Arizona Comprehensive Asthma Control Plan ........... “ The Arizona Department of Health Services sponsored the development of this plan with the intent to set priorities and suggest strategies to address asthma as a serious chronic disease and public health issue. ” ............... Letter From Our Director Dear Arizona Residents: Asthma is a major public health issue of growing concern in Arizona. Within the past decade statewide prevalence rates have continued to increase and are much higher than the national average. Asthma is one of our states most common and costly diseases. More than 600,000 Arizonans suffer from asthma, of which 100,000 are children. Nationally, direct and indirect costs exceed $14 billion annually. The direct impact of asthma includes hospitalizations, emergency department visits, and deaths. The indirect effects of asthma reach well beyond asthmatics themselves and include missed school and workdays, and quality of life issues. For people impacted by asthma, quality of life decreases as daily activities are disrupted due to symptoms associated with the disease. The Arizona Department of Health Services has developed this Arizona Comprehensive Asthma Control Plan. This plan sets priorities, objectives, and strategies to reduce deaths attributable to asthma in our state, reduce the proportion of Arizonans who are burdened by the disease, and attempts to reduce the direct and 1 indirect costs associated with the disease. The plan promotes improvements in the treatment and management of the disease, as well as promoting patient education and secondary prevention. The exact causes of asthma have not yet been determined, but research indicates that both environmental and genetic factors contribute to the disease. Risk factors for asthma include a family history of the disease, low socioeconomic status, and living in an inner-city environment. This plan is designed to assist stakeholders, policymakers, healthcare professionals, educators, and public health workers to develop and coordinate approaches to address asthma among their constituents. The plan is an important step in raising awareness of the serious public health problem of asthma and provides a framework for action to reduce the impact of asthma in Arizona. Sincerely, Susan Gerard Director Arizona Comprehensive Asthma Control Plan ............... Ta b l e o f C o n t e n t s ............... Ta b l e o f C o n t e n t s I. Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 II. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 III. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Definition of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Prevalence of Asthma Nationwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Economic Impact of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 An Asthma Attack/Episode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Diagnosis of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 3 Treatment of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Burden of Asthma in Arizona . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 IV. Objective Sections: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Epidemiology and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Treatment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Patient Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 School/Childcare Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Collaborative Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Advocacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Public Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 V. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Arizona Comprehensive Asthma Control Plan ............... Acknowledgements ............... Acknowledgements TRUST Commission Special Thanks The Arizona Department of Health Services Janet Bourbouse, M.A. would like to thank the Advisory Council of the Arizona Department of Health Services Tobacco Revenue Use, Spending and Tracking (TRUST) Commission for supporting the development of the Arizona Comprehensive Asthma Control Plan. Donna Bryson, R.N. American Lung Association of Arizona Nancy Cohrs, R.R.T., R.C.P. American Lung Association of Arizona Arizona Asthma Coalition We would like to thank the Arizona Asthma Dilia Loe, M.T.S. Arizona Department of Health Services 5 Coalition for providing input for the development of the plan. William Pfeifer, President/CEO American Lung Association of Authors Arizona/New Mexico Rhonda Kay Follman, M.S. Patricia Tarango, M.S. American Lung Association of Arizona Arizona Department of Health Services Meryl S. Salit, R.R.T., R.C.P., M.B.A. Margaret Tate, M.S., R.D. Arizona Department of Health Services Arizona Department of Health Services Arizona Comprehensive Asthma Control Plan ............... Executive Summary ............... Executive Summary Asthma is one of the nation’s most While the exact causes of asthma have not yet been determined, research indicates that both common and costly diseases,1 affecting over 31 million Americans,2 environmental and genetic factors contribute to the disease.5 Risk factors for asthma include a family with direct and indirect costs history of the disease, low socioeconomic status, exceeding $14 billion annually.3 living in an inner-city environment, and race Asthma is a chronic respiratory (Hispanic and African American).6 The Arizona Department of Health Services disease characterized by inflammation of the airways, tightening of the muscles surrounding the airways, and an increase in mucus production. 4 sponsored the development of this plan with the 7 intent to set priorities and suggest strategies to Although there is no cure for asthma, proper disease address asthma as a serious chronic disease and management strategies including pharmacological public health issue. The plan continues the focus treatments, effective asthma education, and the placed on asthma in the Healthy People 2010 report. elimination of triggers from the environment are The plan is meant to serve as an ambitious and essential to ensure quality of life for those with comprehensive approach to improving the health the disease. and quality of life for those with asthma living in The direct effects of asthma include Arizona. This plan should be seen as a fluid hospitalizations, emergency department visits, and framework for stakeholders to further develop and death. The indirect effects of asthma are identify objectives and strategies to address the widespread and reach far beyond asthmatics issues. Due to the complexity of the disease, it is themselves. Indirect effects include missed days important that a comprehensive approach be taken from school and work, and quality of life issues. For and that community stakeholders work many people with asthma and their families, quality collaboratively to implement the plan. of life decreases as daily activities are disrupted due to symptoms associated with the disease. Arizona Comprehensive Asthma Control Plan ............... TA B L E 1 Overriding Goals: • Reduce asthma deaths in Arizona. • Reduce asthma-related hospitalizations and emergency department visits in Arizona. • Reduce the number of asthma-related missed school and work days. 8 Executive Summary TA B L E 2 ............... P l a n O b j e c t i v e s b y To p i c Epidemiology and Research 1. Establish a surveillance system for accurately tracking asthma deaths, illness, disability, and financial burden in Arizona. 