Asthma: benchmarking for quality improvement

Benefits of subspecialty adherence after asthma hospitalization and patient perceived barriers to care

BACKGROUND

Comparative studies have demonstrated that asthma education to pediatric patients decreases average hospital usage and that allergy specialists provide stronger asthma education and more improved outcomes.

OBJECTIVE

To evaluate the real-world benefits of allergy subspecialty involvement outside inpatient consultation and the impediments for patients in establishing allergy subspecialty care.

METHODS

The study population was composed mostly of minority children 0 to 18 years old seen at a large university-affiliated stand-alone children's hospital who had a hospital discharge diagnosis of asthma from 2009 to 2013. The retrospective portion of the study compared all variables pertaining to asthma, teaching, and discharge reconciliation for the following subgroups: patients recommended to allergy and immunology (AI) follow-up who adhered to the appointment (adherent), patients recommended to AI follow-up who did not adhere (nonadherent), and patients not recommended to AI follow-up (non-referred). In the phone interview portion of the study, the nonadherent patients were contacted to identify barriers to AI follow-up.

RESULTS

Of the referred sample, the adherent group had significantly fewer visits to the pediatric intensive care unit, days in the pediatric intensive care unit, and days in the hospital. Providing more specific hospital discharge instructions increased AI follow-up and hospital teaching given on the baseline admission decreased hospital visits. Phone interviews showed that nonadherent patients most commonly missed follow-up because the parents believed it unnecessary because their child showed acute improvement or from advice from their primary care physician.

CONCLUSION

These results showed improvement in outcomes for patients who attended AI follow-up and specifically identified key barriers that could be addressed in a standardized form to prevent nonadherence in the future.

A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program

The purpose of this study was to examine the challenges of integrating an asthma disease management (DM) program into a primary care setting from the perspective of primary care practitioners. A second goal was to examine whether barriers differed between urban-based and nonurban-based practices. Using a qualitative design, data were gathered using focus groups in primary care pediatric practices. A purposeful sample included an equal number of urban and nonurban practices. Participants represented all levels in the practice setting. Important themes that emerged from the data were coded and categorized. A total of 151 individuals, including physicians, advanced practice clinicians, registered nurses, other medical staff, and nonmedical staff participated in 16 focus groups that included 8 urban and 8 nonurban practices. Content analyses identified 4 primary factors influencing the implementation of a DM program in a primary care setting. They were related to providers, the organization, patients, and characteristics of the DM program. This study illustrates the complexity of the primary care environment and the challenge of changing practice in these settings. The results of this study identified areas in a primary care setting that influence the adoption of a DM program. These findings can assist in identifying effective strategies to change clinical behavior in primary care practices.

Asthma guideline use by pediatricians in private practices and asthma morbidity

OBJECTIVE

We sought to examine whether pediatric clinicians in private, non-health maintenance organization practices could implement the national asthma guidelines and whether, when implemented, these guidelines would decrease medical services utilization and improve asthma care for children.

METHODS

A trial of a disease management program (Easy Breathing II) involving 20 private pediatric practices in the greater Hartford, Connecticut area was conducted between January 1, 2001, and December 31, 2003. Demographic data on participating practitioners and patients were obtained from questionnaires. Medical services utilization data from claims were obtained from ConnectiCare, a regional managed care organization.

RESULTS

Of the 16750 children enrolled in Easy Breathing II, 2458 were enrolled in ConnectiCare and 490 had asthma. Inhaled corticosteroid use increased in the community overall during the study period. After enrollment in Easy Breathing II, with adjustment for age, gender, ethnicity, asthma severity, season, and calendar year, children with persistent asthma experienced an additional 47% increase in inhaled corticosteroid use, a 56% reduction in outpatient visits, and a 91% decrease in emergency department visits for treatment of asthma. Adherence to national asthma guidelines for prescribing inhaled corticosteroids was 95%. Seventeen of the 20 practices are still using Easy Breathing, 5 years after program implementation.

CONCLUSIONS

Pediatric primary care clinicians in private practice settings can implement an asthma management program patterned after the national asthma guidelines. When implemented, this program is successful in reducing medical services utilization for children with asthma. Just as differences in patterns of medical services utilization exist in private practices, compared with urban clinics, the impact of disease management on medical services utilization differs in private practices, compared with urban clinics.

Randomized controlled trial of emergency department interventions to improve primary care follow-up for patients with acute asthma

OBJECTIVE

Emergency department (ED) visits for asthma are frequent and may indicate increased morbidity and poor primary care access. Our objective was to compare the effect of two interventions on primary care follow-up after ED treatment for asthma exacerbations.

