Asthma & Social Determinants of Health

Welcome back to Run the List, a medical education podcast and partnership with McGraw-Hell Medical. Our host are Dr. Naveen Kamar, Dr. Walker Red, Dr. Emily Gatowski, Dr. Joyce Ao, and myself Blake Smith. As a quick disclaimer, this podcast is meant for informational and educational purposes only and should not be understood as medical advice under any circumstances. Welcome back to Run the List. I'm thrilled to be welcoming our guests, Dr. Akila Jefferson, to teach us about asthma today. She is an assistant professor of pediatrics in the Division of Allergy and Immunology at the University of Arkansas for Medical Sciences College of Medicine, and Arkansas Children's Research Institute. She also has a secondary appointment in the Department of Medical Humanities and Biowethics. While Dr. Jefferson cares for patients with a wide array of allergic and immunologic diseases, she is especially interested in severe asthma and transitions of care, as well as novel approaches to health policy and social determinants related to disparate outcomes among patients with asthma. Recently, she has awarded the National Minority Quality Forums 2021 40 under 40 leaders in Minority Health Award. So it is a true privilege to have her here today to discuss such an important topic. In this episode, we're going to briefly overview some of the diagnosis and management involved with asthma, while also discussing that important intersection of asthma and health disparities. So Dr. Jefferson, are you ready to run the list? Thanks, Walker. Sure thing. Let's get started. Okay, so our case today is Miss A. She is a 19-year-old college student who is establishing primary care with you as she transitions from her pediatrician. Aside from asthma, she does not have any other medical problems. So Dr. Jefferson, before we learn more about Miss A's story, could you remind us just how we define and diagnose asthma in the first place? Absolutely. So asthma really is one of the most common diseases of childhood, and it is the most common chronic disease of childhood. But it can start at any age, so you can find it in kids and you can find it in adults and even in the elderly who never had it before. It is really mostly defined as bronchial hyperreactivity and smooth muscle hypertrophy leading to chronic inflammation of the airways. That result in kind of variable air flow obstruction with symptoms like weezing, coughing, shortness of breath and chest tightness. There are different triggers for asthma, including things like viruses, allergens, exercise, medications, exposures to cold air, and many, many others. But those are kind of the most common things that cause asthma exacerbations and will trigger symptoms and patients. Otherwise, asthma can be diagnosed a few different ways and little kids is often hard because we like to do something called pulmonary function testing and small children often cannot do that. But as you get older, so kids who are probably about five to six years old, you can start doing pulmonary function test, which can really pinpoint if there is obstruction in the airway and confirm air flow obstruction with things like reduced FEV-1, which is forced expatory volume in one second and reduced FEV-1 to FVC ratio, which is a force vital capacity. The other thing that is notable for asthma is that airway obstruction is reversible. So it's usually not fixed, although as a patient's age, sometimes that air flow obstruction can become fixed with time. There are other ways that you can look at air flow, hyperreactivity and reversibility, things like metacolean challenges, exercise challenges, and then also we can look at things like peak expatory flow for control, things like pheno or forced fractional, sorry, exalt nitric oxide to look at airway inflammation. Those are all the kind of different ways that we can look at the diagnosis. And then of course, asthma can be clinically diagnosed, so based on symptoms and signs and family history and what the patient is showing you in front of you. The last thing, which I don't think will have time to get into, are these sort of overlapped syndromes, so may call asthma plus syndromes, where you can have asthma and things like chronic obstructive pulmonary disease, overlapped. That's really oftentimes found in older people, people who smoke people with obesity, things like that. Thank you so much for sharing that overview. So while there are different approaches to the initial HMP when you meet a patient, I've actually always found it helpful to start my patient visits with what we traditionally call the social history. I basically just ask the patient about who they are as a person to help get to know them and also understand the overall context within which the patient is lived. Because that can also help inform our approach to the social and environmental factors that always impact a patient's health. So Dr. Jefferson, you know, you're an expert in this area, so I'd love to hear more about how you think about those factors and their impact in asthma and sort of along with that are there certain questions you make sure you ask to inform how you are going to care for a patient. I'm so happy that you start your HMP that way and I think it's so important to do, as you just said, we can never think about, we should never think about patients as living in a vacuum or in a bubble. They're always living within some sort of social context and all that really matters when you come down to how their disease is manifesting, their risk factors, how they are able to manage it, exacerbations and many, many other things. So I always take a detailed history similar to what you do, especially a social history and asking about exposures, like housing, conditions, other environmental exposures. Here we have a large rural population, so people who live on farms, people who are around animals that we may not otherwise think about, who may be exposed to things like burning of fields, all these different things. We think about air pollution, smoking, of course, is very, very important, so second-hand smoking and personal smoking, psychosocial stress, distance to care is very important in