asthma.json

{
  "name": "Asthma",
  "remarks": [
    "This module is mostly based on statistics from the AAAAI and CDC. See:",
    "http://www.aaaai.org/about-aaaai/newsroom/asthma-statistics",
    "http://www.cdc.gov/nchs/fastats/asthma.htm",
    "http://www.cdc.gov/nchs/products/databriefs/db94.htm"
  ],
  "states": {
    "Initial": {
      "type": "Initial",
      "direct_transition": "Delay_For_Atopy"
    },
    "Delay_For_Atopy": {
      "type": "Delay",
      "remarks": [
        "The Atopy module must be processed before any of the allergy modules so ",
        "atopy can appropriately influence allergies. Delaying the smallest possible ",
        "time step to ensure this happens."
      ],
      "exact": {
        "quantity": 1,
        "unit": "weeks"
      },
      "conditional_transition": [
        {
          "condition": {
            "condition_type": "Attribute",
            "attribute": "atopic",
            "operator": "is not nil"
          },
          "transition": "Atopic"
        },
        {
          "transition": "Not_Atopic"
        }
      ]
    },
    "Atopic": {
      "type": "Simple",
      "remarks": [
        "45% of all atopic patients develop asthma. See the Atopy model for more info."
      ],
      "distributed_transition": [
        {
          "distribution": 0.45,
          "transition": "Asthma_Incidence"
        },
        {
          "distribution": 0.55,
          "transition": "Terminal"
        }
      ]
    },
    "Not_Atopic": {
      "type": "Simple",
      "remarks": [
        "There is a possibility that non-atopic patients develop asthma. However, ",
        "this asthma is likely more environmental and more likely to develop in ",
        "adulthood. Overall, 8-9% of the population gets asthma. In this model 6.8% ",
        "of those patients are atopic. The remaining 1.2-2% are not."
      ],
      "distributed_transition": [
        {
          "distribution": 0.023,
          "transition": "Asthma_Incidence"
        },
        {
          "distribution": 0.977,
          "transition": "Terminal"
        }
      ]
    },
    "Asthma_Incidence": {
      "type": "Simple",
      "remarks": [
        "8.6% of children have asthma, 7.4% of adults. To model childhood-only, lifetime, and adult-onset",
        "asthma I try to distribute the patients in a reasonable (but slightly arbitrary) manner:",
        "       ,-> 1.6% childhood-only                              ",
        " birth --> 7.0% lifetime             = 8.6% childhood asthma",
        "       `-> 0.4% adult-onset          = 7.4% adult asthma    ",
        "Collectively this sums to 9% of people getting asthma in their lifetime, which is consistent with",
        "my extrapolation based on the AAAAI's estimates: (1/14 had asthma in 2001, 1/12 in 2009, so I extrapolate",
        "1/11 for 2016)."
      ],
      "distributed_transition": [
        {
          "distribution": 0.95,
          "transition": "Delay_For_Childhood_Asthma"
        },
        {
          "distribution": 0.05,
          "transition": "Delay_Until_Adulthood"
        }
      ]
    },
    "Delay_For_Childhood_Asthma": {
      "type": "Delay",
      "remarks": [
        "Typically asthma symptoms don't appear until the child is at least 3."
