February 26, 2019
By Barbara P. Yawn, MD, MSc, FAAFP
The health care industry is progressing, albeit somewhat slowly, toward a value-based system, but a gap remains when it comes to asthma care. This gap primarily exists because collectively we still underestimate the importance of comprehensive asthma strategies. Earlier this year, researchers at the Centers for Disease Control and Prevention (CDC) released findings of a paper highlighting “the critical need to support and further strengthen asthma control strategies.” Dr. Tursynbek Nurmagambetov, lead study author, stressed that, “[To] reduce asthma-related ER visits, hospitalizations, absenteeism and mortality, we need to support guidelines-based care, expand self-management education and reduce environmental asthma triggers at homes.”
For the most part, we are able to identify those individuals with the greatest risk of having their uncontrolled asthma lead to costlier care and hospitalization. The CDC has reported that hospitalizations for asthma account for $1.5 billion in annual hospital charges and represent almost a third of childhood asthma costs. Dr. Nurmangambetov and his colleagues argue that this financial burden can be reduced, and patient outcomes can be improved, when payers, accountable-care organizations and health care systems fully accept the evidence that allergy evaluation and trigger management can dramatically improve clinical care and reduce costs.
IDENTIFYING CANDIDATES FOR ASTHMA ASSESSMENT AND EVALUATION
Providing value to patients in asthma care requires a continuous process informed by clinical and claims data that helps shape new, more successful approaches, the results of which can also be measured. Certain patients respond better to certain treatments, and data is already helping to stratify populations. The more data we produce–and share–across payers and systems, the better able we are to predict outcomes and prescribe care plans that ultimately reduce the systemwide costs of managing asthma. Allergy evaluations are a key part of this process.
The process is started by identifying those with asthma using ICD-10 codes. Patients with at least two visits in the past 18 months should be flagged with an asthma code to help limit the group to people most likely to have asthma, and rule out those prescribed short-term inhaler use for a respiratory event or postviral cough. The prescription order system can then be used to pinpoint people with asthma who have been prescribed 3 or more months of daily maintenance therapy. For example, a large health care system could treat 2.2 million people identified with asthma. Of those 2.2 million people, 819,000 meet the criteria for high asthma burden and an allergy evaluation. Of that group, 215,000 (26.3%) have already had the evaluation. Using this type of big data allows a focus on the high-risk group (ie, 819,000 – 215,000 = 609,000) who have not had the evaluation, rather than the entire population of 2.2 million people with asthma.
To make asthma care more efficient and effective, some health care organizations are taking proactive approaches. According to a study that appeared in Annals of Family Medicine, practices are embedding asthma assessment tools into their electronic health records, making them easily accessible during a patient visit. This is often done with the Asthma Action Plan and the Asthma APGAR tools. Making these tools available at the point of care can improve chance of completion, even when the visit may be for another problem, ensuring that asthma assessment and care isn’t overshadowed by other, more obvious chronic diseases.
THE ROLE OF METRICS IN ASTHMA
Value-based care models rely on metrics, transparent and valid measures designed to be used in performance scorecards and compared to benchmarks of excellence. There are two types of metrics in assessing asthma care: process and outcomes. Each must be shown to be clinically important, have evidence of improving outcomes and be easily measured. If significant extra work is needed to record data or care flow is disrupted to collect metrics, their use will not be sustained over time.
Currently, the only asthma quality metrics in widespread use are part of the Healthcare Effectiveness Data and Information Set (HEDIS) measures focused on medication use. And, although measures of medication use and adherence are important, they only reflect part of the patient story.
Dealing with triggers through allergy testing in asthma management of high-risk individuals is a good example of a process metric that can be derived from claims data and correlated with outcomes. Aeroallergen assessment through in-vitro blood testing or other methods in high-risk patients should be considered for an updated HEDIS or other quality metric to help guide this important but often overlooked aspect of asthma management.
Regular clinician and team feedback can change practice behavior. This is especially true when care teams are empowered to follow a workflow model that incorporates tools and resources, supported by diagnostic testing results that guide patients’ trigger avoidance. Ultimately, when process metrics, such as appropriate trigger testing rates, are coupled with improvement in outcomes, such as decreased urgent and emergent asthma interventions, and then aligned with payment methodology for improved results, significant quality improvement in practice team care patterns will be sustainable. Quality metrics can also help clinicians and medical directors understand how to better align decision-making in clinical practices with the value to the patient, which clearly emerges in the analysis of when and why to perform allergy trigger testing.
CLOSING THE ASTHMA CARE GAP
Insurance coverage for basic components of asthma, including allergy testing, is excellent. But there are disparities in allergy and asthma care across the U.S. that disproportionately affects children, adult women, the poor, African Americans and Americans of Puerto Rican descent. Additionally, we know that environmental and genetic influences can also be contributing factors.
Research conducted by Dr. Robin Andrew Evans-Agnew, Ph.D., published in Health Promotion Practice, describes more than 30 evidence-based causes for disparities in asthma and allergy management. For example, according to the Global Initiative for Asthma (GINA), an asthma risk factor such as air pollution is more prevalent in urban areas, and this disproportionately affects African American patients. African Americans are also less likely to receive National Institutes of Health (NIH) guideline-directed care.
Clinicians can gain considerable disease-management leverage by understanding the determinants of disparity and critically reviewing their own care delivery model. Change starts with clinical recognition that such disparities exists.
A care gap exists in the delivery of non-medication elements of asthma care, and data support that. Improved efficiency in allergy testing and management can close the gap and improve quality of asthma care, patient satisfaction, value and resource utilization for the entire health care system. At its core, asthma care is about personalizing care by not only gathering the relevant data, but also assessing possible disparity based on social determinants of health and providing the appropriate counseling and, if necessary, intervention. This is how we’ll close the gap that has prevented asthma care from delivering true value to those who continue to suffer.
Barbara P. Yawn, MD, MSc FAAFP, is a family physician researcher who currently focuses on respiratory diseases, specifically COPD screening/case finding and implementation of new tools to improve asthma outcomes. She is/was a member of the International Primary Care Respiratory Group; EPR-3 science panel, editor in chief of Respiratory Medicine Case Reviews and Chief Science Officer of the COPD Foundation. She is retired form her position as the director of research at the Olmsted Medical Center and is an Adjunct Professor of Family and Community Health at the University of Minnesota. She serves as a consultant to multiple NIH and PCORI founded studies of asthma and COPD. Dr. Yawn was chair of an Allergy and Asthma Task Force convened and supported by Thermo Fisher Scientific.