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Managing Asthma Care

Thomas F. Plaut, M.D.
The American Journal of Managed Care
Vol. 3, No. 3, March 1997

This article is designed for physicians, medical directors, and healthcare policy makers.
Edits are italicized.

Goal:
To provide the reader with the tools needed to monitor and manage the care of all enrollees with asthma.

Objectives:

  • Become familiar with a health maintenance organization (HMO)-wide data collection system.
  • Learn the essential elements of asthma care for patients.
  • Learn how to track the implementation of these elements in various HMO settings.

The National Heart, Lung, and Blood Institute published the Guidelines for the Diagnosis and Management of Asthma in 1991. The Guidelines was written to guide primary care practitioners in the diagnosis, assessment, treatment, and education of asthma patients. Although asthma experts who serve as consultants to managed care organizations are aware of the Guidelines, only a few have been able to implement them successfully on an HMO-wide basis. It is relatively easy to implement a program serving a small number of patients with special staff. Improving asthma care in an entire HMO requires that the administration generate reliable data and design a mechanism for inducing physicians to provide up-to-date asthma care. I have seen no published account of an HMO that has done this. In addition, the physicians must recognize the value of new techniques for care such as monitoring peak flow and using anti-inflammatory medicines to prevent attacks.

The update of the Guidelines, published February 1997, refined the earlier recommendations but introduced no major changes.

Before embarking on an intervention, it is important to understand the asthma care status of an organization. This can be accomplished by collecting appropriate data. Data collection is important for setting goals, planning the intervention, and evaluating outcomes. To be useful, data must be collected from accurate sources in a timely fashion. Reliable data can be used to measure the impact of the intervention and to identify problem areas within the HMO. Timely identification of problems can lead to their early remedy.

Many asthma programs collect a wide array of data but have no clear plan for responding to the results. In this article, I present a concise data collection instrument that I have used to compare asthma outcomes in more than a dozen HMOs. I then outline the essential elements of care for patients with moderate or severe chronic asthma. Finally, I present a simple tool for tracking implementation of these elements in the hospital, emergency department, or office.

Monitoring Outcomes of Care

The rate of hospital days generated by asthma provides more useful information than does any other measure of care. Hospital days are a better indicator of asthma care than hospital admissions because the rate of hospital admissions fails to distinguish between brief admissions for rescue therapy and admissions for which poor management necessitated prolonged stays. Transfers from one hospital to another are counted as admissions, confounding the data. The data should be expressed in days per thousand enrollees and can be compared with data from previous years and with data published by other HMOs and the National Center for Health Statistics (Table 1).2

Physicians who are under pressure to reduce admissions often will try to do so by providing intensive treatment in the office or emergency department. The number of admissions may decrease, but if treatment is inadequate the length of stay will increase. This outcome is not good for patients and is fiscally unsatisfactory (unless charges are based on admissions, rather than on days).

It is difficult to interpret the results of interventions that focus on high-risk patients but that lack control groups. Most patients who are hospitalized for asthma will not be readmitted during the following year, regardless of whether they participate in an asthma intervention. Thus a 50% drop in hospitalizations of patients who were hospitalized the preceding year should not be credited to an intervention.

To ensure reliability, data on hospital stays for asthma, pneumonia, bronchitis, and bronchiolitis must be collected from two independent sources, such as a nurse case manager, who can obtain data directly from the hospital ward; and staff from the business office, who should be able to provide regular monthly reports of hospital days categorized by first-listed diagnosis.

The misdiagnosis of asthma is common and skews data significantly.3 Diagnostic styles vary from physician to physician and from group to group. Clearly, a group that diagnoses bronchitis rather than asthma will have a lower rate of asthma hospitalizations than will a group that diagnoses the disease correctly. These diagnostic differences will stand out on a tracking system such as the Hospital Days for Respiratory Illness (Table 1). In addition, physicians who want to improve their asthma statistics, rather than their asthma care, can shift a diagnosis from asthma to pneumonia. Conversely, physicians who improve their diagnostic ability will shift a diagnosis from pneumonia to asthma, thereby worsening their asthma statistics. Finally, an epidemic of viral pneumonia might lead to a rise in hospitalization rates for asthma, as well as for bronchitis, bronchiolitis, and pneumonia. Failure to understand factors such as these may result in misinterpretation of the data.

