Asthma Care Quality Improvement
Module 1: Making the Case for Asthma Care Quality Improvement (continued)
The Quality Improvement Opportunity
Despite this gloomy picture of asthma's care quality and cost burdens, significant opportunities for improvement exist. There is potential for high returns on investment made by purchasers and the health care system as a whole through asthma care quality improvement.
Availability of Asthma Management Guidelines
Great strides in the care and treatment of people with asthma have occurred over the last 15 years. Although there is no cure for asthma, the disease can be managed and the severity and frequency of asthma attacks can be controlled through appropriate monitoring, effective use of medications, and eliminating or decreasing exposure to triggers.
In 1997, Guidelines for the Diagnosis and Management of Asthma was published by the National Asthma Education and Prevention Program (NAEPP), coordinated by NHLBI. These guidelines (updated in 2007) represent a science-based strategy for the diagnosis and management of asthma and ask patients, families, and providers to work together to control the condition. In addition the NAEPP has published Key Clinical Activities for Quality Asthma Care: Recommendations of the National Asthma Education and Prevention Program, which identifies four components of care and recommends a core set of 10 key clinical activities for ensuring quality asthma care, as follows:
|Components of Asthma Care||Key Associated Clinical Activities|
|Assessment and monitoring||1. Establish asthma diagnosis.|
|2. Classify severity of asthma.|
|3. Schedule routine followup care.|
|4. Assess for referral to specialty care.|
|Control of factors contributing to asthma severity||5. Recommend measures to control asthma triggers.|
|6. Treat or prevent comorbid conditions.|
|Pharmacotherapy||7. Prescribe medications according to severity.|
|8. Monitor use of beta-2-agonist drugs.|
|Education for partnership in care||9. Develop a written asthma management plan.|
|10. Provide routine education on patient self-management.|
Source: National Heart, Lung and Blood Institute, 2003.
More information on steps associated with these key clinical activities and updates to the guidelines is available at: http://www.nhlbi.nih.gov/health/prof/lung/asthma/asthmacare.pdf.
By applying these guidelines, health care professionals can provide the best care available for their patients. In the future, guidelines could change. And, to provide the best treatment possible for their patients, clinicians must keep abreast of changes in the best practices.
Much remains to be done in improving the scientific basis for clinical practice across all of medical care, and asthma is no exception. An AHRQ-supported Evidence-based Practice Center conducted a systematic review of interventions for the management of asthma in 2001. The report (BCBS Technology Evaluation Center, 2001) examined five types of asthma interventions and concluded the following:
- Chronic use of inhaled corticosteroids (ICS) for children with mild-to-moderate asthma improves their long-term outcomes; however, studies had insufficient followup time or patient numbers to assess the cumulative effects of using ICS.
- Evidence is insufficient for showing that early initiation of ICS prevents asthma progression.
- Limited evidence suggests that ICS dosage may be reduced without diminishing asthma control.
- Limited evidence also suggests that there is no benefit to using antibiotics routinely in addition to ICS.
- There is insufficient evidence to determine whether the use of a written asthma action plan, including a peak-flow-meter-based vs. a symptom-based plan, improves outcomes.
These inconclusive findings illustrate the early stage of research on asthma care quality. Nevertheless, the expert judgment of clinical specialists, assembled by the NAEPP, establishes the best practice today for helping patients and providers achieve optimal asthma care.
Potential for Positive Return on Investment
State government officials want programs that improve the health of their residents; but at the same time, they must weigh the cost of those programs against all of the competing demands of society. Therefore, for State officials to wear the mantel of quality improvement, such programs must result in enough savings to offset their expense, at the very least.
Research suggests that investing in asthma prevention and control initiatives can improve health outcomes and reduce health care costs. Just as clinical research on effective asthma care is new and emerging, so is research on the return on investment for asthma quality improvement. A systematic review of return on investment for asthma suggests positive potential financial savings (Goetzel, et al., 2005).4 In that review, $2.72 was saved for every dollar spent on asthma disease management programs, on average, across six studies that provided sufficient data to calculate per-participant cost savings relative to program costs. The average program cost was $269 and the average cost saving was $729 per participant. Thus, while it is early to draw definitive conclusions, the results are quite promising.
