| | Care of Patients with Asthma
Purpose
To evaluate the care of patients with asthma seen in the Allergy and Immunology Department of Gundersen Lutheran Medical Center.
Background
Asthma is the nation’s sixth most common disease and one of the costliest, with an estimated 20 million people in the U.S. affected by the disease. In 2002, asthma accounted for over 13.9 million outpatient visits, over 1.9 million emergency room visits and 484,000 hospitalizations. Children ages 5-17 missed 14.7 million school days and adults ages 18 and over who were currently employed missed 11.8 million work days due to asthma. In this same year, 4,261 people died from asthma. (1)
Asthma-related suffering, cost and death can be greatly reduced through treatment with appropriate and effective medications and medical management. Long term control of airway inflammation is necessary to control symptoms, with inhaled corticosteroids being the most effective anti-inflammatory for mild and moderate asthma. Long term control medications include inhaled and oral corticosteroids and leukotriene modifiers. People with asthma have a higher risk of complications from upper respiratory infections, and annual nfluenza vaccine is recommended for patients with persistent asthma of any age
Spirometry evaluation is an important tool for diagnosis and management of asthma and is recommended at diagnosis, with exacerbations and for monitoring every 1-2 years. Peak expiratory flow meters can be used to monitor asthma patients at home and at clinic.
Aims
1. To increase the percent of patients with diagnosis of asthma who receive an annual flu shot.
2. To maintain the percent of patients with diagnosis of asthma who were prescribed any anti-inflammatory agent (inhaled or oral corticosteroids, and/or leukotriene modifiers).
3. To increase the percent of patients with asthma who receive spirometry.
4. To decrease the ratio of patients with asthma who are seen in Urgent Care, TEC or have hospitalizations for exacerbation of asthma.
Methods/Measures
The data represent all patients, ages 18 and older seen by providers in the Allergy Department from January 2003 through December 2004 with a diagnosis of persistent asthma without exacerbation (ICD-9 codes: 493.00 through 493.92) listed as the primary diagnoses at any visit. Mild intermittent and exercise induced asthma patients were excluded in influenza and anti-inflammatory data. The warehouse was queried to determine whether these patients had been prescribed a corticosteroid or a leukotriene receptor blocker, whether they had received a flu shot, had spirometry evaluation and to determine if they were seen in Urgent Care, TEC or were admitted to the hospital for an asthma-related diagnosis. Spirometry evaluation rate was calculated from the number of patients in the measurement year who had spirometry within that year divided by the total asthma patients seen that year. Rate of Urgent Care, TEC and hospital visits was calculated from the number of unique patients with diagnosis of asthma seen in these three settings after an asthma related clinic visit divided by the total number of unique patients seen in the two one-year periods. The same methodology was used to calculate the other indicators. The number of patients seen in 2003 was 627 and in 2004 the total was 723.
The medications, along with their generic equivalents were as follows:
Beta-2 agonists: Albuterol, Maxair, Serevent, Combivent, Foradil
Inhaled Steroid: Flovent, Pulmicort, Vanceril, Advair, Beclovent, Azmacort, Qvar
Leukotriene Receptor Blockers: Singular, Accolate
Results
Conclusions
1. The number of patients with persistent mild, moderate or severe asthma who were offered or given influenza vaccine remained the same (chi square test p-value = 0.8) from previous year.
2. The aim to have anti-inflammatory medications prescribed for patients with persistent asthma has been maintained at over 99%.
3. Spirometry evaluation was performed on 33% of patients seen in 2004. This is a significant increase (chi square test p = 0.001) from 2003 results.
4. The number of patients seen in the hospital, Urgent Care and TEC in 2004 increased slightly from the previous year but the rate did not statistically change (p=>.3).
Next Steps
1. Ongoing, yearly measurement will occur to ensure that Gundersen Lutheran is providing excellent care to its patients with asthma.
2. Patients with persistent asthma will continue to be evaluated at each clinic visit with either spirometry or peak flow meter. Patients with stable asthma will be followed with peak flow meter. Spirometry is used primarily at diagnosis of disease, with exacerbations, or as disease monitoring. At this time we have no simple way to track peak flow readings from office visits since it is not a billable test. The same is true for asthma action plan developed for individuals with moderate to severe asthma. Since these are important in the care of asthma patients, tracking of these parameters would be useful. Discussion with Information Services and Administrative staff will include these concerns.
3. In reviewing the influenza vaccination data, patients who are seen annually in the spring and summer usually did not have it mentioned in the clinic note. Providers in the Allergy Department will discuss and implement methods for better documentation of influenza vaccine status. Information needs to be updated in the Immunization Summary for vaccines given outside of Gundersen Clinic, for patients who refuse vaccine, or for those patients in which influenza vaccine is contraindicated.
4. The Preventive Care Flowsheet would be useful for documentation of influenza in this group of asthma patients under the age of 65 years. If influenza vaccine is not included in the individual Preventive Care Flowsheet, it would be beneficial to have a method for it to be added for our asthma patients, especially those under age 65 years.
References
(1) www.cdc.gov/nchs/products/pubs/pubd/hestats/asthma/asthma.htm
Activity Leaders
Cherie Nigl, PA-C
Vanee Songsiridej, MD
ACKNOWLEDGEMENTS
Judy Weibel, RHIA
Jane Robinson, RHIA
Jeff Falk, M.S. |