Asthma Disease Management Program Research Articles

Stratifying asthma populations by medication use: how you count counts

Asthma disease management programs typically use pharmacy data to identify high-risk individuals for outreach. Provider-directed pharmacy profiling seeks to identify physicians whose prescribing of recommended asthma medication is suboptimal. Both strategies require an accurate approach to counting prescribed asthma medication. We compare two methods for counting the use of bronchodilators and inhaled anti-inflammatory medication. One approach uses simple counts of dispensed medication. An alternative, canister-equivalent method standardizes these medications on the basis of variation in both potency and medication-days supplied per prescription. We evaluate whether these alternative methods yield different population risk profiles when applied to managed care enrollees who have asthma and to the physicians treating them. Retrospective cohort study of patterns of medication use by asthmatic patients receiving care within a group-model health maintenance organization and prescribing of asthma medications by the physicians treating them. Each method yields a different risk profile of the patient and physician populations, respectively. Relative to simple counts, the canister-equivalent method results in a 40% increase in the population identified as having high bronchodilator use and chronic anti-inflammatory medication use. On the physician-level, the mean anti-inflammatory:bronchodilator ratio (AIF:BD) was 1.50 by the canister-equivalent method compared with 1.08 by the simple-count method. When stratified by each method, 36% of physicians were assigned to different quartiles of anti-inflammatory:bronchodilator ratio. A novel canister-equivalent method for counting dispensed asthma medications yields different risk profiles compared with simple counts of asthma medications. Asthma disease management programs should consider alternative approaches to improve the accuracy of risk profiling based on patterns of medication use.

Relationships Between Self-Reported Asthma Utilization and Patient Characteristics

Background: Identifying asthmatic individuals most likely to utilize medical care in the future will help to direct intervention and medical resources; however, there are currently limited models for future utilization.Objective: This study investigated the relationship between patient characteristics and medical utilization, using an asthma disease management patient population.Methods: We analyzed a sample of 1412 adults, enrolled for 6 months in an asthma disease management program, for relationships with utilization. Individuals answered demographic, socioeconomic, and medical questions via telephonic contact upon enrollment. Follow-up regarding medical utilization occurred during the subsequent 6 months. Relationships between utilization and enrollment answers were statistically modeled.Results: Oral steroid bursts, day and night symptom frequencies, age, gender, education level, and employment status all had a significant relationship to medical utilization. Those individuals who had used oral steroids 6 months prior to enrollment, patients with more than five night-time asthma symptoms per month, and those with “continuous” day symptoms were more likely to report utilization. Those patients under 44 years old, females, those who were not high school graduates, and patients who defined themselves as unemployed because of their asthma were also more likely to report utilization. While those unemployed because of asthma were already more likely to report utilization, individuals in the 45+ age category were more likely than those 18–44.Conclusions: Identifying asthma patients likely to utilize medical care is feasible, although more investigation is needed to demonstrate applicability to a general asthma population.

Impacts of a PBM-Based Disease Management Program on Asthma Medication Use

OBJECTIVE: To evaluate the impact of an asthma disease management program conducted by a pharmacy benefit management (PBM) organization. DESIGN: A prospective analysis of the outcomes of an education-based disease management program for a large population of asthma medication users, compared to the outcomes for a matched longitudinal control group. SETTING: Merck-Medco Managed Care, L.L.C., a national PBM that manages prescription benefits and provides mail-service and online pharmacy services. PATIENTS: The intervention group consisted of 19,289 patients with asthma, aged 6 and older, divided into high-risk, low-risk, and maintenance subgroups based on history of asthma medication use. The control group consisted of 19,253 asthma patients matched on age and gender. INTERVENTIONS: Patients in the intervention group received asthma education materials and had call-in access to pharmacists trained in optimal asthma care. Physicians were notified when their patients were enrolled, and they received asthma therapy guidelines if their patients’ medications or self-reported status indicated suboptimal therapy. MAIN OUTCOME MEASURES: Antiinflammatory controller medication (AICM) use and inhaled short-acting beta-agonist medication use. RESULTS: Intervention group patients showed larger increases in AICM use than control group patients (17.8% versus 13.6%, for high-risk patients, p<0.001; 12.7% versus 8.9%, for lowrisk patients, p<0.001). Significant increases in usage of inhaled corticosteroids were found for both highand low-risk groups (p<0.001), compared to the control group. Among patients who started using AICMs, use of inhaled short-acting beta-agonists decreased significantly (p<0.01). CONCLUSION: A PBM-based asthmaeducation program can improve asthma therapy by increasing usage of AICMs and reducing reliance on quick-relief medications. These treatment changes are consistent with clinical practice guidelines, and are associated with improved symptom control and reduced health care utilization and costs.

