Improving Adherence to Asthma Guidelines and Asthma ......1. Implement evidence-based asthma...

Improving Adherence to Asthma

Guidelines and Asthma Therapies:

Closing the Gap

Supporter – Genentech

Program authors: David A. Beuther, MD, FCCP and Flavia Hoyte, MD

Data From: 09/28/2012 – 09/28/2013

RELEASE DATE: 09/28/2012

VALID FOR CREDIT THROUGH: 09/28/2013

MAXIMUM OF 1.00 AMA PRA CATEGORY 1 CREDIT(S)™

http://www.medscape.org/viewprogram/32600

© 2013 THERASIM, INC. MODIFIED: 10/18/2013

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Executive Summary An independent educational grant awarded from Genentech included simulation as an educational activity

to address gaps and learning objectives of the physicians treating Asthma. This report summarizes the impact of

the simulation. Decisions made by clinicians within the simulated patient cases are measured and results are

aggregated in the report below.

Gaps The following gaps were identified within the educational grant.

Adherence to asthma diagnosis and management guidelines continues to be suboptimal.

Patient adherence to asthma medications remains suboptimal.

Non-adherence to medications results in reduced asthma control.

New research describes emerging therapies that are not yet covered in current asthma guidelines

Learning Objectives The learning objectives for this simulation are derived directly from the above identified gaps.

1. Implement evidence-based asthma guidelines in their clinical practices and take the steps necessary to

overcome identified barriers

2. Adjust medications to improve asthma control based on domains of both risk and impairment as

described in Expert Panel Report 3 (EPR-3)

3. Facilitate medication adherence in their patients by offering medication regimens individually suited to

patients’ needs and lifestyles

Target Audience The specific audience targeted within the supported educational grant and resulting simulation consisted of

clinicians in the fields of Allergy & Clinical Immunology and Pulmonary Medicine.

Below are the numbers of specialist, and non-specialist (other) users for the two cases in this program:

Case 01: Specialist Users n = 75 Non-specialist users n = 313

Case 02: Specialist Users = n = 21 Non-specialist users = n = 95

Key Findings Clinician performance leaves ample room for improvement on the essential decisions related to tests,

diagnoses, and treatment of both patients.

Simulation users scored the highest on decisions to treat the patient with asthma medications, but failed to

select treatments that would increase disease response and reduce adverse side effects.

Decisions regarding the non-pharmacological management of asthma were especially low, with scores less

than 20% before clinical guidance.

Recommendations for Further Education Based on the above key findings and the analysis provided in detail in this report, the following further

education can be suggested.

Current treatment options according to guidelines for optimizing asthma treatment

Non-pharmacological management that encourages medication adherence and teaches self-

monitoring techniques


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MedSims Patient Cases The case analyses outlined below contain information that the learner is presented with at the introduction

stage of the case. Additional elements of information are made available as they begin their decision making

process and progress through the case.

CASE 01 – Detailed Analyses

Jessica G. Jessica first began treatment for asthma ~4 years ago, when she presented to her primary

care physician complaining of several months of cough, chest tightness, SOB, and malaise.

She noticed these symptoms predominantly while playing basketball. At the time a chest X-

ray showed possible atypical pneumonia. She was treated with an antibiotic and was

diagnosed clinically with asthma. Initial treatment of her asthma was with a short-acting beta

agonist. While Jessica considers her initial treatment to have partially relieved some of her

symptoms, she experienced adverse-effects that made her hesitant to consistently take them. Today, she

presents with dyspnea at rest, and worsening SOB and chest tightness, and palpitations and light-headedness.

Chief Complaint “I am short of breath.”

Current Diagnosis Asthma; Anxiety/stress

Current Medications

Albuterol 90 mcg/inhalation

Alprazolam .25 mg oral tablet

Fluticasone-salmeterol 250 mcg-50 mcg inhalation powder

Vitals Age: 20

BP: 129/84

Height: 169 cm

Weight: 56 kg

BMI: 19.6


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Essential User Decisions: To demonstrate mastery of the learning objectives, users were expected to make the following decisions:

Learning Objective Essential User Decision

1. Implement evidence-based

asthma guidelines in their clinical

practices and take the steps

necessary to overcome

identified barriers

1. Order Methacholine Test

2. Order either Spirometry OR Pulmonary Function Tests

2. Adjust medications to improve

asthma control based on

domains of both risk and

impairment as described in

Expert Panel Report 3 (EPR-3)

5. Continue use of ICS and lower dose

6. Continue use of Rescue Inhaler, but switch to one with

less adverse effects.

7. Facilitate medication

adherence in their patients by

offering medication regimens

individually suited to patients’

needs and lifestyles

1. Order medication adherence counseling

2. Order asthma medication/inhaler Technique


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Case 01 Findings The graph shown below represents data for both specialist and other user groups, and shows data before users

were offered Clinical Guidance. The selected decision points correlate to the established learning objectives

for this CME activity as noted previously.

