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* From Advocate Health Care, Chicago, IL.
Correspondence to: Patti Ludwig-Beymer, PhD, RN, Care Management, Advocate Health Care, 2025 Windsor Dr, Oak Brook, IL 60523
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Introduction |
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Before launching the adult asthma improvement program, Advocate Health Care set about to determine a baseline measure of the problem of asthma within the primary service areas surrounding their eight system hospitals. They decided to examine hospitalization rates for asthma compared with the goal of 160 per 100,000 population set by the "Healthy People 2000" government initiative. Advocate Health Care obtained data from the Illinois Hospital and Health Systems Association for the total number of asthma admissions for members of the communities surrounding each of the system hospitals. They also obtained total population figures using zip codes from the primary service area for each Advocate Health Care hospital. Utilization rates were calculated using hospital admissions for the numerator and total population in the primary service area for the denominator. Although there was tremendous variation among the rates of the eight hospitals, those hospitals located within the city had the highest rates and also tended to have patient populations in which there were lower socioeconomic status, a greater proportion of African Americans, and increased barriers to access to health care.
To identify care provided within the hospitals, Advocate Health Care conducted an analysis of their hospital financial databases using International Classification of Diseases, ninth revision, codes to identify emergency department (ED) visits and hospitalizations for asthma. Table 1 provides a summary of the 1996 data along with the total number of Illinois asthma hospitalizations per primary service area.
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From the findings noted above, Advocate Health Care believed there were opportunities to improve patient care and established the Adult Asthma Clinical Improvement Team. The interdisciplinary team brought together individuals from medicine (including specialists in allergy and immunology, emergency medicine, family practice, internal medicine, and pulmonology) nursing, pharmacy, respiratory care, and administration. Drawing heavily on the national and international asthma guidelines, the team developed goals to improve asthma care in a variety of settings, including the ED, the hospital, and physician offices.
The team developed clinical pathways for inpatient and ED asthma care, an outpatient protocol packet, and a 16-page patient education booklet and wallet card. To date, the clinical pathway protocol has been implemented in six hospitals and EDs, and the outpatient protocol has been implemented in 19 physician offices throughout the Advocate Health Care system. In addition, two hospitals have implemented standing orders for inpatient and ED asthma care. The program has not been as effective at some of the sites because of diminished enthusiasm and lack of physician sponsorship.
In general, physicians appear to be satisfied with the protocol, particularly the patient education materials, asthma classification scale, and asthma flow sheet. However, some physicians have expressed concern about the additional patient time required to effectively implement the protocol. Part of this is a function of the type of practice. Offices in some locations see relatively few patients with asthma, contributing to erosion of skills; smaller offices may lack dedicated resources for patient education. The members of the asthma team recognize that resolving these issues will require a change in the approach to delivering primary care. However, despite their concerns, physician interest in the asthma initiative continues, with several practice sites currently testing the asthma program.
The asthma team decided to track several outcome measures. Patient quality of life is initially measured during an office visit using the Asthma Quality of Life Scale developed by Marks et al,1 2 with follow-up surveys mailed to the patients' homes. The team is also examining the issues surrounding ED revisits within 30 days. Currently, they are focused on identifying patients with frequent revisits to the ED and readmissions to the hospital. They plan to conduct chart audits to identify the underlying factors resulting in readmission. Once the chart audit is complete, the team will focus on developing a strategy for overcoming the identified factors.
Advocate Health Care has entered into partnerships with several pharmaceutical companies to enhance the implementation of their asthma program. The benefits have ranged from receiving an unrestricted educational grant, which covers the costs of outcomes data management and printing of patient education materials, to providing food, peak flowmeters, and placebo inhalers for a "Learn at Lunch" program.
In addition to the Advocate Health Care system work described here, the individual hospitals have addressed asthma issues in a variety of creative ways. For example, Bethany Hospital has implemented an asthma outreach program to area clinics (as described elsewhere in this supplement). Trinity Hospital has created a database of asthma patients that can be accessed from a variety of locations, and South Suburban Hospital implemented a large Open Airways Program to address some of the needs of their pediatric population.
Advocate Health Care recognizes that development and implementation of the Adult Asthma Program has not been easy. However, it has fostered an environment in which physicians and other clinicians can come together, learn from each other, and have the opportunity to implement the best practices at their local sites.
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Footnotes |
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Funded, in part, by an unrestricted educational grant from Glaxo Wellcome, Inc. The items for the "Learn at Lunch" were provided by Rhone-Poulenc Rorer, Inc.
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References |
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