METHODS

We performed a randomized controlled trial of patients 2 to 54 years old who were judged safe for discharge receiving prednisone, and who were available for contact at 2 days and 30 days. Patients were excluded if they were previously enrolled or did not speak English. Patients received usual discharge care (group A); free prednisone, vouchers for transport to and from a primary care visit, and either a telephone reminder to schedule a visit (group B); or a prior scheduled appointment (group C). Follow-up with a primary care provider for asthma within 30 days was the main outcome. Secondary outcomes were recurrent ED visits, subsequent hospitalizations, quality of life, and use of inhaled corticosteroids 1 year later.

RESULTS

Three hundred eighty-four patients were enrolled. Baseline demographics, chronic asthma severity, and access to care were similar across groups. Primary care follow-up was higher in group C (65%) vs group A (42%) or group B (48%) [p = 0.002]. Group C intervention remained significant (odds ratio, 2.8; 95% confidence interval, 1.5 to 5.1) when adjusted for other factors influencing follow-up (prior primary care relationship, insurance status). There were no differences in ED, hospitalizations, quality of life, or inhaled corticosteroid use at 1 year after the index ED visit.

CONCLUSION

An intervention including free medication, transportation vouchers, and appointment assistance significantly increased the likelihood that discharged asthma patients obtained primary care follow-up but did not impact long-term outcomes.

Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

OBJECTIVES

To determine whether an organized, citywide asthma management program delivered by primary care providers (PCPs) increases adherence to the National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines and whether adherence to the guidelines by PCPs decreases medical services utilization in low-income, minority children.

STUDY DESIGN

Analysis of the utilization of medical services for a cohort of 3748 children with asthma who presented for care at one of six primary care urban clinics in Hartford, Connecticut, and who were enrolled in a disease management program (Easy Breathing) between June 1, 1998 and August 31, 2002.

RESULTS

Of the 3748 children with physician-confirmed asthma, 48% had persistent disease. Paid claims for inhaled corticosteroids increased 25% ( P <.0001) after enrollment in Easy Breathing. Provider adherence to the NAEPP guidelines for anti-inflammatory therapy increased from 38% to 96%. Easy Breathing children with asthma experienced a 35% decrease in overall hospitalization rates ( P <.006), a 27% decrease in asthma emergency department (ED) visits ( P <.01), and a 19% decrease in outpatient visits ( P <.0001).

CONCLUSIONS

An organized, disease management program increased adherence to the NAEPP guidelines for anti-inflammatory use by PCPs in urban clinics. Adherence to this element of the guidelines by PCPs reduced hospitalizations, ED visits, and outpatient visits for children with asthma.

Inhaled corticosteroids and allergy specialty care reduce emergency hospital use for asthma

BACKGROUND

The interrelationships between optimal inhaled corticosteroid (IC) therapy, allergy specialist care, and reduced emergency hospital care for asthma have not been well defined.

OBJECTIVE

We sought to evaluate the independent effectiveness of various levels of IC dispensing and allergy specialist care in reducing subsequent emergency asthma hospital use.

METHODS

Asthmatic patients (n = 9608) aged 3 to 64 years were identified from an electronic database of a large health maintenance organization. The outcome was any year 2000 asthma hospitalization or emergency department visit. The main predictors were at least one allergy department visit and the number of IC canisters dispensed in 1999. Analyses were adjusted for age, sex, insurance type, and asthma severity (1999 emergency asthma hospital use, beta-agonist use, and oral corticosteroid use).

RESULTS

Dispensing of 7 or more canisters of ICs (odds ratio [OR], 0.64; 95% CI, 0.43-0.94) and allergy care (OR, 0.73; 95% CI, 0.55-0.97) were associated with reduced subsequent emergency asthma hospital use. More patients with allergy specialist care than those without such care received 7 or more dispensations of ICs (24.7% vs 8.3%, P <.001). When 7 or more dispensations of ICs and allergy specialist care were simultaneously included in an adjusted model, both ICs (OR, 0.68; 95% CI, 0.46-1.00) and allergy care (OR, 0.77; 95% CI, 0.58-1.02) were independently associated with a lower risk of year 2000 emergency asthma hospital care, although significance was borderline.

CONCLUSION

Allergy care reduces emergency hospital use for asthma by increasing use of ICs but probably also has an independent effect.

