The
National Heart, Lung, and Blood Institute published
the Guidelines for the Diagnosis and Management
of Asthma in 1991. The Guidelines was written
to guide primary care practitioners in the diagnosis,
assessment, treatment, and education of asthma
patients. Although asthma experts who serve as
consultants to managed care organizations are
aware of the Guidelines, only a few have been
able to implement them successfully on an HMO-wide
basis. It is relatively easy to implement a program
serving a small number of patients with special
staff. Improving asthma care in an entire HMO
requires that the administration generate reliable
data and design a mechanism for inducing physicians
to provide up-to-date asthma care. I have seen
no published account of an HMO that has done this.
In addition, the physicians must recognize the
value of new techniques for care such as monitoring
peak flow and using anti-inflammatory medicines
to prevent attacks.
The update of the Guidelines, published February
1997, refined the earlier recommendations but
introduced no major changes.
Before
embarking on an intervention, it is important
to understand the asthma care status of an organization.
This can be accomplished by collecting appropriate
data. Data collection is important for setting
goals, planning the intervention, and evaluating
outcomes. To be useful, data must be collected
from accurate sources in a timely fashion. Reliable
data can be used to measure the impact of the
intervention and to identify problem areas within
the HMO. Timely identification of problems can
lead to their early remedy.
Many
asthma programs collect a wide array of data
but have no clear plan for responding to the
results. In this article, I present a concise
data collection instrument that I have used
to compare asthma outcomes in more than a dozen
HMOs. I then outline the essential elements
of care for patients with moderate or severe
chronic asthma. Finally, I present a simple
tool for tracking implementation of these elements
in the hospital, emergency department, or office.
Monitoring
Outcomes of Care
The rate of hospital days generated by asthma
provides more useful information than does any
other measure of care. Hospital days are a better
indicator of asthma care than hospital admissions
because the rate of hospital admissions fails
to distinguish between brief admissions for
rescue therapy and admissions for which poor
management necessitated prolonged stays. Transfers
from one hospital to another are counted as
admissions, confounding the data. The data should
be expressed in days per thousand enrollees
and can be compared with data from previous
years and with data published by other HMOs
and the National Center for Health Statistics
(Table 1).2
Physicians who are under pressure to reduce
admissions often will try to do so by providing
intensive treatment in the office or emergency
department. The number of admissions may decrease,
but if treatment is inadequate the length of
stay will increase. This outcome is not good
for patients and is fiscally unsatisfactory
(unless charges are based on admissions, rather
than on days).
It
is difficult to interpret the results of interventions
that focus on high-risk patients but that lack
control groups. Most patients who are hospitalized
for asthma will not be readmitted during the
following year, regardless of whether they participate
in an asthma intervention. Thus a 50% drop in
hospitalizations of patients who were hospitalized
the preceding year should not be credited to
an intervention.
To
ensure reliability, data on hospital stays for
asthma, pneumonia, bronchitis, and bronchiolitis
must be collected from two independent sources,
such as a nurse case manager, who can obtain
data directly from the hospital ward; and staff
from the business office, who should be able
to provide regular monthly reports of hospital
days categorized by first-listed diagnosis.
The
misdiagnosis of asthma is common and skews data
significantly.3 Diagnostic styles vary from
physician to physician and from group to group.
Clearly, a group that diagnoses bronchitis rather
than asthma will have a lower rate of asthma
hospitalizations than will a group that diagnoses
the disease correctly. These diagnostic differences
will stand out on a tracking system such as
the Hospital Days for Respiratory Illness (Table
1). In addition, physicians who want to improve
their asthma statistics, rather than their asthma
care, can shift a diagnosis from asthma to pneumonia.
Conversely, physicians who improve their diagnostic
ability will shift a diagnosis from pneumonia
to asthma, thereby worsening their asthma statistics.
Finally, an epidemic of viral pneumonia might
lead to a rise in hospitalization rates for
asthma, as well as for bronchitis, bronchiolitis,
and pneumonia. Failure to understand factors
such as these may result in misinterpretation
of the data.
Before I agree to work as an asthma consultant,
I stipulate that every admission for asthma
be considered the result of HMO or physician
failure, unless proven otherwise. This stance
places the responsibility on the managed care
organization to provide proper equipment and
training for staff and education for patients.
It encourages physicians and staff to improve
their method of asthma care, rather than place
the onus for a hospital admission on the patient.
