ASTHMA DISEASE MANAGMEMENT

Pursuing Patient Involvement

When member participation in a quality activity is low, many plans would abandon their efforts and move on. Not this plan. When its asthma disease management program failed to attract more than minor levels of participation, the plan repeatedly tried other interventions. Even though none of the individual interventions attracted the majority of patients with asthma, the plan's persistence resulted in meaningful improvement.

Not only was asthma one of the top reasons for hospital admission to this plan, but it has consistently been one of the most frequent reasons for outpatient services, including emergency room visits. The plan had distributed asthma guidelines from the National Heart, Lung and Blood Institute (NHLBI) to participating physicians in 1991, but had not measured compliance with them. Recognizing an important need to improve asthma care, the plan began to work with local allergists to implement a comprehensive asthma disease management program.

The targeted population was all patients in the plan with diagnosed asthma. The plan used claims, encounters, and pharmacy data to identify patients with asthma. In order to better understand the therapeutic needs of this population, and target the interventions appropriately, the plan stratified patients with asthma according to the severity of their disease. Patients were assigned to a class from 0 (least severe) to 3 (most severe).

Using this classification system and data from 1995, the plan analyzed the care rendered. The plan discovered that although only a small percentage of patients with asthma were considered class 3, as a group they consumed the greatest amount of resources. Patients with asthma who were considered class 1 represented the largest group of patients, and as a group they consumed the second greatest amount of resources.

The plan initially used three performance measures:

• rate of inpatient admissions for asthma (per 100,000 total members)
• rate of emergency room visits for asthma (per 100,000 total members)
• percentage of patients with asthma considered class 3 on anti-inflammatory medications

Using encounter, claims, and pharmacy data, the plan established baseline scores for these measures. Data from 1995 showed the rate of inpatient admissions for asthma to be 10.4 per 100,000, the rate of ER visits for asthma to be 29.7 per 100,000, and the percentage of patients with class 3 asthma on anti-inflammatory medications to be 15.7%.

The plan used one benchmark: the inpatient admission rate. A clinic that cared for 7,500 patients with asthma had reported a program that had reduced inpatient admissions to 0%.

Goals for the initiative were established following the baseline measurement. The plan aimed to reduce the rate of inpatient admissions to 7.8 per 100,000, to decrease the rate of ER visits to 22.3 per 100,000, and to increase the rate of members with class 3 asthma receiving anti-inflammatory agents to 50.7%.

The plan met with a physician advisory committee to determine the barriers to this initiative. The advisory committee identified a key barrier: physicians were not prescribing appropriate medication for patients with asthma.

The plan worked in collaboration with the disease management arm of a major pharmaceutical company in implementing a disease management program for asthma. The program consisted of practitioner-focused interventions and member-focused resources. For the practitioners, the plan developed a step-care algorithm based on NHLBI guidelines in conjunction with the physician advisory committee. A physician brochure was developed and distributed with the guidelines to promote the use of the algorithm.

A patient profile for patients with asthma was also developed and distributed to practitioners. The report contained information on inpatient admissions, ER visits, and drug utilization.

Member interventions included the development and distribution of an asthma care kit. This kit contained:

• a peak flow meter
• a placebo metered-dose inhaler
• an instructional video on the appropriate use of a metered-dose inhaler
• an educational brochure on asthma
• a pamphlet for documenting a management plan, including a plan for acute exacerbations (a sample page is included in QP Tool )
• a personal diary for peak flow meter readings
• a spacer for the metered-dose inhaler delivery

The pharmaceutical company funded the kits. Over 2,500 kits were hand-delivered to the offices of primary care physicians (PCPs). Members were encouraged to make appointments with their PCPs to discuss their asthma conditions, create management plans, and receive their kits. Over 1,000 members confirmed receiving a kit.

The plan also expanded the health education network for asthma by training external personnel. There were 114 individuals recruited. Included were personnel from hospitals and home care agencies, several pharmacists, and some physician office nurses (mostly from pediatric practices).

ALTERNATE SITES FOR HEALTH EDUCATION Although the plan had hoped that members would participate in free classes offered by pharmacies, these classes proved unpopular. It was difficult to find space to conduct a class, and members wanted individual classes, while the pharmacists wanted group classes.

Despite the emphasis on increasing access to health education classes, less then 10% of the targeted members attended health education programs. Neither advertising nor incentives significantly increased program attendance.

