Prevalence of Asthma in the US

Jennifer Weber (Yale Center for Asthma and Airway Disease): I am going to discuss asthma prevalence just to start. As a quick reminder of what asthma is, it is a chronic respiratory disease that involves airway constriction or bronchoconstriction, inflammation, and mucus hypersecretion. Common symptoms of asthma are chest tightness, cough, wheezing, and shortness of breath that might be more likely to present nocturnally or with exposure to other triggers.

A lot of Americans have an asthma diagnosis, just about 27 million people in 2022. Asthma disproportionately affects those of Black ethnicity. Then you can see on the little graphic on the right there, non-Hispanic Black is the highest, and Hispanic people are also pretty affected by it. 8.7% of adults in 2022, so just under 9%, so very common disease, and 6% of children are affected by asthma.

[00:06:54]

Severe Asthma Is Unlike “Regular” Asthma

To talk a little bit about what a patient experience is with severe asthma, I am going to hand it over to Ms. Giselle.

Giselle Sanchez: The severity of my asthma has changed my life in many areas, both emotionally, socially, and it has hindered many areas due to the fact that I want to avoid any type of triggers to avoid any type of an asthma episode.

What I avoid are the things that clearly I can see that will trigger an asthma moment. It is usually weather. The weather has an impact. How I take care of my body when it comes to cold weather, and emotionally, how I am feeling. If I am feeling overwhelmed with anything, usually I will start to wheeze, and my asthma will have an impact on my emotions as well.

In those areas, I am very careful and very mindful so that I do not have an episode or get worse if I start to feel that something is coming in.

[00:08:26]

Impact of Severe Asthma on Quality of Life

Jennifer Weber: You have heard directly from our patient, Giselle, about how much severe asthma can impact quality of life. Here is some data to back it up as well. If you look at our figure on the right side, you can see the bar in yellow is representative of patients with severe asthma. The higher the number, the lower the quality of life is.

Severe asthmatics are disproportionately affected by low quality of life as they defined by physical limitation. Maybe they cannot work. They cannot do activities they love, and their overall health scores are just lower, unfortunately. Uncontrolled symptoms that we discussed a little bit, that wheeze, cough, shortness of breath can really impair their daily functioning and affect all areas of their life.

[00:09:13]

Fear of Asthma Exacerbations

Patients with severe asthma also have a lot of fear and anxiety related to their asthma, especially the ones with difficult-to-treat or severe illness. Those that get hospitalized, for example. In a small survey of 14 patients with severe asthma, every single one of those patients were worried that their asthma would worsen, leading to them living a restricted life or even being fatal.

You can see some quotes directly from patients in that study there, and you can see they think about it a lot. It really can just negatively impact their life.

[00:09:44]

          Fear of Asthma Exacerbations

This fear from asthma exacerbations is multifactorial. When they are experiencing an asthma exacerbation, things that they describe are:

• Distress;
• Panic;
• Fear of dying; or
• Feeling helpless after failed efforts and failed medications.

This impacts their life. I mentioned a little bit, things like work, being able to care for their children or keep up with their children, things like that, that really just make it challenging to manage this disease from a psychological standpoint.

Then these patients get treated with oral corticosteroids, which can further increase the risk for toxicities and negative outcomes, have a host of side effects, and really just contribute to poor quality of life overall.

Finally, the poor perception of severe asthma, and what we mean by that is it can be poor understanding from the patient, poor understanding from the healthcare team or those in the patient's life, just not understanding how significant and harmful this disease can be, really plays into how challenging it is for them to get over that fear of asthma.

[00:10:49]

Health Disparities in Asthma

Asthma is a disease that does affect everyone, young, old, rich, poor. To some extent, we can say it does not really matter. However, what we do know is that patients that are disproportionately affected by asthma tend to be of lower socioeconomic status, tend to be of certain race and ethnic groups. There are multiple different factors here that play into it.

Lower education, patients that are close to the poverty line, patients who are uninsured or underinsured, who have poor health literacy, who cannot adhere to asthma therapies for whatever reason, or under a lot of stress, that can all really play into how well they can manage their asthma on their own.

