ADULT ASTHMA INPATIENT ADMISSIONS

Reducing Hospitalizations With Better Outpatient Care

When a health plan's performance already exceeds goals such as those in Healthy People 2000, it might seem that no further quality improvement effort is needed. But even good performance can be improved. This health plan, aware of the importance of asthma care to its population, realized that hospitalization represented a failure of outpatient treatment. It set about improving its ambulatory care for patients with asthma, aiming to decrease a hospitalization rate that already had met a national goal.

In 1993, between 14 and 15 million people in the United States were affected by asthma. Health care costs related to asthma in 1990 were estimated at $6.2 billion for both adults and children.

For this plan, asthma hospitalization was common and increasing, and the plan wanted to reverse the trend.

The plan used HEDIS 2.5 methodology throughout this activity. The target population consisted of patients with asthma aged 20 to 39 years who had been continuously enrolled in the plan throughout the year. The plan used pharmacy data to identify this population. Members were included if pharmacy data showed that they had received any of the following:

• one or more prescriptions for cromolyn sodium or aerosol corticosteroid, or
• one prescription for a bronchodilator and at least one prescription for cromolyn sodium or at least one prescription for aerosol corticosteroid, or
• two prescriptions for a bronchodilator, or
• two prescriptions for theophylline

The performance measure used was the percentage of adult patients with asthma who had been hospitalized one or more times during the year. Hospital claims and encounter data were used to derive the measure.

Data from1994 produced a baseline performance rate of 0.73% for adult asthma-related admissions.

The plan's goal and benchmark, to reduce the hospitalization rate for patients with asthma to less than 1.60% per year, were chosen from Healthy People 2000. Although the plan had already met this goal, it felt that asthma care represented an important issue for its membership, and other health plans had reported even lower hospitalization rates.

COMPARABLE MEASUREMENT One of the benefits of using HEDIS data is the ability to compare performance across plans or delivery systems. Although this plan used HEDIS measures, its benchmark and goal were not comparable with its performance measure. The benchmark looks at the hospitalization rate for all patients with asthma, while the HEDIS measure used was for all adult patients with asthma. Although the plan addressed pediatric asthma care in a separate activity, no combined hospitalization rate was calculated. Comparison of results from this study with benchmark performance is therefore not meaningful and may be misleading.

Prior to implementing any interventions, the plan conducted a barrier analysis. Through its analysis, the plan realized that there were limitations to the interpretation of its data because there was no adequate risk or severity adjustment method. Another confounding factor noted was that the prescription drugs used for the treatment of asthma are also used to treat other types of obstructive pulmonary disorders.

The plan identified the following barriers:

• variability in patient and provider knowledge about asthma management
• lack of formal adult asthma classes
• limited knowledge of effective self-management methods
• many members had not chosen a primary care provider
• the time spent in the office was possibly too limited
• providers were unaware of the impact and value of "teachable moments" when they interacted with members

The plan implemented a number of interventions:

• the chief of internal medicine approved the use of 1991 National Institutes of Health (NIH) treatment guidelines for the plan (an algorithm based on these guidelines is included in QP Tool ; also included is the plan's pediatric asthma care algorithm)
• added peak flow meter reading as a vital sign for patients with asthma and promoted use of this tool to manage patients
• revised its advice-nurse protocols to include information about the usefulness of peak flow meter readings, and to solicit peak flow readings when speaking to patients about their asthma symptoms
• created an adult asthma education curriculum to include education about the usefulness of peak flow meter readings (samples of patient education material for both adults and children are included in QP Tool )
• decided on a single standard peak flow meter

The plan began by training its staff and practitioners about the rationale for the guidelines, patient education techniques, the use of peak flow meters, and the proper use of inhaled steroids.

The plan sought to implement frequent and wide-ranging interventions. In the first year, the plan began a pilot program at two of its medical centers.

Interventions aimed at clinicians included monthly communication with primary care physicians (PCPs) about which of their patients had been enrolled in the educational program. The plan also developed an incentive program that enabled clinical and nonclinical staff to earn annual bonuses by meeting clinical goals relating to the population's adult asthma admission rate.

Program revisions were made based on formal and informal feedback from members, physicians, and center staff. Discussion sessions solicited suggestions for all aspects of the program, including educational sessions, incentives, and clinical guidelines.

For pharmacists and pharmacy staff, the plan initiated training on clinical guidelines, new formulary choices, and identifying patients who could benefit from inhaled steroids.

As members of a high-risk group, adult patients with asthma also received reminders to receive an annual flu shot.

The first remeasurement, using 1995 data, showed a hospitalization rate of 0.71%. There was no statistical difference between this rate and the prior year's rate.

In 1996, the plan concentrated its efforts on members. It expanded the 1995 pilot effort to all its centers. In August, a business plan was written for a more formal and extensive program. The Healthwise Handbook, a popular commercial self-help book, was customized and distributed to all members.

The second remeasurement, using 1996 data, indicated a statistically significant decrease in admissions, with a rate of 0.44%.

In 1997, the plan continued with close attention paid to previously implemented programs, while also adding several new interventions.

What had been an informal program was rolled out as a more formal and extensive disease management program in 1997, implementing the formal business plan that had been developed.

New in-service training for correct inhaler usage was directed at physicians, nurses, and pharmacists. The plan emphasized the problems of overuse of beta agonists and underuse of inhaled steroids. Information about how long an appropriately used inhaler should last helped identify patients who were overusing their beta-agonist medication. (A sample information sheet is included in QP Tool .)

At the request of PCPs, a new allergist was hired. An asthma registry was also started that listed patients with asthma by ambulatory center and helped to facilitate patient tracking and compliance with clinical guidelines.

Remeasurement using 1997 data showed a rate of 0.34%, a statistically significant improvement over the previous year's measurement.

The plan has been very successful: it reduced the adult admission rate by more than half by carefully planning its interventions to build on the previous ones and to progressively cover more ground each year.

The quality initiative development process became a valuable management tool for this plan. The process is driving the plan's general approach to quality improvement and the means by which their successes are documented. The discipline of continuing cycles of measurement is now systematized into plan processes. Indeed, many of this effort's lessons have been incorporated into newer activities, like the asthma registry, which is being modified for use with other diseases.

As a result of this initiative, approximately 1,000 members avoided hospitalization for asthma for over three years. This profile demonstrates how a plan can use quality improvement methods to make a large number of people's lives demonstrably better, while also saving important plan resources.