Complete data tables are presented in the Appendix.

Initial Performance The essential decision points relating to the learning objectives for this case were initially appropriately chosen

by an average of 48% by specialists and an average of 47% by the other users.

13%

12%

64%

65%

48%

81%

15%

13%

57%

67%

49%

87%

0% 20% 40% 60% 80% 100%

Order: Medication/Inhaler Technique

Order: Adherence Counseling

Initiate: Rescue Inhalers

Continue: Inhaled Corticosteroid (ICS)

Order: Methacholine Challenge Test

Order: PFT - OR - Spirometry

LO

3LO

2LO

1

Initial Reinforced Decisions

Specialists n = 75 Others n = 313


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Analysis: Essential tests for this patient were ones that would rule out possible etiologies of her symptoms other than

asthma. Useful for doing so would have been a Methacholine Challenge Test and either Pulmonary Function

Tests (PFT) or a Spirometry. A methacholine challenge test would provide definitive evidence for a diagnosis of

asthma, but was only ordered by 49% of specialists and 48% of other users. Conversely, both sets of users

excelled at the decision to order either PFT or spirometry, with scores of 87% for specialists and 81% for other

users.

A diagnosis was not required for this simulation, since the results of the patient’s workup indicate asthma as the

cause of her symptoms.

The foundation of this case was to adjust and optimize the patient’s asthma treatment. Prior to today’s visit the

patient was taking albuterol and a fluticasone-salmeterol to treat her asthma. For the patient which this case

was based on, the use of albuterol in the initial treatment was not incorrect, but does represent an aggressive

treatment option. In this activity an appropriate decision would have been to swap albuterol for levalbuterol,

as it would cause less jittery sensations. The graph above shows that 57% of specialists and 64% of non-

specialists ordered a rescue inhaler; however, only 9% of specialists and 4% of non-specialists switched to

levalbuterol (see appendix).

Knowledge deficits related to how to administer inhaled corticosteroids and concerning the need to take daily

controller medication for a disease that often feels intermittent to the patient, contribute to poor medication

adherence. Inhaled corticosteroid use is frequently associated with mild-but-irritating adverse effects. These

adverse effects can be reduced but not eliminated through good technique, spacer use if applicable, and

mouth rinsing. For some patients, a major barrier to adherence is the negative stigma of taking "steroids," which

can sometimes be overcome by patient education. Prior to clinical guidance both user groups performed

poorly at the decisions to provide education concerning the use of asthma medications and the management

of adverse side-effects. Less than or equal to 15% of both specialist and non-specialist users initially considered

non-pharmacological treatments essential for optimizing the patient’s asthma control.


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Case 01 Impact of Clinical Guidance Clinical guidance is shown to the user following decision points made throughout the simulation.

The chart below highlights the percentage of participants that initially made the appropriate decision in the

simulation as well as the percentage that did so after receiving educational guidance.

Impact of clinical guidance is displayed here within the Allergy & Clinical Immunology and Pulmonary

Medicine audience groups only.


Overall Impact Clinical guidance resulted in a 54% average improvement on essential decisions made by Allergy & Clinical

Immunology and Pulmonary Medicine specialist users.

Analysis The greatest immediate educational impact for specialist users was at the three decisions related to patient

education: adherence counseling (190% change), and asthma medication technique counseling (155%

change).

0% 20% 40% 60% 80% 100% 120%

Order: Adherence Counseling

Order: Medication/Inhaler Technique

Continue: Inhaled Corticosteroid (ICS)

Initiate: Rescue Inhalers

Order: Methacholine Test

Order: PFT - OR - Spirometry

LO

3LO

2LO

1

Specialist Users n = 75

Before CG Add'l After CG

3%

27%

28%

20%

155%

190%


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Case 01 Summary In the case on which this simulation was based, the clinician ordered a methacholine challenge test, which

was very positive, PC[20] of 1.25 mg/mL, thus confirming a diagnosis of asthma. An ECG and echocardiogram

confirmed no significant structural heart disease or cardiac cause of dyspnea. The patient was prescribed

levalbuterol instead of albuterol, which was not completely effective but did cause less jitteriness.

On additional history concerning her asthma medications, it becomes clear that the fluticasone/salmeterol

had been causing significant upper airway adverse effects as well as jitteriness, so she was hesitant to take it

consistently. She knows how to use her inhalers properly and rinses her mouth regularly after administering her

inhaled steroid medication. The patient also considers her symptoms to be episodic and that they do not

warrant daily medication. Finally, she reports severe financial hardship, limiting her access to medications

despite having insurance coverage.

Asthma education, including pathophysiology, medication mechanism of action, and medication usage, was

provided, and Jessica now understands the importance of daily, consistent controller medication use. She was

also educated about and provided with local and industry resources that are available for indigent patients to

obtain lower-cost asthma medications.