As an asthma provider, clinical pearl for all of you, we really need to focus on these things and help that our patients eliminate these barriers as much as possible, or help them find accommodations for these barriers, so we can really get their disease under control.

Medications are not always the full picture. We really do have to look at these psychosocial factors. Then there is, of course, some systemic issues within the environment and the health system that negatively impact patients with asthma. Poor quality housing and neighborhood, big impactors.

If you are living in a home full of mice and roaches, you have mold, you have smokers that live next door, poor insulation, just a few examples of things that can really affect people with asthma, it makes it very challenging to perfectly manage their disease or even get their disease well-managed with those things playing against them.

Outdoor air pollution, something we unfortunately cannot control for patients on an individual level. Just be aware that cities and places with increased pollution, people are at an increased risk of having asthma. There are also areas where there is less access to health care and quality foods. Of course this is all going to play into asthma management as well.

Finally, there is biologic factors that some we can control for and some we cannot. There is a genetic predisposition to asthma. Parents with asthma are more likely to have a child with asthma than parents that do not have asthma, for example, nutrition, healthy diet, exercise is not mentioned there, but these are all things that are important and preventing asthma or maintaining asthma. That is just not always possible with certain populations, but if we can control something like smoking cessation, that is what you want to focus on.

[00:13:24]

What Triggers Asthma? 

There are a variety of asthma triggers. I am not going to read all of these off, but it is very important to consider this not just once, but each time you meet with your patient who has asthma. This is important for asthmatics of all severities, but especially patients with severe asthma.

We can use cold air as one example here. We cannot exactly protect patients from cold air all the time, but we can provide some small modification strategies for them. What I mean by that, if they know they are going to have to walk to the bus to go to work, you can suggest that they wear a scarf over their face to help reduce that exposure, help humidify and warm the air that they are breathing in.

Stress is another big one. If there is something we can help the patient with, if we can connect them with a social worker, a behavioral health specialist, to help reduce that stress, even just a little bit, that could be a big change.

Pets, another great example. Some significant cases, we may suggest that patients rehome pets or do not bring pets into the home. If they are not willing to part with their fur babies, we can tell them no pets in the bedroom. Keep an asthma-friendly bedroom. Let us use dust mite covers. Let us use high-quality air filters. Let us vacuum. Let us use a dust mask when you change the vacuum. Small things.

This is not low-hanging fruit. This is very important. If we can modify the environment, we might be able to better control that asthma.

[00:14:53]

Access to Asthma Specialists

Access to asthma specialists, I did mention briefly that this disproportionately can affect patients that are of minority race groups. In a study of patients with severe uncontrolled asthma, there were a large portion of them that had no access to an asthma specialist and no treatment escalation. This is alarming. In this large study here, 41% of patients who identified as Black did not have access to the specialist, and 38% of Hispanic or Latinx patients, as compared to White people, 33%.

A little bit lower there. You can see there is a disparity. Unfortunately, we need more asthma specialists. The best thing we can do for patients, even if you are not focused in pulmonology, is escalate their therapy per guidelines and try your best to get that asthma under control and look at their environment. Always important to see if we can get them engaged with a specialist. If not, see if you can escalate the treatment.

[00:15:59]

Costs of Severe Asthma

Asthma can be a very expensive disease. As many of you who may work in the pulmonology realm may understand, just one emergency room visit, one hospitalization can cost thousands and thousands of dollars. That is not even accounting for the outpatient costs of medications, inhalers, biologics, office visits, imaging. It all adds up over time.

It is the highest cost here, you will see in patients with severe and uncontrolled asthma. That is the column on the right that is the cost throughout a 12-month follow-up. In this study here, they are estimating that average, severe, uncontrolled asthmatic patient is costing about $23,000. The majority of that is actually coming from outpatient costs, so very high.

As you can see, the non-severe asthmatic patients on the left, the cost is substantially lower at about $16,000. Another good argument of getting that asthma under good control.

I am going to pass it off to Tyler now, who is going to review our case studies.

