Transcription of NAEPP Webinar: Regional Perspectives on Educating Diverse Communities about Asthma
May 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 NHLBI, the National Institutes of Health, or the U.S. Department of Health and Human Services.
To help bridge the disparity gap in asthma care and outcomes, this webinar, hosted by the National Asthma Education and Prevention Program (NAEPP), coordinated by the NHLBI, focuses on the importance of using tailored approaches for asthma education that take into account regional and population differences and other factors that can influence help–seeking and self–management behaviors. The webinar includes an overview by Dr. James P. Kiley, director of the Division of Lung Diseases, NHLBI, and a panel discussion moderated by Dr. Michael LeNoir, National Medical Association representative to the NAEPP. The four panelists are Michelle M. Cloutier, M.D., Connecticut Children ’s Medical Center; Michael Cabana, M.D., M.P.H., University of California, San Francisco; Michael B. Foggs, M.D., Advocate Health Centers, Chicago, IL; and Leroy Graham, M.D., Not One More Life, Atlanta, GA.
Gilmore: My name is Lisa Gilmore. Welcome to Regional Perspectives on Educating Diverse Communities About Asthma, a webinar presented by the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH). Last Tuesday, May 1, was World Asthma Day, and May is Asthma Awareness Month. The NAEPP and its partners are encouraging everyone to get involved in helping Americans breathe easier. For helpful resources that you can download, visit the NAEPP’s National Asthma Control Initiative (NACI) Web site. And while you are there, sign up for the NACI In the Know eNewsletter to learn more about how to improve asthma control and reduce asthma disparities during Asthma Awareness Month and beyond.
In addition to hearing from our presenter and four panelists today, you will have the opportunity to pose questions to the panel for discussion at the end of the program. Now I am pleased to present our moderator for today’s webinar, Dr. Michael LeNoir. Dr. LeNoir is a practicing consulting allergist and pediatrician from Oakland, CA; National Medical Association (NMA) representative to the NAEPP Coordinating Committee; and head of the NMA Allergy and Asthma Rescue Project, a Strategic Partner in the NAEPP’s National Asthma Control Initiative. Over to you, Dr. LeNoir.
LeNoir: One in 12 Americans has asthma, a chronic disorder of the airways—25 million people and that number is growing. For the past 22 years, the National Asthma Education and Prevention Program and its member organizations have raised awareness about asthma and provided evidence–based clinical practice guidelines for asthma care and control. However, gaps in implementing these guidelines and other factors have led to significant disparities among racial and ethnic minority populations in asthma morbidity and mortality.
Today’s webinar will begin with an overview of asthma disparities from the national perspective with Dr. James Kiley of the National Heart, Lung, and Blood Institute. I will then moderate a panel discussion with asthma experts from the eastern, western, mid–western, and southern regions of the country, who will offer their unique perspectives on the problem and what to do about it. At the end of the webinar, you’ll have the opportunity to hear the panel’s responses to some of your questions. You can type in your questions at anytime using the questions box on your screen, but we will hold these questions until the end of the webinar. It is now my distinct pleasure to introduce Dr. James Kiley. Dr. Kiley is the director of the Division of Lung Diseases at the NHLBI at NIH. He received his M.S. and Ph.D. degrees from Kansas State University. Dr. Kiley is the author or coauthor of numerous scientific publications and abstracts on asthma and other pulmonary research. Dr. Kiley, please proceed.
Kiley: Thank you very much, Dr. LeNoir. It’s really a pleasure for me to join you today in recognition of May as National Asthma Awareness Month. As Lisa mentioned in her introduction, I think we are all here today because we are committed to improving the lives of those who have asthma and their families. We should feel really good about the accomplishments that we have made over the last 20 years. Since the NAEPP was launched, we have become much better at detecting and diagnosing asthma and have seen asthma deaths fall by over a third. We have fewer hospitalizations for most age groups and fewer emergency department visits and lost school or workdays. And, in just five years, we have emphasized the importance of action plans for asthma and about one third of patients have one.
This is a mostly positive outlook from where we have been and shows progress in improving asthma control, but clearly there is a lot more we need to do. We still see some of the trouble spots— that is, asthma disparity persists. And the difference in asthma prevalence between ethnic groups is striking. Even more striking is that the disparities for the more severe outcomes—emergency department visits, hospitalizations, and deaths—are even greater. So disparities exist for the more severe outcomes. So, it’s pretty clear that the minority children have higher rates of asthma and for those who do, studies consistently show that African Americans and Hispanic children are less likely to be prescribed, or to take, the recommended treatments.
The problem we are faced with right now, even with good news on the national front with the statistics, is that this gap exists in terms of disparities in overall asthma control. There are a number of barriers that stand in the way of achieving asthma control, particularly in minority populations. Clearly, there is a lack of clinicians providing quality comprehensive care. We need to educate the clinician community to a greater degree to be certain that the tools, skills, and concepts are up to date for dealing with asthma based on today’s evidence. There is a lack of access to affordable asthma medication, and that’s clearly a barrier. Another barrier is the lack of education or use of self–management skills. Finally, the exposures to various allergens, irritants, and pollutants. There are plenty of barriers, and you’ll hear about some of those today, but we need to make sure those barriers do not stand in the way of controlling asthma, particularly in minority populations.
Now, at the same time we are trying to identify the barriers and the important aspects of where the gap may exist, I wanted to touch on a little bit of how national–level programs help address these barriers. First, most people know that the National Institutes of Health and many other federal agencies stimulate and support research to improve asthma management and identify optimal treatments. As part of our mission, we developed guidelines with the community through the National Asthma Education and Prevention Program, and that’s geared towards translating the science of asthma and recommendations to improve clinical practice. A dynamic cycle exists in how these guidelines are capturing the evidence and how that evidence is informing the guidelines. As we gain experience implementing them in practice, we learn about gaps in the evidence and the pressing questions that need further investigation. Then the clinical trials that are ongoing, whether through our asthma networks or other means, focus on answering those questions to inform future practice. It’s a cyclical process, and one that builds on itself so that we continuously evaluate where we are and where we have been, and then identify and obtain evidence to fill gaps where the evidence is missing.
At the same time, the National Heart, Lung, and Blood Institute supports numerous demonstration and education research programs to find innovative ways to educate minority and ethnically diverse populations about asthma management. Many of these evidence–based programs have been packaged by our partners—the CDC, the EPA, and other groups such as the American Lung Association, the Asthma and Allergy Foundation of America, and the Allergy and Asthma Network Mothers of Asthmatics. These are all groups that have taken our materials and repackaged them in their own way so that they can disseminate information widely across the country.