One of the reviewed studies evaluated an asthma intervention, the Virginia Health Outcomes Partnership (VHOP), targeted to reduce emergency visits by low-income asthma patients in a Medicaid primary care case management program (Rossiter, et al., 2000). About 20 percent of Medicaid asthma-related claims in Virginia were for emergency department visits (Rossiter, 2000). The VHOP invited physicians in one community to participate in training to improve their management of patients with asthma, including patient education, medication use, and need for emergency care. The VHOP also provided feedback reports to participating physicians on their patients' use of services. One-third of about 200 physicians invited actually participated. These physicians reduced their patients' use of emergency services by 41 percent from the same quarter a year earlier, compared to only an 18-percent reduction for a comparison group that was not invited to participate. All of the 200 physicians invited to participate (counting those not trained) reduced their patients' use of emergency services by 6 percent more than the non-intervention group. At the same time, physicians in the participating community dispensed more asthma medications. The increased drug costs were more than offset by lower emergency care costs. The projected direct savings to Medicaid was $3 to $4 for every dollar spent on training for participating physicians.
More recent studies also support the conclusion that disease management programs for asthma can save money. Patients of physicians who participated in another asthma education program were less likely to be admitted to an emergency room or a hospital to treat their asthma than patients whose physicians did not participate (Brown, et al., 2004). An asthma disease management program implemented by Colorado Medicaid from 2002 to 2003 showed that the program saved $203,000 in health care expenditures beyond the cost of the program, compared to the pre-program costs of treating asthma (National Jewish Medical and Research Center, 2004). Not only did emergency room visits decline, but missed work days also declined.
These interventions can deliver substantial cost savings if they reduce the number of repeat hospitalizations and emergency visits. A study using 1997 data found that each hospitalization increased annual expenditures for asthma significantly—from $305 for someone not hospitalized, to $1,690 for someone hospitalized once, to $5,987 for someone hospitalized twice (Atherly, et al., 2003).
Thus, not only can health care professionals improve asthma care to help their patients achieve better control of asthma symptoms and improve their lives, they can also reduce the use of expensive health care services and, thereby, cut the cost of asthma care. These consequences of quality improvement would benefit not only consumers of health care, but also the two other groups that bear the cost—third-party payers (public and private) who incur the cost of asthma care and employers who incur the cost of health insurance and lost productivity for their workers with asthma.
4 This review found 12 studies. However, only 6 provided sufficient data for a return on investment calculation, and some of those studies were limited by small numbers of cases, incomplete patient care costs, and study designs that did not control for rising health care costs and other shifting external factors.
Estimating the Costs of Asthma Care and Potential Savings From Quality Improvement
To bring the potential of quality improvement home, State officials will want to know what the potential cost savings are in their State. For example, what could be saved in Medicaid costs? Medicaid recipients are an important focus since they include people with low incomes and children who have higher prevalence and hospitalization rates for asthma (CDC, 2007a; CDC, 2007b).
This section estimates the cost of asthma care from three perspectives:
- The cost of asthma care statewide.
- The cost for Medicaid.
- The cost of excess hospitalizations for asthma.
Next, this section guides State analysts through the steps they could take to estimate the potential savings in the State while implementing a Medicaid disease management program in asthma like the one in Virginia. (Those savings were not calculated here because the number of physicians participating in Medicaid in each State was not available.)
A caveat about estimating costs. Data on the cost of asthma care are not available uniformly across States. Some States may have tallied the costs for their Medicaid recipients, but probably few States have estimated the costs of asthma for their entire population. The numbers in this section simply apply various national averages from published research to State data to estimate what the cost might be in each State. Where possible the national averages are age or race specific. To assume that the cost for every State by age and racial subgroup will equal the national subgroup is unrealistic.5 Therefore, AHRQ urges State analysts to use local data to develop better estimates of the cost of asthma for their State. The numbers presented are intended to help State and local officials think about the scale of problem and of the impact that they might be able to make with quality improvement initiatives for asthma.
5 Several other factors are not accounted for in these estimates: First, changes in the typical services used between 1994 and 2004 are excluded, despite that fact that medication costs have risen (Sullivan, et al., 1996), and inpatient stays have declined (Mannino, et al., 1998). Second, differences in use of services by age are not always included, despite the fact that from 1985 to 1994 the estimated real direct cost of asthma care actually declined per affected child, but increased per adult (Weiss, et al., 2000). Third, differences in the age distribution across racial/ethnicity groups is not factored into the State-level estimates. Finally, the asthma cost calculated here is not net of health care cost without chronic disease because it was not available; subtracting the cost of those without chronic illness from those with asthma would indicate how much a State spends for asthma care alone. Thus, the State-level estimates in this section could overestimate or under estimate of today's true cost of asthma to States and their residents.
