Educational materials (slide-set and accompanying script) used to train-the-trainers in SAFTINet practices on incorporating the Asthma Control Test into their clinical workflow and decision-making for patients with asthma. For more information on SAFTINet, please see http://www.ucdenver.edu/academics/colleges/medicalschool/programs/outcomes/COHO/saftinet/Pages/default.aspx

1. +
ACT Training
SAFTINet Partner Engagement Community

2. +
ACT Training
SAFTINet Partner Engagement Community
Outline
1. Clinical
Use of the
Asthma
Control Test
(ACT)
2. Workflow
for Using the
ACT

3. +
1. Clinical Use of the Asthma
Control Test (ACT)
A. Background
B. Guideline-based context for the ACT
C. The ACT

4. +
Asthma Epidemiology
Up to 18% diagnosed by
high school graduation
More common in males
before age 12 and in
females after age 12
Over 3,900 deaths
(14/day)
Disproportionately affects
children and African Americans

5. +
2 million ED visits
500,000 hospitalizations
Costs of asthma
$16 billion American Lung Association Fact Sheet: Asthma in Adults, June 2004. Available at: http://www.lungusa.org/site/.
National Institute of Allergy and Infectious Disease. Focus on Asthma. Available at: http://www3.niaid.nih.gov/news.
American Medical Association. Clinical Performance Measures – Asthma, 2005.
Asthma-Related Annual Utilization

6. +
NIH Guidelines
 National Institutes of Health, National
Heart, Lung and Blood Institute. Expert
Panel Report 3: Guidelines for the
Diagnosis and Management of Asthma
(EPR-3 2007).
 Available at:
http://www.nhlbi.nih.gov/guidelines/asthm
a/asthgdln.htm.
EPR-3

7. +
Guidelines: Ambulatory
Asthma Care
 Diagnose asthma
 Identify precipitating factors and co-morbidities
 Classify asthma severity
 Assess patient’s knowledge/skills for self-management
 Provide an asthma action plan
 Monitor asthma control
 Administer influenza vaccine to all with asthma

8. +
Guidelines: Ambulatory
Asthma Care
 Diagnose asthma
 Identify precipitating factors and co-morbidities
 Classify asthma severity
 Assess patient’s knowledge/skills for self-management
 Provide an asthma action plan
 Monitor asthma control
 Administer influenza vaccine to all with asthma
ACT helps here

9. +
Assessment/Monitoring:
Control vs. Severity
 Used for evaluating
disease activity and
initiating therapy
 Categories:
 Intermittent
 Persistent (mild,
moderate, severe)
 Is not what the ACT
measures
 Used for monitoring
and adjusting therapy
 ACT score can be used
to measure part of
control (impairment)
Severity Control

10. +
Control
 Includes two domains
 Impairment is the present: effects on quality of life
and functional capacity
 Risk refers to the future: exacerbations and
progressive loss of pulmonary function
 Well controlled vs. not well controlled/very poorly
controlled
 Should be measured at least every 6 months
 Use control rating to step up or step down therapy
after assessing compliance, device technique and
environment

11. +
Assessing Control

12. +
Assessing Control

13. +
Assessment of Control Using
Standardized Tools: ACT (Asthma
Control Test)
 Simple assessment and easy-to-use scoring
method
 Assesses asthma control over the past 4 weeks:
 activity limitations
 daytime symptoms
 nighttime symptoms
 short-acting beta-agonist (SABA) use
 self-assessment of level of control
 Available in >12 languages

14. +
Childhood ACT
Child questions
Parent questions
Instructions

15. +
Childhood ACT: Instructions
 Suggested changes for SAFTINet
 Change “Asthma Control Test” to “Breathing Survey”
 Change “asthma” to “breathing”
 Remove the instructions that include the parent adding up the
score and bringing the test to their child’s doctor

16. +
Childhood ACT: Child Questions

17. +
Childhood ACT: Parent Questions

18. +
ACT: Teen/Adult Version

19. +
ACT: Scoring
< 19 suggests poor control
 Childhood version
 Validated in children 4-11 years
 4 child questions, scored 0 (worst) to 3
 3 parent questions, scored 0 to 5
 Score range 0 to 27
Teen/Adult version
 For patients >12 years
 5 questions, scored 1 to 5
 Score range 0 to 25