Current issues with influenza vaccination in egg allergy

Influenza infection, with its accompanying morbidity and mortality, represents a major public health concern yearly to the elderly and high-risk groups, including asthmatic patients. Active prevention with vaccination consistently falls short of reaching optimal immunization rates in all risk groups. Asthmatic patients and others with concomitant egg allergy might be denied active immunization because of the risk of inducing adverse reactions with a vaccine derived from egg embryo tissue. Evidence supports the relatively safe administration of influenza vaccine to individuals with egg allergy in whom vaccination is indicated when specific protocols are followed under the supervision of experienced physicians. A practical protocol that includes incremental dosing of influenza vaccine is presented to guide clinicians in influenza vaccination in this high-risk group.

The burden of asthma in the United States: level and distribution are dependent on interpretation of the national asthma education and prevention program guidelines

Asthma imposes a growing burden on society in terms of morbidity, quality of life, and healthcare costs. Although federally sponsored national surveys provide estimates of asthma prevalence, these surveys are not designed to characterize the burden of asthma by self-reported disease activity. We sought to characterize asthma burden in the United States. This study was based on a cross-sectional random-digit-dial household telephone survey designed to identify adult patients and parents of children with current asthma. Global asthma burden was comprised of three components: short-term symptom burden (4-week recall), long-term symptom burden (past year), and functional impact (activity limitation). Using this construct, only 10.7% of individuals were classified as having a global asthma burden consistent with mild intermittent disease, and 77.3% had moderate to severe persistent disease. These results suggest that a majority of the United States population with asthma experiences persistent rather than intermittent asthma burden. In addition, the discordance in type and distribution of asthma symptoms reported by individual subjects suggests that the exact estimate of the burden of asthma is related to how the National Asthma Education and Prevention Program classification is operationalized. Inquiry into recent day or nighttime symptoms alone underestimates the burden of asthma and may lead to inadequate treatment of asthma based on national guideline recommendations.

A preliminary retrospective treatment and pharmacoeconomic analysis of asthma care provided by allergists, immunologists, and primary care physicians in a teaching hospital

Allergy immunology specialists (AIs) differ from primary care physicians (PCP) in their treatment of asthma. A limited retrospective chart review of several visits over a 1-year period in 1997 evaluating the quality of asthma care by AIs vs. PCPs was conducted in an academic center. Data concerning quality, effectiveness and cost of asthma care was randomly collected from 15 AIs and 15 PCPs from charts at 3-month intervals over a 1-year period. Information obtained from data collection forms revealed that asthma patients evaluated by AIs had more visits and received a greater quantity of medication compared to those treated by PCPs. All 15 patients with persistent asthma followed by AIs were treated with inhaled corticosteroids at each visit in contrast to only 80% of those treated by PCPs. The total numbers of controller medications (i.e., inhaled corticosteroids, salmeterol, cromolyn, and theophylline) that were utilized, as recommended, by the National Asthma Expert Panel (NAEP) of the National Heart, Lung, and Blood Institute (NHLBI) guidelines were 70 by AIs vs. 24 by PCPs over three visits. Cromolyn was prescribed five times over three visits by AIs and not at all by PCPs. Recognition and treatment of coexisting allergic rhinitis was evident in only 13% of patients treated by PCPs as compared to 80% in those treated by AIS. (p < 0.0001). However, all patients treated by AIs were skin tested to explore the presence of allergic triggers, while no patients treated by PCPs were evaluated for IgE-mediated reactions. Treatment cost for allergic rhinitis was therefore higher, at $2039, for AIs as compared to $741 for PCPs. There were no peakflow values in charts obtained from PCPs. However, all charts from AIs had peakflow values, which improved during the course of therapy in 33% of patients. Total medication costs for asthma were higher for AIs @ $5,646.30 vs. $1,932.25 for PCPs. Total medication costs for allergic rhinitis plus asthma were higher for AIs @ $7615 vs. $2681 for PCPs. However, patients treated by AIs had more severe asthma and required more frequent visits. Ipratropium bromide was prescribed a total of four times over several visits by PCPs vs. only once by AIs. In comparing asthma care between AI specialists and PCPs, it was found that AI specialists treat more severe asthmatics, provide more frequent follow-up visits, utilize peak flow rates, prescribe more controller medications, and more often recognize and treat comorbid conditions such as allergic rhinitis that impact on asthma care. Thus, although treatment costs for AIs are higher, these costs are justified by a quality of care that is more consistent with national (NHLBI) guidelines.