The NAEPP guidelines and the educational programs have led to numerous federal activities, all aimed at addressing the barriers to asthma care and control by improving implementation of evidence–based practices for clinicians and patients of different age ranges and diverse racial and ethnic backgrounds.
These different programs all are fostering partnerships at the regional and state level and even local community levels. And, these partnerships with professional societies and patients and private organizations are having an enormous impact on helping to not only deliver the messages and get the information to the individuals and the payers and providers that need it, but also to coordinate activities across these different federal efforts.
Now, some of you may know that over the past year and a half or so, the Asthma Disparities Working Group under the President’s Task Force on Environmental Health Risks and Safety Risks to Children has been in the process of developing a Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities. This grew out of an increasing recognition that as wonderful as the separate programs are across the federal agencies, some of which I just referenced a minute ago, we are not having the collective impact that we would like and that we really need. So we think the federal programs need to get together, learn from each other ’s experiences, and focus in a coordinated and collaborative way on this issue. And we have just developed a draft plan that highlights four key strategies. These strategies focus on collaborating so we can maximize our results and get the right care to the right children with the right community support to help them. The four strategies are to 1) remove barriers to the delivery of guidelines–based asthma care, 2) build local capacity to deliver integrated community–based care, 3) improve capacity to identify those most in need, and 4) accelerate the efforts to prevent the onset of asthma.
What all this really comes down to is that there are many efforts underway that are facilitated by the national program, and they are all taking evidence and trying to capture that evidence and translate that evidence into messages. And most of that is developed with national–level expertise, but it is critical that that expertise also be supported at the regional and local level.
So what you see here is the national level of research that is translated into clinical practices, and it needs to be implemented at the state and local level in targeted programs that can be used to focus on diverse communities. It’s really getting the care to the patient at the regional and local level that is the critical need, and it’s how we will be successful. We really need to work together, and I’m quite excited about participating in this webinar today as it introduces you to national practices for asthma care to meet the needs of particular communities, to educate diverse communities about asthma. I thank you for your attention, and I’ll turn this back over to Dr. LeNoir.
LeNoir: Thank you, Dr. Kiley, for your presentation. Next, our distinguished panel of asthma experts will share their thoughts on addressing asthma disparities from a regional perspective. I will ask the first question, and each panelist will have up to five minutes to respond. Time permitting, I will then ask a couple of additional questions of the panelists, and they will each have two to three minutes for their responses. We will leave time at the end of the webinar to address your questions to the panel. We invite you to type in your questions at any time using the questions box on your screen. We will hold these questions until the end of the webinar.
I’d like to introduce our four panel presenters:
First, Michelle M. Cloutier, M.D. Dr. Cloutier is a pediatric pulmonologist from the Asthma Center at the Connecticut Children’s Medical Center in Hartford, CT.
Second, Michael Cabana, M.D., M.P.H. Dr. Cabana is the chief of the Division of General Pediatrics at the University of California in San Francisco.
Third, Michael B. Foggs, M.D. Dr. Foggs is the Chief of Asthma, Allergy, and Immunology for Advocate Health Centers in Chicago, IL, and immediate past chair of the National Medical Association’s Allergy and Asthma Immunology section.
Finally, Leroy Graham, M.D. Dr. Graham is a pediatric pulmonologist at the Georgia Pediatric Pulmonology Associates in Atlanta and founder and medical director of Not One More Life, a faith–based asthma initiative.
I’d like to begin our discussion with our very first question to Dr. Cloutier, and then in order, Dr. Cabana, Dr. Foggs, and Dr. Graham. What is your perspective on asthma disparities in your region and what actions are needed to address the problem?
Cloutier: Thank you, Dr. LeNoir. I’m specifically going to talk about New England, then Connecticut (CT), and then specifically about Hartford, CT, and what we have been doing. Now, New England has the highest prevalence of asthma in the United States. The reasons for that are not totally clear, but we know that climate dampness, dust mite proliferation, the high population density in CT, and the many urban areas with lower housing quality appear to contribute to this prevalence of asthma.
We run a program here in CT called Easy Breathing that aids clinicians in diagnosing asthma, determining asthma severity, and placing children on the right therapy for their asthma. Currently, there are 106,000 children in CT that are enrolled in this program. To no one’s surprise, as we move from the wealthy area into the urban core, we see that asthma frequency increases with lower socioeconomic status across all ethnic groups. Connecticut has been divided into five socioeconomic groups—namely, wealthy, rural, suburban, urban periphery, and urban core. We also see that asthma severity increases with lower socioeconomic status. If we look at asthma severity, the percentage of children who have intermittent asthma decreases as you move from the wealthy to the urban core, while the percentage that have persistent asthma increases. And that certainly is not a surprise to anyone on this webinar.
However, what is very interesting is when we look at persistent asthma by ethnicity. African–American children have high rates of asthma, but what is striking is that it is high across all of the different areas of the state, including rural, suburban, and urban areas. Our Hispanic children also demonstrate a very high rate of persistent disease, but asthma rates in the urban periphery and urban core are much higher among Hispanic children than among African-American children. In wealthy areas of the state, however, asthma prevalence among Hispanic and Caucasian children is relatively similar. Note that no comparable data for African-American children in wealthy areas are available. The benefit of the Easy Breathing program is to remember that everyone, whether in urban areas or in other communities, is diagnosing asthma in the same way, and they are determining asthma severity also in the same way, so we are able to look across this wide range of socioeconomic groups.
In CT, African–American children, as part of our program, undergo allergy skin tests. Eighty percent of all of our children in CT have a positive allergy skin test to one or more environmental allergens. It is remarkable that African–American children with asthma in CT are more likely to be sensitized to outdoor allergens, that is, to grasses and trees, while Hispanic children—which in our community is primarily Puerto Rico children with asthma—are more likely to be sensitized to indoor allergens. In addition, environmental tobacco smoke exposures are twice the rate in the urban areas than in the suburban areas. We believe that all three of these factors offer opportunities for intervention.
If we now turn out attention to health care utilization in CT statewide, the rates of children who are hospitalized or have emergency department visits for asthma are relatively low. This is in contrast to rates in Hartford, which are extremely high. Now, Hartford is the second poorest medium–sized city in the United States, for those of you aren’t familiar with Hartford, and it’s situated in the second richest state in the United States. So Hartford residents’ incomes are decreasing while state residents’ incomes are increasing. Thus, there is a growing disparity.