Cost of Asthma Care Statewide
A statewide view of asthma costs is provided to encourage States to stimulate quality improvement on a statewide basis, not only in Medicaid. Three sources were combined to calculate the direct cost of medical care on a statewide basis: Weiss, et al. (2000) for national expenditure data, the U.S. Census for State population estimates, and the Behavioral Risk Factor Surveillance System for State-level asthma prevalence. Direct costs include medical expenditures for hospital care, physician services, and medications. The Weiss study, which provides expense per person with asthma, is for the year 1994 and was updated to 2004 here, using the medical care component of the Consumer Price Index. The total cost for asthma care in the State was calculated by multiplying the per-person cost by the number of people with asthma in the State.
Table 1.3 shows the calculated estimates by State for 2004. Across all the States, spending on asthma care totaled to over $15 billion, according to these estimates. The difference in totals between the ALA report and the summed State estimates here points out the imprecision of the method, noted in the caveat above. The higher summed State estimate points out the imprecision of the method here, noted above. Thus, State analysts should attempt to develop these estimates with their own data.
Expenditures on asthma in the top four States in asthma costs—California, Texas, New York, and Florida—together were estimated at over $7 billion. Improving asthma care and reducing avoidable admissions and emergency care might save health care systems in States substantial dollars.
Cost of Asthma Care for Medicaid
Three components were used to estimate the cost of asthma care for Medicaid:
- National asthma prevalence separately by age and by race/ethnicity.
- State Medicaid populations separately by age and by race/ethnicity.
- Estimated national expenditures per person with asthma.
Data sources for each of these components are listed below:
|Components Needed To Estimate Medicaid Costs of Asthma||Source of Information|
|National asthma prevalence separately by age and by race/ethnicity||Centers for Disease Control and Prevention (CDC) Health Data Interactive Web site available at: http://18.104.22.168/hdi/ReportFolders/ReportFolders.aspx?IF_ActivePath=P,19|
|State Medicaid populations separately by age and by race/ethnicity||Centers for Medicare & Medicaid Services (CMS) Web site available at: http://www.cms.hhs.gov/MedicaidDataSourcesGenInfo/02_MSISData.asp|
|Estimated national expenditures per person with asthma||Weiss KB, Sullivan SD, Lyttle CS. Trends in the cost of illness for asthma in the United States, 1985-1994. J Allergy Clin Immunol September 2000;106(3):493-9.|
Note: Appendix Figure B.1 gives more information on the flow of data, assumptions, and calculations made to derive Medicaid spending for asthma by State. Appendix Tables B.1-B.6 give subgroups eligible for Medicaid in each State by age and race/ethnicity.
Table 1.4 shows the estimated expenditures likely to occur by State Medicaid agency, based on the above calculations. Nationally, Medicaid programs spent, according to these estimates, over $4 billion dollars on asthma alone. The States with the highest expenditures (California, Texas, New York, and Florida) spent over $1.8 billion for asthma care for their Medicaid enrollees.
Improving asthma care by reducing emergency room visits and avoidable hospitalizations (i.e., hospital admissions that might have been avoided with high quality ambulatory care) should have a substantial impact on Medicaid spending.
Estimating potential Medicaid savings from asthma disease management—a Virginia example. Below are steps for estimating the Medicaid savings from training physicians in the Virginia Health Outcomes Partnership program described earlier. Estimates for Virginia are below. Using these steps together with State data, it is possible for a State to develop a "ballpark" estimate of how much might be saved in Medicaid costs with a similar asthma disease management intervention.
