Allegheny Health Network Improving Care of Asthmatic Patients

Allegheny Health Network Improving Care of Asthmatic Patients: A Collaborative Approach Lydia Travnik D. O. , M. P. H. , Sandy Clemente M. D. , Dawn Karns D. O. , Klara Roman M. D. , Phyillis Acquah M. D. , Srinvasu Sunkara M. D. , Caitlin Clark D. O. , Lisa Hudson RRT, Joseph Snatchko, OMS 3 St. Vincent Hospital, Erie PA Introduction Asthma is a major health problem that is still largely underdiagnosed and undertreated. A widely recognized crucial step in reducing management costs and improving quality of life involves an early diagnosis by a general practitioner. Spirometry is an important diagnostic tool and can play a central role in diagnosis and management of obstructive lung disease. A significant number of patients are clinically diagnosed with asthma without proper utilization of spirometry. These patients are prescribed medications, often times without proper instructions as to how or when to use them, and at times are lost to follow up due to multiple reasons resulting in the lack of improvement to their symptoms, and increased asthma exacerbations. Objectives 1. Identify patients in our practice with a diagnosis of asthma or presumed asthma who have not had formal pulmonary function testing or in house spirometry. 2. Perform baseline in office spirometry, with the assistance of a trained respiratory therapist, in order to screen for presence of and severity of asthma. 3. Assess if need formal PFT’s are indicated and, if so, refer for testing. 4. Maximize appropriate therapy for patients using results of screening and evidence-based treatment guidelines based on disease classification. 5. Instruct and demonstrate proper use of inhalers with assistance of respiratory therapist. 6. Improve treatment compliance and follow up. Methods Discussion 1. Implementation of biweekly Asthma Clinic 2. Use of EMR to identify patients with diagnosis of asthma or wheezing who have not had spirometry performed. 3. Patient referrals from residents and faculty within St. Vincent Family Medicine Clinic 4. In-office spirometry with a hand-held office spirometer conducted by a trained respiratory therapist on patients age 6 and older, and those patients that were able to follow instructions for accurate testing 5. Maximized medical therapy based on spirometry results. Those with inconsistent or moderate to severe obstruction referred formal PFTs in hospital setting 6. Demonstrated proper use of medications/inhalers by respiratory therapist 7. Follow up appointment made with patient’s PCP Primary care physicians diagnose and care for a Results A total of 109 patients were seen and evaluated in the St. Vincent Family Medicine Asthma Clinic from December 2013 -November 2014. Twenty patients were excluded from the results because their clinic visit was for follow up purposes. Of the participants, 47% were males, and 53% were females. Ages ranged from 2 -73 years old: 26% were less than 18 years old, 22% were 19 -40 years old, 40% were 41 -65 years old, and 11% were greater than 65 years old. Smokers made up 55% of the patients evaluated. Spirometry was attempted in a total of 89 patients; 3 patients were unable to complete spirometry due to illness, age less than 6, or lack of understanding of the directions. Of those who completed testing, 15 of the sessions were not technically adequate because the results were not reproducible. Seventy-one results (83%) were categorized as technically adequate, with a quality rating A through C by the spirometer, and had spirometry results which were reproducible. Within this category, normal spirometry results were obtained in 37 patients (52%); obstructive disease in 26 patients (37%); and restrictive disease in 9 patients (13%). Of the 89 patients in which spirometry was performed, 42 (47%) had a pre-existing diagnosis of asthma, and 7 (8%) of COPD. Of those without a history of asthma or COPD, 19 (40%) patients had normal spirometry results, 11 (23%) had obstructive disease, 6 (13%) had restrictive disease and 16 (34%) were referred formal pulmonary function testing (PFT) with before and after bronchodilation. Of the 89 participants, a total of 35 patients (39%) were referred formal PFTs due to obstructive or restrictive findings, or due to results which were not reproducible with a high clinical suspicion for abnormal findings. Seventeen patients required a change to their medication regimen in concordance with current guidelines. large portion of the millions of Americans with asthma and COPD, with only approximately 20% under the care of a pulmonary specialist. There is debate over the accuracy and value of in-office spirometry for the management of obstructive lung disease. Studies show that it is possible to perform technically adequate spirometry in primary care practices when training has been offered to office staff on performing spirometry and evaluation and interpretation of spirograms. Only accurate and reproducible spirometric measurements allow a diagnosis of airway obstruction. The idea of multidisciplinary involvement in diagnosing and treating chronic disease, such as asthma, is evolving. Participation of individuals specially trained in spirometry performance and respiratory medication administration techniques can be a crucial part of the success of in-office s p i r o m e t r y References Akinbami LJ, Moorman JE, Bailey C, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001– 2010. NCHS data brief, no 94. Hyattsville, MD: National Center for Health Statistics. 2012. Ferguson, GT, Enright, PL, Buist, S, et al. Office Spirometry for Lung Health Assessment in Adults. CHEST 2000; 117: 1146 -1161. Global strategy for asthma management and prevention: update report 2002. NIH Publication No. 02 -3659. Available at: www. ginasthma. com. Accessed November 20, 2015. Lusuardi, M, De. Benedetto, F, Paggiaro, P, et al. A Randomized Controlled Trial on Office Spirometry in Asthma and COPD in Standard General Practice. CHEST 2006; 129: 844 -852. Moorman JE, Akinbami LJ, Bailey CM, et al. 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