If we look at the impact of asthma on emergency department visits, we also see differences by ethnicity. And we see that rates of emergency department (ED) visits, now controlling for severity, are higher in Hispanic, primarily Puerto Rican, children than in Black, primarily African–American, children, and there was a significant decrease of about 31% in ED rates for Hispanic children in our Easy Breathing program.
Rates of hospitalization for asthma before entry into the Easy Breathing program for our Black and Hispanic children were very high, and they decreased after implementation of the program in both Black and Hispanic children by about 35%. This decrease has been sustained now for 14 years.
So what contributes to the differences in the baseline and program results? ED visits, at least in Hartford, are higher for Hispanic children than for African–American children. When we pursued the reason for these high ED visits in our Hispanic community, again primarily Puerto Rican, the theme that came up every time, in every focus group—the first theme, the most important theme—was the perception of death. The reason our Hispanic families bring their children to the emergency room is they are afraid their children are going to die, either because they have known someone who has died from asthma or they have known someone who they perceived as having a life–threatening asthma attack. Hospitalization rates, however, are higher and the stays are longer for African–American children than for Hispanic children in Hartford. And their pattern is different because what they tell us, or what we have found, is these children are sicker when coming to the ED. Our African–American community is under–accessing the emergency room and when they come in, they are much sicker. And then, finally, for all of the children in our program, regardless of ethnicity, they fill their asthma prescriptions less than one third of the time, and this is a major barrier as well as an opportunity for us. I’ll end there, thank you very much.
LeNoir: Thank you, Dr. Cloutier. Now I’ll go to Dr. Cabana, who is in the western region. Dr. Cabana is Chief of the Division of General Pediatrics in the University of California, San Francisco. Dr. Cabana.
Cabana: Thanks for the opportunity to speak. Much of the data that I’ll present comes from a report called the Burden of Asthma in California, which was a surveillance report published in 2007. UCSF is located in San Francisco, and the San Francisco Bay area has a very diverse pediatric population. Different parts of the city serve different populations. There is a very large Hispanic and Asian community here in San Francisco and a large African–American population across the Bay. It is also a city where there are different levels of affluence among the different counties—Marin County here in the East Bay and then different parts of San Francisco as well. There is great diversity in terms of the ethnicity, the different cultures, and the different levels of affluence. Also, approximately one third of San Francisco residents were born outside the United States; in many ways, it is a gateway city for many immigrant populations. So there are many challenges in serving this community here in California and many disparities.
One of the figures from the Burden of Asthma in California report shows various measures of asthma by race and ethnicity as a ratio in comparison with the same measures for Blacks. For Blacks or African Americans, the ratio is set at one. Blacks have a higher rate of lifetime asthma prevalence compared with Whites, Hispanics, Asians, and Pacific Islanders, but Native Americans have the highest lifetime prevalence here in California. In terms of emergency department visits for asthma, African Americans have the highest ratio compared with other groups. In terms of hospitalizations for asthma, African Americans again have the highest ratio. And in terms of asthma mortality, there are disparities as well.
There are many different ways to address these disparities. Through the NAEPP’s National Asthma Control Initiative, we started the Bay Area Asthma Champions program in coordination with the Regional Asthma Management and Prevention Program (RAMP), located in Oakland. In Dr. Kiley’s presentation, he talked about different ways you can address the issues, whether it is access to medication, controlling the environment, improving patient self–management, or working with providers. The Bay Area Asthma Champions Program focuses on providers. Also, Dr. Kiley talked about local, regional, or wider interventions. Our program is pretty much a local initiative focused on providers. We are actually using principles of academic detailing to use our resources to visit providers to develop a cohort of asthma champions in some key practices throughout the Bay Area. When we visit these asthma champions, we promote the six key Guidelines Implementation Panel, or GIP, messages based on the asthma guidelines to address some of these issues. But we also try to improve awareness of some of these disparities and give clinicians tools to address some of them.
We worked with Lee Pachter, D.O., formerly from CT, who worked with Michelle Cloutier; and with Sande O. Okelo, M.D., Ph.D., from Johns Hopkins, who provided consultation on developing some techniques or teaching some techniques to providers. In our presentation, we talk about the Awareness–Assessment–Negotiation technique. This starts when you look at what the provider has to do or deal with. Health care providers need to become aware of commonly held beliefs in the community. Then when they meet a specific family, it is important that they approach them with an open mind and assess whether the patient applies or adheres to these culturally oriented beliefs.
One of the techniques to assess whether the patient adheres to the culturally oriented beliefs that we discuss is taking a health beliefs history and, based on that, negotiating and potentially integrating practices that might be consistent with what the provider wants to do or thinks needs to happen. Or, if there is a conflict, health care providers can negotiate with folks and focus on higher priorities. So this Awareness–Assessment–Negotiation technique means the provider needs to be aware of the commonly held beliefs of the patients they serve and to recognize that these community beliefs might not apply to all patients just because they happen to be in a specific demographic.
The health beliefs history includes some general questions that allow providers to assess whether these beliefs apply to specific patients. They start out with very nonjudgmental open–ended questions, such as, “What do you think is wrong? Why do you think you have this illness? What do you think caused it? What do you think started it when it did?” And it helps open up a dialogue.
In summary, to address the needs of diverse populations in the Bay Area, we developed the Bay Area Asthma Champions program, and we relied on a lot of the wonderful resources that others have developed from across the country. We think using this technique is helpful as a general approach at the provider and local level. There are three advantages here. Number one, any given provider is going to have to deal with multiple cultures and multiple groups, so having an approach to handling this diversity allows providers to be flexible. It’s not just memorizing specific behaviors that are associated with specific groups. Two, it avoids stereotyping. And three, it promotes communication to help address different beliefs about asthma. Open communication in addressing different beliefs about asthma might help mitigate some of the disparities as well. Thank you.
LeNoir: Dr. Cabana, how many outside physicians have been designated asthma champions in your area?
Cabana: So far, we have found 23 practices. I think 26 practices initially signed up. We are planning on visiting approximately 23 practices, and hopefully, it will have a snowball effect.
LeNoir: Alright, thank you very much. At this time, we will get a response from Dr. Michael Foggs.
Foggs: Thank you, Dr. LeNoir. Now, we are facing what I call an asthma paradox. We have the most sophisticated knowledge about the immunopathogenesis of asthma, coupled with the best pharmacologic therapeutic interventions within our armamentarium for treating asthma. But despite this fact, certain ethnic groups in America have had no substantial improvement in asthma morbidity and very little improvement in asthma mortality if you use the definition of success as zero asthma mortality, which is what we tend to do within our circles. If you look at the latest data from the National Center for Health Statistics, you can see that there are discrepancies in asthma morbidity as defined by hospital discharges with asthma as the first listed diagnosis per 10,000 population.