I
guided HMO-wide pediatric asthma interventions
at Kaiser sites in Martinez/Antioch, California,
and the state of Oregon. The intervention emphasized
the early and accurate diagnosis of asthma,
early use of steroids, use of a compressor driven
nebulizer in the home, peak flow monitoring
in the office and at home and preventive treatment
of chronic asthma with anti-inflammatory medicines.
We collected data on 113,000 children retrospectively
for the 12 months prior to April 1989 and prospectively
during the following year.4 The intervention
was universal rather than selective, in that
it included all pediatricians and all enrollees.
Although the interventions antedated the Guidelines,
they emphasized its major elements. Before the
intervention, these children had been hospitalized
for asthma at 37% of the US rate. They generated
hospitalizations for bronchitis, bronchiolitis,
and pneumonia at less than 25% of the national
rate (Table 2). During the year-long intervention,
hospitalization for asthma dropped more than
15%. The reduction was maintained during the
following year. Because hospitalization for
bronchitis, bronchiolitis, and pneumonia also
decreased, the improvement in asthma outcomes
could not have been the result of diagnostic
transfer.
Elements
of Care
The elements of care described in this section
are essential for a good outcome in any setting,
whether the hospital, emergency department,
physician's office, or the patient's home. In
order to obtain the best results, they must
be supplied by the HMO. Asking patients to pay
out of pocket for devices and learning materials
is not cost effective. For example, if a patient
is expected to purchase a peak flow meter but
does not, the HMO's savings on that item will
be erased many-fold by the cost of an avoidable
emergency room visit.
Devices
for Monitoring Status and Delivering Medicines
Peak Flow Meter. Health professionals
use peak flow to make the diagnosis of asthma,
monitor the effect of treatment in an acute
attack, and monitor the effect of preventive
treatment. Patients use peak flow to guide their
use of asthma medicines, aid in telephone communication
with their provider, and determine when they
should see a physician. The peak flow meter
gives a much more accurate and sensitive measure
of airflow than do either the stethoscope or
the presence of any clinical sign.
Holding Chamber. This device
is used to aid delivery of inhaled medicines
by a metered-dose inhaler (MDI). It eliminates
the problems of positioning and hand-breath
coordination, decreases the bad taste of medicine,
and reduces the frequency of hoarseness and
yeast infections that occur with the use of
inhaled steroids. The holding chamber reduces
the systemic effects of medicines by capturing
nonrespirable particles exiting the MDI. Even
infants can use a holding chamber, if it is
fitted with a mask.
Compressor-Driven
Nebulizer (CDN). This device is used
to administer an inhaled bronchodilator to a
patient who is too sick or too uncoordinated
to use a holding chamber. Providing a "loaner"
CDN for home use may enable the patient to be
discharged safely from the hospital a day earlier
than would otherwise be possible.5 The CDN is
the most convenient device for delivering cromolyn
to a child who is younger than 5 years of age.
Underused
Medicines
Most primary care physicians that I have met
in my consultations do not understand that treatment
with anti-inflammatory medicines will reduce
the frequency and severity of asthma episodes.
As a result they do not accept the recommendation
of the 1991 Guidelines that a patient who has
symptoms or signs of asthma three or more times
a week receive these drugs. (The 1997 Guidelines
recommends anti-inflammatory medicines for patients
who have symptoms more than twice a week).6
Preventive Medicines. Inhaled
steroids prevent asthma episodes by reducing
airway hyperresponsiveness and preventing inflammation
of the airways. Cromolyn and nedocromil block
both the early and late asthmatic reactions.
These drugs should be prescribed for almost
every patient who has signs or symptoms of asthma
3 or more times per week,1 as they reduce the
frequency and severity of asthma episodes.
Oral
Steroids. These medicines relieve the
inflammation of the airways. When started promptly,
at the adequate dosage, they begin to produce
an effect in 1 to 6 hours. Almost all patients
who have been hospitalized should take oral
steroids for at least several days after discharge.
Patients with moderate or severe asthma should
be instructed in the use of oral steroids and
should have them at home for use during an attack.
Materials
for Learning About and Tracking Asthma
Booklet. A basic booklet should
be accurate, concise, clear, and cover the basics
of asthma, medicines, and treatment devices.7
It will aid discussion in the office and will
enable patients to continue to learn about asthma
between visits. Patients who understand and
can monitor their asthma are able to start treatment
early. This early intervention often prevents
the occurrence of serious attacks.
