Improving Asthma Management: One Health Plan's Experience

Objective: To demonstrate that including the patient's perspective of disease control (patient-reported symptoms) in asthma treatment and management decisions improves patient outcomes and reduces healthcare resource utilization.

Study Design: Two study phases gathered patients' assessments of disease control. Phase 1 used a retrospective physician questionnaire. Phase 2 used a patient questionnaire at each office visit. Physicians and patients were members of the Independent Health Association, a health insurer in upstate New York.

Methods: Phase 1 gathered patients' assessment of asthma control retrospectively using a physician questionnaire. Physicians received a list of pediatric patients in their practice who had intermittent and persistent asthma as their primary diagnosis. They reviewed a sample of these actively managed patients and answered 10 questions about them. Phase 2 was designed to include the patient’s perspective. The Asthma Control Test was sent to every patient with asthma to complete and to bring to each physician visit.

Results: In phase 1, emergency department visits and hospitalizations for asthma decreased during the program. Emergency department visits decreased from 3.71 to 2.92 per year (P < .01), and hospitalizations decreased from 0.83 to 0.81 per year (not statistically significant). Results for phase 2 are not yet available.

Conclusions: Although not a controlled program, for the participating practices the Independent Health Association health plan seems to have improved patient outcomes when they included retrospective, documented, patient-reported symptoms in their asthma management decisions. Emergency department visits and hospitalizations decreased. Managed care organizations should consider adding the patient’s perspective of disease control to their asthma management decisions.

(Am J Manag Care. 2007;13:482-485)

Management of patients with asthma must extend beyond traditional measures of control. Incorporation of the patient's perspective is key. Asthma symptoms can be assessed at every healthcare visit and categorized as well controlled or not.

• Tools are available to assess patient symptom control, including the Asthma Control Test, the Asthma Control Questionnaire, and the Asthma Therapy Assessment Questionnaire.
• Emergency department visits and hospitalizations for asthma decreased during phase 1.

The results of current research regarding the outcomes of care for patients with asthma have prompted healthcare professionals to rethink how the disease is managed. One shift in thinking includes the patient's perspective of asthma management at each office visit. This article reviews how a health plan included this patient perspective in their healthcare decisions and found that it led to improved outcomes.

UNCONTROLLED ASTHMA IS AN ECONOMIC BURDEN

National and international asthma guidelines define asthma as a chronic inflammatory disorder of the airways.^1,2 The chronic inflammation contributes to airway hyperresponsiveness that may be associated with wheezing, breathlessness, chest tightness, and nighttime or early morning coughing.

Almost 20 million Americans have asthma, and more than half report a recent asthma exacerbation.³ Asthma is not defined by age, affects young and old alike, and is considered a major health problem in the United States and a serious chronic illness in children. More than 14 million school days and 14.5 million workdays were lost in 2004 because of an asthma-related illness.^3,4 Restricted activity and unhealthy function days account for another 100 to 150 million days.^5,6 In 2003, the annual economic burden attributed to asthma in the United States exceeded $16 billion. Almost 75% of these costs resulted from direct healthcare expenditures, while the remaining costs are considered indirect resulting from morbidity (including lost school days, wages, and work productivity) and mortality.⁴

Asthma Is Often UncontrolledCommunity-based findings suggest that asthma symptoms are not controlled in most patients.⁷ This uncontrolled asthma results in direct costs and indirect costs⁸ and contributes to higher healthcare expenditures. When asked about the status of their asthma control, many patients overestimated their level of actual disease control. Alternatively, patients and physicians who were asked in a survey about the status of asthma control using a general question underestimated the effect of asthma on daily functioning.⁹ In a study by Patel et al,¹⁰ when asked to define their level of asthma control, 70% of adult patients and 90% of adults reporting for pediatric patients said that their asthma was well controlled. However, when specific questions were asked of adult patients about missed work, nocturnal symptoms, and frequency of rescue medication use, the percentage of responses indicating poor control increased (34%, 48%, and 95%, respectively). Other investigations substantiate these findings.¹¹

