Improve quality of asthma care with guidelines, risk assessments
Improve quality of asthma care with guidelines, risk assessments
Managed care organization study shows wide variations of care
If you’re looking to improve asthma care at your organization, make sure providers follow appropriate clinical guidelines and use risk assessments to determine the best patient treatment. That’s what a large consortium of managed care organizations (MCOs) did, and patients’ health improved significantly. Costs decreased, as well, because patients required fewer emergency department visits and hospitalizations.
"Based in part on this project, we have been able to demonstrate on a large scale, improved quality of care, improved patient health, and reduced health care costs, both for the health plan and the purchaser," says Joseph M. Healy Jr., PhD, director of quality and outcomes measurement at Harvard Pilgrim Health Care in Boston.
15 MCOs participate in project
The two-year, employer-initiated asthma project took place in 15 large MCOs around the country. The project was coordinated by the Health Outcomes Institute, part of Stratis Health, in Bloomington, MN. Researchers from the Johns Hopkins University School of Hygiene and Public Health in Baltimore helped collect and analyze study data.
Michael Huber, executive director of the Health Outcomes Institute, says the project was conducted because an initial study of 6,612 asthmatic adults in the MCOs indicated there was opportunity for improvement with asthma care. For example, in severe asthmatics, 74% reported using a corticosteroid inhaler, and 30% reported using a home peak flow meter to determine lung function. Only half of the patients reported that they knew what to do when asthma flare-ups occurred, such as adjusting medications.
The asthma quality improvement interventions instituted by the participating MCOs were as follows:
• Patient-focused education.
Education strategies practiced by all the MCOs ranged from informal discussions between providers and patients to formal classes for asthma patients. Eight of the MCOs sent out educational mailings on asthma, and five carried out formal home visits to assess patients. Ten MCOs provided free peak flow meters to patients, and seven had case management programs for asthma.
• Provider interventions.
Seven MCOs sponsored formal continuing education programs on asthma treatment, and six sponsored seminars on the topic. As many as 75% of MCO physicians treating asthma patients were reached by those efforts. Five MCOs gave physicians results of audits or report cards on asthma care, and three gave results from provider surveys on asthma practice patterns. Four MCOs provided information from medical record reviews. Six established special management programs or units related to asthma care, and two expanded telephone access to providers with expertise in asthma care.
Huber says the study revealed one consistent finding: Treatment by a specialist was associated with greater conformity to international asthma treatment guidelines from the U.S. Department of Health and Human Services in Washington, DC.1 The term "specialist" was ot defined; it could have been any provider who had received education on the guidelines — not necessarily a pulmonologist.
"For example, Trigon, one of the [MCO] participants in the project, published a very brief guideline summary and distributed it to each of its network [physicians]," says Huber. (See sample of guideline summary from Trigon Blue Cross Blue Shield in Richmond, VA, p. 32.)
Are specialists necessary?
William Glasheen, PhD, director of health care assessment at Trigon, says the guidelines were developed for primary care physicians.
"We were looking at our opportunities [for improvement], and we noticed that it was our primary care physicians who weren’t following guidelines," says Glasheen. "So there were several things we could have done. We could have referred more patients to specialists, but the other thing you can do is help fill knowledge deficits [of providers]. That’s what we did, and we came up with a one-page guideline targeted to primary care physicians that was developed by our own specialists."
The guidelines have led to improvements in "process to proximal outcome to distal outcome," says Glasheen. "Not only that, but we show a shift of care toward more people choosing to have the primary care physician manage their asthma," he adds.
High-risk patients targeted
Identifying high-risk patients also was a hallmark of the project. "Simple patient-reported measures" were used to identify high-risk patients who should be the focus of intervention programs as a way to improve care, says Huber. A risk index screening questionnaire was developed to determine which patients were at highest risk of problems such as emergency department visits or missed workdays. (See sample index, p. 31.)
"We used the . . . patient-reported data to classify at the front end patients who are likely to be greater consumers of care down the road so we can address them earlier," says Huber. "We can improve their health status and decrease the cost [of asthma care]."
By the end of the project, outcomes had improved significantly. Among severe asthmatics, the proportion having a home peak flow meter increased to 55%. In addition, the proportion of severe asthmatics who cancelled activities in the previous four weeks due to asthma declined by 14% to 21% across all the MCOs. There was a 10% to 12% reduction in hospitalizations and emergency department visits by moderate and severe asthmatics, and the proportion of patients reporting asthma attacks three or more times a week declined among severe asthmatics by 15%.
Huber says the project is evidence that MCOs can improve disease management. "Managed care organization interventions can make a difference," says Huber. "There hasn’t been empirical evidence of that to this point, but now, here it is."
Reference
1. International Consensus Report on Diagnosis and Management of Asthma. U.S. Department of Health and Human Services, PHS/NIH Publication No. 91-3,091; 1992.
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