General Sessions
Medical Home: A Primer for Pediatrics and Chapter Champions
Presented by: Adriana Matiz, MD, FAAP
Food Allergy and Anaphylaxis: Myths, Facts, and Addressing Misperceptions in the Primary Care
Setting
Presented by: Michael Pistiner, MD, MMSc, FAAAAI, FAAP
Food Allergy and Anaphylaxis: What’s on Primary Care’s Plate
Presented by: Ruchi S. Gupta, MD, MPH, FAAP
Critical Partnerships: Schools, Child Care, and Families
Presented by: Michael Pistiner, MD, MMSc, FAAAAI, FAAP and David Stukus, MD, FAAAAI, FACAAI,
FAAP
Culturally Effective Care = Effective Care
Presented by: Rhonique Shields Harris, MD, MHA, FAAP
Asthma Care: Advice from a Subspecialist
Presented by: Julie Katkin, MD, FAAP
Children and Teens with Asthma: Raising the Floor in Pediatrics
Presented by: James Stout, MD, MPH, FAAP
Bringing It All Together: What’s Your Action Plan?
Presented by: Chuck Norlin, MD, FAAP
Concurrent Breakout Sessions - Friday
(1)/(3) What’s Hot in Food Allergy: What Will We Need to Know Tomorrow?
Presented by: David Stukus, MD, FAAAAI, FACAAI, FAAP
(2)/(4) Approaches to Remote Monitoring and Telehealth
Moderated by: James Stout, MD, MPH, FAAP
Panel Presenters: Jay M. Portnoy, MD, FAAP, Mark Ruthman, David Stukus, MD, FAAAAI, FACAAI,
FAAP, and Tonya Winders, MBA
Concurrent Breakout Sessions - Saturday
(5)/(7) Quality Improvement Meets Asthma, Allergy, and Anaphylaxis
Presented by: David Stukus, MD, FAAAAI, FACAAI, FAAP
(6)/(8) Breaking Down the Barriers to Adherence
Presented by: Julie Katkin, MD, FAAP
CONFERENCE SCHEDULE
Friday, October 9, 2015
1:00pm-4:15pm
Registration Desk Open (Signature Ballroom Foyer)
1:30-1:40pm
Welcome and Announcements (Signature II)
Chuck Norlin, MD, FAAP
Fan Tait, MD, FAAP
1:40-2:15pm
Medical Home: A Primer for Pediatrics and Chapter Champions (Signature II)
Adriana Matiz, MD, FAAP
2:15-2:25pm
Question & Answer Session (Signature II)
2:25-3:00pm
Food Allergy and Anaphylaxis: Myths, Facts, and Addressing Misperceptions in the
Primary Care Setting (Signature II)
Michael Pistiner, MD, MMSc, FAAP, FAAAAI
3:00-3:35pm
Food Allergy and Anaphylaxis: What’s on Primary Care’s Plate? (Signature II)
Ruchi S. Gupta, MD, MPH, FAAP
3:35-3:55pm
3:55-4:15pm
Break (outside Medallion and Mister Lincoln Rooms)
4:15-5:15pm
Concurrent Breakout Sessions
A1.
What’s Hot in Food Allergy – What Will We Need to Know Tomorrow?
(Medallion Room)
David Stukus, MD, FAAP, FAAAAI, FACAAI
A2.
Approaches to Remote Monitoring and Telehealth (Mister Lincoln Room)
Moderator: James Stout, MD, MPH, FAAP
Panel Presenters: Jay M. Portnoy, MD, FAAP, Mark Ruthman, David Stukus,
MD, FAAP, FAAAAI, FACAAI and Tonya Winders, MBA
5:15-5:30pm
Break (outside Medallion and Mister Lincoln Rooms)
5:30-6:30pm
Concurrent Breakout Sessions (repeated)
A3.
What’s Hot in Food Allergy – What Will We Need to Know Tomorrow?
(Medallion Room)
A4.
Approaches to Remote Monitoring and Telehealth (Mister Lincoln Room)
Moderator: James Stout, MD, MPH, FAAP
Panel Presenters: Jay M. Portnoy, MD, FAAP, Mark Ruthman, David Stukus,
MD, FAAP, FAAAAI, FACAAI and Tonya Winders, MBA
6:30-7:00pm
Break
7:00-8:30pm
Dinner & MHCC Spotlight Presentations (Signature III)
AMA PRA Category 1 Credit(s)™ for Friday: 3.75
Saturday, October 10, 2015
7:00-8:00am
Breakfast/Networking (Signature Ballroom Foyer)
8:00-8:15am
Welcome and Announcements (Signature II)
Adriana Matiz, MD, FAAP; Tonya Winders, MBA
8:15-8:50am
Critical Partnerships: Schools, Child Care, and Families (Signature II)
Michael Pistiner, MD, MMSc, FAAP, FAAAAI
8:50-9:25am
Culturally Effective Care = Effective Care (Signature II)
Rhonique Shields Harris, MD, MHA, FAAP
9:25-9:40am
9:40-9:55am
Break (Signature Ballroom Foyer)
9:55-10:30am
Asthma Care: Advice from a Subspecialist (Signature II)
Julie Katkin, MD, FAAP
10:30-11:05am
Children and Teens with Asthma: Raising the Floor in Pediatrics (Signature II)
James Stout, MD, MPH, FAAP
11:05-11:20am
11:20-11:30am
11:30am-12:45pm
Lunch/Networking/Roundtable Discussions (Signature I / 1ABC)
12:45-1:45pm
Concurrent Breakout Sessions
B5.
Quality Improvement Meets Asthma, Allergy and Anaphylaxis (Medallion Rm.)
B6.
Breaking Down the Barriers to Adherence (Mister Lincoln Room)
1:45-2:00pm
2:00-3:00pm
Concurrent Breakout Sessions (repeated)
B7.
Quality Improvement Meets Asthma, Allergy and Anaphylaxis (Medallion Rm.)
B8.
Breaking Down the Barriers to Adherence (Mister Lincoln Room)
3:00-3:10pm
3:10-3:40pm
Bringing It All Together: What’s Your Action Plan? (Signature II)
3:40-3:45pm
Closing Remarks (Signature II)
AMA PRA Category 1 Credit(s)™ for Saturday: 6.25
Maximum AMA PRA Category 1 Credit(s)™ for Conference: 10.00
EDUCATIONAL NEED
Many physicians and health care professionals who provide primary care to pediatric patients have
not yet adopted the medical home model even though it is widely known to be the standard for
providing high-quality, comprehensive, and cost-effective health care. As a Medical Home Chapter
Champion, you play a critical role in the dissemination of best policies and practices to pediatric health
care providers nationwide through the leadership and networks of AAP chapters; advocacy for change
at the local, state, and national levels; the provision of technical assistance, as well as tools and
resources to pediatricians and other pediatric health care providers; and assistance in aligning
national and state, local, and/or community priorities.
LEARNING OBJECTIVES
Through your participation at the 2015 MHCCPAAA Educational and Networking Conference, you will
be better equipped to:





