Finally, practical tools for measuring asthma outcomes in clinical practices

AOMS offers flexible, patient-based approach to managing asthma

There is a great need to monitor asthma-specific health outcomes for the more than 12 million people impaired by the debilitating effects of asthma, but the practical ability to do so in clinical practice has been missing. However, an ongoing project of the Joint Council of Allergy, Asthma and Immunology (JCAAI) and QualityMetric in Lincoln, RI, is close to solving this problem.

The research has yielded an approach called the Asthma Outcomes Monitoring System (AOMS), which uses patient-based outcomes assessments to monitor adult and pediatric patients with asthma. The goal is to perfect a set of assessment tools and data-collection and processing technologies while standardizing the definition and measurement of asthma outcomes across practice settings, thus making it possible to document and compare outcomes.

A large part of this work has been accomplished. The tools, for the most part, are ready. A yearlong pilot program in 23 JCAAI-member practices involving about 35 board-certified allergists, 400 adults, and 400 children is nearing completion. This shakedown cruise for the assessment tools has ironed out most of the wrinkles. The job ahead is to automate the tools and make the program available to the industry.

The JCAAI, which is jointly sponsored by the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology, put that task into the hands of executives at QualityMetric, a company founded by John E. Ware, developer of the SF-12 and SF-36 forms. A number of top researchers at The Health Institute at the New England Medical Center in Boston are also officers at QualityMetric.

"We’re working with different data collection and processing vendors to provide services using the AOMS and to do so with a variety of different technologies, so that people have access to this program using whatever technology for data capture or processing they think will work," explains Martha Bayliss, MSc, senior director for clinical applications at QualityMetric. Bayliss also is project director for the AOMS.

That technology ranges from manual forms to a number of different electronic approaches. (See list of initial vendors, p. 7.) This will give users unprecedented versatility in configuring their data-collection systems, allowing them to be as automated as they want to be or can afford to be within the constraints of their organization’s budgets. Of course, the more automated the system, the faster the data get back to the doctor and he or she can incorporate it into the treatment regimen.

"So if somebody wants a touch screen in his or her office, we can make that happen," she says. "If someone likes the paper and pencil approach and sending the forms in for processing, we can make that work. If someone wants an Internet approach for keying the data in, we can make that happen. Our job is to make sure that the questioning, scoring, and reporting are constant across all those different platforms so that everyone is confident about the data, although they can vary the way they collect it and how much that costs them and who they deal with."

It all adds up to unprecedented choice and flexibility in how you can monitor asthma outcomes, with a guarantee that your outcomes are being measured in the same way that every other AOMS users are. That’s the beauty of the program. The underlying science remains constant for any of the technologies. And that science is considerable.

The AOMS team has developed forms that monitor generic and asthma-specific functional health and well-being, patient satisfaction, asthma symptoms, disease severity, treatment, and utilization of services. An "encounter" form is completed for each interaction with the patient.

An intake form is filled out when the patient is enrolled in the program. Quarterly surveys are mailed to the patients to assess quality of life, functionality, and satisfaction with treatment. Also, each time a patient makes an office visit, he or she completes a patient encounter form, and the physician completes an encounter form as well. (See excerpts from forms, pp. 3-5).

"This lets us keep on top of the treatment regimen," explains Bayliss, "to get a measure of clinical lung functioning, etc. We’re also interested in how closely the physician assessment of the patient functioning matches up the patient’s self-assessment. We think that if you want to know how a person feels, you have to ask the person. But we also would like to know how far the doctor is from the patient in making that evaluation."

Every patient form includes both generic and asthma functioning. For adults, the short form SF-12 is used for generic functioning, and the longer SF-36 is used for asthma-specific functioning. For children, functional health is assessed using the CHQ PF [Landgraf JM, Abetz L, Ware JE. Child Health Questionnaire (CHQ): A User’s Manual, First Edition. Boston: The Health Institute, New England Medical Center; 1996] complemented by a new asthma-specific module.

The AOMS team was careful to develop a series of questions within every assessment form that replicates asthma severity staging as outlined in the National Heart, Lung and Blood Institute’s asthma standards of care guidelines. "We think that is important because this is information that the physicians already know about — severities 1, 2, 3, and 4 — so our data can then provide a link from what they already know to new kinds of information they might not be familiar with," Bayliss says.

Building national standards

The AOMS team’s long-term goals are to make the AOMS instruments the national standard for outcomes assessments in asthma and build a national database of patient outcomes from which benchmarks can be drawn. Two critical factors are working in its favor. First, the AOMS survey forms are available royalty-free to any clinician who wants to use them (reselling is prohibited without licensing and royalties, and applies for the most part only to vendors and consultants). Permission to use the forms is routinely granted by QualityMetric or the JCAAI. Further, QualityMetric and the JCAAI have teamed up to develop scoring and analysis tools that are available for a modest royalty fee. And the AOMS team has the sponsorship of the country’s two leading asthma organizations, as well as the considerable reputation of the research done by The Health Institute.

Second, the approach the team has taken in disseminating the tools not only offers the user a great deal of flexibility, but ensures a standardized platform across all vendors. No one wants to invest in monitoring asthma outcomes only to find that the data are not comparable or that the methodology is deemed substandard by the institutions crafting standards of care for asthma in the industry.

The national database of asthma outcomes is a bit further in the future, but market trends — such as the provider’s need to predict demand and prove quality of care — should help it become established as well.

"That will be a new use for this kind of information," Bayliss explains, "for prospective purposes, for predicting who’s going to use a lot of services in the coming year. Typically, we’ve focused on a retrospective look at how the treatment has worked up to the present. I think this is a turning point for the field and a new orientation to understanding what these kind of data can do for different people."

The outcomes database would be built from outcomes reported by physicians using the AOMS programs. QualityMetric would house and maintain the database, Bayliss says.

The database would be unique in that it would consist of outcomes that have been collected by a single methodology, whose quality assurance is tightly controlled and guided by the asthma organizations that set standards of care in the field.

"The data would be anonymous and stripped of anything that could identify the patient or practice," Bayliss says. "It would become part of a national repository which builds national norms for asthma patients, according to severity levels, different age groups, different practice characteristics, different payment arrangements, and so forth. That has a lot of value. [AOMS users] will have the ability to access this data repository and compare their practices to the rest of the country. It will provide benchmarks."

Before QualityMetric can build the database, however, the AOMS tools must become more widely used. Meanwhile, the company is developing assessment tools for rhinitis, similar to the AOMS instruments. As with AOMS, the idea is to create national standards and tools for outcomes measurement, while promoting their homogenous use by providers.

[For more information, contact Martha S. Bayliss, Senior Director, Clinical Applications, QualityMetric Inc., 640 George Washington Highway, Lincoln, RI 02865. Telephone: (401) 334-8800. E-mail: mbayliss@qmetric.com.]