Transcription of NAEPP Webinar: Use Maintenance of Certification Process to Assess and Improve Your Asthma Care
August 8, 2012
The following webinar transcript is not a verbatim representation of the webinar as originally presented. It has been edited to clarify meaning and to update content. The views expressed within this webinar transcript do not necessarily reflect those of the National Heart, Lung, and Blood Institute (NHLBI), the National Institutes of Health, or the U.S. Department of Health and Human Services.
With asthma accounting for more than a quarter of all physician office visits for lung diseases among primary care patients in 2009, physicians are on the front lines in combating the burden of asthma. This webinar describes currently available programs approved for Maintenance of Certification by the American Board of Family Medicine that enable physicians to assess and improve the quality of asthma care they deliver according to clinical guidelines developed by the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI). Following a brief introduction by Rachael Tracy, NHLBI, the webinar’s co–presenters, Michael D. Hagen, M.D. of the American Board of Family Medicine and Kurt Elward, M.D., M.P.H. of Virginia Commonwealth University, will discuss their collaborative efforts to engage physicians and their practice teams in using tested asthma quality improvement programs.
Tracy: My name is Rachael Tracy and I am the acting coordinator for the National Asthma Education and Prevention Program (NAEPP). On behalf of the NAEPP and its National Asthma Control Initiative (NACI), I would like to welcome everyone to our webinar titled, Use Maintenance of Certification Process to Assess and Improve Your Asthma Care. We are very excited to bring this webinar to you. I will begin by introducing our two presenters, Dr. Michael Hagen and Dr. Kurt Elward.
Dr. Michael Hagen is senior vice president of the American Board of Family Medicine (ABFM). As a Strategic Partner in the NAEPP’s National Asthma Control Initiative, ABFM collaborated with the University of Kentucky and with Dr. Kurt Elward, Medical College of Virginia, to emphasize the NAEPP’s six guidelines–based key actions in ABFM's Maintenance of Certification for Family Physicians Self–Assessment Modules (SAMs) and to examine the use of a group SAM process led by expert faculty. The SAMs are approved by ABFM for Part II Maintenance of Certification credit.
Dr. Kurt Elward is a family physician and clinical professor of family medicine at the Virginia Commonwealth University, Medical College of Virginia and a member of the NAEPP Coordinating Committee and Guidelines Implementation Panel. As medical director for the Medical Society of Virginia Foundation’s Improving Asthma Care and Treatment—or IMPACT™—a NACI Clinical Champion and Demonstration Project, Dr. Elward worked with his colleagues to engage pediatric and primary care practice teams in Virginia in asthma quality improvement collaboratives. MSVF’s IMPACT™ has received joint approval for Part IV Maintenance of Certification credit from the American Board of Family Medicine, the American Board of Internal Medicine, and the American Board of Pediatrics, all members of the American Board of Medical Specialties.
Again, we are very excited to bring this webinar to you on behalf of the NAEPP and the NACI, and we are very delighted that both presenters were able to take time from their busy schedules to share this very valuable information with us. Thank you.
Hagen: Welcome, everybody. This is Michael Hagen, M.D., senior vice president of the American Board of Family Medicine and professor in the Department of Family and Community Medicine at the University of Kentucky. We have been working with Dr. Elward and the NACI project for several years now to use our Maintenance of Certification process at the ABFM to promote the key messages of the NAEPP’s Expert Panel Report 3—Guidelines for the Diagnosis and Management of Asthma (EPR–3). Actually, Dr. Elward was the motivator behind this effort, and he conceived the project. I will turn it over to Kurt.
Elward: Thanks, Michael, and thank you, everybody, for being here. What we would like to do today is give you an understanding of how the Maintenance of Certification works and some ideas about how to leverage this to seize dissemination opportunities for you and your states. We partner with the ABFM and other specialty boards to use this process, and we are happy to provide you with some initial results of our collaboration and what we think has some exciting potential for the future.
NACI Projects with Maintenance of Certification (MOC) Incentive
American Academy of Allergy, Asthma & Immunology
Asthma Specialist Tool to Help Manage Asthma and Improve Quality (ASTHMA IQ) for Primary Care includes a Practice Improvement Module approved by the American Board of Internal Medicine (ABIM) for Part IV (Performance in Practice) MOC credit.
American Board of Family Medicine
Asthma Self-Assessment Modules approved by ABFM for Part II (Lifelong Learning) MOC credit.