Beginning in 2000, there has been a conspicuous improvement in asthma morbidity overall as related to first–listed hospital discharge, according to the National Center for Health Statistics. The data are problematic, however, because at the same time, the number of first–listed hospital discharges for asthma not reporting race increased dramatically. There has been no explanation for this particular pattern, which was first thought to be an artifact but after successive years of ongoing discrepancy between the data for African Americans, Caucasians, and other minorities on a national scale, this indeed is problematic.
In Chicago, it’s been known for a long time that there is a discrepancy in asthma morbidity and mortality for African Americans in comparison with other groups with perhaps other geographic domains—the Puerto Rican population, as a subset of the Hispanic/Latino population, being outliers. Chicago has for a long time been uniquely identified as a city that is not conducive to good asthma control by virtue of a variety of meteorological influences. These meteorological influences are coupled with typical findings of urban life, including high pollution indices and high crime rates, in that we now know that violence is considered to be a potentially modifiable risk factor for increased asthma morbidity and mortality.
Another interesting point is that African–American asthma mortality in Chicago is different from other areas based upon statistics that have been measured from 2000 to 2010. That’s one of the reasons we think that African Americans and Puerto Ricans with asthma, as well as women who have asthma, and in particular, minority women, should have aggressive management of asthma. They are likely to benefit from it not only from the standpoint of aggressive anti–inflammatory pharmacological interventions, but also from the standpoint of aggressive ongoing asthma education, aggressive implementation of self–efficacy teaching of self–management techniques, and expedient referral to an asthma specialist. That is not taking place in Chicago and many other urban areas.
One of the reasons asthma is problematic in America, especially in urban populations and especially among African Americans, is because there may be a difference in immunologic expression of asthma on the basis of the immunologic profile being differentially responsive to corticosteroids. A brief, very important preclinical study from National Jewish Health demonstrated that there is indeed a discrepancy in the corticosteroid response between Blacks and Whites, even among those who don’t have asthma. In this particular study, they looked at T–lymphocytes that had been activated via mitogenic stimulation, and they determined what the log concentration of dexamethasone was needed to suppress T–lymphocyte activation. What they determined was that a discrepancy existed between African Americans and Whites, even those African Americans who did not have asthma. This suggests that a more robust inflammatory process may be operative, which is, in fact, partially refractory to the gold standard for treating chronic persistent asthma, namely, inhaled corticosteroids.
So that raises a philosophical question from the standpoint of treatment of asthma. Is it important to assess airway remodeling to the extent possible to guide asthma therapy or should we be content with simply suppressing expression of the disease instead of attacking the pathophysiology of the disease? Certainly, we want to neutralize asthma symptomatology, but asthma is episodically expressive from the standpoint of deterioration in the form of wheezing, chest tightness, coughing, and breathlessness, and the mindset of many urban patients with asthma is that asthma is an event, not a chronic lung disease. Therefore, they respond to the event and they are not treating their disease; and it is not their fault completely because in some cases, their providers have a similar mindset.
It is very important to control bronchospastic events of the airways, not only from the standpoint of improving the patient’s quality of life, and decreasing morbidity and the likelihood of mortality in association with an exacerbation of asthma, but also it is very important from the standpoint of inhibiting premature loss of lung function. A study by Grainge reported in the New England Journal of Medicine last year [Grainge CL et al. Effect of bronchoconstriction on airway remodeling in asthma. N Engl J Med. 2011 May 26;364(21):2006–15] demonstrated that airway remodeling, contrary to what we have been taught for decades, is not simply a by–product of an inflammatory insult in association with eosinophils still considered to be the primary inflammatory infector cell associated with the expression of inflammatory asthma. But instead, in conjunction with inflammation and independent of inflammation, compressive mechanical injury to the airways in the form of bronchospasm is associated with morphologic change of the airways that characterizes airway remodeling.
This particular study also demonstrates that one of the mediators associated with airway remodeling with morphological change of the airways, namely epithelial release of transforming growth factor beta, is indistinguishable from a statistically significant standpoint from that of allergen induction with dust mites. By the same token, there is virtually identical increased thickness of the sub–basement membrane via collagen deposition after methacholine challenge, a non–inflammatory insult to the airways.
LeNoir: Dr. Foggs, are you saying that inflammation is not the only factor in the development of airway remodeling?
Foggs: That is correct. This landmark study published in the New England Journal of Medicine just last year clearly demonstrated not in vitro only but also in vivo via trans–bronchial biopsies and monitoring of a variety of pro–inflammatory mediators that methacholine challenge can induce airway remodeling. It shows that airways lability is associated with airway remodeling. A comparison of the respiratory epithelium before and four days after a methacholine bronchoprovocation in the absence of any antigenic stimulation, shows that the sub–basement membrane (the structure under the layer of epithelial cells) is much thicker after a methacholine bronchoprovocation. And, very importantly, you can see using a periodic acid–Schiff stain showing the goblet cells, that there has been goblet cell hyperplasia in addition to sub–basement membrane thickening after methacholine challenge: a non–inflammatory stimulus.
And this is very important because we know from the classic FACET [Formoterol and Corticosteroids Establishing Therapy] study [Tattersfield AE et al. Exacerbations of asthma: a descriptive study of 425 severe exacerbations. The FACET International Study Group. Am J Respir Crit Care Med. 1999 Aug;160(2):594–9] that by monitoring morning and evening peak expiratory flows and day and night asthma symptom scores that we can identify a window of opportunity for identifying an asthma exacerbation. This window of opportunity is very important because we know that if a person intervenes 5 to 10 days prior to a major asthma exacerbation by virtue of paying attention to the symptomatology and objectively assessing lung function at home via home monitoring that, in these individuals, there can be a forestalling of an asthma exacerbation [Bjermer, L and Diamant Z. Complementary therapy in asthma: inhaled corticosteroids and what? Curr Opin Pulm Med. 2009 Jan;15(1):46–51]. This is very important because by forestalling the asthma exacerbation and decreasing the amount of bronchoconstriction, you can improve outcomes not only from the standpoint of attenuation of the inflammatory foci, but from the standpoint of reducing compressive mechanical forces that are known to be conducive to airways remodeling.
So what this shows is that suppressing inflammation alone is insufficient for the management of asthma.
Our aim is that we don’t get airway remodeling associated with poorly controlled chronic asthma and instead, preserve lung function. If we are talking about intervening in the African–American community, we have to start looking at Vitamin D levels. We know that African–Americans have profoundly lower Vitamin D levels than Caucasians. This has been demonstrated in many geographic locations throughout the world, including America. Observational studies have shown that Vitamin D insufficiency and deficiency is associated with decreased lung function and increased airways responsiveness and bronchoconstriction. By extrapolation, one can conclude potentially loss of lung function prematurely. Thank you.