Role of the specialist in the treatment of asthma

The preponderance of literature supports the efficacy of specialist care for asthma. Not every patient with asthma needs to be treated by a specialist, however. An optimal health care delivery model for asthma (i.e. one that provides high quality care that is cost effective) requires some mix of primary and specialty services. A tiered model of care in which the primary care physician acts as the first point of contact and decision-maker with regard to referral and that includes asthma specialists, including allergists, pulmonologists, and other health care professionals with expertise in asthma, appears to be a reasonable solution. The number of studies that compare various models for organizing asthma care is limited, however. Thus, further research is needed to determine how best to align the roles of primary care physicians, allied health professionals, and subspecialists in order to ensure seamless communication and cost-effective care that is targeted to individual patient needs.

Stratifying asthma populations by medication use: how you count counts

BACKGROUND

Asthma disease management programs typically use pharmacy data to identify high-risk individuals for outreach. Provider-directed pharmacy profiling seeks to identify physicians whose prescribing of recommended asthma medication is suboptimal. Both strategies require an accurate approach to counting prescribed asthma medication.

OBJECTIVE

We compare two methods for counting the use of bronchodilators and inhaled anti-inflammatory medication. One approach uses simple counts of dispensed medication. An alternative, canister-equivalent method standardizes these medications on the basis of variation in both potency and medication-days supplied per prescription. We evaluate whether these alternative methods yield different population risk profiles when applied to managed care enrollees who have asthma and to the physicians treating them.

METHODS

Retrospective cohort study of patterns of medication use by asthmatic patients receiving care within a group-model health maintenance organization and prescribing of asthma medications by the physicians treating them.

RESULTS

Each method yields a different risk profile of the patient and physician populations, respectively. Relative to simple counts, the canister-equivalent method results in a 40% increase in the population identified as having high bronchodilator use and chronic anti-inflammatory medication use. On the physician-level, the mean anti-inflammatory:bronchodilator ratio (AIF:BD) was 1.50 by the canister-equivalent method compared with 1.08 by the simple-count method. When stratified by each method, 36% of physicians were assigned to different quartiles of anti-inflammatory:bronchodilator ratio.

CONCLUSIONS

A novel canister-equivalent method for counting dispensed asthma medications yields different risk profiles compared with simple counts of asthma medications. Asthma disease management programs should consider alternative approaches to improve the accuracy of risk profiling based on patterns of medication use.

Asthma pharmacotherapy and utilization by children in 3 managed care organizations. The Pediatric Asthma Care Patient Outcomes Research Team

BACKGROUND

Asthma is the most common chronic disease among children and the most frequent cause of hospitalization. Appropriate pharmacotherapy is a cornerstone of published national guidelines for the care of children with asthma.

OBJECTIVE

The goal was to compare the baseline pharmacotherapy and health care utilization from 1996 to 1997 in children with asthma at managed care organizations (MCOs).

METHODS

A common protocol was used to extract the study sample from 3 MCOs with automated claims and pharmacy databases. Children were selected if they were 3 to 15 years old as of June 1997 with 1 or more encounters (outpatient, emergency department visit, hospitalization) with an asthma diagnosis in the previous year.

RESULTS

Of the 13,352 children studied, less than 40% were given controllers during the 12-month interval, with ranges of 15% to 77% by level of bronchodilator use, 31% to 44% by age, and 38% to 42% by MCO. Among children given 6 or more bronchodilators, controller dispensing ranged from 73% to 89% among the 3 MCOs. Variability was most evident for inhaled corticosteroids, for which dispensing ranged from 51% to 70%. Rates of asthma hospitalization and emergency department visits also differed among the MCOs, ranging from 21 to 37 per 1000 person-years and 37 to 142 per 1000 person-years, respectively.

CONCLUSION

Five years after dissemination of national guidelines for care, the pattern of asthma therapy does not reflect guideline recommendations. Variation among health care organizations with respect to asthma therapy and utilization of health services exists. In addition, controller medications may not be used by all children who could benefit from them.