Medical Society of Virginia Foundation
Improving Asthma Care and Treatment (IMPACT™) quality improvement program approved jointly by the ABFM, ABIM, and American Board of Pediatrics (ABP) for Part IV MOC credit.
University of Washington
Spirometry 360 quality improvement and feedback program approved by ABFM and ABP for Part IV MOC credit.
Visit Quality Improvement: The Importance of Feedback for the full article from the NACI In the Know eNewsletter.
Our focus has been how to use the Maintenance of Certification process to disseminate the six key messages of the NAEPP’s Guidelines Implementation Panel (GIP) Report in an effective and efficient manner, and to get feedback from front–line clinicians about the guidelines and where additional efforts can be focused. One of the key points of our projects is that we want to provide clinicians what they need now and for the future, in the context of what they want now, which is really recertification. We want to use opportunities where they have to be someplace, and give them something that will complete what they are “required” to do, but really use this as a novel vehicle for guidelines dissemination. In addition, we will talk about supporting potential collaboration and evaluation opportunities.
As you know, we are trying to promote the EPR–3 Guidelines and GIP Report. One of the things we realized on the Guidelines Implementation Panel was the challenge of interfacing with community groups and other national entities that have a very specific reach or a very broad reach into the actual users of the guidelines and how we could leverage this. The ABFM has been a key player in how to make this happen.
Again, here are the six key GIP messages: 1) use inhaled corticosteroids, 2) use written asthma action plans, 3) assess asthma severity, 4) assess and monitor asthma control, 5) schedule follow–up visits, and 6) control environmental exposures that worsen asthma. These are not high tech, as we all know, and they are very primary care oriented. We tried to incorporate these key messages into the self–assessment tool that we will talk about in a few minutes.
The current challenges for physicians include that recertification is costly, and it can be time intensive. Traditionally, it has been based on individual work, and not on practice or systems. There is also a lack of opportunity to really consider what helps guidelines implementation in their practice and answer questions such as how did the NAEPP come up with that recommendation? Why did they decide on doing that? What about this situation? Those are really big challenges to meet because those are the kind of questions that help physicians understand why they should adhere to the guidelines. We also realize there is insufficient time and staffing to implement the guidelines and to think about how to incorporate them into practice, and conflicting demands particularly in primary care. In primary care, what you do each day is not just see patients with asthma. You see patients with asthma in the context of many other diseases and a larger set of circumstances.
What we wanted to do with this project was to think about how we could orient clinicians to the guidelines and the six key messages in a way that was effective and efficient, and how we could provide them useful tools in a context that stimulated understanding and implementation.
Hagen: I thought we would give a bit of an overview about what we mean by Maintenance of Certification. As you may know, in the United States there are 24 medical specialty boards that are all members of a parent organization called the American Board of Medical Specialties (ABMS). Historically, the medical specialty boards have certified physicians for a lifetime. That is, after they complete their residency training after medical school, they would sit for an examination and have a certificate on their wall for the rest of their life. Obviously, learning does not stop there. Around 2000, the member boards of the ABMS recognized that to assure the public that member physicians or diplomats of the member boards continued their life–long learning, certification should become a continuous process. Hence, all of the boards adopted the notion of Maintenance of Certification as an ongoing, continuous, participation in life–long learning activities.
The Maintenance of Certification process has four components. The first is demonstration of professionalism, which for most boards right now consists of demonstration of an unrestricted license to practice medicine in some jurisdiction in the United States or territories, but there are additional requirements coming down the line in terms of peer surveys, and surveys of patient experience that would be part of this in coming years. Part II is demonstration of life–long learning, which for the ABFM we’ve accomplished using self–assessment modules, which we’ll describe more in a minute. Part III is demonstration of cognitive expertise, which is demonstrated through sitting for a proctored, secure examination at some period which varies from one board to another; for the ABFM it is every 10 years. Part IV is performance in practice, which consists of formal quality improvement activities, either through modules that our board has provided or other boards have provided or through third parties.
The Self Assessment Modules or SAMs, which you’ve now heard several times, consist of several parts. The first part is a 60–item knowledge assessment that includes critiques and references that the user sees after going through all of the items. In the items are the usual suspects, such as multiple choice, multiple true or false, and some fill–in–the–blank style items. Once individuals have completed the knowledge assessment successfully, they then move into a clinical simulation, which focuses on the management of a patient with the problem covered in the knowledge assessment—specifically, in this case, asthma.
