Primary Care Asthma Program lungontario.ca/pcap

A newsletter for all health care professionals in primary care in Ontario Winter 2019

AFHTO “Bright Lights” Awards

e are pleased to announce that PCAP is the successful winner of the Association of Family Health Teams of Ontario’s (AFHTO’s) 2018 Bright Lights board award. This award recognizes an organization or individual that has made extraordinary contribution to team-

based primary care. This honour was rewarded to PCAP in recognition of its promotion of best practices in treatment of respiratory diseases. We are honoured to have been chosen for this award and we will

continue to provide evidence-based best practice care to those living with lung disease.

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Severe Asthma in Canada By Delanya Podgers Nurse Practitioner Asthma Program - Kingston Health Sciences Centre, Kingston, Ontario 1 The Canadian Thoracic Society (CTS) recently published a position paper (2017) on the recognition and management of severe asthma to guide practitioners who provide care to patients with severe asthma. Although the prevalence of severe asthma has been estimated to account for 5-10% of the population with asthma, it is the reason for more than half of the overall direct and indirect costs of asthma.

Defining Severe Asthma

The CTS defines severe asthma as asthma which requires treatment with high dose inhaled corticosteroid (ICS) as well as a second controller, or systemic corticosteroids for 50% of the previous year to maintain control, or asthma which remains uncontrolled despite this therapy. Asthma is considered uncontrolled when at least one of the following is present:

Poor symptom control: as defined by the CTS control criteria or other standardized questionnaires: Asthma Control Questionnaire (ACQ) consistently >1.5, Asthma Control Test (ACT) <20 or child Asthma Controlled Test (cACT) <20.

Frequent severe exacerbations: two or more courses of systemic corticosteroids (≥3 days each) in the previous year.

Serious exacerbations: at least one hospitalization, intensive care unit admission or mechanical ventilation in the previous year.

Airflow limitation: after appropriate bronchodilator withhold forced expiratory volume in one second (FEV1) <80% of personal best post (or < the lower limit of normal (LLN), in the face of reduced of FEV1/FVC defined as less than the LLN).

It is important that common causes of poor control be assessed and addressed. This begins with ensuring an accurate, objective diagnosis with pulmonary function testing. It has been suggested that up to a third of patients with presumed asthma have been found to have alternate diagnoses. Following a diagnosis, patients should be provided with self-management education which includes trigger reduction and avoidance, device technique, and development of a written asthma action plan. Device technique and medication adherence should be assessed on a regular basis.

Numerous co-morbidities can mimic asthma or worsen asthma symptoms. These commonly include upper airway disease such as rhino-sinusitis, gastro esophageal reflux disease, vocal cord dysfunction, anxiety and depression. Assessment and treatment of these disorders may improve asthma control. When symptoms remain poorly controlled, evaluating for uncommon comorbidities such as allergic bronchopulmonary aspergillosis or eosinophilic granulomatosis with polyangiitis is important.

Phenotyping Asthma

Asthma is a heterogeneous disease with multiple phenotypes or characteristics that, once identified, can help providers better understand and treat the disease. Biomarkers such as peripheral eosinophils, sputum differential cell counts, blood total immunoglobulin E (IgE), and fractional exhaled nitric oxide (FeNO) can be used to characterize phenotype and further guide treatment in patients with confirmed severe asthma.

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Eosinophils, both peripheral and sputum are useful in identifying those patients who may respond to anti-interleukin 5 (anti-IL5) therapies such as mepolizumab, reslizumab and benralizumab. Serum IgE has been shown to play an important role in severe allergic asthma and high levels of IgE can be used to identify those who are likely to respond to omalizumab. FeNO, although useful to identify airway inflammation, does not act as a predictor for response to biologic therapies.

Biologic Therapies

Omalizumab

Omalizumab is approved for patients 6 years and older with moderate to severe asthma who have an elevated IgE level, positive skin test or in vitro reactivity to a perennial aeroallergen and who are inadequately controlled on high dose ICS and one other controller. It is administered by subcutaneous injection every 2 to 4 weeks determined by baseline IgE levels and body weight. Omalizumab has been shown to reduce exacerbations, reduce ICS dose, and improve overall symptom control. There is a small risk of anaphylaxis therefore administration in a monitored setting is required.

Reslizumab

Reslizumab is approved in adult patients with a blood eosinophils count of >400 cells/µL at initiation and are inadequately controlled with medium to high dose ICS and an additional controller. A weight based dose is administered by intravenous infusion every 4 weeks. Reslizumab has been shown to reduce asthma exacerbations and improve FEV1. Administration in a monitored setting is required.