      ],
      "range": {
        "low": 2,
        "high": 5,
        "unit": "years"
      },
      "direct_transition": "Childhood_Asthma_Begins"
    },
    "Delay_Until_Adulthood": {
      "type": "Delay",
      "range": {
        "low": 18,
        "high": 40,
        "unit": "years"
      },
      "direct_transition": "Adult_Asthma_Begins"
    },
    "Childhood_Asthma_Begins": {
      "type": "ConditionOnset",
      "target_encounter": "Asthma_Diagnosis",
      "assign_to_attribute": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "233678006",
          "display": "Childhood asthma (disorder)"
        }
      ],
      "direct_transition": "Set_Childhood_Asthma"
    },
    "Set_Childhood_Asthma": {
      "type": "SetAttribute",
      "attribute": "asthma_type",
      "value": "childhood",
      "direct_transition": "Asthma_Diagnosis"
    },
    "Adult_Asthma_Begins": {
      "type": "ConditionOnset",
      "target_encounter": "Asthma_Diagnosis",
      "assign_to_attribute": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "195967001",
          "display": "Asthma (disorder)"
        }
      ],
      "direct_transition": "Set_Adult_Asthma"
    },
    "Set_Adult_Asthma": {
      "type": "SetAttribute",
      "attribute": "asthma_type",
      "value": "lifelong",
      "direct_transition": "Asthma_Diagnosis"
    },
    "Asthma_Diagnosis": {
      "type": "Encounter",
      "encounter_class": "ambulatory",
      "reason": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "185345009",
          "display": "Encounter for symptom (procedure)"
        }
      ],
      "direct_transition": "Asthma_Symptom1"
    },
    "Asthma_Symptom1": {
      "type": "Symptom",
      "symptom": "Wheezing",
      "range": {
        "low": 25,
        "high": 75
      },
      "direct_transition": "Asthma_Symptom2"
    },
    "Asthma_Symptom2": {
      "type": "Symptom",
      "symptom": "Shortness of Breath",
      "range": {
        "low": 25,
        "high": 75
      },
      "direct_transition": "Asthma_Symptom3"
    },
    "Asthma_Symptom3": {
      "type": "Symptom",
      "symptom": "Chest Pressure",
      "range": {
        "low": 0,
        "high": 50
      },
      "direct_transition": "Asthma_Symptom4"
    },
    "Asthma_Symptom4": {
      "type": "Symptom",
      "symptom": "Cough",
      "range": {
        "low": 0,
        "high": 25
      },
      "direct_transition": "Asthma_Symptom5"
    },
    "Asthma_Symptom5": {
      "type": "Symptom",
      "symptom": "Nasal Congestion",
      "range": {
        "low": 0,
        "high": 25
      },
      "direct_transition": "Asthma_Symptom6"
    },
    "Asthma_Symptom6": {
      "type": "Symptom",
      "symptom": "Mucus Secretion",
      "range": {
        "low": 0,
        "high": 25
      },
      "direct_transition": "Asthma_Screening"
    },
    "Asthma_Screening": {
      "type": "Procedure",
      "reason": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "171231001",
          "display": "Asthma screening (procedure)"
        }
      ],
      "direct_transition": "Prescribe_Maintenance_Inhaler"
    },
    "Prescribe_Maintenance_Inhaler": {
      "type": "CallSubmodule",
      "submodule": "medications/maintenance_inhaler",
      "direct_transition": "Prescribe_Emergency_Inhaler"
    },
    "Prescribe_Emergency_Inhaler": {
      "type": "CallSubmodule",
      "submodule": "medications/emergency_inhaler",
      "direct_transition": "Asthma_CarePlan_Selector"
    },
    "Asthma_CarePlan_Selector": {
      "type": "Simple",
      "conditional_transition": [
        {
          "condition": {
            "condition_type": "And",
            "conditions": [
              {
                "condition_type": "Age",
                "operator": ">=",
                "quantity": 18,
                "unit": "years"
              },
              {
                "condition_type": "Attribute",
                "attribute": "smoker",
                "operator": "==",
                "value": true
              }
            ]
          },
          "transition": "Smoker_CarePlan"
        },
        {
          "transition": "Nonsmoker_CarePlan"
        }
      ]
    },
    "Smoker_CarePlan": {
      "type": "CarePlanStart",
      "assign_to_attribute": "asthma_careplan",
      "reason": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "699728000",
          "display": "Asthma self management (regime/therapy)"
        }
      ],
      "activities": [
        {
          "system": "SNOMED-CT",
          "code": "710081004",
          "display": "Smoking cessation therapy (regime/therapy)"
        },
        {
          "system": "SNOMED-CT",
          "code": "710818004",
          "display": "Inhaled steroid therapy (procedure)"
        },
        {
          "system": "SNOMED-CT",