Identifying Those With Uncontrolled AsthmaTraditionally, claims-driven markers (rescue medications, emergency department [ED] visits, and hospitalizations) were relied on to identify patients receiving suboptimal treatment. These markers address disease severity, and their assessment was typically used as a framework to help physicians make therapy decisions such as stepping treatment up or down. However, it is unclear that interventions targeting these claims-driven markers substantially improved asthma symptom control for the patient.¹⁰

Asthma Can Be Better Controlled

The Independent Health Association (IHA), a health insurer in upstate New York, has an experimental asthma program with the goals to improve health and to decrease costs through improved asthma management. They found improved patient outcomes when they included documented patient-reported symptoms (the patient's perspective) in their treatment decisions. ED visits and hospitalizations for asthma in this population decreased during the program.

How Did This Health Plan Experiment Come About?In 1999, New York Governor George Pataki called for a reduction in asthma-related ED visits and school absenteeism.¹² Regional coalitions were formed to provide asthma education, improve asthma care coordination, and develop data systems to track asthma improvement and improvement efforts data. The IHA used the regional initiative to put forward an improvement program for pediatric patients with asthma. The IHA has a member base of almost 375 000, including approximately 90 000 members who are younger than 18 years. Almost 10% of this pediatric population carries a diagnosis of asthma, making an asthma initiative a high priority.

The IHA, in collaboration with a physician advisory panel, developed an innovative component to its existing Practice Excellence pay-for-performance program more than 3 years ago. The new program was a 2-part patient-centered initiative designed to address patients with asthma aged 5 to 18 years. Children younger than 5 years were excluded from the program because of diagnostic and coding difficulties in this population. Regional practice guidelines, based on available national guidelines for asthma management, were developed and accepted by all major regional health plans in the service area of the IHA, making possible the introduction of a uniform initiative.

The program was designed to encourage pediatricians to review current practice patterns, provide them with an accurate population-based profile of their patients, and offer education that supports improvements in care. For phase 1, pediatricians with at least 200 commercial members in their practice were paid for their participation in the program. One hundred twenty-two pediatricians (>90% of those eligible) participated.

Design and Results of Phase 1In phase 1, pediatricians retrospectively reviewed the patient records to assess disease control. Beginning with a baseline study (cycle 1) and every 6 months thereafter, physicians received a list of pediatric patients in their practice who had intermittent and persistent asthma, defined as 2 or more office visits, ED visits, or hospitalizations within a 12-month period with asthma as the primary diagnosis. Physicians reviewed a sample of these actively managed patients and, using a form with 10 questions based on critical elements of the regional guideline, answered questions about them that addressed documentation of asthma classification, pulmonary function tests, and symptoms. A different sample of patients was selected for review in each cycle.

Completed medical record reviews were scored; each element was scored individually, and a composite score was calculated. A new severity score was calculated based on the patient's reported symptoms and was compared with the physician's assessment of severity. Based on the results of the scoring, physicians were contacted and were asked to reconsider their severity scoring and to reassess treatment strategy based on the new severity rating. Physician account executives met with each pediatrician and provided them with a report that contained a profile of their patients, outcomes of the data collection, and the community peer mean score. Participants attended educational sessions at which physician asthma experts (ie, board-certified allergists, one in private practice and another academic based) commented on the phase 1 findings and principles of guideline-based asthma care management. The report and the educational sessions reinforced potential care management improvements. Physicians accepted the report findings because it was a summary of their own data that they had submitted for aggregation.