Mepolizumab

Mepolizumab is approved for adult patients with severe eosinophilic asthma who have a blood eosinophil count of >150 cells/µL at initiation or >300 cells/µL in the previous 12 months and remain poorly controlled despite high dose ICS and another controller. It is administered by subcutaneous injection every 4 weeks. Mepolizumab has been shown to reduce oral corticosteroid requirements by 50%. Additionally, improvements have been observed in both quality of life and FEV1. Administration in a monitored setting is required.

Benralizumab

Benralizumab is approved in adult patients with severe eosinophilic asthma. It is administered by subcutaneous injection every 4 weeks for a three injection induction, after which frequency drops to every 8 weeks. Benralizumab has been shown to reduce exacerbations, improve FEV1 and improve asthma-related quality of life. Administration in a monitored setting is required.

There have been no head-to head comparisons between anti-IL5 medications.

Tiotropium Bromide in Severe Asthma

The use of a long acting muscarinic antagonist (LAMA), specifically tiotropium bromide 5mcg once daily, as an add-on therapy for patients with severe asthma who remain uncontrolled despite combination inhaled corticosteroid / long acting beta agonist therapy may be considered. Of note, tiotropium bromide is not approved by Health Canada for use in those 6-17 years of age, however has been approved by the United States Food and Drug Administration in ages 6 and older. Based on a published meta-analysis that included adolescents ages 12-17 years, the CTS endorses use of tiotropium bromide 5mcg for those patients 12 years and older.

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Macrolide Therapy

Macrolides have both anti-microbial and anti-inflammatory properties and there is evidence that chronic use of macrolides in adult patients with severe asthma may decrease the frequency of exacerbations and improve overall asthma control. Specifically, azithromycin has been shown to decrease the risk of exacerbations and improve asthma-related quality of life and as such may be a useful add-on therapy with no phenotypic predictor. Macrolides should be avoided in patients with a pronged QTc interval, therefore this should be assessed prior to initiation. Due to the possibility of antibiotic resistant organisms and hearing loss, consideration should also be given to these potential adverse effects.

Bronchial Thermoplasty

Bronchial thermoplasty (BT) is an endoscopic procedure in which thermal energy is applied to the airway smooth muscle and aims to decrease bronchial constriction and airway hyper-responsiveness. Three separate BT procedures are typically performed at 3 week intervals. Ongoing research focuses on the patient phenotype who would best respond to this therapy. At this time BT is available in a very few specialized centers in Canada and remains a largely investigative tool.

Referral to Specialist Care

Patients with objectively confirmed asthma who remain uncontrolled on high dose ICS therapy should be re-evaluated for potential reasons for poor control. This includes medication adherence, device technique and environmental exposures. Co-morbidities that mimic or worsen asthma should be assessed and, if present, treated. A patient who remains uncontrolled despite optimization of self-management and co-morbidities meets the CTS criteria for severe asthma. Patients with suspected severe asthma should be referred for a specialist evaluation and asthma education. Fitzgerald, J.M., Lemiere, C., Lougheed, M.D., Ducharme, F.M., Dell, D.S., Ramsey, C., Yang, M.C., Cote, A., Watson, W., Olivenstein, R., Van Dam, A., Villa-Roel, C., and Grad, R. (2017). Recognition and management of severe asthma: A Canadian Thoracic Society position statement. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 1(4), 199-221.

Patient Experience Survey: A PCAP Tool By Jessica Sit PCAP Coordinator, South Riverdale CHC, Toronto

This year, a Primary Care Asthma Program (PCAP) working group developed a patient experience survey. The survey was developed to provide a standardized practice-based tool that allows PCAP sites to measure and monitor the experiences of their patients in order to make improvements to the quality of care. The survey contains questions aimed to evaluate all aspects of the patient experience including: administrative processes and clinical encounters. It also includes subjective questions about the patient experience related to comfort, respect, equity, and self-reported knowledge and understanding of treatment plans. Utilizing this data will help contribute to the PCAP program's quality improvement initiatives with intentions to further enhance program delivery whilst creating positive patient experiences and clinical outcomes. If your site would like more information or use the patient experience survey, please contact the PCAP provincial coordinator, Aisha Balasubramaniam (abalasubramaniam@lungontario.ca)

