Adaptation of an Asthma Management Program to a Small Clinic

The authors adapted a successful large-scale, specialist-run asthma management program to an existing multi-specialty clinic utilizing existing resources and achieving similar outcomes.
Published Online: July 31, 2017
Kenny Yat-Choi Kwong, MD; Nasser Redjal, MD; Lyne Scott, MD; Marilyn Li, MD; Salima Thobani, MD; and Brian Yang, MS
ABSTRACT

Objectives: Asthma management programs, such as the Breathmobile program, have been extremely effective in reducing asthma morbidity and increasing disease control; however, their high start-up costs may preclude their implementation in smaller health systems. In this study, we extended validated asthma disease management principles from the Breathmobile program to a smaller clinic system utilizing existing resources and compared clinical outcomes. 
 
Study Design: Cox-regression analyses were conducted to determine the cumulative probability that a new patient entering the program would achieve improved clinical control of asthma with each subsequent visit to the program.
 
Methods: A weekly asthma disease management clinic was initiated in an existing multi-specialty pediatric clinic in collaboration with the Breathmobile program. Existing nursing staff was utilized in conjunction with an asthma specialist provider. Patients were referred from a regional healthcare maintenance organization and patients were evaluated and treated every 2 months. Reduction in emergency department (ED) visits and hospitalizations, and improvements in asthma control were assessed at the end of 1 year. 
 
Results: A total of 116 patients were enrolled over a period of 1 year. Mean patient age was 6.4 years at the time of their first visit. Patient ethnicity was self-described predominantly as Hispanic or African American. Initial asthma severity for most patients, classified in accordance with national guidelines, was “moderate persistent.” After 1 year of enrollment, there was a 69% and 92% reduction in ED/urgent care visits and hospitalizations, respectively, compared with the year before enrollment. Up to 70% of patients achieved asthma control by the third visit. Thirty-six different patients were seen during 1 year for a total of $15,938.70 in contracted reimbursements. 
 
Conclusions: A large-scale successful asthma management program can be adapted to a stationary clinic system and achieve comparable results.
Takeaway Points

Identifying patients who are likely to incur high healthcare costs is a crucial goal of innovative care delivery models. Insurance claims or electronic health records are often used to identify high-cost patients, but sometimes they are unavailable. The results of this study show that: 
  • Self-reported health and healthcare utilization based on survey data can be useful in predicting whether privately insured patients will incur high healthcare costs when claims-based expenditure and health information from prior years is not available. 
  • Among the survey-based measures, questions on inpatient stays and emergency department visits in the previous year were the strongest predictors of incurring high healthcare costs in the following year.
A disproportionate health burden exists due to uncontrolled asthma among inner city children.1 Many asthma disease-specific programs have proven to be effective in reducing asthma-related morbidity and improving disease control. Most effective strategies, however, provide long-term follow-up using asthma-specific providers who follow national asthma guidelines.1-8

The Breathmobile/pediatric asthma disease management program (PADMAP) is an effective disease management and treatment program utilizing teams of asthma and allergy specialists who provide regular care to children with asthma in inner cities across the United States via mobile asthma clinics.4-9 These clinics have consistently achieved impressive asthma-related metrics for the past 20 years, including highly significant reductions in asthma-related hospitalizations, emergency department (ED) visits, and urgent care visits.5,6 In addition, the programs have shifted urgent care visits to regular care and increased the number of controller medications prescribed.4

As with most clinically effective disease management programs, the Breathmobile/PADMAP program requires significant start-up resources. An estimated $365,865 per year was required to purchase and operate 1 Breathmobile for the first 7 years.5 This, however, was recouped in long-term asthma-related health savings during subsequent operating years. In a cost analysis study, the return on investment (ROI) per mobile unit was $6.73 per invested dollar. The annual estimated ED cost in 4 geographic regions was reduced by $2,541,639.10 Therefore, the Breathmobile/PADMAP model is also one of the most cost-effective asthma management programs in the United States. Smaller health systems with smaller budgets and fewer patients may not have the resources to start an effective Breathmobile-like asthma program; yet, these groups have a similar percentage of patients with asthma and, therefore, incur a similar proportion of asthma-associated health and economic burden.

In this study, we describe a collaboration between a tertiary care center with a long established and successful Breathmobile/PADMAP program (Los Angeles County + University of Southern California [LAC+USC] Medical Center) in Los Angeles, California, and a stationary clinic system at Harbor- University of California, Los Angeles (UCLA) Medical Center (HUMC) in Torrance, California, to establish a fixed asthma-specific clinic at the HUMC using previously validated strategies. The need for start-up funds was avoided by using the clinic’s existing resources. We compared the efficiency of settings, asthma-related morbidity, and asthma control to previously published Breathmobile metrics.4,5 We also determined whether standard Medi-Cal (California’s Medicaid) reimbursements for asthma-related services were sufficient to allow a stationary clinic version of the Breathmobile/PADMAP system to be self-sustaining.