[00:17:05]

Skill Building and Feedback

Tyler Kuhk: Thanks, Jennifer. I think that was a really good introduction. When we talk a lot about disease processes, and we focus on the science of it, I think all that qualitative data is actually really important. It really guides the way that we have to practice, because I think we have to get a little bit creative in some aspects of some of the populations we treat, so great way to start the presentation off.

We are going to talk about Rosa, who is a 39-year-old middle school teacher, and she reports some asthma symptoms during the school year.

She is one of these patients that presents to you and tells you she is had asthma since childhood. She notes more frequent exacerbations over the past year, though she is often using her rescue inhaler between classes and recently had a steroid burst after a severe flare.

She is expressing frustration to you about missing work, and says that her students notice when I cannot talk without coughing, and she shares that getting to a specialist is difficult because the nearest pulmonologist is more than an hour away.

Jennifer, I do not know about where you are practicing. I am in a fairly urban area where we have easier access to that. What factors do you think, in patients especially like this, that do not have easy access to pulmonary or even an APP that specializes in asthma? What factors do you think are contributing, in this case, to this patient's asthma burden?

Jennifer Weber: I am working in an academic medical center in two locations. This is a very interesting way my practice is divided. One of our locations is right downtown, or what you would consider like inner city. The other location is in a surrounding suburb. Some of our patients need to take the bus. They need to walk. It is so important to understand that as their asthma specialist, because when the weather is really bad, they have a hard time getting into the clinic, just as an example.

Being in those two locations and just seeing the disparities between the patients, like the ones that can just drive to the clinic in the suburb or the ones that might need to take the bus or walk to the clinic in the city. Just things you need to think about. Something that could contribute to patients like Rosa’s case just really being challenging to get there.

It sounds like she works. It is hard to get off of work. How can we help her with that? Just little things to think about, little clinical pearls when you are taking care of these patients.

Tyler Kuhk: For sure. Yes, I work in Washington state. There is a lot of urban and rural areas. I think something I would like to do as an APP that does a lot of asthma is really teach our primary care NPs and providers in the area, to empower them to do the best job that they can do, because sometimes it is hard for them to get in.

[00:19:46]

Poll 3

We are going to move to some questions. Which factor most likely contributes to disparities in asthma outcomes, while we are talking about this, for patients like Rosa? Would it be:

1. Variability in immune cell activation across populations;
2. Challenges in timely access to specialty and follow-up care;
3. Excessive use of short-acting beta agonists for mild symptoms; or
4. Differences in medication metabolism based on age and sex.

We will give you a few moments to answer that. 91% of you chose the correct answer, challenges and timely access to specialty and follow-up care.

[00:20:36]

Faculty Discussion

We have a little bit of time to have a little bit of a discussion here, and we can bring Dr Louie on this as well.

If you are dealing with a patient like Rosa, what are some of the things that you guys are asking in clinic to these patients to gather more data to guide what you are going to do next with them?

Dr Samuel Louie (University of California, Davis): First of all, good morning, everybody. One of the key things that we try to first confirm is that the diagnosis of asthma is correct. If we presume it is correct, then as many of us in clinical practice knows, up to 80% of the problem is that the patient does not know how to use their inhaler. That leads to anxiety, depression. They do not follow the prescribed treatment plan.

I think, as Jennifer pointed out, it really comes down to education. Education should be free to the patient, but they do not consume it. We have to find a better way to communicate and connect whenever we are in the presence of a patient.

Tyler Kuhk: Do you have anything to add to that, Jennifer?

Jennifer Weber: Yes, I think that is excellent. Thank you, Dr Louie. It is always so important to empower these patients. It is not only us managing their disease, but the patient really has buy in, and they feel comfortable and confident saying like, “Hey, I need help. I know my asthma is not controlled right now.” That is just I think so critical in managing these patients.