Asthma guidelines would assess her as having poorly-controlled, moderate persistent asthma, based upon daily

symptoms. Recommendation is to utilize Step 3 therapy: low-dose ICS/LABA or medium-dose ICS monotherapy.

In this case, her PCP initially prescribed Step 4 therapy, which is not necessarily incorrect but probably is more

than she needed. Given the adverse effects she is experiencing, stepping down to ICS monotherapy may be

preferable.

She was switched from fluticasone/salmeterol to beclomethasone HFA 80 mcg 2 P bid. She had persistent

upper airway adverse effects (hoarse, sore throat) and jitteriness that did not resolve over four weeks, so she

was switched to montelukast 10 mg daily.

At 6 weeks she reported no adverse effects, as well as 60% reduction in cough and dyspnea, no nocturnal

symptoms, infrequent rescue beta-agonist use, and increased activity, although her asthma control test score

only improved to 18 (normal 20-25). Her clinician could have added a low-dose inhaled steroid but did not do

so because the patient was continuing to improve, was afraid of adverse effects, and could not afford to take

two asthma controller medications. Her asthma was well-controlled several months later.


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CASE 02 – Detailed Analyses

Sandra S. Sandra S. is a 43-year-old female with a history of allergies and asthma. She was in the ER last

week for an asthma flare and one of the doctors there told her that she needed to make an

appointment to get better control of her asthma. Despite this recent improvement on

controller therapy, the patient's asthma is "poorly controlled" by EPR-3 guidelines. She is

waking up a couple of times a month due to her asthma, is going to the emergency room

and receiving prednisone once a year on average, her asthma control test (ACT) score is a

13, and she is needing her albuterol inhaler once or twice daily. All of these correspond with poor asthma

control and the need to escalate therapy and evaluate/target any potential co-morbidities

Chief Complaint “The ER doctor sent me here. He said I need help with my asthma.”

Current Diagnosis Obstructive Sleep Apnea; Sinusitis; Osteoarthritis; Obesity; Hypertension; Allergic

Rhinitis; Allergic Conjunctivitis; Seizures; Asthma

Current Medications

Fluticasone 50 mcg/inh nasal spray

Fluticasone-salmeterol 25 mcg-50 mcg inhalation powder

Lisinopril 10 mg oral tablet

Carbamazepine 200 mg oral

Cetirizine 10 mg oral

Albuterol 90 mcg/inh

Vitals Age: 43

BP: 130/82

Height: 165 cm

Weight: 95 kg

BMI: 34.9


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Essential User Decisions: To demonstrate mastery of the learning objectives, users were expected to make the following decisions:

Learning Objective Essential User Decision

1. Implement evidence-based

asthma guidelines in their clinical

practices and take the steps

necessary to overcome

identified barriers

1. Order Methacholine Challenge Test

2. Order Provoked Laryngoscopy

3. Order Pulmonary Function Test

4. Diagnose Gastroesophageal Reflux Disease

5. Diagnose Vocal Cord Dysfunction

2. Adjust medications to improve

asthma control based on

domains of both risk and

impairment as described in

Expert Panel Report 3 (EPR-3)

1. Continue a short-acting beta agonist

2. Step-up therapy

3. Initiate Proton pump inhibitor

3. Facilitate medication

adherence in their patients by

offering medication regimens

individually suited to patients’

needs and lifestyles

1. Allergen avoidance counseling

2. Asthma pathophysiology and medication counseling

3. Speech Therapist counseling


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Case 02 Findings The graph shown below represents data for both specialist and other user groups, and shows data before users

were offered Clinical Guidance. The selected decision points correlate to the established learning objectives

for this CME activity as noted previously.


Initial Performance The essential decision points relating to the learning objectives for this case were initially appropriately chosen

by an average of 35% by specialists and an average of 36% for the other users.

20%

1%

73%

76%

5%

11%

45%

21%

76%

29%

5%

67%

71%

10%

24%

19%

19%

76%

0% 20% 40% 60% 80% 100%

Order: Asthma Pathophysiology and MedicationEducation

Order: Speech Therapy

Order: Asthma Step-Up Group

Order: Inhaled Corticosteroid

Diagnose: Vocal Cord Dysfunction

Diagnose: Gastroesophageal Reflux Disease


Order: Provoked Laryngoscopy

Order: Pulmonary Function Tests

LO3

LO2

LO1

Initial Decisions Reinforced

Specialists n = 21

Others n = 95


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Analysis: The users’ first attempts to treat this patient (graphed above) show that both user groups performed less than

average at decisions related to the first learning objective, with the exception of pulmonary function tests.

Perhaps the most definitive test that could have been performed is the methacholine challenge test, which

was only ordered by 19% of specialists and 45% of other users. In addition to an insightful workup for this patient,

simulation users should have diagnosed two comorbidities of asthma: Gastroesophageal reflux disease, and

vocal cord dysfunction. Less than or equal to 24% of all users diagnosed the patient with either of these

conditions.

