Pharmacy & Therapeutics- August 2008 - (Page 454) Monitoring Asthma Control Using Claims Data And Patient-Reported Outcomes Measures Tom James, MD, and Michael Fine, MD INTRODUCTION Asthma is a chronic disease that can be functionally debilitating for many patients and costly from both an economic and societal perspective. Poorly controlled asthma takes a toll on patients and is associated with increased emergency department (ED) visits, hospitalizations, unplanned physician visits, and missed school days and workdays, as well as loss of productive days. The burden of asthma is borne out not only in terms of patient symptomatology and inconvenience but also by its direct and indirect economic impact. Asthma creates a financial burden on patients and their families, payers, and employers through direct medical expenditures and missed workdays. The current standard treatment of asthma is based on consensus-based guidelines such as those of the National Asthma Education and Prevention Program (NAEPP).1 Although these guidelines, which were revised in 2007, are generally the most widely accepted in the U.S. for the treatment of asthma, many patients who are treated according to these or to other evidence-based guidelines still do not achieve adequate symptom control. There may be striking variability among individuals in their response to recommended therapies as well as individual variations in the clinical manifestation of the disease. This variability of response is so common within any population that it must be expected. For a health plan population, management cannot be achieved without methods to track individuals with variable responses to standard therapy. The most recently released versions of the guidelines recommend tracking a measure of asthma control at regular visit intervals and using this measure to guide therapeutic decisions. Calculating the degree of variation of response to process measures allows health care providers to characterize the population and to make treatment decisions for each patient. The variable expression of asthma among patients may be difficult to recognize. Variations in disease may be expressed in terms of both functional symptoms and patients’ responses to therapy. These differences are obser ved even among patients with apparently similar severity of disease.2,3 Individual patients also respond in various ways to different classes of medications for asthma, including inhaled corticosteroids, leukotriene modifiers, and beta-adrenergic agonists.4–7 Because of the inherent variability in responses to therapy, many patients remain symptomatic despite close adherence to NAEPP guidelines.1–3 Dr. James is Physician Advisor at Humana, Inc., in Louisville, Kentucky. Dr. Fine is Senior Medical Director at Health Net of California in Huntington Beach, California. This variability in the clinical expression of asthma and response to therapy has an impact on patients’ symptoms, clinical outcomes, and health care costs. Fewer than 20% of patients with poorly controlled asthma account for almost 80% of direct expenditures for asthma care.8 Unfortunately, identifying these frequent users of health plan resources is a daunting task, because data must be available from many sources. Predictive modeling through the use of claims data alone has proved to be of limited value in terms of identifying members of the high-risk cohort. Data derived from Healthcare Effectiveness Data and Information Set (HEDIS) measures do not accurately predict which individuals will become frequent users of health care resources. Instead, health care plans must incorporate regular and careful monitoring of symptoms through the use of patientreported outcomes as part of an overall asthma-management strategy to identify patients with disease that remains uncontrolled. In this article, we review the limitations of using retrospective and administrative claims data to identify patients at risk for asthma exacerbations and their subsequent extensive use of resources; conversely, however, we highlight the importance of carefully tracking symptoms in order to assess the level of asthma control. Finally, we recommend a diseasemanagement strategy for managed care organizations (MCOs) in which patient-reported outcomes tools are used, in addition to claims data, to identify patients whose asthma remains poorly controlled despite clinical follow-up and their use of recommended asthma therapy. VARIABILITY IN RESPONSE TO ASTHMA MEDICATIONS Disease-management programs are based upon a predictable course of a disease. Diabetes, heart failure, and renal failure are examples of disease states in which anticipated progression can be slowed through closer adherence to evidence-based guidelines. However, the variability in patient response to pharmacotherapy is a confounding factor in the treatment of asthma in the managed-care setting. This variation of response affects the clinician’s confidence in predicting outcomes of the covered population. Despite the high prevalence of patients who are treated in accordance with the NAEPP guidelines (updated in 2007), asthma often remains uncontrolled, partially because of the variability of the treatment’s effectiveness.9 This finding is observed for all the commonly used classes of asthma controller medications, including inhaled corticosteroids, leukotriene modifiers, and beta-adrenergic agonists.4–7,10 This pattern is apparent even when we Disclosure: The authors have no commercial or financial relationships to report in regard to this article. Accepted for publication March 20, 2008. 454 P&T® • August 2008 • Vol. 33 No. 8
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