National Asthma Education and Prevention Program working group report on the financing of asthma care

Quality of care for childhood asthma: estimating impact and implications

We conducted a review of 164 relevant publications to consolidate the evidence on gaps in the quality of asthma care, the impact of those gaps, and the costs and benefits of closing those gaps. Researchers used a wide variety of definitions for measures of quality asthma care, clinical and utilization end points, and disease severity. Gaps in care were most evident for pharmacologic treatment, particularly the underuse of inhaled corticosteroids, with median usage rates of 40%; however, in studies with large proportions of black subjects, the inhaled corticosteroid usage rate was only 32%, compared with 51% for nonminority populations. Studies on outcomes focused on emergency department visits, hospital admissions, and missed school days. Because only 6 studies included information on the costs of improving asthma care, no consensus estimates of the cost/benefit ratio for better asthma care could be derived. There was insufficient evidence in the literature for assessment of the impact of gaps in care and the costs of closing those gaps. More economic evaluations of the impact of gaps in asthma care and of interventions to improve asthma control are needed. Future research on gaps in asthma care and their impact must use standardized definitions for key variables such as disease severity and care utilization to allow comparisons across studies and building of an evidence base that is convincing for policy makers and purchasers of care.

Educational program for smoke-induced respiratory diseases in Brazilian Amazon: assessing knowledge about asthma

Economic and cultural considerations underlie the forest clearing by burning that occurs in the Brazilian Amazon region. The prevalence of respiratory diseases markedly increases during the annual burning season. As part of a nongovernmental initiative to reduce forest fires, health professionals received updated training about respiratory diseases aggravated by smoke. The aim of the present study was to describe and evaluate this educational program. A total of 1500 health care professionals received theoretical and practical guidance. Some of the involved community health agents (CHA) and nurse technicians completed a questionnaire that assessed knowledge about asthma before and after training. Asthma was recognized as an inflammatory disease by 274 of 743 (36%) CHA and nurse technicians on the initial questionnaire compared with 542 of 684 (80%) on the final questionnaire (p < 0.0001). The concept that asthma and allergic bronchitis are the same disease was initially acknowledged by 250 of 743 (33%) CHA and nurse technicians compared with 671 of 684 (90%) after the training (p < 0.0001). The usefulness of bronchodilators was identified by 442 of 743 (60%) CHA and nurse technicians before the training vs. 497 of 684 (73%) after the training (p < 0.0001). Training significantly influenced knowledge about asthma in the group studied. The impact of this program on health care remains unknown.

Budesonide inhalation suspension reduces the need for emergency intervention in pediatric asthma: a named-patient case series

This report describes 15 children aged 10-35 months frequently hospitalized with uncontrolled asthma who were monitored for a mean of 26.9 months to assess the efficacy of budesonide inhalation suspension (AstraZeneca LP, Wilmington, DE) in reducing emergency interventions. Budesonide inhalation suspension was previously shown to relieve asthma symptoms, improve pulmonary function, and reduce rescue medication use in children as young as 6 months with mild to severe persistent asthma. We now show that > or = 1 year of treatment with budesonide inhalation suspension at doses between 0.25 and 1.5 mg/d decreased the burden of asthma. The mean number of hospitalizations caused by asthma or respiratory illness decreased from 1.8 +/- 1.37 in the period before initiation of treatment with budesonide inhalation suspension to 0.33 +/- 0.62 during treatment. Likewise, the mean number of oral prednisone courses decreased from 8.1 +/- 13.7 to 1.8 +/- 2.1, and the mean number of acute respiratory illnesses requiring additional therapy decreased from 2.7 +/- 2.3 before treatment with budesonide inhalation suspension to 0.87 +/- 0.74 during treatment. Numbers of emergency department visits decreased or remained the same after initiation of budesonide inhalation suspension treatment in all but two children. There was no effect on growth rate in this group of children with moderate to severe asthma. In this case series, budesonide inhalation suspension represents a safe, effective treatment option to prevent recurrent emergency intervention for patients < 3 years of age with poorly controlled asthma.

Insurance and quality of care for adults with acute asthma

OBJECTIVE

The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma.

DESIGN

Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured.

SETTING AND PARTICIPANTS

Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma.

RESULTS

Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied.

CONCLUSIONS

Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance.

Improving childhood asthma outcomes in the United States: a blueprint for policy action

BACKGROUND/OBJECTIVE

Asthma is increasingly being recognized as an important public health concern for children in the United States. Effective management of childhood asthma may require not only improving guideline-based therapeutic interventions, but also addressing social and physical environmental risk factors. The objective of this project was to create a blueprint for improvement of national policy in this area.

DESIGN/METHODS

A nominal group process with nationally recognized experts and leaders (referred to as "the committee") in childhood asthma.

RESULTS

The committee identified 11 policy recommendations (numbered in order below) in 2 broad categories: Improving Health Care Delivery and Financing, and Strengthening the Public Health Infrastructure. Recommendations regarding Improving Health Care Delivery and Financing include the development and implementation of quality-of-care standards in 1) primary care, 2) self-management education, and 3) case-management interventions, and the expansion of insurance coverage and benefit design by 4) extending continuous health insurance coverage for all children, 5) developing model insurance benefits packages for essential childhood asthma services, and 6) educating health care purchasers in how to use them. Recommendations for Strengthening the Public Health Infrastructure include public funding of asthma services that fall outside the insurance system through establishing 7) public health grants to foster asthma-friendly communities and 8) school-based asthma initiatives. 9) Launching a national asthma public education campaign, 10) developing a national asthma surveillance system, and 11) establishing a national agenda for asthma prevention research, with an emphasis on epidemiologic and behavioral sciences, are also recommended.

CONCLUSIONS

Implementing these recommendations will require coordination of activities at the national, state, and local community level, and within and outside the health care delivery system. With a further commitment of national and local resources, implementation of these recommendations will likely lead to improved child and family asthma outcomes in the United States. childhood asthma, health care policy, health care services.

Asthma management: curtailing costs and improving patient outcomes

As our understanding of asthma has evolved, so have pharmaceutical strategies for managing this disorder. Once considered a disorder of airway smooth muscle, asthma now is regarded primarily as a chronic inflammatory disorder of the airways. Traditional therapy sought to suppress bronchoconstriction and other signs and symptoms of asthma when they occurred, but contemporary strategies center on managing the underlying inflammation through long-term medications intended to reduce the overall risk of acute attacks. Direct and indirect costs of illness for asthma were estimated at $6.2 billion in 1990. Undoubtedly the costs are considerably higher today due to the increasing prevalence of the disorder. The costs associated with the illness are not distributed evenly among the 15 million Americans with asthma. About 20% of the patients account for 80% of the expenditures. By identifying the high-cost patients and educating them regarding the proper use of medication, it may be possible to curtail costs associated with asthma. Healthcare professionals, especially in their role as educators, are critical to reducing morbidity, mortality, and costs associated with asthma patients.

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.