          "code": "708409001",
          "display": "Home nebulizer therapy (procedure)"
        }
      ],
      "direct_transition": "End_Diagnosis_Encounter"
    },
    "Nonsmoker_CarePlan": {
      "type": "CarePlanStart",
      "assign_to_attribute": "asthma_careplan",
      "reason": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "699728000",
          "display": "Asthma self management (regime/therapy)"
        }
      ],
      "activities": [
        {
          "system": "SNOMED-CT",
          "code": "710818004",
          "display": "Inhaled steroid therapy (procedure)"
        },
        {
          "system": "SNOMED-CT",
          "code": "708409001",
          "display": "Home nebulizer therapy (procedure)"
        },
        {
          "system": "SNOMED-CT",
          "code": "229298005",
          "display": "Breathing control (regime/therapy)"
        }
      ],
      "direct_transition": "End_Diagnosis_Encounter"
    },
    "End_Diagnosis_Encounter": {
      "type": "EncounterEnd",
      "direct_transition": "Maintaining_Asthma"
    },
    "Maintaining_Asthma": {
      "type": "Delay",
      "exact": {
        "quantity": 6,
        "unit": "months"
      },
      "conditional_transition": [
        {
          "condition": {
            "remarks": [
              "Childhood-only asthma ends"
            ],
            "condition_type": "And",
            "conditions": [
              {
                "condition_type": "Age",
                "operator": ">",
                "quantity": 18,
                "unit": "years"
              },
              {
                "condition_type": "Attribute",
                "attribute": "asthma_type",
                "operator": "==",
                "value": "childhood"
              }
            ]
          },
          "transition": "Childhood_Asthma_May_Subside"
        },
        {
          "transition": "Potential_Asthma_Attack"
        }
      ]
    },
    "Childhood_Asthma_May_Subside": {
      "type": "Simple",
      "distributed_transition": [
        {
          "distribution": 0.83,
          "transition": "Childhood_Asthma_Becomes_Lifelong_Asthma"
        },
        {
          "distribution": 0.17,
          "transition": "Next_Wellness_Encounter"
        }
      ],
      "remarks": [
        "After a validation study, 248 children were identified as having asthma; these children were reassessed annually until age 19 years when 205 (83%) remained.",
        "\"Remission and persistence of asthma followed from 7 to 19 years of age.\" Andersson M, Hedman L, Bjerg A, Forsberg B, Lundbäck B, Rönmark E. Pediatrics. 2013 Aug;132(2):e435-42. doi: 10.1542/peds.2013-0741.",
        "https://www.ncbi.nlm.nih.gov/pubmed/23897917"
      ]
    },
    "Childhood_Asthma_Becomes_Lifelong_Asthma": {
      "type": "ConditionEnd",
      "referenced_by_attribute": "asthma_condition",
      "direct_transition": "Lifelong_Asthma"
    },
    "Lifelong_Asthma": {
      "type": "SetAttribute",
      "attribute": "asthma_type",
      "value": "lifelong",
      "direct_transition": "Next_Adult_Welness_Encounter"
    },
    "Next_Adult_Welness_Encounter": {
      "type": "Encounter",
      "wellness": true,
      "direct_transition": "Lifelong_Asthma_Begins",
      "reason": "asthma_condition"
    },
    "Lifelong_Asthma_Begins": {
      "type": "ConditionOnset",
      "target_encounter": "Next_Adult_Welness_Encounter",
      "assign_to_attribute": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "195967001",
          "display": "Asthma (disorder)"
        }
      ],
      "direct_transition": "End_Wellness_1"
    },
    "Potential_Asthma_Attack": {
      "type": "Simple",
      "remarks": [
        "Once every 6 months we simulate whether or not the patient has an asthma attack",
        "53% have an attack each year (57% children, 51% adults), source: AAAAI.",
        "This means a 26.5% rate of attack per 6 month period."
      ],
      "distributed_transition": [
        {
          "distribution": 0.735,
          "transition": "Maintaining_Asthma",
          "remarks": [
            "No asthma attack occured"
          ]
        },
        {
          "distribution": 0.265,
          "transition": "Asthma_Attack"
        }
      ]
    },
    "Asthma_Attack": {
      "type": "Simple",
      "distributed_transition": [
        {
          "distribution": 0.1885,
          "transition": "Asthma_ED_Visit",
          "remarks": [
            "The CDC documented 10 ED visits per 100 people with asthma each year.",
            "http://www.cdc.gov/nchs/products/databriefs/db94.htm",
            "Assuming hospitalization always comes from an attack, for those that have attacks each 6-month period (26.5%)",
            "5/26.5 people (per 100) --> 18.85% rate of hospitalization from attack."