LeNoir: Thank you, Dr. Foggs, and we will come back to that a little later since many of you might have questions. Next, Dr. LeRoy Graham is a pediatric pulmonologist at the Georgia Pediatric Pulmonology Associates in Atlanta, Georgia, and founder and medical director of Not One More Life (www.notonemorelife.org), a faith–based asthma initiative. Dr. Graham.
Graham: Well, thank you, Mike. Just to give you an orientation to what we are doing in the South, the region appears to have lower asthma prevalence, and I would say that is indeed true from an overall look. Data here in Georgia suggests that if you look at the Atlanta metro area, we look very much like the urban centers that some of my previous colleagues discussed. For instance, here in Atlanta and Georgia, the asthma prevalence rate among children is about 12%. If you look at African Americans statewide, it is about 13.5%. If you look at those in the six or seven metro Atlanta counties, which now measure about 6–7 million people, we see an asthma prevalence rate of about 17% among African–American children.
We also see the same disparities that many people have spoken of. Looking at the Georgia statistical set from 2010, we have the asthma prevalence I discussed, but if we look at children with asthma and just the disease burden, we find that 38% of children with asthma in the state of Georgia had an asthma attack within that year compared with about 14% of Caucasian children with asthma. If we look at other disease burden classes, we find that in Georgia, children in general are more likely to use the emergency department, with about 1,428 asthma–related ED visits for children ages 0 to 4 per 100,000 patient population versus an overall age–adjusted rate of ED visits due to asthma of 560 per 100,000 persons in Georgia.
So in Georgia, and specifically in Atlanta, we have a very good snapshot of disparities not only for people of color but also for children. As a pediatric pulmonologist, I obviously have a bias there.
If you look at the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample database from children’s hospitals across the country, asthma remains the single most common diagnostic code for admission from the emergency room to the hospital in the United States. Obviously, there are many omissions there but if you look at single diagnostic codes, that is what falls out.
Here in Atlanta, this was brought to our attention somewhat pointedly this past fall. We had a cluster of about five pediatric asthma deaths. These occurred from about early October to mid November. It appeared to correlate, without any of implication of causality, with the peak of what was a very virulent RSV [respiratory syncytial virus] season. Most of us on this call know that the primary trigger for children having exacerbations is often current viral illness. We are doing a root cause analysis with Children’s Healthcare of Atlanta and several community organizations and other organizations, but some preliminary data show that 4 out of 5 of these pediatric asthma deaths were African–American children. Only one child had an asthma action plan. Two of the five children remarkably had no formal diagnosis of asthma though they had been prescribed asthma medications. We found that only two of these children had ever had spirometry.
That takes me to another point. I think Mike [Foggs] brought up this issue of lability, and certainly, this can be appreciated in a clinical context. But the need for more spirometric measurement in primary care is a huge issue and clearly an under–met need. If you look across data just looking at spirometry in practices, our family practice colleagues approach 40%, and depending on the study, pediatric and internal medicine may be somewhere between 20–30%, regardless of how it is used, just using it as a clinical tool in practice.
Outside of my clinical practice, I’m the founder of Not One More Life, Incorporated. We are not a faith–based organization but a not–for–profit organization that partners with communities of faith to deliver free programs related to asthma and, increasingly other lung disease, specifically COPD [chronic obstructive pulmonary disease]. We start with education, then screening both by symptom assessment by using a validated metric and by spirometry to ATS [American Thoracic Society] standards by certified respiratory therapists. The participants then move on to the next station, which is sitting with a physician or mid–level practitioner, like a physician assistant, to discuss the results of their symptom assessment, also the demographic data they gave as to diagnosis, comorbidities, and things like that, and then their lung function. From that information, they are told whether or not there is an issue. Basically, what we do is educate a patient on the spot, but more important, we do outcome monitoring at 1, 3, 6, and 12 months, at which times we do a needs assessment and we do an assessment of utilization post our intervention. We also look at needs and resources and ability to give patients medication.
Since our inception, we have screened just under 6,000 participants here in Atlanta. And to give you some of the data, we find that 51% of patients that attend our program either have abnormal symptom scores and/or manifestly abnormal lung function as shown by spirometry. Yet in that population, only 25% report an actual diagnosis of underlying lung disease; the majority (22%) cite an asthma diagnosis. If you drill down just in this population of those who admit they have been given a diagnosis of asthma, we find that 38% are on no medication at all. That means no albuterol and no controller medication. We find that 23% of them have been admitted to the hospital for asthma, but only 21% are on an inhaled corticosteroid. Inhaled corticosteroids are arguably, the single best treatment, at least as a start, to control the underlying inflammation. So I think that in Not One More Life initiative, we see this incredible snapshot among people that are drawn to us by the fact we are using a validated community partner.
I look at Dr. Kiley’s presentation, which was excellent, and the interplay between the various surveillance and interventional studies. Not a criticism, but an acknowledged fact, is that many of these studies suffer from under–representation, both in terms of minority participants and minority investigators. We still deal in 2012, unfortunately, with the stigma of things like Tuskegee and so forth. I am quite sure, as I know many of the members on the NHLBI’s AsthmaNet and Severe Asthma Research Program network, and certainly the NIH, that these biases do not exist. However, the sequelae, the resonance of them do.
So, in the Not One More Life initiative, we have a program that goes down on their turf, partnering with a validated asset in their community known to be a safe harbor. It’s no surprise that I started this in the South where, before integration, there was no social safety net for African Americans, and the church was indeed that social safety net and continues to be that for many people. It’s a place of validated trust. So what we are doing in the Not One More Life initiative now, and I can’t say that we have nailed it, but I can say that 90% of the people that have abnormal lung function do, in fact, have a regularly scheduled visit with a respiratory–focused plan within three months of seeing our program. We are now looking at similar robust metrics looking at utilization, and the data are very promising. But everything Dr. Kiley said is still true. We have not enjoyed the dividend of evidence–based management among our minority populations.
Previously mention was made of the importance of communication in asthma care, and the Physician Asthma Care Education (PACE) program, which was started by a former partner of mine, Randy Brown [Dr. Randell Brown], emphasizes that. And I think that goes to the issue that we have to find enhanced tools for communication, enhanced tools for education. We talk a lot about whether or not these are culturally fair or culturally relevant. My experience, and some authors are starting to write this, is our minority populations don’t necessarily want you to have the dialectic to talk to them, but they want to see your heart. They want to see that you’re sincere. They want to see straight talk. Talk to, not talk down to. I teach medical students, residents, and fellows, that simple things like getting people to come into a room and sit down and be on eye level with the patient, asking questions that go to not just why they are there but how they are doing, and implicating different measures of establishing trust are key.
