Asthma Education: PriorityOne

Thomas Kallstrom, RRT, FAARC, AE-C

Associate Executive Director/Chief Operating Officer

American Association for Respiratory Care

Asthma, Why Should We Care?

Consider this

20 million Americans Almost half under the age of 18Prevalence on the increaseOver 5,000 deaths annuallyMost common discharge diagnosis in

pediatric hospitalsSchool children miss more school due

to asthma compared to non-asthmatics

Patients, Clinicians, Payers Need All The Help

They Can Get!!

76%

1%

2%

2%

2%

5%

1%

1%

1%

3%

4%

0%

1%

83%

3%

4%

2%

1%

7%

1%

13%

2%

6%

5%

5%

6%

0% 20% 40% 60% 80% 100%

Doctors

Other health professionals

Patient organizations

Library

Newspaper

Family/friends

Other 2004 Results

1998 Results

Main Source of Asthma InformationWeighted Comparison

OQ98. Where do you get most of your information about asthma? (Ages 4 – 18) (Unweighted N = 660)

NQ59. Where do you get most of your information about asthma? (Unweighted N = 801)Why lanham

Awareness of Underlying Causes of Asthma Symptoms: Aided & Unaided

Q48. Based on what you know or have heard, what are the causes of asthma?Q50a. Have you ever heard that inflammation of the airways is one of the underlying causes of asthma symptoms? Q51a. Have you ever heard that tightening of the muscles surrounding the airways, sometimes called broncho-constriction, is another major factor causing asthma symptoms? Unweighted N=801

93%

28%

90%

29%

0%

20%

40%

60%

80%

100%

Did not know (unaided) Did not know (aided)

Perc

en

t of

resp

onden

ts

Airway inflammation

Bronchoconstriction

Patient v. Physician Perspective (1998)

0102030405060708090

100

Act Plan PEFM PFT Demo MDI

patientphysician

Awareness of NIH Published Guidelines for Treating AsthmaWeighted Comparison

OQ62a. Are you aware that the U.S. National Institutes of Health have published guidelines for doctors on how best to treat asthma? (Ages 4 – 18) (Unweighted N = 660) NQ60a. Are you aware that the U.S. National Institutes of Health have published guidelines for doctors on how best to treat asthma? (Unweighted N = 801)

23%

76%

1%

30%

68%

1%0%

20%

40%

60%

80%

100%

Yes, aware No, not aware Not sure

1998 Results

2004 Results

Children and Asthma in America:Goals of Asthma Therapy Are Inadequately Met

62%

54%

67%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Activity Limitation Missed School in Past Year Symptoms Passed 4 Weeks Sudden Severe EpisodesPast Year

Results of a large national survey of parents of children with asthma (4-15 years old) and children with asthma (16-18 years old). A total of 801 interview were completed.

Children and Asthma in AmericaTM: A Landmark Survey. Executive Summary. SRBI; 2004.

Unscheduled Emergency Visits: Doctor’s Office, Clinic, or Elsewhere in the Past Year Because of Asthma Weighted Comparison

OQ33a. Has your asthma caused any other unscheduled emergency visits to a doctors office, clinic or somewhere else in the past 12 months? (Ages 4 – 18) (Unweighted N = 660) NQ14a. Has (your/your child’s) asthma caused any other unscheduled emergency visits to a doctors office, clinic or somewhere else in the past 12 months? (Unweighted N = 801)

35%

65%

30%

70%

0%

20%

40%

60%

80%

100%

Yes, other emergency visits No other emergency visits

1998 Results

2004 Results

Let’s talk about Patient Adherence first

Adherence

Definition The degree to which patient behavior

coincides with clinical recommendations of the caregiver

May be intentional or unintentional

What Influences Adherence with Asthma

Therapy?