Elward: We thought with the SAMs there was an opportunity to convey the essential content of the guidelines to primary care physicians. With the SAMs, we could reach a broad audience and use those 60 questions not just to review asthma and its pathology, but also to really target the key guidelines. In addition, we could give them some of the tools that could be used for optimal asthma care, to teach them really how easy it would be to use the Asthma Control Test™ (ACT) or the Asthma Therapy Assessment Questionnaire© (ATAQ), show them the asthma action plan and how it might be filled out, and explain the rationale behind each of the key messages in the context of primary care. We also thought that it was a great opportunity, given that we’re really dealing with front–line clinicians—people who might not go out of their way to go to a conference on asthma guidelines—to reach them and learn what barriers and what challenges they have in their use of the NAEPP guidelines.
The project came out of my personal experience with the Maintenance of Certification process and those of my colleagues in several ways. Everyone has to do this process, and there is concern about how to just get through it. They found some of the parts very helpful, but there was an opportunity to really extend their impact. A few years ago we had decided to do group SAMs where we would get anywhere between 15 and 30 clinicians together and walk through the questions and possible answers and use that as a teaching opportunity, and really get through it a little more quickly but also more efficiently, and in a way that really facilitated learning.
That ended up being a very successful model. In talking to Dr. Hagen, it seemed like a great opportunity to test this out with the asthma SAM. We were able to listen to physicians as they were going through the questions and learn about what challenges they had in a variety of situations, how they had been successful at implementing certain aspects of asthma care, and really think about what kind of messaging we could provide. A lot of it was being able to listen to clinicians in a large group setting and then design some specific teaching slides and interventions during the SAM process that would address what we heard. We also felt it was important to really help them understand why the NAEPP had come up with the guidelines, but also specifically in working with environmental issues and looking at other aspects of the guidelines, how well they could avail themselves of community resources, asthma educators, school nurses, and other people who are really essential in the guidelines implementation process when you get down to the individual patient level.
What we did was modify the knowledge assessment to emphasize all of the guidelines elements, but particularly the six key messages. In addressing the use of written asthma action plans, we provided the evidence behind them and discussed them in a clinical context using clinical cases. For the assessment of asthma severity and control, we discussed and presented the data involving long–term control medications. We also developed specific slides about the importance of asthma triggers and how to evaluate those and deal with them in a primary care setting.
The next step was to develop a standardized curriculum for presenting the asthma SAM with an emphasis on key messages. We worked with four family medicine chapters in the United States who agreed to take the lead on this effort and trained each of the two to four presenting faculty in each state to put on a number of group SAM opportunities in each state so that we could see what the impact was like across the country, but also really get enough numbers so that we could do a good evaluation. Participants included family physician groups in Colorado, Florida, Oklahoma, and Virginia. We had very good participation in all four states. We allowed them to present in their own fashion, in the way they felt most comfortable. We had a set of standard slides that we developed in collaboration with the ABFM that would convey the key messages most effectively. What we allowed them to do, however, was to adjust their presentation based on what resources were available in the states.
Participants began the group SAM process by conducting a pre–participation chart audit of 15 charts using a one–page abstraction form to summarize information from their charts based on the six key messages. There was also a short, pre–participation survey looking at their familiarity with the guidelines and some of the challenges they saw. We then took them through the group SAM process, and then they completed a post–participation survey. The surveys only took about 5 minutes, and they were focused on the key messages and what the participants knew or learned, respectively, about the SAM before and after. Then at 6 months, we are performing post–participation audits, which is another chart review and short survey.
Hagen: I will share a sample of some of the pre– and post–group SAM survey results we obtained from the participants. These specifically came from one of the sessions that Dr. Elward conducted in Virginia, but we have this information also from the participants in Florida, Colorado, and Oklahoma.
The pre– and post– surveys asked participants for their level of agreement or disagreement with a series of statements based on the six key actions. The questions included five response levels (1= agree strongly, 2 = agree, 3 = neutral, 4 = disagree, or 5 = strong disagree). Parenthetically, all of the survey results were statistically significant by the Mann–Whitney U Test with a p value of <0.001, which indicates a substantial difference between the pre– and post–survey results.
