2012 Asthma Supplement

Attachment B: 2012 Asthma Supplement Questions

This amount of space will be occupied by the questionnaire title, OMB information, assurance of confidentiality, introduction, and provider background information. It is estimated that this supplement will take 15 minutes for the provider to complete.

Background information:

A. Provider specialty

B. Census contact name

C. Provider serial number

D. Census contact telephone

Introduction: The National Institutes of Health, Centers for Disease Control and Prevention, and the US Environmental Protection Agency are conducting a special survey on asthma care provided in community health centers and private office settings. We are interested in the clinical decisions you make about asthma. Please answer the following questions about your actual practice. In responding, do not worry about the ideal or “correct” answer. We appreciate your time on this important public health concern.

1.0 For which of the following age groups do you see patients (don’t include patients of other practitioners at your site)?

Check all that apply:

□ children 0-12 years □ adolescents 12-21 years □ adults 18-64 years □ older adults 65 years and above

1.1 In your current practice, have you participated in an organized asthma improvement program that focused on improving quality of care or patient outcomes for patients with asthma?

□ yes □ no □ don’t know

1.2 Does your practice have an asthma registry? (an additional system often separate from medical records to track and manage only patients with asthma)?

□ yes □ no □ don’t know

1.3 Do you use a structured encounter form (i.e, an asthma template) when asthma is the primary reason for the visit?

□ yes, often □ yes, sometimes □ no □ don’t know

1.4 During your last normal week of practice, how many visits did you have with patients with asthma (don’t include patients of other practitioners at your site)?

________ Number of asthma visits □ don’t know

1.5 Consider a non-asthma visit with a patient with asthma. Which strategy below is closest to how you decide to address asthma?

□ I only address asthma when the patient raises a concern about asthma

□ I ask the patient about their asthma and I any specific concerns that the patient mentions

□ I ask the patient about their asthma and regardless of concerns, I fully review all aspects of asthma care

□ Regardless of the reason for the visit or patient concerns, I fully review all aspects of asthma care

1.6 How many of your patients (don’t include patients of other practitioners at your site) have:

Circle one number in each row.	very few or none	some patients	about half of patients	most patients	all or nearly all patients	Don’t know
… asthma of mild severity?	1	2	3	4	5	6
… asthma of moderate severity?	1	2	3	4	5	6
… severe and/or difficult-to-control asthma?	1	2	3	4	5	6

1.7 Are you notified by the hospital when one of your patients is admitted for asthma?

□ yes, in all or most cases □ yes, in some cases □ rarely or never □ don’t know

1.8 Are you notified by the hospital when one of your patients is seen in the emergency department for asthma?

□ yes, in all or most cases □ yes, in some cases □ rarely or never □ don’t know

2.1 How often do you use the following criteria to diagnose asthma?

Criteria: circle one number in each row.	Rarely or never	In some cases	In about half of cases	In most cases	In all or nearly all cases
1. History of recurrent cough, wheeze, chest tightness, difficulty breathing	1	2	3	4	5
2. Worsening of symptoms in the presence of pollen, smoke, exercise, pets, or other specific exposures?	1	2	3	4	5
3. Family history of asthma	1	2	3	4	5
4. Physical exam findings	1	2	3	4	5
5. Peak expiratory flow rate in your office	1	2	3	4	5
6. Lung function testing/spirometry (in your office or by referral)	1	2	3	4	5
7. Response to bronchodilators (e.g., Albuterol)	1	2	3	4	5
8. Methacholine challenge	1	2	3	4	5
9. Refer patients to a specialist for diagnosis	1	2	3	4	5
10. Other (specify):	1	2	3	4	5

The next two questions ask about your assessment of asthma severity and asthma control. Underlying severity is the intrinsic intensity of the disease process whereas asthma control is the degree to which asthma symptoms are minimized by therapy.

3.1 For patients for whom you make the initial diagnosis of asthma, do you make an initial severity assessment in order to determine the type and level of initial therapy needed?

□ yes □ no □ don’t know how to assess severity

3.2 Once a patient receives treatment, ongoing symptom patterns can show the degree to which a patient’s asthma is controlled. How frequently do you ask about the following symptoms or perform the following tests to assess asthma control?