2. Support research investigating causes, triggers, and management of asthma as well as healthcare policies and outcomes particularly as the activities relate to state issues. Treatment and Management 3. Increase the accuracy of diagnosing asthma in the pediatric and adult population by educating healthcare providers about methods and criteria for diagnosis. 4. Increase the proportion of persons in Arizona who receive appropriate care according to established guidelines. 5. Educate healthcare providers/professionals in Arizona to provide individuals with asthma and their families with the best practice of care, education and resources to effectively manage their condition. 6. Increase the number of Arizonans with asthma who receives written management plans from their healthcare provider. Patient Education 7. Improve self-management knowledge and behavior in people with asthma, their families and other caregivers. 9 Secondary Prevention 8. Reduce exposure to asthma triggers (allergens and irritants) in the home, preschool, school, workplace and outdoor environment to prevent asthma episodes or reduce their severity. School/Childcare Issues 9. Maximize good asthma management practices in the school setting. 10. Maximize good asthma management practices in the childcare setting. Disparity 11. Identify and eliminate disparities in asthma prevention, diagnosis, and management throughout the state. Collaborative Efforts 12. Foster communication, collaboration and networking opportunities among patients, caregivers, healthcare professionals, public health officials and other stakeholders. Advocacy 13. Advocate and support policies that promote asthma friendly communities. Public Awareness 14. Improve public awareness and sensitivity to the needs of persons with asthma. Arizona Comprehensive Asthma Control Plan ............... Introduction ............... Introduction Definition of Asthma Prevalence of Asthma Nationwide Asthma is a chronic respiratory disease where the small airways in the lungs become inflamed and narrowed in response to triggers. It is estimated that more than 31 million people nationwide (111 people per 1,000) have at some point in their lifetime been diagnosed with asthma, 7 of which over 8 million are children.11 This is a Common triggers that initiate an prevalence rate of 11% for adults and 12% for asthma attack or episode include children. Current asthma prevalence rates are based allergens, airway irritants (e.g. smoke), sharp changes in weather, exercise, and infections. Asthma attacks may involve shortness of breath, cough, wheezing, chest pain, chest tightening, or any combination of these symptoms. Asthma is a serious public health issue. It is one of the nation’s most common and costly chronic diseases.8 The burden of asthma is widespread and includes direct and indirect impacts encompassing medical, economic, and quality of life issues.9 Medically, the disease is responsible for emergency department visits, hospitalizations, and death.10 The economic impact of the disease is derived from the direct and indirect costs associated with medical care and missed work and school days. Quality of on the number of people who have been diagnosed 11 with asthma by a healthcare provider and still currently have asthma. In 2002, more than 20 million people (72 people per 1,000) nationwide self-reported currently having asthma (14 million adults and 6.1 million children). More than 12 million people who self-reported currently having asthma also reported having an asthma episode or attack during the previous year (approximately 60%). Asthma is more prevalent among African Americans (12% for persons age 14 years and younger, 9% for persons 15 years and older) of all age ranges than White non-Hispanics (7% for persons age 14 years and younger, 7% for persons life components of the disease include activity limitations and access to care. Arizona Comprehensive Asthma Control Plan ............... age 15 years and older) and Hispanics (8% for become inflamed, and the muscles around the persons age 14 years and younger, 5% for persons airways tighten, thus causing the airways to narrow. age 15 years and older).12 Nationally, for persons Asthma attacks or episodes can range from severe age 14 years and younger, asthma is more prevalent attacks or episodes characterized by chest tightness, in males (10%) than females (6%). However, for severe wheezing, inability to breathe, and blue lips persons age 15 years and older, asthma is more and fingertips to mild attacks or episodes prevalent in females (8 %) than males (5 - 6%). characterized by chest tightness, wheezing, mucus Economic Impact of Asthma Nationally the economic burden of asthma is substantial with more than $14 billion annually (2002 estimates) attributed to direct and indirect costs associated with the disease. 13 National estimates for direct medical costs due to asthma totaled more than $9.4 billion in 2002. Inpatient hospitalizations were the biggest direct medical expenditure totaling more than $4 billion. Indirect 12 costs associated with the disease are estimated to be emission, and trouble sleeping at night.14 Asthma attacks or episodes are brought on by triggers.15 Triggers are irritants or allergens that can be found either indoors or outdoors. Common triggers include cold air, tobacco smoke, perfume, paint, hair spray, allergens (particles that cause allergies) such as dust mites, pollen, molds, pollution, animal dander, the common cold, influenza, and other respiratory illnesses. Eliminating and controlling triggers are the most effective way to prevent asthma exacerbations. over $4.6 billion. Indirect costs include loss of productivity due to missed school and work days. Missed school days represent the largest indirect Diagnosis of Asthma The requirements for diagnosis of asthma expenditure with an estimated value of $1.4 billion include an evaluation of the patient’s history of of lost productivity annually. variable respiratory symptoms, physical An Asthma Attack/Episode According to the American Lung Association, the exact cause of asthma has yet to be examination, in addition to objective measures of pulmonary function.16 This history should include the patients past and current medical history, social and environmental history, and family history. 13 determined. However, factors leading to an asthma attack or episode and what happens to the lungs during an attack or episode are well understood. During an asthma attack or episode the cells in the airways increase in mucus production, the airways Physical examination and testing for airflow obstruction, as well as reversibility and exercise testing are also used to determine a diagnosis of asthma. Elimination of alternative diagnoses (i.e., croup, congestive heart failure, cystic fibrosis, etc.) is also required. Once the diagnosis for asthma has been made, a statement about the level of severity 14 ............... Introduction should be included. Classification of asthma faceted approach and include pharmacological severity is based on frequency of daytime treatments, patient and family education, and symptoms, frequency of nighttime symptoms, attempts to eliminate and control triggers.18 impact on daily life, lung function measurements, Common pharmacological treatments for asthma and diurnal variability. include anti-inflammatory medications, fast-acting There are four levels of severity, which include severe persistent, moderate persistent, mild persistent, and mild intermittent. Severe persistent bronchodilators, and leukotriene receptor antagonist medications. Anti-inflammatory medications prevent and asthma is characterized by continual symptoms with reduce inflammation and swelling in the lungs.19 frequent nighttime symptoms along with pulmonary These medications are considered to be long-term, function below 60% of predicted. Moderate controller medications that take several days to persistent asthma is characterized by daily become fully active. In all but one of the asthma symptoms and nighttime symptoms occurring more severity classifications, (Mild Intermittent), than five times per month along with pulmonary controller medications should be the first line drugs function below 60% of predicted. Mild persistent of choice. Inhaled steroids are the most effective asthma is characterized by symptoms occurring anti-inflammatory medications currently available. three to six times per week and nighttime symptoms Although extremely critical to the prevention of occurring three to four times per month with asthma attacks, anti-inflammatory medications are pulmonary function at or above 80% of predicted. not useful in stopping an acute exacerbation. Mild intermittent asthma is characterized by 15 Leukotrienes mediate airflow obstruction, occasional symptoms (twice or less per week) and hyperresponsiveness and inflammation through occasional nighttime symptoms (twice or less per multiple channels.20 The leukotriene receptor month) with pulmonary function at or above 80% of antagonist medications help to prevent those effects. predicted. This class of medication is included in the Treatment of Asthma According to the National Institute of Health (NIH), the goals of asthma treatment should include: the prevention of chronic asthma symptoms and exacerbations, the maintenance of normal activity levels, normal or near-normal lung function, controller category. Fast acting bronchodilators, which help to relax the muscles around the airways and reduce bronchoconstriction, are useful in helping to relieve an acute exacerbation.21 They are also used to reduce symptoms in exercise-induced asthma, when they are used to pre-treat before activity. Fast acting minimal side effects, and patient satisfaction with the care received.17 To obtain these goals, effective treatment of asthma should consist of a multi- Arizona Comprehensive Asthma Control Plan ............... bronchodilators should not be used as a regular 12%.25 More than 390,000 Arizona adults, or every day treatment for asthma. According to NIH approximately 12% were told by a doctor or health guidelines, if they are used more than twice a week, care professional they currently have asthma. In the patient should be strongly considered for addition, more than 230,000 Arizona adults who controller therapy.22 currently have asthma reported having an episode or Burden of Asthma in Arizona Prevalence 16 attack within the past year (approximately 59%). An average of 80 deaths occur each year in Arizona due to asthma.26 In the past decade, asthma prevalence and Currently, there is no statewide survey to mortality rates in Arizona have exceeded national accurately determine the number of children in averages in nine out of 10 years.23 The prevalence Arizona with asthma. However, according to the for asthma statewide increased from 11% in 200024 nationwide survey (NHIS) utilizing U.S. Census to 12% in 2003. More than 600,000 Arizonans have, data, it is estimated that more than 79,000 Arizona at some time in their life, been diagnosed with children have had an asthma episode in the past 12 asthma. In 2003, the prevalence rate for asthma months and that more than 120,000 Arizona among Arizona adults (persons 18 years of age or children have been diagnosed with asthma at some older) who have been diagnosed with asthma at time in their life.27 Table 3 below illustrates some point in their lifetime was approximately TA B L E Estimated Prevalence Rates For Most Arizona Counties Based On The NHIS For Pediatric Asthma And The Arizona BRFS For Adults 3 Total Pop 14 & Under 65 & Over Pediatric Asthma COCHISE 120,439 26,629 18,250 2,683 7,698 COCONINO 120,295 28,495 8,561 2,869 7,913 GILA 51,565 10,531 10,410 1,072 3,260 MARICOPA 3,303,876 774,314 374,333 75,751 216,543 NAVAJO 102,202 28,993 10,340 2,936 6,009 PIMA 881,221 184,249 124,925 18,303 58,660 PINAL 196,275 41,032 31,649 4,106 12,893 SANTA CRUZ 40,035 11,099 4,376 1,109 2,379 YAVAPAI 179,057 30,548 39,073 3,123 11,921 YUMA 167,407 41,136 28,799 4,083 10,329 TOTAL: 5,162,372 1,177,026 650,716 116,035 337,605 County Adult Asthma Introduction estimated prevalence rates for most Arizona White/Caucasian Arizonans followed by counties based on the NHIS for pediatric asthma Hispanics/Latinos, and African Americans (65%, and the Arizona BRFS for adults.28 16%, and 6% respectively). ............... For persons under 21 years of age, Arizona Hospitalizations Hospitalization Discharge Data show a total of Arizona Hospitalization Discharge Data show a total of 32,171 asthma-related hospitalizations for 2,952 hospitalizations due to asthma as a primary complication.30 Approximately 39% of this group 29 Arizona residents. The average length of stay was approximately four days with a total of 132,479 days for all asthma-related hospitalizations. An