20. +
Assessing Control and Adjusting
Therapy in Teens and Adults

21. +
Assessing Control and Adjusting
Therapy in Children 5–11
• Consider short course of
systemic oral corticosteroids,
• Step up 12 steps, and
• Reevaluate in 2 weeks.
• For side effects: consider
alternative treatment options.
• Step up at least
1 step and
• Reevaluate in
26 weeks.
• For side effects:
consider alternative
treatment options.
• Maintain current
step.
• Regular followup
every 36 months.
• Consider step down
if well controlled for
at least 3 months.
Recommended Action
for Treatment
(See figure 4-1b for
treatment steps.)
Lung function
<60% predicted/
personal best
6080% predicted/
personal best
>80% predicted/
personal best
• FEV1 or peak flow
Evaluation requires long-term followup.
Medication side effects can vary in intensity from none to very troublesome and
worrisome. The level of intensity does not correlate to specific levels of control but
should be considered in the overall assessment of risk.
Treatment-related
adverse effects
>3 per year23 per year01 per yearExacerbations
Risk
Several times per day>2 days/week2 days/week
Short-acting
beta2-agonist use
for symptom control
(not prevention of EIB)
Extremely limitedSome limitationNone
Interference with
normal activity
Classification of Asthma Control (511 years of age)
Impairment
Components of Control
Reduction in
lung growth
<75% predicted7580% predicted>80% predicted• FEV1/FVC
2x/week2x/month1x/month
Nighttime
awakenings
Throughout the day
>2 days/week or
multiple times on
2 days/week
2 days/week but not
more than once on
each day
Symptoms
Very Poorly Controlled
Not Well
Controlled
Well
Controlled

22. +
Assessing Control and
Adjusting Therapy
Components
of Control
Classification of Asthma Control
Well Controlled Not Well
Controlled
Very Poorly Controlled
Age 5-
11
ACT >20 13-19 <12
Age
>12
ACT >20 16-19 <15
Recommended
Action for
Treatment
• Regular followups
every 1-6 months
to maintain control
• Consider step
down if well
controlled for at
least 3 months
• Step up 1
step and
• Reevaluate
in 2-6 weeks
• Consider short
course of oral
systemic
corticosteroids
• Step up 1-2 steps,
and
• Reevaluate in 2
weeks

23. +
Stepwise Approach for Managing
Asthma in Teens and Adults
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required.
Consider consultation at step 3.
Step 1
Preferred:
SABA PRN
Step 2
Preferred:
Low-dose ICS
Alternative:
LTRA
Cromolyn,
Nedocromil, or
Theophylline
Step 3
Preferred:
Medium-dose
ICS
OR
Low-dose ICS +
either LABA,
LTRA, or
Theophylline
Step 5
Preferred:
High-dose ICS
+ LABA
Alternative:
High-dose ICS
+ either LTRA
or Theophylline
AND
Omalizumab
may be
considered for
patients who
have allergies
Step 6
Preferred:
High-dose ICS
+ LABA + oral
corticosteroid
Alternative:
High-dose ICS
+ either LTRA
or Theophylline
+ oral
corticosteroid
AND
Omalizumab
may be
considered for
patients who
have allergies
Step up if
needed
(first, check
adherence and
environmental
control and
comorbid
conditions)
Step down if
possible
(and asthma is
well controlled
at least
3 months)
Patient Education and Environmental Control at Each Step
Step 4
Preferred:
Medium-dose
ICS + LABA
Alternative:
Medium-dose
ICS + either
LTRA or
Theophylline
Assess
control
Quick-Relief Medication for All Patients
• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute
intervals as needed. Short course of systemic oral corticosteroids may be needed.
• Caution: Increasing use of beta-agonist or use >2 times a week for symptom control (not prevention of EIB) indicates inadequate
control and the need to step up treatment.
Key: ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist, LTRA, leukotriene receptor
antagonist; SABA, inhaled short-acting beta2-agonist

