Pharmacy & Therapeutics- August 2008 - (Page 464) Monitoring Asthma Control as lost workdays needed for time to care for a child with asthma, as well as reduced productivity at work and at home, are not reported in the medical claims data. However, these types of measures could be collected with PRO tools. HEDIS data are useful for analyzing process measures of care, such as the use of inhaled steroids for patients with persistent asthma. Because of the variable responses of patients with asthma, these process measures are not useful for determining individual outcomes. Index of Asthma Control Vollmer et al. Similar to instruments for assessing asthma severity and control, patient-reported measures can help in assessing quality of life and the use of asthma-related health care. In a study of 5,181 members of the Northwest Division of Kaiser Permanente, Vollmer et al. reported a simple index of asthma control employing self-reported measures of health care utilization and quality of life.27 This index featured a fivelevel measure of asthma control problems (range, 0–4), which exhibited marked and highly significant cross-sectional associations with self-reported use of health care resources and with generic and disease-specific quality-of-life instruments. Each increase in the number of asthma-control problems was also correlated with clinically significant quality-of-life impairment (physical and mental health, functional limitations) and increased use of health care resources such as doctor or ED visits and inpatient stays. THE IMPORTANCE OF TRACKING SYMPTOMS The tracking of important measures of disease activity (e.g., symptoms, the use of rescue medication, missed days of school or work) is a valuable tool for assessing asthma control and the risk of exacerbations. These patient-reported measures serve as practical indicators of lifestyle limitations and, ultimately, use of resources; they are also crucial for evaluating the level of asthma control in a plan’s patient population. INTEGRATING PATIENT AND CLAIMS DATA Questionnaires and Surveys Studies have shown that using validated questionnaires to assess asthma symptoms and to track similar measures (e.g., use of health care resources, quality of life) is a reliable method of determining disease severity and asthma control. Juniper et al. The authors sought to validate the use of the Asthma Control Questionnaire (ACQ) for assessing disease control in patients whose asthma was stable between clinic visits.25 In this seven-item questionnaire, patients were asked to assess the severity of their symptoms (e.g., wheezing, shortness of breath, limitations in activities) during that week. The reliability of the ACQ was high, with an intra-class correlation coefficient (ICC) of 0.90 in patients whose asthma was stable between clinic visits. The questionnaire was also very responsive to changes in asthma control (P < .0001). As an asthma instrument, the ACQ had strong evaluative and discriminative properties that could be used with confidence in clinical trials and in cross-sectional surveys. Nathan et al. The Asthma Control Test (ACT), a five-item patient-based survey, is used to identify patients with poorly controlled asthma.26 The internal consistency reliability of the ACT scale ranged from 0.79 to 0.83 (based on the degree of asthma control) and was 0.84 when all patients in the study were included. As a screening tool, the test also identified patients whose asthma was not adequately controlled without requiring an assessment of FEV1. This test was a reliable and valid measure that showed promise in identifying patients with poorly controlled asthma. Disease Management The combined use of retrospective and administrative claims data and PRO information may be useful in the ability to identify patients at risk for asthma exacerbations and subsequent ED visits and hospitalizations. Currently, several asthma disease-management programs utilize medical and pharmacy claims data to predict a population at risk, and they employ nurse-derived PROs to develop a viable strategy to identify those asthma patients who represent the highest risk. Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.28 For asthma, this includes, but is not limited to, the routine assessment of pulmonary function, patient education, monitoring of medication adherence, review of symptoms and their impact on daily functioning, frequency of exacerbations, and development of an action plan. Although these measures cannot be easily assessed through administrative data, they are clinically important in identifying patients with uncontrolled asthma. That is why disease-management programs are beneficial in chronic diseases, such as asthma; they help improve overall quality of care (and better patient functioning), result in less use of health care resources, and decrease medical costs. Buchner et al. A study was performed to evaluate an asthma disease-management initiative based on the 1997 NAEPP guidelines.29 In the second year of this program, the proportion of plan members who were prescribed oral or inhaled corticosteroids increased by 30%. The members responded to this therapy and needed fewer inpatient services. A similar trend was observed for health-related quality of life, satisfaction with quality of care, exposure to patient education, disease knowledge, and members’ confidence in their ability to manage their disease. All these parameters showed statistically significant improvements during the follow-up year (year two) of the program for both adults and children. COMMENT: As with many other chronic diseases, the management of asthma requires a multidisciplinary approach in order to identify, evaluate, and treat asthmatic health plan members. Multidisciplinar y inter ventions must focus on Electronic Medical Records The use of electronic medical records (EMRs) to track symptoms and monitor responses to therapy is another helpful tool for determining disease severity and control. EMRs enable clinicians to view the patient’s entire medical history or to focus on a specific disease state. This capability can lead to greater adoption of evidence-based medicine, which may result in better overall care and in less use of health care resources. 464 P&T® • August 2008 • Vol. 33 No. 8
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