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QUALITY STANDARD ADDRESSES CARE FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE

By Aisha Balasubramaniam Interim Provincial Coordinator for the PCAP Program – The Lung Association - Ontario Although chronic obstructive pulmonary disease (COPD) is a progressive illness, there are significant opportunities to improve the quality of life of people with this disease. The goals of COPD management include slowing the progression of airflow limitation; reducing the frequency and severity of and treating acute exacerbations; relieving symptoms such as breathlessness and anxiety; improving exercise tolerance, managing comorbidities; and reducing mortality. In December of 2018, Health Quality Ontario (HQO) released quality standards to address care for people with COPD. The COPD quality standards provide guidance to health care providers, patients and caregivers on the diagnosis, management, and treatment of COPD in community-based settings by providing a set of concise statements designed to help health care professionals provide best evidence care.

The development of the fourteen standards could not have been completed without the knowledge, experience and skills of lived experience advisors and a variety of health care providers. PCAP coordinator, Christina Dolgowicz, who is a Lung Health Coordinator and Registered Respiratory Therapist/Certified Respiratory Educator, participated as a member of the committee and shared her extensive knowledge and experience with respiratory diseases. The experts met over a year’s time to complete a comprehensive review of the evidence and ranked priorities for COPD management and determined performance measures. This resulted in fourteen quality standards and a brief summary is listed below:

Quality Statement 1: Diagnosis Confirmed with Spirometry People clinically suspected of having COPD have spirometry testing to confirm diagnosis within 3 months of developing respiratory symptoms. 1 Quality Statement 2: Comprehensive Assessment People with COPD have a comprehensive assessment to determine the degree of disability, risk of acute exacerbation, and presence of comorbidities near the time of diagnosis and on an annual basis. The severity of airflow limitation, as initially determined by spirometry testing to confirm diagnosis, is reassessed when people’s health status changes. 1 Quality Statement 3: Goals of Care and Individualized Care Planning People with COPD discuss their goals of care with their future substitute decision-maker, their primary care provider, and other members of their interprofessional care team. These discussions inform individualized care planning, which is reviewed and updated regularly. 1 Quality Statement 4: Education and Self-Management People with COPD and their caregivers receive verbal and written information about COPD from their health care professional and participate in interventions to support self-management, including the development of a written self-management plan. 1 Quality Statement 5: Promoting Smoking Cessation People with COPD are asked about their tobacco-smoking status at every opportunity. Those who continue to smoke are offered pharmacological and nonpharmacological smoking cessation interventions. 1

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Quality Statement 6: Pharmacological Management of Stable COPD People with a confirmed diagnosis of COPD are offered individualized pharmacotherapy to improve symptoms and prevent acute exacerbations. Their medications are reviewed at least annually. 1 Quality Statement 7: Vaccinations People with COPD are offered appropriate influenza and pneumococcal vaccinations. 1 Quality Statement 8: Specialized Respiratory Care People with a confirmed diagnosis of COPD are referred to specialized respiratory care when clinically indicated, after receiving a comprehensive assessment and being offered treatment in primary care. This consultation occurs in accordance with the urgency of their health status. 1 Quality Statement 9: Pulmonary Rehabilitation People with moderate to severe, stable COPD are referred to a pulmonary rehabilitation program if they have activity or exercise limitations and breathlessness despite appropriate pharmacological management. 1 Quality Statement 9: Pulmonary Rehabilitation People with moderate to severe, stable COPD are referred to a pulmonary rehabilitation program if they have activity or exercise limitations and breathlessness despite appropriate pharmacological management. 1 Quality Statement 10: Management of Acute Exacerbations of COPD People with COPD have access to their primary care provider or a health care professional in their care team within 24 hours of the onset of an acute exacerbation. 1 Quality Statement 11: Follow-Up After Hospitalization for an Acute Exacerbation of COPD People with COPD who have been hospitalized for an acute exacerbation have an in-person follow-up assessment within 7 days after discharge. 1 Quality Statement 12: Pulmonary Rehabilitation After Hospitalization for an Acute Exacerbation of COPD People who have been admitted to hospital for an acute exacerbation of COPD are considered for pulmonary rehabilitation at the time of discharge. Those who are referred to a pulmonary rehabilitation program start the program within 1 month of hospital discharge. 1 Quality Statement 13: Palliative Care People with COPD and their caregivers are offered palliative care support to meet their needs.