Provide guidance and support to health care professionals to advance the implementation of
medical homes for children with asthma, allergy, and/or anaphylaxis.
Apply and promote team-based, family-centered care and effective co-management between
primary and subspecialty care settings to improve outcomes for children with asthma, allergy,
and/or anaphylaxis.
Evaluate the most up-to-date evidence and practice guidelines to distinguish myths vs. facts, and
apply these in daily practice.
Identify strategies for overcoming cultural barriers and educating patients and families to support
and improve treatment adherence.
Serve your local area as a Medical Home Chapter Champion (MHCC), and leverage collaborative
relationships, available resources, and networking opportunities to develop and implement a
clear, measurable action plan for the next year.
ACKNOWLEDGEMENT OF SUPPORT
This conference is supported by grants from the AAP Friends of Children Fund and the Allergy &
Asthma Network.
FACULTY
Ruchi S. Gupta, MD, MPH, FAAP
Associate Professor of Pediatrics
Northwestern University Feinberg School of
Medicine
Pediatrician
Ann & Robert H. Lurie Children’s Hospital of
Chicago
Chicago, Illinois
Chief Medical Officer
Health Services for Children with Special
Needs (HSCSN)
Washington, DC
Baylor College of Medicine
Texas Children’s Hospital
Houston, Texas
Columbia, University
Medical Director
NewYork-Presbyterian Hospital
New York, New York
Professor
University of Utah
Salt Lake City, Utah
Michael Pistiner MD, MMSc, FAAAAI, FAAP
Pediatric Allergist
Harvard Vanguard Medical Associates
Boston, Massachusetts
Jay M. Portnoy, MD, FAAP
Professor of Pediatrics
U. Missouri-Kansas City School of Medicine
Director of Allergy, Asthma, & Immunology
Children’s Mercy Hospital
Kansas City, Missouri
Mark Ruthman
Manager, Digital Publishing
American Academy of Pediatrics
Elk Grove Village, Illinois
James W. Stout, MD, MPH, FAAP
Professor, Department of Pediatrics
Adjunct Professor, Department of Health
Services
University of Washington
Seattle, WA
Assistant Professor of Pediatrics
Nationwide Children’s Hospital
Columbus, Ohio
Tonya Winders, MBA
Chief Executive Officer
Allergy & Asthma Network
Vienna, Virginia
PLANNING GROUP
Michele Carrick, MSW, LICSW
President, New England Chapter
Asthma and Allergy Foundation of America
Reading, Massachusetts
Harvey L. Leo, MD, FAAAAI, FAAP
Associate Research Scientist
Department of Health Behavior and Education Center for Managing Chronic Disease
University of Michigan School of Public Health
Allergy and Immunology Associates of Ann Arbor, PC
Ann Arbor, Michigan
Columbia, University
Medical Director
NewYork-Presbyterian Hospital
New York, New York
Michael Pistiner MD, MMSc, FAAAAI, FAAP
Pediatric Allergist
Harvard Vanguard Medical Associates
Boston, Massachusetts
Professor, Department of Pediatrics
Adjunct Professor, Department of Health Services
University of Washington
Seattle, WA
CONTINUING MEDICAL EDUCATION CREDIT
The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The AAP designates this live activity for a maximum of 10.00 AMA PRA Category 1 Credits™.
Physicians should claim only the credit commensurate with the extent of their participation in the
activity.
This activity is acceptable for a maximum of 10.00 AAP credits. These credits can be applied
toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American
Academy of Pediatrics.
The American Academy of Physician Assistants (AAPA) accepts certificates of participation for
educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited
by ACCME. Physician assistants may receive a maximum of 10.00 hours of Category 1 credit
for completing this program.
This program is accredited for 10.00 NAPNAP CE contact hours of which 0 contain
pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners
(NAPNAP) Continuing Education Guidelines.
Disclosure of Commercial Support for AAP CME Activities
The AAP gratefully acknowledges support for the Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis Educational and Networking
Conference in the form of funding from the AAP Friends of Children Fund and the Allergy and Asthma Network.
No commercial support is associated with this CME activity.
Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid
The AAP CME/CPD program develops, maintains, and improves the competence, skills, and professional performance of pediatricians and pediatric healthcare professionals by providing quality, relevant, accessible, and
effective educational experiences that address gaps in professional practice. The AAP CME/CPD program strives to meet the educational needs of pediatricians and pediatric healthcare professionals and support their
lifelong learning with a goal of improving care for children and families. (AAP CME/CPD Program Mission Statement, May 2015)
The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on
Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and
resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.
All AAP CME activities will strictly adhere to the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance
with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection
of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.
The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is
committed to providing learners with commercially unbiased CME activities.
Activity Title:
Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis Educational and Networking Conference
Activity Location: Double Tree by Hilton Hotel, Rosemont, IL
Activity Dates: October 9 & 10, 2015
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with
the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities. Listed below are the disclosures provided by individuals in a position to influence and/or control CME activity content.
* A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Name
Role
Relevant
Financial
Relationship
(Please indicate
Yes or No)
Name of Commercial Interest(s)*
Please list name(s) of entity
AND
Nature of Relevant Financial Relationship(s)
(Please list: Research Grant, Speaker’s Bureau, Stock/Bonds
excluding mutual funds, Consultant, Other - identify)
Disclosure of Off-Label (Unapproved)/Investigational Uses of Products
AAP CME faculty are required to disclose to the AAP and to learners when
they plan to discuss or demonstrate pharmaceuticals and/or medical devices
that are not approved by the FDA and/or medical or surgical procedures that
involve an unapproved or “off-label” use of an approved device or
pharmaceutical.
(Do intend to discuss or Do not intend to discuss)
Dana Bright, MSW, LSW
AAP Staff &
Planning
Group
Member
No
N/A
Do not intend to discuss
Michele Carrick, MSW
Planning
Group
Member
No
N/A
Name
Role
Relevant
Financial
Relationship
(Please indicate
Yes or No)
AND
pharmaceutical.
Chineme, Nkemdilim,
MPH
AAP Staff,
Planning
Group
Member &
Disclosure
Admin
No
N/A
Michelle Esquivel, MPH
AAP Staff,
Planning
Group
Member &
Disclosure
Resolver
No
N/A
Ruchi Gupta, MD, MPH,
FAAP
Faculty
Yes
Paid Consultant relationship with Mylan
Research Grant relationship with Mylan
Research Grant relationship with FARE
Faculty
No
N/A
Harvey Leo, MD, FAAP
Planning
Group
Member
No
N/A
Adriana Matiz, MD,
FAAP
Planning
Group
Member &
Faculty
No
N/A
Faculty
No
N/A
Michael Pistiner, MD,
MMSc, FAAP
Faculty &
Planning
Group
Member
Yes
AAN Consultant/Subject Matter Expert
Revised May 2015
Name
Role
Relevant
Financial
Relationship
(Please indicate
Yes or No)
AND
pharmaceutical.
Jay Portnoy, MD, FAAP
Faculty
No
N/A
Mark Ruthman
Faculty
No
N/A
Rhonique Shields-Harris,
MD, MHA, FAAP
Faculty
No
N/A
Melissa Singleton, MEd
Planning
Group
Member
Planning
Group
Member &
Faculty
Planning
Group
Member &
Faculty
Faculty
No
N/A
No
N/A
No
N/A
No
N/A
AAP
Reviewer
AAP
Reviewer
AAP
Reviewer
AAP
Reviewer
AAP
Reviewer
AAP
Reviewer
No
None
No
None
Yes
No
I have a paid Consultant relationship with Abbvie
Inc.
None
No
None
No
None
Jim Stout, MD, FAAP
David Stukus, MD, FAAP
Tonya Winders, MBA
D. Michael Foulds, MD
Zoey Goore, MD
Ivor Hill, MD
Robert Wiebe, MD
Rickey Williams, MD
D. Corey Lachman, MD,
Revised May 2015
10/7/2015
Medical Home:
A Primer for Pediatrics and
Chapter Champions
Adriana Matiz, MD
Columbia University Medical Center
Disclosures
• I have no relevant financial relationships with
the manufacturer(s) of any commercial
product(s) and/or provider(s) of commercial
services discussed in this CME activity.
• I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
1
10/7/2015
Objectives
• Advance the implementation of medical
homes for children with asthma, allergy,
and/or anaphylaxis.
– Define a “medical home”
– Discuss the elements of a medical home
– Describe a local “asthma medical home” model
– Describe a local “allergy and anaphylaxis medical
home” model
Objectives – cont’d
• Describe the roles and responsibilities of
Medical Home Chapter Champions on
Asthma, Allergy, and/or Anaphylaxis.
– leverage collaborative relationships
– available resources
– networking opportunities
– develop and implement a clear, measurable action
plan for the next year
2
10/7/2015
What is the Medical Home?
• “The Medical Home is the model for 21st
century primary care, with the goal of
addressing and integrating high quality health
promotion, acute care and chronic condition
management in a planned, coordinated and
family-centered manner.”
What it is NOT?
• A family-centered medical home is not a
building, house, hospital, or home healthcare
service, but rather an approach to providing
comprehensive primary care.
3
10/7/2015
The medical home: child and family in partnership with professional clinicians.
Cooley W C , and McAllister J W Pediatrics 2004;113:14991506
Reproduced with permission
Care in the Medical Home
•
•
•
•
•
•
•
Accessible
Continuous
Comprehensive
Family-Centered
Coordinated
Compassionate
Culturally effective
• Delivered or directed by a
well-trained physician
who provides primary
care
• Develop a partnership of
mutual responsibility and
trust with families
National Center for Medical Home Implementation |
www.medicalhomeinfo.org
4
10/7/2015
Elements
• Care Partnership
Support
• Clinical Care
Information
• Care Delivery
Management
• Resources and Linkages
• Measurement and
Practice Improvement
• Payment and Finance
Care Partnership Support
• PRIMARY physician
• COORDINATE multiple visits
on same day with multiple
clinicians or multiple tests
• triage to determine urgency
of visits
• same day capacity
• appointment given on
same day patient calls
• during office hours offer
physician, nurse telephone
advice
• urgent phone advice within
a specified time
• 24/7 PHYSICIAN SUPPORT
• secure e-mail consultation
• practice website with
information/policies
• LANGUAGE SUPPORT for
patients with limited English
• identify health insurance
resources for uninsured
patients
5
10/7/2015
Clinical Care Information
• updated problem list
• progress notes in template
form
• OTC meds, supplements,
alternative therapies list
• prescribed medication list
• growth charts and BMI
• PROCESS FOR TRACKING
TESTS, REFERRALS AND
THEIR RESOLUTION
• age appropriate dev screen
questions
• template for age
appropriate risk factors (at
least 3 – seat belt,
secondary smoke)
• prevention milestones
Care Delivery Management
• REGISTRY
• assessment of CARE
COORDINATION needs
• tracking of tests and
referrals with monitoring of
progress
• PLANNED VISITS of
appropriate length
• co-management
agreements with
subspecialists
• planned OUTREACH and
communication with
schools and other
community
• other needed education,
advocacy and linkages to
community supports
• use of a medical summary
(CARE PLAN)
• use of an action plan
• use of an emergency plan
6
10/7/2015
Resources and Linkages
• family to family supports
• health insurance assistance
• state funded family relief
(food, housing)
• educational RESOURCES
• employment RESOURCES
• condition specific patient
education RESOURCES
• patient self-management
tools
• language RESOURCES
• home care
• external assistance
management
Measurement and Practice
Improvement
• feedback from families
• feedback to providers on Quality
Improvement measures
• share feedback to all staff for improvement
strategies
7
10/7/2015
Payment and Finance
• Improved coding
• Improved reimbursement and positioning for
negotiating contracts with insurances
Case of Patient “X”
• 15 year old hispanic male
• Obese, ADHD, persistent asthma, allergic
rhinitis
• Medications: Fluticasone INH, Albuterol prn
Cetirizine
• ED 2x/year
• 2 courses of oral steroids
8
10/7/2015
Visit
• Background
– Friday at 3:40pm ( busy)
– Last visit 6 months ago but he should have been
back about 4 wks later
– Presents with his mom – argues frequently with
her
Old Model of Care
• Rushed visit
• Pulmonary appointment ????
• Assess control
– Distracted (not taking his ADHD meds)
– Poor historian
– Mom and him not talking to each other
• Reality – 3 patients after him and it is already 4:15pm
• Medication reconciliation- blue pump, orange pump
• ????SPACER
9
10/7/2015
Pediatric Asthma Medical Home Model
• Registry with risk stratification
• Assessed for asthma “control”
• Education
– Provider, nursing, community health worker
• Care plans
• Strengthen school linkages
• Access
10
10/7/2015
Patient X at the Practice
Prior to the visit the
patient’s chart is
reviewed by the MD
Identified at
registration
Risk level, Classification,
Care Plan, School forms,
goal setting & medication
management
RN education and
CHW education
Asthma
Control
Test
EMR asthma
section for providers
Follow-up appt given
upon discharge
11
10/7/2015
Risk Stratification
Level 1: intermittent or well controlled with no recent
exacerbations
Level 2: poorly controlled (ACT score <19 OR 1 or 2
exacerbations in the last year requiring oral steroids)
Level 3: more poorly controlled ( >3 exacerbations OR >
hospitalizations in past year)
***ANY PSYCHOSOCIAL STRESSOR CAN LEAD TO A
HIGHER PRIORITY LEVEL
12
10/7/2015
Back to the Patient
• Pre-visit plan ( registry as a Level 3)
• Use of the asthma slot
• Community Health Worker (CHW) referral
(home visit)
• Care Plan
• Asthma Control Test (ACT) screen at every visit
13
10/7/2015
More days……..
Medical Home for Allergy and
Anaphylaxis
•
•
•
•
•
Care Plans
School linkages
Culturally appropriate tools
Registry
Risk stratification
14
10/7/2015
MHCCPAAA Program Goals
• Promote the delivery of high quality
asthma, allergy and anaphylaxis care
in the medical home through
–team-based
–patient- and family-centered care
coordination
–co-management
15
10/7/2015
Education
• Educational Webinar Series (3 total in 2015)
 December 2015 (upcoming live); July 2015
(recorded); January 2015 (recorded)
 Champions should:
 Plan to participate and invite others to
attend
 Share relevant information/resources
acquired through webinars with chapter
constituency and colleagues
Education – cont’d
• Local/Chapter Educational Opportunities
 Chapter annual (and other educational) meetings
 Hospital grand rounds/residency training opportunities
 Chapter and/or state-wide webinars, other educational seminars
• Education in Quality Improvement for Pediatric
Practice (EQIPP)
 The ‘Asthma - Diagnosing and Managing in Pediatrics’ EQIPP course
was recently updated
 EQIPP: Medical Home in Pediatric Primary Care
 Explore other EQIPP (http://eqipp.aap.org) or PediaLink
(http://pedialink.aap.org/visitor) courses
 EQIPP courses are ABP-approved Performance in Practice Quality
Improvement Activities (Part 4 MOC) and CME credit
16
10/7/2015
Communications
• Monthly Champions E-Correspondence
• Program updates, news, resources and upcoming
events
• Includes monthly ‘call to action’ and ‘resource
highlight’
• Listservs
• Champions are all subscribed to the program’s listserv
• Consider subscribing to the National Center for
Medical Home Implementation listserv
(http://www.medicalhomeinfo.org/contact/listserv.asp
x)
Communications – cont’d
• ‘Ghost written’ Articles
• 4-5 will be written on selected topics over the two years
• Chapter Champions will customize and disseminate via
chapter newsletters, Web site, etc.
• Regional Conference Calls
• Purpose: Share updates and information with other
champions on calls facilitated by assigned PAC member
• Schedule: 2-3 a year
• Format: Could vary based on interest and availability
17
10/7/2015
Policy and Advocacy
Legislation
 Is your state pursuing medical home legislation?
 What about asthma, allergy and/or anaphylaxis
legislation?
 Get involved and serve as the “voice” for pediatrics
Medical Home Demonstration
 When possible, get involved in Medical home
demonstration projects/initiatives in your state
(Medicaid or otherwise) http://www.pcpcc.org/initiatives
Policy and Advocacy – cont’d
Engaging Chapter Leadership
 Work with chapter leadership in disseminating
existing asthma, allergy and anaphylaxis care best
practices
Engaging State Pediatric Care Agencies
 Collaborate with the state Title V and Medicaid staff
and others in state government agencies on medical
home, asthma, allergy and anaphylaxis activities and
initiatives
18
10/7/2015
Work Plan
19
Food Allergy and
Anaphylaxis:
Myths, Facts, and Addressing
Misperceptions in the Primary Care
Setting
Michael Pistiner MD, MMSc
Pediatric Allergist, Harvard Vanguard Medical Associates
Voluntary Instructor, Boston Children’s Hospital
Disclosures
• I am co-founder and content creator of
AllergyHome.org, free educational material.
1
Objectives
• Use evidence, best practice and the 2010 Guidelines
for the Diagnosis and Management of Food Allergy in
the United States of the National Institute of Allergy
and Infectious Diseases (NIAID) to debunk common
food allergy and anaphylaxis myths.
• Identify current best practices in the management of
a suspected or confirmed food allergy in pediatric
practice.
• Discuss strategies for addressing mortality issues for
food allergy in a way that educates and empowers
patients and families – and ultimately enhances
safety practices.
the Unknown can be Scary
Families can come up with their own answers
2
Children Believe Grown-ups
With Food Allergies Can Come
Uncertainty
3
Headlines Can Cause
Deadly
Allergies
F
E
A
R
Social Media Can Be
Deadly
Allergies
Scary
4
Emotional and Social Impact
Fear of adverse events and death
Fear of ridicule
Social isolation
Limitations in activities
(Bollinger et al. Ann Allergy Asthma Immunol. 2006;96(3):415-21)
(Marklund et al. Health and Quality of Life Outcomes 2006, 4:48)
(Avery et. al. Pediatr Allergy Immunol 2003; 14:378-382).
Risk-taking and coping strategies
of adolescents and young adults with
food allergy (174subjects/ mean age 16 [13-21])
• Avoidance
– 54% knowingly ingested a potentially unsafe food
– 42% willing to eat a food labeled “may contain”
• Communication
– 60% tell their friends
• Preparedness
– 61% always carry their epinephrine
• Situations and circumstances influence self-injectable epinephrine
availability (little perceived risk, inconvenience, social pressures)
Recruited via advertisements on food allergy
organizations web sites and mailings
Sampson et al.JACI. 2006;117:1440-5.
5
Challenging Balance
Risk Taking
Anxiety
6
Myth Can Compromise Care
Let’s Bust Some Myths
7
8
Food Allergens and Reaction
Severity
Original Chart Data Source: (see above)
9
Where in school did symptoms begin?
• 45% of the cases had symptoms
develop in the classroom
• 14 % cafeteria
• 9% health office
• 7% playground/outside/recess
• Various locations both inside and
outside the school building
DATA HEALTH BRIEF: EPINEPHRINE ADMINISTRATION IN SCHOOLS.
Massachusetts Department of Public Health Bureau of Community Health
Access and Promotion. School Health Unit.
10
“Cost-Benefit Study of School Nursing
Services.”
• The study projected an annual savings of
– 129 million dollars in teacher time,
– 28 million dollars in lost parent productivity
– 20 million dollars in medical care cost
• Netted against the investment in school nurses, the bottom line
projected annual savings of 98 million dollars.
• A good start for a changing dialogue.
• Didn’t account for cost saving of potentially fewer emergency room
visits, hospital admissions or other costly medical expenditures.
Wang, et.al. JAMA Pediatrics. May 2014
11
True or False? You will experience
anaphylaxis (a severe allergic
reaction) if the food that you are
allergic to touches your skin.
AllergyHome Online Quiz:
5,335 respondents
33% of participants answered TRUE
12
“Relevance of casual contact with peanut
butter in children with peanut allergy”
• 0.2ml of peanut butter under gauze for 1 minute
– None of the 30 children had a systemic
reaction
(Simonte. JACI 2003. V112. N1. 180-2)
• 1 gram of peanut butter applied to skin for 15
minutes
– None of 52 subjects had systemic reactions
(Wainstein. Pediatric Allergy Immunology 2007; 18:231-9)
• Take Home Point: Isolated skin contact on intact
skin did not cause severe or systemic reactions
13
(Tulve et al. Journal of Exposure Analysis and Environmental Epidemiology (2002) 12, 259–264)
(Nicas et al. J Occup Environ Hyg. 2008 Jun;5(6):347-52)
True or False? The smell of peanut
butter will cause an allergic
reaction in people with peanut
allergies.
5,373 respondents
41.6% of participants answered TRUE
14
“Relevance of casual contact with peanut
butter in children with peanut allergy”
30 Children with history of anaphylaxis to peanuts
• Peanut butter was held 12 inches from their
noses for 10 minutes
• None of the 30 children had any reaction
(Simonte. JACI 2003. V112. N1. 180-2)
15
Inhalation in some settings can cause
allergic reactions
• Reactions of
inhalation with
active cooking
• Caution with
powders, flours,
small particles of
food, etc.
(Simonte, et al, JACI 1999)
(Roberts Allergy. 2002)
Myth vs. Fact
Food Allergy Myth
Food Allergy
Fact
Peanut: >100 KU/L
“My kid would have a severe
reaction, his numbers are off
the charts”
Specific IgE testing cannot
be used to predict the
severity of an allergic
reaction. There is currently
no testing that can make
this prediction.
.
16
Specific Allergen Restriction
“Nut-free”? :
Points to Ponder
Banerjee DK, Kagan RS, Turnbull E, Joseph L, St Pierre Y,
Dufresne C, Gray-Donald K, Clarke AE. Peanut-free guidelines
reduce school lunch peanut contents. Arch Dis Child. 2007
Nov;92(11):980-2. Epub 2007 Jun 7.
Young M, Muñoz-Furlong A, Sicherer SH. Management of food
allergies in schools: a perspective for allergists. J Allergy Clin
Immunol. 2009 Aug;124(2):175-82.
17
18
True or False? Using hand sanitizing gels (like Purell) is a
good way to clean your hands of food allergens
.
17% of the 5,298 respondents answered TRUE
19
Proper Cleaning can Prevent CrossContact
What Works for Hands: Soap and water, commercial hand wipes
What Works for Table Tops: Soap and water, commercial
cleaners, commercial wipes
(JACI 2004-Perry et al)
Cross-contact Resource for Families and
caregivers
20
Food Allergy Advisory Statements
• Statements (Numerous formats: No regulation)
– “may contain”
– “processed in a facility that …”
– “manufactured on shared equipment with…”
– etc
• 7 % of food products with advisory labeling for
peanut had detectable amounts
• Label terms did not correlate with allergen levels
contaminating products (Hefle et al. JACI 2007)
• Take Home Point: Avoid products with advisory
labeling for allergen of concern
21
Label Reading: Anyone responsible for
serving, preparing or distributing food
•
Each label on food should be
read every time
– Ingredients in products can
switch without warning
•
Understand labeling laws and
their limitations
•
Avoid items with advisory
statements
•
Beware of outside foods
Label Reading Resource for Families and
Caregivers
22
23
Symptoms of Anaphylaxis
•
•
•
•
80-90 % have skin findings
70 % have respiratory (nasal, throat, chest)
40 % GI
35 % Cardiovascular (dizziness, tachycardia,
hypotension, and hypotonia).
• And others ……
http://www.niaid.nih.gov/topics/foodallergy/clinical/Pages/default.aspx
Train Families to Recognize Anaphylaxis
www.foodallergy.org
• The lack of skin symptoms should not delay
treatment of anaphylaxis
• Get families comfortable with the signs and
symptoms of anaphylaxis
• Review emergency care plans with your families
24
Benadryl should be given first for a
serious allergic reaction.
20% of the 5,276 respondents answered TRUE
25
Epinephrine is 1st Line for Anaphylaxis
“The use of antihistamines is the most common
reason reported for not using epinephrine and
may place a patient at significantly increased
risk for progression toward a life-threatening
reaction.”
Simons, et. al. Anaphylaxis in the community: learning from the survivors. J Allergy
Clin Immunol. 2009 Aug; 124: 301–306
26
Dosing of Epinephrine Auto-injectors
• Epinephrine 0.15mg
– 10-25kg
• Epinephrine 0.3mg
– >=25kg (55lb)
• consider switching at lower
weight for children with
asthma and other risk factors
for fatality as 0.15mg dose is
1.7 fold under-dose at 25kg
(0.3mg dose is 1.2 fold
overdose)
Sicherer and Simons. Pediatrics. 2007 Mar;119(3):638-46, NIAID 6.3.1.1.
True or False? The needle in the
EpiPen or Auvi-Q is long.
5,375 respondents
19% of participants answered TRUE
27
28
Why Call an Ambulance?
• Transfer to an emergency facility for observation and
possible further treatment
• Epinephrine’s effects are often short-lived and
repeated doses may be necessary
• Observation for 4 to 6 hours or longer based on
severity of the reaction to monitor for biphasic
anaphylaxis
29
Who needed epinephrine?
• 9% of the cases were
school staff
visitors
students
DATA HEALTH BRIEF: EPINEPHRINE ADMINISTRATION IN SCHOOLS. Massachusetts
Department of Public Health Bureau of Community Health Access and Promotion.
School Health Unit.
Myth vs. Fact
Food Allergy Myth
“Food allergy related deaths
are common”
Food Allergy
Fact
The odds of dying from
anaphylaxis in one year,
for a child age 19 or less
with a food allergy, is
about 3.3 in one million
(Umasunthar, et. al. Clinical and
. Volume 43,
Experimental Allergy.
Issue 12, pages 1333–1341,
December 2013)
.
30
Beware of Misinformation
“Even for a severely allergic
child …. the mortality rate is
estimated at roughly 1 in 1,000,
because parents of such
children tend to be extremely
careful.”
Beware of Misinformation
“Even for a severely allergic child …. the
mortality rate is estimated at roughly 1 in
1,000, because parents of such children
tend to be extremely careful.”
?
31
How Common is Food Allergy
Related Death?
• The odds of dying from anaphylaxis in one
year, for a child age 19 or less with a food
allergy, is about 3.3 in one million
(Umasunthar, et. al. Clinical and Experimental Allergy. Volume 43, Issue 12, pages 1333–
1341, December 2013)
How Common is Food Allergy
Related Death?
• We can very roughly extrapolate that we can
expect close to 20 deaths (twenty too many) a year in
the United States in children (6million x
3.3/million/year)
(6 million projection based on 8% Prevalence as per Dr. Ruchi Gupta and
colleague’s study (J Pediatr.2011))
32
Lightening Mortality
• Average of 107 deaths per
year (adults and children)
– A study based on national
mortality statistics from death
certificates for 1968-1985
Lopez RE, Holle RL. Demographics of lightning casualties. Semin Neurol
1995;15:286-95.
Flu Deaths
• 170 deaths in US children <age 18 from
2012-2013 Flu Season
CDC
33
Traffic Accident Mortality
• 1,140 US children
under 14 years of age
died in traffic
accidents in 2011
• 41% were
unrestrained
National Highway Traffic Safety Administration (Traffic Safety Facts 2011 Data)
Traffic Accident Mortality
• Child safety seats alone reduce
fatal injury
– 70% in infants
– 54 % in toddlers
• Restraint use saved 263 lives
– Children < age 5 years
– Safety seats or seat belts
• Major national efforts towards
education and enforcement of
child restraints
National Highway Traffic Safety Administration (Traffic Safety Facts 2011 Data)
34
Drowning Deaths
• ~706 US children under 14 years of age
died annually from drowning (20052009)
http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html
Food Allergy Related Mortality
Peanut or
Tree nut
Allergies
Adolescence or
Young Adulthood
Asthma
Prior
Anaphylaxis
Relying on
Antihistamines
Delay or No
Administration of
Epinephrine
(Bock JACI 2001;107:191)
(Bock JACI 2007;119:4:1016-18)
(Sampson et al. JACI 2006;117:391-7)
(CDC, Voluntary Guidelines for Managing Food Allergies. 2013)
35
Food Allergy Related Mortality
Peanut or
Tree nut
Allergies
Prior
Anaphylaxis
Adolescence or
Young Adulthood
(70% age 12-21)
Asthma
Relying on
Antihistamines
Delay or No
Administration of
Epinephrine
(88%)
(Bock JACI 2001;107:191)
(Bock JACI 2007;119:4:1016-18)
Dispel
Myths
36
Facts
Use the
to
Educate and Empower
For more information and tools to
educate families:
http://www.allergyhome.org/healthcar
e/
37
Label Reading Essentials
Cross Contact with Food Allergens
http://allergyhome.wpengine.netdna-cdn.com/wpcontent/uploads/2014/08/Cross-Contact-OnePager-v3.0-AFA-version.pdf
38
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Food Allergy and Anaphylaxis:
What’s on Primary Care’s Plate?
Ruchi S. Gupta, MD, MPH
Ann and Robert H. Lurie Children’s Hospital
Northwestern Feinberg School of Medicine
ruchigupta.com
Disclosures
• I have the following financial relationships with
the manufacturers of any commercial products
and/or providers of commercial services
discussed in this CME activity:
– Research Support from: Mylan investigator initiated
grant; FARE
– Consultant for: Mylan
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10/7/2015
Objectives
• Describe the various team roles (primary care, pediatric subspecialist,
other health professionals, patient/family, school/child care) associated
with managing food allergies in children.
• Assess what is within, and what is beyond, the scope of primary care in
managing food allergies in children, and address common questions from
parents, caregivers, and/or patients related to the testing process, crosscontamination, airborne exposure, label reading, and types of allergic
manifestations.
• Identify when to refer or not to refer a patient with a suspected or
confirmed food allergy, and provide appropriate management in the
primary care setting during any waiting period to see a specialist.
• Utilize NIAID Guidelines to determine when to prescribe epi-pen, and
advise patients on its use and storage, and also to assess oral allergy
symptoms not requiring an epi-pen.
How should a primary care physician play
a role in managing food allergies?
• The pediatrician is often the first and sometimes only
physician children can access
• Even if children are referred to an allergist, the time
from referral to being seen was on average 4 months in
the Chicago and suburban areas*
• Pediatricians must provide the means and guidance to
appropriately manage reactions in the interim**
*Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, Holl JL. The prevalence, severity, and distribution of childhood food allergy in the United States.
Pediatrics 2011 Jul; 128(1):e9-e17.
**Gupta RS, Lau CH, Dyer A, Pongracic J, Holl JL. Current Food Allergy Diagnosis and Management Practices of Pediatricians. Paper presented at: American College of
Allergy, Asthma, and Immunology Annual Scientific Meeting 2012; Anaheim, CA.
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Guidelines to Food Allergy
Management
1. Document Reaction History
2. Testing
3. Prescribe Medication
4. Counseling
5. Referral to Allergist
NIAID Guidelines
1) Document Reaction History
• Begin with detailed medical history, including:
– Reaction History
– Suspected Foods
– Caregiver Response (ED, PCP, etc.)
– Medications Given
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Reaction History
Common Signs and Symptoms
of Anaphylaxis
Gupta, R. “Anaphylaxis in the Young Adult Population. 2014.” The American Journal of Medicine. 127,S17-S24.
4
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Suspected Foods
Caregiver Response (ED, PCP, etc.)
5
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Medications Given
Classifying a Reaction
•
•
Food allergy represents loss of immunologic tolerance
Anaphylaxis occurs with IgE mediated reaction primarily
Boyce J et al. J Allergy Clin Immunol 2010; 126: S1-58
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Defining Food Allergy
• Sensitization: make antibody against a protein (IgE)
--Can be detected via skin test or blood test
--Foods contain multiple allergens, recognition is not specific
• Allergy = “typical” symptoms and sensitization
• Positive tests alone DO NOT indicate allergy
--Tests indicate recognition, not allergy (allergy is a clinical scenario)
--Tolerant individuals can test positive (e.g. high rate of + peanut tests)
• Over-testing is rampant
--Only test to confirm a likely history of reaction, not out of curiosity
--Knowing when a test will aid your diagnosis is the most important skill
• Gold-standard test is the food challenge
Peanut sensitization data from Arbes SJ et al J Allergy Clin Immunol 2005; 116: 377-83
2) Testing
• Pediatricians can use allergen-specific serum
immunoglobulin E (IgE) test to the specific food
suspected.
• Note: Diagnostic testing must be guided by reaction
history. There is NEVER an indication to test for all
common food allergens with a food allergy panel!
• Discuss testing with allergist you refer to
7
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Applying Allergy Tests
Sampson, HA. J Allergy Clin Immunol 2004;113:805-1
Wang J and Sampson HA Clin Exp Allergy 2007; 37: 651-660
Constraints of Allergy Testing
• Tests can’t differentiate sensitization vs. allergy
• The negative test is more reliable than a positive test
• Tests can’t determine “severity” based on size of test
--Size of skin test or sIgE only predicts likelihood of reactivity
--But…even the likelihood data is not statistically sound
--Example: risk for anaphylaxis at 2.5 kUa/L is same at >100 kUa/L
Chapman et al. Ann Allergy Asthma Immunol. 2006;96:S1-S68.
Nowak-Wegrzyn et al.. J Allergy Clin Immunol 2009;123:S365-383.
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Serum Specific IgE Time Trend
Shek L.P., et al. J. Allergy Clin. Immunol. 2004;114:387–391.
Allergist Role in Testing
Skin Prick Testing:
• Assesses IgE bound to mast cell in skin
• Wheal 3mm > negative control is positive
• High NPV, but only a 30-50% PPV (which is lousy)
• False positive rate high (especially in adults)
• Results are technique and placement dependent
--Back is 20% more reactive than arm, test size differs considerably with brand of probe
• Considered safe—0.008% reaction rate
--Intradermal tests for foods not done due to high rate of irritant reactions
• Dependent on valid positive and negative controls
Sicherer and Sampson J Allergy Clin Immunol 2006; 117: S470-475
Sampson HA J Allergy Clin Immunol 2004; 113: 805-819
Metcalfe, DD, Sampson HA, Simon RA. Food Allergy: Adverse Reactions to Foods and Food Additives, 4th ed,
Chapter 20
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Oral Food Challenge
• Most definitive test to diagnose or rule-out food allergy
• Used to determine if child has outgrown a prior food
allergy, or to confirm food allergy if diagnosis is in