Table 1. Hospital Days for Respiratory Illness/1,000 Enrollees


Before I agree to work as an asthma consultant, I stipulate that every admission for asthma be considered the result of HMO or physician failure, unless proven otherwise. This stance places the responsibility on the managed care organization to provide proper equipment and training for staff and education for patients. It encourages physicians and staff to improve their method of asthma care, rather than place the onus for a hospital admission on the patient.

I guided HMO-wide pediatric asthma interventions at Kaiser sites in Martinez/Antioch, California, and the state of Oregon. The intervention emphasized the early and accurate diagnosis of asthma, early use of steroids, use of a compressor driven nebulizer in the home, peak flow monitoring in the office and at home and preventive treatment of chronic asthma with anti-inflammatory medicines. We collected data on 113,000 children retrospectively for the 12 months prior to April 1989 and prospectively during the following year.4 The intervention was universal rather than selective, in that it included all pediatricians and all enrollees. Although the interventions antedated the Guidelines, they emphasized its major elements. Before the intervention, these children had been hospitalized for asthma at 37% of the US rate. They generated hospitalizations for bronchitis, bronchiolitis, and pneumonia at less than 25% of the national rate (Table 2). During the year-long intervention, hospitalization for asthma dropped more than 15%. The reduction was maintained during the following year. Because hospitalization for bronchitis, bronchiolitis, and pneumonia also decreased, the improvement in asthma outcomes could not have been the result of diagnostic transfer.

Table 2 - Hospital RatesElements of Care
The elements of care described in this section are essential for a good outcome in any setting, whether the hospital, emergency department, physician's office, or the patient's home. In order to obtain the best results, they must be supplied by the HMO. Asking patients to pay out of pocket for devices and learning materials is not cost effective. For example, if a patient is expected to purchase a peak flow meter but does not, the HMO's savings on that item will be erased many-fold by the cost of an avoidable emergency room visit.

Devices for Monitoring Status and Delivering Medicines

Peak Flow Meter. Health professionals use peak flow to make the diagnosis of asthma, monitor the effect of treatment in an acute attack, and monitor the effect of preventive treatment. Patients use peak flow to guide their use of asthma medicines, aid in telephone communication with their provider, and determine when they should see a physician. The peak flow meter gives a much more accurate and sensitive measure of airflow than do either the stethoscope or the presence of any clinical sign.

Holding Chamber. This device is used to aid delivery of inhaled medicines by a metered-dose inhaler (MDI). It eliminates the problems of positioning and hand-breath coordination, decreases the bad taste of medicine, and reduces the frequency of hoarseness and yeast infections that occur with the use of inhaled steroids. The holding chamber reduces the systemic effects of medicines by capturing nonrespirable particles exiting the MDI. Even infants can use a holding chamber, if it is fitted with a mask.

Compressor-Driven Nebulizer (CDN). This device is used to administer an inhaled bronchodilator to a patient who is too sick or too uncoordinated to use a holding chamber. Providing a "loaner" CDN for home use may enable the patient to be discharged safely from the hospital a day earlier than would otherwise be possible.5 The CDN is the most convenient device for delivering cromolyn to a child who is younger than 5 years of age.

Underused Medicines

Most primary care physicians that I have met in my consultations do not understand that treatment with anti-inflammatory medicines will reduce the frequency and severity of asthma episodes. As a result they do not accept the recommendation of the 1991 Guidelines that a patient who has symptoms or signs of asthma three or more times a week receive these drugs. (The 1997 Guidelines recommends anti-inflammatory medicines for patients who have symptoms more than twice a week).6

Preventive Medicines. Inhaled steroids prevent asthma episodes by reducing airway hyperresponsiveness and preventing inflammation of the airways. Cromolyn and nedocromil block both the early and late asthmatic reactions. These drugs should be prescribed for almost every patient who has signs or symptoms of asthma 3 or more times per week,1 as they reduce the frequency and severity of asthma episodes.

Oral Steroids. These medicines relieve the inflammation of the airways. When started promptly, at the adequate dosage, they begin to produce an effect in 1 to 6 hours. Almost all patients who have been hospitalized should take oral steroids for at least several days after discharge. Patients with moderate or severe asthma should be instructed in the use of oral steroids and should have them at home for use during an attack.