Effect of allergist intervention on patient-centered and societal outcomes: allergists as leaders, innovators, and educators

Atopic disorders, which afflict millions of Americans and hundreds of millions worldwide, are at epidemic levels with concomitant increases in morbidity and mortality. Environmental and lifestyle changes over the past three to five decades are proposed causes for this pandemic and as such present major burdens to reverse. The scope of allergy practice bridges directly on this challenge. Allergy as a specialty is a major leader in developing effective strategies to confront this epidemic. Allergists have made major contributions to the understanding of the risk factors, immunology, pathophysiology, immunomodulation, and prevention of atopic and immunologic disorders. Allergist epidemiologists and clinicians have helped develop and implement national and international guidelines in the recognition, management, and prevention of asthma and rhinitis. Allergist clinical researchers are active in (1) outcomes research that demonstrates convincingly the value of allergy as a specialty in asthma, allergic rhinitis, anaphylaxis, drug and food allergy, and other atopic disorders, (2) National Institutes of Health clinical trials that will form the basis for the future treatment of asthma and allergic disease, and (3) pharmaceutical trials that evaluate new, effective, and safe medication to treat atopic disease. Allergist educators, comprising academic and practicing allergists, supported by allied health professionals, national associations, and affiliated lay organizations, provide comprehensive education to fellows, residents, colleague physicians, media, the public, and patients. Documentation of the value of allergists in improving patient-centered and societal outcomes in their core domain, allergy, is the appropriate final topic contribution in the important series "New millennium: The conquest of allergy."

Cost implications for the use of inhaled anti-inflammatory medications in the treatment of asthma

OBJECTIVE

To compare the expected costs of treating patients with asthma with versus without inhaled anti-inflammatory medications, adjusting for other factors that also influence medical care expenditures.

DESIGN

Nonlinear exponential regression analyses were used to estimate relationships between medical care expenditures and treatment with inhaled corticosteroids, sodium cromoglycate (cromolyn) or nedocromil. The regressions adjusted for differences in patients' demographics, location, plan type and severity of illness.

SETTING

Large, self-insured, corporate-sponsored medical plans represented in MarketScan database.

PATIENTS AND PARTICIPANTS

7466 continuously enrolled patients with asthma.

INTERVENTIONS

Treatment with inhaled corticosteroids, sodium cromoglycate or nedocromil.

MAIN OUTCOME MEASURES

(i) Total inpatient, outpatient and pharmaceutical expenditures; and (ii) asthma-related expenditures in the 1996 calendar year.

RESULTS

If all patients had been treated with inhaled anti-inflammatory drugs, total expenditures would be expected to be about $US944.82 per patient lower, on average, than would be the case if no patients received these drugs. Asthma-related expenditures would be about $US498.74 per patient higher, on average, if all patients were treated with these drugs.

CONCLUSIONS

Using inhaled anti-inflammatory agents would be associated with higher asthma-related expenditures but lower total expenditures. Treatment with inhaled anti-inflammatory drugs may represent an investment in better care that pays off with better health and lower total medical care expenditures.

Asthma care practices, perceptions, and beliefs of Chicago-area asthma specialists. Chicago Asthma Surveillance Initiative Project Team

INTRODUCTION

Few studies have closely explored how well physicians who consider themselves specialists in asthma adhere to national guideline recommendations for the diagnosis and treatment of asthma. The purpose of this study is to characterize current knowledge, attitudes, beliefs, and self-reported treatment practices of the asthma specialists working in one large metropolitan area.

METHODS

In 1997, a cross-sectional survey was mailed to asthma specialists (allergists or pulmonologists) engaged in direct patient care with a practice location in the Chicago area (Cook County or one of the five surrounding counties). An approximately 50% random sample of asthma specialists was surveyed. The survey included items on (1) asthma diagnosis; (2) clinical monitoring of asthma patients; (3) pharmacologic and nonpharmacologic asthma treatment; (4) opinions and beliefs about asthma treatment options and reasons for referrals; (5) involvement in continuing medical education; (6) experiences with managed care; (7) use of asthma practice guidelines; (8) demographic information about the respondents; and (9) characteristics of the practice settings.

RESULTS

A total of 113 eligible surveys were returned (response rate, 72.0%). Ninety-nine percent of the respondents indicated they would prescribe inhaled corticosteroids for patients > or = 5 years old with moderate persistent asthma, and 85.5% would prescribe them for patients < 5 years old. The respondents reported that 71.2% of their patients with moderate or severe persistent asthma were routinely given written treatment plans. The use of these plans was reported more frequently by allergists than pulmonologists (77.6% vs 58.9%, p = 0.01). Nearly half of the respondents were involved in the development of hospital-based asthma programs; fewer (14.9%) were involved in developing asthma programs for managed care organizations. A majority (63.4%) of the physicians had given a formal professional education presentation on asthma in the past year. A majority of the respondents who care for patients under managed care contracts reported that these patients have encountered barriers to access in seeking specialty care.

