ASTHMA DISEASE MANAGEMENT

Removing Barriers to Optimal Care

Despite advances in treatment, the prevalence, morbidity, and mortality of asthma continue to rise nationally. According to the United States National Asthma Education and Prevention Program, asthma is the most common chronic disease of childhood and the number-one condition that causes children to be absent from school. Nationally, it is the most common cause of pediatric hospitalization. Additionally, asthma causes approximately 5,000 deaths each year in the United States.

Understanding the importance of improving care for its patients with asthma, this plan embarked on a quality improvement activity to optimize care for both its adult and pediatric patients with asthma.

The targeted population consisted of all commercial and Medicaid members who had two or more encounters with an ICD-9-CM diagnosis of asthma (493.xx). The plan identified this population using claims and encounter data. The plan then stratified the identified members according to severity into three groups:

• Level 1, mild: Members with two to five office visits for asthma
• Level 2, moderate: Members with one inpatient asthma admission or one to four emergency room visits for asthma or six to nine office visits for asthma
• Level 3, severe: Members with more than one inpatient asthma admission or more than four emergency room visits for asthma or more than nine office visits for asthma

STRATIFICATION SCHEMES The use of claims information to assign a disease severity level to members is both interesting and creative. Other stratification schemes for asthma patients require surveys or medical record reviews, both of which are time- and resource-intensive processes. Once this scheme was designed, data extraction was quick and efficient.

The plan formed an advisory committee that included primary care physicians (PCPs), allergists, pulmonologists, respiratory therapists, and nurse practitioners. The committee selected six performance measures:

• rate of patients with moderate and severe asthma with visits to specialty care physicians (SCPs) - allergists or pulmonologists
• emergency room visits per 1,000 asthmatic patients
• inpatient admissions per 1,000 asthmatic patients
• rate of asthmatic patients on inhaled steroids
• rate of patients with moderate and severe asthma who own a peak flow meter
• average number of days absent from school or work in the past month for patients with moderate and severe asthma

The plan used claims, encounter, and pharmacy data for measures one through four. Measures five and six were determined by telephone survey of all Medicaid patients with moderate and severe asthma, and a random sample of commercial members with moderate and severe asthma. Baseline data were collected for the period June 1995 to May 1996. Please see PARAMETERS for baseline measurements.

The plan identified 4,875 active members in the target population. Initial stratifications provided a breakdown of this population by severity level:

• Level 1, mild: 71%
• Level 2, moderate: 26%
• Level 3, severe: 2%

Due to rounding, percentages do not always equal 100.

After reviewing the baseline data, the plan set performance goals for each measure. The plan used input from its advisory committee, a PCP focus group, and a survey of members. The goals included:

• increasing visits to SCPs for level 2 and 3 members by ten percentage points
• decreasing emergency room visits per 1,000 members by 10%
• decreasing inpatient admission per 1,000 members by 10%
• increasing the number of asthmatic patients on inhaled steroids by ten percentage points
• increasing the number of level 2 and 3 asthmatic patients who own a peak flow meter by ten percentage points
• decreasing the number of days absent from work or school in the past month for level 2 and 3 patients with asthma to less than two days per month

Since the advisory panel thought that no truly comparable benchmarks had been published, the plan did not use any benchmarks for this activity.

Prior to implementing any interventions, the plan identified barriers through input from its advisory panel, the PCP focus group, and the member survey. Key barriers identified:

• patient noncompliance with medication regimens prescribed
• lack of patient understanding of the role of inhaled steroids versus beta agonists in the control of asthma
• failure by the patient to notify the physician of symptoms indicative of an exacerbation
• lack of benefit coverage for peak flow meters and spacers
• the need for assistance with smoking cessation, particularly for parents of children with asthma

The plan developed two master strategies for the initiative:

• design and implement member education programs that foster a sense of partnership between the member and his or her PCP
• develop and implement a program to provide PCPs with information about their asthmatic patients

These strategies established the framework for the development of the plan's interventions.

The plan devoted significant resources to this project. It added two case managers, committed systems resources, and obtained statistical consultation to guide the design of the study and its quantitative analysis.

To implement its member strategy, the plan developed a program of tiered educational interventions. All asthmatic patients could receive education through seminars, such as "Enhancing Patient Self-Care in Asthma Management" mailings and newsletter articles. In addition, all level 2 and 3 patients with asthma were entered into an active case management program. The staff tracked each member intervention in its database.

The plan expanded coverage to include peak flow meters and spacers under its durable medical equipment benefit. A program to distribute them to members at no cost also was implemented at four health centers.

ADMINISTRATIVE BARRIERS Not all barriers to care are clinical in nature. Benefit structure, contractual relationships, and authorization systems can all have a significant impact on care. In this case, attention to these administrative barriers resulted in the identification and resolution of what had been a significant issue for members.

The plan also begin to implement interventions with its provider network. All PCPs received profiles of their asthmatic patients from the health plan. These profiles summarized hospitalizations, emergency room visits, office visits for treatment of asthma, and asthma-related prescriptions filled in the past year. A clinical practice guideline also was created. It was based on the National Heart, Lung, and Blood Institute Asthma Guideline, and customized with input by the advisory board. This guideline was distributed to all plan-affiliated PCPs, allergists, and pulmonologists.

Remeasurement was performed using data from June 1996 through May 1997. The health plan demonstrated statistically significant improvement in five of the six measures. Visits to specialists increased five percentage points over baseline to 22%, and the percent of asthmatic patients on inhaled steroids increased from 35% to 40%. The percent of adults who own a peak flow meter increased to 74% and the percent of children with a peak flow meter increased to 54%. Emergency room visits decreased from 390/1,000 to 265/1,000, and inpatient admissions decreased to 60/1,000.

There was no improvement in the sixth measure - decreasing the average number of days absent from work or school to less than two days. The remeasurement showed the average for adults was 2.7 days, and for children, 1.3 days.

The plan continued with its disease management program strategies of patient education and providing PCPs with useful patient information. Provider feedback from the advisory committee initiated an improvement in the member profiles of patients with asthma. The name and quantity of asthma medication obtained was included on each profile for physician review. Flags were used to indicate those members who were possibly overusing beta agonists or underusing inhaled corticosteroids.

Although benefit coverage had already been expanded to include peak flow meters and spacers as durable medical equipment, members reported that it was inconvenient to obtain these from the vendor locations. The plan modified its delivery of these items to allow patients to obtain them from participating pharmacies.

Intensive educational efforts for members and providers also continued through various mechanisms. The asthma management guidelines were updated and distributed to all nurse practitioners and physician assistants and active case management began. The plan worked with the American Lung Association to distribute asthma and smoking cessation educational materials to appropriate members. Additionally, an asthma newsletter was sent with a flu shot reminder to all members with asthma.

The plan continued to measure the results of its interventions. Data from 1997 through 1998 showed that emergency room visits and inpatient admissions for asthma decreased (by 3% and 11%, respectively). Visits to specialists by level 2 and 3 patients with asthma increased to 60%. The percentage of patients with asthma on inhaled steroids increased to 45%, and days lost from work/school in the past month decreased to 2.2 days for adults and 1.2 days for children. However, the percentage of patients with asthma with peak flow meters remained flat.

The asthma disease management program has attracted significant attention. Plan staff members have been invited to present the initiative at a seminar sponsored by a state medical society. Member-participants have been featured in at least three television programs. Recently, the asthma program was featured as the topic of grand rounds at a local hospital as an example of how good managed care works.