          ]
        },
        {
          "distribution": 0.8115,
          "transition": "Asthma_Attack_Followup",
          "remarks": [
            "If the attack did not result in an ED visit the patient still visited his/her physician for a followup"
          ]
        }
      ]
    },
    "Asthma_ED_Visit": {
      "type": "Encounter",
      "encounter_class": "emergency",
      "reason": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "183478001",
          "display": "Emergency hospital admission for asthma (procedure)"
        }
      ],
      "direct_transition": "End_Asthma_ED_Visit"
    },
    "End_Asthma_ED_Visit": {
      "type": "EncounterEnd",
      "direct_transition": "Delay_For_Followup"
    },
    "Delay_For_Followup": {
      "type": "Delay",
      "range": {
        "low": 1,
        "high": 3,
        "unit": "days"
      },
      "direct_transition": "Asthma_Attack_Followup"
    },
    "Asthma_Attack_Followup": {
      "type": "Encounter",
      "encounter_class": "ambulatory",
      "reason": "asthma_condition",
      "codes": [
        {
          "system": "SNOMED-CT",
          "code": "394701000",
          "display": "Asthma follow-up (regime/therapy)"
        }
      ],
      "direct_transition": "Followup_End"
    },
    "Followup_End": {
      "type": "EncounterEnd",
      "direct_transition": "Maintaining_Asthma"
    },
    "Next_Wellness_Encounter": {
      "type": "Encounter",
      "wellness": true,
      "direct_transition": "Maintenance_Medication_End",
      "reason": "asthma_condition"
    },
    "Maintenance_Medication_End": {
      "type": "MedicationEnd",
      "referenced_by_attribute": "maintenance_inhaler",
      "direct_transition": "Emergency_Medication_End"
    },
    "Emergency_Medication_End": {
      "type": "MedicationEnd",
      "referenced_by_attribute": "emergency_inhaler",
      "direct_transition": "Childhood_Asthma_Subsides"
    },
    "Childhood_Asthma_Subsides": {
      "type": "ConditionEnd",
      "referenced_by_attribute": "asthma_condition",
      "direct_transition": "Asthma_Symptom1_Ends"
    },
    "Asthma_Symptom1_Ends": {
      "type": "Symptom",
      "symptom": "Wheezing",
      "exact": {
        "quantity": 0
      },
      "direct_transition": "Asthma_Symptom2_Ends"
    },
    "Asthma_Symptom2_Ends": {
      "type": "Symptom",
      "symptom": "Shortness of Breath",
      "exact": {
        "quantity": 0
      },
      "direct_transition": "Asthma_Symptom3_Ends"
    },
    "Asthma_Symptom3_Ends": {
      "type": "Symptom",
      "symptom": "Chest Pressure",
      "exact": {
        "quantity": 0
      },
      "direct_transition": "Asthma_Symptom4_Ends"
    },
    "Asthma_Symptom4_Ends": {
      "type": "Symptom",
      "symptom": "Cough",
      "exact": {
        "quantity": 0
      },
      "direct_transition": "Asthma_Symptom5_Ends"
    },
    "Asthma_Symptom5_Ends": {
      "type": "Symptom",
      "symptom": "Nasal Congestion",
      "exact": {
        "quantity": 0
      },
      "direct_transition": "Asthma_Symptom6_Ends"
    },
    "Asthma_Symptom6_Ends": {
      "type": "Symptom",
      "symptom": "Mucus Secretion",
      "exact": {
        "quantity": 0
      },
      "direct_transition": "End_Asthma_CarePlan"
    },
    "End_Asthma_CarePlan": {
      "type": "CarePlanEnd",
      "referenced_by_attribute": "asthma_careplan",
      "direct_transition": "End_Wellness_2"
    },
    "Terminal": {
      "type": "Terminal"
    },
    "End_Wellness_1": {
      "type": "EncounterEnd",
      "direct_transition": "Maintaining_Asthma"
    },
    "End_Wellness_2": {
      "type": "EncounterEnd",
      "direct_transition": "Terminal"
    }
  },
  "gmf_version": 1
}