In comparing the pre– and post–survey results for the group SAMs, we saw improvements in the total number of participants who responded that they agree or agree strongly with each of the following statements based on the six key actions:
- Inhaled steroids are recommended for all persistent asthmatics
- Asthma action plans are evidence based and should be provided to all persons with asthma
- I feel comfortable with my ability to assess control
- I am familiar with the ACT and ATAQ for asthma control assessment
- I feel confident in understanding the importance and frequency of planned visits
- The EPR–3 guideline is easy to understand
- The EPR–3 guideline is easy to read
- The EPR–3 guideline will be useful in my practice
- The approach to severity assessment is clear for me
In addition to these itemized responses, we received a number of free text responses. Many of them indicated that teasing these key messages out of the original guidelines document was difficult, but that the focused presentation in the group SAM greatly facilitated identifying these particular key messages.
Now I will turn it back to Dr. Elward.
Elward: What we will be doing at the end of the 6–month project is to look at the actual chart reviews to determine whether those changes in knowledge and perspective translated into actual improvements in their day–to–day care. I think what was evident in the initial surveys was that some fundamental awareness of what was important in the guidelines just wasn’t out there, and the process that we went through really did help wake them up to what the severity classification was about, what control is about, and where to find things in the guidelines. Some people still didn’t get the overall format, but a lot of them felt much more comfortable about how they would use the guidelines and where to go with that. There were very significant differences in the pre– and post–survey results, and it does seem that we were able to convey the key messages in the guidelines in a very effective fashion not just in one state but in four different states with different presenters using the same format.
It seems that the group SAM process does influence perspective and openness to the guidelines. Many of the participants really appreciated what the guidelines were about at the end of the session, and they really hadn’t gotten it before.
We also were able to identify some specific challenges. One of the challenges is severity classification. This is still a challenge for many primary care doctors. Severity classification is technically supposed to be best done when people are off of their medicines, and we hardly ever see people off of their medicines at least initially. How to do that in the context where people are already taking something is still a challenge.
There is this great primary care challenge in terms of what I would consider “moderate intermittents” or “seasonal persistents.” Those are not formal classifications for asthma severity in the guidelines, but there are many primary care doctors that see people who really need more aggressive care certain times of the year and at other times actually need almost “mild intermittent” asthma care, to use an older term. They just need their albuterol once in awhile, but during certain times of the year, need much more aggressive therapy. That is something that might need to be expanded and focused on in future iterations of the guidelines because our perception is that a good 20–30% of primary care patients can fall into that category, and that involves stepping up and stepping down long–term control medication. I think focusing on that is very important.
With acute care of asthma, what we found is that there is a lot of opportunity to convey to primary care doctors the importance of more aggressive oral steroid therapy in the acute phase and to get away from some of the automatic use of combination agents or inhaled steroids alone, instead of appropriately treating patients in the acute phase according to the guidelines.
Planned care is also a very significant challenge. It is a concept that many primary doctors understand very well for diabetes and heart disease, but it has not filtered down yet for asthma care. We will find out more results from our project, but the appreciation of how to incorporate planned care into asthma we think is still a challenge for primary care physicians, although we did make some strides in the process. We have learned a number of things from the groups about how to message planned care visits. What is important to them? What are the barriers? A lot of primary care doctors still do not believe that people will come back for asthma follow–up visits. Our approach includes a variety of messages, but one is you won’t know until you try. You don’t know until you plan those visits before the worst parts of the year, give patients some key educational materials, connect them to community groups like the asthma coalitions that can help, and really plan those visits and make it all happen.
Asthma action plans are also a challenge. It was evident that there is still a lot of confusion and lack of knowledge about asthma action plans, but when you explain the rationale behind them and the evidence base behind asthma action plans, there is much more receptivity to using them. I think this is another area where we can provide some additional educational materials to front–line clinicians.
One thing we are seeing in our project, from the feedback that I am getting from the participating clinicians, is that they are starting to use asthma control tools more consistently. They realize that it is, indeed, very easy to do, and there has been much more openness to asthma action plans. Several of the people who have gone through the program, at least in Virginia, have given me feedback that they are making an effort with planned visits and focusing on asthma as a real emphasis in terms of planned care.
The messaging involving inhaled corticosteroids has also improved. We used the SAMs as an opportunity to really convey answers to common concerns, understanding why we give inhaled corticosteroids, and helping them with some specific messaging. We were also able to improve the awareness of spirometry and just how important that is in the primary care setting as well as in overall management of respiratory disease, but particularly for asthma. We were able to talk about how that service can be a) easily incorporated into primary care and b) more easily referred for testing at pulmonary labs.