The patient’s presentation of symptoms at today’s visit indicates by EPR-3 guidelines that she is poorly

controlled. She is waking up a couple of times a month due to her asthma, is going to the emergency room

and receiving prednisone once a year on average, her asthma control test (ACT) score is a 13, and she is

needing her albuterol inhaler once or twice daily. All of these correspond with poor asthma control and the

need to step-up therapy. Treatment options for Sandra include: addition of a leukotriene receptor antagonist,

or addition of omalizumab. Additionally, users could increase the dose of her inhaled steroid, but it would not

be as effective as with a leukotriene inhibitor or omalizumab. The faculty author for this case grouped these

three treatment options as an Asthma Step-Up group. Considered in this way >67% of all users escalated the

patient’s treatment. However, the graph below shows a breakdown of these treatments and a different user

story. Overwhelmingly, specialist users continued the patient’s fluticasone-salmeterol before and after clinical

guidance. Only 5% before, and 10% after chose a leukotriene inhibitor (montelukast), and only 5% chose

omalizumab.

5%

5%

0%

0%

67%

0%

10%

5%

0% 20% 40% 60% 80% 100%

omalizumab

montelukast

zafirlukast

zileuton

fluticasone-salmeterol

32

1

Breakdown of Asthma Step-Up Group

N = 16

Before CG Add'l After CG


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Case 02 Impact of Clinical Guidance Clinical guidance is shown to the user following decision points made throughout the simulation.

The chart below highlights the percentage of participants that initially made the appropriate decision in the

simulation and the percentage that did so after receiving educational guidance.

Impact of clinical guidance is displayed here within the Allergy & Clinical Immunologists and Pulmonologists

audience groups only.


Overall Impact Clinical guidance resulted in a 117% average improvement on essential decisions made by specialists.

29%

5%

67%

71%

10%

24%

19%

19%

76%

19%

14%

10%

10%

10%

29%

38%

43%

10%

0% 20% 40% 60% 80% 100%

Order: Asthma Pathophysiology and Medication Education

Consult: Speech Therapy

Order: Asthma Step-Up

Order: Inhaled Corticosteroid

Diagnose: Vocal Cord Dysfunction

Diagnose: Gastroesophageal Reflux Disease


Order: Provoked Laryngoscopy

Order: Pulmonary Function Tests

LO

3LO

2LO

1

Specialist Users n = 21

Before CG % Add'l After CG%

13%

225%

200%

120%

100%

13%

300%

67%

14%


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Analysis Clinical guidance had a major impact on several decision points for this patient. The largest impact was seen

at the decision to schedule a consult with a speech therapist (300% change). Speech therapists trained in

vocal cord dysfunction (VCD) techniques can help patients with VCD learn the breathing techniques they

need to minimize the role of VCD in their respiratory symptoms.

Both diagnoses for the patient saw significant increases. After clinical guidance the diagnosis of

gastroesophageal reflux disease improved by 120% and vocal cord dysfunction by 100%.

Clinical guidance had little impact on the pharmacological treatment of this patient.

Case 02 Summary This patient is a 43-year-old Caucasian female who has a history of allergic rhinitis by skin testing and a clinical

diagnosis of asthma and presents to improve her asthma control given frequent emergency room visits. An

important detail in Ms. S's history is that her asthma and allergies were mild until approximately 8 years ago,

when several changes occurred in her life. She began working in a new hair salon, she moved into an older

house, and she began living with pets for the first time in her life. One or all of these changes worsened her

underlying conditions and should all be evaluated further and targeted. In addition, her asthma worsening has

resulted in frequent prednisone bursts over this time and a decreased ability to exercise due to respiratory

symptoms. These factors have resulted in weight gain, which has led to the development of hypertension,

obstructive sleep apnea, osteoarthritis, and frequent heartburn, none of which she had previously. The

presumed gastroesophageal reflux disease (GERD) that is leading to this heartburn and the obesity itself are

likely leading to worsening of her underlying respiratory symptoms.

In reviewing the patient's asthma history over the past couple of years, it is important to note that she is doing

much better since starting a combined inhaled corticosteroid/long-acting beta-agonist (ICS/LABA). She had

initially been tried on an inhaled steroid, but was not educated regarding the side effects of this medication

class (dysphonia and oropharyngeal candida infection, also called thrush) and proper use of this inhaler (with

an aerochamber followed by rinsing/gargling well) to minimize these side effects. Accordingly, the patient

developed thrush shortly after starting the medication. Thinking she had to choose between improved asthma

control and the "miserable" sensation of the thrush, she decided to discontinue her inhaled corticosteroid.

Several years later, she was prescribed an ICS/LABA, with appropriate education regarding side effects and

proper use. Since then, she has been using the inhaler regularly, with considerable benefit to her asthma, as

evidenced by the decrease in nighttime symptoms and emergency room visits.


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CONCLUSION Overall, simulation users performed below average on all decisions points relating to learning objectives in both

cases.

Learning objective 1 was achieved by an average of 49% by all users in both cases.