Materials for Learning About and Tracking Asthma

Booklet. A basic booklet should be accurate, concise, clear, and cover the basics of asthma, medicines, and treatment devices.7 It will aid discussion in the office and will enable patients to continue to learn about asthma between visits. Patients who understand and can monitor their asthma are able to start treatment early. This early intervention often prevents the occurrence of serious attacks.

Asthma Diary. A diary, which shows the relationships among the "pieces" of the asthma puzzle,8 is an essential aid in the management of the disease. It should display peak flow scores in graphic form and provide space to record asthma triggers, signs, symptoms, and medicines. The diary enables patients to recall accurately events occurring since their last visit, identify triggers that provoke an episode, learn when to start and when to reduce medicines, and remember to take medicines regularly.

Home Treatment Plan. A written home treatment plan will improve compliance and reduce the frequency of medication errors. An effective plan will be based on the zone system of asthma care9 and will be easy to read and understand. The zone system defines the level of care needed and is based on peak flow scores or the signs of asthma. The green zone signifies that the patient's status is good and he requires only his usual maintenance medicines. The yellow zone signifies a moderate problem for which a change in medication routine and removal of triggers is required. The red zone signifies serious trouble for which the patient should take emergency medicines and see a doctor.


Monitoring the Process of Care

The function of monitoring is to obtain information that can be used to improve asthma care. An effective system must produce reliable data and timely, understandable feedback, which must be given with reference to predetermined goals. Monitoring is done in the hospital by a utilization review nurse who reports to the physician in charge of the asthma intervention.

Because the elements of care are similar in the hospital, emergency department, and the physician's office, a single instrument - the Asthma Care Data Sheet - can be used to monitor them (Table 3). I have developed and used earlier versions of this sheet, which tracks the use of the medicines, devices, and learning tools that comprise the elements of care, in several asthma interventions.

Acceptable care requires that, on discharge, every patient treated in the hospital, with the exception of children younger than 5 years of age, receive each of the seven elements of care shown on the data sheet; these children do no receive peak flow meters. Some office and emergency department patients will not require preventive medicine for treatment.

The reviewer, usually the utilization review nurse or nurse case-manager, fills out the identifying information and checks whether a patient has received each item before leaving the hospital, emergency department, or office. The data sheet provides space to record data from before the hospitalization or visit, if desired. The instrument takes only a few minutes to complete. Data from the sheet can be analyzed to determine whether a physician, group of physicians, or an entire site is adhering to the asthma care protocol. The data should be analyzed by the physician and the manager in charge of the intervention. Results should be displayed in a form that is clear and easy to understand (Table 4). In this sample of data from 14 hospitalized children, only one child had received any of the elements of care preadmission. As a result of an asthma intervention, their care improved greatly, but still did not reach the expected standard of 90% compliance with the protocol.

Table 3 - Asthma Care Data Sheet

Managed Care

In my work as a consultant,10 I have found that about 20% of physicians will implement the basic elements of asthma care within a few weeks of our first meeting. The others do so much more slowly, perhaps because of practice overload, too many demands for change, or perceptions that they already are doing a good job.

Interventions to improve care for any disease take time and energy, and the number of changes that can be implemented in a given year is limited. Not only must physicians change their practice methods, but managers, data specialists, and case managers must meet their commitments to provide data and support for the program. Unreliable data or untimely data collection will not be useful in changing physician behavior. Furthermore, if an HMO supplies inferior learning and tracking materials to patients or neglects to provide essential devices as covered benefits, the results of an intervention will be compromised.

An asthma intervention should call explicitly for the following elements of care, which might be implemented all at once or one item at a time. While some HMOs will decide to implement the entire program at once, others may find it simpler to get cooperation from physicians if they introduce items individually. Order of implementation is based on importance of the various items and the patient's comprehension of them. The elements of care are: oral steroids; asthma booklet; holding chamber; peak flow meter; asthma diary; home treatment plan; and preventive medicines.

The Asthma Care Data Sheet can be used to monitor care at discharge (from the hospital, emergency department, or office). Because hospitalized patients consume the most resources,11 have the most serious problems, and are the easiest to identify, an intervention should focus on their care first. Ideally, a patient's care should be reviewed and, if necessary, changed during the hospitalization. Because logistics and time constraints generally preclude this, I focus on the patient's status at the time of discharge. A nurse case manager can complete the Asthma Care Data Sheet within 24 hours of discharge. The physician in charge of the asthma program can note any deficiencies and arrange for their prompt remedy.