Our next steps are to further analyze the data on the impact of the group SAMs at the 6– month level, and we are undertaking an individual SAM arm of the study. We realize there may be group dynamics that influence how successful this has been. We would like to know what happens when people take the new and improved version of the SAM as individuals and learn what the differences are when compared with the group SAM. We hope that there will be a lot of similarities, but we expect that we will find some opportunities that are specific to the group processes, and learn from those and incorporate them into the individual learning experience.
We also have plans to evaluate longer–term impact. We are realistic enough to know that a single session on asthma is not likely to create huge long–term improvements. Our purpose was to really see how much we could get out of the session and really plant seeds to extend the process. We are making efforts to link this to the quality improvement efforts of the ABFM and how we can create opportunity within what they call Part IV or the quality improvement projects that they also have to do for recertification. Michael and I are also undertaking a qualitative analysis of challenges and opportunities, a glimpse of which I just conveyed to you, and we hope that we will have the opportunity to feed that back to the NAEPP as topics of interests for future guidelines development.
I think there are a number of partnership opportunities, and certainly the American Board of Family Medicine—and in a larger sense the American Board of Medical Specialties—has been very interested in how they would use the Maintenance of Certification process. One of the things for which I really want to give kudos to Michael and the ABFM is their consistent interest in how the certification process can be more than a test and much more of a tool in terms of how you can use the Maintenance of Certification process to really convey important knowledge in ways that affect patient care. I want to compliment and praise the ABFM on that consistent focus. I think for all of you in the different states, your state chapters of the American Academy of Family Physicians have a number of real leaders in the state and they have a number of educational opportunities that you might want to engage, not only state meetings, but also Web sites. They have their fingers on the pulse of a lot of the members and there is a lot of openness on how they would partner with groups on asthma and other chronic diseases. I would be glad to facilitate introductions for you in any of the state chapters and see if I could help you promote your individual projects or if there is any interest in doing some SAMs in your state, in the way we have done here in our four states. We’d be glad to help you with that. Collaboration with the asthma coalitions as well as academic institutions is also important. I know the Virginia Asthma Coalition has been a really dynamic force in the state of Virginia, and throughout the country. I think the asthma coalitions are really the backbone of a lot of important change and advocacy for asthma and for patients with asthma. There is a great opportunity to combine these kinds of partnerships and to think outside of the box somewhat and come together to get the messages out.
What we presented today is one aspect in a variety of efforts to use the Maintenance of Certification as an incentive. What you heard today is the ABFM’s use of the SAMs. The Medical Society of Virginia Foundation also has a quality improvement project linked to Maintenance of Certification, which has actually been able to offer credit to not only family physicians but also to internists and pediatricians. This is in an extension to the usual Maintenance of Certification process, which has been very effective. In addition, the American Academy of Allergy, Asthma and Immunology has developed a special online tool— Asthma Specialist Tool to Help Manage Asthma and Improve Quality (ASTHMA IQ) for primary care—which seems to be having a very big impact in improving overall quality of care, and it has a practice improvement module approved by the American Board of Internal Medicine (ABIM) for Part IV credit. That’s an additional incentive for doctors to really do what they should be doing, and it really helps engage doctors who are on the frontlines and may be a little harder to reach yet make up a lot of physicians providing asthma care.
I will put in a very strong word for the University of Washington; they have an outstanding spirometry program that has gotten approval for Part IV credit by the ABFM and the American Board of Pediatrics. Drs. Karen Smith and Jim Stout have really taken spirometry training to another level with their Spirometry 360 program. The MSV Foundation actually used Spirometry 360 as a major component of its spirometry training, and the feedback, comfort level, and use of spirometry dramatically increased as a result. It really empowered the clinicians and particularly empowered their staffs. I really want to laud all of those programs that are using this approach. I think that for any of you on the call who would really like to lend your efforts into these or have ideas as to how some of your outreach, particularly the community outreach, could be incorporated into some of these efforts, I think that would be very timely to consider these. I will close for questions for Michael and me, and I really appreciate your time today. Thank you.
Question and Answer Session
Gilmore: Thank you, Dr. Elward and Dr. Hagen. This is Lisa Gilmore, and I am here with my colleague Kate Fink helping and assisting with the logistics of today’s webinar. I’d also like to thank Rachael Tracy from the National Heart, Lung, and Blood Institute for all of her support and work in this area. Thank you all for participating in today’s webinar. We definitely want you to stay and continue to ask questions. I want to add that a transcript of the webinar will be provided to you. We will send you a notice when it is available so that you will have the details from today’s webinar. Dr. Hagen, I believe we sent you a question regarding some of the survey data you presented.
