New Asthma Assessment and Management Tool Improves Outcomes

Tara Haelle

March 15, 2018

Use of a new asthma assessment tool called APGAR leads to improved asthma control and improved patient outcomes in terms of asthma-related emergency, urgent care, and hospital visits, according to a cluster-randomized trial published March 12 in the Annals of Family Medicine.

Healthcare visits related to asthma were 51% lower among patients whose providers used APGAR instead of providing usual care, the authors found. Use of APGAR, which stands for Activities, Persistent, triGGers, Asthma medications and Response to therapy, also increased patient adherence to guidelines for managing asthma and slightly improved asthma-related quality of life.

"The Asthma APGAR tools provide a broad array of information beyond what is included with most control assessments and beyond what is collected in most primary care asthma visits," write Barbara P. Yawn, MD, from the Department of Research at Olmsted Medical Center in Rochester, Minnesota, and colleagues.

Despite widespread use of the Asthma Control Test (ACT) in the United States and other validated metrics for assessing asthma control in Europe, no evidence so far suggests these tools improve outcomes, Yawn told Medscape Medical News.

"The Asthma APGAR is different in that it not only assesses asthma control status but also asks about the most common reasons for being out of control (unidentified triggers or allergens), how and why patients are taking medicines, and whether or not patients think their asthma medicines help," Yawn said. "The Asthma APGAR is intended to replace the ACT in primary care, where it has been shown, by this study, to improve patient and practice outcomes."

APGAR's first three questions generate a score that links to a care algorithm with more specificity than just step-up therapy.

"None of the other tools are linked to care algorithm. They give you a score and you have to decide what to do next," Yawn explained. "This was reason for developing [the new] tool: to provide one-stop guidance instead of just a 'score.' "

Similar to ACT and other tools, the APGAR assessment asks how frequently breathing difficulties have interfered with the patient's activities in the previous 2 weeks and how many days and nights they experienced asthma symptoms or needed to use their rescue inhaler. In the question about what exacerbates patients' asthma or breathing problems, the triggers listed are dust mites, dust, trees, flowers, cigarettes, smoke, cold air, colds, exercise, cats, dogs, mold or "other." The APGAR also asks whether patients can avoid those triggers.

For the current trial, the researchers randomly assigned 18 practices to the intervention or usual care groups. Training in use of APGAR was provided to a physician and nurse at each intervention practice, who then trained other practice employees. Training for usual care practices included a short asthma overview and study procedures training. All usual care practices received APGAR training at the conclusion of the trial.

To be eligible for participation, patients had to be between ages 5 to 45 years, have persistent asthma requiring daily maintenance medication, and have no other chronic lung diseases. Primary endpoints, assessed at baseline, 6 months, and 12 months, were asthma-related quality of life and patient-reported asthma control for both adults and children, using the ACT, the Asthma Quality of Life Questionnaire, and the child-adapted versions of these.

Secondary outcomes included emergency visits, urgent care visits and hospitalizations related to asthma, and "changes in practice documentation of adherence to elements of the 2007 National Asthma Education and Prevention Program (NAEPP) US asthma guidelines assessed by research staff review of medical records." Because the study design was pragmatic, patients determined any visits or care without any minimums.

Of 1066 patients enrolled, 692 (65.0%) returned both the baseline and 12-month questionnaires, which were mailed to patients and were used to assess patient-reported outcomes. In addition, medical records were available for nearly all patients (n = 1063; >99%) and were used for practice-assessed outcomes.

Compared with the 6 months before the study began, asthma-related healthcare visits in the intervention group dropped from 17.5% to 10.6% in the last 6 months of the trial (P = .001). The usual care group's visits increased nonsignificantly from 15.9% to 20.9% (P = .06) at the same points. After adjustment for age, sex, race income, ethnicity, the patient's healthcare visit history, and practice random effects, patients in the control group were more than twice as likely to report a healthcare visit compared with those in the intervention group (odds ratio [OR], 2.1; 95% CI, 1.01 - 4.2; P = .04).

At 12 months, 54.3% of intervention patients reported having control of their asthma compared with 46.0% of usual care patients, but the difference was not significant (P ≤ .06). There was a statistically significant increase in the proportion of patients in the intervention group who reported having controlled asthma during the trial, from 40.8% at baseline to 54.3% at 12 months (P < .0001). The change in control among usual care patients was a nonsignificant increase from 42.6% to 46.0% (P = .86).

Small improvements were seen with use of APGAR in patient asthma-related quality of life, although mostly with no statistical significance. The 12-month scores, on a scale from one to seven, were 5.37 in the intervention group and 5.14 in the usual care group (P = .07). The difference gained statistical significance after adjustments for age, sex, race, ethnicity, and a practice variable (P = .04).

"This discrepancy [in less improved quality-of-life scores] likely highlights the different aspect of a patient's life assessed by the domains of asthma control and the broader assessment of living with asthma or asthma-related quality-of-life," the authors write. "Use of the Asthma APGAR system was designed to address asthma control and may not improve overall asthma-related quality of life."

At 12 months, intervention patients also had more than triple the odds of adhering to at least three elements of nonmedication guidelines than the usual care patients (OR, 3.89; 95% CI, 1.87 - 8.07; P < .001). Because the practice sites were smaller practices outside the inner city, however, the authors acknowledge that these findings may not be generalizable to large healthcare systems.

The researchers also assessed the challenges of implementing APGAR use in clinical practice. "Although practice change was reported as difficult, clinicians and practice staff who used the tools found them helpful," the authors report. "Both physicians and nursing staff reported that learning and determining how to implement the new system required additional time and practice, but they thought that it rapidly 'streamlined' asthma visits."

At the same time, the practices may have needed to delay other practice improvements during the first study year to focus on APGAR implementation. "The enrolled practices did comment that they were unable to begin other new quality improvement projects for any medical condition for at least the first 6 to 12 months of working to implement the Asthma APGAR tools, but did not believe they eliminated any preexisting practice activities," the authors write.

The research was funded by AHRQ. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2018;16:100-110. Abstract

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