average of $20,185 was spent per hospitalization with a total healthcare expenditure of $650 million for all hospitalizations. was between one and four years of age, 46% were between five and 14 years of age, and 9% were between 15 and 21 years of age. The average length of stay for this group was approximately 2.5 days with a total of 7,250 days for all hospitalizations. An average of $8,153 was spent per hospitalization Additionally, a greater number of females were with a total healthcare expenditure of $24 million. hospitalized for asthma-related complications (66% females vs. 34% males). The majority of hospitalizations were among Non-Hispanic 17 TA B L E 4 Arizona Asthma Hospitalization Discharge Rates, 1999-2003 120 RATE PER 100,000 115 110 114.2 114.9 2002 2003 10 6.7 105 100 98.2 95 89.4 90 85 80 1999 2000 2001 YEAR Arizona Comprehensive Asthma Control Plan ............... Objectives ............... Objectives Epidemiology and Research adults living in Arizona. The BRFSS is not utilized to obtain data about participant family members. In Objectives addition to these two survey sources, the Arizona 1. Establish a surveillance system for accurately Department of Health Services, Bureau of Public tracking asthma deaths, illness, disability, and financial burden in Arizona. 2. Support research investigating causes, triggers, and management of asthma as well as healthcare policies and outcomes particularly as the activities relate to state issues. Health Statistics maintains the Arizona Hospital Discharge Database. Hospital discharge data are available from this source for persons hospitalized with asthma as the primary diagnosis. This source does not include data from federal or Native 19 American facilities and does not include emergency Rationale Systematic asthma surveillance is essential as the first step in determining asthma’s impact in room data unless the person was admitted to the hospital. A surveillance system, which includes state- Arizona. Asthma is not a condition reportable to specific data for adults and children in addition to the Arizona Department of Health Services, emergency room data from all medical institutions, therefore obtaining asthma data from one is needed to more accurately assess the burden of centralized source is difficult. Currently, prevalence asthma throughout Arizona. Currently pediatric rate data for the disease are obtained from two prevalence rates are determined utilizing the NHIS sources: the NHIS and the BRFSS. The NHIS data obtained from a national sample. A system to collects national asthma prevalence data from across obtain more accurate state-specific data pertaining the U.S. for survey participants and their families. to pediatric asthma is needed to assess the burden of State prevalence rates are then extrapolated from asthma for children in Arizona. Until emergency U.S. Census data utilizing Centers for Disease room data and hospitalization data from all medical Control and Prevention (CDC) configured weights. The Arizona BFRSS collects data from selected Arizona Comprehensive Asthma Control Plan ............... facilities statewide are obtained, the true economic  to collect data not available through existing impact of the disease cannot be determined. A data sources. more comprehensive understanding of the distribution of the morbidity and mortality of   obtained from all medical facilities statewide Although there is no cure for asthma and the including federal and Native American institutions. cause of the disease has not been identified,   successful disease management. In addition, a better understanding of environmental conditions 20 Disseminate reports based on acquired data to community stakeholders. role of airway inflammation have led to pharmacological treatments that have been key to Conduct special studies to assess the burden of asthma among disparate populations. disease have led to new and better techniques to manage the disease. Research findings about the Create an infrastructure for emergency department and hospitalization data to be evaluation of programs for the disease. scientific advances in the understanding of the Expand the Arizona BRFSS to include children of survey participants. asthma statewide will assist local efforts in the development, planning, implementation, and Develop new surveys or utilize existing surveys Objective 2. Support research investigating causes, triggers, and management of asthma as well as and triggers related to asthma exacerbations has healthcare policies and outcomes particularly as evolved due in part from research findings. More the activities relate to state issues. research is needed to address issues pertaining to disease onset, progression, increases in prevalence rates, and potential cures for the disease. Strategies  Increase awareness for the need of asthma research. Objective  environmental triggers and asthma 1. Establish a surveillance system for accurately exacerbations. tracking asthma deaths, illness, disability, and financial burden in Arizona. Conduct research studies on the link between  Conduct etiological studies on asthma. Strategies  Conduct studies focusing on a cure for asthma.   Conduct research on the increase of morbidity Establish a standardized case definition of asthma and establish criteria for the and mortality of asthma in Arizona, with an measurement of asthma morbidity and emphasis on disparate populations. mortality.  Ensure adequate resources to develop and maintain new and existing surveillance systems. Treatment and Management Healthcare provider education on the current best practices for asthma is key to the improvement of Objectives asthma diagnosis and management as well as 3. Increase the accuracy of diagnosing asthma in continuity of care for patients. Although many the pediatric and adult population by educating healthcare providers about methods and criteria for diagnosis. practitioners have at some point in their career received education on the diagnosis and management of asthma, keeping current on the 4. Increase the proportion of persons in Arizona who receive appropriate care according to established guidelines. 5. Educate healthcare providers/professionals in latest best practices for the disease can be a challenge. Advances in asthma research and improved treatment strategies make it necessary for Arizona to provide individuals with asthma and providers to continually receive education on their families with the best practice of care, current diagnostic methodology and management education and resources to effectively manage techniques. Strategies to assess usage barriers, their condition. promote guideline utilization, and facilitate provider 6. Increase the number of Arizonans with asthma who receive written management plans from their healthcare provider. education are needed to enable healthcare professionals to provide the best care possible for patients. 