question
• Challenge food given in increasing amount
• Should only be performed under supervision of an
board-certified allergist with appropriate appropriate
emergency medical treatment available
10
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3) Know What Medications to
Prescribe
• Medications for treatment of symptoms:
– Epinephrine autoinjector (1:1000)
• EpiPen, Auvi-Q, AdrenaClick (Generic) brands
• All come as twinpacks with 0.15 and 0.3 mg strengths
– Recommended < 25kg= .15 mg, >25kg=.30 mg
– Actual dose is 0.1mg/kg, so 0.15mg or 0.3mg
may UNDERDOSE certain individuals
– There is no such thing as a “mild” food allergy
that does not require an epinephrine
prescription
NIAID Guidelines
Anaphylaxis Practice Parameters. JACI.2005
Muraro A. Et Al. Mgmt. Anaph childhood. Allergy 2007
Sampson et al. JACI 2006;117:391-7
Food Allergy and Epinephrine
• Urge families to always carry two epinephrine
auto-injectors
• Timing is imperative: administer epinephrine
promptly for a reaction
• Prescribe epinephrine auto-injector and
emphasize carriage and usage
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4) Counseling
• Allergen Avoidance
• Reaction Recognition
• Usage of Epinephrine auto-injector
– How
– When
• Use of Food Allergy & Anaphylaxis Action Plan
Counseling
1. Allergen Avoidance
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Labeling Study Objectives and
Methods
• To gather preliminary information regarding consumer
perspective of food allergen labeling practices from multiple
countries
• To share summary data to help advance the dialogue amongst
key stakeholders (i.e. food industry, food scientists, clinicians
and researchers, government regulators, and patient groups)
• Subjects included those with food allergy, those with family
members with food allergy, and caregivers of those with food
allergy
• Survey captured information about the prevalence of specific
food allergies, severity of reaction, buying practices in
response to different type of labeling such as ‘may contain’
Marchisotto MJ & Harada L; Kamdar O, Smith BM, Khan K, Sicherer S, Taylor S, LaFemina V, Muraro A, Waserman S, Gupta RS. Food Allergen Labeling and Purchasing Habits
in the US and Canada. JAMA Pediatrics. 2015. Under review.
Labeling Study Results
•
6,684 respondents: 5,507 (82.4%) from the U.S and 1,177 (17.9%) from
Canada
•
Up to 40% of respondents purchase food with common precautionary
allergen labeling (PAL)
•
Severe allergic reaction history made respondents less likely to purchase
foods containing PAL
•
Canadians had higher odds of buying “may contain allergen” labeling
•
The US had lower odds of buying products that utilized the “manufactured
in a facility that also processes allergen” or “manufactured on shared
equipment with products containing allergen”
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Respondent Purchasing Behavior
Variable
Frequency, % (n)
All Respondents
(US & Canada)
United States
Canada
87.7% (5,574)
89.9% (4,730)
77.2% (844)
11.3% (716)
9.4% (492)
20.5% (224)
1.0% (63)
0.7% (37)
2.4% (26)
Never
59.7% (3,795)
58.9% (3,098)
63.5% (697)
Sometimes
34.2% (2,174)
35.0% (1,841)
30.4% (333)
6.1% (389)
6.1% (322)
6.1% (67)
Purchase Product with the
Following Label:
“May Contain Allergen”
Never
Sometimes
Always
“Manufactured in a Facility
that Also Processes
Allergen”
Always
“Manufactured on Shared
Equipment with Products
Containing Allergen”
83.3% (5,301)
83.0% (4,375)
84.7% (926)
Sometimes
Never
14.2% (904)
14.5% (762)
13.0% (142)
Always
2.5% (160)
2.6% (135)
2.3% (25)
Respondent Knowledge about Labeling Laws
Variable
Frequency, % (n)
All Respondents
(US & Canada)
United States
Canada
True
71.7% (4,522)
70.7% (3,740)
72.7% (782)
False
17.2% (1,092)
17.6% (929)
15.2% (163)
11.8% (749)
11.7% (618)
12.2% (131)
Food Source Names of Major
Allergens Required by Law
Don’t Know
Advisory Label Required by
Law
True
28.8% (1,831)
25.6% (1,355)
44.1% (476)
False
54.4% (3,460)
57.9% (3,061)
37.0% (399)
Don’t Know
16.9% (1,075)
16.5% (871)
18.9% (204)**
True
63.3% (4,024)
63.3% (3,345)
63.3% (679)
False
8.5% (539)
8.3% (441)
9.1% (98)
28.2% (1,746)
28.4% (1,501)
27.5% (295)
Advisory Label Not Based on
Amounts
Don’t Know
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Counseling
2. How to recognize an allergic reaction
3. When to use Epinephrine Auto injector vs Antihistamine
4. How to use the epinephrine auto injector
5. Food Allergy &Anaphylaxis Emergency Care Plan
Counseling
6. Medication Identification Jewelry
7. Food Allergy Prognosis
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10/7/2015
Physician Support Tool
Available at
foodallergythrive.com
Physician Support Tool
Available at
16
10/7/2015
When To Use Epinephrine
• Guidance/data are unclear, can be a grey area
--Very rare physiologic harm from use
--Families must use own judgment, we outline optimal use
• Epinephrine strongly recommended for…
--Airway or respiratory compromise
--Cardiovascular/circulatory compromise
--Vomiting
--2 or more organ system involvement (e.g., anaphylaxis)
Simons FE et al. World Allergy Organization J 2014, 7:9
5) Referral to Allergist
• Work with your allergist to develop a
plan for the child.
• Average wait time in Chicago is 4
months, therefore it is crucial that
pediatricians teach families how to
manage reactions in the interim*
Gupta RS, Lau CH, Dyer A, Pongracic J, Holl JL. Current Food Allergy Diagnosis and Management Practices of Pediatricians. Paper presented at: American
College of Allergy, Asthma, and Immunology Annual Scientific Meeting 2012; Anaheim, CA.
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Food Allergy Guideline Adherence
Among Pediatricians
• Chart reviews of 49 patients from three clinicstwo in suburban Chicago and one from urban
Chicago clinic revealed high rates of guideline
adherence with respect to allergist referral
(67.3%)
• Less consistent adherence regarding:
–
–
–
–
Documentation of reaction history (38.8%)
Appropriate use of diagnostic tests (34.7%)
Prescription of epinephrine auto-injectors (44.9%)
Counseling families in food allergy management
(24.5%)
Gupta, Ruchi S., et al. "Food allergy diagnosis and management practices among pediatricians." Clinical pediatrics 53.6 (2014): 524-530.
Potential Reasons for Guideline
Nonadherence by Pediatricians
• Pediatricians suggested that poor adherence was
due to:
• Lack of documentation
• Time constraints prevented complete documentation in
the patient’s chart
• Unfamiliarity with guidelines
• Clarity regarding the pediatrician’s role in managing
food allergy
 Findings emphasize the need to better establish the role
of the pediatrician and to improve awareness and
adherence to guidelines.
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Quality of Care
• Surveys from 849 families with at least on food allergic child were
included in analysis
• Almost all parents felt that they were treated with courtesy and
respect by their child’s pediatrician (99%).
• Parents felt that their children’s pediatricians (98%) listened to their
questions and concerns.
• Parents felt their pediatrician (94%) showed respect for what they
had to say about their child’s food allergies.
• Parents also reported that their child’s pediatrician (84%) explained
food allergy in a way they could understand.
Blumenstock J, Dyer A, Smith B, Sohn MW, Oh E, Wang X, Pongracic J, Gupta RS. Parent Report of Food Allergy Management by Pediatricians and Allergists. J Allergy Clin
Immunol Pract. 2015; under review.
Quality of Care
• Parents reported 36% of pediatricians
explained when to use epinephrine for their
child’s food allergy
• 17% of pediatricians demonstrated how to use
epinephrine
• 20% of pediatricians provided a written
emergency health care plan to help manage
their child’s allergic reaction
Blumenstock J, Dyer A, Smith B, Sohn MW, Oh E, Wang X, Pongracic J, Gupta RS. Parent Report of Food Allergy Management by Pediatricians and Allergists. J Allergy Clin
Immunol Pract. 2015; under review.
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Absence of physician involvement affects
the management of food allergies
• Many families without physician involvement:
– Simply avoid the food allergen
– Do not carry epinephrine or any medications
– Have higher rates of ED visits
– Do not have an action plan in schools
– Do not always avoid cross contaminated food
– Have not been counseled on avoidance or risks
Rates of ED visits
• Ambulatory care visits, including emergency department (ED)
visits, due to food allergies are on the rise
• Over a 5-year study period (2008-2012), there were a total of
1,893 ED visits due to food-induced anaphylaxis among
children in Illinois
Dyer, Ashley A., et al. "Pediatric emergency department visits and hospitalizations due to food-induced anaphylaxis in Illinois." Annals of Allergy, Asthma & Immunology
115.1 (2015): 56-62.
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Economic Impact:
Comparing Willingness-to-Pay to Cost
Total Annual Cost
per Child:
Total Annual Cost
In the U.S.:
$4,184
$24.8 billion
Adapted from: Gupta RS, Holdford D, Bilaver L, Dyer A, Holl J, Meltzer D. The high economic impact of childhood food allergy in the United States. JAMA Pediatrics Sept 2013 16,
published online before print.
C23690-003-r05_Neural Tube.pptx
Page 2
Cost of Food Allergy Medical Visits
• Data analyzed from 1,623 US caregivers with a
food-allergic child
• Children in the lowest income stratum spend two
and one half times the amount on emergency
department and hospitalization costs as a result
of their food allergy than higher income
children($1,021, SE ±$251 versus $416, SE ±$99).
• Spending on specialists visits were lower in the
lowest income group ($228, SE ±$22) compared
with the highest income group ($311, SE ±$18).
Socioeconomic Disparities in the Economic Impact of Childhood Food Allergy. American Journal of Public Health. 2015. Under Review.
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Increasing knowledge regarding the diagnosis and
management of food allergies among primary care
providers
• Sampled 407 primary care physicians
• 22% felt adequately prepared by their medical training to
care for food-allergic children
• 28% felt comfortable interpreting lab tests to diagnose food
allergy
• It is not clear:
– When to give epinephrine
– When to test
– How testing should be interpreted
Gupta, Ruchi S., et al. "Food allergy knowledge, attitudes, and beliefs of primary care physicians." Pediatrics 125.1 (2010): 126-132.
What the Pediatrician Can Offer
•
•
•
•
•
You can make an accurate diagnosis
You can prescribe epinephrine
You can initiate (carefully selected) testing
You can create an anaphylaxis management plan
Make sure families have two epinephrine autoinjectors with them at school
• You offer a level of trust and confidence that the
specialist often can never reach—these patients
trust you implicitly!
22
10/7/2015
What the Allergist Can Offer
•
•
•
•
•
•
•
•
Specific training in teasing out subtleties of dx
Allergen skin testing
Oral food challenge
Experience in anaphylaxis management
Experience with schools/organizations
Nutrition/dietary support
Experience in managing QoL issues
The opportunity for co-management…..
Available Resources
•
Follow 5 steps to diagnosis:
1.
2.
3.
4.
5.
Document Reaction History
Testing
Prescribing Medication
Counseling
Referral to Allergist
•
NIAID guidelines
•
Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis
•
AAP Initiatives:
– Webinars
– CME
•
–
–
–
–
Video for primary care physicians
Parent educational handout
Food allergy management tool
Educational handout for caregivers
23
10/7/2015
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, Holl JL. The prevalence, severity, and distribution of childhood food allergy in
the United States. Pediatrics 2011 Jul; 128(1):e9-e17.
Gupta RS, Lau CH, Dyer A, Pongracic J, Holl JL. Current Food Allergy Diagnosis and Management Practices of Pediatricians. Paper presented at:
American College of Allergy, Asthma, and Immunology Annual Scientific Meeting 2012; Anaheim, CA.
Panel, NIAID-Sponsored Expert. "Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored
expert panel." Journal of Allergy and Clinical Immunology 126.6 (2010): S1-S58.
Anaphylaxis Practice Parameters. JACI.2005
Muraro A. Et Al. Mgmt. Anaph childhood. Allergy 2007
Sampson et al. JACI 2006;117:391-7
Simons FE et al. World Allergy Organization J 2014, 7:9
Gupta RS, Lau CH, Dyer A, Pongracic J, Holl JL. Current Food Allergy Diagnosis and Management Practices of Pediatricians. Paper presented at:
American College of Allergy, Asthma, and Immunology Annual Scientific Meeting 2012; Anaheim, CA.
Blumenstock J, Dyer A, Smith B, Sohn MW, Oh E, Wang X, Pongracic J, Gupta RS. Parent Report of Food Allergy Management by Pediatricians and
Allergists. J Allergy Clin Immunol Pract. 2015; under review.
Dyer, Ashley A., et al. "Pediatric emergency department visits and hospitalizations due to food-induced anaphylaxis in Illinois." Annals of Allergy,
Asthma & Immunology 115.1 (2015): 56-62.
Socioeconomic Disparities in the Economic Impact of Childhood Food Allergy. American Journal of Public Health. 2015. Under Review.
Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, Holl JL.
Sicherer SH, Mahr T. Pediatrics. 2010; 126(6): 1232-1239.
Gupta RS. The Food Allergy Experience. North Charleston, SC: CreateSpace; 2012.
Illinois State Board of Eduation IDoPH. Guidelines for Managing Life-threatening Food Allergies in Illinois Schools. 2010:78.
Gupta, R. S., Rivkina, V., DeSantiago-Cardenas, L., Smith, B., Harvey-Gintoft, B., & Whyte, S. A. (2014). Asthma and food allergy management in
Chicago Public Schools. Pediatrics, 134(4), 729-736.
Gupta, R. “Anaphylaxis in the Young Adult Population. 2014.” The American Journal of Medicine. 127,S17-S24.
Peanut sensitization data from Arbes SJ et al J Allergy Clin Immunol 2005; 116: 377-83
Shek L.P., et al. J. Allergy Clin. Immunol. 2004;114:387–391.
Sampson, HA. J Allergy Clin Immunol 2004;113:805-1
Wang J and Sampson HA Clin Exp Allergy 2007; 37: 651-660
Chapman et al. Ann Allergy Asthma Immunol. 2006;96:S1-S68.
Nowak-Wegrzyn et al.. J Allergy Clin Immunol 2009;123:S365-383.
Sicherer and Sampson J Allergy Clin Immunol 2006; 117: S470-475
Sampson HA J Allergy Clin Immunol 2004; 113: 805-819
Metcalfe, DD, Sampson HA, Simon RA. Food Allergy: Adverse Reactions to Foods and Food Additives, 4 th ed, Chapter 20
Gupta RS, Holdford D, Bilaver L, Dyer A, Holl J, Meltzer D. The high economic impact of childhood food allergy in the United States. JAMA Pediatrics
Sept 2013 16, published online before print.
24
Critical Partnerships:
Schools, Child Care, and Families
Michael Pistiner MD, MMSc
Pediatric Allergist, Harvard Vanguard Medical Associates
Voluntary Instructor of Pediatrics, Boston Children’s Hospital
Disclosures
• I am co-founder and content creator of
AllergyHome.org, free educational material.
AllergyHome.org
1
Objectives
• Describe preventive and emergency preparedness
strategies, consistent with the CDC guidelines, that need
to be implemented in the school or child care settings for
children with food allergy and/or anaphylaxis.
• Describe the primary care pediatrician’s role in
addressing questions from schools, child care settings,
and families related to treatment of allergy and
anaphylaxis.
• Encourage families to partner with the school and child
care communities to maintain the quality of life and
safety of the child with food allergy.
AllergyHome.org
Food Allergies
• Increasingly common
• Can be life threatening
• Parents rely on the
school community
• Deaths still occur
AllergyHome.org
2
Pediatric Food Allergy:
What’s Our Role?
• Provide medical management
– Diagnosis and treatment
• Provide education and anticipatory guidance
– Practical food allergy management strategies
Our Responsibilities Extend to the
School Setting
• Much of our patients days are spent in the care of
early childcare centers and schools
• We play a vital role (direct or indirect) in food allergy
education in school
3
We Play a Key Role in Assisting
Schools in the Care of OUR Patients
• Write Food Allergy Emergency Care Plans
• Prescribe epinephrine
• Work with our patient’s school to establish
reasonable individual health plan
• Consider 504 when school unable to implement adequate policy
Many Play a Direct Role in
School Health
• Help guide and establish food allergy policy
• Prescribe stock epinephrine and write standing
orders
• Assist in school community education
• Help bridge the gap between families of students
with and without food allergies
*Especially important in schools without school nurses
4
Food Allergy School Education
Families
Schools
Food Allergy School Education
Families
Schools
5
Consolidate Your Efforts
• Reinforce and teach universal food
allergy management strategies
– This will emphasize the very same
strategies that need to be implemented in
School
– Practical and evidence based when
possible
• Maintain safety and quality of life
• Minimize negative impact on others
• Correct misperceptions and
unreasonable expectations
Pillars of Food Allergy Management
Prevention
Emergency
Preparedness
These must be applied at all times and in all settings
AllergyHome.org
6
Essential Resources
Essential Resources:
School Nurses
•
Critical players in school food allergy
management (Allergy, Anaphylaxis
and Asthma Champion)
– Implement and guide policy
– Educate school community
– Familiar with school resources and
culture
– Recognize and treat anaphylaxis
– Create care plans (IHCP, 504 etc)
– Serve as liaison to families
•
Collaborators and partners
– Work closely with physicians
– Extend healthcare into the school
day
7
Essential Tools/Resources:
Food Allergy
Emergency Care Plan
•
Critically important and practical document
•
Understandable for non licensed staff
•
Accessible for staff responsible for the care of the student
•
Strongly encourage submission to the school
•
In some states only school nurse can give antihistamines
www.foodallergy.org
The Voluntary CDC Guidelines:
•
Guide schools and early care
and education programs in the
management of food allergies
•
Contributions from experts
experienced in school health
and the management of food
allergies and anaphylaxis
•
Excellent foundation to
implement Head Start center
policies
•
Allows for variation in
implementation
AllergyHome.org
8
The Voluntary CDC Guidelines:
5 “Priority Areas”
1. Appropriate food allergy
management is implemented for
the individual student
2. Schools are prepared for allergic
emergencies
3. Staff gets food allergy training and
professional development
4. Students and families get food
allergy education
5. Educational environments are
healthy and safe
AllergyHome.org
Teach Practical Food Allergy
Management Strategies
Prevention
Emergency
Preparedness
These must be applied at all times and in all settings
AllergyHome.org
9
Food Allergy Management
Prevention
AllergyHome.org
A.C.T. to Prevent Accidental
Exposures
AVOID
COMMUNICATE
TEACH
AllergyHome.org
10
Exposures
AVOID
COMMUNICATE
TEACH
AllergyHome.org
A.C.T. to prevent
Avoid Food Allergen
Ways to come in contact with allergen
Through the mouth
Breathing in
Touching the skin
Oddharmonic:flickr
AllergyHome.org
11
Oral Ingestion of Food Allergen
AllergyHome.org
Avoiding Oral Exposure
• Each label on food should
be read every time
– Ingredients in products can
switch without warning
• Understand labeling laws
and their limitations
• Avoid items with advisory
statements
• Beware of outside foods
AllergyHome.org
12
Food Sources in Non-edible items:
finger paint: milk or
egg whites
play dough: wheat
And others…
Shaving cream: Paste: wheat
milk
pet food: anything
bean bags/furniture: bird feed: nuts,
nuts
seeds
Food Related
Activities
AllergyHome.org
Skin Contact With Food Allergens
(Simonte. JACI 2003. V112. N1. 180-2)
(Wainstein. Pediatric Allergy Immunology 2007; 18:231-9)
13
Inhalation of Food Allergen
AllergyHome.org
Cross Contact
Presence of Unintended Food Allergen
AllergyHome.org
14
Cross Contact
• Exposure to small amounts of allergen is
enough to cause a serious allergic reaction
• Allergens withstand heating and drying
• Allergen on/in object/surfaces, food, or saliva
• Routine training for all staff about sources of
cross-contact and prevention of exposure is
essential
AllergyHome.org
Common Sources of Cross-contact
Deep fryers
Kitchen slicers
Food splatter
Buffets
Garnishing
AllergyHome.org
15
More Ways For Cross-contact to Occur
Sanitizing dip
buckets
Table tops
High chairs, car
seats, etc.
Sponges/dishrags
Hands
Utensils, dishware, cups,
water bottles
AllergyHome.org
Saliva and Pets Can Also Be
Sources For Cross-contact
Saliva
Pet licking
Pet food
(Maloney. JACI. 2006)
(Munoz-Furlong. Pediatrics 2003)
Read ingredients
AllergyHome.org
16
Each Age Group Will Have Different Issues
With Cross-contact
Be aware of the developmental
level and capabilities of the child:
Will influence classroom/school policies
Self Care
AllergyHome.org
Proper Cleaning Can Prevent
Cross-Contact
• Establish a cleaning protocol to avoid cross-contact
What Works: Soap and water,
commercial hand wipes
What Doesn’t: Hand sanitizers
(JACI 2004-Perry et al)
What Works: Soap and
water, commercial cleaners,
commercial wipes
AllergyHome.org
17
Exposures
AVOID
COMMUNICATE
TEACH
AllergyHome.org
A.C.T. to Prevent
Communicate
• Encourage parents to partner with their nurse
and/or principle
• Suggest Emergency identification jewelry
(Mass Dept of Education. Managing Life Threatening Food Allergies in Schools.2002)
18
Exposures
AVOID
COMMUNICATE
TEACH
AllergyHome.org
A.C.T. to Prevent
Teach their children and
communities
• Parents should lead by example and model positive behaviors
and attitudes
• Teach their children age appropriate food allergy
management skills
• Parents can consider working with the school nurse and/or
teacher to educate classmates and parents about the needs
of children with food allergies (anonymous vs child focused)
(NSBA, Safe at School and Ready to Learn 2011)
• Teach other parents who accept responsibility for caring for
the child with food allergies (drop off parties and playdates)
AllergyHome.org
19
Food Allergy Management
Emergency
Preparedness
AllergyHome.org
Be Prepared to R.E.Act
Recognize Anaphylaxis
Epinephrine
Activate Emergency Response
AllergyHome.org
20
Be Prepared to R.E.Act:
Who should know about allergic reactions?
• Anyone who interacts with students, staff or visitors
• Discuss with your school nurse and/or school principal
and know your role in your school’s emergency protocol
(emergency care plan).
• Some staff may be trained to recognize and treat
anaphylaxis in those with a known allergy, when a school
nurse or doctor is not available.
• In states with stock epinephrine laws, select staff may
receive additional training to recognize and treat
anaphylaxis in those that do not have a an allergy that is
known to the school when a school nurse is unavailable.
(Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs, CDC 2013)
(NSBA, Safe at School and Ready to Learn 2011)
AllergyHome.org
Epinephrine
Call 911-Tell them child with anaphylaxis
Telephone (NEVER wait to give Epinephrine)
Doctors and parents (as per action plan)
AllergyHome.org
21
Be prepared to R.E.Act
Epinephrine
AllergyHome.org
Treatment of Anaphylaxis:
Epinephrine Auto-injector
• Contact the school nurse immediately and refer to emergency care plan
and/or emergency protocol.
• Once anaphylaxis is recognized, the next step is for epinephrine to be
administered. Also, for all cases of anaphylaxis, someone on your team
must call emergency services, 911 as soon as possible.
• For those with a known allergy and an auto-injector, in some states,
trained unlicensed assistive personnel can administer an epinephrine
auto-injector in the event that a nurse is unavailable.
• For those without known allergies, confirm that 911 was called and
continue to attempt to contact the school nurse. In some states, stock
auto-injector laws allow for trained unlicensed assistive personnel to
administer epinephrine auto-injectors to those with unknown allergy
history.
(Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs, CDC 2013)
(Simons et al. JACI 1998; 101:1;33-37)
AllergyHome.org
22
Be prepared to R.E.Act
Treatment of Anaphylaxis:
Epinephrine Auto-injectors
Adrenaclick ®
&
generic epinephrine
Auvi-Q®
EpiPen ®
Currently 4 auto-injectors available in US (October 2013)
online video training available
AllergyHome.org
Recommend having Two doses of
epinephrine available
1 in 8 Children need a second dose of epinephrine for food-related anaphylaxis
(Rudders et. al., Pediatrics. 2010 Apr;125(4):e711-8)
23
Where and How to Store Epinephrine
• Store epinephrine in a welldefined, secure, and
accessible location
• Avoid Extreme temperatures
– Keep at 15-30°C (59-86°F)
– Do not store in car
EpiPen package insert
Epinephrine
24
Pillars of Food Allergy Management
Prevention
Emergency
Preparedness
Solid Understanding
Applying Food Allergy Management
to Specific School Settings
25
Section 504/Americans with
Disabilities Act
• In cases where school policies are not
adequate
– Helpful for children who’s allergies are interfering
with their education
– Children with disabilities (i.e. food anaphylaxis)
cannot be denied the benefits of institutions
receiving federal funding
– Americans with Disabilities Act covers nonreligious schools in private sector
(Mass Dept of Education. Managing Life Threatening Food Allergies in Schools.2002)
Take Home Points
26
Exposures
AVOID
COMMUNICATE
TEACH
AllergyHome.org
Epinephrine
AllergyHome.org
27
Use Your Resources
For more information and tools to
educate schools:
http://www.allergyhome.org/school
s/
AllergyHome.org
28
Let’s Keep
Them Happy
and Safe
Thank You!
AllergyHome.org
29
10/7/2015
CRITICAL PARTNERSHIPS:
SCHOOLS, CHILD CARE
AND FAMILIES
Section of Allergy & Immunology
Disclosures
• I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or
provider(s) of commercial services discussed in this CME
activity.
• I do not intend to discuss an unapproved/investigative use
of a commercial product/device in my presentation.
1
10/7/2015
Objectives
• Write care plans/action plans for children diagnosed with
asthma, as well as care plans/transport guidelines for
undiagnosed/undesignated students as needed by schools
or child care settings.
• Describe the primary care pediatrician’s role in addressing
questions from schools, child care settings, and families
related to treatment of asthma.
• Assist in management of school transition issues for children
with asthma, as well as management of other school issues
faced by these children.
Asthma in the School Setting
• Asthma is the most common chronic health condition
among children
• Average school will have 2 or 3 children with asthma in
every classroom
• Leading cause of
• Missed school days
• Poor school performance
• Exercise limitations
2
10/7/2015
Unrecognized Consequences
• Poorly controlled asthma significantly impacts quality of
life
• Poor sleep quality
• Fatigue
• Moodiness
• Inability to concentrate
• Takes vigilance to recognize in students with
asthma!!!!
Most Importantly…
• Asthma is NOT “one size fits all”
• Heterogeneous disease that changes over time
• Variable symptoms
• Variable onset
• Variable duration
• Variable triggers
• Variable response to therapy
• So….
• Definition of loss of control
is NOT “one size fits all”
• Management of loss of control
3
10/7/2015
GREEN Zone  All systems clear
RED Zone  Too late, seek care
YELLOW Zone
Written Treatment Plans
• Asthma action plans typically follow a “traffic light” model
• Green – daily management when symptoms are well
controlled
• Red – onset of severe exacerbation requiring
course of systemic corticosteroids and contact with
health care provider
• Every patient should be provided with an asthma action
plan
• Include instructions for recognition of loss of control AND
activation of the yellow zone intervention plan
4
10/7/2015
Written Treatment Plans
• Providing patients with individual written plans:
• Decreases symptoms
• Reduces unscheduled health care visits
• Improves quality of life
• Empowers patients to guide self-management
• Written action plans are recommended in all iterations of
NHLBI guidelines
• Often under utilized
• 25% of 18,000 asthmatic children in Chicago schools have plan
1.
2.
3.
Gibson PG, Powell H. Cochrane Database Syst Rev. 2003;1:CD001117.
Thoonen BP, et al. Thorax. 2003;58:30-6.
Gupta RS, et al. Pediatrics. 2014 Oct;134(4):729-36.
5
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6
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Yellow Zone Management
• Instruct patients to activate the yellow zone intervention
plan when there is acute loss of asthma control in a
setting outside a medical care facility, i.e. home, school
• Yellow zone is defined as:
• An increase in asthma symptoms
• An increase in use of reliever medications
• A peak flow rate decrease of at least 15% or lower than 80% of
personal best
• The presence or increase in nocturnal asthma symptoms
*Need to consider patient variability in baseline symptoms
Dinikar C, et al. Management of acute loss of asthma control in the yellow zone: a practice
parameter. Ann Allergy Asthma Immunol. 2014 Aug;113(2):143-59.
7
10/7/2015
What if Yellow Zone is Started Too Early?
• A “false” start may lead to initiation of
management when not necessary
• Risk of a “late” start may result in episode progression
and need for systemic corticosteroids/ER care
Don’t want to be late!
How Much Time From Yellow to Red?
• Substantial variability in literature and real life
• Mean time from 1st appearance to peak of symptoms 5.1
days (range <30 min to >2 weeks)1
• Mean interval peak of symptoms to recovery 6.2 days
• Often lead time of days to peak of exacerbation
• Window of opportunity to intervene
• Symptoms may recover before lung function improves
• Prudent to continue yellow zone management ~2 weeks
Partridge MR, et al. BMC Pulm Med. 2006;6:13.
8
10/7/2015
What About Peak Flow Monitoring?
• Fallen out of favor by many physicians
• Evidence that measurement may not be better predictor
than monitoring symptoms1,2
• Use of PEF should be individualized
• Ideal for subset of asthmatics: “poor perceivers”
• More ER visits, hospitalizations, near-fatal & fatal exacerbations3
1. Bhogal S, et al. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005306.
2. Buist AS, et al. Am J Respir Crit Care Med. 2006 Nov 15;174(10):1077-87.
3. Magadle R, et al. Chest. 2002 Feb;121(2):329-33.
Short Acting Rescue Inhalers
• Advise patients to use a short acting b2 agonist (SABA)
for reliever use in yellow zone
• Dose: 2 to 4 puffs every 4 to 6 hours
• In addition to their escalated yellow zone treatment
• If SABA use exceeds 12 puffs per day  advise patients
to contact their provider for guidance
9
10/7/2015
Before We Go Any Further…
• Please
• Please
• I beg of you
• Do not teach patients that albuterol is an ‘emergency’
inhaler
• Educate patients/parents that albuterol is a ‘rescue’ or
‘reliever’ inhaler
• If you have asthma, you will need albuterol
• When parents are taught ‘emergency use only’
• Removes empowerment for self management
• Delayed administration
• Rush to the ER
SABA Use
• 2007 NHLBI Guidelines
• 2-6 puffs of SABA every 3-4 hours for 24-48 hours for home use
• No evidence of explanation for category A rec is provided
• 2011 Global Strategy for Asthma Management and
Prevention
• 2-4 puffs of SABA every 20 min for 1 hour
• 2-4 puffs of SABA every 3-4 hours with good response
• 6-10 puffs for moderate exacerbation
10
10/7/2015
Every Student Should Have an Asthma
“Contract” with the School
Role of the Student (Family)
• Meet with doctor regularly to monitor & manage asthma
• Adhere to recommended treatment plan
• Must use controller medications EVERY DAY to maximize benefit
• Communicate with school
• Child has a diagnosis of asthma
• Bring extra albuterol to school (with spacer)
• Bring a copy of the written treatment plan OR instructions on what
symptoms to watch for and how to treat
• Any current symptoms or new developments
11
10/7/2015
Role of the School
• Be receptive to family communication
• Ask questions, if necessary, to better understand
• Make necessary accommodations to limit student’s
exposure to stated triggers
• Store albuterol in a secure place that the student can
access easily
• Allow access to albuterol during school hours
• Monitor student for development of any symptoms
• Have designated personnel that can respond to student in a
timely fashion if symptoms develop
• Communicate any problems to the family so they are aware
Asthma Symptoms
 Cough
 Shortness of breath
 Wheeze
 Chest tightness
 Chest pressure
 Difficulty breathing
 Increased work of breathing
 Respiratory distress
12
10/7/2015
Asthma Symptoms in School
• Can be chronic and relatively mild
• Ongoing cough
• Can occur suddenly and without warning
• Immediate onset
• Cough, wheeze, difficulty breathing
What is an Asthma Trigger?
 Stimulus that provokes airway hyper responsiveness and
airflow limitation
 Can be internal or external
 Every person with asthma has their own individual
triggers
 May be one specific trigger
 May be numerous triggers
 Exposure to trigger can lead to acute or chronic
symptoms
13
10/7/2015
Most Common Asthma Triggers
 Upper respiratory infections
 Changes in the weather pattern
 Spring and autumn
 Exercise
 Exposure to passive tobacco smoke
 Inhalant allergens
Triggers Found at School
 Gym class
 Viruses
 Weather
 Bus stop
 Recess
 Allergens
 Cat and dog dander
 Cockroaches
 Foods
 Cleaning supplies
 Fumigation
 Emotional stressors
14
10/7/2015
Triggers Found after School
 Athletic events and practice
 Extremes of weather
 Changes in weather pattern
 Relevant aeroallergens
 Tree pollen: Feb  May
 Grass pollen: May  July
 Ragweed pollen: August  1st frost of autumn
 Mold spores: Spring through autumn
 Tobacco smoke
What Can You do About Triggers?
 Recognize that each child with asthma is unique and has
their own triggers
 Avoidance is the best strategy
 Some triggers are unavoidable
 Make sure albuterol is always available at school
 Early recognition of symptoms
 Use albuterol every 4 hours as needed throughout school day
 May need to limit activity when ill
 Monitor for worsening respiratory symptoms
15
10/7/2015
Specific Triggers: Exercise
 Pre-treat with 2 puffs of albuterol with spacer at least 15
minutes before exercise
 Warm up period may help prevent symptoms
 If symptoms occur during exercise:
 Stop activity and rest
 May use albuterol again as rescue medication even if it hasn’t
been 4 hours
 Do not resume activity for at least 15-30 minutes and only if
symptoms have resolved
Specific Triggers: Weather
 May need to limit outdoor activity at certain times
 Written communication to school
 Hot, humid weather
 Limit outdoor activity during afternoon hours
 Watch for ozone action days
 Cold weather
 Cover mouth and nose to help humidify air
16
10/7/2015
Specific Triggers: Viruses
 Tough to avoid – can be contagious 1-2 days prior to





