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(Chest. 1999;116:208S-209S.)
© 1999 American College of Chest Physicians

United HealthCare of Illinois*

Working to Improve Asthma Care

Mitchell J. Trubitt, MD, FCCP

* From United HealthCare of Illinois (Dr. Trubitt), Chicago, IL,

Correspondence to: Mitchell J. Trubitt, MD, FCCP, United HealthCare of Illinois, Box 909714, Chicago, IL 60690-9714


   Introduction
TOP
 Introduction
The Action Plan
 Discussion
 References
 
Asthma has consistently placed among the top five most frequent reasons for hospitalization among the enrollees of United HealthCare of Illinois and is the leading cause of pediatric inpatient admissions. In response to these findings, United HealthCare set about to design and implement an intervention to address the high rates and disproportionate costs of inpatient admissions for asthma. This report provides an overview of the efforts that United HealthCare of Illinois implemented to reduce asthma morbidity. A detailed report of this effort can be found elsewhere.1


   The Action Plan
TOP
 Introduction
 The Action Plan
Discussion
 References
 
A review of medical records consistently revealed insufficient use of preventive or anti-inflammatory therapies, lack of documented patient education, near absent use of peak flowmeters, and lack of pulmonary function testing. The intervention was to be targeted at pediatric patients with moderate-to-severe persistent asthma—frequently an indicator of suboptimal treatment. However, United HealthCare had no reliable source for accurate outpatient data on their capitated populations. As a proxy for asthma severity, United HealthCare chose to target patients with the greatest number of hospitalizations or the highest cost of care for asthma during the year before the start of the intervention.

The investigators leading the intervention noted that the national asthma care guidelines endorsed appropriate referral to specialty care for infants and patients with moderate or severe asthma. In previous studies, specialty care has been linked with reductions in hospitalizations and emergency department visits as well as improved quality of life.2 3 Therefore, improving access to specialty care became the focus of the intervention. Pediatric asthma patients and their caregivers who were enrolled in the intervention were referred to designated specialty asthma centers for assessment, treatment, and education. Their primary care physicians were also afforded an opportunity to consult freely with the designated specialists through the use of a hotline at each asthma center. United HealthCare selected three hospitals to be the sites of the designated asthma centers: Children's Memorial Hospital, Cook County Hospital, and LaRabida Children's Hospital and Research Center. United HealthCare absorbed the costs of all elements of the program.

To implement the pilot program, the investigators at United HealthCare identified 250 members, 2 to 16 years of age, as having the highest costs for asthma care in the previous year. Approximately two thirds of this group belonged to Medicaid; the remaining third belonged to commercial accounts. All had been hospitalized for asthma at least once during 1994 through 1995. These 250 children constituted the pool for enrollment into the study. United HealthCare planned to refer 50 patients to each specialty care center.

Evaluation took the form of organizational outcomes measures, such as total number of inpatient days, inpatient days per 1,000 members per year, and annual cost of care per member, as well as individual outcomes measures, such as number of nights of lost sleep, symptom-free days, and school absences. The outcomes data were drawn from a number of sources, including the following: reports of inpatient admissions and associated costs, reports of durable medical equipment costs, encounter forms designed for use by the asthma care centers, claims data from the asthma care centers, and claim submissions from other medical resources used by study patients. The investigators also measured quality-of-life outcomes.

The United HealthCare investigators encountered a number of difficulties in attempting to implement their asthma intervention. They had difficulty in reaching patients because of unreliable telephone communication and undeliverable correspondence. Membership in the Medicaid group was inconsistent because of involuntary loss of eligibility and the lack of a membership lock-in feature in the Illinois Department of Public Aid program. Also, despite initially agreeing to participate in the intervention, one third of the patients and their caregivers never kept the appointments at the center to which they were assigned. Among those who did attend the asthma centers, patient compliance with follow-up visits was often poor. After failing three consecutive appointments, patients were dropped from the study. The hotlines established for the primary care physicians were also rarely used.

Although participation in the asthma intervention did not meet the initial goals set by United HealthCare, they were able to collect hospital utilization data and cost data that were considered accurate for 88 participants. Completed quality-of-life data were available for 57 participants. The data, summarized in Tables 1 and 2 , indicate a marked reduction in inpatient utilization and cost and a marked improvement in quality-of-life measures.


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  		Table 1. Hospital Utilization and Cost Data (n = 88)

 

   Discussion
TOP
 Introduction
 The Action Plan
 Discussion
References
 
The investigators at United HealthCare learned several lessons in this first attempt at a pediatric asthma care intervention. They realize that they did not necessarily completely capture patients with moderate-to-severe persistent asthma using the proxy of high utilization and cost. However, United HealthCare of Chicago believes the results of this study are encouraging enough to warrant future use of this utilization-based definition of an asthma population at high risk for poor outcomes. Of course there is also concern that the dramatic improvement seen in this pilot study may be, in part, related to the natural history of this disease, rather than to the intervention itself.

In addition to the problems inherent in dealing with the high-risk populations discussed above, the investigators recognize that their intervention presents many practical operational concerns about large-scale feasibility and sustainability. However, a review of other asthma interventions currently available to managed care plans revealed similar difficulties. Therefore, on the basis of this first intervention, United HealthCare has decided to work with the Chicago Asthma Consortium in seeking an effective community-wide solution for the improvement of asthma care.


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  		Table 2. Quality-of-Life Data (Symptom-Free Days, Schools Days Lost, Sleep Loss) (n = 57)*

 

   References
TOP
 Introduction
 The Action Plan
 Discussion
 References
 
  1. Evans III R, Trubitt M, Gaye A, et al. A community partnership for improved quality of care for children with asthma. Am J Managed Care (in press)
  2. Zeiger, RS, Heller, S, Mellon, MH, et al (1991) Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol 87,1160-1168[CrossRef][ISI][Medline]
  3. Mayo, PH, Richman, J, Harris, HW (1990) Results of a program to reduce admissions for adult asthma. Ann Intern Med 112,864-871



This article has been cited by other articles:


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K. B. Weiss and E. N. Grant
The Chicago Asthma Surveillance Initiative: A Community-Based Approach to Understanding Asthma Care
Chest, October 1, 1999; 116(suppl_2): 141S - 145S.
[Abstract] [Full Text] [PDF]

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