Compliance with National Asthma Management Guidelines andSpecialty Care: A Health Maintenance Organization Experience

Abstract

Legorreta AP, Christian-Herman J, O'Connor RD, Hasan MM, Evans R, Leung KMArch Intern Med.1581998457464To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991. To compare the current status of asthma disease management among patients in a large health maintenance organization (HMO) with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines.Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major HMO in California (Health Net).In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African-American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of β2-agonist metered-dose inhalers.Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large HMO and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.Most HMOs claim to be interested in programs such as population-based asthma disease management intervention programs. Unfortunately, most are not willing to pay for it. Primary care physicians are given incentives not to refer to specialists. Capitated specialists are generally not provided with compensation that would allow the time and attention these patients need. Until payers of health care demand changes (and show a willingness to pay for them), it seems to me that asthma will remain an undertreated disease.