Asthma APGAR Tool Improves Management in Primary Care Setting
By CINDY SANDERS
A study published last month in the Annals of Family Medicine assessing the efficacy of the Asthma APGAR tool in the primary care setting found usage improved asthma control and decreased asthma-related hospital admissions and emergency room visits.
Barbara Yawn, MD, MSc, FAAFP, lead author of the study from the Department of Research at Olmsted Medical Center in Rochester, Minn., said the cluster-randomized, controlled, pragmatic study enrolled 1,066 patients between the ages of five and 45 across 18 U.S. family medicine and pediatric practices to compare outcomes in patients with persistent asthma using the APGAR tool vs. usual care. The study included 245 children, 174 adolescents and 647 adults.
Yawn, who is also chief science officer for the COPD Foundation and an adjunct professor at the University of Minnesota in the Department of Family and Community Health, said participants could not have any other lung disease such as COPD. The also had to be diagnosed with persistent asthma requiring daily maintenance medication like an inhaled corticosteroid, montelukast, or combination therapy.
"The reason we even worked on developing the APGAR tools is because we had seen that ACT - the Asthma Control Test - has been around 20 years, and it's still not widely used," Yawn said of the impetus behind the tool and subsequent study. While ACT creates a score, Yawn said a key issue for many providers was how to apply that score to the next steps. "It became clear to me we needed a tool that was more broadly based for primary care and was linked to suggestions for action," she continued.
Working with primary care physicians, office staff and patients, the research team created the APGAR tool with six questions for patients assessing asthma control. The first three questions ask about asthma in relation to activities and persistence of symptoms during the day and night. The next question specifically looks at triggers, followed by a question about asthma medications taken over the past two weeks and frequency of treatment. The final question asks about response to these medications.
Like ACT, APGAR creates a score. However, Yawn explained, the APGAR score is tied to a care algorithm with specific actions. For those with a score of zero or one, they are in the green zone with asthma in control. A score of two or higher moves patients to the yellow or red phase of the algorithm.
"Anyone with a score of two or greater is out of control," she explained. "From previous research, we knew with somewhere between 60 to 80 percent of asthma patients, their asthma is not in control, and they'd be in the yellow part."
From the questionnaires, it became clear that a number of patients used their inhalers incorrectly or mixed up rescue and maintenance medications. "If a patient doesn't think their medications are working, they're probably not going to take them," Yawn pointed out. "Unfortunately," she continued, "a lot of times when people are out of control, they just get their medications stepped up ... but if they aren't adhering, giving them twice as much medicine to not adhere to is probably not helpful."
With the algorithm, providers have a stepwise process to address a range of potential issues impacting patient control. "If they're having an acute exacerbation, you have to deal with that immediately," said Yawn of moving into the red zone. "Otherwise, before you just step up their medications, think about adherence, correct usage, triggers, etc. It helps you think through what you ought to look at."
Participating patients or parents of young children were asked to complete both a baseline and 12-month questionnaire with 65 percent (692 patients) completing both for the researchers to analyze patient-reported outcomes. In addition, electronic health record data was available for 99.7 percent of participants (1,063 patients) to allow the team to evaluate practice outcomes.
In the APGAR group, there was a 50 percent decrease in emergency room visits, hospitalizations and urgent care visits compared to the usual care cohort (10.6% v. 20.9%, P=.004). "We were very excited about that," said Yawn. "It's a big number."
Between baseline and one year, patients with "in control" asthma in the APGAR group increased significantly compared to the usual care group (13.5% v. 3.4%, P=.0001 vs. P=.86). "In the usual care group, we didn't' improve the rates of patients in control, but we did in the APGAR group. We went from about 41 percent being in control up to about 54 percent being in control. That's about a 25 percent relative improvement and about a 13 percent absolute improvement."
Additionally, APGAR practices improved adherence to three or more asthma guideline elements compared to the usual practice groups (20.7% increase v. 1.9% decrease, P=.001).
Yawn said the study intentionally focused on smaller practices that tend to have fewer resources and staff educators. "We wanted to show that in practices without lots of additional support, you could improve asthma care using these tools," she stated.