Although decisions regarding treatment (LO2) for both patients were higher than scores for other decisions,

simulation users failed to make the appropriate decision to optimize treatment and encourage medication

adherence. For Jessica (case 01), the adverse effects of her albuterol interfered with her quality of life leading

her to not consistently use her medication. Users failed to recognize this and the majority continued treatment

with albuterol instead of switching to levalbuterol. For Sandra (case 02), her symptoms were worsening despite

treatment with a mild dose of ICS/LABA combination therapy. The majority of simulation users continued her

treatment with this regimen, but failed to initiate treatment with a more effective prostacyclin, either in addition

to or in place of her current treatment. Similarly, non-pharmacological orders were selected by a small

percentage of users overall. These decisions reflect an oversight by clinicians to recognize the importance of

patient education and counseling in order to promote medication adherence, self-monitoring techniques, and

life-style adjustments.

Future Educational Recommendations According to the data we have collected for this activity, future educational interventions should focus on:

Current treatment options according to guidelines for optimizing asthma treatment

Non-pharmacological orders to encourage medication adherence and to teach self-monitoring

techniques


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METHODOLOGY

Virtual Patient Simulation TheraSim, Inc. is the exclusive simulation provider for Medscape, LLC. Through the power of simulation training,

TheraSim enables healthcare professionals to more rapidly assimilate new medical information and make more

effective clinical decisions.

Learners will be presented with realistic case scenarios to challenge their application of clinical knowledge in

particular indications. Through the simulations learners will make lab, diagnose and therapeutic decisions to

address the virtual patient who sits in front of them.

AIME – Clinical Guidance Supported by the world’s smartest simulation mentor, AIME, learners will receive individual mentoring and

debriefing at every decision point.

Additionally, as a participant ends a patient simulation, the TheraSim Clinical Simulator provides “last chance”

clinical guidance on critical aspects of each case that the participant has either failed to address or addressed

inappropriately.

Case Vignettes Case vignettes have gained considerable support for their value in predicting physician practice patterns.

Results from recent research studies demonstrate that case vignettes (when compared with chart review and

standardized patients) are a valid and comprehensive method of measuring a physician’s process of care in

actual clinical practice. (Luck 2006; Peabody 2000; Peabody 2004)

Furthermore, case vignettes are more cost-effective and less invasive than other means of measurement.

Decision Constraints Diagnostic and therapeutic choices are not constrained – that is, learners can choose from the universe of

possible diagnoses and available drug therapies. As a result, this data can provide insight into the clinical

decisions being made in actual practice.

The analysis for each patient case simulation focuses on those participants that meet the following criteria:

Completed the case

Exhibited engagement with the case by ordering at least one therapy, one drug, or one lab test

Engaged with the debrief section by reviewing case summary, performance analysis, and literature