CONCLUSION

The results suggest that asthma specialists in the Chicago area are providing asthma care that is, in many ways, consistent with national guidelines. However, there are also important differences in care that are not consistent with the guideline recommendations. Perhaps even more notable are differences in reported asthma care between the two subspecialty groups of allergists and pulmonologists. The effect of these differences on the management of persons with asthma is not known. It is hoped that information from this community-based survey will serve to catalyze discussions among Chicago-area asthma specialists as to how they might envision improving care for persons with asthma in their community.

Restructuring asthma care in a hospital setting to improve outcomes

STUDY OBJECTIVES

To restructure asthma care as the pilot program in hospital-wide redesign aimed at providing better and more standardized care. We chose asthma care to begin our reorganization because it is the highest-volume diagnosis at our hospital and it involves a broad spectrum of services.

DESIGN

Key elements of our restructuring included the following: (1) establishing a pulmonary unit with expanded bed capacity from 8 to 22 beds for asthma patients; (2) standardized treatment protocols; (3) availability of direct admission by primary care physicians who maintained management of their patients with the option of consultation with a specialist; and (4) use of case managers who helped patients and their families overcome obstacles to optimum care.

SETTING

A hospital serving a high proportion of Medicaid patients.

PATIENTS/PARTICIPANTS

Children with asthma and their families.

INTERVENTIONS

Standardized care for asthma; use of case managers to facilitate adherence to treatment.

RESULTS

With the restructured asthma care program, parent satisfaction with treatment was sustained; the average length of stay and use of the emergency department (ED) were reduced; observation unit use increased; and there were fewer readmissions to both the inpatient unit and the ED.

CONCLUSIONS

We conclude that an inner-city hospital can provide optimum care for asthma patients by standardizing treatment, aggregating asthma patients in one location, and providing education and follow-up through the use of case managers. The protocol shifts some costs from expensive services such as the pediatric ICU and the ED to less costly case management and outreach personnel. In the long run, this allocation of resources should help to lower costs as well as improve quality of care.

A survey of asthma care in managed care organizations: results from the Chicago Asthma Surveillance Initiative

INTRODUCTION

Managed care, both via staff model health maintenance plans and nonstaff model plans, has become a major source of health-care funding in the United States. However, very little is known about the asthma-specific products and services offered by these plans. The purpose of this study is to examine the asthma-specific products and services offered by managed care within the Chicago area.

METHODS

Between December 1997 and February 1998, a self-administered survey was mailed to the medical directors of the 19 managed care organizations (MCOs) in the Chicago area. The survey covered the following content areas: general characteristics of the MCOs, asthma-related services, monitoring of asthma care, and asthma-related quality improvement efforts. The medical directors were asked to respond separately for staff model capitated plans, nonstaff model capitated plans, and noncapitated plans.

RESULTS

Responses were received from 13 of the 19 eligible Chicago-area MCOs (a response rate of 68.4%). Three of the responding MCOs (23.1%) offered a staff model plan, 11 (84.6%) offered a nonstaff model capitated plan, and 6 offered some type of noncapitated plan. Asthma education programs, although available in all plan types, were offered much less frequently in the nonstaff model capitated and noncapitated plans, 36.4% and 33.3%, respectively. Asthma case management programs were also available in some, but not all of the health plans. Only 54.5% of the nonstaff model capitated health plans promoted the use of asthma practice guidelines. Among the responding MCOs, asthma quality improvement efforts related to National Committee on Quality Assurance accreditation were infrequent in 1995. Sixty-one percent of the MCOs reported that program development for improving asthma care was a very high priority relative to programs for other health conditions.

CONCLUSION

The results of this study suggest that many, but not all, of the basic elements of asthma care services are offered by the MCOs in the Chicago area. Findings from this study also suggest ways in which asthma-related product and service delivery might be changed to improve outcomes for asthma in this community.

An investigation of the medical care utilization of children with severe asthma according to their type of insurance

A comparison of the medical care utilization of children with severe asthma according to insurance type was performed. Subjects were grouped by which type of insurance they had: capitated, fee for service, or Medicaid insurance. Medical records were coded into utilization categories, by presenting complaint, sick- or well-child visit, and if a generalist or specialist provided care during the visit. The Medicaid group had less specialist, sick-child care than the groups with capitated or fee for service insurance. The Medicaid group also had more emergency room visits than the other two groups. The three groups had a similar amount of total physician/clinic visits. Even though similar care was shown to be available for those with Medicaid insurance, this low resource group often uses expensive emergency room care.