Designing and Implementing Medicaid Disease and Care Management Programs
Section 8: The Care Management Evidence Base (continued)
Review Synopsis: Asthma
To evaluate the effect of care management on asthma, we reviewed 34 relevant articles. Of these, 23 examined the impact of patient interventions, 6 examined the impact of provider interventions, and 5 examined the impact of a combination of patient and provider interventions. The interventions evaluated most commonly were:
- In-person care management (15 articles).
- Telephonic care management (6 articles).
- Patient reminders (1 article).
- Self-management and monitoring (3 articles).
- Patient education (5 articles).
- Patient incentives (2 articles).
- Provider education (6 articles).
- Patient site improvement (1 article).
- Provider profiling and feedback (2 articles).
Findings are organized below by measurement category (i.e., clinical outcome measures, clinical process measures, activation measures, and utilization measures).
Clinical Outcome Measures
Our search returned 19 relevant studies, all of which found that care management interventions can lead to improved clinical outcomes. Clinical outcomes examined include:
- Quality of life.
- level of self-efficacy.
- Number of symptoms.
Of the nine intervention categories, in-person care management and patient education appeared to exert the strongest impact on clinical outcomes. Both interventions significantly improved quality of life and level of self-efficacy in the studies reviewed as well as reduced the number of symptoms. Provider education and practice site improvement appeared to have the weakest effects, demonstrating no significant impacts on clinical outcomes.
Impact on Quality of Life
- In-Person Care Management. Three articles studying in-person care management found significant improvement in quality of life.1-3 One study found that patients were more likely to have improved quality of life, in particular daytime quality of life.1 Another study found that quality of life improved significantly at 6 months, whereas at 12 months, no significant improvement occurred.3
- Telephonic Care Management. Two studies examined improvement in quality of life when using telephonic care management. Both studies showed that quality-of-life scores improved, with one study demonstrating significantly higher scores at 6 months.3,4
- Patient Education. One study found that patient education improved patients' quality of life, physical, and social domains significantly.5 However, contrasting results from another study showed that children's quality of life failed to improve significantly as a result of the education intervention.6
Impact on Level of Self-efficacy
- In-Person Care Management. One study demonstrated significantly improved self-efficacy levels when in-person care management was used. The investigators concluded that improvements in psychosocial outcomes are achievable with this particular intervention.7
- Self-Management and Monitoring. One study found that with a self-management and monitoring intervention, children can improve their asthma self-efficacy levels significantly.6
- Patient Education. The same study that found improvements in self-efficacy levels due to a self-management and monitoring intervention also found that children's self-efficacy level could be improved with patient education.6
Impact on Symptoms
- In-Person Care Management. In general, two studies showed that symptoms are reduced significantly when an in-person care management intervention is employed.3,8 In particular, one study found that symptoms were reduced significantly at 6 months, while at 12 months symptom reduction was insignificant.3 However, another study found that the number of symptom-free days remained the same after an in-person care management intervention was used when compared to the control group.9
- Telephonic Care Management. Four studies explored the impact of telephonic care management on number of symptoms present.3,10-12 Three of the studies found that telephonic care management significantly reduced the number of symptoms patients reported.3,10,11 One study showed that at 6 months, asthma symptoms were reduced significantly, but at 12 months, no significant change in asthma symptoms had occurred. In addition, another study showed that the number of days and nights with symptoms was reduced significantly when a telephonic care management intervention was used.12
- Self-Management and Monitoring. Three studies found that self-management and monitoring was an effective intervention to significantly reduce the number of symptoms and symptom days reported.6,13,14
- Provider Profiling and Feedback. The results of one study also showed that provider profiling and feedback techniques were successful at significantly decreasing the number of symptoms reported.15 During this study, patients experienced 21.2 percent fewer symptom days than the control group.
Clinical Process Measures
We identified 19 studies that showed how care management can improve clinical process measures. The clinical process measures examined in this review include medication use, action plan development and use, management practices, and adherence to medication. Of the nine intervention categories, the intervention that appeared to exert the strongest impact on clinical process measures was in-person care management, which significantly affected medication use, action plan development and use, and self-care practices. Patient and provider education also proved effective in improving clinical process measures.