If you look at those deaths that we discussed, they are emblematic. I know every pediatrician that managed each of these children. They are very good pediatricians, but things were missing: a lack of spirometric assessment or a lack of an asthma action plan. So what we do in the Not One More Life initiative, in addition to our patient program, is offer continuing medical education (CME) for providers dealing with high–risk populations.
I think the future is bright. There is much to be done—everyone has stated the problem. I am very privileged to be here. I do have a slightly different bend from being ground level with a community–based approach. Thank you.
LeNoir: In the interest of time, I’m going to modify our protocol just a bit, by getting two answers from Dr. Foggs. Since we have gotten good responses from Dr. Cloutier and Dr. Cabana about what their leverage points are, I’m going to ask them to answer the third question while I ask Dr. Foggs and Dr. Graham to answer the second question.
For Dr. Foggs, what are the leverage points to close the asthma disparity gaps? In addition, what specific interventions can be used to take advantage of these opportunities at the system level?
Foggs: Well, there has to be some form of behavior modification at the institutional level. We have a large system here in Chicago. We have 6,000 doctors, 13 hospitals, and about 300 group practices. We are the largest health provider for the entire state, including all of the university medical schools. We even have our own intern and residency programs, but we have found in our system that for about 10 years, many of us fought to get the administration to actually see things our way. And finally, when we got buy–in from the administration, we saw some institutional modifications based on their understanding of the fundamental problem. The fundamental problem with regard to asthma in our system is the need for early diagnosis, early intervention, aggressive intervention, early referral to an asthma specialist, case managers, and spending the resources on the front end so that resource utilization doesn’t have to be spent as much on the back end, thereby decreasing morbidity and mortality, which you have demonstrated in refereed journals via publications.
This need also includes the standards of spirometry, validated questionnaires, and screening and establishing a registry for institutions. This can even be for group practices. It doesn’t have to be for an organization as large as ours. From the standpoint of monitoring patients, you have to establish the diagnosis, and you have to establish it early. Because a late diagnosis results in poor outcomes, and in some cases, there is no diagnosis or misdiagnosis. Therefore, education is required on the part of the primary care specialist to ensure they understand the fundamentals of asthma. They have to rethink the disease based on evidence–based clinical data and translate that into clinical application.
LeNoir: So are you of the opinion that this kind of quality approach institutionally to asthma reduces the disparity gap? Is there a disparity in outcomes for African Americans, Latinos, or other minority populations within your system?
Foggs: There are some disparities within our system. Most of them are due to modifiable risk factor barriers, which have to do with language barriers in some cases, so we have language translators in four languages in the state of Illinois for our patients, full–time interpreters, as well as a telephone system to allow us to access interpreters. The disparities that we see are not due to lack of access because everyone in our system either has Medicare or commercial health insurance. We also have some Medicaid patients, and some charity is done by our institution on a large–scale basis.
There are modifiable barriers that have to do with lack of patient understanding about the fact they suffer from a chronic lung disease. They have to be taught the concept of inflammation. I use the first, second, and third degree burn analogy. In addition, they have to understand that asthma is not an event. It doesn’t come and go. Patients come to the office saying, “My asthma is back, doctor,” and I answer, “But where did it go?” Then we have a conversation about the fact they had an episode. Just like a person with heart disease had chest pain episodically, the heart disease did not disappear when the chest pain disappeared. So likewise, we teach that paradigm to patients with asthma. Now their belief system is based upon a set of fundamental information about what constitutes injury or inflammation. So now they have a rationale for taking the medication that they previously decided they weren’t going to take because of other reasons.
LeNoir: Dr. Graham, what are the leverage points or the teachable moments to close the asthma disparity gap at the patient and family level?
Graham: I think at the patient and family level, it starts with accountability. Dealing with minorities, I’m very clear that we have to eliminate the victim mentality. We deal with these facts and data and the disparity of disease burden, and what we are going to do about it. What I find in my conversations, and the conversations with the Not One More Life initiative, is people often say no one took the time to explain it to me. It’s getting on their turf and starting with that level. We try to preach the concept of control. We may talk about spirometry. We may talk about emergency room visits. But I start with, “What is this doing to your life? How is this working out for you?” I deal with a lot of single moms, single parents whose lives are disrupted. I try to find in that discussion some traction point where I can relate to something that they will own to make better.
I am a big proponent of asthma action plans, and they are underutilized. What I tell them is, “This is your asthma action plan.” And I start it out with, “What you take every day and not what you take when you get into trouble in the second paragraph, this is what you do to stay out of trouble.” I think what we promulgate, and this is no criticism to the NHLBI or the NAEPP, is much too wordy. The other thing we do is tell people that health care is another form of commerce. I use an example when I’m talking to people about buying a flat screen TV. Everyone has bought one. Even poor people have bought one. And I say, “What did you do? You researched everything about that flat screen TV. You read up on Wikipedia, the library, you comparison–shopped. To the point that you were almost contentious when you entered into the store to buy it.” Yet people of color, or perhaps people in general, are far too passive about their own health care. So in the Not One More Life initiative, we give people what the NAEPP tells doctors are the goals for asthma care. No use of emergency room. No missed time from school or work, and medicine that works without side effects. And I tell people, “If the government tells people this is what should be your doctor’s goal, isn’t this what you should expect?” So we actually get people going back to a doctor and knowing what they should expect and hopefully not in a contentious fashion, but really demand that and become active participants in their own health.
I think the paternalistic aspects of medicine have to go away with high–risk populations. You have to force the issue of accountability, but you have to let them know that they are in control. We have been very successful, I think, with this in the Not One More Life initiative. I think personally, I’ve had great success for myself and my partners doing this, but I think we have to move from this top–down stage. I want to emphasize a point that if we start looking at interventional studies, we need to do more of these studies on a community–based level. Nothing against my academic colleagues, but there are too many studies that come into these communities. They are short–term. They achieve goals. They get lauded and published in great journals, but they leave nothing of permanence in the community. The community is wise to that. And you have a lot of people who have distrust in these studies that come in and have impact and they get free medicine for 18 months and then it is gone. I think moving to, and I’m biased obviously, and working with programs like the Not One More Life initiative, where we are now networked to 15 cities across the United States with the expansion we are doing in Dallas in two weeks, where we already have nearly 6,000 participants here in Atlanta. I would argue that the partnership between government, our academic colleagues, and well–designed community–based programs like myself, Dr. Cloutier in Hartford, and others, I think this is where we need to turn. And I think when we do that and start talking accountability and actionable communication, it’s going to get better. The last thing I want to point out—and we are doing this in the Not One More Life initiative with a grant—we need to teach primary care providers how to practice evidence–based medicine with increased utilization of spirometry to appreciate the lability and the physiological consequences of asthma.