Criteria: Circle one number in each row.	Rarely or never	In some cases	In about half of cases	In most cases	In all or nearly all cases
1. Ability to engage in normal daily activities	1	2	3	4	5
2. Frequency of daytime symptoms	1	2	3	4	5
3. Frequency of nighttime symptoms	1	2	3	4	5
4. Patient perception of symptom control	1	2	3	4	5
5. Control assessment tool e.g., Asthma Control Test (ACT) or Asthma Therapy Assessment Questionnaire (ATAQ)	1	2	3	4	5
6. Patient symptom diaries	1	2	3	4	5
7. Frequency of rescue inhaler use (such as Albuterol)	1	2	3	4	5
8. Frequency of exacerbations requiring oral steroids	1	2	3	4	5
9. Patient report of emergency department or urgent care visit for asthma	1	2	3	4	5
10. Peak flow results at home	1	2	3	4	5
11. Peak flow results in your office	1	2	3	4	5
12 . Spriometry in the office	1	2	3	4	5

4.1 How often do you use each of the following strategies to help patients control their asthma?

Circle one number in each row.	Rarely or never	In some cases	In about half of cases	In most cases	In nearly all cases	Not applicable
1. Provide as asthma action plan (a written care plan that outlines medications, triggers, symptom management, and when to seek for emergent care)?	1	2	3	4	5	n/a
Assessment by history of triggers at the patient’s… 2A. …home (e.g., pets, mold, second-hand smoke) 2B. …school (e.g., dust, fumes, exhaust) 2C …workplace (e.g., occupational exposures)	1 1 1	2 2 2	3 3 3	4 4 4	5 5 5	n/a n/a n/a
3.Specific assessment by history of triggers specific to individuals (e.g., exercise, weather, strong emotions)	1	2	3	4	5	n/a
4. Assessment of actual medication use (not filled prescriptions)	1	2	3	4	5	n/a
5. Education about avoiding/controlling triggers	1	2	3	4	5	n/a
6. Prescription of a spacer for short-acting beta agonist metered dose inhaler	1	2	3	4	5	n/a
7. Prescription of a spacer for inhaled corticosteroid metered dose inhaler	1	2	3	4	5	n/a
8. Regularly scheduled (non-urgent) asthma follow up visits to assess management	1	2	3	4	5	n/a

4.2 How often do you see patients for regularly scheduled (non-urgent) asthma visits in the following categories?

Circle one number in each row.	No regular schedule	Monthly or more frequently	Every 3 months	Every 6 months	Yearly
Not on controller medication with … 1A. … no exacerbations in past year 1B. … one exacerbation in the past year 1C … two or more exacerbations in the past year	1 1 1	2 2 2	3 3 3	4 4 4	5 5 5
On controller medication with … 2A. … symptoms under control 2B. … symptoms not controlled	1 1	2 2	3 3	4 4	5 5

4.3 How often do you make the following recommendations about environmental exposures that exist in a patient’s home?

Recommendation: circle one number in each row.	For all asthma patients	Only for patients with known or reported sensitivity to this trigger	Rarely or never recommend
Using dust mite control measures (removing carpets, using mattress/pillow covers, laundering sheets in hot water, HEPA vacuum cleaning, reducing humidity, etc)	1	2	3
2. HEPA air filtration (remove airborne allergens, mold, particulates)	1	2	3
3. Controlling mold	1	2	3
4. Controlling household pests (e.g. cockroaches, rodents)	1	2	3
5. Removing pets from the home	1	2	3
6. Avoiding pollen (e.g., limit outdoor time, close windows)	1	2	3
7. Avoiding air pollution (e.g., limit outdoor time)	1	2	3
8 Making changes to cooking appliances (e.g., stoves or exhaust vents)	1	2	3
9. Avoiding second-hand tobacco smoke	1	2	3
10.Other (specify):	1	2	3

5.1 For children (0-17 years) with asthma, how do you use the following medications?

If you do not see patients in this age range, please skip to question 5.2

Medication: mark (x) for ALL that apply on each row.	Do not use	Rescue/for acute symptoms	First line control therapy	Add on control therapy if first line not effective	For difficult to control asthma
1. Short acting beta agonists (e.g. Albuterol)	1	2	3	4	5
2.Inhaled corticosteroids (ICS) as a single agent	1	2	3	4	5
3.Long acting beta agonists (LABA) (e.g., salmeterol/Serevent) as a single agent	1	2	3	4	5
4. Combination medication that includes both LABA and ICS (e.g., fluticasone and salmeterol/Advair)	1	2	3	4	5
5.Leukotriene modifiers (e.g., montelukast/Singulair)	1	2	3	4	5
6.Methylxanthines (e.g., sustained-release theophylline)	1	2	3	4	5
7.Immunotherpay (omalizumab/Xolair)	1	2	3	4	5
8.Oral corticosteroids (short course ≤14 days)	1	2	3	4	5
9.Oral corticosteroids (longer course >14 days)
10.Other (specify):	1	2	3	4	5