Asthma Diary. A diary, which
shows the relationships among the "pieces"
of the asthma puzzle,8 is an essential aid in
the management of the disease. It should display
peak flow scores in graphic form and provide
space to record asthma triggers, signs, symptoms,
and medicines. The diary enables patients to
recall accurately events occurring since their
last visit, identify triggers that provoke an
episode, learn when to start and when to reduce
medicines, and remember to take medicines regularly.
Home
Treatment Plan. A written home treatment
plan will improve compliance and reduce the
frequency of medication errors. An effective
plan will be based on the zone system of asthma
care9 and will be easy to read and understand.
The zone system defines the level of care needed
and is based on peak flow scores or the signs
of asthma. The green zone signifies that the
patient's status is good and he requires only
his usual maintenance medicines. The yellow
zone signifies a moderate problem for which
a change in medication routine and removal of
triggers is required. The red zone signifies
serious trouble for which the patient should
take emergency medicines and see a doctor.
Monitoring
the Process of Care
The function of monitoring is to obtain information
that can be used to improve asthma care. An
effective system must produce reliable data
and timely, understandable feedback, which must
be given with reference to predetermined goals.
Monitoring is done in the hospital by a utilization
review nurse who reports to the physician in
charge of the asthma intervention.
Because the elements of care are similar in
the hospital, emergency department, and the
physician's office, a single instrument - the
Asthma Care Data Sheet - can be used to monitor
them (Table 3). I have developed and used earlier
versions of this sheet, which tracks the use
of the medicines, devices, and learning tools
that comprise the elements of care, in several
asthma interventions.
Acceptable
care requires that, on discharge, every patient
treated in the hospital, with the exception
of children younger than 5 years of age, receive
each of the seven elements of care shown on
the data sheet; these children do no receive
peak flow meters. Some office and emergency
department patients will not require preventive
medicine for treatment.
The
reviewer, usually the utilization review nurse
or nurse case-manager, fills out the identifying
information and checks whether a patient has
received each item before leaving the hospital,
emergency department, or office. The data sheet
provides space to record data from before the
hospitalization or visit, if desired. The instrument
takes only a few minutes to complete. Data from
the sheet can be analyzed to determine whether
a physician, group of physicians, or an entire
site is adhering to the asthma care protocol.
The data should be analyzed by the physician
and the manager in charge of the intervention.
Results should be displayed in a form that is
clear and easy to understand (Table 4). In this
sample of data from 14 hospitalized children,
only one child had received any of the elements
of care preadmission. As a result of an asthma
intervention, their care improved greatly, but
still did not reach the expected standard of
90% compliance with the protocol.
Managed
Care
In my work as a consultant,10 I have found that
about 20% of physicians will implement the basic
elements of asthma care within a few weeks of
our first meeting. The others do so much more
slowly, perhaps because of practice overload,
too many demands for change, or perceptions
that they already are doing a good job.
Interventions to improve care for any disease
take time and energy, and the number of changes
that can be implemented in a given year is limited.
Not only must physicians change their practice
methods, but managers, data specialists, and
case managers must meet their commitments to
provide data and support for the program. Unreliable
data or untimely data collection will not be
useful in changing physician behavior. Furthermore,
if an HMO supplies inferior learning and tracking
materials to patients or neglects to provide
essential devices as covered benefits, the results
of an intervention will be compromised.
An
asthma intervention should call explicitly for
the following elements of care, which might
be implemented all at once or one item at a
time. While some HMOs will decide to implement
the entire program at once, others may find
it simpler to get cooperation from physicians
if they introduce items individually. Order
of implementation is based on importance of
the various items and the patient's comprehension
of them. The elements of care are: oral steroids;
asthma booklet; holding chamber; peak flow meter;
asthma diary; home treatment plan; and preventive
medicines.
The
Asthma Care Data Sheet can be used to monitor
care at discharge (from the hospital, emergency
department, or office). Because hospitalized
patients consume the most resources,11 have
the most serious problems, and are the easiest
to identify, an intervention should focus on
their care first. Ideally, a patient's care
should be reviewed and, if necessary, changed
during the hospitalization. Because logistics
and time constraints generally preclude this,
I focus on the patient's status at the time
of discharge. A nurse case manager can complete
the Asthma Care Data Sheet within 24 hours of
discharge. The physician in charge of the asthma
program can note any deficiencies and arrange
for their prompt remedy.