Steps for Estimating Potential Medicaid Savings From an Asthma Disease Management Program
|1. Total annual spending for emergency department visits for asthma pre-intervention for Medicaid recipients||$5,056,020|
|2. Total annual number of Medicaid claims for emergency department visits||9.363|
|3. Payment per claim: Divide step 1 by step 2 (5,056,020/9,363)||$540|
|4. Emergency visit reduction factor: Adjusted to four quarters and to exclude added costs per physician and added drug prescribing (both included below; see steps 7 and 8)||0.06|
|5. Emergency care visit annual saving after training physicians: Multiply step 1 by step 4 (5,056,020 X 0.06)||$303,361|
|6. Number of physicians participating in primary care case management who might accept training in asthma management||200|
|7. Asthma drug cost: Multiply step 6 by $180 per physician per year (200 X 180)||$36,000|
|8. Program training costs: Multiply step 6 by $235 per physician (200 X 235)||$47,000|
|9. Total drug and training costs: Add steps 7 and 8 (36,000 + 47,000)||$83,000|
|10. Total Medicaid savings: Subtract step 9 from step 5 (303,361 - 83,000)||$220,361|
|11. Savings per Medicaid claim: Divide step 10 by step 2 (220,361/9,363)||$23.54|
Source: Estimates derived from Rossiter, et al., 2000.
Note: See Rossiter, et al., for further detail on derivation of the emergency visit reduction factor, asthma drug cost, and program training cost. Based on the VHOP experience, step 6 assumed that one-third of Medicaid participating physicians in any disease management program would accept training in asthma management.
People with asthma who have poor asthma management have a high number of repeat ED visits. Data from the National Medical Expenditure Survey show that only about 20 percent of all asthma patients account for about 80 percent of the total costs of asthma (Weiss, et al., 2001; Smith, et al., 1997). A recent study showed that from a group of more than 3,000 patients, asthma patients with 6 or more ED visits accounted for 68 percent of total ED visits (Griswold, 2005).
If these asthma patients with multiple ED visits can be identified with State Medicaid data, then States can estimate potential cost savings from reducing the number of patients with repeat emergency room visits. Multiplying the number of patients who have different numbers of visits by the average cost per visit for each group gives an estimate of total ED costs for patients with asthma who have frequent ED visits for each group. These costs represent a potential target for reducing health care costs for patients with asthma and compare the cost of moderate emergency use to high emergency department use for asthma.
Cost of Excess Hospitalizations
Rates of avoidable hospitalizations have been developed as indicators of the quality of ambulatory care, including care for asthma. Hospitalizations occur because of exacerbations of asthma symptoms such as an asthma attack, during which a patient cannot breathe and could die without medical attention. Some asthma hospitalizations could be avoided with planned care, patient education, proper use of long-term controller medications for people with persistent asthma, and patient awareness and avoidance of asthma triggers. However, even for patients and physicians who comply with the best practices, asthma attacks beyond their control may still occur and hospitalization may be necessary for survival. It is the wide variation in asthma admissions rates across the country (Table 1.2) that suggests considerable improvement can be made in ambulatory care and self-management that results in reduced hospitalizations and, thus, lower costs for asthma care.
A recent study found that about half of admissions for children with asthma in one hospital may have been preventable. In a Massachusetts inner-city hospital, 26 percent of parents thought their child's hospitalization for asthma could have been avoided, 38 percent of primary care physicians thought an admission could have been avoided, and 43 percent of the inpatient attending physicians who saw a child with asthma in the hospital had that view (Flores, et al., 2005). These assessments were independent of each other. The one group without a personal stake in the assessment of the chronic care of the children was the inpatient physicians with the highest assessment of avoidable admissions. Of all admissions for children with asthma, 54 percent of admissions were assessed as preventable by any of the three sources.
Estimating potential cost savings from reducing excess hospitalizations for pediatric asthma—a Massachusetts validation. By comparing the Massachusetts hospitalization rate with the average for States with the lowest rate of hospitalization for children with asthma, the apparent excess (or percent to be reduced in order to achieve best-in-class performance) in Massachusetts is 60.8 percent (Table 1.2). This potential for reduction of pediatric asthma hospitalizations for Massachusetts is similar to the 54-percent estimate of hospitalizations that might have been prevented, based on the judgment of parents, physicians or attending physicians at the Boston hospital described above. This supports the use of hospitalization rates above and beyond the best-in-class States average rate as a metric to evaluate how much States could save with better quality of asthma care. Using Massachusetts as an example, the steps in the following calculation show how a State may develop a ballpark estimate of the potential cost savings from reducing excess hospital admissions for pediatric asthma. Note that the cost of implementing a quality improvement program to reduce hospitalizations is not included in the calculation.
