Wednesday, August 10, 2011

The 15-Minute Asthma Visit

From CDC Expert Commentary

David B. Callahan, MD
Posted: 08/01/2011

Hello, I am Dr. David Callahan, with CDC's National Asthma Control Program and a Captain in the US Public Health Service. I am speaking to you as part of the CDC Expert Commentary Series on Medscape. Today I would like to discuss how clinicians can provide evidence-based care for their patients with asthma in a routine 15-minute office visit. Today's discussion is based on the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.

The goal for long-term management is to control asthma by reducing impairment and risk.
Reducing impairment involves limiting the impact on the patient's day-to-day life by preventing symptoms, limiting the need for quick-relief medications, and maintaining normal activity levels.
Reducing risk means minimizing the need for emergency department visits and hospitalizations and avoiding adverse effects from medications.

Here are 4 key steps to follow:
1. Schedule regular 15-minute visits. Routine follow-up care -- scheduling office visits at periodic intervals-- is an essential part of caring for patients with asthma.
It allows the clinician to monitor and adjust therapy and reinforce the key components of asthma management over time.
An asthma management flow sheet, updated at each visit, can provide a way to make sure that essential components of asthma care are covered across multiple appointments. These routine follow-up visits can reduce the challenge of providing quality asthma care in a typical 15-minute office visit.
2. Assess control, beginning with a standardized questionnaire. Assessing control is part of every routine asthma visit and is the basis for stepwise management of asthma medications. Assessing impairment -- a component of control -- can be done using a questionnaire that the patient completes while awaiting the visit. Standardized questionnaires like the Asthma Control Test™, the Asthma Control Questionnaire, and the Asthma Therapy Assessment Questionnaire and others are informative and easy to use. Risk can also be inferred by asking the patient about unplanned, urgent care visits for asthma exacerbations, in conjunction with an analysis of spirometry results that may have been done at a recent separate visit. Occasional spirometry can also help assess progressive loss of lung function over time, another component of the risk domain.
3. Review the patient's written asthma action plan at each visit and discuss asthma triggers. Reviewing the patient's written plan can serve several functions in the routine visit. It offers an opportunity to provide focused self-management education, including use of a peak flow meter or an asthma symptom diary.
Similarly, you can review daily asthma management, including use of long-term controller medications, as you discuss the "green zone" used when the patient is doing well. Discussing the yellow and red zones can help the patient recognize symptoms that call for prompt attention, as well as appropriate use of short-acting beta-agonist quick-relief medications.
The asthma action plan should include information on specific asthma triggers that the patient should avoid. Encouraging a multipronged approach to reduce exposure to asthma triggers can be done over multiple visits and reinforced with written patient education materials.
Two triggers demand special attention: tobacco smoke and air pollution.
If the patient is a smoker, a return visit should be scheduled to specifically address smoking cessation. For all other patients, avoidance of environmental "secondhand" smoke can be recommended at each visit.
Air pollution is a common asthma trigger, and the air quality index (AQI) can provide the day-to-day information your patients need to know in order to determine when to modify their activities. In particular, ground-level ozone, a primary component of smog, can trigger asthma symptoms directly and can also sensitize the patient to other triggers. Particulate-matter air pollution is also an important asthma trigger. When air pollution levels are high -- when the AQI is "code orange" or worse -- patients with asthma should avoid outdoor activities. Informing patients where to find the AQI -- such as the newspaper, weather forecasts, or the Environmental Protection Agency Website -- takes only a moment and can be included on the asthma action plan.
4. Review medications. Of course, long-term management depends on optimal use of asthma medications. Inhaled corticosteroids are the most effective medications for long-term management of persistent asthma, and assessing their use in the context of stepwise management of asthma can be done as you review medications and administration techniques. Ensuring that the patient has an adequate supply of controller and rescue medications, and scheduling the next follow-up visit, can wrap up your 15-minute office visit.
Finally, the goal of good asthma care is for your patient to be able to enjoy life with as few symptoms as possible, and partnering with your patient through scheduled follow-up care can achieve that goal.

No comments: