Allen J. Dozor, MD, on Developing a High-Risk Asthma Program
Children with high-risk asthma require closer follow-up than routinely scheduled visits, and having a program dedicated to these patients is crucial for high-quality care and reduced hospitalizations.
This was the topic of Dr Allen J. Dozor’s session at Celebration of Pediatric Pulmonology and Sleep 2019. Consultant360 caught up with Dr Dozor after his presentation and asked him a few questions.
Allen J. Dozor, MD, FAAP, is professor and chief of the Division of Pulmonology, Allergy, and Sleep Medicine at New York Medical College. In addition, he is the director of the Children's Environmental Health Center of the Hudson Valley, director of the Armond V. Mascia, MD Cystic Fibrosis Center, and co-director of the Children's Health TSI at New York Medical College.
C360: To start, can you give us a brief overview of your session? How did it come about?
Allen J. Dozor: This conference was organized by the Pediatric Pulmonology and Sleep Section of the American Academy of Pediatrics, and the organizing committee specifically asked me to give this presentation. Every pediatrician and asthma specialist struggles with the relatively small percentage of patients with asthma who continue to require recurrent emergency department (ED) visits and hospitalizations, so there was a lot of interest in this topic and challenge.
C360: How do you define “high-risk asthma”? Would this differ between clinics?
AJD: It has been recognized for many decades that there is a relatively small subset of children (and adults) with asthma, who frequently require oral steroids, hospitalizations, urgent visits, ED visits, and so on. In my talk, I reviewed the history of clinical studies and descriptions of these patients, with many different attempts of organizing these patients into categories, such as “Near-Fatal Asthma,” “Refractory Asthma,” “Brittle Asthma,” “Uncontrolled Asthma,” and “Severe Asthma.”
Yes, I know every asthma specialist or clinic might come up with their own definition. There are clear geographic differences in the proportion of patients with asthma that would be considered “high risk” for frequent or severe exacerbations. The most important criteria is that they do in deed have asthma and that their poor control is not because some other diagnosis or comorbidity has been missed.
One of the first and most essential roles of a “high-risk” asthma clinic is to complete a rigorous diagnostic evaluation to make sure something is not being missed. This includes not only looking for explanations other than asthma and for looking for potential environmental triggers that may explain why this particular patient’s asthma has been so difficult to control. Then, high-risk patients continue to demonstrate poor asthma control despite being on moderate or high doses of combined ICS/LABA therapy.
C360: What is the difference between a high-risk asthma program and a typical asthma clinic? Is there an in-patient aspect?
AJD: In the ideal world, we would be able to rally the resources to give equally excellent follow-up care to all patients with asthma, and there would be no reason for a “high-risk” asthma program. However, our clinics and pediatric pulmonary practices all care for huge numbers of children with asthma, most of whom are relatively easy to control. There is a major shortage of pediatric asthma specialists relative to the number of patients, so most children with asthma in many parts of the nation are cared for primarily by their primary care provider. And, optimal care for these patients include a multidisciplinary team, including such vital providers as asthma educators, respiratory therapists, social workers, dieticians, and so on. So, for many clinics, the only way to mount sufficient resources is to triage these services to a smaller subset of so-called “high-risk patients.”
There is absolutely an in-patient element to doing this right. The number one risk factor for requiring hospitalization for asthma is having been hospitalized. So, essentially every child hospitalized for asthma, at least the second time around, should be considered high risk. That is how our program works. We have developed a system to assure that every child discharged from the hospital is given an appointment to our high-risk program before he or she is discharged, and most important, we have a coordinator whose responsibility is to overcome as many barriers as possible to actually get that patient to that appointment.
We have taken advantage of a smartphone app that each of our attending pediatric pulmonologists utilize as they make rounds in the hospital or consult in the ED, so they can quickly and easily notify our high-risk asthma coordinator at the bedside each time they recognize a patient who needs to be added to the list for close and consistent follow-up care. We developed an intense quality improvement program a few years ago to do just that, were able to increase the proportion of what we defined as high-risk patients who actually made it to their clinic appointment from less than 50% to more than 90%, and have been able to maintain that level for a few years.
Asthma specialists cannot do this easily by themselves. It takes a village. Our multidisciplinary team is critical for the success of this program.
C360: How can other providers implement a similar program?
AJD: It does not have to be complicated. After practicing pediatric pulmonology for more than 30 years, I believe that the single most important step in optimizing asthma care is scheduling and assuring frequent scheduled visits, even when the patient is doing well. The specific medications are far less important than frequent visits, with measurement of lung function whenever possible.
These routine visits cannot be done during the scheduled routine well-child visits that all pediatricians require. It takes too much time. The visit has to be just about asthma, nothing else. In fact, many excellent primary care pediatricians have set up their own asthma clinics and do just as good a job as either a pediatric pulmonologist or pediatric allergist.
In fact, this is true of optimal care of all chronic illnesses, not just asthma. If patients are not doing well, shorten the duration between routine scheduled visits. If patients are doing really well, do not let the scheduled visits drift to more than every 6 months for a child with asthma. Put bite into that demand. Do not fill prescriptions or sign forms unless they adhere to scheduled visits. I do not think it is too much to ask every patient with persistent asthma to be seen by their asthma specialist at least every 6 months, even if they seem to be doing well. That may mean missing school or parents missing work, but that is the key to success.
C360: What else should our audience of pulmonologists know about developing a high-risk asthma program?
AJD: Asthma specialists, primary care providers, and parents need to be empowered not to settle. It is amazing to me how many parents we meet that have become used to frequent courses of oral steroids, frequent urgent visits, ED visits, and even hospitalizations. This should be extraordinarily rare. I tell every parent, that if his or her child requires any of these things, CHANGE THE PLAN! Do not settle. I do not have stock in any of the medications, care must be individualized. The thing about kids is that just when you think you have figured it out, they change on you. Flexibility is the key.