- Medication Characteristics

- Patient Variables

- Clinician Factors

Adherence

Generally poor

Peds: Under use 55% of time (electronic monitor MDI) Coutts et al. Arch Dis Child. March,1992

73% reported use but only 15% actually did and in same study 14% have >100 actuations 3 hours before clinic. Rand et al. Am Rev Respir Dis, June 1992

Medication Characteristics

TasteScheduleSide EffectsExpenseDelivery MethodMultiple Doses/MedicationsPrescribed Duration of Medication

Look for………

A GUIDE TO AEROSOL DELIVERY DEVICES FOR RESPIRATORY THERAPISTS

Dean Hess, Ph.D., RRT, FAARC Timothy Myers, BS, RRT Joseph L. Rau, Ph.D., RRT, FAARC

COMMON ERRORS: MDI USEFailure to coordinate actuation with inhalation (27%)Short or no breath-hold after inspiration (26%)Too rapid an inspiratory flowrate (19%) Inadequate shaking prior to use (13%)Stopping inspiration when aerosol hits throat (6%)Firing MDI multiple times during inspirationPlacing wrong end of inhaler in mouth, holding upside

down, or failure to take cap off

McFadden ER Jr. J Allergy Clin Immunol 1995;96:278-82.

Patient Variable

Misperception of Attack Severity

Failure to Obtain Medication

D/C due to Side Effects

Apathy

Beliefs and Expectations

Social Stigma

Memory Loss

What About The Patients?

Survey 1230 peds and 604 adultsSurvey 1230 peds and 604 adults–58-79 reported side effects58-79 reported side effects–Most reported to MDMost reported to MD–Patient response was to skip treatment (25%), Patient response was to skip treatment (25%), adjust dose (33%)adjust dose (33%)–MD more likely to alter adult dose vs pedsMD more likely to alter adult dose vs peds

White et al. J Allergy Clin Immunol, Aug 99White et al. J Allergy Clin Immunol, Aug 99

Side Effects?

Jittery (58% peds v. 64% adults)

Restlessness (57% v 42%)

Tachycardia (56% v. 64%)

Clinician Factors

Poor Communication

Failure to Monitor Patient

Incorrect Medication

Incorrect Dosage

Misconception of Severity

So, what can an RT do about this?

Education Essentials

Start at time of diagnosis and at every

intervention

Keep it short and to the point

Understand patient/family dynamics

Provide education at patient’s level

Have patient recap what was discussed

Be approachable not judgmental

Key messages

Normal vs. asthmatic airway

What occurs during an attack

Meds (long-term control vs. short acting)

Skills (devices and monitoring)

Environmental controls

Tailor to patient needs

Patient Education is .....more than telling patients about their condition

Assessment-the 1st and most overlooked component of the patient education process-

assessing the need for patient education (perform a mini-needs assessment)

identifying common problems of the learner (barriers to learning)

assessing readiness of learner

FAQ Does patient understand his/her illness/ symptoms? Is he/she aware of any previous illness or conditions? Has previous education about his/her condition been provided ? Has

he/she responded to suggestions ? What are social habits? Does he/she smoke, drink? Has his/her condition impacted their employment? What is his/her level of education? Is he/she literate? Is English the primary language spoken at home? Are there any unusual cultural influences on his/her health beliefs or

practices? Is there adequate medical coverage?

Who are the best device educators?

Surveyed 30 RT, RN and MDs

Demonstration of MDI

MDI, MDI with Spacer and DPI

Knowledge assessment

Chest 1994;105:111-16

Results

0102030405060708090

100

AstmaKnowledge

MDI Spacer DPI

RTRNMD

Educating the Educator

77% RT had formal device education in

school

30% RN

43% MD

Conclusion

Many medical personnel lack

rudimentary skills with devices

RN and MD seldom receive formal

training of devices

So, You want to Educate?

Hospital based education better attended if: A university education

Longer history of asthma

Older in age

Higher level of asthma knowledge

Chest 2001;120:778-84

Common Problems of the Learner- barriers to learning -

language and culture – ESL, growth of Spanish influence, religious beliefs, diverse cultures

low health literacy level Reading level- average

adult at 8th grade level

Results of National Adult Literacy Survey (NALS)

Level 1 22% functionally illiterateLevel 2 27.5% marginally illiterateLevel 3 31.5% functionally literateLevel 4 16% functionally literateLevel 5 3% high-level literacy

Point: almost 50% (49.5%) are either functionally or marginally illiterate – a menacing/monumental problem

Determine Literacy

One quarter of American adults cannot

read or understand basic writing

Addressing educational deficits at all

levels are essential

Low literacy by definition imparts

educational challenges

Key Risk Factors for Limited Literacy

Elderly Low income Unemployment Did not finish high school Minority ethnic group (Hispanic, African American) Recent immigrant to US (do not speak English) Born in US but English is second language

Point: sound like some of your patients !