symptom onset
Good hand washing
Sneeze into elbow
Don’t share utensils or drinks
Flu shots for everyone
Recognize when student with asthma is ill
 May need to receive albuterol throughout the day
 May need to limit activity during acute illness
Back to School Blues
 Asthma exacerbations and hospital admission rates
are highest in September and October
 Coincides with return to school for most children
 Likely combination of factors:
 Changes in the weather pattern
 Respiratory viruses circulate within schools
 What can we do about it?
 Cancel school…yeah, right
 Vigilance from parents, school personnel, physicians
 Make sure baseline asthma control is optimized heading into
school year
17
10/7/2015
Specific Triggers:
Outdoor Allergens
• May need to take allergy medication or avoid outdoor
activity on high pollen count days
• Pollen levels highest before lunch time
• Dry, warm, windy days for trees, grass, weeds
• Damp, rainy days for mold spores
• Ideally, will wash face, hair and change clothing after
spending significant time outdoors
Specific Triggers:
Indoor Allergens
• Cat and dog dander is ubiquitous
• Microscopic, sticky protein found on clothes, hair, upholstered
furniture, carpeting
• Higher cat ownership rates in classroom are associated with
worsening asthma control1
• Dust mites
• Avoid carpeted surfaces
• Thrive in high humidity areas
• Remove stuffed animals and pillows
1. Almqvist et al. Am J Respir Crit Care Med 2001;162:694-8
18
10/7/2015
Specific Triggers:
Indoor Allergens
• Cockroaches
• Clean all areas where food is consumed
• Rodent infestation
• Presence of cockroach and rodents associated with highest
levels of allergens, but present at low levels in all schools
• Levels highest in low income and inner city areas
Specific Triggers:
Indoor Allergens
• Food allergens
• Need to strictly avoid consumption if allergic
• Casual exposure rarely provokes respiratory symptoms
• Some foods may provoke asthma symptoms when inhaled through
cooking process
• Fish
• Mold spores
• Fix sources of water damage and clean with bleach solution
19
10/7/2015
Specific Triggers: Inhalant Irritants
 “Anything with a scent can trigger asthma symptoms”
 Easy on the Old Spice
 Recognize that strong perfumes and colognes can cause
breathing difficulty for some children with asthma
 Notification before fumigation
 Make sure scent is gone before allowing students to enter area
 Strictly enforce no smoking policies
Food Allergy vs Asthma?
• When in doubt, GIVE EPI!!!
• Asthma purely respiratory = albuterol
• Food allergy rarely just respiratory
• Hives
• Vomiting
• Runny nose, watery eyes
• Food allergy typically occurs close to meals/snack time
• When in doubt, GIVE EPI!!!
• Viral illnesses can mimic many symptoms – can tell by
severity, duration of symptoms
20
10/7/2015
Thank You
Questions????
21
10/7/2015
Chief Medical Officer, Vice President of Medical Affairs
Health Services for Children with Special Needs, LLC
MHCCPAAA Conference October 9-10, 2015
Disclosures
I have no relevant financial relationships with the
provider(s) of commercial services discussed in this
CME activity.
I do not intend to discuss an unapproved/investigative
use of a commercial product/device in my presentation.
1
10/7/2015
Objectives
 Identify components of culturally effective care,
including respect for the beliefs, values, actions,
customs, and unique health care needs of distinct
population groups.
 Describe the role of cultural competence in
overcoming health disparities.
 Explore the relationship of cultural issues to fear of
medications, need for education, and lack of
treatment adherence among patients/families.
Case Vignette
 AT is a 13 year old young man who comes to your
practice for the first time with an acute episode of
wheezing. Per his mother and grandmother he has
had similar episodes in the past often after a visit to
their family “doctor” to cure him of teenage ways. The
family relocated to your area one year ago from
Bolivia. AT is serving as the interpreter because mom
and grandmother speak limited English.
How do you address this case from a culturally
competent approach in your practice?
2
10/7/2015
Patient Centered Medical Home
What is Cultural Effective Care
 Print materials are available in the child/youth and
family’s primary language
 Cultural background of the child/youth and family,
including values, beliefs and customs, are respected
and considered in all aspects of care provision
 Interpretation and/or translation is available to the
child/youth and family if needed
3
10/7/2015
Culturally Linguistic and
Appropriate Services (CLAS)
 The National Standards for Culturally and
Linguistically Appropriate Services in Health and
Health Care (the National CLAS Standards) are