review


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APPENDIX

Case 01 Impact of Clinical Guidance

Impact of Clinical Guidance: Specialists n = 75

Diagnoses Before CG Add'l After CG Improvement

Asthma, Severe Persistent 3% 0% 0%

Impact of Clinical Guidance: Other Users n = 313


Asthma, Severe Persistent 10% 1% 6%


Treatments Before CG Add'l After CG Improvement

Combination ICS/LABA 56% 5% 10%

Cromolyn/Nedocromil 0% 0% inf

Influenza Vaccine 0% 0% inf

Inhaled Corticosteroid (ICS) 67% 13% 20%

Ipratropium 0% 0% inf

LABA 0% 0% inf

Leukotriene Receptor Antagonists (LTRA) 7% 0% 0%

Nasal Corticosteroid Spray 3% 1% 50%

Omalizumab 0% 0% inf

Oral Antihistamine 0% 0% inf

Pneumococcal Vaccine 0% 21% inf

Rescue Inhalers 57% 16% 28%

SABA 57% 16% 28%

Systemic Corticosteroid 3% 0% 0%

Theophylline 1% 0% 0%

Tiotropium 0% 0% inf


19



Combination ICS/LABA 51% 5% 9%

Cromolyn/Nedocromil 0% 0% -100%

Influenza Vaccine 0% 5% 1500%


Ipratropium 0% 0% 0%

LABA 0% 1% inf

Leukotriene Receptor Antagonists (LTRA) 9% 1% 7%

Nasal Corticosteroid Spray 4% 3% 82%

Omalizumab 0% 0% inf

Oral Antihistamine 1% 0% 0%

Pneumococcal Vaccine 1% 30% 2375%

Rescue Inhalers 64% 16% 25%

SABA 64% 16% 25%

Systemic Corticosteroid 0% 0% inf

Theophylline 0% 0% inf

Tiotropium 0% 0% 0%


Labs/Tests Before CG Add'l After CG Improvement

Pulmonary Function Tests (without images) 55% 4% 7%

Electrocardiogram (ECG) 24% 3% 11%

2-D Echocardiogram (Transthoracic) 19% 0% 0%

Chest CT scan 16% 3% 17%

Alpha-1-Antitrypsin Level 23% 3% 12%

Chemistry Screen 19% 0% 0%

Pulse Oximetry - After Walking 32% 20% 63%

Chest X-Ray 61% 12% 20%

Complete Blood Count (CBC) - Basic 39% 4% 10%

Methacholine Challenge Test (MCT) 49% 13% 27%

Pulse Oximetry - At Rest 25% 23% 89%

Spirometry 57% 4% 7%

Total Serum IgE 49% 3% 5%

Asthma Control Test 57% 3% 5%


20



Pulmonary Function Tests (without images) 64% 7% 11%

Electrocardiogram (ECG) 38% 4% 9%

2-D Echocardiogram (Transthoracic) 39% 3% 7%


Alpha-1-Antitrypsin Level 34% 4% 12%

Chemistry Screen 32% 3% 9%

Pulse Oximetry - After Walking 51% 19% 38%

Chest X-Ray 60% 17% 28%

Complete Blood Count (CBC) - Basic 47% 5% 11%


Pulse Oximetry - At Rest 42% 21% 50%

Spirometry 64% 9% 14%

Total Serum IgE 46% 5% 11%



Non-Pharmacological Before CG Add'l After CG Improvement

Adherence Counseling 13% 25% 190%

Avoidance of Environmental Triggers 12% 24% 200%

Bronchial Thermoplasty 0% 0% inf

Asthma Pathophysiology and Medication Education 12% 8% 67%

Self monitoring of Asthma 16% 19% 117%

Asthma Medication/Inhaler Technique 15% 23% 155%

Allergen Avoidance Counseling 8% 12% 150%

Allergen Immunotherapy 1% 0% 0%

Exercise 9% 4% 43%

Allergy 13% 5% 40%

ENT 1% 0% 0%

Gastroenterology 0% 0% inf

Occupational Medicine consult 0% 0% inf

Pulmonary 0% 3% inf

Speech Therapy 0% 0% inf


21


Non-Pharamacological Before CG Add'l After CG Improvement



Bronchial Thermoplasty 2% 1% 33%






Exercise 9% 10% 111%

Allergy 6% 4% 63%

ENT 1% 0% 50%

Gastroenterology 0% 0% 0%


Pulmonary 7% 5% 74%

Speech Therapy 0% 0% 0%


Case Drugs Before CG Add'l After CG Improvement

omalizumab 0% 0% inf

cromolyn 0% 0% inf

nedocromil 0% 0% inf

methylprednisolone 1% 0% 0%

dexamethasone 0% 0% inf

prednisone 1% 0% 0%

prednisolone 0% 0% inf

theophylline 1% 0% 0%

budesonide-formoterol 4% 0% 0%

formoterol-mometasone 0% 0% inf

fluticasone-salmeterol 52% 5% 10%

formoterol 0% 0% inf

salmeterol 0% 0% inf

ipratropium 0% 0% inf

tiotropium 0% 0% inf

montelukast 7% 0% 0%

zafirlukast 0% 0% inf

zileuton 0% 0% inf

beclomethasone 0% 1% inf


22


Drugs Before CG Add'l After CG Improvement

omalizumab 0% 0% inf

cromolyn 0% 0% -100%

nedocromil 0% 0% inf

methylprednisolone 0% 0% inf

dexamethasone 0% 0% inf

prednisone 0% 0% inf

budesonide 1% 0% 0%

flunisolide 1% 0% 0%

fluticasone 8% 5% 67%

triamcinolone 0% 0% inf

ciclesonide 0% 0% inf

mometasone 0% 1% inf

albuterol 48% 16% 33%

levalbuterol 9% 0% 0%

pirbuterol 0% 0% inf

budesonide nasal 0% 0% inf

fluticasone nasal 0% 0% inf

mometasone nasal 1% 0% 0%

cetirizine 0% 0% inf

chlorpheniramine 0% 0% inf

desloratadine 0% 0% inf

diphenhydramine 0% 0% inf

fexofenadine 0% 0% inf

loratadine 0% 0% inf

pneumococcal 23-valent vaccine 0% 21% inf

influenza virus vaccine, live, trivalent 0% 0% inf

influenza virus vaccine, inactivated 0% 0% inf

metaproterenol 0% 0% inf

albuterol-ipratropium 0% 0% inf

alprazolam 17% 7% 38%


citalopram 0% 0% inf

midazolam 0% 0% inf

warfarin 0% 0% inf


23

prednisolone 0% 0% inf

theophylline 0% 0% inf

budesonide-formoterol 2% 0% -17%

formoterol-mometasone 1% 0% -25%


formoterol 0% 0% inf

salmeterol 0% 1% inf

ipratropium 0% 0% 0%

tiotropium 0% 0% 0%



zileuton 1% 0% 50%

beclomethasone 4% 2% 64%

budesonide 2% 1% 57%

flunisolide 0% 0% inf

fluticasone 8% 6% 73%





levalbuterol 4% 2% 58%

pirbuterol 0% 0% 0%


fluticasone nasal 0% 0% inf

mometasone nasal 0% 0% inf

cetirizine 1% 0% 0%






pneumococcal 23-valent vaccine 1% 30% 2375%

influenza virus vaccine, live, trivalent 0% 1% inf

influenza virus vaccine, inactivated 0% 4% 1100%

metaproterenol 0% 0% inf

albuterol-ipratropium 0% 0% inf

alprazolam 24% 2% 7%


citalopram 0% 0% -100%

midazolam 0% 0% 0%

warfarin 0% 0% 0%


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Case 02 Impact of Clinical Guidance