Hagen: The question that came is, “Do the survey responses represent percentages or numbers?” They are counts. They’re actually numbers of responses so they represent count data. Just a word about the statistical tool that we chose: A lot of people will look at Likert–scale data, such as a 5– or 7– point scale, as continuous data and look at the means of those responses. I think the more conservative approach is to consider these as non–linear data because the difference between a 1 and a 2 is not necessarily the same as the difference between a 2 and a 3. So we used a nonparametric measure called the Mann–Whitney U Test that does not assume any particular distribution of the underlying data. That was the rationale for choosing this approach, and that was count data.
Gilmore: Dr. Elward, we just forwarded a question to you. This question is regarding whether for clinician education programs there is sometimes a challenge of getting clinicians who really need to get this education to participate. What are your thoughts about recruiting physicians, not just physician champions who are already interested, but others who really could benefit?
Elward: That’s a great question. That is one of the reasons that we developed this kind of program. There were some people who would normally be very hard to reach who showed up because we were also offering some additional credit as a part of this. They had to get the asthma self–assessment module done sometime in the next few years, and we made it very attractive to do it. That’s really why we did what we did. A couple of things we also did, that we tried out in Virginia: We engaged the Virginia Department of Health, and we asked them to look at their data about where most of the hospital admissions, emergency room (ER) visits, and other problem areas for asthma were. They do have data at the state level about how many asthma diagnoses there are and the use of inhaled corticosteroids, high rates of ER visits, high rates of hospitalizations, and high rates of death throughout the state. We worked with them to offer the SAMs in those areas of the state that seemed to have significant problems.
That is one thing you might wish to do in terms of any of your educational needs is to partner with the state or even go to some of the managed care corporations; they know exactly where their costs are going and where the ER use is high. At least from the state health department, they actually gave us some funding to provide some of these programs in areas that seemed to be at risk. The next step after we got the funding was to identify specific places we could give the SAMs and target clinicians in those areas for these programs.
Gilmore: Thank you, Dr. Elward. I wanted to ask a similar question as a follow–up. These programs are tailored for physicians for Maintenance of Certification, but physicians work with a team in their practice. Are there ways that they can think about engaging others in their practice and enlisting their help and support in improving the quality of asthma care they provide according to the guidelines?
Elward: That’s a great question, too. We try to convey within the SAMs process that same message. One clinician alone, even three or four doctors in the same practice, will never be as effective as they would be if they engage their staff and if they engage community groups. As we talked through the process of proper assessment and control and planned visits, I think that message came across and people actually realized that they were markedly underutilizing their staff. One of the messages that we gave them was the opportunity to send their staff to courses like the Asthma Educators Institute, which is a short, focused course that is available for nurses in many states through the American Lung Association. I think it’s about $150–$200, which is one of the best values out there to ramp up their staff.
I think we used this opportunity as a way of really promoting that. In the MSVF project, we actually took groups of practices and walked them through their quality improvement requirement for their Maintenance of Certification process. Within that project, there were specific educational opportunities we gave for nurses and staff, and we strongly emphasized the concept of a team in terms of making sure that you trained your nurses, you made sure your front office people who are doing your check–in and the check–out knew how important it was to make sure that people were coming back for follow–up and making sure they handle asthma questions appropriately. I think there are a lot of good opportunities for staff training. We emphasize that in the SAM process, but we also targeted that in the MSVF program and we found that it was a key to good success.
Gilmore: Dr. Hagen, there is a question that came to you regarding people who have asthma that is resistant to steroids. And for those who are resistant to that form of treatment, what is the preferred treatment according to the guidelines, what are their options for treatment?
Hagen: I am going to defer this question to Dr. Elward.
Elward: We get that a lot. Was the question about what we say to people that are resistant to steroids?
Hagen: Are you talking about people who are resistant to prescribing steroids or patients who are resistant to the effects of steroids?
Gilmore: I think patients who are resistant to the effects of steroids.
Elward: We do talk about that. It was in one of our slides for the group SAM. It is not a lot of people, but there are individuals who don’t seem to respond as well to inhaled steroids. The messaging we tried to provide was that a large majority of people with asthma do in fact benefit a great deal, and when they don’t, there are other options such as leukotriene agents, which have a very strong place in asthma management. Those should be considered. The important thing is to recognize when people are not responding to inhaled steroids and to get steroid–resistant patients to specialists. When you put people on inhaled steroids, and you go up a little bit on the dose and you’re not seeing the improvement that you want, that should be a trigger for referral. One of the best things you can do as a primary care physician is to get them to good specialty care when the time is right.