24. +
Stepwise Approach for Managing
Asthma in Children 5–11
Key: ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist, LTRA, leukotriene receptor
antagonist; SABA, inhaled short-acting beta2-agonist

25. +
Stepwise Approach for Managing
Asthma in Teens and Adults
a: Daily Medication
step 4 care or higher is required.
ultation at step 3.
Step 5
Preferred:
High-dose ICS
+ LABA
Alternative:
High-dose ICS
+ either LTRA
or Theophylline
AND
Omalizumab
may be
considered for
patients who
have allergies
Step 6
Preferred:
High-dose ICS
+ LABA + oral
corticosteroid
Alternative:
High-dose ICS
+ either LTRA
or Theophylline
+ oral
corticosteroid
AND
Omalizumab
may be
considered for
patients who
have allergies
Step up if
needed
(first, check
adherence and
environmental
control and
comorbid
conditions)
Step down if
possible
(and asthma is
well controlled
at least
3 months)
al Control at Each Step
ep 4
rred:
-dose
ABA
native:
-dose
ther
r
ylline
Assess
control
of symptoms: up to 3 treatments at 20-minute
ACT fits in here
Note the other
components in the
blue box

26. +
Guidelines: Ambulatory
Asthma Care
 Identify precipitating factors
 Identify comorbidities that may aggravate asthma
 Assess patient’s knowledge/skills for self-management
 Classify asthma severity
 Monitor asthma control
 Provide an Asthma Action Plan
 Administer influenza vaccine to all patients with asthma
ACT helps here

27. + 2. Possible Workflow for Using
the ACT

28. +
Identify patients with Asthma
 Run reports to yield patient registries based upon
 ICD9 code 493 (asthma) in the electronic health record (EHR)
 Reason for visit: any
 Reports run by a clinical analyst the prior day
 Medical assistant reviews report and flags patient charts for
receiving ACT before the clinic opens in the morning
For adolescents and young
men this may be the only way
to measure their control
Think like you do for
immunizations, missed
opportunities
EHR marker flags
patient for ACT

29. +
Who can give ACT
 Physician or other clinician seeing patient
 Been shown to miss most patients
 Nursing staff putting patient in room
 Can be combined as a vital sign
 Receptionist
 May allow patient time to complete before in office

30. +
Administering the ACT: An example
of patient flow
 Several laminated copies of ACT in English and
Spanish are available at the front rooms of the office
 Receptionist asks about patient’s preferred language
and then hands the patient the ACT and erasable
marker to flagged patients at check-in

31. +
Administering the ACT: An example
of patient flow
 Medical assistant or rooming nurse addresses
questions about ACT while checking heart rate and
blood pressure
 Medical assistant or rooming nurse scores and enters
ACT result in the asthma worksheet in the EHR
 Laminated ACT remains with the patient in the exam
room

32. +
Possible script
 “Hello, we are starting a new program that will help us take care of
patients with asthma/wheeze/breathing problems better. We are
asking any patient with asthma etc to fill out this form so that we
can figure out the best way to help you get better.”
 If the patient is adult, ask them to read the questions and give the
answer that describes how they have felt over the last 4 weeks
 If you are treating a child under 12, the parent and child should
read the first 5 questions and the CHILD should pick the face.
The parents then answers the last 3 questions.
 Tell them that there is no need to add the numbers up, the
provider will review it with them and add up the total in the room

33. +
Clinician Interaction with ACT
 Clinician reviews ACT score
 Clinician also has available the laminated
ACT copy to review specific items
 The clinician enters the score in the EHR if
not already entered
 After encounter, medical assistant or rooming
nurse wipes clean the laminated ACT and
returns it to the receptionist

34. +
Documenting ACT results in EHR
 ACT template has been developed in our EHR
 Result entered directly into template (describe where)

35. +
Discussion
 No one way is right for everyone
 May have several strategies for different types of
situations
 Urgent visits
 Asthma check ups
 others

36. +
Potential Barriers
Brainstorm on Solutions
 Lack of familiarity with the ACT
 Time and resource constraints
 Patient literacy levels
 Fit within the clinical workflow