22 Rationale Asthma is a very complex disease requiring Due to the episodic nature of the disease, asthma can be difficult to diagnose. According to the NIH continuity of care by all healthcare providers guidelines, establishing a diagnosis of asthma diagnosing, treating, and managing patients with the should include a medical history including the disease. The National Institutes of Health, National presence of symptoms of airway obstruction, Heart, Lung, and Blood Institute (NIH/NHLBI) objective measures of pulmonary function, and the publishes a practical guide of best practices for the exclusion of alternative diagnoses. Improved diagnosis and management of asthma for healthcare diagnosis of the disease could potentially speed up providers. Unfortunately, widespread adherence to treatment efforts and eliminate ambiguous these established guidelines has not been achieved. diagnoses such as reactive airway disease. Numerous barriers including lack of consensus on According to the NIH guidelines, the goals of best practices, time restraints, and access to asthma treatment and management for patients educational sessions for rural providers prevent should be to prevent chronic asthma symptoms provider knowledge of and adherence to the including exacerbations, maintain normal activity established guidelines. levels, have normal or near-normal lung function, have no or minimal side effects, and be satisfied with the care received. These goals should be Objectives obtained utilizing a comprehensive management Objective approach including pharmacological interventions, 3. Increase the accuracy of diagnosing asthma in implementation of environmental control measures, the pediatric and adult population by educating and patient education. Strategies need to be healthcare providers about methods and criteria for diagnosis. developed to enhance patient care and disease management utilizing a comprehensive approach. According to the NIH guidelines all persons with Strategies  asthma should be provided written instructions on when to increase medications and return for care if ............... Assess the use of spirometry in the diagnosis of asthma.  Improve asthma diagnosis by utilizing objective symptoms worsen. These set of instructions are measurements of lung function and ruling out known as a written asthma action plan. A written other diagnoses with similar symptoms. asthma action plan should include: clear instructions on how to follow it; instructions on how to recognize signs of worsening asthma and signs Objective 4. Increase the proportion of persons in Arizona who receive appropriate care according to that indicate the need to call the doctor or seek NIH/NHLBI guidelines. emergency care; and, when to use a fast-acting bronchodilator. The guidelines indicate that all Strategies patients with asthma should have a written asthma  guidelines. action plan and know how to use it. Unfortunately many asthmatic patients never   techniques to educate patients on asthma action plans. Moreover, coordinated efforts among Promote provider use of the NIH guidelines in all healthcare settings. need to be made to increase provider education on the use of written asthma action plans and Identify barriers, systemic and individual, to the use of NIH guidelines by healthcare providers. receive an asthma action plan or instructions on how to follow the plan if supplied with one. Efforts 23 Assess current provider knowledge of the NIH  Develop and utilize protocols for the diagnosis and treatment of asthma during hospitalization and emergency department visits based on the NIH guidelines. healthcare providers, school health offices, and parents need to be put into action to disseminate asthma action plans to school health offices for students with asthma. Objective 5. Educate healthcare providers/professionals in Arizona to provide individuals with asthma and their families with the best practice of care, education and resources to effectively manage their condition. Arizona Comprehensive Asthma Control Plan ............... Strategies   medical providers, government and non- Identify, update and/or develop asthma government agencies, families, and other education curriculum for healthcare providers stakeholder organizations to promote, develop, based on the NIH guidelines.  asthma.   plans for all patients with asthma.  Include instructions on how to develop and use written asthma action plans in healthcare Encourage periodic provider education sessions on NIH guideline updates.  use, and disseminate written asthma action Conduct provider education utilizing interactive techniques on diagnosis and management of Coordinate efforts with schools, health plans, provider education programs.  Include instructions on the proper techniques Develop or adopt an asthma education program and use of peak flow meters as related to to certify health educators in Arizona. written asthma action plans in healthcare provider education programs. Encourage providers to promote healthy living practices to patients such as good nutrition, physical activity, and yearly influenza  Develop and make available on-line a standard asthma action plan. vaccinations.  Create an incentive program to motivate Patient Education healthcare providers to participate in 24   educational sessions. Objective Partner with non-profit agencies and 7. Improve self-management knowledge and community organizations to facilitate provider behavior in people with asthma, their families education. and other caregivers. Develop and promote standardized education for pharmacists to facilitate pharmacy consultation with patients, families, and caregivers on the proper use of asthma medications and optimal techniques for peak Rationale According to the NIH guidelines, the goal of all patient education is to help patients take the actions needed to control their asthma. These actions flow meters and spacers. include: taking daily medications as prescribed, Objective 6. Increase the number of Arizonans with asthma using delivery devices (e.g. spacers, inhalers) correctly, identifying and controlling factors that who receive written management plans from increase symptoms, using a peak flow meter and their healthcare provider. monitoring symptoms, and following a written asthma action plan. Effective patient education Strategies  Promote the use of asthma management plans as part of a larger comprehensive asthma education program for medical providers. should involve a partnership between patients and 26 Objectives healthcare professionals with frequent reinforcement  ............... Increase funding for asthma education programs that instill and promote good asthma of key messages. management skills for youth and adults (e.g. Patient education should be comprehensive in asthma camps, patient workshops). approach and address patient concerns. In addition, patient education should address disease  Establish asthma support groups for patients, families, and caregivers. manifestation, compliance strategies, and quality of  life issues. Good disease management should also information and resources available on the be coupled with other healthy practices including good nutrition, abstinence from tobacco use, regular Develop a clearinghouse of asthma related Internet.  