intended to advance health equity,
improve quality,
help eliminate health care disparities
Why Culturally Effective Care?
 All cultures have systems of health beliefs to explain
what causes illness, how it can be cured or treated, and
who should be involved in the process.
 The extent to which patients perceive patient
education as having cultural relevance for them can
have a profound effect on their reception to
information provided and their willingness to use it.
4
10/7/2015
Asian Pacific Islanders
 Asians/Pacific Islanders are a large ethnic group in the
United States.
 There are several important cultural beliefs among Asians
and Pacific Islanders that clinicians should be aware of.
 The extended family has significant influence, and the
oldest male in the family is often the decision maker and
spokesperson.
 The interests and honor of the family are more important
than those of individual family members. Older family
members are respected, and their authority is often
unquestioned
Hispanic or Latino
 Although Hispanics share a strong heritage that includes
family and religion, each subgroup of the Hispanic
population has distinct cultural beliefs and customs.
 Older family members and other relatives are respected
and are often consulted on important matters involving
health and illness.
 Fatalistic views are shared by many Hispanic patients who
view illness as God’s will or divine punishment brought
about by previous or current sinful behavior.
 Hispanic patients may prefer to use home remedies and
may consult a folk healer, known as a curandero.
5
10/7/2015
Native Americans
 Cultural aspects common to Native Americans usually
include being oriented in the present and valuing
cooperation.
 Native Americans also place great value on family and
spiritual beliefs. They believe that a state of health exists
when a person lives in total harmony with nature.
 Illness is viewed not as an alteration in a person’s
physiological state, but as an imbalance between the ill
person and natural or supernatural forces. Native
Americans may use a medicine man or woman, known as a
shaman.
African American
 Many African-Americans participate in a culture that
centers on the importance of family and church.
 There are extended kinship bonds with grandparents,
aunts, uncles, cousins, or individuals who are not
biologically related but who play an important role in
the family system.
 Usually, a key family member is consulted for
important health-related decisions. The church is an
important support system for many AfricanAmericans.
6
10/7/2015
Airtime…..
 Grey’s Anatomy Video
 http://www.bing.com/videos/search?q=cultural+comp
etent+care++greys+anatomy&qs=n&form=QBVR&pq=
cultural+competent+care+greys+anatomy&sc=027&sp=1&sk=#view=detail&mid=4B63A05F2609BAD9B4E14B
63A05F2609BAD9B4E1
What Now?
 As can be seen, each ethnic group brings its own
perspectives and values to the health care system, and
many health care beliefs and health practices differ
from those of the traditional American health care
culture.
7
10/7/2015
Health Disparities
 Health disparities are preventable differences in the
burden of disease, injury, violence, or opportunities to
achieve optimal health that are experienced by socially
disadvantaged populations.
Health Disparities
 Healthy People 2020 defines a health disparity as “a
particular type of health difference that is closely
linked with social, economic, and/or environmental
disadvantage.
8
10/7/2015
Asthma Prevalence in
District of Columbia Wards
Prevalence of Asthma in the District by Ward
17.5%
18%
15.7%
16%
14%
10%
11.4%
10.5%
12%
9.1%
9.0%
10.7%
8.5%
6.8%
8%
6%
4%
2%
0%
Overall US
Ward 1
Ward 2
Ward 3
Ward 4
Ward 5
Ward 6
Ward 7
Ward 8
*Source: DC DOH: Behavioral Risk Factor Surveillance Report ( BRFSS) 2010
17
Strategies for Working with Patients in Cross
Cultural Settings
 Learn about the cultural traditions of the patients you care for.
 Pay close attention to body language, lack of response, or
expressions of anxiety that may signal that the patient or family
is in conflict but perhaps hesitant to tell you.
 Ask the patient and family open-ended questions to gain more
information about their assumptions and expectations.
 Remain nonjudgmental when given information that reflects
values that differ from yours.
 Follow the advice given by patients about appropriate ways to
facilitate communication within families and between families
and other health care providers.
9
10/7/2015
Background Statistics – Health Services for
Children with Special Needs, LLC (HSCSN)
 HSCSN Membership Residence 2012
 61% (3,414) of our enrollees live in Wards 7 & 8
 HSCSN Membership Racial/Ethnic Demographics 2012 (Self-
Reported)
 African American: 87%
 Latino/Hispanic: 1%
 Unknown: 10%
 Other: 1%
 HSCSN Membership Asthma Prevalence
 In 2012, of the overall HSCSN population, asthma represents
24%
19
Goals of Asthma Pilot Project
 Utilize a mixed-team, disease-focused approach to
improve outcome measures for high-utilizing enrollees
with asthma
 Outcome measures include:
 ER and inpatient utilization
 having a current Asthma Action Plan
 getting a flu shot
 having medication at home and in school
 survey scores – Asthma Control Test and Pediatric
Health Survey
10
10/7/2015
Asthma Project Description
(Phase 1)
 Initial home visit on entry into project: 1) Asthma
Assessment, 2) Asthma Education, 3) Environmental
Assessment and 4) Resource Identification
 Baseline survey administration (asthma surveys and 5
questions regarding “social determinants”) after home
visit
 Meetings twice weekly to review home visit findings
and to develop plans to address gaps in care, including
appointment scheduling for needed follow ups
Healthcare Literacy
 Healthcare Literacy
 * the degree which an individual has the capacity to
obtain, communicate, process, and understand basic
health information and services to make appropriate
health decisions.
*As Defined by The Patient Protection and Affordable Care Act of 2010, Title V
http://www.cdc.gov/healthliteracy/Learn/
22
11
10/7/2015
Healthcare
Literacy-Continued
 Barriers
 acceptance of asthma diagnosis
 member not taking/receiving medication as ordered
 caregiver/member understanding: use of spacer
 caregiver/member understanding: use of
medications