LeNoir: Thank you very much for all of that. Dr. Cloutier, I’m going to ask you the next question. Your university and your programs are known for their translational component. Why don’t patients adhere to asthma action plans? And why don’t providers adhere to guidelines?
Cloutier: Well, Dr. LeNoir, I think that is a wonderful question. I think one of the major issues is readily fixable. We tend to make our asthma action plans readable, but they aren’t necessarily understandable, and there is a difference. Simply taking language and making it so that someone who can read at the third– and fifth–grade level can read something does not mean they understand it. I’m going to give two quick examples about this. The first is that we don’t call it an asthma action plan. We asked our families what an asthma action plan meant to them, and they said that was a legal document against their doctor who provided care for their asthma. So then we called it an asthma management plan, to which families responded that it didn’t come from the doctor. That it came from my insurance company, from the managed care company.
So we call it an asthma treatment plan, my asthma treatment plan. And families say that is my treatment. More important, however, than the title of it, are some of the instructions. For example, under daily treatment plan, “Use these medicines every day to keep your child well.” And perhaps there is an anti–inflammatory that you use daily and a bronchodilator that you used for rescue. Families could read that message very readily, but when we asked them to explain to us what it meant to them, their response in over 80% of the time was, “I don’t want my child to take a medicine every day. Therefore, I’m going to choose to use that medicine that I can use as needed, mainly albuterol.” Yes, they could read it, but they didn’t understand the instructions in terms of what they needed to do. So we had to change the wording to say, “Use all of these medicines everyday.” To which they said, “You mean I have to use that medicine everyday, meaning the anti–inflammatory.” And the answer is yes.
I think the second thing is in terms of, “How do I get clinicians to agree?” The problem with the guidelines is that they are 440 pages in length and they have some 70 tables and figures. And I think it is very difficult for pediatricians and other primary care clinicians to adhere to guidelines that are very lengthy and very difficult to get through and, importantly, very difficult to apply to their own practice. Our Easy Breathing program is two pieces of paper. That is the entire guideline for them. They also have an asthma treatment selection guide. It doesn’t say to them, “Use this medicine in this range of strengths with one to two puffs one to two times a day.” It gives them very clear–cut suggestions and ways to actually adhere to the guidelines. Currently, 96% of our patients in Connecticut have an asthma treatment plan, and of those treatment plans, 95% adhere to the national guidelines for prescribing anti–inflammatory therapy. So I think if we can make things in a way that is actually usable, that is not complex, it doesn’t have to have all of the bells and whistles. It has to have the essence of what it means to manage asthma. And ask for patients to do the essence for what it means to manage their asthma.
LeNoir: All right, Dr. Cabana, I’d like to ask you the same question. Why don’t patients adhere to asthma action plans? And why don’t providers adhere to guidelines? Maybe more emphasis on, do we expect too much?
Cabana: Sure, a great question, looking at adherence at the patient level versus adherence at the provider level. One of the things that has most impressed me about asthma action plans is that the evidence base for asthma action plans by themselves is really not that great. It is positive but it has a modest effect. It is only when asthma action plans are part of a broader program that includes asthma education is there more of an effect. I think it’s not the paper that is important. You can have a very nice asthma action plan with lots of colors and some nice illustrations, but it’s like Dr. Graham said, it’s when you really tailor that asthma action plan to the patient and really make sure that the patient understands the different components of it, and when that action plan shows up on the patient’s refrigerator or the bulletin board in the kitchen, that’s when it will make a difference. We have residents who are assigned to do these quality improvement programs or projects in our clinics, and one of the projects was to make sure every patient had an asthma action plan. It is something easy to find in a chart, to see if an asthma action plan is there, but the unintended consequences is we are counting the number of papers in these charts. But, really, has this asthma action plan been delivered with the appropriate education that should accompany it? I think we can’t focus on the piece of paper itself without addressing the education that is delivered along with it.
Related to provider adherence, it is hard since you have limited time to deliver all this educational information to patients about asthma, and there are a lot of competing demands. I agree with Dr. Cloutier, the asthma action plan has to be very usable and useful and distilled down to its essence. I think the NAEPP Guidelines Implementation Panel breaking it down into the six key points is a great way that resonates with providers. When we visit them and say, “If you only had a limited amount of time, what are the six key messages that are important?” It’s important to have the evidence base, it’s important to have the guidelines, but then taking it down a step further to the Guidelines Implementation Panel (GIP) messages, that is a really great tool for us as well.
LeNoir: Thank you. I want to thank all of our panelists, and I want to take the opportunity to get questions from our audience. I have some questions here, and there may be more time for you to type in questions that you have. For Dr. Cloutier, and for other members of the panel, maybe a quick response: How do you account for the relative parity in asthma prevalence among wealthy African Americans and wealthy Caucasians and children in your assessments with your patient population [in your Easy Breathing program]?
Cloutier: Actually, we don’t have enough data on wealthy African Americans in Connecticut to be able to calculate an asthma prevalence rate for wealthy African–American families. So the parity that they are speaking of refers to the asthma prevalence rates I discussed earlier for our Hispanic population and our Caucasian population. We do in fact see that rates of asthma decreased with increasing socioeconomic status in all groups except African Americans. It could be a reflection of environment, especially in our Hispanic kids, who might not be exposed to mice or cockroaches and indoor allergens to which they may be sensitized. I think there are environmental factors that play a major role in asthma, and it’s not all genetics and it’s not all environment—it’s the combination of the two.
LeNoir: Would any other of the panelists like to respond to that question?
Graham: There are two more studies, one by Christine Joseph looking at middle–class African Americans in a suburb of Detroit back when the auto industry was flush, and it showed that those African–American children, even when leveled for household income, were more likely to be atopic, more likely to be asthmatic, more likely to have lower pulmonary function, even when leveled for the ethnic differences. A similar study was done by Blixen and colleagues in 1999 with HMO data out of the Cleveland Clinic with the premise being most middle–class people are able to afford a Kaiser HMO product, and there again, they found higher prevalence in African–American members and found they were also less likely to have regular visits, more likely to have ER visits, and less likely to have consults from an allergist or pulmonologist. So I would agree with Dr. Cloutier. I would also talk about the cultural issues. I think, like Mike said, that many follow the belief that asthma is an episode not a disease and have lowered expectations. Some of that does not simply go away with economic advancement.