5.2 For adults (18 years and over) with asthma (how do you use the following medications?

If you do not see patients in this age range, please skip to question 6.1

Medication: mark (x) for ALL that apply on each row.	Do not use	Rescue/for acute symptoms	First line control therapy	Add on control therapy if first line not effective	For difficult to control asthma
1. Short acting beta agonists (e.g. Albuterol)	1	2	3	4	5
2.Inhaled corticosteroids (ICS) as a single agent	1	2	3	4	5
3.Long acting beta agonists (LABA) (e.g., salmeterol/Serevent) as a single agent	1	2	3	4	5
4. Combination medication that includes both LABA and ICS (e.g. fluticasone and salmeterol/Advair)	1	2	3	4	5
5.Leukotriene modifiers (e.g., montelukast/Singulair)	1	2	3	4	5
6.Methylxanthines (e.g., sustained-release theophylline)	1	2	3	4	5
7. Immunotherpay (omalizumab/Xolair)	1	2	3	4	5
8.Oral corticosteroids (short course ≤14 days)	1	2	3	4	5
9.Oral corticosteroids (longer course >14 days)
9.Other (specify):	1	2	3	4	5

6.1 Below are several strategies and tools that could be used to help patients control their asthma. First specify if you use each strategy, and next, specify the most important barrier (if any) you face to using each strategy.

	Do you use this strategy?		No barrier	Poor patient adherence	Poor patient health literacy	Lack of staff/equipment	Lack of MD training	Lack of time	Lack of payment
	Choose yes or no		Circle one
1. Using written asthma action plans	YES	NO	1	2	3	4	5	6	7
2. Using home peak flow monitors	YES	NO	1	2	3	4	5	6	7
3.Performing in-office spirometry	YES	NO	1	2	3	4	5	6	7
4. Educating patients to recognize worsening asthma	YES	NO	1	2	3	4	5	6	7
5. Educating patients on avoiding risk factors or triggers	YES	NO	1	2	3	4	5	6	7
6. Involving patients in treatment decision-making	YES	NO	1	2	3	4	5	6	7
7. Teaching inhaler technique	YES	NO	1	2	3	4	5	6	7
8. Observing inhaler use by patient	YES	NO	1	2	3	4	5	6	7
9. Advising patients on changes to home environment	YES	NO	1	2	3	4	5	6	7
10. Advising patients on changes to work environment	YES	NO	1	2	3	4	5	6	7

6.2 Which, if any of the following concerns about prescribing inhaled corticosteroids to patients with persistent asthma do you have?

	Is this a concern?	Does this concern ever prevent you from prescribing inhaled corticosteroids?
No concerns about lower doses, but concerned with side effects at higher doses	YES NO	YES NO
Concerned about long-term side effects with continued use (e.g., cataracts, bone loss, delayed growth in children)	YES NO	YES NO
Concerned about patient confusion between rescue and control medications	YES NO	YES NO
Concerned about patient non-acceptance	YES NO	YES NO
Other:	YES NO	YES NO

6.3 How often, if ever, do you encounter these patient concerns or misunderstandings about inhaled corticosteroids?

Circle one number in each row.	Do not encounter	Rarely	Sometimes	Often
1. Short-term side effects (such as thrush)	1	2	3	4
2. Long-term side effects (such as bone loss, cataracts, delayed growth in children)	1	2	3	4
3. Misunderstanding of risks or side effects, or belief in myths (e.g., muscle development, aggression, addiction)	1	2	3	4
4. Confusion between rescue medication and controller medication	1	2	3	4
6. Other (specify):	1	2	3	4

7.1 Indicate which of the following ways, if any, you have learned about the asthma guidelines (check all that apply)

	I read the full version of the guidelines
	I read to the summary version of the guidelines
	I used short versions or “cheat sheets”
	In continuing medical education materials or courses
	With an electronic tool/reference
	from colleagues/word of mouth
	From an asthma improvement initiative or other program in my practice
	I am unfamiliar with the guidelines

8.0 Who completed this survey?

□ the physician to whom it was addressed □ office staff □ other

CLOSING STATEMENT

Thank you for completing this special survey. We appreciate your time and effort.

The following proposed screener question will be added to the 2012 NAMCS induction interview form. The purpose of this question will be to determine asthma supplement eligibility.

“Do any of the patients you treat have asthma?”