Gastroesophageal Reflux Disease (GERD) 24% 29% 120%

Vocal Cord Dysfunction (VCD) 10% 10% 100%

Sinusitis, Chronic 0% 0% inf

Bronchitis, Chronic 0% 0% inf



Gastroesophageal Reflux Disease (GERD) 11% 23% 220%

Vocal Cord Dysfunction (VCD) 5% 5% 100%

Sinusitis, Chronic 0% 0% inf

Bronchitis, Chronic 0% 0% inf



ACE-Inhibitor / ARB 57% 5% 8%

Antihistamine 67% 5% 7%

Asthma Step-Up Group 67% 10% 14%

Chronic oral steroid therapy 0% 0% inf

H2 Antagonists 0% 0% inf

Influenza virus vaccination 5% 0% 0%


Inhaled Cortocosteroid add-on therapy 14% 5% 33%

Leukotriene modifying agents 5% 10% 200%

NSAIDs 0% 0% inf

Nasal Steroid 14% 5% 33%

Nasal Steroid Spray 67% 0% 0%

Omalizumab (Anti-IgE receptor) antibody 5% 0% 0%

Proton Pump Inhibitors 10% 43% 450%

S.pneumoniae vaccination 14% 0% 0%

Short acting beta-agonist 67% 10% 14%

Theophylline (Methylxanthines) 0% 0% inf


25

anti-epileptics 43% 5% 11%



ACE-Inhibitor / ARB 71% 5% 7%

Antihistamine 73% 5% 7%

Asthma Step-Up Group 73% 12% 16%

Chronic oral steroid therapy 0% 0% inf

H2 Antagonists 0% 0% inf

Influenza virus vaccination 2% 0% 0%


Inhaled Cortocosteroid add-on therapy 0% 2% inf

Leukotriene modifying agents 14% 1% 8%

NSAIDs 0% 1% inf

Nasal Steroid 0% 2% inf

Nasal Steroid Spray 66% 7% 11%

Omalizumab (Anti-IgE receptor) antibody 6% 3% 50%

Proton Pump Inhibitors 8% 28% 338%

S.pneumoniae vaccination 6% 0% 0%

Short acting beta-agonist 77% 12% 15%

Theophylline (Methylxanthines) 0% 0% inf

anti-epileptics 67% 7% 11%



Complete Blood Count (CBC) w/ Differential 52% 0% 0%

Serum Immunoglobulin Measurement 38% 5% 13%

MRI (Brain) 5% 0% 0%

Total Serum IgE (kU/L) 67% 10% 14%

Pre/Post work Peak flows 48% 19% 40%

Exhaled NO (Nitric Oxide) 48% 0% 0%


Pulmonary Function Tests (w/ images) 76% 10% 13%


CT Sinuses 62% 5% 8%

Eosinophil Count 33% 0% 0%

Esophagram (Barium Swallow) 33% 5% 14%


26

Impedence Probe 10% 0% 0%


Provoked Laryngoscopy 19% 43% 225%



Complete Blood Count (CBC) w/ Differential 58% 5% 9%

Serum Immunoglobulin Measurement 35% 6% 18%

MRI (Brain) 17% 3% 19%

Total Serum IgE (kU/L) 58% 6% 11%

Pre/Post work Peak flows 58% 17% 29%

Exhaled NO (Nitric Oxide) 31% 7% 24%


Pulmonary Function Tests (w/ images) 76% 14% 18%


CT Sinuses 51% 6% 13%

Eosinophil Count 46% 8% 18%

Esophagram (Barium Swallow) 26% 15% 56%

Impedence Probe 19% 9% 50%


Provoked Laryngoscopy 21% 25% 120%


Non-Pharmacological Before CG Add'l After CG Improvement








Exercise 33% 5% 14%

Bronchial Thermoplasty 0% 0% inf



Pulmonary 5% 0% 0%



27

ENT 10% 10% 100%

Allergy 33% 5% 14%


28


Non-Pharamacological Before CG Add'l After CG Improvement








Exercise 23% 9% 41%

Bronchial Thermoplasty 1% 0% 0%



Pulmonary 8% 4% 50%

Occupational Medicine consult 1% 2% 200%

ENT 12% 5% 45%

Allergy 22% 8% 38%


Case Drugs Before CG Add'l After CG Improvement

cetirizine 57% 5% 8%

fexofenadine 5% 0% 0%

desloratadine 5% 0% 0%



levocetirizine 0% 0% inf




fluticasone nasal 67% 0% 0%

triamcinolone nasal 0% 0% inf

ciclesonide nasal 0% 0% inf

beclomethasone 10% 0% 0%





omalizumab 5% 0% 0%

fluticasone 0% 5% inf

budesonide 0% 0% inf


