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The American Journal of Managed Care July 2017
The Price May Not Be Right: The Value of Comparison Shopping for Prescription Drugs
Sanjay Arora, MD; Neeraj Sood, PhD; Sophie Terp, MD; and Geoffrey Joyce, PhD
US Internists' Awareness and Use of Overtreatment Guidelines: A National Survey
Kira L. Ryskina, MD, MS; Eric S. Holmboe, MD; Elizabeth Bernabeo, MPH; Rachel M. Werner, MD, PhD; Judy A. Shea, PhD; and Judith A. Long, MD
Cost-Effectiveness of a Patient Navigation Program to Improve Cervical Cancer Screening
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Sora Al Rowas, MD, MSc; Michael B. Rothberg, MD, MPH; Benjamin Johnson, MD; Joel Miller, MD, MPH; Mohanad AlMahmoud, MD; Jennifer Friderici, MS; Sarah L. Goff, MD; and Tara Lagu, MD, MPH
Availability and Variation of Publicly Reported Prescription Drug Prices
Jeffrey T. Kullgren, MD, MS, MPH; Joel E. Segel, PhD; Timothy A. Peterson, MD, MBA; A. Mark Fendrick, MD; and Simone Singh, PhD
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Adaptation of an Asthma Management Program to a Small Clinic
Kenny Yat-Choi Kwong, MD; Nasser Redjal, MD; Lyne Scott, MD; Marilyn Li, MD; Salima Thobani, MD; and Brian Yang, MS
Leveraging EHRs for Patient Engagement: Perspectives on Tailored Program Outreach
Susan D. Brown, PhD; Christina S. Grijalva, MA; and Assiamira Ferrara, MD, PhD

Adaptation of an Asthma Management Program to a Small Clinic

Kenny Yat-Choi Kwong, MD; Nasser Redjal, MD; Lyne Scott, MD; Marilyn Li, MD; Salima Thobani, MD; and Brian Yang, MS
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.
Patients engaged in the clinic were likely to achieve asthma control, and those with milder disease were more likely to achieve control sooner. On average, 50% of mild persistent patients with asthma achieved control by the second visit, and by the third visit, 70% of these patients were in control. Patients with moderate or severe persistent asthma took longer to achieve disease control. Approximately 97% of patients with mild persistent asthma, and approximately 90% with moderate/severe persistent asthma achieved control by their sixth visit (data not shown).

Allergy Testing and Environmental Control Education

Patients had allergy testing and environmental avoidance education based on results of the allergy testing. Thirty-three percent of patients received in vitro-specific IgE testing for inhalant allergens; the rest received epicutaneous skin testing. There was no statistical difference between patients who had the 2 different types of IgE testing in terms of probability of achieving asthma control by the third visit (data not shown).

Reduction in Morbidity

Enrollment in the program resulted in a 69% and 92% reduction in ED/urgent care visits and hospitalizations, respectively. This was achieved by comparing the number of ED/urgent care visits and hospitalizations in the 1-year period following enrollment into the program compared with the previous year before entry into the program (Figure 2).

Cost to Deliver Care

A total of 116 unique patients were seen at HUMC-UCLA during the 1-year period. Based on reimbursement rates at the time of the study, the costs to deliver care for patients using skin and in vitro testing were $435.50 and $505.70 per patient per year, respectively (Table 2). (These are standard California Medi-Cal reimbursement rates for asthma specialists for high-complexity visits and follow-up.) Overhead for 1 half day a week of clinic services was $10,000 per year.

DISCUSSION

This study demonstrated that the Breathmobile/PADMAP asthma disease management system could be implemented in a stationary clinic and achieve similar asthma-related outcomes. Existing resources in a multi-specialty pediatric clinic were used to realize treatment goals and were sustained financially from standard Medi-Cal/Medicaid reimbursements.

Patients engaged in the Breathmobile/PADMAP program(s) saw reductions of asthma-related ED visits or hospitalizations from 37.3% before program entry to 8.7% (76% reduction) within the first 6 visits in the program.5 In our clinic, there were more children with ED visits (58%), but similar hospitalizations (24%), in the year prior to program entry. This may be due to the higher number of African American patients within our system. Some evidence suggests that these patients may have poorer response to asthma controllers and relievers compared with patients of other ethnicities.4-11,13 PADMAP data also showed that African American children with asthma have a higher risk of losing asthma control even after gaining initial disease control. However, there may be other confounding variables to account for this difference—such as household income—that we did not examine in this study. The magnitude of morbidity reduction between PADMAP and our system was, however, similar (68% and 91% reductions in ED visits and hospitalizations, respectively, after program entry compared with the year before).

Traditional asthma metrics emphasize reductions in asthma-related urgent care visits and hospitalizations.1,2 Many patients, however, experience considerable asthma-related impairment from symptoms without requiring urgent care visits or hospitalizations. These impairments include school and work absences, decreased exercise and activity, and reduced quality of life.14,15 Therefore, a paramount objective of asthma management is to gain asthma control in an expeditious manner. Breathmobile/PADMAP was the first asthma disease management system to demonstrate that regardless of initial asthma severity, up to 70% of children with asthma could achieve asthma control after 3 visits if they remained engaged in the program and were treated in accordance with NHLBI ERP-2 and ERP-3 asthma guidelines.4

In our clinic, 70% to 80% of patients achieved asthma control as defined by NHLBI ERP-2 and ERP-3 asthma guidelines after 3 clinic visits. Significantly more patients with an initial diagnosis of mild persistent asthma achieved asthma control compared with those initially diagnosed with moderate or severe persistent asthma by visit 3. However, by visit 6, the probability of asthma control was similar across the 3 groups. Results from Breathmobile/PADMAP and our study highlight the necessity of scheduling regular visits in order to successfully control asthma.

