What is the true measurement of success?
What is the true measurement of success?
Patient-reported outcomes track real-world results
Most asthma management programs focus on such outcomes measures as utilization of medical services. There's good reason for that focus. The direct costs of asthma were estimated at $6.2 billion in 1990. Those costs included direct medical expenditures such as inpatient and outpatient care, emergency room visits, doctor visits, and medications.
However, there are additional costs for employers in terms of lost productivity. When Glaxo Wellcome designed the outcomes measures for its asthma management program, it went beyond utilization and looked at issues of productivity and ability to perform activities of daily living. "Too many programs focus on the effectiveness of medical interventions without looking at what patients report as outcomes," says John E. Paul, PhD, director of clinical economics and outcomes assessment for Glaxo Wellcome in Research Triangle Park, NC. "It's important to focus on the total impact of the disease on the patient." (For a look at specific measures used by Glaxo Wellcome, please see charts, at right and on p. 8.)
"Managed care organizations can use these results to sell asthma management programs to employers," says Deborah O. Lucas, MPH, manager of clinical economics and outcomes assessment for Glaxo Wellcome. Imagine being able to report results like these from Glaxo Wellcome's six-month data of 137 patients in its asthma management program:
· 68.3% of patients reported some or a lot of difficulty in daily indoor or outdoor work at baseline compared to 41.9% at three-month follow-up and 37.7% at six-month follow up.
· 69.8% of patients reported some or a lot of limitations in physical activities at baseline compared to 41.9% at three-month follow-up and 47.3% at six-month follow-up.
Glaxo Wellcome Care Management Division's Asthma Self-Management Program (ASMP) includes eight weekly education sessions using a behavioral modification support group model, says Paul. The program is taught by nurses, case managers, pharmacists, and respiratory therapists. It includes sessions on the following topics:
· principles of asthma management;
· nature of asthma medications;
· attack prevention and management;
· problem solving;
· relapse prevention;
· communication with health care providers.
Patients in the ASMP complete a questionnaire during the first weekly session for baseline data prior to any asthma education. In addition to the questionnaire completed in class, patients are given a questionnaire on medical history and previous health care utilization to bring home and return at the next class session.
Patients complete the same questionnaire at the last session. "We then begin following patients quarterly from the date of their last class," says Lucas. Three- and six-month follow-up surveys are conducted by interactive voice response (IVR) system, she says. "However, we contract with a third-party data vendor to contact patients who don't respond to the IVR. We have an overall response rate of 90%," she says.
In addition, Glaxo Wellcome mails patients questionnaires at 12 months. "We also use the third party vendor to contact patients who didn't mail back their questionnaires by phone," says Lucas, adding that Glaxo is just now completing an analysis of 12-month data for early ASMP graduates.
"We consider the three-, six-, and 12-month follow-up contacts themselves as part of the intervention," notes Paul. "The follow-up questionnaires are as much for learning reinforcement as for data collection. If we asked patients whether or not they are using their metered dose inhaler or keeping a diary of asthma triggers, we believe the mere asking will serve as a trigger for renewed positive behaviors."
Paul says Glaxo Wellcome relies on standardized, validated outcomes measurement tools. "There's a whole body of measures available in the literature. Using standardized measures allows disease management programs to accurately compare their outcomes to those of other programs."
The next issue Glaxo Wellcome hopes to measure is whether self-confidence is a strong predictor of positive outcomes in asthma management, says Lucas. "We have built the whole concept of self-confidence into the program. We feel strongly that if patients believe they know how to manage their asthma it will reduce serious complications and improve outcomes," she says. "We don't have any data for that yet, but we've designed the instruments to measure it and plan to capture that data in the future."
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