Something I would ask our patient, Rosa, about how we could help her, for example, would a telehealth visit be of use to her? Not for the first visit, not to get a pulmonary function test, confirm the asthma diagnosis, do the assessment. Of course, we need to see them in person once in a while. If this was a checkup, we know her well, and her asthma is worsening. She is using her reliever inhaler more often. Why not do a telehealth if that could eliminate that barrier to access that she is having? I would also ask her, “How else can we help you?” For example, do you need work accommodations so that you can leave for an hour or two to get to the clinic on time, so we can actually see you in person and get this better? Other things that are always important are can they afford their medications? Where are they getting their medications? Just understanding what the issues are so we can actually help them overcome them.

Tyler Kuhk: Great answer. Paul had actually asked a question, does virtual health care help with patients who cannot travel? I think you touched on that. I think we are seeing a lot more of that. I do not know how often you guys are using telemedicine for your asthmatic patients. Dr Louie, are you doing telemedicine for any of your asthma patients? Do you find it helpful?

Dr Louie: We are, but my personal experience is that I would rather see the patient in person because there is so much you can actually get, particularly if a family member, especially the daughter, accompanies the patient. There has been issues with payment for telehealth. It is really very difficult to practice medicine. In any form is better than no contact at all, rather that they make an effort to try and get to us or we get to them somehow.

The one thing that [inaudible] to see Jennifer, see me, and clinical practice. The majority of patients who are socioeconomically disadvantaged, they use the emergency room. It is just terrible because they get prednisone, they get antibiotics, and it is repeated over and over again. There is no accountability anymore in the current healthcare business model.

Tyler Kuhk: We are running good on time. I just wanted to maybe pose one question from the audience. Maybe, Jennifer, you might be able to help with this. April is asking what suggestions that you might have to help a school, for example, understand that a middle school or a high school student may need some extra time to get between classes without having to move forward with a formal health plan. Personally, I do not see adolescents or children in my practice. I am just curious if you had any suggestions for April's question when we are talking about this topic.

Jennifer Weber: I do not take care of the pediatric population myself. What I will say is I have written all letters for patients with these very basic requests that they have. Maybe for a school, it would look similar to a situation I see often, where patients who have a pretty active job, for example, they stock a warehouse. They just say they need 15-minute breaks to take their inhaler, maybe once or twice throughout the day if they are flaring.

I will write letters that just say I am taking care of this patient in our pulmonology practice. They have an underlying lung disease. They would benefit from having 15-minute breaks up to every four hours as needed. Please provide them a private space to do this. I can provide them with formal accommodations, if needed. I think that is something that simple, does not take me very long to write that letter, but it is very helpful for these patients. I do not see why something like that cannot be implemented in a school.

Tyler Kuhk: Great conversation. We will move along. There was a comment here from Catherine[?] basically saying that she asks her patients what can I do for you? What do you need? I think that is actually a really good practice to have, because part of this is listening and getting a really thorough history. It is not just science. It is also a huge social aspect to this disease. I think you highlighted that really well.

[00:26:43]

Commitment to Practice Change

This is just a data collection poll. We just want to know how will you get your patients’ perspectives on their disease and symptoms. If you want to take a few moments just to enter an answer for that, and then we will move into our post-test, and then continue along. Just give a few moments for that.

[00:27:26]

Posttest 1

People are wrapping that up. We are going to move to our post-test question. Remember, we asked this in the pre-test. We have this 45-year-old woman with severe asthma who has had multiple emergency visits this year despite using high-dose ICS/LABA therapy as prescribed. She reports difficulty accessing medication refills due to transportation issues. Which of the following statements best describes the impact of health disparities on the overall burden of living with severe asthma? Would it be:

1. Disparities in asthma care are primarily due to genetic differences in airway inflammation across racial and ethnic groups;
2. Structural barriers greatly influence the asthma burden across populations;
3. The inflammatory phenotype is the strongest determinant of disease burden; or
4. Stepwise therapy achieves similar outcomes for patients with severe asthma.

We will give you a few moments to answer that.

We have our pre-test here. 69% of people answered B in the first go, and then 81% of you answered B in the second.

[00:28:41]

          Posttest 1: Rationale

Jennifer did a wonderful job. Everybody listened. Disparities and severe asthma are driven by complex, multifactorial, systemic influences. I think we appreciate that after the first part of this presentation.