ciclesonide 5% 0% 0%


29


zileuton 0% 0% inf


naproxen 0% 0% inf

ibuprofen 0% 0% inf

celecoxib 0% 0% inf

flurbiprofen 0% 0% inf

ketoprofen 0% 0% inf

ketorolac 0% 0% inf

meloxicam 0% 0% inf

nabumetone 0% 0% inf

oxaprozin 0% 0% inf

piroxicam 0% 0% inf

sulindac 0% 0% inf

meclofenamate 0% 0% inf

diclofenac 0% 0% inf

cimetidine 0% 0% inf

famotidine 0% 0% inf

nizatidine 0% 0% inf

ranitidine 0% 0% inf

carbamazepine 43% 5% 11%

lisinopril 52% 5% 9%

benazepril 0% 0% inf

captopril 0% 0% inf

enalapril 0% 0% inf

fosinopril 0% 0% inf

irbesartan 0% 0% inf

losartan 5% 0% 0%

quinapril 0% 0% inf

ramipril 0% 0% inf

valsartan 0% 0% inf

perindopril 0% 0% inf

trandolapril 0% 0% inf

candesartan 0% 0% inf

olmesartan 0% 0% inf

telmisartan 0% 0% inf

eprosartan 0% 0% inf

moexipril 0% 0% inf

azilsartan 0% 0% inf



budesonide-formoterol 0% 5% inf


formoterol-mometasone 5% -5% -100%




30

levalbuterol 0% 0% inf

dexlansoprazole 0% 0% inf

esomeprazole 5% 0% 0%

lansoprazole 0% 0% inf

omeprazole 5% 43% 900%

pantoprazole 0% 0% inf

rabeprazole 0% 0% inf

acetaminophen 0% 0% inf


Drugs Before CG Add'l After CG Improvement

cetirizine 68% 4% 6%



loratadine 4% 0% 0%


levocetirizine 0% 0% inf




fluticasone nasal 65% 7% 11%

triamcinolone nasal 0% 0% inf

ciclesonide nasal 1% 0% 0%

beclomethasone 0% 1% inf





omalizumab 6% 3% 50%

fluticasone 0% 0% inf

budesonide 0% 0% inf




zileuton 0% 0% inf


naproxen 0% 0% inf

ibuprofen 0% 0% inf

celecoxib 0% 1% inf

flurbiprofen 0% 0% inf

ketoprofen 0% 0% inf

ketorolac 0% 0% inf

meloxicam 0% 0% inf

nabumetone 0% 0% inf


31

oxaprozin 0% 0% inf

piroxicam 0% 0% inf

sulindac 0% 0% inf

meclofenamate 0% 0% inf

diclofenac 0% 0% inf

cimetidine 0% 0% inf

famotidine 0% 0% inf

nizatidine 0% 0% inf

ranitidine 0% 0% inf

carbamazepine 67% 7% 11%

lisinopril 67% 4% 6%

benazepril 0% 0% inf

captopril 0% 0% inf

enalapril 0% 0% inf

fosinopril 0% 0% inf

irbesartan 1% 0% 0%

losartan 1% 1% 100%

quinapril 0% 0% inf

ramipril 0% 0% inf

valsartan 0% 0% inf

perindopril 0% 0% inf

trandolapril 0% 0% inf

candesartan 0% 0% inf

olmesartan 0% 0% inf

telmisartan 1% 0% 0%

eprosartan 0% 0% inf

moexipril 0% 0% inf

azilsartan 0% 0% inf



budesonide-formoterol 4% 0% 0%


formoterol-mometasone 0% 1% inf



levalbuterol 0% 0% inf

dexlansoprazole 0% 0% inf

esomeprazole 0% 6% inf

lansoprazole 0% 3% inf

omeprazole 7% 15% 200%

pantoprazole 1% 3% 300%

rabeprazole 0% 1% inf

acetaminophen 1% 0% 0%


32


33

REFERENCES

Luck J, Peabody JW, Lewis BL. An automated scoring algorithm for computerized clinical vignettes: evaluating

physician performance against explicit quality criteria. Int J Med Inform. 2006;75:701-707.

Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M Comparison of vignettes, standardized patients, and

chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA.

2000;283:1715-1722.

Peabody JW, Luck J, Glassman P, Jain S, Hansen J. Measuring the quality of physician practice by using

clinical vignettes: A prospective validation study. Ann Intern Med. 2004;141:771-778.


34

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