As the healthcare industry moves towards an integrated system, data is becoming available to multiple stakeholders, including healthcare professionals, health plans, pharmacies and other healthcare resources. This will bring much-needed transparency and, eventually, could improve outcomes for patients, including those with conditions such as asthma.
Asthma is the most common chronic disease among children and adolescents. According to statistics published in Personalizing Asthma Management for the Clinician, the disease has become more prevalent over the past 20 years surpassing rates of 8 percent of the population, and this trend is projected to continue. Along with that will likely come increases in the number of asthma exacerbations.
As other chronic diseases have seen improvements in patient outcomes through the use of big data, including population health data, so too could asthma. It’s now possible to use these data to identify patients most likely to benefit from enhanced asthma care and allergy evaluation.
According to a report that appeared in Allergy, the European Journal of Allergy and Clinical Immunology, while allergy trigger testing for high-risk asthma patients requires resources, the cumulative cost of poorly controlled asthma (ED visits, hospital visits, extended stays, etc.) can well exceed the cost of taking this proactive approach. Controlling a patient’s asthma symptoms based on assessment, diagnostic testing and a tailored care plan that follows is likely less costly in the end.
Delivering excellence in value-based asthma care is predicated on the concept that we can simultaneously improve quality while containing costs. This presupposes that we’re using patient data to design and deliver more successful approaches to care, the results of which can then be measured and replicated.
Opportunities for Improving Population Health
Certain patients will be more likely to benefit from certain treatments, and data is already helping stratify populations. The more data we produce—and share—across payers and systems, the better able we are to predict outcomes and prescribe care plans that ultimately reduce the systemwide costs of managing asthma. Allergy evaluations are a key part of this process.
Using billing and ICD-10 codes, including prescription data, we can identify those with asthma and flag certain high-risk patients, according to asthma guidelines. This would enable providers and plans to focus finite resources on patients who have not had allergy evaluations, rather than intervening with all asthma suffers. This prioritization saves valuable time and resources.
Innovative healthcare organizations are also taking a proactive stance on asthma assessment, embedding tools such as the Asthma Action Plan, according to the American Lung Association; and the Asthma APGAR tool, according to a study that appeared in Annals of Family Medicine, into their electronic health records (EHRs) to make asthma care more efficient and effective. Having these tools easily accessible during an asthma visit—or visits for other health problems—ensures that asthma care isn’t an afterthought in the discussion of a patient’s overall diagnosis and care planning.
Developing Quality Metrics
Quality metrics, based on validated measures, are critical for health systems and plans that adopt value-based care models. For asthma care, metrics fall under processes and outcomes. Both sets of metrics are vital and must be shown to be clinically relevant, have evidence of improving outcomes and be easily measured. If collecting the metrics disrupts clinical workflow, it’s likely the quality program will be unsustainable.
Currently, the only quality metrics related specifically to asthma are the Healthcare Effectiveness Data and Information Set (HEDIS) measures focused on medication use, according to the National Committee for Quality Assurance. Although measures of medication use are important, other measures in asthma care are critical too, such as testing and management of high-risk asthmatics. This is a good example of a process metric that can be derived from claims data and correlated with outcomes. Aeroallergen assessment through diagnostic testing in high-risk patients should be considered for an updated HEDIS measure or other quality metric to help guide this important but often overlooked aspect of asthma management.
Regular clinician and team feedback can change practice behavior, especially when care teams are empowered to deploy a workflow model that incorporates tools and resources to support the team, using allergic sensitization test results to teach patients trigger avoidance. When process metrics, such as appropriate trigger-testing rates, are coupled with improvements in outcomes, such as decreased urgent and emergent asthma interventions, and then aligned with payment methodology for enhanced results, significant quality improvement in practice team care patterns will be sustainable.
Understanding and Addressing Disparities
As with most chronic diseases, insurance coverage for basic components, including allergy testing, is excellent. However, disparity in allergy and asthma care is prevalent in the U.S. According to several research initiatives and published reports conducted by the Centers for Disease Control and Prevention (CDC), the Global Initiative for Asthma (GINA), and others, asthma disproportionately affects children, adult women, the poor, African Americans and Americans of Puerto Rican descent; and we know that environmental and genetic influences can also be contributing factors.
According to a report published in Critical Care Medicine in 2012, given the complexity of disparity sources and the admixture of American society, healthcare professionals profess incomplete confidence in identifying and tackling these important issues with differing populations in clinical care.
Research conducted by Dr. Robin Andrew Evans-Agnew, Ph.D., published in Heath Promotion Practice, describes more than 30 evidence-based causes for disparities in asthma and allergy management. For example, according to data from GINA, urban areas, which often have a predominance of African American patients, are heavily concentrated with asthma risk factors such as air pollution. According to a study published in Academic Pediatrics, African Americans are also less likely to receive National Institutes of Health (NIH) guideline-directed care.
Clinicians can gain considerable disease-management leverage by understanding the determinants of disparity and critically reviewing their own care delivery model. Change starts with clinical recognition that such disparities exist, an obvious fact that is sometimes missed and, according to research published in the Journal of Asthma, when clinicians are trained in cultural competence in addition to asthma care, their confidence in using better counseling and patient-centered approaches are enhanced, compared to standard asthma care training alone.
Data has demonstrated that a care gap exists when it comes to the delivery of non-medication elements of asthma care, as indicated by a clinical assessment published in Mayo Clinic Proceedings. Improved efficiency in allergy testing and management addresses “the gap” intended to improve quality of asthma care, patient satisfaction, value and resource utilization for the entire healthcare system. It’s important for all of us to remember that, at its core, asthma care is about the clinician-patient relationship and personalizing care by not only gathering the relevant data, but also quickly assessing the environmental issues and providing the appropriate counseling. All are critical to improving outcomes.
Barbara P. Yawn, M.D., MSc FAAFP, is a family physician researcher who currently focuses on respiratory diseases, specifically COPD screening/case finding and implementation of new tools to improve asthma outcomes. She is/was a member of the International Primary Care Respiratory Group; EPR-3 science panel, editor in chief of Respiratory Medicine Case Reviews and Chief Science Officer of the COPD Foundation. She is retired form her position as the director of research at the Olmsted Medical Center and is an Adjunct Professor of Family and Community Health at the University of Minnesota. She serves as a consultant to multiple NIH and PCORI founded studies of asthma and COPD. Dr. Yawn was chair of an Allergy and Asthma Task Force convened and supported by Thermo Fisher Scientific.