Quality Statement 14: Long-Term Oxygen Therapy People with stable COPD who have clinical indications of hypoxemia receive an assessment for and, if needed, treatment with long-term oxygen therapy.

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Each quality standard comes with a detailed explanation and indicators to help clinicians and organizations assess the quality of care they are delivering and identify gaps and areas for improvement. These indicators measure processes, structures, and outcomes. In addition, tools and resources to support clinicians and organizations in their quality improvement efforts accompany each quality standard. The

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resources and direction of care provided by Primary Care Asthma Program (PCAP) program coincides with the COPD HQO quality standards.

The full report is available on the HQO website at https://www.hqontario.ca/Evidence-to-Improve-Care/Quality-Standards/View-all-Quality-Standards/Chronic-Obstructive-Pulmonary-Disease/Resources. For further questions, please contact PCAP Coordinator and HQO COPD quality standards advisory member, Christina Dolgowicz (cdolgowicz@nlchc.on.ca).

About Health Quality Ontario: Health Quality Ontario (HQO) is the agency in Ontario mandated to advise government and health care providers on the evidence to support high-quality care, to support improvements in quality, and to monitor and report to the public on the quality of health care provided in Ontario. The agency received this mandate through the Excellent Care for All Act, 2010 (ECFAA). The goal of ECFAA, as well as Ontario’s Action Plan for Health Care, is to transform the health care system by creating greater public accountability, increasing the focus on quality, bringing patient satisfaction to the forefront and basing patient care decisions on the best scientific evidence available.

Excited About Opportunity Ahead By: Christina Sperling The new Director of Respiratory Health Programs - The Lung Association - Ontario

The lung health of Ontarians has always been important to me, and as such, many years ago, I pursued the profession of Respiratory Therapy. I started my career as a clinician, and have moved through various leadership positions over the last 17 years. I have been very lucky to have supported the health care of patients in both the acute and non-acute care settings. Today, I am very enthusiastic to work for The Lung Association – Ontario, a charitable organization that is passionate about “Creating a world in which no one struggles to breathe”. I feel energized by the opportunity that exists ahead. As part of my portfolio, I have the pleasure of supporting the Primary Care Asthma Program (PCAP) and all of the wonderful work that is already happening. I believe that the efforts that currently exist to support asthma patients across the province will continue to evolve, and we all will have the chance to be part of something great. Currently in Ontario there are over 2 million people living with asthma. PCAP is an evidence-based program that has proven to provide patients with the opportunity to take charge of their disease. Through my leadership I hope to continue to grow the program across Ontario, allowing more patients to have access to PCAP. I’d like to create a more structured and sustainable post implementation strategy for PCAP sites that provides ongoing follow-up, formalized evaluation, and constructive feedback. Finally, I envision the development of a performance management framework that captures quantitative and qualitative data from all PCAP sites that demonstrates the impact of the program in a meaningful way to all stakeholders. I can honestly say that I feel very optimistic about the opportunities that lie ahead. The individuals that currently support PCAP are highly engaged and dedicated to improving patient outcomes. I feel very privileged to get to work in collaboration with this team and look forward to the work that is to come.

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Did you know? There is a new PCAP Chart Audit Tool!

Along with government legislation in documentation of personal health records, providers are accountable to their licensing colleges as well as their employer. A chart audit tool has been designed for respiratory educators delivering the Primary Care Asthma Program (PCAP) and outlines the minimum documentation expectations. The purpose of this tool is to: a) Promote ongoing compliance with College documentation standards

b) Support continuous quality improvement initiatives This tool has been created as an e-fillable PDF document. Once chart audits are completed, results may be collated electronically or manually, and be reviewed by a peer or supervisor. Check out this new tool today, available on the PCAP website!

www.lungontario.ca/pcap

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Provider Education Program Update – December 2018 By Lana Biro Program/Curriculum Developer, Provider Education Program - The Lung Association - Ontario

The Provider Education Program (PEP) develops, implements and evaluates certified continuing medical education programs and materials in accordance with the Canadian Thoracic Society (CTS) respiratory guidelines. The Provider Education Program incorporates multiple methods to effectively transfer asthma and COPD knowledge and skills into practice. Workshops and OTNs

This has been a busy year for us, and to date we have held 23 workshops with over 700 health-care providers participating. Our free, certified workshops include COPD, Adult Asthma, Adult and Pediatric Asthma, COPD vs. Asthma, Preschool Asthma, and Spirometry Interpretation. In addition, PEP continues to work closely with PCAP, and as part of this collaboration, two education sessions have been delivered using the Ontario Telemedicine Network (OTN) technology. These sessions were created based on the needs expressed by the PCAP Coordinators. The OTNs were on “Asthma COPD Overlap” and “Personalized COPD Management: CTS Pharmacotherapy Update”. In addition, the Work-Related Asthma program delivered 3 workshops reaching approximately 80 health care professionals.