Asthma Disease Management: A Worksite-Based Asthma Education Program

Asthma accounts for an estimated 3 million workdays lost each year in the United States in addition to reduced worker productivity. Although asthma disease management programs are relatively common in managed care organizations, they have generally not been offered at the workplace. Seventy-six employees participated in a five-session worksite-based asthma education program. A total of 47 of 76 (61.8%) employees completed baseline and 12-month follow-up Asthma Therapy Assessment Questionnaires (ATAQ). The ATAQ includes measurement of poor asthma control, behavior/attitude barriers, knowledge barriers, patient/provider communication barriers, and efficiency. Significant improvement was noted in measures of asthma control (p < 0.05), communication (p < 0.005), knowledge (p < 0.001), and the total ATAQ Index declined from 5.53 to 4.04 (p < 0.001). Employee satisfaction results for the program were exceptionally high. A worksite-based asthma education program should reduce medical care costs, worker absenteeism, and improve worker productivity. The worksite can be a very effective location for disease education programs.

Bank One's worksite-based asthma disease management program.

Non-occupational asthma is a common disease affecting approximately 6% of the US population. Asthma accounts for an estimated 3 million workdays lost each year in the United States and for reduced employee job productivity. Although asthma disease management programs are relatively common in managed care organizations, they generally have not been offered at the workplace. A total of 168 employees with asthma were identified, and 76 participated in a worksite asthma disease management program. Of them, 41 (53.9%) completed an Asthma Therapy Assessment Questionnaire (ATAQ) at baseline, post-program (2 months), 4 months, and 12 months. The total ATAQ Index declined from 3.59 at baseline to 2.76 at 12 months (p < 0.01). After the program, significantly more employees reported using controller medications (the desired behavior) rather than reliever medications. A worksite-based disease management program for asthma should reduce medical care costs and absenteeism and improve worker productivity.

Environmental management of asthma at Massachusetts managed care organizations.

Asthma management staff at eight Massachusetts managed care organizations (MCOs) were interviewed to learn the extent of inclusion of environmental prevention strategies in their asthma disease management policies. Six of the plans had formal asthma disease management programs, all reported to be based on the National Heart Lung and Blood Institute guidelines, but none followed these guidelines in their entirety. Three MCOs provided for home visits that included addressing environmental factors for severe asthmatics. Despite the limited role that MCOs appear to play in environmental prevention of asthma, the authors identify opportunities and encourage efforts to expand these programs.

The populations and quality improvement seminar for medical residents.

Objective: To teach primary care residents to apply the fundamentals of quality improvement to a clinical problem. Description: As the evidence for deficiencies and variation in clinical quality grows, it has become apparent that physicians need to play a leadership role in improving quality of care. Traditional residency training does not provide trainees with the knowledge and skills to assess the care of a population of patients or to initiate, manage, and evaluate changes in health care delivery. Our course, the Populations and Quality Improvement Seminar, is an effort to address this deficiency. We use the disciplines of outcomes measurement, process improvement, and continuous quality improvement as a framework to analyze organizational change. The residents then apply this framework to a clinical problem. Working in pairs and linked both to a faculty mentor and a clinical database manager, they generate an improvement project derived from their clinical experiences in the General Medical Clinic at San Francisco General Hospital. Using Batalden's framework for the continual improvement of health care,1 for example, the seminar group explores strategies to enhance the likelihood that each project will succeed. Recurrent themes include clarifying and applying existing professional knowledge on the subject, defining a target population, creating tension for change, generating methods to measure performance, exploring variation, understanding the impact of the entire system on the desired outcome, promoting interdisciplinary collaboration, valuing the customer's perspective, and encouraging flexible pilots and cycles of improvement. Seminar participants have begun groundwork on and/or evaluation of a variety of clinical problems such as establishing a clinical pharmacist intervention to improve medication adherence in patients with chronic illness, improving specialty-primary care communication in an asthma disease management program, increasing providers' knowledge and use of post-coital contraception technologies, and developing and evaluating a psychosocial screening tool for new patients that is administered by nurses. Both the didactic portions and the project-oriented work are being carried out over a two-year period during ambulatory months, representing 15% of the residents' outpatient didactic curricular time. The seminar is facilitated by two dedicated faculty members and frequent guest faculty. Discussion: The seminar has empowered residents to improve the care delivered in their continuity clinic and has created working relationships focused on quality-of-care issues between the clinic staff, residency program, and the academic division's faculty. Greatest success has been achieved by selecting projects that already have organizational momentum and then shaping and/or improving on them. Challenges have included linking faculty interests with those of the residents, addressing residents' concerns about the possible infringement on traditional clinical learning that results from from a shift to project-oriented learning, and navigating the tension between “research”/study design and “quality improvement”/project design. We plan to evaluate the effectiveness of the individual clinical projects, residents' satisfaction with this component of their ambulatory curriculum, and the impact of this seminar on residents' experiences and attitudes toward their ambulatory clinical work, their level of comfort in being agents of improvement in clinical care, and their subsequent career decisions.

