Improving Asthma Guidelines to Change Outcomes

How has a career-long dedication to improving asthma care changed outcomes for kids?

In 2004, when Monica Federico, MD, joined the Children’s Hospital Colorado team as an attending physician, the city was going through significant changes. 

“As Colorado was getting bigger and Denver was building up, there were so many people coming from Mexico and other places who were building Colorado for us, and their children needed care,” Dr. Federico says. “And for about 50% of the families that we were taking care of, the parents spoke Spanish.”

At the time, Dr. Federico was the only member of the pulmonary team at the Breathing Institute who spoke Spanish. With an influx of Spanish-speaking families seeking care for pulmonary issues — and especially asthma — this skill became indispensable. 

Systemic barriers to asthma care

Having a team member who could more clearly communicate with families was vital, but patients still faced additional difficulties accessing appropriate care for asthma, which is the one of the most common chronic conditions in children. 

“Unfortunately, asthma is worse if you have worse housing — if you live in neighborhoods with increased violence and stress or increased particulate-matter pollution. Families living in historically redlined neighborhoods are more likely to be exposed to barriers to health like housing instability and poor air quality,” Dr. Federico notes. “Because of racially discriminatory housing policies such as redlining, people who live in those neighborhoods are more likely to be from minoritized populations. We see disparities in those populations; they are more likely to have asthma and worse asthma control. These differences are not due to their race or ethnic background. It has more to do with years of systemic racism in the area in which they live.”

Given this reality, Dr. Federico’s hope was to develop new pathways that would facilitate easier access to care. Around the same time, new national guidelines around asthma care were released. This created a new opportunity to work alongside the State of Colorado and local pediatric practices to develop standardization in asthma treatment, with the hopes of simplifying home care for parents and caregivers of kids with the condition. 

Creating a standard approach for asthma treatment

With new national recommendations in hand, Dr. Federico worked alongside families, patients, nurses, respiratory therapists and other experts to build an asthma program and develop guidelines for Children’s Colorado’s outpatient, inpatient and emergency asthma care. This work has since extended to Children’s Hospital Colorado, Colorado Springs.

At the same time, she began working with experts across the state to create a similar set of asthma guidelines for community-based primary care pediatricians. Her goal in doing this was to ensure that no matter where families sought care, they would receive the same consistent approach to care and clear instructions for asthma management. 

“If you get a different message every time about how to take care of asthma or what to expect from the care, then it's really confusing to families,” Dr. Federico says. “You might go to a clinic where you see a different provider every time. Whatever your situation is, it's just important that you hear the same thing every time because there's so much going on in life then you think, ‘What do I do and how do I do it and who do I call?’ We are setting up a very predictable system for families that very often do not have very predictable lives.”

In 2018, the team learned that data indicated that a new type of treatment was showing incredible promise in kids with asthma, shifting the paradigm away from the practices they’d been teaching internally at Children’s Colorado and to community providers around the Denver metro area and state. Instead of a daily inhaled steroid (paired with albuterol when symptoms worsen), the National Heart, Lung and Blood Institute recommended a new option that would allow kids with asthma to use a stronger combined treatment only as needed, rather than every single day. 

Though this treatment is not yet approved by the U.S. Food and Drug Administration, its safety has been tested, and Dr. Federico and Heather De Keyser, MD, decided to work with other specialists and pediatricians to update the primary care pediatric guidelines developed in 2007 to reflect this new option. To do this, the team worked with Children’s Colorado’s Pediatric Care Network to develop community-based, pediatrician-driven guidelines that have been disseminated nationwide.

Pediatric asthma outcomes

By continuously updating Children’s Colorado’s asthma guidelines, standardizing care across the state and region, and connecting more kids and families to specialty asthma care, this work has removed many barriers to care so patients can more effectively manage asthma at home. 

To create additional opportunities for families to access the care they need, Dr. Federico worked with the Breathing Institute and other specialty providers to develop  an evening asthma clinic to allow more flexibility, a clinic for kids with severe asthma and a home-visit program that brings asthma education directly to patients. The team also obtained grants to hire new team members dedicated to asthma education and to help families and children with asthma navigate inpatient and outpatient asthma treatment.

All of this has added up to significant change. When Dr. Federico began her work, the team saw fewer than 500 patients for specialty asthma care yearly. That number has since grown to nearly 7,000, reflecting the impact that better access can have on a community. She’s seen increased scheduling with primary care, decreased no-show rates for appointments and decreased rates of return to the emergency department. All of this adds up to improved asthma management, which can be lifechanging for kids and families.

“We really want, for the sake of children and children’s health, to be clear that if your asthma is controlled, you can play, run and go to school,” Dr. Federico says. “This control improves quality of life for families.”

And that’s exactly what the team is seeing. In the last 10 years, Dr. Federico has noted a more than 5% decrease in 12-month readmission rates to the hospital for kids with the condition.

“It really speaks to improved chronic disease care from everybody who touches these children with asthma — not just us at Children's Colorado, but in the whole community, which is pretty exciting,” she says, noting that the credit belongs to so many different people. “This has been collaborative, community-based, participatory work. We continue to work with the community to deliver what they have asked us to provide, and we will continue to do that. This is not Children's Colorado saying this is the right way to do this. This is us asking providers in the community, other health systems and our patients how to do this right.”