Steps for Estimating Potential Savings From Reducing Excess Pediatric Asthma Hospitalizations
|1. Hospital admission rate for pediatric asthma per 100,000 population under age 18 (Table 1.2)||184.13|
|2. Estimated population under age 18 in State (U.S. Census, 2000; http://www.census.gov/popest/states/asrh/SC-est2004-02.html)||1,464,189|
|3. Number of pediatric asthma hospital admissions: Multiply step 1 by step 2 (184.13 X 1,464,189)||2,696.01|
|4. Percent of pediatric asthma hospital admissions to be reduced to achieve best-in-class (Table 1.2)||60.8%|
|5. Number of hospital admissions for pediatric asthma to reduce (excess hospitalizations): Multiply step 3 by step 4 (2,696.01 X 0.608)||1,639.17|
|6. Mean cost for pediatric asthma hospitalization*||$3,213|
|7. Total cost of all pediatric asthma hospitalizations in State: Multiply step 3 by step 6 (2,696.01 X $3,213)||$8,662,280.13|
|8. Total cost of excess pediatric asthma hospitalizations in State: Multiply step 5 by step 6 (1,639.17 X $3,213)||$5,266,653.21|
|9. Potential cost savings from reducing excess hospitalizations: Subtract step 8 from step 7 ($8,662,280.13 - $5,266,653.21)||$3,395,626.92|
Summary and Synthesis
This module provides background on asthma as a disease, its prevalence, complications, and associated costs. This module also examines the evidence from both the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) regarding the substantial variation in quality of care for asthma that exists across the Nation, between States, and across population subgroups.
Evidence from research indicates that quality improvement can enhance health outcomes, reduce disparities across States and population groups, and provide a return on the investment. The return includes both cost savings and improved quality of life for people with asthma and their caregivers.
Resources for Further Reading
- American Lung Association Trends in Asthma Morbidity and Mortality, available at: http://www.lungusa.org/atf/cf/%7B7a8d42c2-fcca-4604-8ade-7f5d5e762256%7D....
- National Asthma Education and Prevention Program, available at: http://www.nhlbi.nih.gov/about/naepp/.
- Institute for Healthcare Improvement Web resources, available at: http://www.ihi.org/IHI/Topics/ChronicConditions/Asthma/.
- Institute of Medicine's Crossing the Quality Chasm: A New Health Care System for the 21st Century, available at: http://www.iom.edu/report.asp?id=5432.
- Institute of Medicine's Fostering Rapid Advances in Health Care: Learning from System Demonstrations, available at: http://www.iom.edu/report.asp?id=4294.
- National Healthcare Quality Report and National Healthcare Disparities Report, available at: http://www.innovations.ahrq.gov.
- Boudreaux ED, Emond SD, Clark S, et al. Acute asthma among adults presenting to the emergency department: The role of race/ethnicity and socioeconomic status. Chest 2003;124:803-12.
- Griswold SK, Nordstrom CR, Clark S, et al. Asthma exacerbations in North American adults: Who are the "frequent fliers" in the emergency department? Chest 2005;127(5):1579-86.
- Lin S, Fitzgerald E, Hwang S, et al. Asthma hospitalization rates and socioeconomic status in New York state (1987-1993). Journal on Asthma 1999;36:239-51.
- Mayo PH, Richman J, Harris HW. Results of a program to reduce admission for adult asthma. Annals of Internal Medicine 1990;112:864-71.
- Ray N, Thamer M, Fadillioglu B, et al. Race, income, urbanicity, and asthma hospitalization in California: a small area analysis. Chest 1998;113:1277-84.
- Stanton MW, Dougherty D, Rutherford MK. Chronic care for low-income children with asthma: strategies for improvement. Rockville (MD): Agency for Healthcare Research and Quality; 2005. Research in Action Issue 18. AHRQ Pub. No. 05-0073.
- Zeiger RS, Heller S, Mellon MH. Facilitated referral to asthma specialist reduces relapse in asthma emergency room visits. Journal of Allergy and Clinical Immunology 1991;87:1160-8.
- Zoratti E, Havstad S, Rodriguez J, et al. Health service use by African Americans and Caucasians with asthma in a managed care setting. American Journal of Respiratory Critical Care Medicine 1998;158:371-7.
Associated Appendixes for Use With This Module
Appendix A: List of Acronyms
Appendix A lists acronyms of organizations, data sources, and other resources used in this Resource Guide.
Appendix B: Estimates of Medicaid Costs by State
Appendix B includes data tables with the cost estimates for racial/ethnic subgroups of Medicaid eligibles with asthma by State and a flow chart of the methodology used to derive the estimates.