inhaler
rescue medications
 caregiver/member understanding: application of
asthma action plan
23
Psychosocial Issues
 Psychosocial Issues
 Involving both psychological and social aspects of
care
 Issues Encountered
 incarceration (caregiver)
 homelessness
 domestic violence
 multiple children with health needs/mental health
needs
 no food in the home
24
12
10/7/2015
Communication Barriers
 Communication Barriers
 no phone
 phone service not consistently maintained
 constantly changing phone numbers/addresses
 address of record not correct address
 caregiver/member/family constantly moving
 caregiver/member/family in shelter, maybe moved to
another shelter with or without notice to team
25
Findings-Initial Home VisitsHousing Status
Unstable Housing Situation
Own
13.20%
9.58%
Rent
75.34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
26
13
10/7/2015
Initial Home VisitsEnvironmental
Pest (rats, roaches, bedbugs)
38.36%
Standing Water Issues
20.55%
Mold/Mildew
17.81%
Pets
19.18%
Smoker in The Home
Some members had multiple
environmental issues , therefore %
will not = 100%
38.36%
0%
5%
10%
15% 20% 25% 30% 35% 40% 45%
27
Initial Home Visits-Pilot
Indicators
Meds @ School
38.36%
Meds @ Home
Flu Shot
69.86%
8.22%
AAP
38.36%
0%
28
10%
20%
30%
40%
50%
60%
70%
80%
*****AAP- Asthma Action Plan
14
10/7/2015
Access
 Barriers to member’s access to service
 transportation
 mental health issues
 inability to pick-up medication from pharmacy
29
Asthma Team
30
15
10/7/2015
Community Partnerships
Breathe
DC
Children's
Law Project
HSCSN
Asthma
Team
Impact
DC
Healthy
Housing
Program
DC DOE
Psychosocial Interventions
 Psychosocial Barriers
 Homelessness
 domestic violence
 incarceration
(caregiver)
 no food in the home
 Interventions
 social work assessments
 Mental health referrals
 community corp. staffer
 referral to outreach
department


food pantries
community resources
32
16
10/7/2015
Communication Interventions
 Communication
Barriers
 no phone
 change:
phone/address
 address different than
that on record
 family/caregiver
moving
 Interventions
 contact info
reconciliation with
provider data
 monthly calls/texts
 Frequent home visits
increase accuracy of
information
33
Access Interventions
 Access Barriers
 transportation
 mental health issues
 inability to pick up
medications from the
pharmacy
 Interventions
 Appointment and
transportation
assistance
 pharmacy home
delivery
 community corp.
staffer
34
17
10/7/2015
Asthma Pilot results:
January 1, 2012 – March 31, 2013 versus January 1, 2014 – March 31, 2015
Number of ER and Inpatient Visits
18
10/7/2015
Number of Beta Med Refills and Cost
Number of Steroid Refills and Cost
19
10/7/2015
Questions?
20
Asthma Care:
Advice from a
Subspecialist
Julie P Katkin, MD
Pulmonary Medicine Section
Disclosures


I have no financial or advisory
relationships relevant to this
presentation (or, sadly, to any
other)
I will not be discussing “off
label” applications of any
medication or therapeutic
modality
1
Session Objectives
•
•
•
•
Review best practices for managing patients with
asthma in primary care, and reasons for referral to a
subspecialist
Review guidelines for screening for allergies in
children with wheezing or asthma
Discuss pros / cons of using inhaled corticosteroids
to treat preschool aged children with presumed
asthma
Review when to step up or down therapy, and the
importance of communication to maintain consistent
care
Goals of Asthma Therapy





Prevent symptoms - improve asthma
control
Maintain normal activity
Prevent recurrent exacerbations
Maintain pulmonary function
Balance therapy with side effects
2
How to Meet These Goals

Develop a systematic approach to asthma
management:






Assess severity
Assess risk
Initiate therapy with medications you like and use often
Re assess severity and risk on a regular basis
Adjust medication when indicated
Asthma therapy is safer than uncontrolled asthma


Don’t rush
A consistent relationship avoids unnecessary shifts in
medication and confusion
Inhaled Corticosteroids




The mainstay of effective asthma care
Most effective long-term controller for
persistent asthma
Decrease asthma-related morbidity and
mortality
Strong argument for early introduction in
the management of symptomatic asthma


See: NAEPP and GINA guidelines
Most cost-effective chronic therapy
3
Inhaled Steroids vs Leukotriene
Modifiers - Asthma Control
JACI (2000).
105:1123-1129
Beneficial Effects of Inhaled
Corticosteroids in Chronic Asthma




Asthma symptoms diminish gradually over
time.
Occurrence of severe exacerbations is greatly
reduced.
Use of quick-relief medication decreases.
Lung function improves significantly, as
measured by PEF, FEV1, and airway
hyperresponsiveness.
Guidelines for the Diagnosis and Management of Asthma.
1997. NIH Publication No. 97-4051.
4
Corticosteroid Mechanisms of Action




Increased transcription of antiinflammatory genes
Reduced transcription of inflammatory
genes
Inhibit the activities of T lymphocytes,
eosinophils, mast cells, macrophages,
dendritic cells and neutrophils
Inhibit many mediators of inflammation,
including histamine, eicosanoids,
leukotrienes, and cytokines
Effects of Inhaled Corticosteroids
on Airway Integrity
E = Epithelium
Membrane
BM = Basement
Laitinen. J Allergy Clin
Immunol.1992;90:3
2-42.
Pre- and post- 3 month treatment with budesonide
(BUD) 600 mcg BID
5
Long-term Effects of Inhaled Steroids

CAMP
Research
Group. N Engl
J Med
2000;343:105
4-1063.


Following completion of CAMP (Childhood
Asthma Management Program) trial, study
medications were discontinued.
Patients were followed-up after 4 months off
therapy.
 Much of the gains in lung function, symptoms,
and improvements in bronchial hyperreactivity
seen with budesonide were lost.
Jury still out on growth: CAMP reported minor,
limited growth delay. Pedersen says they catch
up. Current thinking is that there may be a
sustained loss of up to 1 cm (about ½ inch) of
adult height with long term, mod-hi dose use.
Asthma are a multifactorial disease(s)
ALLERGIES AND ASTHMA
6
Allergies and Asthma
In very young children, food sensitivities can
help predict asthma


Especially milk, egg, or peanut allergy
For older children, environmental allergens
are more problematic



Seasonal aeroallergens
 Ragweed, tree and grass pollens
Perennial aeroallergens
 Dust mites, molds, cockroaches, mouse urine
Identifying Allergic Triggers


NAEPP, GINA, WHO all recommend testing for
allergies when a diagnosis of asthma is made
Skin testing:






Specific IgE testing:




More thorough and specific
requires expertise
Stressful for the child
Immediate results allow rapid counseling
Necessary to plan immunotherapy
Requires only a blood draw
Added benefit of seeing total IgE
Must know appropriate regional tests
Ultimately, use what you know
7
Managing Seasonal Allergies

Allergic episodes can trigger an asthma
exacerbation, or sustain it


Seasonal allergies often require multiple
approaches to achieve control





Do not confuse with anaphylaxis
Avoidance when possible
Antihistamines, nasal steroids
Immunotherapy when possible and appropriate
Stubborn seasonal allergies are often best
managed by an allergist
NB: All significant food or drug allergies should
prompt referral, at least once
Managing Perennial Allergies

Limit exposure when possible





Sadly, this sometimes means removing Fido
Don’t kick Fido out ahead of your data!
Don’t assume that people have been reasonable
about their pets
Omalizumab
Single trigger and/or single component
interventions generally are not effective



Some combination of interventions is required
Bed covers, pest controls, HEPA filters, new floors,
mold remediation, duct cleaning, etc.
Home visits are often needed to help families identify
exposures and remediate them
8
Multi-trigger, Multi-component
Interventions
Kreiger, J., Home Is
Where the Triggers Are:
Increasing Asthma
Control by Improving
the Home Environment.
Pedi All Immunol
Pulmonol 2010; 23(2):
139.
What if I’m not sure it’s asthma yet?
YOUNGER PATIENTS WITH
RECURRENT WHEEZING
9
Younger Patients with
Recurrent Wheezing


Switching gears….


Children under 5 present a
more difficult problem for the
primary care practicioner
How do you know when they
have asthma?
Does it matter?
When and how should we use
inhaled corticosteroids in this
group?
Natural History of Wheezing in
The Tucson Study
From: Taussig
et al. JACI
2003; 111:663
10
Modified Asthma Predictive Index
1. The child must have a history of 4 or more wheezing
episodes with at least one physician diagnosis.
Adapted from: Guilbert et
al, Atopic characteristics
of children with recurrent
wheezing at high risk of
developing asthma. JACI
2004; 114: 1282.
2. In addition, the child must have a history of 4 or more
wheezing episodes with at least 1 confirmed by a physician.
mAPI: Major criteria
Original API: Major criteria
• Parental history of asthma
• Parental history of asthma
• Physician-diagnosed atopic
dermatitis
• Physician-diagnosed atopic
dermatitis
• Allergic sensitization to ≥1
aeroallergen
mAPI: Minor criteria
Original API: Minor criteria
• Allergic sensitization to
milk, egg, or peanuts
• Physician-diagnosed
allergic rhinitis
• Wheezing unrelated to colds
• Wheezing unrelated to colds
• Blood eosinophils ≥4%
• Blood eosinophils ≥4%
Inhaled steroids improve lung function in
toddlers with persistent asthma
From: Teper et al. Am J Respir Crit Care Med (2005). 171:587-90.
11
Prevention of Early Asthma in Kids
(PEAK) Trial
From: Guilbert et al.
NEJM 2006; 354:
1985
Budesonide
Suspension vs.
Montelukast
Study performed at National
Jewish
•395 patients enrolled
•131 patients were 5 years of age or
younger
•BIS users had a more rapid
response, with fewer exacerbation
in the first 24 weeks, although the
difference at 52 weeks was not
significant
•Peak flows were better over time in
the BIS group
•Parental assessment of control
was better in the BIS group
•Results may be affected by the
mild severity of the starting group;
investigators had anticipated
enrolling more “moderate”
patients.
•
From: Szefler et al, Comparative study of budesonide inhalation suspension and montelukast in young children with mild persistent
asthma. J Allergy Clin Immunol 2007; 120: 1043.
12
Fluticasone in Children
< 2 Years of Age
Children enrolled were <2
years of age
•History of at least 3 episodes
of bronchodilator responsive
wheezing by physician
assessment
•First degree family history of
asthma or atopy
•30 children completed the
study
•Double blind assignment to
groups; each child received 1
inhalation via MDI with spacer
twice daily
•
From: Teper AM et al, Effects of Inhaled Fluticasone Propionate in Children Less
than 2 Years Old with Recurrent Wheezing. Pediatr Pulmonol 2004; 37: 111-115.
•Children aged 24 – 47 months
•332 participants randomized
•At least 2 exacerbations the year
before enrollment
•Required regular maintenance
therapy for at least 6 weeks
before enrollment
•12 week treatment period
Time to First Asthma Exacerbation
From: Wasserman RL et al.,
Efficacy and safety of inhaled
fluticasone propionate
chlorofluorocarbon in 2- to 4-year
old patients with asthma: results of
a double-blind, placebo-controlled
study. Ann Allergy Asthma
Immunol 2006; 96: 808-818.
13
2009 Meta Analysis of ICS in Young
Children
From: Castro-Rodriguez et al, Efficacy of inhaled corticosteroids in infants and
preschoolers with recurrent wheezing and asthma: a systematic review with metaanalysis. Pediatrics 2009; 123:e519-e525.
Key Points from 2013 Meta Analysis
From: CastroRodriguez and
Sorenson, The
role of inhaled
corticosteroids
in
management
of asthma in
infants and
preschoolers.
Curr Opin
Pulm Med
2013; 19:5459





In preschoolers and infants with episodic viral wheeze, pre emptive
therapy with high doses of ICS is associated with benefit;
unfortunately, a 1-year study also reported small reductions in
weight gain and the rate of growth. More studies needed.
Maintenance ICS has not been sufficiently studied in infants and
preschoolers with episodic viral wheeze to justify general use.
In patients with multiple-trigger wheeze, evidence supports the
efficacy of maintenance ICS therapy; in such cases this is
considered the preferred treatment by most guidelines.
Intermittent treatment is likely to increase the frequency of under
treatment. More long term and dose-response studies are needed to
assess the optimal doses and safety of intermittent as well as
regular ICS treatments in these age groups.
If you have preschool children you think would benefit from
maintenance ICS therapy (multiple trigger-wheeze, positive API,
complicated course), go ahead and start, but strongly consider
referral to an asthma specialist for ongoing care.
14
What if all of this is not working?
STEPPING UP ASTHMA
THERAPY
When to Step Up?

Rule of 2s (with 2 grains of salt)







Use quick relief more than 2 times per week
Refill quick inhaler more than twice a year
Wake at night with asthma more than twice a
month
ACT or ACQ scores consistently low
Repeated visits to office, EC or urgent care
Limited activity
Missed school
15
Leukotriene Modifiers:
Add-On Therapy
AJRCCM (1999).
160:1862-1868
Long Acting 2-Agonists:
Clinical Effects
Regularly used, salmeterol or formoterol:
 Improves lung function
 Improves asthma control
 Reduces nocturnal symptoms
 Improves quality of life
 Decreases need for rescue 2-agonists
 Protects against exercise-induced
asthma.
16
Effect of FP/Salmeterol (Advair) on FEV1
Treatment Day 1
Advair 100mcg
FP 100mcg
45
SALM 50mcg 40
35
Placebo
Percent change in FEV1
45
40
35
30
25
20
15
10
5
0
Treatment Week 12
30
25
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 101112
0 1 2 3 4 5 6 7 8 9101112
Day 1
Time (hours)
Baseline
Time (hours)
Kavuru et al. J Allergy Clin Immunol. 2000;105:1108-1116.
Fluticasone/Salmeterol (Advair)
Decreases Asthma Exacerbations
1.0
* 3%
11%
0.8
Probability
of Remaining
in the Study
35%
0.6
49%
0.4
ADVAIR 100/50
FP 100
Salmeterol 50
0.2
Placebo
0
7
14
21
28
35
42
49
Study Day
56
63
*P0.020 vs FP 100, salmeterol 50, and placebo at endpoint.
70
77
84
Doses in mcg b.i.d.
Kavuru et al. J Allergy Clin Immunol. 2000;105:1108-1116.
17
Comparison of Step-up Therapies and the
Overall Probability of Best Response
From: Lemanske et al. N Engl J
Med. 2010 362:975-85
When to Refer to an Asthma
Specialist: Some of the Reasons





Over 5 years old on combination therapy
Under 5 years old on moderate ICS dose
Poor control despite therapy
Complicated course, complicated family
Serious complications of asthma



Intubation for asthma, maybe PICU
LOC, stroke, ECMO, anything that scares you
Unsure of diagnosis
18
We’re doing really well here…..
STEPPING DOWN ASTHMA
THERAPY
When to Step Down?


Rules? We don’t need no stinkin’
rules…
Clinical judgment is paramount




Sustained time without acute exacerbation
Patient observed during worst part of year
Spirometry and patient self assessment are
congruent
Most patients tolerate standard asthma
meds without significant side effects

But poor tolerance of medication should be a
signal for change, when possible
19
Dr. Katkin’s Rules for Stepping
Down

Remove the most concerning medication
first





1. Decrease to at least moderate dose ICS
2. Stop the LABA – life is easier without black
box warnings
3. Decrease ICS slowly to the point of
continued control
If there are renewed problems, go back up
to regain control
If step down fails twice, stop stepping
down!
What does all this have to do with my medical home?
THE ASTHMA CENTERED
MEDICAL HOME
20
The Asthma Specific Visit

Frequent visits advised to review medications,
control and asthma action plan






At least twice a year for any asthmatic; 3-4 times a year
for more severe disease or other need
Ensure refills of the proper medications at a known
pharmacy
Review procedures for after hours contact and urgent
assistance
Review and if necessary replace Asthma Action
Plan (AAP)
Debrief after any urgent care visits, within a
reasonable and USEFUL time frame
Consolidate and “weed out” the medications
What to Assess During an Office Visit

Level of control



Medication usage








Interim history: ER, steroids, hospital, etc
ACT, ACQ, etc
Do parent / patient use medications with good
technique?
Do they know which inhaler is which?
Is there good use of quick relief medications?
Do they have medication at school or daycare?
Do all relevant caregivers understand the AAP?
Side effects or concerns about medications
Lab results
Is it time to step up or down?
21
Specific Goals for the Asthma Medical
Home

Agree upon and maintain a core group of preferred
medications with which everyone in practice is familiar
and comfortable





Know your formularies!
Make CLEAR NOTES regarding any choices that are atypical
for your practice (eg, allergy, TriCare)
Have a clear plan for urgent care
Try not to change your partners’ prescriptions
without good reason; communicate if you do
Make note of referrals, test results and dates of
subspecialty visits