Work with community organizations to make exercise, and yearly influenza vaccinations. Patients asthma education materials available at public should be made aware that there is no cure for libraries statewide. asthma, but with proper management the disease can be controlled. Strategies  Encourage improved patient/provider Secondary Prevention Objective 8. Reduce exposure to asthma triggers (allergens relationships to enhance asthma education and and irritants) in the home, preschool, school, self-management skills. workplace, and outdoor environment to prevent asthma episodes or reduce their severity.  27 Educate patients, families, and caregivers about asthma and what happens during an asthma attack. Rationale Although there is no known cure for asthma,  Educate patients, families, and caregivers about environmental triggers and environmental control measures in the home.   Educate patients, families, and caregivers about induce asthma exacerbations. Triggers may include air pollutants, chemicals, mold, cockroaches, dust asthma medications and medical regimen mites, pollen, animal dander, and viral respiratory adherence. infections. Attempts to reduce and eliminate Educate patients, families, and caregivers about asthma triggers from the environment are critical to the use of asthma action plans and proper reduce the impact of asthma in workplaces, schools, techniques for peak flow use.  research indicates that environmental triggers may homes, and communities. Educate patients, families, and caregivers about healthy living practices including proper Strategies nutrition, exercise, and yearly influenza  vaccinations. Promote public awareness of environmental factors that contribute to asthma exacerbations. Arizona Comprehensive Asthma Control Plan ...............    promote environmentally healthy homes. school setting should be approached utilizing a Educate patients, families, and caregivers about comprehensive design created to maximize school triggers and how to eliminate and avoid them. health services and draw upon existing community Develop and update existing educational resources while promoting and fostering internal materials on occupational asthma.  Promoting asthma-friendly initiatives within the Collaborate with city neighborhood services to Disseminate educational materials on occupational asthma to employers, employees, relationships among school personnel. This comprehensive approach should address issues regarding access to healthcare, student, staff, and healthcare providers, and health insurance plans. family education, healthy school environments  Promote indoor air quality management plans for all public buildings. including indoor and outdoor air quality, and the promotion of physical activities.  Promote awareness of secondhand smoke and Asthma-friendly initiatives should also be its effect on people with asthma. promoted within the childcare setting. Childcare School/Childcare Issues staff should be mandated to acquire education on what asthma is, symptom recognition, and what to 28 Objectives do in emergent situations. In addition, childcare 9. Maximize good asthma management practices facilities should aim to reduce environmental in the school setting. 10. Maximize good asthma management practices triggers and adopt clean indoor and outdoor air management plans. in the childcare setting. Objective Rationale 9. Maximize good asthma management practices in the school setting. The impact of asthma in the school setting is quite significant. Annually, millions of days of school are missed due to asthma. According to the CDC, asthma is the number one cause of school Strategies  Promote comprehensive healthcare for students with asthma. absenteeism for school-aged children with chronic health conditions. Management of asthma within  Establish and promote a standardized asthma education curriculum for school personnel. the school setting is vital for children with the disease to be present and able to learn. School health services should empower students to manage their disease, work to reduce exacerbations, and be able to respond to emergencies when necessary.  Provide age-appropriate asthma education programs for children with asthma in the school setting. Objectives  In partnership with the Arizona Department of Education, establish standardized asthma management protocols, policies, and guidelines Objective 10. Maximize good asthma management practices in the childcare setting. for school districts statewide. These policies should address issues such as medication access.  Educate school personnel, parents, healthcare Strategies    Promote that there be one full-time nurse in statewide.  Develop a strategy to assist school nurses in obtaining written asthma action plans from statewide.  Enhance and encourage school-based asthma  physicians for all children with asthma. prevalence rates. Develop a system to distribute poor air quality/high ozone warnings to school districts and establish alternative activities for children with respiratory illnesses on these days.     29 Develop a system in accordance with HIPAA regulations to share written asthma action plans with appropriate childcare personnel. Disparities Promote physical activity/education and sports program participation for students with asthma. Objective Increase funding to provide asthma-related 11. Identify and eliminate disparities in asthma resources and education to school nurses and prevention, diagnosis, and management health aides. throughout the state. Support student enrollment/utilization of school-based health clinics.  Develop a strategy to assist childcare facilities in obtaining written asthma action plans from surveillance for missed school days and student  Promote that asthma education be included as part of childcare provider licensure. physicians for all children with asthma.  Promote indoor air quality and environmental management plans to childcare providers every school across the state.  Establish standardized asthma management protocols and policies for childcare centers Promote indoor air quality and environmental management plans to school districts statewide.  