our populations too, how easy or hard it is to get where you need to go to get your medications and to see your doctors. And then, you know, secondarily, we know that asthma disproportionately impacts communities of color, so we always ask, I always ask about that. So race and ethnicity is important and I know sometimes people are uncomfortable asking those questions but they are important because we live in a society where that matters, right? And so asking kind of how that impacts their daily life, their symptoms, access issues, anything else that might be going on. The last thing is really, and you kind of touched on this a little bit about intersections, or what we would call intersectionality, so thinking about how different aspects of a person really impact the way that they live and the way that their disease may manifest. So I am a woman, but I'm also a black person, so I'm a black woman, which has a different impact than if I were a black man or a white woman, for instance. And how that kind of manifests with the way that I interact with the healthcare field in general, how my background influences the way that I feel about things, all those things are very important. So I think for providers being very aware of all that context is important so that we treat patients with dignity and respect and so that we understand where they're coming from. And then last but not least, socioeconomic status is always at play, which really plays into everything that we talk about, exposures, distance, how hard or easy it is to get where you need to go, if you can take time off of work, if you have a job, if you don't have a job, if you have a home, if you don't have a home, all these different things that really matter as far as a patient's health, and specifically with asthma, their health outcomes. Wow, thank you so much for sharing that perspective. That is incredibly helpful in reframing how we think about curing for our patients. And so in Miss A's case, we do ask a little bit more history and she lets us know that growing our per family was often concerned about sort of some of the hazardous materials with which their apartment was constructed and they were under a great deal of stress, sometimes financially and other times with just intermittent access to care with her pediatrician. And also sometimes with her medications, for instance, she recalls having to limit the use of her inhalers at different points. She was hospitalized several times over the course of her childhood. Now that she's recently moved to start college and is living in a new environment, she actually feels like her symptoms are improved somewhat. She's currently just taking daily ad wear or fluticus and some metarole and in a butarole inhaler as needed. On exam, her vital signs are normal and her chest exam has some very faint scattered expatory noises, but is otherwise reassuring. So Dr. Jefferson, could you just take a chance to explain how you think about medical management of asthma in general? Absolutely. So I would start with breaking it down into either chronic management or exacerbation management. And you want to think about those things a little differently depending on which part we're talking about. So we'll talk about chronic management first. We always want to think about step wise or step up therapy for asthma. And that starts from people who have intermittent asthma, meaning symptoms that are not always there, who may just need something like a sabba or l-buteroles, another name for that, short acting, bronchodilators, to relieve their symptoms on a short-term basis versus other people who require more control or medications who have daily symptoms to control their symptoms. So for step wise therapy, there are really two guidelines that I like to use to guide me. The first are the NHLBI/NAPP guidelines that were just updated in 2020. And then the second are the Gina guidelines, which are the -- they're updated almost annually, and they're what's used mostly in Europe. But both of them are very similar as far as looking at step up or step wise therapy. How to figure out which type of medication a patient needs and when you need to change based on if they're doing better or doing worse. So the other thing that we think about are triggers, which I mentioned and how to avoid triggers, how to manage triggers, how often someone needs to be followed up, coming up of course with an asthma action plan, which is an individualized therapy plan, and then also working with our respiratory therapist to do inhaler teaching for patients who require inhalers. So, for breaking medications down into different groups, we have the relievers that I mentioned so things like short-acting bronchodilators like Elbutarol, they're used as needed for symptom relief. We can also have short-acting anti-colonurgics or anti-muscarinics is another name for it like Ipertropium, and some people may think of that as like a duoneb, right, where you have Elbutarol and Atrevent together, and then you can have controller medications which are out those daily medicines, which are generally inhaled corticosteroids plus something or minus something actually. So, you can have a lava, which is a long-acting bronchodilator like Formodarol or Selmetarol, you can have those long-acting anti-muscarinics or llamas, which are teotropium, another name is Spiriva, that people are probably know about. And then you just basically based on where a patient is, if they are a mild asthmatic, if they are mild intermittent, mild persistent, if they are moderate persistent or a severe persistent, and you use your guidelines to figure out which medications are most appropriate for them, and when you need to step them up and step them down. So, I would encourage everyone to really look at those guidelines to make sure you're familiar with them, and remember that all step up and step down therapy is age-dependent. So, what you do in a kid is going to be different from what you do in an adolescent will be different from what you do in adults. And so, always being cognizant of that. The last thing that we use a lot here, especially in our severe asthma patients, are biologics, somonoclonal antibodies. You