METHODS

Study Population

Pediatric patients with asthma were recruited into the study from the Pediatric Allergy-Immunology Clinic at HUMC and the Harbor Medical Foundation (MFI) clinic. These clinics serve the children with Medi-Cal coverage assigned to a large local healthcare maintenance organization (HMO). Patients at the HUMC clinic are referred through the LA County Department of Health Services, EDs, clinics, and inpatient services. Patients at the MFI clinic are referred by HMO asthma disease management coordinators. There were no specific referral guidelines for referring patients to asthma specialty care; however, patients were referred if they were not controlled after being prescribed inhaled corticosteroids, had more than 1 urgent care or ED visit for asthma exacerbation during the last year, or were hospitalized for asthma exacerbation during the last year. All patients had persistent asthma and the majority had previous ED visits and/or were previously hospitalized for asthma exacerbations.

Clinic Structure and Operation

The HUMC/MFI clinics’ operations were modeled identically to that of the Breathmobile/PADMAP system. Staff consisted of 1 allergy–immunology specialist and 2 nursing/asthma educators (1 registered nurse and 1 licensed vocational nurse). One medical technician coordinated appointments and financial matters in a fashion similar to the patient financial worker on the Breathmobile/PADMAP system.5 In contrast to the Breathmobile/PADMAP program which uses full-time allergy–immunology staff, the HUMC/MFI clinic used pediatric nurses who also staffed other pediatric subspecialties, including neurology, nephrology, and rheumatology. Each clinic was held 1 half-day per week.

Patients were evaluated and treated in accordance with National Heart, Lung, and Blood Institute Expert Panel Review 3 (NHLBI EPR-3) asthma guidelines.2 All patients were seen on a regular basis, with follow-up appointments every 6 to 8 weeks. Allergy testing used either skin tests or in vitro–specific-immunoglobulin E (IgE) serum tests (Quest Diagnostics; Madison, New Jersey), as stipulated by the guidelines. Use of in vitro or in vivo testing was left to the discretion of the provider. Generally, patients were allergy tested on their second or third follow-up visit.

The allergy–immunology specialist provider (principal author) had extensive clinical and administrative experience working with the original Breathmobile/PADMAP system. Although the nonprovider staff did not have clinical experience with the Breathmobile/PADMAP system, they were trained by the provider on asthma education in accordance with NHLBI ERP-3 asthma guidelines.

Care Coordination and Disease Management

Care coordination and disease management strategies and principles were made in collaboration with the LAC+USC Breathmobile/PADMAP system and transferred to the HUMC/MFI asthma clinic. On an ongoing basis, the allergy–immunology specialist provider had regular meetings with the LAC+USC Breathmobile/PADMAP team to ensure collection of the correct data and execution of the correct strategies.

Disease activity was tracked electronically, similar to Breathmobile/PADMAP programs, in real time and using identical asthma metrics. These included: baseline asthma severity, current disease activity, current disease control, step-up or step-down in asthma therapy, ED visits, hospitalizations, systemic steroid rescue, prescribed asthma controller, Asthma Control Test (ACT) score, and spirometry testing. Breathmobile/PADMAP clinical data is recorded in the AsmaTrax electronic health record (EHR), and our clinics entered identical data fields directly into Excel spreadsheets. Criteria for asthma metrics, such as asthma control, were assessed in accordance with NHLBI ERP-3 guidelines.2

In general, patients were given follow-up appointments for 6 to 8 weeks; however, earlier appointments were also scheduled depending on disease severity. Asthma control, asthma-related ED visits, and hospitalizations for patients and medications were reviewed by the provider at the end of each visit. Patients who missed their appointments had these metrics from their previously kept appointment reviewed. An early follow-up visit (2 to 4 weeks) was scheduled for patients who had experienced any of the following conditions since their last visit: 1) more than 3 visits with not well- or very poorly controlled asthma, 2) required ED visit or hospitalization since their last visit, or 3) missed current visit and had not well- or very poorly controlled asthma at their last visit. Patients were given a regular follow-up visit (6 to 8 weeks) if they had all the following conditions: 1) well-controlled asthma at their last visit, 2) fewer than 3 previous visits with asthma control rated as not well- or very poorly controlled, and 3) no ED visits or hospitalizations since their last visit.  Patients with missed appointments who also fulfilled all 3 criteria were scheduled for a return visit within 6 to 8 weeks (Figure 1).

Outcomes

Primary outcomes were reduction in ED visits, hospitalizations, and time to achieve asthma control (asthma rated by NHLBI EPR-3 asthma guidelines as “controlled”). Asthma control, ED visits, and hospitalizations since patient’s last appointment were recorded at every clinical encounter and recorded in EHRs (mobile clinics) and paper charts (fixed clinic). Cumulative ED visits and hospitalizations over a period of 1 year after enrollment were totaled from retrospective EHR and chart review. Time-to-achieving asthma control was defined as the number of visits or provider encounters after enrollment until asthma was rated as controlled. A 1-year period was chosen because the study was funded for this period of time.

The secondary outcome was to determine whether current Medi-Cal/Medicaid reimbursements could sustain operations for patients seen at the MFI clinic, which has a contract with a regional HMO. Patients served as their own historic controls when comparing reductions in ED visits and hospitalizations before and after entry into the program. ROIs with regard to reduced ED visits and hospitalizations were also calculated.

Methods

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