Establish and implement standardized asthma education curriculum for childcare staff. providers, and students about asthma medication “self-carry” policies. ............... Develop a system in accordance with HIPAA regulations to share written asthma action plans with appropriate school personnel. Rationale Asthma does not affect all Arizonans equally. Disparities in the morbidity and mortality for certain groups exist. Among Arizona communities, disparities may be characterized by race, ethnicity, gender, age, income, health status, education, sexual Arizona Comprehensive Asthma Control Plan ............... orientation, or geographic location. In Arizona asthma disproportionately affects African Strategies  Identify specific populations with increased Americans and individuals of low socioeconomic rates of asthma and/or with limited access to status. In addition, females have higher prevalence asthma resources. rates for the disease than males and children under  asthma in identified disparate populations. the age of 14 years old are more likely to be hospitalized for the disease than adults.  Collaborate with partners to identify and promote available asthma-related resources and For asthma, health disparities and low education to rural and border communities. socioeconomic status are closely related. According to the U.S. Census Bureau, almost 10% of Explore factors contributing to the burden of  Develop, promote, and disseminate asthmarelated resources that are culturally sensitive. Arizonans currently live in poverty. Inadequate or lack of insurance coverage, substandard housing  related resources that meet the needs of all conditions, and the lack of resources to effectively Arizona residents taking into account factors control the disease lead to increase hospitalizations such as socioeconomic status, race, education and deaths for people of low socioeconomic status. level, language, and age. Other factors also contribute to health disparities  communities across the state. cultural and language barriers, physical distance, lack of transportation in rural areas, and an increase  system to aid uninsured residents to obtain remote communities in Arizona have difficulty health insurance coverage.  Improving access to care is critical in eliminating services, medications, and/or medical equipment statewide. Encouraging families to have on-going primary care programs, medications, and monitoring devices is Identify emergency assistance programs and organizations providing free or discounted health disparities in Arizona for asthma. is essential. Improving access to educational Working in conjunction with the Arizona Health Care Cost Containment System, develop a in the geriatric population. In addition, many recruiting and retaining healthcare professionals. Investigate the utilization of mobile clinics (e.g. Breathmobiles) to deliver services to remote in Arizona for asthma. These factors include 30 Develop, promote, and disseminate asthma-  Assist healthcare providers and community healthcare organizations to provide asthma education to all patients diagnosed with asthma also needed. In addition, educational programs in Arizona. curriculum should be culturally and linguistically sensitive and age-appropriate. Collaborative Efforts Objective 12. Foster communication, collaboration, and networking opportunities among patients, caregivers, healthcare professionals, public health officials and other stakeholders. 32 Objectives Rationale ............... Advocacy Partnerships are essential for any successful disease control program. For asthma, local and statewide coalitions and stakeholder workgroups Objective 13. Advocate and support policies that promote asthma-friendly communities. exist. These collaborative efforts among medical organizations, government agencies, patient groups, Rationale and policy makers serve to provide a concerted effort in reducing the prevalence and mortality of the disease. By sustaining and expanding strong networks, stakeholders can address barriers to good asthma care, promote unified, consistent messages to raise awareness of asthma, promote established clinical guidelines, create and implement a standardized patient education program, reach undiagnosed patients with information, and create a platform for community advocacy to combat the disease. Strategies  Secure resources to support a statewide asthma coalition as an ongoing effort to develop and promote partnerships among stakeholders to address barriers to good asthma care and Asthma-friendly communities can aid in the overall reduction of disease morbidity and mortality. Educating policymakers about asthma and the issues and barriers surrounding good asthma care in Arizona can provide an infrastructure for future legislative action. Efforts should focus on eliminating disparities in disease treatment and management and promoting healthy living environments for all Arizonans. Moreover, efforts should serve to engage and mobilize community members to take actions in reducing environmental asthma triggers and address indoor and outdoor air quality issues. Strategies  management.  Encourage stakeholders to convey clear,  Educate policymakers about the burden of asthma in Arizona.  consistent messages about asthma-related issues. Improve health coverage for uninsured or underinsured populations/patients with asthma.  Promote the delivery of consistent asthma Develop and disseminate a resource list of messages and policy recommendations so as to on-going statewide resources and educational focus efforts on priority issues and concerns. programs. 33  Promote clean indoor and outdoor air quality.  Decrease exposure to environmental asthma triggers.  Support a statewide smoke-free initiative in all public buildings. Arizona Comprehensive Asthma Control Plan ...............  Bring asthma stakeholders together to  continually refine, alter, promote and monitor the implementation of the Arizona Comprehensive Asthma Control Plan. asthma and secondhand smoke.  businesses, and policymakers.  