Know who is seeing an asthma specialist
Keep communications with subspecialists open
22
10/7/2015
Children and Teens with Asthma:
Raising the Floor in Primary Care
October 10th 2015
Jim Stout, MD, MPH, FAAP
Disclosures
I have no relevant financial relationships
with the manufacturer(s) of any
commercial product(s) and/or provider(s)
of commercial services discussed in this
CME activity.
I do not intend to discuss an
unapproved/investigative use of a
commercial product/device in my
presentation.
1
10/7/2015
Learning Objectives
• Describe how to confirm a diagnosis of asthma (including use of spirometry to
monitor), how to identify triggers and assess severity.
• Describe the various team roles (primary care, pediatric subspecialist, other health
professionals, patient/family) associated with managing asthma in children.
• Assess when to refer or not to refer a patient with suspected or confirmed asthma,
•
•
•
and perform optimal management during any waiting period.
Consider severity and triggers when determining or changing treatment plan, e.g.,
when is it appropriate to treat with inhaled steroids on a seasonal or intermittent
basis, any guidelines for “step down” therapy, when to stop chronic inhalers.
Identify basic asthma management strategies for patients/families and address
such issues as effective device use, pets, what is poorly controlled asthma or the
poor-perceiving child.
Manage the planned asthma visit.
NHLBI Asthma Guidelines
Evolution in understanding of asthma & focus of care
1970s1980s
Bronchoconstriction
Symptoms
Relieve Symptoms
1980s1990s
Inflammation
Bronchial
Hyper-reactivity
Prevent Symptoms &
Attacks
1990s2000s
Remodeling
Fixed
Obstruction
Prevent Symptoms,
Attacks, & Remodeling
2
10/7/2015
medicalhomeinfo.org/downloads/pdfs/KeyPoints
ForAsthmaGuidelineImplementation.pdf
Six Components of Asthma Management
1. Assessing Asthma Severity and Control
2. Education and Partnership with Patients and Families
3. Control of Environmental Factors and Co-morbid
Conditions
4. Medications
5. Collaboration with Specialists and Other Care
Providers/Settings
6. Population Management
3
10/7/2015
Oral Steroid
Bursts
Symptom
Frequency
• Day and Night
• SABA Use
The Asthmatic Airway
4
10/7/2015
Spirometry
Best
Pred.
%Pred
Trial 2
Trial 1
FVC(L)
3.38
3.49
97
3.35
3.28
FEV1(L)
2.58
2.76
94
2.51
2.51
FEV1/FVC (L/s)
0.76
0.80
0.75
0.77
FET(s)
6.94
7.23
6.25
18 yr. old Female
Height: 64”
Weight: 137 lbs.
Efforts: 3
FVC VAR: 70ml
FEV1 VAR:. 70ml
Volume/time curves
Flow/volume curves
10
5
10/7/2015
ASSESSING ASTHMA CONTROL (SEVERITY)
EPR-3 (8/28/07): p76, 310
Assessing Asthma Severity
Based on age, and:
• Impairment (frequency/intensity of symptoms, lung
function, functional limitations over past 2-4 weeks)
Risk (exacerbations over the past year)
•
Levels of severity:
•
•
•
•
Intermittent
Persistent/Mild
Persistent/Moderate
Persistent/Severe
6
10/7/2015
Assessing Asthma Control
Based on:
• Impairment (frequency/intensity of symptoms, lung
•
function, functional limitations over past 2-4 weeks,
questionnaire, e.g., Asthma Control Test)
Risk (exacerbations, reduced lung growth, adverse
effects of meds)
Levels of control:
• Well Controlled
• Not Well Controlled
• Very Poorly Controlled
Symptom
Frequency
Lung Function
• Day & Night
• SABA Use
• FEV1 % Predicted
• FEV1/FVC
Oral Steroid
Bursts
7
10/7/2015
Spirometry and Asthma
• Teens and children > 5y in whom diagnosis of
asthma is being considered
• Degree of airway obstruction (impairment)
• Patients’ perceptions of obstruction are
inaccurate
• Clinical symptoms alone underestimate severity
~30% of the time in primary care
Stout, et al. Classification of asthma severity in children: contribution of pulmonary function testing. Arch Ped Adol Med. (2006) 160:844-50.
Cowen, et al. Classifying asthma severity: objective versus subjective measures. J Asthma. (2007) 44:711-5.
Fuhlbrigge, et al. FEV(1) is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001 Jan;107:61-7.
Stepwise Treatment of Asthma
8
10/7/2015
When to “step down” treatment?
• Three months of no symptoms or
exacerbations, and normal lung
function
• Caveat: be mindful of seasonality
• Let’s do some cases…
9
10/7/2015
15 yr. old Female
Height: 62”
Weight: 144 lbs.
Best
Pred
%Pred
Trial 3
Trial 1
FVC( L)
3.11
3.10
100
2.96
2.89
FEV1(L)
2.10
2.96
70
2.07
1.99
FEV1/FVC
0.67
0.85
0.70
0.69
FET(s)
5.64
5.89
4.16
Efforts: 3
FVC VAR: 150ml
Case 1
A 15-year-old girl with asthma
is here for a routine visit. She
is taking a combination
product, one inhalation BID,
and states that she is doing fine.
A. Spirometry shows significant
obstruction, which may suggest
she is having more symptoms
than she lets on
FEV1 VAR:. 30ml
B.
Spirometry shows significant
restriction
C. Spirometry is grossly abnormal,
suggesting she may not be really
taking her medications regularly
D. Spirometry is normal
E. A & C
Reference: US Department of Health and Human Services. National Institutes of Health (NIH). National Heart Lung
and Blood Institute. NIH Publication Number 08-5846. October 2007.
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed November 20, 2013.
19
4/15
Case 2
Through an interpreted visit, you learn that a singleparent mom and her three children (ages 4, 7, and 10y)
live in a moldy basement apartment. All three children
have allergy symptoms and night time cough and
wheeze at home, particularly in the fall and winter
months. She fears eviction if she complains to her
landlord.
What are your options for helping this family?
10
10/7/2015
Control of Environmental Factors
• Triggers
–
–
–
–
Allergens
Irritants
Air pollution
Respiratory viruses
• Co-morbid conditions
– Allergies
– GERD
– Sinusitis or otitis media
Assess exposure to and clinical
significance of irritants and allergens
• History/Skin tests (pets, seasonal pollens)
• Skin Tests (dust mites, roaches, mold, rodents)
• Blood (RAST, ImmunoCap) tests
• Smoke/irritant exposure
11
10/7/2015
Why Skin Test?
• Diagnosis Avoidance strategies
• Education
• Self-management support
• Community linkages
Medical-Legal Partnership (MLP)
• An innovative collaboration between medical
providers, social workers, and attorneys to address
the unmet legal needs and improve the health of
vulnerable patients and families
• Headquartered at George Washington University,
founded in 2006
• MLPs established in 262 healthcare institutions in 36
states
12
10/7/2015
Case 3
A 12 year-old girl is new to your town and your clinic,
and complains of a persistent cough and shortness of
breath whenever she exercises that has kept her from
participating in PE for the last several years. Your exam
is entirely normal, and her lung function is normal. You
prescribe an albuterol inhaler, and after a month she
returns, claiming that it didn’t really help. She
demonstrates good technique with a spacer.
What is your next step?
Vocal Cord Dysfunction
• 30% of “intractable asthma” (Newman et al)
• Formal diagnosis: direct visualization via scope
•
•
•
(specialty referral)
Inspiratory spirometry loop can be strongly
suggestive (proceed with caution)
Underlying causes: anxiety, GERD, post-nasal drip
Current treatment strategy: “throat relaxed
breathing” training via patient education videos or
a trained speech therapist
13
10/7/2015
Collaborating in Care
Consulting an asthma specialist is recommended at Step 3
for kids under 5 and Step 4 for older kids (referral should be
considered at the previous step). Options may vary by
geography, insurance, etc.:
• Asthma specialty clinic
• Pediatric Pulmonology
• Pediatric Allergy
Explicit understanding of roles in shared management is
ideal.
When to seek specialty input?
• When you’re scared
• When you’re confused
14
10/7/2015
Case 4
A 9-year old male presents to your clinic in November
complaining of nightly cough for the past 2 months.
He denies symptoms of GE Reflux. He has visited the
emergency room twice in the past year where he
received albuterol with good symptomatic relief. You
obtain spirometry in your office.
Pre-Post Bronchodilator Testing
pre-albuterol
post-albuterol
predicted
3
Vol (l)
3
pre-albuterol
post-albuterol
2
2
Flow 1
(l/s)
0
100
1
-1
-2
Vol (l)
2
%VC
max
80
60
VCmax
1
40
20
0
Time (sec)
0
0
2
4
6
8
15
10/7/2015
Spirometric values:
Measurement PreMed
FVC
(L)
1.55
FEV1
(L)
1.00
FEV1/FVC
.64
FEF25-75 (L/sec) .97
Pred
1.46
1.29
.86
1.64
%Pred PostMed
106
1.55
77
1.31
.85
59
1.68
%Pred %Change
106
0
101
31
103
74
A 9-year old male presents to your clinic in November complaining of
nightly cough for the past 2 months. He denies symptoms of GE Reflux.
He has visited the emergency room twice in the past year where he
received albuterol with good symptomatic relief. You obtain spirometry
in your office. The BEST choice of treatment would be to:
A. Start fluticasone 44 mcg 2 puffs twice daily for 4-6 weeks
and then reassess
B. Start fluticasone 110 mcg 2 puffs twice daily for 4-6 weeks
and then reassess
C. Start a leukotriene modifier as you suspect his symptoms
are likely due to post-nasal drainage from allergic rhinitis
D. I cannot feel confident at this time that this patient should
be treated with asthma medications
16
10/7/2015
Patient/Parent Education
• Identifying symptoms and intervening early can
•
•
enhance quality of life and prevent many an ED
visit/admission
Proper technique in using inhalers is key to their
effectiveness
Understanding the goals of management, the roles
of family, schools, and clinicians, and the impact of
triggers and medication empowers parents
Asthma Education Resources
for Patients/Parents
• Allergy and Asthma Network site offers lots of
information and purchasable materials, such inhaler
posters, symptom logs, etc. – aanma.org
• CDC – cdc.gov/asthma/
• Medline Plus –
nlm.nih.gov/medlineplus/asthma.html
• Search “asthma patient education” on Google or
YouTube
17
10/7/2015
NAEPP Guidelines: every patient with persistent asthma should
have a written home management plan (EPR-3, p115-123)
18
10/7/2015
Putting it all together:
The Planned Asthma Visit
1. Assessing Asthma Severity and Control
2. Education and Partnership
3. Control of Environmental Factors and Co-morbid
Conditions
4. Medications
5. Collaboration with Specialists and Other Care
Providers/Settings
6. Population Management
Thank you!
38
19
10/7/2015
References & Resources
• National Asthma Control Initiative (NHLBI) nhlbi.nih.gov/healthpro/resources/lung/naci/asthma-info/index.htm
– Guidelines for the Diagnosis and Management of Asthma (EPR-3) (440 pgs):
nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf
– Asthma Quick Reference Guide (12 pgs) –
nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf
– Physician Asthma Care Education (PACE); multi-media seminar to improve care
for asthma and to improve documentation/coding for reimbursement –
nhlbi.nih.gov/health-pro/resources/lung/physician-asthma-careeducation/index.htm
– Asthma and Physical Activity in School (NHLBI) –
nhlbi.nih.gov/files/docs/public/lung/phy_asth.pdf
• National Center for Medical Home Implementation (AAP) –
medicalhomeinfo.org
• Medical Home Chapter Champions Program on Asthma, Allergy
and Anaphylaxis (MHCCPAAA) – https://www.aap.org/enus/professional-resources/practicesupport/medicalhome/Pages/Asthma-Allergy-andAnaphylaxis.aspx
• Medical Home Portal – medicalhomeportal.org
– Asthma module for primary care clinicians –
medicalhomeportal.org/diagnoses-and-conditions/asthma
– Asthma FAQ page for families – medicalhomeportal.org/living-withchild/diagnoses-and-conditions---faqs/asthma
20
10/7/2015
• Spirometry 360 – spirometry360.org
• National Asthma Registry (NAR) – email Ed Wise (ewise@aap.org)
• Allergy & Asthma Network – aanma.org
https://aanma.site-ym.com/store/
– Asthma Control Test for Children (4-11 years, commercial
sponsor) – asthma.com/resources/childhood-asthma-controltest.html
• Asthma Control Test (≥12 years, commercial sponsor) –
asthma.com/resources/asthma-control-test.html
• Consortium on Children’s Asthma Camps – asthmacamps.org
– Asthma inhaler posters:
• Help Your Child Gain Control Over Asthma (32 pg. pdf brochure
from the Environmental Protection Agency) –
epa.gov/asthma/pdfs/ll_asthma_brochure.pdf
also in Spanish – epa.gov/asthma/pdfs/controlar_el_asma.pdf
• Comprehensive asthma information from CDC - cdc.gov/asthma/
– Education resources for kids: cdc.gov/asthma/children.htm
– Education resources for parents: cdc.gov/asthma/parents.html
• eAsthmaTracker – symptom.ly
• National Center for Medical-Legal Partnership – medicallegalpartnership.org
21
10/7/2015
Bringing it all Together:
What's Your Action Plan?
Chair, Project Advisory Committee
Medical Home Chapter Champions Program on Asthma, Allergy and Anaphylaxis (MHCCPAAA)
Professor of Pediatrics
Division of General Pediatrics
Department of Pediatrics
University of Utah Health Sciences Center
Disclosures
I have no relevant financial relationships with the manufacturer(s) of any
commercial product(s) and/or provider(s) of commercial services
discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use of a
commercial product/device in my presentation.
1
10/7/2015
Objectives
 Review and summarize the role of Medical Home Chapter
Champions on Asthma, Allergy, and Anaphylaxis.
 Identify planned changes and/or action steps upon
returning to your practice and home chapter.
 Anticipate and address likely barriers to change.
Medical Home is the Context and
Foundation
Along with the Medical Neighborhood, involving coordination
and collaboration among:
 Primary care practices
 Specialty care practices (particularly allergy, pulmonology, and
asthma programs)
 Schools, sports/recreation programs
 Patient/family organizations and advocacy (e.g., Allergy &
Asthma Network, formerly Allergy and Asthma Network Mothers
of Asthmatics)
 Social services (e.g., access to care, environmental intervention)
2
10/7/2015
Roles of the Medical Home
 Timely, accurate diagnosis
 Appropriate treatment and follow-up; preventive measures
 Appropriate referral; care coordination and collaborative care
 Assure training on medication use, storage
 Action plans for patients, families, schools, others
 Education about prevention/avoidance strategies
 Assess & assist with needs for school, recreation, and environmental
interventions
MHCCPAAA Program Goals
1. Lead and facilitate adoption and implementation of the patient-and familycentered medical home for children and youth with asthma, allergy and
anaphylaxis through a network of AAP Chapter Champions
2. Support and enhance improved outcomes for children with asthma, allergy
and anaphylaxis through comprehensive, team-based care coordination and
effective co-management between primary and subspecialty care settings
3. Advance policy efforts that support family-centered asthma, allergy and
anaphylaxis care within pediatric medical homes.
3
10/7/2015
Roles of the MHCCPAAA Chapter
Champion
 The activities of a Chapter Champion will vary depending on the
needs and resources of the chapter/state and the interests and
expertise of the Champion
 Champions develop and implement a workplan and participate in
MHCCPAAA activities to achieve program goals – we want to hear
from you!
 Champions should engage their chapter leaders and serve as a
resource for information, ideas, and support for their chapters
related to asthma, allergy, & anaphylaxis
 AAP staff will support champions throughout the program period –
please take advantage of them
Program Resources for Chapter
Champions
 Regional Conference Calls to share questions, ideas, successes,
barriers, solutions
 Strategic Program Communications, e.g., e-newsletters, “ghostwritten” articles
 Listservs to ask questions, to seek/share ideas, resources, or
collaboration
 Program Webpage to find resources, previous issues of the enewsletter, information on the program, archived webinar
recordings, etc.
4
10/7/2015
Some Things To Think About
Legislation
 Is your state pursuing medical home legislation?
 What about asthma, allergy and/or anaphylaxis legislation (e.g., selfcarry/administer inhalers in school, epipen access/use)?
 Get involved and serve as the “voice” for pediatrics, become a “go to”
contact for issues related to asthma, allergy, & anaphylaxis
Medical Home Demonstration
 Get involved in Medical Home demonstration projects/initiatives in
your state (Medicaid or otherwise) –pcpcc.org/initiatives
Some Things To Think About
Engaging Chapter Leadership
 Work with chapter leadership in disseminating best practices in
asthma, allergy, and anaphylaxis care
Engaging State Pediatric Care Agencies
 Collaborate with state Title V and Medicaid staff and others in
government agencies on medical home, asthma, allergy and
anaphylaxis activities and initiatives
5
10/7/2015
Program Resources
 aap.org/en-us/professional-resources/practice-support/medicalhome/Pages/AsthmaAllergy-and-Anaphylaxis.aspx
 aap.org/en-us/professional-resources/practice-support/medicalhome/Pages/ResourcePacket.aspx
• Medical Home resources
• Asthma, allergy, & anaphylaxis resources
 allergyasthmanetwork.org
 See National and State Initiatives at www.medicalhomeinfo.org
If you’re attending the 2016 NCE in San Francisco, please attend “Management of Allergy
and Anaphylaxis in Pediatric Primary Care”
Workplan
 Prepare and submit a
workplan
 Helps program staff
connect you to other
champions working on
similar activities and to
identify resources that
could be useful
 Workplans can be
completed online in
SurveyMonkey or by
completing the Word
workplan template
6
10/7/2015
Commitment to
Change
 Identify planned
changes and/or action
steps upon returning to
your practice and
home chapter
 Anticipate and address
likely barriers to
change
 AAP Staff will follow-up
with attendees again in
8-10 weeks
Evaluation
 Please provide your
critical feedback –
this program is all
about improvement
and your input is key
to doing so
7
10/7/2015
Program Questions or Help Needed?
Contact:
Nkem Chineme, MPH
Program Manager
Division of Children with Special Needs
800/433-9016, ext 4342
nchineme@aap.org
8
10/7/2015
What’s Hot in Food Allergy:
What Will We Need to Know
Tomorrow?
Columbus, Ohio
………………..……………………………………………………………………………………………………………………………………..
Disclosures
activity
of a commercial product/device in my presentation
1
10/7/2015
Objectives
• Discuss the Learning Early About Peanut Allergy (LEAP)
study and findings
• Consider implications and applications of recent evidence
on practice guidelines
• Describe the process for diagnosing and classifying food
allergy, including co-morbidities such as asthma.
How Common Are
Food Allergies?
2
10/7/2015
Prevalence of Food Allergy
• Many reports have listed food allergy in 17-30% of the
general population
• Self reported measures without confirmation through appropriate
testing
• DBPCT performed with appropriate testing and confirmed
with food challenges place prevalence between 2-6% of
general population
• On average, at least one child in every classroom in
America
•Good Housekeeping Institute, Consumer Research Department. Women’s opinions of food allergens. New York: A Good
Housekeeping Institute Publication. 1984.
Good Housekeeping Institute, Consumer Research Department. Childcare findings V, Children and Food. New York: A
Good Housekeeping Report. 1989.
Sloan AE, Powers ME, Sloan AE, Powers MD. A perspective on popular perceptions on adverse reaction to food, J Allergy
Clin Immunol. 1986;78:128 –133.
•Bock SA. Prospective appraisal of complaints of adverse reactions to foods in children during the first three years of life.
Pediatrics. 1987;79:683– 688.
Why are Food Allergies Becoming More
Common?
• No clear answers
• Incidence of atopy also on rise
• Hygiene hypothesis
• Delayed introduction of foods may actually be
contributing to development of food allergies
• Manner of food production
• Roasting vs. boiling peanuts
Du Toit G et al. JACI. 122(5). Nov 2008;984-91.
3
10/7/2015
Risk Factors for Development of Food
Allergy
• Eczema
• Asthma
• Environmental allergies
• Family history of allergies
Myth
No Milk ‘til 1 Year…
No eggs ‘til 2 Years…
And No Nuts ‘til 3!!!
(And Avoid Eating
Anything While
Breastfeeding)
4
10/7/2015
Food Introduction - Background
2000 Recommendations from American
Academy of Pediatrics
• Delay introduction of solid foods until 4-6 mos
• Use hypo-allergenic formula for at risk infants
• Introduce whole cow’s milk at 12 mos
• Avoid eggs until 2 years of age
• Avoid peanuts, tree nuts, fish until 3 years of age
• Mothers of at-risk infants should avoid consumption of
peanuts during pregnancy and while breast feeding
(Based on few studies with various limitations)
2008 vs 2000 AAP Recommendations
Intervention
2008
2000
Define ‘high risk’
Parent or sibling with atopy
Both parents or 1 parent
and sibling
Avoidance of foods
during pregnancy
Lack of evidence
Possibly peanut
Exclusive breast feeding
until
Evidence for 3-4 mos
6 months
Avoidance of foods
during lactation
Some evidence for reduced Peanuts, tree nuts and
atopic dermatitis
consider egg, milk, fish and
“other foods”
Prevention formulas
Certain hydrosylates may
delay onset compared with
cow’s milk based, not soy
“Hypoallergenic” formulas,
not soy
Types of solid foods
Evidence to wait until 4-6
mos; no evidence for
specific foods
No solids until 6 mos, milk
til 1 yr, egg til 2 yrs,
peanuts, nuts, fish til 3 yrs
5
10/7/2015
What’s the Deal with Peanuts????
What’s the Deal with Peanuts?
• Prevalence of food allergy has doubled in past decade
• Food allergy:
• Overall, affects 8% of children
• Peanut allergy ~1%
• 2008 Study: Prevalence of peanut allergy in Israeli
children 10-fold less than in United Kingdom1
• ARR: 9.8 (95% CI, 3.1-30.5)
• Median monthly consumption of peanut in infants 8-14
months old1
• Israel = 7.1 grams
• UK = 0 grams
Du Toit G, et al. J Allergy Clin Immunol. 2008 Nov;122(5):984-91
6
10/7/2015
2015 – Let’s Take the LEAP!
Du Toit G et al. Randomized trial of peanut consumption in infants at risk for
peanut allergy. N Engl J Med 2015 Feb 23; [e-pub].
(http://dx.doi.org/10.1056/NEJMoa1414850)
LEAP Study
• Landmark food allergy study
• Demonstrated that early introduction of peanut may
protect against development of peanut allergy
• Protocol:
• Infants 4-11 months of age
• Moderate-to-severe eczema and/or egg allergy
• Skin prick test (SPT) and in office challenge
• Randomized to two groups:
• Consume 2 grams peanut 3 days/week until age 5
• Peanut avoidance
• Follow up challenge at 5 years of age
Du Toit G, et al. N Engl J Med. 2015 Feb 26;372(9):803-13.
7
10/7/2015
LEAP Study
• 640 infants randomized (median age 7.8 months)
• 542 SPT negative
• 98 SPT positive (1-4 mm wheal)
• Primary prevention = no sensitization
• Secondary prevention = sensitized, not allergic
• ***SPT > 5 mm excluded from study
• 95% confidence interval for likely clinical reaction = 8 mm for
positive peanut allergy
LEAP Results
86% Reduction
70% Reduction
Primary
Prevention
Secondary
Prevention
8
10/7/2015
Limitations of LEAP
• DO NOT try this at home!!!
• Not applicable to anyone already diagnosed with peanut
•
•
•
•
•
allergy
Not 100% effective
Low risk infants not included in the study
History of other food allergies not included
Yet to be replicated in other populations
Cannot extrapolate peanut feeding practices
• Source
• Duration
• Amount
LEAP: Next Steps
• NIH/NIAID Expert Panel convened summer 2015
• Interim communications released, including AAP
• Goal: Introduce peanut to infants early in life (5 months of
age)
• Risk stratification by eczema presence/severity and other
food allergies
• High risk: skin prick test followed by avoidance or
supervised feeding
• If successful  we could prevent 100,000 cases of
peanut allergy/year!!!
Fleisher D, et al. Ann Allergy Asthma Immunol. 2015 Aug;115(2):87-90.
9
10/7/2015
Case Discussion
Case Discussion
• 2 year old boy develops rapid onset hives, swelling,
difficulty breathing after eating brownie with walnuts
• 911 called and EMS give epinephrine
• Symptoms resolve within 15 minutes
• Does he need to go to the Emergency Department?
• Should have have self-injectable epinephrine prescribed?
10
10/7/2015
New Guidelines – For Physicians
Campbell RL, et al. Ann Allergy Asthma Immunol 113 (2014) 599-608.
Epinephrine and Anaphylaxis
• First line therapy
• Provides rapid resolution of symptoms
• Use requires monitoring in ED due to risk of biphasic
reaction (~20% of cases)
• Side effects are minimal when administered IM at
recommended dosages
• 0.15 mg < 30 kg
• 0.3 mg > 30 kg
• Majority of deaths from anaphylaxis are associated with
delayed or lack of epinephrine administration
11
10/7/2015
Myths/Misconceptions Patients May Have
• Many feel epi is harmful
• Do not understand that epi treats all symptoms of
anaphylaxis
• Cannot demonstrate proper use of self-injectable
epinephrine1
• 84% misuse during demonstration
• <60% carry epi with them at all times2
1. Bonds R, et al. Ann Allergy Asthma Immunol. 2015 Jan;114(1):74–76.
2. Curtis C, et al. Ann Allergy Asthma Immunol. 2014 Jun;112(6):560-2.
Case Discussion
• Family brings son to see you in office for follow up one
week later
• Doing fine
• Avoiding nuts
• What is your diagnosis?
• Is there any testing you want to perform?
• Do you refer to an allergist?
12
10/7/2015
Case Discussion
• You obtain serum IgE testing to evaluate for tree nut
allergies
• Order a ‘childhood allergy profile’
• Results
• Milk 1.19
• Egg 0.87
• Peanut 6.65
• Walnut 47.91
• Almond 13.49
• Pistachio 8.54
• Cashew 9.32
• What is your advice?
• Do you need more information?
Sensitization
Allergy
• Sensitization
• The detection of specific IgE toward an allergen through skin prick,
intradermal, or serum specific IgE testing
• IgE mediated hypersensitivity
• Characteristic clinical symptoms upon exposure to an allergen
AND…
• The detection of specific IgE toward that allergen
13
10/7/2015
IgE Mediated Food Allergies
• Cow’s milk, egg, soy, wheat, peanuts, tree nuts, fish, and
shellfish account for > 90% of all food allergy
• Reactions are objective, immediate onset and
reproducible with every exposure to the offending food, no
matter what form
• Typical symptoms:
• Urticaria
• Angioedema
• Emesis
• Rhinorrhea
• Wheezing
• Hypotension
• Anaphylaxis
IgE Mediated Food Allergies
• The best test to determine whether someone is allergic to
a food is ingestion of that food
• Specific IgE testing is best utilized to confirm a suspicious
history
• Delayed onset, non IgE-mediated food sensitivity or
intolerance cannot be confirmed with IgE testing
14
10/7/2015
Serum Specific IgE Testing
• Levels of IgE specific for food and/or inhalant allergens
can be obtained through routine venipuncture
• Test offers convenience
• Do not need to stop antihistamines
• Can test several allergens at once
• Don’t need to undergo the dreaded skin testing
• Commercial panels widely available and marketed as
excellent screening tools
• Results reported in a range from 0.1 kU/L – 100 kU/L
• Also reported as arbitrary classes (1 through 5)
!
• A big “ ” will accompany any value reported > 0.10 kU/L
Rates of Sensitization > Clinical Allergy
• NHANES data reveal 28% of children & 15% of adults with specific IgE >
0.35 kU/L
• Clinical allergy rates 2-8%
Liu AH et al. JACI. 2010;126(4):798-806.
15
10/7/2015
Specific IgE Cutoff Points
• Values differ by food
• Values only established for select number of foods
• The level does not equate to the severity of reaction
• In general, the higher the level, the more likely it has clinical
relevance
Sampson HA. JACI. 2001;107(5):891-6.
A Quick Word About IgG…
• Serum IgG antibodes towards foods touted by many
practitioners as a tool to diagnose food allergy/intolerance
• IgG may actually be a marker for food tolerance, not
intolerance
• Early recovery from cow’s milk allergy associated w/increasing IgG 4
• “IgG and IgG subclass antibody tests for food allergy do
not have clinical relevance, are not validated, lack
sufficient quality control, and should not be
performed”
J Allergy Clin Immunol. 2010 Jun;125(6):1315-1321
Ann Allergy Asthma Immunol. 2008 Mar;100(3 Suppl 3):S15-S66
16
10/7/2015
Case Discussion
• Patient eats milk, egg regularly without any problems
• Has never knowingly eaten peanut
• Do you tell them to avoid peanut? (IgE = 6.65 kU/L)
• Any other pertinent history?
• Additional history:
• Has itchy, watery eyes in spring and summer
• Well controlled with OTC antihistamines
• Strong family history of asthma, allergic rhinitis, eczema
Case Discussion
• Given this scenario, what is the best advice regarding
peanut?
A.
B.
C.
D.
E.
F.
G.
H.
Complete and strict avoidance
Gradual introduction at home
In office challenge without any additional testing
Eat at home but not at school
Oral desensitization
Component diagnostic testing
All of the above
None of the above
17
10/7/2015
Oral Immunotherapy (OIT)
• Multiple recent trials investigating oral desensitization to
foods (milk, egg, peanut)
• Sublingual
• Oral
• Concept: Gradual build up followed by daily maintenance
dose helps promote tolerance
• This is NOT a cure
• Cannot consume more than maintenance dose without risk of
reaction
OIT
• Academia  Not ready for prime time!
• Practicing allergists  We should be doing this!
• Many questions unanswered re: how to identify optimal
candidates
• High rates of reactions during both build up and maintenance
phase
• High rates of drop out due to rigorous schedule
• Potential to cause other allergic conditions (Eosinophilic
esophagitis)
• Can improve quality of life
• Lead to faster resolution???
Le UH, Burks, AW. World Allergy Organ J. 2014 Dec 8;7(1):35
18
10/7/2015
Component Diagnostic Testing
• Can measure specific IgE levels towards specific
allergenic proteins
• Some antigens more likely to cause anaphylaxis
• Some antigens represent cross sensitization with
seasonal aeroallergens
• Most useful:
• No history of prior ingestion
• Elevated IgE towards food
• History of allergic rhinitis with + IgE towards pollen
• Not useful:
• Prior anaphylaxis to that food
Kattan J, Wang J. Curr Allergy Asthma Rep. 2013 Feb;13(1):58-63.
Component Diagnostic Testing: Peanuts
• 9 potential antigens identified from peanuts
• Ara h 1, 2, 3  associated with reaction/anaphylaxis
• Ara h 6  cross reacts with Ara h 2
• Ara h 8  cross reacts with birch pollen; lower allergy risk
• Ara h 9  can have allergic reaction
• CDT interpretation:
• Get values for Ara h 1, 2, 3, 6, 8, 9
• + Ara h 1, 2, 3, 9  avoid
• + Ara h 8, with negative others  consider challenge
http://www.questdiagnostics.com/testcenter/testguide.action?dc=TS_Peanut_Com
ponent_Panel
19
10/7/2015
Conclusion
• Misperceptions about allergic conditions are common
among patients and physicians
• Utilize current guidelines to provide the best evidence
based care and answer patient questions
• Stay tuned – the evidence is constantly changing,
therefore our clinical practice must evolve to keep up
Commitment to Change –
What’s Your Action Plan?
What step(s) can you take to begin to
implement the guidance we've discussed
here…
• ... in your own practice?
• ... to serve your chapter or community?
20
10/7/2015
Thank You
21
10/8/2015
Remote Physiologic Monitoring with a Smart Phone
Approaches to Remote Monitoring and Telehealth Session, MHCCPAAA Conference, October 9th
Disclosures
• I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity
• I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation
1
10/8/2015
Objectives
• Discuss current mobile health applications for asthma and/or allergy, including remote self‐
monitoring for medication use, symptoms and pulmonary function, cough, physical activity and indoor air quality.
• Explore current and future innovations in telehealth to overcome challenges associated with access to specialists for managing asthma and/or allergy in children.
EPR-3 (8/28/07): p72, 307
2
10/8/2015
Lung Function
Symptom
Frequency
• FEV1 % Predicted
• FEV1/FVC
• Day & Night
• SABA Use
Oral Steroid
Bursts
The Current Scenario
• Diagnostic spirometry is generally only done in the clinical setting. Though home devices exist, they often lack complete platforms.
• Spirometers are relatively expensive, & have minimal coaching capability.
• No mobile apps currently measure spirometry
Clinical Spirometer Home Spirometer 6
3
10/8/2015
SpiroSmart
Basic results computed
on the phone
Complex machine learning algorithms run
in the cloud and compute all measures
Flow Features
Shwetak N. Patel - University of Washington
4
10/8/2015
Auto‐regressive estimate
envelope detection
Shwetak N. Patel - University of Washington
curve
regression
example curves
5
10/8/2015
Training through Feedback Reporting System Cycle
Spirometry 360 © University of Washington
6
10/7/2015
Asthma Apps For Providers and Teens
Studying Mobile for Engagement
Mark Ruthman
Manager, Digital Publishing
mruthman@aap.org
I have no relevant financial relationships with the manufacturer(s) of any commercial products(s) and/or
provider(s) of commercial services discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
AHRQ Grant objective/challenge to associations:
Create provider and teen apps that can communicate in order to test
the effect on visits and communications.
Chose Asthma as the topic of focus due to ongoing management
characteristics, wealth of AAP content, desire to build app around this
topic/audience, etc.
AAP App team has built around a dozen apps, including both clinical
and parent tools. This was the first pair of apps with HIPAA-compliant
data sharing, designed to connect providers and teens.
1
10/7/2015
Asthma Apps For Providers and Teens
Mission – create provider and teen apps that can communicate to test effect on visit.
Chose Asthma due to management nature, wealth of AAP content, etc.
Provider App: AAP Asthma Care for Clinicians
https://itunes.apple.com/us/app/aap-asthma-care-forclinicians/id962525650?mt=8
Key features:
• NHLBI Guidelines
• Tools to assess level of control and medication needs
• Ability to invite patients
Teen App: AAP Asthma Tracker for Adolescents
https://itunes.apple.com/us/app/aap-asthma-tracker-foradolescents/id962487757?mt=8
Key features:
• Tracking/journaling tools
• Medication reminders
• Device demonstration videos and other patient education
• Ability to send data to provider
2
10/7/2015
Provider App: AAP Asthma Care for Clinicians
224 downloads, 618 sessions
Teen App: AAP Asthma Tracker for Adolescents
106 users, 335 sessions
3
10/7/2015
Lessons Learned:
Tools for providers to educate, direct teens to apps, motivate them to
download and populate it. 10 doctors participated, and got some teens to
download the apps, but not to complete the survey.
Integration with workflow for providers to get data.
Support for other languages.
Next Steps:
New round of development and testing, leading to broader release.
Incorporate Flurry data and provider follow-up survey comments.
4
10/7/2015
Asthma Health Storylines
Created in a partnership with Self Care Catalysts Inc.
Tonya Winders, MBA
President & Chief Executive Officer
Allergy & Asthma Network
Disclosures
services discussed in this CME activity
product/device in my presentation
1
10/7/2015
ASTHMA HEALTH STORYLINES
SUITE OF HEALTH TOOLS
Suite of health tools that are currently on the
Asthma Health Storylines app, based on user
input and consultation with the Allergy &
Asthma Network
1. Medication Tracker
2. Symptom Tracker
3. Daily Moods
4. Daily Vitals
5. Appointment Calendar
6. My Journal
7. Healthy Doses
8. Daily Asthma Control
9. Questions to Ask
10. Health Reports
2
10/7/2015
SOME EXAMPLES OF THE HEALTH TOOLS
ADDITIONAL FEATURES ON THE SIDEBAR
Invite in others to share
and message with
Add additional Health
Tools that matter to you
Sync other devices such
as Fitbit, Jawbone etc.
Link to Asthma Control
test for Adults, children
and teens
The main page displays all your
Health Tools for managing asthma
and overall health. You can add
more tools by clicking on the red +
icon at the bottom right corner.
Add other conditions if
applicable to your profile
Links to Allergy & Asthma
Network Resources
The My Storylines page found
under the left menu gives you a
summary of your overall health,
and enables you to share more
with your care team.
3
10/7/2015
MY STORYLINES – SELF DISCOVERY AND TOOL FOR
MORE EFFECTIVE HCP/PATIENT INTERACTIONS
The My Storylines gives a summary of
all that has been inputted into the app to
give a picture of your overall health.
The My Storylines page found
This can beThe
shared
with
themenu
care
team
under
thepage
left
gives
you a to
My Storylines
found
summary
of your
overall
health,
under
the
left
menu
gives
you
a on
have more effective
discussions
how
and
enables
to share more
summary of
your
overallyou
health,
best to manage
theyouindividual’s
asthma
with
your care
and enables
to share
moreteam.
with your care team.
ACCESSING ASTHMA HEALTH STORYLINES
The mobile app is free for all users on iOS and Android devices. There is also a web version
available, accessible through the browser of any desktop computer or mobile device.
https://asthma.healthstorylines.com
4
10/7/2015
ASTHMA CARE:
A MOBILE HEALTH
APPLICATION FOR CHILDREN
AND ADOLESCENTS
The Ohio State University
Columbus, Ohio
Disclosures
activity
of a commercial product/device in my presentation
1
10/7/2015
Methods
• A personalized, interactive iOS smartphone application
(Asthma Care) was created using Xcode (Apple Inc.
Cupertino CA)
• We conducted a prospective, 30-day pilot study
• Patients seen in outpatient A/I clinic at pediatric academic
medical center with physician diagnosed asthma
• Ages 9-16 years old
• Persistent asthma determined by use of at least one controller
medication
Farooqui N, Phillips G, Barrett C, Stukus D. Annals Allergy Asthma Immunology. 2015
Jun;114(6):527-9.
Methods
• Primary outcome measure
• Device usage
• Acceptability of app
• Secondary outcome measure
• User engagement in self-management
behaviors
2
10/7/2015
Asthma Care: Personalized Medicine
• User inputs their personal information:
• Name
• Daily and reliever medications
• Personal triggers
• Appointment dates
3
10/7/2015
Asthma Care: Reminders
• Asthma Care reminders:
• Daily (or 2 x/daily) reminders for medications
• Daily reminders for trigger avoidance
• Occurs around 5 pm every day
• Attempt to minimize interference with school, sleep
• Attempt to maximize interaction with caregivers
• “Sam” is their asthma buddy, who provides helpful tips
4
10/7/2015
Asthma Care: Interaction with User
• User role:
• Input use of daily medication
• Input use of rescue medication
• Input any symptoms
• They receive immediate feedback:
• Level of asthma control
• Can track their medication use and symptoms
• Asthma Action Plan activated through
• Recording of any symptoms
• Recording of any albuterol use
5
10/7/2015
6
10/7/2015
Activation of Action Plan: Green Zone
Activation of Action Plan: Yellow Zone
7
10/7/2015
Activation of Action Plan: Red Zone
8
10/7/2015
Results
• 12/21 (57%) of subjects reported having a previous
written asthma action plan at home
• 0/12 (0%) keep it with them at all times
• 6/12 (50%) never look at their treatment plan
• 4/12 (33%) don’t feel comfortable using their written action plan
• 12/12 (100%) reported feeling more comfortable using
Asthma Care compared with a written plan
• 12/12 (100%) preferred using Asthma Care compared
with a written plan
9
10/7/2015
Results: Acceptability
• 21/21 (100%) reported a better understanding of their
asthma after using the app
• 20/21 (95%) prefer receiving asthma education through
mHealth apps compared with other modalities
• 21/21 (100%) would recommend Asthma Care to friends
and family members with asthma
Results: Interaction
• 17/21 (81%) interacted with the app multiple times/day
• 3 others used it at least once/day
10
10/7/2015
Results: Avoidance Strategies
PRE-SURVEY
POST-SURVEY
Mean # of triggers
reported
4.76 (1 – 8)
4.86 (1 – 8)
Mean # of correct
avoidance strategies (%)
2.95 (36.9)
4.24 (53)
% Correct avoidance
strategies adjusted for #
of reported triggers
66.3 (0 – 100)
88.2 (20 – 100)
p<0.0001
Asthma Care Availability
• Currently available in both iOS and Android versions
• FREE for anyone to use
www.nationwidechildrens.org/asthmacare
11
10/7/2015
Thank You
………………..…………………………………………………………………………………………………………………………………….
.
12
10/7/2015
My Experience with
Telemedicine
Jay M Portnoy, MD
Director, Division of Allergy, Asthma & Immunology
Children’s Mercy Hospitals & Clinics
Kansas City, Missouri
Disclosures
manufacturer(s) of any commercial product(s)
and/or provider(s) of commercial services
discussed in this CME activity.
1
10/7/2015
Patient Care: 2001
Crossing the Quality Chasm
• Patient care is:
•
•
•
•
•
•
Safe
Effective
Efficient
Patient Centered
Timely
Equitable
Alternative types of encounter
• Synchronous
•
Clinic visits
•
Telephone- ad hoc
•
Telephone- Scheduled
•
Group meetings
•
Webinars
• Asynchronous
•
•
E-mail
Patient portals
• Telephone visits
•
•
•
•
Charged $20 or $40
Most patients were very happy
A few complained that the doctor “didn’t do anything” because no
physical contact
Currently there is no charge
2
10/7/2015
Telemedicine: My Workflow
• Set up the laptop and
audio device
• Log in to the EMR
• Log in to telemedicine
• Connect to St. Joseph or
Wichita
The Encounter
• I ask my usual questions
• Notes entered into EMR
• Instructions printed to
patient’s location
• E-prescriptions sent to
pharmacy
• Orders entered including
blood tests
• Spirometry is available
3
10/7/2015
The Physical Exam
Patient instructions
• Handouts printed to
patient
• Nurse reviews
instructions
• Inhaler technique
4
10/7/2015
Patient Experience (telemedicine video)
Asthma study
• Patients scheduled in allergy
clinic from Wichita or St. Joseph
• Offered telemedicine or face-toface
• Asked to participate in a study
• Consent signed (IRB approved)
• Measured day 1, 30 and 180:
• Asthma Control test
• Quality of Life (caregiver and
patient)
• Satisfaction
Age
Study
Control
Total
<4
20
11
31
4 to 11
27
16
43
12 +
10
4
14
Total
57
31
88
5
10/7/2015
Satisfaction
After my experience today, I would recommend
health care appointments by telemedicine to a family
member or friend.
The appointment using telemedicine was as good as
an appointment in person.
Response
Strongly
Agree/YES!
Response
Strongly
Agree/YES!
Number of Responses
51
Agree/Mostly
Neutral/No
Opinion
3
Grand Total
Number of Responses
51
3
3
Agree/Mostly
Neutral/No
Opinion
57
Grand Total
57
3
Asthma Control Test
Control Group
20
15
10
5
0
<4
4 to 11
12 +
Axis Title
Day 1
Day 30
Day 180
Asthma Control Test (ACT)
Asthma Control Test (ACT)
Telemedicine Group
25
25
20
15
10
5
0
<4
4 to 11
12 +
Axis Title
Day 1
Day 30
Day 180
*TRACK for <4 years normalized to 25 points
6
10/7/2015
Quality of Life
Caregiver QOL
Patient QOL
100
100
50
50
-
<4
4 to 11
Day 1
Day 30
12 +
<4
Day 180
4 to 11
Day 1
Day 30
12 +
Day 180
Integrating Telemed into Practice
Time
8:00
8:45
9:30
10:15
11:00
11:30
Lunch
13:00
13:45
14:30
15:15
16:00
16:30
Patient
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
xxxx
Location
SC- New
TH- Joplin- new
TH- St. Joseph- new
SC- New
TH- Joplin- F/U
SC- F/U
SC- New
TH- Wichita- new
SC- New
TH- Joplin- new
SC- F/U
SC- F/U
• Patients can be seen
wherever they are
• Demand determines
distribution of Telemed
• Pct seen in August, 2015
Clinic
Telemed
Phone
New
53%
18%
0
F/U
16%
4%
9%
7
10/7/2015
Extending Telemed into Additional
Communities
• It just takes a tablet to
connect
• PCP can connect via
iPad.
• Ad hoc or scheduled
consultations from PCP
office
Billing and Coding
• At least 40 miles between patient and provider
• Facility fee may be billed for by the facility with the
patient
• Professional fee billed by the provider
• Can bill if a provider does the exam and relates that
to the consultant (so can use an iPOD instead of a
robot)
• Need to indicate in note that it was a telemedicine
encounter
8
10/7/2015
So where are we going?
• Telemedicine in patient homes? Why not?
• Telemedicine interface with the EMR directly
• Audio/video documentation
• Robodoc?
Who knows? But it is cool…
9
10/7/2015
What step(s) can you take to begin to implement the
guidance we've discussed here…
10
10/7/2015
QUALITY IMPROVEMENT
MEETS ASTHMA, ALLERGY
AND ANAPHYLAXIS
David Stukus, MD, FAAP, FAAAI, FACAAI
Chair, Quality Improvement Expert Panel
Medical Homes Chapter Champions Program on
Asthma, Allergy and Anaphylaxis
Columbus, Ohio
Disclosures
activity
of a commercial product/device in my presentation.
1
10/7/2015
Objectives
• Examine a current quality improvement (QI) project on
patient engagement and application of evidence-based
guidelines relative to the management of asthma, allergy,
and anaphylaxis (AAA).
• Apply practical, take-home guidance that can be
implemented through the medical home model to improve
outcomes for children with asthma, allergy, and
anaphylaxis.
What is a Medical Home?
• 1st introduced by AAP in 1967
• Initially designed as ‘home’ for patient’s medical records
• Modern version
• Cultivated partnership between the patient, family, and primary
provider in cooperation with specialists and support from the
community
• Patient/family is the focal point of this model, and the medical home
is built around this center
• NOT just children with special needs
2
10/7/2015
Joint Principles of the Patient-Centered
Medical Home
• Patient centered
• Comprehensive
• Coordinated
• Accessible
• Committed to quality and safety
Research vs. QI Measurement
What’s the Difference?
Measurement for
Research
Measurement for Learning and
Process Improvement
Purpose
To discover new knowledge
To bring new knowledge into daily practice
Tests
One large "blind" test
Many sequential, observable tests
Biases
Control for as many biases as
possible
Stabilize the biases from test to test
Data
Gather as much data as
possible, "just in case"
Gather "just enough" data to learn and complete
another cycle
Duration
Can take long periods of time to
obtain results
"Small tests of significant changes" accelerates the
rate of improvement
3
10/7/2015
It Takes an Effective Team
to Do QI Work!
• Members representing different kinds of expertise in the
practice
• Who would you include on your team?
• Clinical Leader
• Technical Expertise
• Day-to-Day Leadership
• Administrative Staff
• Parent Partner
• Project Sponsor
How Teams Get Results
• Engage leaders
• Assign responsibility for key tasks
• Meet
• Small tests of change
• Use of technology, including decision-support in
your EMR and registries to manage populations of
patients.
• Use of best practices, tools and resources
4
10/7/2015
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
AIM
MEASURES
IDEAS
Medical Homes Chapter Champions
Program on Asthma, Allergy and
Anaphylaxis
5
10/7/2015
Medical Home Chapter
Champions Program on AAA
 Program of the Division of Children with Special Needs.
 Supported by the Allergy and Asthma Network (AAN).
 The overall goal of the program is to promote the delivery of
high quality asthma, allergy and anaphylaxis care in the
medical home through team-based, patient- and familycentered care coordination and co-management among
patients and their families, primary care pediatricians, and
pediatric asthma and allergy specialists.
QI Project Goals
The Quality Improvement component will comprise
of two phases.
 Current Phase (Phase 1: May 1–Oct 31, 2015):
 Develop and enhance tools that support the
interface between primary care pediatricians and
pediatric subspecialists in team-based provision
of asthma, allergy and anaphylaxis care via the
coordination and implementation of a web-based
(virtual) learning initiative (Web&ACTION model)
6
10/7/2015
Practice Improvement Teams
Practice Improvement Teams
1. Ochsner for Children, New Orleans,
LA
(team members: 3)
7. Family Allergy & Asthma CARE,
Flower Mound, TX
(team members: 6)
2. Elmwood Pediatric Group, Rochester,
NY
(team members: 7)
8. Allergy Asthma & Immunology Relief
(AAIR), Charlotte, NC (team members:
4)
3. Kids Count Pediatrics, PLLC, Elkin,
NC
(team members: 7)
9. Pediatrics at Orange UVA, Orange, VA
(team members: 5)
4. UH Rainbow Babies and Children’s
Hospital,
Cleveland, OH (team
members: 15)
10. Pediatric Pulmonology, DartmouthHitchcock Medical Center, Lebanon,
NH (team members: 5)
5. ABC Pediatric Clinic, Houston, TX
(team members: 2)
11. Winthrop Pediatrics Associates,
Mineola, NY
(team members: 2)
6. Quality of Life Health Services, Inc12. Cadence Physician Group Pediatric
Pediatrics, Heflin, AL (team members:
Pulmonology, Winfield, IL (team
3)
members: 3)
Web&ACTION Process Plan
Recruit,
Enroll,
Orientation
Webinar/Call
and Consent
Practice
Participants
(May, 2015)
Pre-inventory
Survey
Baseline
Data
Collection
(June)
Educational
Webinar 1
Action Period
1
(July)
Educational
Webinar 2
Action Period
2
(August)
Educational
Webinar 3
Action Period
3
(September)
Postinventory
Survey
Wrap-up
(October)
7
10/7/2015
Sampling Plan during Action Periods
Primary Care or
Combined Allergy &
Pulmonology Practice
• 10 records per
participating
physician for patients
with asthma
diagnosis
• 10 records per
participating
with
allergy/anaphylaxis
diagnosis
• There could be an
overlap of records for
some patients
Pulmonology Practice
Allergy Practice
• 10 records per
participating
with asthma
diagnosis
• 10 records per
participating
with
allergy/anaphylaxis
diagnosis
Educational Webinar Topics and
Dates
July 7
12-1pm
CT
• Topic: Quality Improvement Education
• Faculty: Ruth Gubernick, PhDc, MPH, PCMH CCE
August 10 • Topic: Asthma, allergy and anaphylaxis family-centered
coordinated care
12-1pm CT • Faculty: Dave Stukus, MD, FAAP, FAAAAI
September
• Topic: Patient and family engagement in the medical home
9
• Faculty: Maureen Damitz, AE-C and Linda Follenweider, MS
12-1pm
PhDc CNP
CT
8
10/7/2015
Quality Improvement Data
Aggregator (QIDA)
 This project utilizes the AAP Quality Improvement Data
Aggregator a web-based data collection and aggregation tool.
 QIDA “group administrator” – access to enter data, view and
analyze practice’s data, complete project-related online surveys
and use the project workspace
 QIDA “project participants” –access to view and analyze
practice’s data and use the project workspace
Example Aim
 Our practice team will improve care for all of our patients
diagnosed with asthma, allergies and anaphylaxis
 What is good about this aim statement?
 What is bad about this aim statement?
9
10/7/2015
SMAART Aim
 What makes a good aim statement?
 Specific: Understandable, unambiguous
 Measurable: Numeric goals
 Actionable: Who, what, where, when
 Achievable: (but a stretch)
 Relevant: to stakeholders and organization
 Timely: with a specific timeframe
Aims and Measures
• Can you think of any specific aims/measures for:
• Asthma
• Food allergies
• Anaphylaxis
• Patient engagement
• Patient centered care
10
10/7/2015
Aims and Measures (Asthma)
• During the Action Periods, our practice team will provide
and document planned, proactive, comprehensive
asthma care by:
 Eliciting level of severity or control of asthma for at least 90%
of all patients during each visit with diagnosis of asthma
 Documenting the provision and review of an asthma action
plan for at least 90% of all patients with visit diagnosis of
asthma
 Eliciting information on provider prescribing or confirming
prescribed controller medication for persistent asthmatics for
at least 90% of all patients with diagnosis of asthma
 Assessing and reviewing proper inhaler use technique for at
least 90% of all patients with diagnosis of asthma
Aims and Measures (Allergy and
Anaphylaxis)
• During the Action Periods, our practice team will provide and
document planned, proactive, comprehensive allergy and
anaphylaxis care by:
 Eliciting allergy diagnosis confirmation using appropriate testing for
at least 90% of all patients at every visit with diagnosis of food
allergy/anaphylaxis
 Confirming that at least 90% of all patients diagnosed with a food
allergy/anaphylaxis have the appropriate epinephrine prescription
based upon current weight
 Documenting the provision and review of an allergy/anaphylaxis
action plan for at least 90% of all patients with a diagnosis food
allergy/anaphylaxis at every visit
 Assessing and reviewing proper self-injectable epinephrine
technique for at least 90% of all patients with a diagnosis of food
allergy/anaphylaxis at every visit
11
10/7/2015
Aims and Measures (Patient and
Family Engagement)
• During the Action Periods, our practice team will enhance
coordinated care and patient and family engagement
by:
 Providing at least one form of active patient and family
engagement strategy during the creation of the asthma or
allergy/anaphylaxis action plan such as motivational
interviewing, teach back method or Ask Me 3 to 90% of all
patients at every visit
 Documenting the provision and explanation of educational
materials (separate from the asthma and allergy/anaphylaxis
action plan) for at least 90% of all patients with a diagnosis of
asthma, food allergy or/and anaphylaxis, and families at
every visit
QI Project Goals
Phase 2 (Nov/Dec, 2015 – July 31, 2016):
• Optimize the role of the primary care physician in the
management of patients with asthma, allergy and
anaphylaxis.
• Improve systems of care for these low complexity, high
cost and common health conditions, including appropriate
referrals to subspecialists and co-management of patients
via the coordination and implementation of a team-based
quality improvement learning collaborative (Breakthrough
Series model).
12
10/7/2015
What stays the same in Phase 2?
• Some of the same asthma and allergy
measures
• Current practice improvement teams
• Practice surveys
• Monthly data entry in QIDA
• Monthly progress reports
• Monthly educational webinars
What’s NEW in Phase 2?
• Additional measures focusing on comanagement between primary care and
subspecialists
• Two-practice teams (primary care + subspecialty
practice) come together as one core team
• Parent Partner joins combined team
• Two in-person learning sessions
• One 6-month Action Period
13
10/7/2015
Team make-up for Phase 2
Practice B
(Introduced in Phase
2 - Breakthrough
Series)
Practice A
(from Phase 1)
Lead
Physician
(Required)
Other
practice
member(s)
(Required)
Parent
Partner
Co-Lead
Physician
(Required)
Other
practice
member(s)
(Required)
Phase 2 teams
• Overall, 11 core 4-person teams
• Core team members will include a
primary care pediatrician, a subspecialist
(asthma or allergy), another office staff,
and a parent partner
• Core team members will attend the inperson learning sessions
14
10/7/2015
The Medical Home Chapter Champions
Program Breakthrough Series Approach
Enroll 11 fourperson teams
Prework
Select
Topic
Recruit
Faculty
Develop
Framework
and
Changes
LS: Learning Session
AP: Action Period
P-D-S-A: Plan-Do-StudyAct
A
P
S
D
LS1:
LS2:
Supports:
Spread
best
practices
via chapter
meetings,
publications
, webinars,
and grand
rounds
Emails • Monthly data and progress reporting • Education (webinars) •
Phone conferences • Feedback between QI Expert Group and teams
Phase 2 Timeline (8-9 months)
Recruitment
& Orientation
(November
2015)
Learning
Session 1
(December
2015)
Action Period
(January –
June 2016)
Learning
Session 2
(July 2016)
15
10/7/2015
Phase 2 Action Period (6 months)
Educational
Webinar 1
Conference
Call
(1 month)
Educational
Webinar 2
Conference
Call
(1 month)
Educational
Webinar 3
Conference
Call
(1 month)
Educational
Webinar 4
Conference
Call
(1 month)
Educational
Webinar 5
Conference
Call
(1 month)
Educational
Webinar 6
Conference
Call
(1 month)
Quality Improvement in Practice
• What is good about implementing QI?
• What is bad about implementing QI?
16
10/7/2015
Why Worry About Asthma?
• Asthma is prevalent
• ~10% of all children in the U.S. have asthma diagnosis
• Asthma is serious
• Leading cause of emergency department visits and hospitalizations
• Over 3,500 deaths from asthma in 20131
• Asthma is disruptive
• Frequent cause of missed school/work
• Disruption in sleep
• Limitations in physical activity
1. http://www.cdc.gov/nchs/fastats/asthma.htm
Written Asthma Action Plans
• Providing patients with individual written plans1,2:
• Decreases symptoms
• Reduces unscheduled health care visits
• Improves quality of life
• Empowers patients to guide self-management
• Written action plans are recommended in all iterations of
NHLBI guidelines
• Often under utilized
• 25% of 18,000 asthmatic children in Chicago schools have plan3
1.
2.
3.
Gibson PG, Powell H. Cochrane Database Syst Rev. 2003;1:CD001117.
Thoonen BP, et al. Thorax. 2003;58:30-6.
Gupta RS, et al. Pediatrics. 2014 Oct;134(4):729-36.
17
10/7/2015
Inhaler Technique
• Improper inhaler technique is very common
and associated with1:
• Increased risk of hospitalization
• Increased emergency room visits
• Increased courses of oral steroids
• Poor disease control
1. Respir Med. 2011 Jun;105(6):930-8. Epub 2011 Mar 2.
Why Worry About Food Allergy?
• Approximately 1 in 13 children has a food allergy1
• 2 in every classroom, in every school in America
• The ONLY current treatment of food allergy is strict
avoidance of the known food allergen
• There is no ‘safe’ amount – trace amounts and crosscontact can cause reactions
• It typically requires ingestion to cause anaphylaxis
1. http://www.foodallergy.org/facts-and-stats
18
10/7/2015
Management of Food Allergy
• Diagnosis – use specific IgE testing to confirm allergy
• Avoidance – reading labels, notifying food handlers
• Preparation – self injectable epinephrine should be
immediately available at all times
• Communication – written food allergy treatment plans
• School/daycare:
• 15% of children with food allergy have had reaction at school
• 20-25% of children with reactions at school have no history of prior
food allergy
• Stock epinephrine legislation passed in every state
• Most are voluntary
Why Worry About Anaphylaxis?
• Affects at least 1 in 50 people living in United States 1
• Risk factors for anaphylaxis have increased significantly
in recent years
• Number of children with food allergies has increased by 50% over
the past decade
• Patients are ill equipped to handle anaphylaxis
• ~50% never receive prescription for self-injectable epinephrine
1.
Wood RA, et al. J Allergy Clin Immunol. 2014 Feb;133(2):461-7.
19
10/7/2015
Why Worry About Anaphylaxis?
• Deaths are rare1
• ~150 deaths per year in U.S. due to food allergy
• ~100 deaths per year in U.S. from other causes of anaphylaxis
• 77% occur in hospital setting
• But…Quality of life suffers2
• Caregivers of children with food allergy have lower QoL
• Associated with many factors
• Milk and egg allergy > peanut, tree nut
1. Ma L, et al. J Allergy Clin Immunol. 2014 Apr;133(4):1075-83.
2. Howe L, et al. Ann Allergy Asthma Immunol. 2014 Jul;113(1):69-74
Fatal Anaphylaxis
• Medications most common cause in adults
• Foods most common cause in children
• Risk factors:
1. Delayed administration of epinephrine
1.
2.
3.
4.
i.e. not carrying epinephrine autoinjectors at all times
History of asthma
Teenagers
History of peanut, tree nut, or shellfish allergy
Curr Allergy Asthma Rep. 2009 Jan;9(1):57-63.
20
10/7/2015
Epinephrine and Anaphylaxis
• Epinephrine is first line therapy1
• Provides rapid resolution of all symptoms associated with
anaphylaxis
• Use requires monitoring in ED due to risk of biphasic
reaction (~20% of cases) NOT because epi is dangerous
• Side effects are minimal when administered IM at
recommended dosages
• 0.15 mg < 25 kg
• 0.3 mg > 25 kg
• Majority of deaths from anaphylaxis are associated with
delayed or lack of epinephrine administration
1. Campbell RL, et al. Ann Allergy Asthma Immunol 113 (2014) 599-608.
Treatment of Anaphylaxis
• Epinephrine administered into lateral aspect of thigh
• When in doubt, give epinephrine!
• Antihistamines are second line therapy
• Corticosteroids ARE NOT helpful!!!
• In controlled setting – epinephrine should still be
administered IM
• Dose = 0.01 mg/kg (max 0.5 mg) every 5 minutes as necessary to
control symptoms
• Supportive care as deemed necessary
1. Campbell RL, et al. Ann Allergy Asthma Immunol 113 (2014) 599608.
21
10/7/2015
Final Thoughts…
• Asthma, food allergies, and anaphylaxis are common,
potentially life-threatening conditions
• Proper diagnosis and evidence based management are a
starting point
• Patient engagement and self-management
are crucial to providing optimal care
Final Thoughts…
• You can do a great job with
• Establishing an accurate diagnosis
• Prescribing an effective medication regimen
• Educating parents and patients about their
asthma and allergies
• Establishing routine follow up visits
• But…care will be sub-optimal if your patients
cannot:
• Recognize symptoms
• Identify proper treatment when symptoms occur
• Use their inhalers or epinephrine autoinjectors correctly
22
10/7/2015
What step(s) can you take to begin to
implement the guidance we've discussed
here…
Changes You May Wish to Make in
Practice
• Involve caregivers, and when appropriate, children in
•
•
•
•
development of the treatment plan
Provide written treatment plans at every visit for asthma
and food allergy
Assure that timely communication occurs to referring
provider and/or specialist receiving referral
Review device technique at every visit
Emphasize preparedness and anticipate challenges
23
10/7/2015
Thank You
Questions???
24
10/8/2015
Breaking Down the Barriers to
Adherence
Julie P Katkin, MD
Pulmonary Medicine Section
Disclosures


