Pharmacy & Therapeutics- August 2008 - (Page 465) Monitoring Asthma Control asthma control to prevent exacerbations and to ensure the appropriate use of medications that will be effective for each patient. This approach should also include education to ensure that patients and their families take an active role. As a strategy, a multidisciplinary approach can help to achieve disease control and reduce associated use of health care resources. Jones et al. Since 1996, the Breathmobile Program has used specially equipped mobile asthma clinics staffed with multidisciplinary teams to provide ongoing preventive care to children with asthma at schools in urban lower socioeconomic settings.30 This program, certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), uses a direct assessment of asthma control at each visit and an EMR to systematically track and display each patient’s pattern of important clinical measures over time. Clinical control of asthma is defined based on the goals of therapy in the NAEPP guidelines. Visits at regular intervals are used to evaluate the response to therapy, to adjust therapy based on response, and to reinforce families’ understanding of strategies to reduce exposure to asthma triggers and adhere to a daily management plan. These strategies have been associated with improved asthma control and a decreased need for acute care, including hospitalizations and ED visits. Patel et al. These authors evaluated the impact of a multidisciplinary asthma disease-management program on processes of care and health care utilization for adults and children in a large, medical group practice throughout the Chicago metropolitan area.31 This intervention included the development of a patient registry, a systematic approach to evaluating asthma control using the Asthma Therapy Assessment Questionnaire (ATAQ), case management, and physician education. Chart reviews and administrative claims analyses showed that the program was beneficial in several areas. Primarily, medical record documentation improved asthma diagnoses (83.3% at baseline vs. 98.6% afterward; P < .001) and patient education (15.7% vs. 26.1%; P < .001). After the program was implemented, the number of asthma-related ED visits decreased from 148 per 1,000 to 88 per 1,000 (P < .001). This trend was also seen for asthma-related hospitalizations, which decreased from 81 per 1,000 at baseline to 37 per 1,000 per year after the program (P < .001). From these results, the authors noted that comprehensive disease-management programs that raise the standards of asthma care across populations have the potential to improve outcomes for this population. Yurk et al. PRO tools are an integral part of a comprehensive strategy to track asthma symptoms and promote disease control. In a prospective cohort study involving 16 U.S. MCOs, the authors evaluated a set of questionnaire-based screening tools to identify the risk of one-year adverse outcomes in adults with moderate-to-severe asthma.32 The 58-item questionnaire included the generic Medical Outcomes Study 36-Item ShortForm Health Survey (SF-36) and condition-specific measures. The strongest predictors for adverse outcomes in the study population were comorbid illness and prior use of the ED. The model discrimination ranged from 0.67 to 0.78 for predicting hospitalization, ED use, absenteeism, and symptoms. As exemplified by this study, questionnaire-based risk models can identify patients with asthma who are at increased risk for adverse outcomes, thereby indicating the importance of patient-reported data in targeting individuals for intervention. Peters et al. The value of an integrated strategy for predicting the future use of health care for asthma has been confirmed.33 Peters et al. combined patient responses from the Asthma Therapy Assessment Questionnaire (ATAQ) with prior use of asthma health care resources from administrative claims data. Although the data served as the strongest predictor of future health care utilization, the ATAQ control index helped to identify 1% of individuals without recent acute care who had an estimated six-fold elevated risk (95% confidence interval [CI], 4.2–8.4) of needing acute care in the future. The added benefit-derived integration of the ATAQ control index is significant, considering that only a small fraction of individuals with acute events in one year had acute events in the previous year. Past care was one of the best predictors of future health care utilization; the more acute the utilization, the better the prediction. COMMENT: A combined approach that uses administrative claims data and patient-reported outcomes is important in identifying patients with uncontrolled asthma, those at risk for future exacerbations, and those who might become frequent users of health care resources in the future. However, these models must provide greater specificity to identify these patients with greater accuracy. CONCLUSION Asthma is a chronic disease that can be debilitating for patients and costly from an economic and societal perspective. Patients with uncontrolled asthma are at high risk for exacerbations that adversely affect health outcomes, which, in turn, leads to an increased use of health care resources. Uncontrolled asthma has a significant financial impact on patients, families, payers, and employers as a result of direct and indirect medical expenditures. Because of the variation both in expression of asthma and in its management by physicians, administrative claims data alone are neither specific nor sensitive enough to identify asthmatic patients with the highest risk for future exacerbations and the subsequent need for increased health care resources. Similarly, data derived from measures such as HEDIS are inadequate as a sole source for stratifying asthma severity in a plan’s patient population. Instead, the complex nature of asthma warrants a combined approach to identify and monitor patients with uncontrolled or difficult-to-treat asthma. This approach requires the incorporation of PRO tools plus predictive modeling, based on retrospective medical and pharmacy administrative claims data. PRO measures provide a practical component to be used in a complementary manner to the claims data so that patients can be properly characterized, evaluated, and treated. All of these steps help to improve outcomes and optimal use of resources. Another potential tool, the EMR, can help identify patients within a practice who might need more attention than is currently provided. For health plans, the use of personal health records (PHRs) that are integrated into the health plan database can supplement the pharmacy and claims data to enhance the strength of predictive modeling. In the updated NHLBI/NAEPP asthma guidelines, released Vol. 33 No. 8 • August 2008 • P&T® 465
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