Important Next Steps

Validate your asthma expertise

Become actively involved in your

community

To the best educator you must be

educated

NAECB

The Asthma Educator Exam

Why bother?

Who offers it?

Are there preparation programs?

What is the credential mean?

What is this Exam all About?

National Asthma Educator Certification Board

(NAECB)

First offered 2002

Open to all RTs, nurses, physicians,

physician assistants (PA-C) pharmacists

(RPh), social workers (CSW). All who

actively have a role in the education of the

asthmatic and……………

Who Else Can Sit For the The Exam?

Health educators (CHES)

Persons providing asthma education,

counseling, or coordination of services

(minimum of 1000 hours exp.)

Who is administering the exam?

Applied

Measurement

Professionals (AMP)

What is an Asthma Educator?

Possesses a comprehensive knowledge of

asthma pathophysiology and management

Understands how asthma is diagnosed

Teaches best use of medications and

delivery devices in understandable terms

What is an Asthma Educator?

Conducts assessments to identify

strengths, resources, psychological

factors, social and economic impact and

educational needs and barriers to

optimal health care management

What is an Asthma Educator?

Works with patients, families and healthcare professionals to develop, implement, monitor, and revise action plan

Serves as a resource to the community

Monitors education programs outcomes and recommends changes

What is the AE-C?

This is the certification awarded

It is totally voluntary

Proof that person is qualified

May be a basis for employment, job

promotion, salary increases, or other

considerations

What are you Tested on?

Recall

Application

Analysis

175 questions (150 are scored the other are

pretest items)

3 ½ hours to complete

How many AE-C’s are there?

1,882

How Many AE-C’s are there in Texas?

175

Home Based Programs: How an Asthma Educator Put This in Action?

Home Based Asthma Program

Environmental assessment

Pre/post knowledge exam

Customized program addressing individual barriers to care

Review of asthma physiology, medications, critique of technique, PEF monitoring, trigger identification and avoidance techniques, symptom assessment, and care plan.

Home Based Asthma Program

Hytech: DME based program in an

inner city population

Managed care

Patients identified by case managers

Physicians orders required

Hytech Homecare

Most of the patients are pediatric asthmatics

Inner city

Poor socioeconomic status

Home Based Asthma Program

Patients with a history of multiple heath care contacts (E.R., Inpatient, Physician office visits)

Mean age: 7.3, 58% black and 43% white

4-5 hours of interactive evaluation,

assessment, and intervention

Trigger Recognition and Education

Environmental Assessment

Inhaled Allergens

animal dander

house dust mites

cockroach

mold

tobacco smoke

Medications

Live demonstration of technique

Intervention as needed

Symptom Monitoring

Peak flow meter

Physical assessment chronic coughchest tightnessdyspneawheezingEIB

Home Based Asthma Program

0

0.5

1

1.5

2

2.5

3

E.R. Admit PCP

pre-programpost-program

Our experience……..Multicenter Indoor Trigger Education

for pediatric asthma patients

N=437 patients in six sites

Majority inner city

Triggers

41% had smokers in the home

36% had either a dog or cat

67% had stuffed animals

52% had mattress or pillow covering

36% washed bedding at least once a week

More admitted mice infestation then cockroach

20% had leaky faucets

53% had natural gas stoves (more in northern states)

RT Intervention

Provided trigger education upon

admission to hospital or at ED visit

Follow up with patients over 4 month

period to discover if any changes had

been made

Findings

Success ranged from single digits to 90% successThe more costly and time sensitive the less likely it

was to be followedOver time families became less stringent in

managing asthma triggersCompliance was best immediately post contact

with patientPatients more likely to intervene with second hand

smoke, mold and mildews then domestic pets

In Summary

Assess deficiencies that need to be addressed

Teach to that need and follow up

Tailor the education to patient

Determine effectiveness

Advance your skill set

Consider the AE-C credential