The goal of returning information to the participating physicians within 3 weeks of completion was not met between the first 2 cycles; therefore, no effect on evaluation and prescribing could be realized. However, beginning with the third cycle, improvements were observed (Table). Only the peak flow guideline failed to show continued improvement. This plateau effect was expected by the participating physicians because they reported a saturation point at which no additional patient participation could be expected. Although a definitive correlation could not be established, ED visits and hospitalizations for asthma in this population decreased during the program. Emergency department visits decreased from 3.71 to 2.92 per year (P < .01), and hospitalizations decreased from 0.83 to 0.81 per year (not statistically significant). It is expected that phase 1 of the program will end after 1 or 2 more cycles because additional improvement gains will not be accomplished with continued use.

Design of Phase 2Phase 2 provided physicians with the patient's perspective at each and every visit. The Asthma Control Test was sent to every patient with asthma to complete and to bring to each physician visit. Pharmacy records were reviewed to identify patients who were frequent users of inhaled albuterol sulfate, defined as 3 U in 4 months, and who were not using a controller medication. Opportunities to step therapy up or down were explored. Results of this phase are not yet available, but it is postulated that reviewing patient-reported symptoms at each office visit will ultimately result in a more tailored treatment regimen, further improving patient outcomes.

CONCLUSIONS

Although not a controlled program, for the participating practices the IHA health plan seems to have improved patient outcomes when physicians included retrospective, documented, patient-reported symptoms in their asthma treatment decisions. Emergency department visits and hospitalizations for asthma in this population decreased during the program. A randomized controlled study would perhaps clarify whether these outcomes were a function of this program or other factors.

Managed care organizations developing asthma initiatives should consider the IHA model of adding the patient's perspective of disease control (patient-reported symptoms) to traditional measures. Traditional claims-based measures of severity indicate asthma status only at specific points. Including the patient's perspective about his or her disease control at each physician visit can serve as the basis for therapy modifications. This can improve disease control and subsequently reduce future resource utilization.

AcknowledgmentsWe acknowledge Marjorie Pestel Zimmerman, MS, RPh, and Strategic Healthcare Alliance for their assistance in the preparation of the manuscript.

Funding Source: Editorial support was provided by Genentech, Inc.

Author Affiliations: From the Independent Health Association, Buffalo, NY.

Author Disclosure: The authors (AWG,TJF) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter discussed in this manuscript.

Authorship Information: Concept and design (AWG, TJF); acquisition of data (TJF); analysis and interpretation of data (AWG, TJF); drafting of the manuscript (AWG, TJF); critical revision of the manuscript for important intellectual content (AWG, TJF); statistical analysis (TJF); obtaining funding (TJF); administrative, technical, or logistic support (AWG, TJF); supervision (TJF).

Address correspondence to: Andrew W. Green, MD, Independent Health Association, 511 Farber Lakes Dr, Buffalo, NY 14221. E-mail: agreen@independenthealth.com.

1. Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA) Web site. http://www.ginasthma.org. Accessed May 16, 2006.2. National Asthma Education and Prevention Program, National Heart, Lung, and Blood Institute. Clinical Practice Guidelines: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Heart, Lung, and Blood Institute, National Institutes of Health; 1997. NIH publication 97-4051.

4. American Lung Association. Trends in Asthma Morbidity and Mortality 2006. New York, NY: Epidemiology and Statistics Unit Research and Program Services, American Lung Association; July 2006.

6. Luskin AT. What the asthma end points we know and love do and do not tell us. J Allergy Clin Immunol. 2005;115(4 suppl):S539-S545.

8. Dolan CM, Fraher KE, Bleecker ER, et al; TENOR Study Group. Design and baseline characteristics of The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study: a large cohort of patients with severe or difficult-to-treat asthma. Ann Allergy Asthma Immunol. 2004;92:32-39.

10. Patel PH,Welsh C, Foggs MB. Improved asthma outcomes using a coordinated care approach in a large medical group. Dis Manag. 2004;7:102-111.

12. New York State Department of Health. Regional Asthma Coalitions in New York State. http://www.health.state.ny.us/diseases/asthma/coalitions.htm. Accessed February 20, 2007.

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