LeNoir: Alright, another question: Can any of the presenters speak to the use of peak flow meters? The question says, “I get tremendous negative push back from providers refusing to teach how to use them or seeing any value with them no matter how severe the asthma is.”
Foggs: Peak flow monitoring is useful, but it is not considered mandatory. The guidelines do not state that all patients who have asthma should, in fact, use peak flow meters. However, if you have a sufficiently motivated patient, it can be of some utility by virtue of the fact that it is useful for home monitoring. Patients who have decreased perception of asthma exacerbation, in particular with the air flow limitation that they don’t recognize because of a variety of reasons, can monitor their peak flow, especially if they have a history of past exacerbations, certainly two or more exacerbations within the past 12 months. They can monitor their peak flow and actually identify when their numbers are dropping before a major exacerbation of asthma. This is profoundly important because as we discussed in the New England Journal of Medicine article, bronchoconstriction can induce airway remodeling. Therefore, you want to control the disease not simply decrease the patient’s symptomatology. You want to control the disease by knowing what the lung function is. And one last word about peak flow monitoring: It is for home use, it is not an in–office instrument for assessing lung function.
LeNoir: Dr. Foggs, do you think that peak flow monitoring connects the patient with the disease in a way that otherwise would not happen? So often asthma is such a subtle problem that families and individuals living with asthma forget that it is difficult.
Foggs: I think it can if you have a sufficiently motivated patient. For all of our patients who have had a rocky course with increased asthma morbidity, we aggressively push the concept of peak flow monitoring using the zone system of the red, yellow, and green as part of the asthma action plans. So I agree with you that’s true, but I also say the stipulation is if the patient is sufficiently motivated. Sometimes if you push it too hard in a patient who does not want to do it, it can negatively impact other facets of care.
LeNoir: Alright, in the brief time that remains, I would like, for the good of the order, to go back to each of you with a general question that we didn’t cover extensively in a previous discussion to see if you have some final thoughts and to answer the question, “Do we expect too much from our patients with asthma?” I ask that question from a personal perspective because I’m supposed to take three things a day. One is a Vitamin D, one is something else, and I can’t remember the third, and if I remember to take them on Tuesday, Thursday, and Saturday, that’s a big week. So are our expectations for patients living with asthma too great, and how can they be simplified? Dr. Cloutier?
Cloutier: I agree with you. I think particularly about many of our urban–dwelling families for whom, today, asthma isn’t the problem but the heat, or the lights, or food, those are problems. So I think we are obligated to bring asthma down to the essence in terms of what we require. For example, not all families of children with asthma need environmental control. There are families with no allergies, and therefore, why are we asking them to do all of these things in the house for a year, particularly things that might be costly to them and may not be beneficial? That is not to say that smoking would ever be acceptable, and I certainly don’t want to imply that, but to really think about what we ask families to do and try to minimize the burden of asthma by asking families, “What can you do? What are you able to do? And how can I help you to be successful?” And sometimes you go to once–a–day therapy. No, it’s not effective as twice a day, but it is a lot more effective than none a day. So sometimes, we have to be ready and able and flexible with our patients to meet their challenge of asthma that, today, just isn’t a problem.
Foggs: I think in some cases, we do expect too much from our patients, but my perspective is that the bar is too low. We need to raise the bar and if that means we need to ask more of our patients, then we have to do so, but at the same time educate them and make it as straightforward and simplistic as possible. I think there is a certain level of acceptable disability with regard to asthma, and that is based upon a mindset that is devoid of the adequate knowledge necessary for patients to be able to prioritize what is important. So I would agree that we don’t necessarily have to implement every environmental control measure in every household. We have to individualize that kind of recommendation in the same way we individualize therapy. On the other hand, if we have a situation that clearly requires intervention, it should be adequately prioritized so that intervention can transpire without creating a burden on the patient, which may otherwise be the case if we didn’t educate the patient. Assist the patient in trying to carry out some of these goals. I think there are certain modifiable risk factors that can be addressed, and I think we should focus on education and behavior modification.
Graham: I agree with a synthesis of what Michelle and Mike said. I think we really do need to make it simple, but I think we do set the bar a little high. We are all fairly good physicians. I think all of the physicians across the country have good intentions. We have to take that skill set and find something that is reasonable for the patient to do and, as Michelle and Mike said, ask them what they can do. I agree wholeheartedly with Mike about setting the bar high. When we assess disability in some of these patients, we are looking at someone who doesn’t have problems because they don’t do much. Just before this webinar, I sat in front of a 13–year–old African–American morbidly obese young girl here because her asthma is out of control. And one of my pre–formatted questions is, “Do you have problems with exercise?” She said “no,” and it just hit me to ask, “What do you do?” She said, “Well, I don’t exercise.” “Why don’t you exercise?” She replied, “I can’t.” “Why can’t you?” She answered, “It hurts when I breathe.” It’s something that, often, in our busy space, we don’t dig a little bit deeper. I tell patients when I start them out on an asthma regimen, “I want you to hold me accountable. If you take what I’m asking you to do and you don’t get the outcome, then I’m not doing my job. You have to come back just like I’m going to challenge you when I check that pharmacy data and find that you aren’t getting your prescription. You need to check me to make sure I have the right plan if, indeed, you are doing what I ask, and it is not getting better.” And that’s all about empowerment and engagement. I think that is what is missing in a lot of ways when we practice asthma medicine.
LeNoir: At this point, I’d like to thank the National Asthma Education and Prevention Program. I’d also like to thank Dr. Kiley and the other members of our panel, but most of all, I’d like to thank those of you who took the time to join our webinar today. I’d like to turn it back over to Lisa Gilmore for final thoughts.
Gilmore: Dr. LeNoir, I would like to thank you for moderating today’s webinar and keeping us on track. We thank all of the participants, as well as the speaker, and the panelists for participating in today’s webinar. We are planning another webinar later in May, so I encourage you to visit the NAEPP National Asthma Control Initiative Web site and to sign up for future eNewsletters, where you will be notified of the webinar. Finally, we hope you will share your feedback about this webinar with us. It helps us with our programming and to make sure we provide you with the best possible information and engage in further dialogue with you. So please use the link on your screen. We will also send a follow–up message to you. So on behalf of the National Education and Prevention Program, the National Heart, Lung, and Blood Institute, and our speakers today, I thank you, and look forward to our next webinar.
(End of webinar)