Impact on Medication Use
- In-Person Care Management. Four studies examined the effect of in-person care management on medication use.1,2,16,17 Two of these studies found that use of controller medication increased significantly when in-person care management was used.2,16 In particular, one study found that corticosteroids use increased significantly in patients with in-person care management,1 while another study showed that some patients received corticosteroids multiple times.17
- Telephonic Care Management. One study found that when telephonic care management intervention was employed, use of asthma medication increased significantly.4
- Patient Reminders. One study showed that corticosteroid use remained the same even when patient reminders were used.18
- Provider Profiling and Feedback. One study showed that, when indicated, provider profiling and feedback helped increase medication use by 46 percent in the intervention group as compared with 36 percent in the control group.15
- Provider Education. Three studies showed that medication use increased significantly when a provider education intervention was employed. In one study, corticosteroid use increased significantly.19 Another study showed that paid claims for corticosteroids increased significantly after using the provider education intervention.8 Similarly, a third study showed that prescriptions for fluticasone increased significantly when provider education was the focused intervention.20
Impact on Action Plan Development and Use
- In-Person Care Management. Two studies explored the impact of in-person care management on development and use of action plans. One study found that in-person care management was more likely to result in action plan development at 6 months. However, at 12 months, the study found no significant differences between the intervention and control groups regarding possession of an action plan.3 The other study showed that action plan development and use failed to result in a significantly improved clinical process measure.21
- Telephonic Care Management. Two studies examined the number of action plans written and used when telephonic care management is employed as an intervention. One study found that the number of written action plans and use of action plans increased significantly with use of telephonic care management.10 This same study also found that at 12 months, possession of an action plan failed to differ significantly between the intervention and control groups. The second study found that availability of action plans at 6 months increased significantly when using telephonic care management.3
Impact on Management Practices
- In-Person Care Management. One study found that self-care practices improved significantly when in-person care management was used.7
- Self-Management and Monitoring. One self-management and monitoring study found that self-care practices improved significantly when this intervention was employed.14
- Patient Education. One patient education study found significant improvement in self-management, symptom identification, and cough symptom treatment.5 Similarly, another patient education study found significant improvement in child and parent management.5,6 The third study found that metered-dose inhaler technique scores improved significantly when patients were educated about proper use of inhalers.22
Impact on Adherence to Medication
- Patient Education. One study found that patient education helped significantly improve adherence to medication.23
- Provider Profiling and Feedback. One provider profiling and feedback study showed that using this intervention significantly improved adherence to steroids.24
- Provider Education. One study found that provider education helped significantly increase provider adherence.8
Eight studies examined the effect of care management on activation measures. The activation measures identified in this literature review include knowledge, followup visits, asthma planning visits, and guideline adherence. In-person care management, telephonic care management, patient education, patient incentives, and provider education appeared to influence activation measures more strongly.
Impact on Knowledge
- In-Person Care Management. One study found that asthma knowledge improved significantly after using in-person care management.7
- Self-Management and Monitoring. One study showed that asthma knowledge improved significantly when self-management and monitoring interventions were used.6
- Patient Education. Three of the studies using patient education found that the intervention significantly improved patient knowledge,5,25 parent knowledge,5 care management knowledge,25 and asthma knowledge.6
Impact on Followup Visits
- In-Person Care Management. One study found that patient followup visits at 6 months increased significantly but failed to demonstrate significant change at 12 months with use of in-person care management.3
- Telephonic Care Management. Two studies found that telephonic care management had an effect on office visits. One of the studies showed that patients with telephonic care management were significantly more likely to have asthma planning visits at 2 weeks.12 The other study found that patient followup visits at 6 months increased significantly, but it failed to demonstrate significant change at 12 months with use of in-person care management.3
- Patient Incentives. One study showed that the likelihood of having asthma planning visits at 2 weeks increased significantly with patient incentives. Similarly, the same study found that after 2 weeks, no differences occurred in asthma planning visits or acute care visits.12
- Provider Education. Provider education interventions also found that the likelihood of having asthma planning visits at two weeks increased significantly with patient incentives. Similarly, the same study found that after two weeks, no differences in asthma planning visits or acute care visits occurred.12
Impact on Guideline Adherence
- Patient Incentives. One study found that guideline adherence increased significantly with use of patient incentives.26
- Provider Education. One study that examined the provider education intervention showed that when provider education was used, guideline adherence rates were significantly higher.26
- Practice Site Improvement. One study found that when practice site improvement interventions were employed, guideline adherence rates were significantly higher.26
We identified 18 studies relevant to utilization and savings. Of these studies, we found that utilization decreased and savings increased. In-person care management, telephonic care management, patient reminders, provider profiling and feedback, and provider education all helped decrease utilization and increase savings.
