1998 OPEN FORUM Abstracts
Seamless Care: Education to Clinic Visits
Maureen George, MSN, RN, CS Coordinator Comprehensive Asthma Care Program University of Pennsylvania Health System, Philadelphia, PA
Disproportionate increases in morbidity and mortality rates in urban, underserved minority populations require new approaches in the treatment of asthma. Investigators reasoned that if patients had a better understanding of their disease, and had adequate outpatient follow-up, then they may have improved clinical outcomes as compared to control patients managed in a conventional manner. Patients entered into the study had a primary diagnosis of asthma at time of Emergency Department (ED) presentation and were between the ages of 18 and 45. Exclusion criteria included co-morbid disease, inability to speak English, absence of a telephone in the primary residence, pregnancy or admission to an intensive care unit. Seventy-seven patients admitted from the ED were randomized to either the inpatient education program (IEP) or to routine care (control group). IEP patients received asthma education, bedside spirometry, discharge planning services and a post-discharge phone call. The patients enrolled in the IEP had a markedly higher follow-up rate to outpatient appointments and significantly fewer ED visits and hospitalizations for asthma in the six-month period following IEP intervention, as compared with that of control patients. This represented a significant cost savings to the Medicaid managed care organization (MCO).
Asthma critical pathways (ACPs) have been identified as one approach to decrease variation in inpatient care and improve clinical outcomes but to date, usefulness of ACPs have not been demonstrated in an in underserved population. Over a 12-month period, an inpatient ACP that incorporated the components of the inpatient education program demonstrated decreased length of hospital stay with subsequent improvements in outpatient follow-up rates. The tenets of the ACP were then incorporated into an Asthma Referral Center (ARC) for Medicaid MCO patients with an ICD-9 code of asthma and a pattern of frequent ED/hospitalizations. Patients were seen for three visits for evaluation and education, and then were referred back to their primary care physician (PCP) for continuing care. To determine if this approach reduced hospital utilization and health care costs, we retrospectively analyzed claims data for each patient pre- and post-ARC intervention. There was a significant reduction in the number of ED visits and hospital days, as well as a, reduction in asthma-related health care costs by 82% after ARC referral. Interestingly, asthma could only be confirmed in 60% in the referrals, however, health resource use also improved in those patients with a diagnosis other than asthma.
Subsequently, an asthma disease state management (ADSM) initiative, formulated by the Comprehensive Asthma Care Program, was also implemented in the PCP network of the integrated health system. Treatment algorithms, standardized patient educational tools, office spirometry and a visiting asthma nurse manager comprised the ADSM program. Inhaled steroid use increased by 30%, health care utilization decreased, asthma severity level was maintained or improved and there were less reported absences from work or school. Taken together, these data suggest that a Comprehensive Asthma Care Program may improve health care to asthmatics in an integrated health system.
The 44th International Respiratory Congress Abstracts-On-Disk®, November 7 - 10, 1998, Atlanta, Georgia.