We also presented them with some data that they could arm themselves with for parents or adult patients who are concerned about inhaled steroids. There is some messaging that we gave them in terms of a graph that shows the relative advantages of proper asthma treatment compared to the relatively low complications associated with inhaled steroids as well as some mathematics about how much you are actually getting of an inhaled steroid versus what you would get if your child ends up with an exacerbation and gets a week of oral steroids. It doesn’t take much math to show that the kids are getting far more steroids from intermittent acute oral treatment than they are if they take controller medication in the form of inhaled steroids.
We try to address both areas and make them aware of the fact that some people out there don’t respond as well. We did also emphasize in several places in the messaging about the use of long–acting beta2–agonists as sole therapy. We really made it clear that there is no place for that. For the specialist community, they know there is a place for long–acting beta2–agonists in specific situations, but the messaging we gave is that is extremely rare, and to think 5 or 6 times, and then think about 10 times more before you ever prescribe or even think about letting someone have a long–acting beta2–agonist alone without an inhaled steroid.
We also worked through each part of the step therapy process. The one thing that is a little confusing is we all know about the four classifications— intermittent, mild, moderate, and persistent asthma— but when you look at the treatment steps, there are six steps. Looking at that, they aren’t really labeled, so working through the different grids can be a challenge. That is one of the things we try to do in the context of the clinical simulation that is in the ABFM module as well as the individual questions, many of which are case based. We try to walk them through the grids and say, here’s why it makes sense.
Gilmore: We have another question for either or both of you. Dr. Hagen, maybe you’d like to tackle this. “Are there other plans with nurse practitioners or physician assistants or other professionals to have similar kinds of Maintenance of Certification, Self Assessment Modules, quality improvement, or lifelong learning programs?”
Hagen: Well, I can say that for the American Board of Family Medicine, obviously, our focus is on family physicians. We have had several instances of programs conducted by advanced nurse practitioners, and we are willing to support those as long as family physicians also participate in the audience. We’ve not made available the SAMs or the materials to non–diplomats because we are in the business of certifying family physicians. We have made it available to audiences that include family physicians plus other allied health personnel.
Gilmore: Could you also, Dr. Hagen, address the question of how often recertification is required, specifically for the ABFM?
Hagen: Sure. The ABFM, which became a specialty in 1969, for historical perspective, was actually the first specialty board to require periodic recertification so we have never had permanent certificates. Our diplomats have always had to recertify every 6–7 years. When we went to Maintenance of Certification, that process now extends to 7–10 years, depending on an individual diplomat’s requirements. Most people choose the 10–year path, which involves three 3–year stages. In each stage, the diplomat has to complete the two self–assessment modules and a Part IV activity, and then they take their examination usually in the 9th or 10th year, but actually they can take it anytime in that 10–year run that they feel it’s most appropriate for them. Some folks for specific reasons choose to recertify at the 7th year, but these are usually folks who have military obligations, know they are going to be out of the country, or are missionaries who know that they will not be in the country to examine in their 9th or 10th year, but the vast majority of individuals are on the 10–year track. This varies by specialty. A lot of the other specialties have more frequent recertification requirements. I don’t think any of them have anything longer than a 10–year interval, but a number of them have 5–year intervals, I think OB/GYN, in particular. So, it does vary by specialty, but for family medicine, it is 7–10 years.
Gilmore: One more follow–up question before a couple of clinical questions that have come in. How can people access the self–assessment modules for asthma? Are they something people can do online, do they have to find a group, what are their options?
Hagen: Currently, the SAMs themselves are only available to diplomats of the board—that is, family physicians that are certified. Having said that, we do have a number of tools and modes of access available to support group SAM activities like the one that Dr. Elward has put together, and we do have a contact person at the ABFM that can walk people through that process. Her name is Ashley Webb. Her email is: firstname.lastname@example.org. She is the head of our support center, and we have put together a set of tools to facilitate the conduct of group SAM activities by state chapters or other organizations that want to engage in this kind of activity. She is the contact person for that.
Gilmore: Thank you, Dr. Hagen.
Elward: I’d be happy to talk with anyone about how we’ve done this. The feedback about how we’ve done it in the four states has been very positive. I’d be very happy to work with you all on the technical or the process aspects of what we do in Virginia as well.