The PADMAP/Breathmobile program is perhaps the most effective ongoing asthma-specific disease-management system in the United States. We chose to extend the services of this successful program to an area where patient demographics were similar. Each Breathmobile is staffed by an asthma specialist provider, 1 RN, 1 respiratory therapist, and a patient financial worker. Since the Breathmobile program’s operational history spanned the publication of 2 editions of national asthma guidelines, care was delivered in accordance with NHLBI ERP-2 and ERP-3 asthma guidelines (dependent on time period).4-10,15-17 We recreated this system within an existing multi-specialty clinic that serves the same inner city children and uses the same diagnosis and treatment guidelines delivered by an asthma specialist. However, due to the smaller size of this clinic, there were not sufficient resources to provide adequate staff for optimal asthma care, and our clinic relied on nurses who also staffed other pediatric subspecialties.

Using existing resources in an established pediatric clinic eliminates the need to raise the large amount of funding necessary to purchase and equip a mobile clinic, which is estimated to be up to $80,000.  A Breathmobile unit may cost up to $241,950 per year to operate for the first 7 years if patients are treated 5 days per week, excluding the salary of the asthma specialist. This translates to $465 per half-day session.5 In our private practice clinic, the total cost—including overhead and excluding compensation for allergy specialists—was $192 per half day. The operating cost for our system was similar to that of the Breathmobile program. Both systems used allergy specialists and nurse practitioners as providers, and outcomes were similar between PADMAP5 and our clinic (data not shown). As patients in this study were all Medi-Cal–enrolled, we postulate that this successful system can be generalized and adapted to other Medicaid populations in the United States.

In a recent study, the ROI for 4 Breathmobiles in southern California in 2010 was $6.73 saved for each $1 invested.10 Calculations were based on savings resulting from fewer ED visits/hospitalizations, reduced school absenteeism, and quality-adjusted life-years saved. Breathmobiles operated an average of 3.7 days per week, treating almost 600 unique patients per unit to achieve these benchmark outcomes. In our study, we were not able to perform such an extensive cost analysis because we only had data on actual cost to deliver care at 1 of the clinical sites, the MFI clinic, and not the HUMC clinic. However, based upon 2015 reimbursement rates for California Medi-Cal, there was a significant ROI in the context of reduced ED visits and hospitalizations (Table 3).

In this study, the cost of care for patients with asthma for a period of 1 year included reimbursements for allergy testing using skin and in vitro allergy testing (Table 2). Both modalities have similar sensitivity and specificity.2 The cost per patient tested with skin testing was slightly lower than similar ones using in vitro tests. Medi-Cal reimbursement rates for allergy skin testing were lower compared with payments for in vitro allergy tests.18 It must be noted, however, that reimbursement rates for both skin prick tests and in vitro allergy tests can vary significantly, depending on the payer. In states such as New Jersey and Illinois, Medicaid payments for skin prick tests and in vitro allergy tests are reimbursed at similar rates.19,20 In other states, such as North Dakota, and Montana, Medicaid payments for skin prick testing ($9.28 and $6.50, respectively) are reimbursed at higher rates compared with in vitro allergy testing ($6.53 and $3.94, respectively).21,22 In systems operating with capitated laboratory services arrangements, in vitro allergy testing is customarily included in the per-patient per-month fee, making use of these tests more cost-effective than skin testing, which may require additional payments.

Finally, due to shortage of asthma specialists to perform skin testing, use of in vitro allergy tests may be necessary in population-level primary care-focused asthma disease management strategies. These limitations are particularly applicable to Medicaid beneficiaries and underserved communities.

The Breathmobile/PADMAP system provides excellent disease management and significant ROI. However, it must operate on a large scale with a full-time dedicated staff to achieve these goals. Smaller health systems lacking large numbers of patients could not afford such large-scale programs. Utilizing existing staff, our system achieved similar health outcomes at current reimbursement levels with the flexibility of being deployed on a smaller scale of 1 half day per week.

The Breathmobile is a mobile specialty clinic in which routine care is brought to neighborhood schools during school hours, making it more convenient for patients to keep their appointments. As appointment adherence is associated with greater asthma control, it follows that the mobile units will have better outcomes compared with a fixed clinic in which patients must be excused from school for the appointment. The results of this study, however, showed that a fixed clinic achieved similar asthma control compared with the more convenient mobile clinic.

NHLBI EPR-3 asthma guidelines recommend allergy testing for inhalant allergens in patients with persistent asthma as a basis for allergen identification and avoidance education.1,2 Breathmobile/PADMAP predominantly utilized skin testing; however, our clinic used both skin testing and in vitro-specific IgE testing.23 There was no difference in the ability to control asthma among patients who received skin testing versus those who had in vitro testing. The flexibility of using a diagnostic test not restricted to allergy specialists aided in delivering patient-specific allergen control measures as indicated by the NHLBI EPR-3 asthma guidelines.24

Limitations

 
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