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
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