I have no financial or advisory relationships
relevant to this presentation (or, sadly, to any
other)
I will not be discussing “off label” applications
of any medication or therapeutic modality
1
10/8/2015
Learning Objectives


Identify strategies to improve adherence in
the management of asthma, allergy, and
anaphylaxis, including addressing such
challenges as missed appointments, incorrect
device usage, and lack of access to
affordable medications.
Assess economic, social and environmental
barriers to adherence that are common to all
chronic conditions.
My Nightmare Asthma Visit





Jimmy has been to Emergency Care three times in the past 6
months. Different urgent care setting each time, mostly at night. Has
not followed up with me after ANY of these events.
Urgent care doctors have prescribed new ICS twice; now he has 3
controller medications at home, and has used 2 different pharmacies
He is using Xopenex or Proventil for quick relief, although I carefully
prescribed ProAir. He has at least 6 quick relief inhalers scattered
among several locations.
He travels between three different households each month. Family
never comes to visits together.
There is no school nurse.
2
10/8/2015
Why is Adherence with
Asthma Therapy a Problem?





Asthma is a chronic disease
Episodic nature of disease
Age group affected: teenagers are poorly
compliant
Asthma therapy is expensive
Need for multi-drug therapy



Confusion about medication use
“Selective adherence” to prescribed medications
“Steroid phobia”
Are You Getting the Full Picture?
Parent vs. Patient

1
Guyatt, G.
PEDIATRICS 1997;
99 (No. 2):165-168.
2 Fuhlbrigge AL, et al.
J Allergy Clin
Immunol 2001;
107:61-67.



Parents of younger children may not have a
good idea of what their asthmatic children are
experiencing.1
Parents’ information is based on behavioral
manifestations (cough, wheezing, nocturnal
awakening, medication use, and possibly
PEF).1
Parents may be less aware of occasional
symptomatic episodes and may only report
more serious events.2
These factors may lead to the physician overestimating the level of asthma control.
3
10/8/2015
Inadvertent Non-adherence: We are
Having Technical Difficulties




Children are not using device +/- spacer correctly
Children are not being observed while they take
their medicine
Parents are leaving children to manage medications
without supervision
TIPS:



Stick to one kind of device (MDI, DPI, aerosol)
Calendars
Use the technology!
Quasi-Intentional Non-adherence





Don’t remember to take the medications
Can’t afford to buy the medications
Sharing medications among family
Transporting medications among multiple
households
TIPS:



Education, education, education
Samples, if you’ve got them
Get the whole family on board
4
10/8/2015
Intentional Non-adherence

Refusal to take medication

I am a teenager
 Not
cool
 Not doing what I am told to do


I am not buying your explanation of my disease
Magical thinking
I

got a Chihuahua and now my asthma is gone
Chaos in the home


Too many homes / caretakers / people
Parents incapable of providing care
Role of Asthma Education
Face to face interactive asthma
education leads to:
 reduced parental/patient anxiety
 lowered asthma severity scores
 reduced asthma morbidity
 reduced asthma mortality
5
10/8/2015
Available Tools

Asthma Action Plan








Important resource for families and schools
Format is key – and often not in our control
Literacy?
No study shows that they work
Electronic communications
Home monitors, prescription counters
Insurance company programs
School nurses!!!!!
Communications are Key

Review existing referrals





Consider needed referrals (see above)
Non-medical supports




Allergist
Pulmonologist
Otolaryngologist
School nurse
Additional caretakers
Social worker
Practice Partners


Clear rationale for decision making documented
DOCUMENT YOUR PLANS FOR “NEXT STEP”
6
10/8/2015
What about Allergy and
Anaphylaxis?
Interactive Discussion
Share experiences, approaches,
successes and failures
What step(s) can you take to begin to implement the guidance
we've discussed here…
...
in your own practice?
... to serve your chapter or community?
7

here - American Academy of Pediatrics

Transcription

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