The plan also mailed a questionnaire based on the 36-question short-form health assessment tool (SF-36), a standard quality of life assessment tool. This survey was mailed to all members with class 2 and 3 asthma, and to a random sample of members with less severe asthma. The response rate was greater than 50%. The results established a baseline measurement for quality of life.

Patients with severe asthma who did not attend health education classes or respond to the quality of life survey were targeted for a home assessment and education. Over 400 member households were contacted via telephone. Only 32 initially agreed to participate, and only 21 completed the program. The plan offered incentives for participants in the home program. When movie tickets were given out for program completion, 45 of 78 additional members completed the program.

As part of its health education umbrella program, the plan developed a program targeted at families with children between the ages of two and 11 years who had asthma. The local chapter of the American Lung Association implemented this program. Twenty percent of the contacted member families expressed interest in the classes, and 6% of these families ultimately attended the program. T-shirts and movie tickets were used as incentives for attending and completing the program.

Working with a nationally recognized center for allergy and immunology care, the plan targeted those members who had refused to participate in all other programs. The strategy was to offer a short, telephone-based educational program. Only a few members chose to participate.

THE DOCTOR-PATIENT RELATIONSHIP The few members who participated in the telephone-based program were asked to develop a comanagement plan with their PCPs. Yet almost one half requested that their PCP not be involved. Members worried about upsetting their PCP by seeking health care advise from another person. The plan decided to notify physicians in advance of the member contact, which dramatically increased member participation.

In 1996, the hospital admission rate was reduced to 7.8 per 100,000 members. The percent of patients with class 3 asthma who received anti-inflammatory agents was increased to 56.4%. Both of these changes were statistically significant.

The annual ER visit rate decreased to 25.8 per 100,000. This decrease was not significant.

The most substantial interventions in influencing outcomes appeared to be the delivery of asthma care kits, written instructions provided to patients by PCPs, and the patient reports sent to the PCPs. Because of low participation rates, the patient interventions did not produce the desired results.

The plan established new goals for 1997. The plan aimed at reducing the rate of inpatient admissions to 5.9 per 100,000, and the rate of ER visits to 16.7 per 100,000. The goal for the rate of patients with class 3 asthma receiving anti-inflammatory agents was increased to 85.7%.

With the baseline quality of life measurement in hand, the plan also set a new goal: to improve quality of life scores by an absolute score of one on at least four of the eight indices contained in the health status assessment tool. The eight indices were:

For children

• physical functioning
• role/social physical
• general health perceptions
• bodily pain discomfort
• role/social emotional
• self-esteem
• mental health
• behavior

For adults

• physical functioning
• role physical
• bodily pain
• general health
• vitality
• social functioning
• role emotional
• mental health

In 1997, the plan continued to produce annual patient reports for PCPs to assist them in identifying and targeting the most severe asthma patients. Cost data were added to the report, at the physicians' request. The plan also improved facility discharge planning, in order to improve the continuity of care.

Remeasurement, using 1997 data, showed a rate of inpatient admissions of 7.5 per 100,000, an ER visit rate of 27.1 per 100,000, and a rate of class 3 patients receiving anti-inflammatory medications of 50.9%. None of these measurements represented a statistically significant change from the prior year.

Only two changes in quality of life scores were statistically significant. The survey score for general health perceptions for children increased, and the score for vitality for adults decreased.

Although disappointed by the 1997 results, the plan remained undaunted. It implemented new interventions to move the initiative forward.

To address those members who were noncompliant with care recommendations, the plan created a high-risk program targeted at those members who drop out of home care management. The medical director sent a letter to PCPs asking them to consider these patients at extremely high risk, and to monitor them closely.

The plan reengineered the patient incentive program. Patients received points for attending classes, visiting their physicians and filling prescriptions. Points could be redeemed for gifts.

The plan worked with PCPs and allergists to increase the awareness of practice guidelines.

They communicated with medical office staff on the status of the practice's patients with asthma, with a particular emphasis on noncompliant patients.

It increased the sophistication of its targeting of patient education efforts with tailored messages and outbound telephone counseling. The plan continued its previous efforts, including the annual distribution of over 600 asthma kits.

Data from 1998 showed significant improvement in the inpatient admission rate and the use of anti-inflammatory agents, but not in ER visits. Five pediatric and eight adult quality of life measures showed significant improvements.

Although any individual component of the program appeared to achieve only limited success and participation, the plan's continuous member recruitment and dedication to new interventions ultimately resulted in meaningful improvement in care for its members with asthma.