Better control of asthma can save millions

Program targets education of doctors, patients

Better management of asthma could save millions of dollars a year in reduced hospital admissions and visits to the emergency department, according to Harvard Pilgrim Health Care in Boston, which tracks more than 20,000 adult and pediatric patients.

An asthma care management program, including patient education and home visits by nurses, is saving the health plan an estimated $1 million a year, says Joseph Healy, PhD, director of quality and outcomes measurement. "That doesn't begin to calculate what we might be saving in terms of work time lost."

Harvard Pilgrim recorded marked reductions in emergency department utilization, hospital admissions, and hospital days, and increases in prescribed inhaled anti-inflammatories and provision of peak flow meters to help patients manage their asthma.

Patients also reported reductions in days lost at work or school due to asthma, as well as less stress.

The case management began with a pilot project at one Harvard Pilgrim clinic, where a nurse monitored the cases of about 150 moderate to severe pediatric asthma patients and consulted with physicians. Among patients in the Asthma Outreach Program, emergency department admissions dropped by 79%, and hospital admissions declined by 86%. The program produced an estimated cost savings of $87,000 in one year for only 53 enrolled patients.1

An allergy nurse developed an asthma control plan for each patient and met with the patient and family to provide education. Initially, the nurse called patients as often as twice a month to monitor their care and use of medications.

"Establishing that caring element is very critical to building that partnership [between patients and providers]," says Dirk Greineder, MD, PhD, director of clinical allergy at Brigham and Women's Hospital in Boston and a staff allergist at Harvard Pilgrim. "You need to let the patients know you care. After a while, you can back off from [making phone calls] because they will call you when they have a problem."

Now, five nurse case managers handle the asthma care needs for the more severe patients at Harvard Pilgrim.

Specialist works with primary care docs

Educating primary care physicians to focus on specific cases forms a cornerstone of the Harvard Pilgrim program.

Greineder, the allergy nurse care manager, and primary care physicians with a special interest in asthma work together to highlight specific cases and provide information to other primary care physicians on how they could improve care. Sometimes, that involves formal meetings with the primary care physician; often, the nurse calls the physician to discuss a certain case.

A nurse care manager must be knowledgeable and sensitive and have strong backup from a physician in order to feel comfortable recommending interventions to another physician, Greineder notes. "Case managers need support. They need their own champions - a physician to support them."

Meanwhile, Harvard Pilgrim distributed the National Heart, Lung and Blood Institute guidelines on asthma care to all physicians and implemented training sessions. Patients receive home treatment plans based on the guidelines, including information about how to respond to certain peak flow meter readings, when to call the doctor, and when to go to an emergency department.

"Another element of the program involved a central consultation program - either to provide consultation to the primary care physician, to see the patient and provide a consultation, or to co-manage care with the primary care physician," says Healy.

A physician's knowledge about asthma care can greatly affect the outcomes of patients, a study by the Managed Health Care Association's Outcomes Management System Consortium finds. In the study, patients treated by a specialist or a generalist with specialized knowledge of asthma care had better outcomes, including fewer work days lost and better health status.

Being identified as high-risk has benefits

Just singling out patients with asthma control problems and focusing on their needs is likely to produce improvements, even without a systematic care management program, Greineder found.

He is currently involved in a major randomized trial that will further detail the impact of an outreach program that improves patient education and coordination of care.

But in one study, Greineder measured the difference in emergency department visits and hospital admissions among those who received the intervention vs. others who were identified as high risk but didn't get the special services such as patient education.

The control patients also had reductions in utilization during the following year, though not as dramatic as the intervention group: 21% vs. 60% for emergency visits, 24% vs. 74% in hospital admissions.2 "Just being identified probably changes the way [patients are] handled," says Greineder.

When studying the impact of interventions, physicians and outcomes managers should consider the "placebo effect" of identifying patients as high risk. But there is another message, as well: Once you stop focusing on the patients' special needs, the benefits of your intervention are likely to decline or even disappear, he says.

References

1. Greineder DK, Loane KC, Parks P. Reduction in resource utilization by an asthma outreach program. Arch Pediatr Adolesc Med 1995; 149:415-420.

2. Greineder DK, Loane KC, Parks P. Outcomes for control patients referred to a pediatric asthma outreach program: An example of the Hawthorne Effect. Am J Man Care 1998; 4:200-206.