The following workshops are confirmed for 2019:

To set up a free workshop for your team or organization, please contact us at pep@lungontario.ca. We will work with you to ensure your learning outcomes are achieved.

Certified E-Module News

The Spirometry Interpretation e-module is now available. This module is an in-depth review of spirometry interpretation, reports and testing criteria and is a follow-up to the Spirometry: A Clinical Primer e-module.

The Adult and Pediatric Emergency Department Asthma Care Pathways (EDACP) is an evidenced-based standardized approach to treating acute asthma exacerbations. The Pediatric EDACP includes the PRAM (Pediatric Respiratory Assessment Measure) to assess the asthma acuity level in children presenting to the ED. E-modules on both pathways are available to assist health care providers become more familiar with the pathways. For more information contact us at edacp@lungontario.ca.

Date Topic Location

February 6, 2019 COPD Toronto

February 26, 2019 COPD Toronto

February 27, 2019 COPD Comorbidities Whitby

March 21, 2019 Pediatric Asthma Action Plan OTN / Webinar

April 25, 2019 COPD Smith Falls

May 23, 2019 Respiratory Medications & COPD vs Asthma Manitoulin Island

TBD Spirometry Interpretation Stratford

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Under-development is a series of COPD mini-modules. Keep your eye out for this series in the New Year. Please visit ola.machealth.ca to take these and other free, certified e-learning modules.

What’s New? The Respiratory Medication Reference for health care providers was updated to include the latest inhaled respiratory medications, as well antibiotics for purulent COPD exacerbation and nasal sprays for allergic rhinitis. The reference also includes the most updated information on medication coverage in Ontario and maximum daily doses. This informative resource has been recently printed and is currently available for all health-care providers in Ontario. The updated electronic version can be accessed on https://bit.ly/2C9ocds

A written asthma action plan (AAP) is an effective tool used by health care providers to help the patient/family understand key

management points, establish good monitoring, and prevent asthma exacerbations. The Lung Association’s Pediatric Asthma Action Plan, released this year on World Asthma Day addresses the need for one, cohesive, evidence-based action plan amongst care providers and was developed iteratively, with contributions from primary care physicians, asthma educators, respiratory experts and patients. The Pediatric Asthma Action Plan has been incorporated into our programming and complements the revised adult AAP (olapep.ca/wp-content/uploads/2018/07/Pediatric-Asthma-Action-Plan-e-fillable.pdf).

The Asthma Action Plan Yellow Zone Formulation Table is a point-of-care tool that helps to guide health care providers with step-up therapy in the yellow zone of the asthma action plan. The tool is available on lungontario.ca website and will be implemented in our Asthma Action Plan e-module and other asthma programming.

PEP, in collaboration with PCAP, is revising the COPD Diagnosis and Management Algorithm and the COPD Care Map, evidence-based tools that assist practitioners with diagnosis and management of COPD. The updates to the

algorithm and care map will be in accordance with the latest guidelines to ensure on-going use of an evidence based approach to care and treatment of those with COPD and will highlight for primary care providers key management principles.

In the coming months, The Lung Association - Ontario is very excited to be launching a new health care professional education and clinical experience section on the lungontario.ca website highlighting educational offering, tools and resources for health care providers.

As part of our marketing and networking strategy, PEP promotes workshops and resources at several conferences. This year PEP exhibited and hosted an Asthma Action Plan talk entitled “How to make a self-management asthma action plan for your patient with asthma” at the NPAO conference. PEP also had two sessions and exhibited at the Family Medicine Forum in November in Toronto. We are also thrilled to be having a poster presentation at the Canadian Respiratory Care conference in April.

To register for any of our programs and news on upcoming events or conferences, please visit our website www.olapep.ca and/or follow PEP on twitter at #ONLung_pep.

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Notes

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End TB 2019: 23rd Annual Conference of The Union-North America Region

Canadian Respiratory Conference (CRC)

April 11 – 13, 2019 in Ottawa, ON

CSRT Annual Education Conference

May 9 - 11, 2019 in Niagara Falls, ON