have things like duplomab, ummelismab, binorelismab, mepulismab, you have so many different ones that we're using now, and those are approved for certain groups of asthmatics based on age and based on the type of asthma that they have. I think it's really important to try to have patients taken care of by expert teams, some multi-disciplinary teams, including people like us, so allergists, then also people like pulmonologists who think about other chronic lung diseases that may be contributing to the asthma. We think about respiratory therapists who are so important with care for our asthmatic patients. We think about psychologists, social workers, again, as we think about these social determinants of health and how we can help people there, nursing, of course, and then any other groups that may be important to your patient population. Here we've thought a lot about medical legal partnerships and helping people who have issues with housing and helping them figure out how to get housing or how to, um, to kind of mitigate poor housing issues. So, um, those are the most important things for kind of chronic management. And then the last thing I'll mention for asthma action plans, making sure you have a plan that people understand. And so that takes a little bit more time to do education, whether it's you or respiratory therapy. Don't assume that all of your patients can read your plan or understand what you wrote down. And some patients may need a pictorial asthma action plans, or you have pictures of medications rather than words, just thinking about all those things when you're managing your patients chronically. And the next step really would be exacerbation management. So that starts with the asthma action plan and helping patients figure out if they're feeling well, what to do and if they're feeling bad, what to do, when to call, you want to go to the emergency room. And then once you're in the, if you have to go to the emergency room in the hospital, understanding if a patient needs to be just in patient admission and ICU admission, if they require intubation, get other medications like oxygen, magnesium, terbutaline, prednisone or other oral steroids. All these things really, really matter. And it takes, I think, reading the guidelines to understand and getting practice, clinical practice in those settings to really become an expert in how to treat those patients when they're having an exacerbation. Okay. Great. Thank you so much, Dr. Jefferson, for giving us all of that background, both some of the medical management, as well as some of those really practical things so we can make sure our patients are empowered to help care for themselves. So we just plan to continue Miss A's treatment that she's currently on for right now. But of course, it's more than just deciding the medicine, the patient needs. There are often some barriers to access and even if access isn't an exact issue, there are other barriers that can be sort of make it difficult for patients to get the care they need. Because as you are starting to mention, it's a really complex disease and there's a lot that goes into it. So if you could just take a few more minutes to discuss any barriers to access you've seen patients face and any other specific ways in which we as healthcare professionals can help sort of improve breaking down those barriers. Absolutely. So we see lots and lots of different ones. A big one is insurance, insurance coverage. So helping patients, and I would say with pediatrics, it's a little bit less common to see these insurance issues because a lot of kids can get enrolled on to Medicaid and other insurance plans specifically for children. But as those patients get older, and we see this a lot in these young adults, so Miss A is, you know, a young adult college student age person. We see a lot there where they're not really necessarily on their parents' insurance anymore. Maybe they could be, but they don't know that they can be. Maybe they're trying to get insurance through work or through school, or maybe they feel that they're very healthy and they don't need to have insurance and they don't want to pay that extra money. All these different things. And so I think one thing is really understanding that where people are coming from, from that standpoint, but then also letting them know how important it is to have a way to get care if they need it and working with them to get enrolled into good insurance plans that are affordable for them. The Affordable Care Act has helped with that a whole lot, right, and doing that. The other thing, I would say a huge barrier that we have are issues with distance to care. So I mentioned that we have a lot of people who live in rural places, but I would argue that this is not just something that we see in rural spaces. It's also an urban problem, and so it's everybody. So for me, if I need to go to the doctor, I hop in my car and I drive there with my guests, right, and I go, and I do what I need to do. A lot of people don't have a car, don't have gas money, don't have public transportation, subway or anything else to get where they need to go. Maybe they have to walk, maybe they have to ride a bike, maybe they have to find a ride, all these things. And so when your patient comes in late to your bare appointment, I always just encourage people don't think that they're just late for no reason. Sometimes they might be, but a lot of times it's because they had an issue getting there. And so really talking to people and understanding what those problems are, if I have a patient who's always late, I start asking questions, they say, "Hey, did you have trouble getting here?" I often actually have kids who are out of breath when they come to the office, and they say, "Why are you out of breath?" They say, "Well, we walked from this bus stop to that bus stop. There's not one close enough." And so it took us a long time, all those little things, but just really being aware of what's happening, I think, and being present in that patient interaction, I think helps patients a thousand percent, and not forgetting that, even though we get busy as providers. And one thing I personally do that we do in our clinic for