Impact on Utilization
- In-Person Care Management. Six in-person care management studies found that the intervention decreased utilization.1,27-30 One study found that the number of unscheduled visits decreased significantly,1 while two studies found that the use of health care services decreased significantly when in-person care management was employed.29,30 Similarly, two studies found that hospital admissions also decreased significantly with in-person care management.27,29 In particular, two studies also noted that length of hospital stay was significantly reduced for intensive care unit (ICU) and non-ICU visits28,29 as well as ER visits.27,29 Contrasting these results are two other studies that found no significant differences in the number of ER visits.2,17 Another study also found no significant differences in the number of emergency medical care services provided to patients engaged in in-person care management11 as well as number of hospital admissions.17 Lastly, one study found that ambulatory visits increased significantly with in-person care management.16
- Telephonic Care Management. One study found that adverse use of health care services decreased significantly with telephonic care management.11
- Patient Reminders. One study found that using patient reminders helped to significantly increase the number of patient followups, while another study showed that patient reminders failed to significantly reduce the number of ER visits.18
- Provider Education. Three studies showed that provider education helped to significantly reduce the number of outpatient visits,8,19 ER visits,8,19 and hospital admissions.8,31
Impact on Savings
- In-Person Care Management. Four studies found that in-person care management increased savings. For instance, one study showed that ER costs, physician office visit costs, and hospital admission costs all decreased significantly as did number of missed school days.29 This study also found that in-person care management significantly increased the number of symptom-free days. Another study found that hospital net savings increased by 9 percent, whereas yet another study valued the annual cost savings at $300,000 when in-person care management was used.28,32 Similarly, one study found that the incremental cost-effective ratio of in-person care management was valued at $9.20 per symptom-free day when compared with usual care.33
- Telephonic Care Management. One study found that telephonic care management significantly reduced the number of lost workdays for caregivers of people with asthma-related illnesses.11
- Provider Profiling and Feedback. One study found that using provider profiling and feedback helped to significantly reduce ER visits as well as number of missed school days.15
- Provider Education. One study found that provider education helped to significantly increase the number of reported information problems as well as the number of partnerships.20
Several care management techniques can be used effectively to treat asthma. According to the literature review we conducted, quality of life, level of self-efficacy, and level of symptoms were cited most frequently as types of clinical outcome evaluated using in-person care management, telephonic care management, patient reminders, self-management and monitoring, patient education, patient incentives, and provider profiling and feedback. In addition, a host of care management interventions that involve in-person care management, telephonic care management, patient reminders, self-management and monitoring, provider profiling and feedback, and patient and provider education showed how clinical process measures, such as medication use, action plan development and use, management practices, and medication adherence, can be improved. Similarly, the same care management interventions also were found to improve activation measures such as knowledge, followup visits, and guideline adherence. Lastly, the evidence demonstrates that these care management interventions can significantly decrease health care utilization and increase savings.
- Teach SJ, Crain EF, Quint DM, et al. Improved asthma outcomes in a high-morbidity pediatric population: results of an emergency department-based randomized clinical trial. Arch Pediatr Adolesc Med 2006;160(5):535-41.
- Gorelick MH, Meurer JR, Walsh-Kelly CM, et al. Emergency department allies: a controlled trial of two emergency department-based follow-up interventions to improve asthma outcomes in children. Pediatrics 2006;117(4 Pt 2):S127-34.
- Sin DD, Bell NR, Man SF. Effects of increased primary care access on process of care and health outcomes among patients with asthma who frequent emergency departments. Am J Med 2004;117(7):479-83.
- Delaronde S, Peruccio DL, Bauer BJ. Improving asthma treatment in a managed care population. Am J Manag Care 2005;11(6):361-8.
- Shames RS, Sharek P, Mayer M, et al. Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma. Ann Allergy Asthma Immunol 2004;92(6):611-8.
- Butz A, Pham L, Lewis L, et al. Rural children with asthma: impact of a parent and child asthma education program. J Asthma 2005;42(10):813-21.
- Velsor-Friedrich B, Pigott T, Srof B. A practitioner-based asthma intervention program with African American inner-city school children. J Pediatr Health Care 2005;19(3):163-71.
- Cloutier MM, Hall CB, Wakefield DB, et al. Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children. J Pediatr 2005;146(5):591-7.
