Because asthma flare-ups cost employers a great deal in lost work time and burden health plans with preventable hospital stays, it was natural that 15 managed care organizations joined 12 major employers in a three-year study evaluating asthma care outcomes.
The project, sponsored by the Managed Health Care Association, a Washington, D.C.-based group representing more than 80 Fortune 500 companies, was undertaken in part because of purchasers' growing demand for accountability from health care plans and concerns that quality of care should be improved, notwithstanding rising pressure to contain costs.
Emphasizing patient education
The study was to determine whether different patterns of asthma care contribute to different patient outcomes, including severity of symptoms, functional status, workdays lost and use of medical care services. A total of 3,487 patients in the 15 health plans took part.
The plans, including Anthem, Harvard Pilgrim Health Care and Blue Cross and Blue Shield of Massachusetts, followed internationally-accepted asthma guidelines that defined standard treatment regimens, but each had the freedom to follow the guidelines as it saw fit.
The guidelines covered four areas: 1) having a steroid inhaler, 2) having a long-acting bronchodilator, 3) having a peak flow meter and 4) reporting all that is needed to know about one of the following: how to avoid precipitants of an attack, how to adjust medications as needed, or how to manage a severe attack.
Each plan had its patients complete two questionnaires, one year apart.
Researchers found that the more the plans adhered to the guidelines, the better outcomes the patients reported. In addition, managed care organizations that invested in educational programs for patients — and physicians — showed improvements in asthma care.
The study found that simple patient-reported measures can be used to identify high-risk individuals who should be the main focus of intervention programs.
In the full sample, severe asthmatics reported 14- to 21-percent declines in canceling activities because of their asthmatic condition. There were significant reductions in hospitalizations and emergency department visits:
Among moderate asthma patients, hospital and emergency department visits declined 10 percent; among severe asthmatics, the rate declined 12 percent.
In general, patients with considerable knowledge about self-management had good outcomes. Those who knew everything they needed to know in at least one of the three aspects of asthma care were found to experience fewer asthma symptoms, less frequent attacks, higher levels of physical functioning and general health.
Specialist vs. generalist
A key finding that has significance in the current debate over whether specialists or primary care physicians should treat the chronically ill was that patients treated by pulmonologists and other physicians who specialize in asthma fared better than those treated by generalists. In fact, patients treated by specialists reported fewer days missed from work.
Many patients with chronic illnesses have attacked the well-entrenched policy of encouraging primary care doctors to treat these conditions. Specialists contend that they should be the ones to treat patients with chronic illnesses because they have greater knowledge and experience and are better able to determine which symptoms signal actual asthma flare-ups.
The debate has led the American Medical Association to call on managed care plans to allow the chronically ill to see specialists as their primary doctors. And in fact, some HMOs, including PacifiCare of California and Blue Shield of California, have started to loosen restrictions on seeing specialists without referrals.
Emphasis on guidelines
Even so, at least one major managed care plan involved in the asthma study reached a somewhat different conclusion about using specialists than that reached by the study's authors. "In our experience, there was not anything magical about being treated by specialists per se as much as there was a knowledge deficit in the primary care physician arena,'' says William Glasheen, Ph.D., director of health care assessment at Richmond, Va.-based Trigon Blue Cross Blue Shield.
"We were able to fill some of this void and show improvement in care by coming up with guidelines that were customized for the [primary care doctor] on how to treat asthma patients with three different severity levels.''
The outcomes study has helped to break new ground, says Alan Peres, manager of health care policy at Ameritech, the large telecommunications company, which participated in the study. It has shown the value of using patient-reported information to identify targets for improvement and to measure progress toward those goals, he says.
Among the questions patients answered at the start and again at the end of the study period were: "Do you own a peak flow meter? Do you use it? Do you have a steroid inhaler? Do you use it? What do you do in case of an attack?"
Self-management is vital for success in treating asthma patients, says Glasheen. "It is important to get patients to understand the disease and what they can do, and have them adhere to all the things they should be doing to control asthma,'' he notes.
The study has broad implications, says Richard Niemeyer, manager of corporate health care benefits for household products manufacturer Procter & Gamble, another employer involved in the study. "Projects like this that measure outcomes will end up documenting best practices and can offer a template of some standard of care. They will have tremendous impact across the country."
Medical staff members at Johns Hopkins University have used the project's data to devise a simple tool for identifying high-risk patients as candidates for education in self-managed intervention. The risk assessment tool focuses on the use of hospital and emergency department services, severe symptoms and to what degree has asthma interfered with work, school and other activities.
Niemeyer believes that when better outcomes are achieved, lower health care costs will follow. The real results of such a study, he expects, will come from managed care companies learning from the findings and adopting protocols that will improve the general health of asthmatics.
— Joan Szabo