Home care.

As soon as the pediatric asthmatic leaves the hospital, emergency department, or physician's office, the provision of their care is in the hands of a parent or guardian, or themselves. Patients often require more intensive intervention by a health care professional. The respiratory therapist is a logical physician extender in the home. This Article explores home-based asthma disease management programs that are respiratory-therapist directed.

Asthma Disease Management Program.

The Asthma Disease Management Program of the Kaiser Permanente Colorado (KPCO) Denver/Boulder Local Market began development in August 1995. Its pilot project was implemented in February 1997 with full implementation in August 1998. A very large team of participants contributed to the initial and ongoing success of this regionwide initiative. Table 1 identifies the complete list of project supporters and contributors. Table 1 Kaiser Permanente Colorado Denver/Boulder Local Market Asthma Disease Management Program Project supporters/contributors

Pediatric Asthma Outcomes After Implementation of a Disease Management Model: The Asthmatter of Fact Program

Asthmatter of Fact is a comprehensive pediatric asthma disease management program designed for use in an independent practice association (IPA) model managed care organization (MCO). To improve the quality of care received by children with asthma and to increase adherence to evidence-based guideline recommendations, as manifested by reductions in emergency room and hospital utilization and in activity days missed. The program features intensive home-based patient education; a unique alignment of incentives with primary care and specialist collaboration; and continuous quality improvement (CQI) based on provider and ancillary staff education and performance feedback. The outcomes measures included hospitalizations and emergency room visits, missed activities days, medication usage and patient satisfaction. Measured outcomes after the first year of the program demonstrated major reductions in hospital admissions (63%), emergency room visits (71%), and urgent care costs ($670 annual savings per patient), accompanied by improvements in quality of life and pharmacy profiles and a high level of patient satisfaction. These results suggest that the Asthmatter of Fact Program for pediatric asthma disease management might serve as a useful prototype in other IPA-model MCO settings.

951 The impact of expert allergy care and a nurse telephonic asthma disease management program on outcomes in asthmatics

951 The impact of expert allergy care and a nurse telephonic asthma disease management program on outcomes in asthmatics

A cohort study of resource use by medicaid children with asthma.

* Abbreviation: AFDC = : Aid to Families With Dependent Children Asthma is the most common chronic disease of childhood and accounts for 1% of all health care expenditures. A substantial portion of the cost is derived from care provided in both the inpatient setting and the emergency department.1 ,2Health care plans are using asthma disease management programs to address the rising cost of asthma care and to meet various accreditation requirements. Most asthma disease management programs enroll patients after either inpatient admissions or emergency department visits, and track their success by showing a decline in the use of hospital resources for asthma over a subsequent period of time. Asthma, especially pediatric asthma, is a relatively dynamic disease and there are scant data to support the assumption that 1 year of increased hospitalization or emergency department utilization is predictive of future utilization. We undertook this study 1) to determine the patterns of hospital utilization over a 2-year period among children with asthma, and 2) to describe factors associated with the persistence of high utilization of hospital resources. ### Study Group Selection and Demographics We elected to study a Medical Assistance population because the mortality and morbidity from pediatric asthma disproportionately affects children of lower socioeconomic status.3 ,4Using all of the Medical Assistance claims data for Allegheny County from the 1992–1993 fiscal year and the corresponding eligibility file, children between the ages of 0 and 16 years who were continuously enrolled in the traditional fee-for-service plan for both the 1992–1993 and 1993–1994 fiscal years were selected. Any child enrolled in one of the managed care plans during either fiscal year was eliminated from the study group. Children from the 1992–1993 fiscal year were identified as having asthma if one of the following combinations of claims was paid for by Medical Assistance during that year: a hospitalization with a diagnosis of asthma (ICD-9 code 493.00–493.99 …