Competent physicians, many of whom have cared for hundreds of patients with asthma, often fail to provide good asthma care.12 They routinely treat patients who have severe wheezing and retractions. Minutes after a treatment with inhaled albuterol these patients breathe more easily. These physicians are impressed with their own ability to bring an attack rapidly under control. Many are unaware that people with mild asthma symptoms should receive preventive treatment to reduce the frequency of severe attacks and hospitalizations and to improve their quality of life.

A physician who believes that his or her present protocol leads to good results will perceive no need to change. Thus, the challenge for an asthma improvement program is to inform physicians and administrative staff how their process of care compares with that of professionals who are achieving the best outcomes, defined here as the lowest rate of hospital days for asthma and related respiratory diagnoses. Every physician whom I have met in the course of providing my interventions has wanted to do a good job of providing asthma care. At the time of our initial meeting, most believed that they were providing good care. After I compared their outcomes and their process of care with those of others, however, many were persuaded to reexamine and improve their protocols. A similar process has induced administrators to be more helpful in providing equipment and support for an asthma program.

Asthma is unique among chronic illnesses in that hospitalization and emergency department utilization rates will drop almost immediately after the onset of a well-planned intervention that is consistent with the Guidelines of the National Heart, Lung and Blood Institute. For example, pediatricians at a Kaiser site in White Plains, New York, with 7,000 pediatric enrollees implemented these changes, reducing hospitalizations by more than 50% and eliminating readmissions during a 2-year intervention.13 In contrast, programs to improve care for diabetes, heart disease, or stroke take much longer to achieve positive results. The challenge, therefore, is to encourage physicians to implement the Guidelines. Some HMOs have offered continuing education; others have offered incentives for using peak flow meters and compressor-driven nebulizers in the office. To achieve the best result, asthma programs must base incentives for physicians on specific outcome and process data.

Summary

I have described simple tools for analyzing asthma outcomes and for tracking the processes of care. Hospital days for asthma should be calculated for the entire enrolled population, but recognizing that misdiagnosis often distorts the data. The Asthma Care Data Sheet highlights deficiencies in care and can be used to track the process of care in any site.

References

1. National Asthma Education Program. Expert Panel on the Management of Asthma. Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Department of Health and Human Services, National Heart, Lung and Blood Institute; 1991.
2. Utilization of Short-Stay Hospitals: United States, 1979-1986 Annual Survey. Hyattsville, MD: National Center for Health Statistics, Series 13.
3. Plaut, TF. Childhood Asthma: A missed diagnosis. HMO Practice 1991;5:102-105.
4. Plaut TF, Tochen ML, Gascoigne GB. Pediatricians Cut Asthma Hospitalization. Presented at the First National Conference on Asthma Management. Sponsored by the National Asthma Education Program of the National Heart, Lung and Blood Institute. October 1992; Arlington, VA.
5. Plaut TF. Safe home use of the compressor-driven nebulizer. AM J Dis Child 1990;14:20-21. Letter.
6. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program, NIH. Bethesda, MD; February 1997.
7. Plaut TF. Rating asthma learning materials. Advance Phys Assist September 1996.
8. Plaut TF. Asthma peak flow diary improves care. Ann Allergy Asthma Immunol 1996;76:476-478.
9. Plaut TF. The zone system: Asthma management simplified. Advance Phys Assist February 1997;33,34,36,76.
10. Plaut TF, Howell T, Walsh S, et al. A systems approach to asthma care. Managed Care Q 1996;4:6-18.
11. Weiss KB, Bergen PJ, Hodgson TA. An economic evaluation of asthma in the United States. New Engl J Med 1992;326:862-866.
12. Plaut TF. Why don't pediatricians give better asthma care? Contemp Pediatr 1994;11:15.
13. Stevens MA, Weiss-Harrison A. A program for children with asthma. HMO Practice 1993;7:91-93.
14. Plaut TF. One Minute Asthma: What You Need to Know. 3rd ed. Amherst, MA; Pedipress, Inc., 1996.

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