- Schatz M, Gibbons C, Nelle C, et al. Impact of a care manager on the outcomes of higher risk asthmatic patients: a randomized controlled trial. J Asthma 2006;43(3):225-9.
- Khan MS, O'Meara M, Stevermuer TL, et al. Randomized controlled trial of asthma education after discharge from an emergency department. J Paediatr Child Health 2004;40(12):674-7.
- Georgiou A, Buchner DA, Ershoff DH, et al. The impact of a large-scale population-based asthma management program on pediatric asthma patients and their caregivers. Ann Allergy Asthma Immunol 2003;90(3):308-15.
- Smith SR, Jaffe DM, Fisher EB, Jr., et al. Improving follow-up for children with asthma after an acute Emergency Department visit. J Pediatr 2004;145(6):772-7.
- Lozano P, Finkelstein JA, Carey VJ, et al. A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study. Arch Pediatr Adolesc Med 2004;158(9):875-83.
- Lindberg M, Ahlner J, Ekstrom T, et al. Asthma nurse practice improves outcomes and reduces costs in primary health care. Scand J Caring Sci 2002;16(1):73-8.
- Kattan M, Crain EF, Steinbach S, et al. A randomized clinical trial of clinician feedback to improve quality of care for inner-city children with asthma. Pediatrics 2006;117(6):e1095-103.
- Finkelstein JA, Lozano P, Fuhlbrigge AL, et al. Practice-level effects of interventions to improve asthma care in primary care settings: the Pediatric Asthma Care Patient Outcomes Research Team. Health Serv Res 2005;40(6 Pt 1):1737-57.
- Lukacs SL, France EK, Baron AE, et al. Effectiveness of an asthma management program for pediatric members of a large health maintenance organization. Arch Pediatr Adolesc Med 2002;156(9):872-6.
- Baren JM, Boudreaux ED, Brenner BE, et al. Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma. Chest 2006;129(2):257-65.
- Cloutier MM, Wakefield DB, Sangeloty-Higgins P, et al. Asthma guideline use by pediatricians in private practices and asthma morbidity. Pediatrics 2006;118(5):1880-7.
- Porter SC, Forbes P, Feldman HA, et al. Impact of patient-centered decision support on quality of asthma care in the emergency department. Pediatrics 2006;117(1):e33-42.
- Homer CJ, Forbes P, Horvitz L, et al. Impact of a quality improvement program on care and outcomes for children with asthma. Arch Pediatr Adolesc Med 2005;159(5):464-9.
- Minai BA, Martin JE, Cohn RC. Results of a physician and respiratory therapist collaborative effort to improve long-term metered-dose inhaler technique in a pediatric asthma clinic. Respir Care 2004;49(6):600-5.
- Schaffer SD, Tian L. Promoting adherence: effects of theory-based asthma education. Clin Nurs Res 2004;13(1):69-89.
- Onyirimba F, Apter A, Reisine S, et al. Direct clinician-to-patient feedback discussion of inhaled steroid use: its effect on adherence. Ann Allergy Asthma Immunol 2003;90(4):411-5.
- Scariati PD, Roberge L, Dye T. Beating asthma: a community-based asthma education initiative. J Am Osteopath Assoc 2006;106(1):16-22.
- Daniels EC, Bacon J, Denisio S, et al. Translation squared: improving asthma care for high-disparity populations through a safety net practice-based research network. J Asthma 2005;42(6):499-505.
- Catov JM, Marsh GM, Youk AO, et al. Asthma home teaching: two evaluation approaches. Dis Manag 2005;8(3):178-87.
- Ebbinghaus S , Bahrainwala AH. Asthma management by an inpatient asthma care team. Pediatr Nurs 2003;29(3):177-83.
- Shelledy DC, McCormick SR, LeGrand TS, et al. The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost. Heart Lung 2005;34(6):423-8.
- Walders N, Kercsmar C, Schluchter M, et al. An interdisciplinary intervention for undertreated pediatric asthma. Chest 2006;129(2):292-9.
- Newcomb P. Results of an asthma disease management program in an urban pediatric community clinic. J Spec Pediatr Nurs 2006;11(3):178-88.
- Dinakar C, Van Osdol TJ, Wible K. How frequent are asthma exacerbations in a pediatric primary care setting and do written asthma action plans help in their management? J Asthma 2004;41(8):807-12.
- Sullivan SD, Weiss KB, Lynn H, et al. The cost-effectiveness of an inner-city asthma intervention for children. J Allergy Clin Immunol 2002;110(4):576-81.