Gilmore: We have a few final, clinical questions that have come in. Dr. Elward, the first question is about oral theophylline. For those who are non–adherent or have no prescription coverage, is theophylline easier to adhere to and cheaper than other long–term asthma mediation. What are your thoughts?
Elward: The question is about oral theophylline for those who are non–adherent or with no prescription coverage. Would taking one theophylline pill a day be easier for adherence? Unfortunately, with the costs of some of the medications, there are some people who need their asthma management the old–fashioned way. There are risks for theophylline treatment. I have given my share of intravenous theophylline treatment in my time as a resident, that probably dates me somewhat, but I would say the problems with adherence to theophylline are also not small. The people who are adherent, then non–adherent, and then decide to go back on theophylline to sort of catch up can overdose. I think there are situations, probably under a specialist’s guidance, where that medication would be appropriate. I think with the development of generic montelukast, there will be a refreshing drop in some of the prices of treatment. I would say that, yes, that is a possibility, although it wouldn’t be my first choice still, but at the same time, some people can’t handle $100–$120 for inhaled medication, so it really puts the asthma patients in a very tough situation, and their clinicians as well.
Gilmore: The second clinical question is about the use of exhaled nitrous oxide. Is the use of nitrous oxide device useful to gauge success of inhaled cortiosteroids? Is Omalizumab (marketed as Xolair) helpful and how often is it used?
Elward: I am not as familiar with the use of nitrous oxide devices to gauge the success of inhaled steroids, so I would probably defer to people who use it more often. There was a lot of enthusiasm about this several years ago, and the enthusiasm has dropped off somewhat and they are not being widely used. There is a role to use that if you are assuring that you’re getting good compliance with the inhaled steroids. Assuming that you’ve documented that, I think there is a role to consider in using the nitrous oxide device to see how well they are doing. That is usually done in a specialist environment.
Xolair is very helpful. Xolair is not commonly used and is very expensive, at least $1,200–$1,800 a month. It has been shown to decrease the use of both inhaled steroids and systemic steroids; it will not eliminate their use, but often it will decrease it. Treatment with Xolair has its own risks. It is an anti–IgG antibody, it is based on that mode of treatment and in the context of a specialist that can be very helpful. Primary care clinicians will very rarely feel comfortable using it, and the insurance preauthorization is pretty intimidating. On the other hand, Xolair can be very helpful for people with severe asthma that is not responding to standard treatment or that needs very high doses of steroids. It definitely plays a role, and it is nice to have it in the asthma armamentarium, but I think its use is rare and it has to have a certain protocol developed to decide who the best candidate is.
Gilmore: Before we wrap up the questions, do any of our three speakers have anything they would like to add or say or additional tools or things that you’d like to share with us?
Hagen: Not here.
Elward: It really has been a pleasure to be part of this initiative and really see the broad variety of activities and initiatives that people are using to get the asthma guidelines out. I think there is an opportunity perhaps for different groups to collaborate and bring each of their strengths to the table in terms of bringing better care to asthma patients.
Gilmore: Thank you to you both. We will provide the audience listening today a follow–up email with both the link to a feedback form where we would very much appreciate your feedback on this webinar because it helps us in planning future webinars. We will also provide the links and the email addresses of Dr. Hagen, Dr. Elward, and Ashley Webb, along with the links to the National Asthma Control Initiative and the National Asthma Education and Prevention Program as well.
Tracy: This is Rachael from the NHLBI, and I just wanted to echo Dr. Elward’s sentiments here. We feel the same way. We highly appreciate presenters from our various NACI project and partners and our NAEPP partners that are able to help conduct these webinars and share their valuable expertise and we were especially excited for this one because we had not had a webinar that particularly focused on clinicians and treatment necessarily from the Maintenance and Certification standpoint. We hope that the information that was shared today is helpful for those who were able to join the webinar, and if you have any suggestions for future topics, again, you will have an opportunity to provide feedback about that in our follow–up e–mail that will come out shortly. We’d like to thank everyone for joining the webinar.
Gilmore: This is Lisa. Again, thank you Rachael and Dr. Hagen and Dr. Elward, and I’d like to thank my colleagues here Kate Fink and Gabriela Duran for their invaluable assistance. With that, we will close. We will be sending you all a follow–up email shortly with additional information from this webinar and a request to fill out a feedback form so we can continue to provide the best webinars possible. Thank you.
(End of webinar)
Last Updated December 2012