that's distance to care issues, sometimes we'll offer telemedicine visits when appropriate. Sometimes we will offer delivery of medications, because people have issues getting to the pharmacy, and so we can deliver medications directly to the home. Those are ways that you can kind of address those little issues. The last thing I would say there is, with all these things, you want to try to understand what the barrier is, define what it is specifically. You want to try to have some sort of answer, so an intervention, right? And then you want to come back and see if your intervention is working. So I'll give you an example for our home delivery service, we realized I put patients on home delivery for their medications, but then I realized that a lot of the pharmacies were requiring patients to call for refills, right? And so I said why they should be getting their refills if it's just getting delivered to them. And so we had to go back and kind of re-educate the pharmacy and say, hey, this is a problem, can we put automatic refills and home delivery and will that help a little bit more? But really define refining what you're doing, the intervention that you're trying to implement to improve the health of the patient is key, in my opinion, to really getting to the, to changing these health disparities and these access issues that patients have. Thank you so much for going through that way in which you think about first defining what the barrier is, then addressing that barrier, then following up to make sure the barrier continues to be addressed. That sort of sustainable intervention is so important. You know, hearing you talk about all of this has really inspired me to be a better advocate and I hope it's on the same far listeners. Taking those extra steps to help our patients is really why we practice medicine in the first place. So Miss A herself continues to follow it with you in clinic. And over the years, she actually becomes interested in addressing health disparities within asthma through her own career. And we could delve into this for another hour or two, Dr. Jefferson, but we should go ahead and start to conclude today's episode. So of the mini pearls you've shared with us. today. What are the few takeaways you really want to make sure our listeners come away with? So number one, thank you for having me. This is great. And I hope that other people take away something good from this to be an advocate for your patients. It's very, very, very important, not just for asthma, but for really every disease. So I'll say that asthma is complex, as we know, and it should not be managed through just one lens. You can't really effectively treat a disease if you don't also address upstream issues, so not just what's in front of you. Like social determinants of health, that may be impacting the patient through many, many different things, whether it is their risk factors, management of disease, or exacerbation risk, any of these things. The top three things I would say, take away, number one, always continue to ask questions. So never just run in and run out of a room. Take your time, ask questions, and that becomes increasingly hard as you begin your practice, the way that our system is set up. We don't have a lot of time, because we have to make the time. The second thing is to really be conscious of structures in which medicine is practiced. There is a very good, I think, framework called structural competency that I would encourage everyone to look into. It's a way to sort of teach medical students and other medical practitioners about the social determinants and structures in which we live. So we don't just live in a house. We live in a house that's in a neighborhood that may be right line for some reason, that may have a power plant in it. It may have all these things, it may have a dumping ground, it may have crime, it may have all these different things, and why is that happening? And what do those different factors? How do they impact the individual who lives there? That is all about structural competency, and us as providers being aware of it, and understanding that it really actually does impact the way people live in the way that their health manifests. But the last thing is, it's always more than non-compliance or difficult patients, and whenever a trainee tells me, oh, this patient is just non-compliant, I really, really urge and tell them to please think deeper into that. It is never just that. And of course, there are people who are non-compliant. Why are they non-compliant? That is really the question, and what can we do to help them get into a better space and a better place with their health? And that is, I think, our job as healthcare providers, as doctors, as residents, as medical students, as fellows, is to be advocates for our patients, period. So even if they are kind of mean, even if they're not the nicest, even if they have an attitude, doesn't matter, we still need to figure out ways to do better for them, and to help them get to a place where maybe they're not in such a bad mood anymore because they feel better. All these little things, right? And so, I just urge everyone, remember, it's not just a difficult patient. That is a horrible label, I think, to put on people in an unfair one. And I'll say, when I was 17 years old, I had a medical emergency, and I wasn't labeled a difficult patient, but I was labeled in a certain way that that made me feel worse than just the pain that I was in for my emergency, right? Blabeled in a certain way by physicians and by doctors. And that is not what patients go to the doctor for. They go so that we can help them, and so that we can hopefully heal them in some kind of way, make their lives a little bit better. Jefferson, for not only bringing your amazing expertise in this area, but also sharing that personal story. And we'll just conclude right there because that's really part of why we do what we do at Run the List is to help students and trainees learn medicine, but also learn it in the context that's going to help them take the best possible care of their patients as people. So thank you to our listeners for tuning in, and we'll see you soon for another episode.