Competent
physicians, many of whom have cared for hundreds
of patients with asthma, often fail to provide
good asthma care.12 They routinely treat patients
who have severe wheezing and retractions. Minutes
after a treatment with inhaled albuterol these
patients breathe more easily. These physicians
are impressed with their own ability to bring
an attack rapidly under control. Many are unaware
that people with mild asthma symptoms should
receive preventive treatment to reduce the frequency
of severe attacks and hospitalizations and to
improve their quality of life.
A
physician who believes that his or her present
protocol leads to good results will perceive
no need to change. Thus, the challenge for an
asthma improvement program is to inform physicians
and administrative staff how their process of
care compares with that of professionals who
are achieving the best outcomes, defined here
as the lowest rate of hospital days for asthma
and related respiratory diagnoses. Every physician
whom I have met in the course of providing my
interventions has wanted to do a good job of
providing asthma care. At the time of our initial
meeting, most believed that they were providing
good care. After I compared their outcomes and
their process of care with those of others,
however, many were persuaded to reexamine and
improve their protocols. A similar process has
induced administrators to be more helpful in
providing equipment and support for an asthma
program.
Asthma
is unique among chronic illnesses in that hospitalization
and emergency department utilization rates will
drop almost immediately after the onset of a
well-planned intervention that is consistent
with the Guidelines of the National Heart, Lung
and Blood Institute. For example, pediatricians
at a Kaiser site in White Plains, New York,
with 7,000 pediatric enrollees implemented these
changes, reducing hospitalizations by more than
50% and eliminating readmissions during a 2-year
intervention.13 In contrast, programs to improve
care for diabetes, heart disease, or stroke
take much longer to achieve positive results.
The challenge, therefore, is to encourage physicians
to implement the Guidelines. Some HMOs have
offered continuing education; others have offered
incentives for using peak flow meters and compressor-driven
nebulizers in the office. To achieve the best
result, asthma programs must base incentives
for physicians on specific outcome and process
data.
Summary
I have described simple tools for analyzing
asthma outcomes and for tracking the processes
of care. Hospital days for asthma should be
calculated for the entire enrolled population,
but recognizing that misdiagnosis often distorts
the data. The Asthma Care Data Sheet highlights
deficiencies in care and can be used to track
the process of care in any site.
References
1. National Asthma Education Program. Expert
Panel on the Management of Asthma. Guidelines
for the Diagnosis and Management of Asthma.
Bethesda, MD: US Department of Health and Human
Services, National Heart, Lung and Blood Institute;
1991.
2. Utilization of Short-Stay Hospitals: United
States, 1979-1986 Annual Survey. Hyattsville,
MD: National Center for Health Statistics, Series
13.
3. Plaut, TF. Childhood Asthma: A missed diagnosis.
HMO Practice 1991;5:102-105.
4. Plaut TF, Tochen ML, Gascoigne GB. Pediatricians
Cut Asthma Hospitalization. Presented at the
First National Conference on Asthma Management.
Sponsored by the National Asthma Education Program
of the National Heart, Lung and Blood Institute.
October 1992; Arlington, VA.
5. Plaut TF. Safe home use of the compressor-driven
nebulizer. AM J Dis Child 1990;14:20-21. Letter.
6. Expert Panel Report II: Guidelines for the
Diagnosis and Management of Asthma. National
Asthma Education and Prevention Program, NIH.
Bethesda, MD; February 1997.
7. Plaut TF. Rating asthma learning materials.
Advance Phys Assist September 1996.
8. Plaut TF. Asthma peak flow diary improves
care. Ann Allergy Asthma Immunol 1996;76:476-478.
9. Plaut TF. The zone system: Asthma management
simplified. Advance Phys Assist February 1997;33,34,36,76.
10. Plaut TF, Howell T, Walsh S, et al. A systems
approach to asthma care. Managed Care Q 1996;4:6-18.
11. Weiss KB, Bergen PJ, Hodgson TA. An economic
evaluation of asthma in the United States. New
Engl J Med 1992;326:862-866.
12. Plaut TF. Why don't pediatricians give better
asthma care? Contemp Pediatr 1994;11:15.
13. Stevens MA, Weiss-Harrison A. A program
for children with asthma. HMO Practice 1993;7:91-93.
14. Plaut TF. One Minute Asthma: What You Need
to Know. 3rd ed. Amherst, MA; Pedipress, Inc.,
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