14. Improve public awareness and sensitivity to the needs of persons with asthma. Disseminate consistent materials and messages about asthma to community groups, schools, Public Awareness Objective Raise Arizona residents’ awareness about Promote basic asthma emergency protocols in first aid and emergency care courses. Future Directions The ultimate goal of creating a comprehensive Rationale Increasing awareness of asthma as a public 34 asthma control plan should be to coordinate existing services and available resources, identify gaps in health concern among the general public can aid services, and provide a guide for future endeavors. efforts in reducing the morbidity and mortality of In order to achieve this goal, future steps for the the disease and increase the quality of life for those Arizona Comprehensive Asthma Control Plan afflicted with the disease. Many individuals are should include stakeholder participation in unaware of the seriousness of asthma and how assessing and modifying the plan as workgroups see debilitating it can be if uncontrolled. Moreover, fit and continual assessment of strides made in many Arizonans are unaware of the link between achieving the goals and objectives set forth. In asthma exacerbations and environmental triggers addition, the plan should be updated and revised on such as secondhand smoke and air pollutants. a continual basis to ensure the plan is addressing Concerted efforts should be made to educate and relevant issues and meeting the needs of persons inform the general public about pertinent asthma- with asthma statewide. related issues. Strategies  Raise Arizona residents’ awareness about asthma as a significant public health issue by promoting asthma-related events, activities and educational opportunities.  Raise Arizona residents’ awareness about asthma and environmental triggers.  Raise Arizona residents’ awareness about asthma and indoor and outdoor air quality. References ............... References 1 Arizona Department of Health Services, Public 6 Arizona Department of Health Services, Health Prevention Services. Arizona Chronic Division of Public Health and Community and Disease Surveillance Indicators Report, Family Health Services. Asthma in Arizona, September 2004. 2002. 2 National Center for Health Statistics. Current 7 National Center for Health Statistics. Current Estimates from the National Health Interview Estimates from the National Health Interview Survey U.S., 2003. Washington, DC: Survey U.S., 2003. Washington, DC: Department of Health and Human Services, Department of Health and Human Services, Public Health Services, Vital and Health Public Health Services, Vital and Health Statistics. Available from URL: http://www. Statistics. Available from URL: http://www. cdc.gov/nchs/fastats/asthma.htm. cdc.gov/nchs/fastats/asthma.htm. 3 American Lung Association, Epidemiology & 8 Arizona Department of Health Services, Statistics Unit, Research and Scientific Affairs. Division of Public Health and Community and Trends in Asthma Morbidity and Mortality, Family Health Services. Asthma in Arizona, April 2004. 2002. 4 Arizona Department of Health Services, 37 9 National Center for Health Statistics. Asthma Division of Public Health and Community and Prevalence, Health Care Use and Mortality, Family Health Services. Asthma in Arizona, 2002. Available from URL: 2002. http://www.cdc.gov/nchs/products/pubs/pubd/he stats/astham/astha.htm. 5 Arizona Department of Health Services, Bureau of Epidemiology and Disease Control, Office of 10 American Lung Association. Asthma Fact Environmental Health. Arizona’s Children and Sheet, 2004. Available from URL: the Environment, December 2003. http://www.lungusa.org/site/pp.asp?c=dvLUK9O 0E&b=22596 Arizona Comprehensive Asthma Control Plan ............... 11 National Center for Health Statistics. Asthma 18 National Heart Lung Blood Institute. National Prevalence, Health Care Use and Mortality, Asthma Education and Prevention Program 2002. Available from URL: Guidelines for the Diagnosis and Management http://www.cdc.gov/nchs/products/pubs/pubd/he of Asthma: Expert Panel Report 2. Bethesda stats/ asthma/astha.htm. MD, Department of Health and Human Services, National Institute of Health. 12 National Center for Health Statistics. Early Publication No. 97-4051. July 1997. Release of Selected Estimates Based on Data From the January-March 2004 National Health Interview Survey, September 2004. 19 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 13 American Lung Association, Epidemiology & 2002. Statistics Unit, Research and Scientific Affairs. Trends in Asthma Morbidity and Mortality, April 2004. 20 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management 14 American Lung Association of Arizona. 38 of Asthma: Expert Panel Report 2. Bethesda Asthma Fact Sheet, 2004. Available from MD, Department of Health and Human URL:http://www.lungusa.org/site/pp.asp?c=dvL Services, National Institute of Health. UK9O0E&b=22596 Publication No. 97-4051. July 1997. 15 American Lung Association of Arizona. 21 National Heart Lung Blood Institute. National Asthma Fact Sheet, 2004. Available from Asthma Education and Prevention Program URL:http://www.lungusa.org/site/pp.asp?c=dvL Guidelines for the Diagnosis and Management UK9O0E&b=22596 of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human 16 Arizona Department of Health Services, Division of Public Health and Community and Services, National Institute of Health. Publication No. 97-4051. July 1997. Family Health Services. Asthma in Arizona, 2002. 22 National Heart Lung Blood Institute. National Asthma Education and Prevention Program 17 National Heart Lung Blood Institute. National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997. Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda MD, Department of Health and Human Services, National Institute of Health. Publication No. 97-4051. July 1997. 23 National Heart Lung Blood Institute. National Asthma Education and Prevention Program 28 Centers for Disease Control. National Health Institute Survey Public USe Data Release, 2003. Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2. Bethesda 29 American Lung Association. State of the Air MD, Department of Health and Human Report, 2004. Available from URL: Services, National Institute of Health. http://lungaction.org/reports/SOTA04_statesensit Publication No. 97-4051. July 1997. ive.html 24 Arizona Department of Health Services, Division of Public Health and Community and Family Health Services. Asthma in Arizona, 2002. 25 Arizona Department of Health Services, Department of Epidemiology. Arizona Behavioral Risk Factor Survey Database, 2000. Available from URL: http://www.azdhs.gov/ plan/hip/for/asthma/index.htm 40 26 Arizona Department of Health Services, Department of Epidemiology. Arizona Behavioral Risk Factor Survey Database, 2003. 27 Arizona Department of Health Services. Arizona Vital Statistics, 2003. Available from URL:http://www.azdhs.gov/plan/report/ahs/ahs2 003/toc03.htm 30 Arizona Department of Health Services. Arizona Hospital Discharge Data, 2003. “ Asthma is one of the nation’s most common and costly diseases, affecting over 31 million Americans, with direct and indirect costs exceeding $14 billion annually. ” Arizona Comprehensive Asthma Control Plan .............. Arizona Department of Health Services Division of Public Health To b a c c o E d u c a t i o n a n d P r e v e n t i o n P r o g r a m w w w. a z d h s . g o v