Asthma and Disease Management: History and Development within an Integrated Healthcare System

The object of this study was to evaluate an asthma disease management program within a group model HMO. We describe program results and the necessary components of a successful disease management program in a managed care environment. The setting was a nonprofit group model HMO in an integrated health system located in central and northeastern Pennsylvania. The participants were 312 asthma patients enrolled in the disease management program. Based on the NIH guidelines, interventions included physician and patient education provided by the asthma disease management implementation staff and specially trained nurse educators in a primary care setting. The main outcome measures were as follows: Preand post-asthma claims per member per month (PMPM) over 1 year; Juniper-based quality-of-life survey at baseline and 6 months after program enrollment; and patient satisfaction with asthma education. The asthma claims PMPM decreased from $28 baseline to $20 1 year after enrollment. In addition, 94.3% of enrollees r...

Partnership for excellence in asthma care: evidence-based disease management.

Our experience with developing and implementing the outpatient component of an evidence-based disease management initiative has been a positive one. Involvement of respected practicing physicians in the planning phase, recommendation of evidence-based guidelines, and the supportive relationship between the hospital and participating practices have been essential to the successful launching of an asthma disease management program by a children's healthcare system. As the implementation phase continues to progress, we are preparing for the 6 month data collection stage, including outcomes measurement and practice pattern feedback. After 1 year of implementation we will analyze the data and report on the effects of the Partnership. We expect that physicians will continue to use the guidelines, and therefore sustain the improved health status of children with asthma. We will continue to invite pediatricians' participation in the Partnership so that more children in our community can benefit from high-quality cost-effective care that results in superior health outcomes.

A disease management case study on asthma

This paper provides an overview of how one pharmacy benefits manager, Med-Impact Pharmaceutical Management, Inc. (San Diego, California), approaches its disease management (DM) program for asthma. This group's experience with DM counters the common but fallacious belief that reduction of component costs leads to reduction of total expenditures. In fact, greater expenditures on certain components (in particular, drug therapies and preventive and follow-up visits to physicians) can result in greatly reduced overall expenditures by reducing hospitalizations and emergency department treatments for asthmatic patients. The program addresses four essential components of DM: physician intervention, patient empowerment, health risk management, and pharmaceutical care. For each of these areas, careful statistical analysis, effective education, and integrated management can help improve patient care while reducing overall costs.

Measuring and monitoring outcomes of disease management programs

After a brief analysis of the financial and health care motives that have led to the current boom in disease management (DM) programs, this paper discusses the pragmatic realities of a particular DM program for treating asthma. A model of the institutional structures necessary for DM to work is presented, emphasizing a process of continuous quality improvement in technical, clinical, and managerial processes. Significant differences between the conventions of controlled clinical trials and the realities of actual patient care may lead to unrealistic expectations about DM, making sound managerial practices and effective communication even more important. A “data warehouse” can help health care systems master the intricacies of programwide data collection and analysis, making possible sound decisions regarding treatment regimens and changes in physician and patient behavior. This paper concludes with a discussion of how the Prudential Health Care DM program for asthma makes use of the practices and systems discussed above.

Disease management program for asthma: baseline assessment of resource use

Resource use by asthma patients was assessed as a step in the development of a disease management program by a university teaching hospital, a health maintenance organization (HMO), and a national pharmacy benefit management company (PBM). Medication profiles and medical records were reviewed for all HMO patients who had a diagnosis of asthma and a pharmacy claim for an asthma-related drug in 1993; patients with chronic obstructive pulmonary disease were excluded. These 656 patients' use of health care resources (outpatient clinic visits, emergency room and urgent care visits, hospital admissions, and, the associated costs were determined, as were variances from the PBM's clinical guidelines for asthma. Members 0-4 years of age had the most outpatient and emergency/urgent care visits and the most hospital admissions. Forty-four of the patients received high-dose beta-agonist therapy, and 20 of these patients did not receive either an inhaled anti-inflammatory drug or a short course of corticosteroids. The 44 patients had more outpatient clinic and emergency room/urgent care visits, more admissions, and greater total health care costs than the other patients with asthma. The asthma patients' mean health care cost in 1993 was $203, compared with $110 for all enrollees in the HMO. For patients with high use of beta-agonists, the mean cost was nearly three times that for the other asthma patients. The baseline review of resource use identified aspects of medication use that were at variance with treatment guidelines for asthma patients.