Trends in Asthma Management

Ross M. Miller, MD, MPH

Asthma continues to be an important chronic condition for public and private payers, especially given the fact that it ranks as the top pediatric condition for commercial and managed Medicaid plans.¹ From a clinical perspective, asthma management has evolved considerably in the past 2 decades, leading to better self-management and more appropriate use of medications. Perhaps most notably, improvements in asthma control have resulted in improved outcomes and quality of life for patients and their families. In terms of payer mix, asthma disproportionately affects Medicaid members for 2 reasons. First, asthma is more prevalent among children than among adults, and the managed Medicaid member base skews toward a younger demographic.² Second, asthma disproportionately affects those at the lower socioeconomic end of the spectrum, again representing the group frequently served by Medicaid programs.³ From a payer perspective, hospitalizations are the most important component of healthcare utilization in asthma, followed by emergency department (ED) visits.³ Hospitalizations and ED visits tend to occur more frequently in patients with uncontrolled severe disease who experience frequent exacerbations. Furthermore, these patients are frequently nonadherent to their prescribed chronic therapy. In asthma, pharmacy management focuses on the appropriate use of controller medications to help limit acute exacerbations (ie, asthma attacks), which can be dangerous and even life-threatening to the patient. These efforts are closely aligned with the national quality initiatives led by the National Committee for Quality Assurance (NCQA), the main accrediting body for managed care health plans. NCQA evaluates payer performance on 2 core asthma quality measures: (1) use of appropriate medication for individuals with asthma, and (2) medication management for individuals with asthma.⁴ These measures provide specific criteria that allow payers to identify and to report appropriate medication use in patients diagnosed with persistent asthma. They also provide the tools needed to help payers proactively identify and intervene with members who have an elevated high risk of developing exacerbations as a result of the suboptimal use of asthma control medications. In addition to targeted pharmacy-based programs, payers play an important role in promoting patient self-management and medication adherence through condition-management initiatives. In asthma, these population-based programs are designed to educate members about their disease, promote awareness of exacerbation triggers, and encourage appropriate use of medications.⁵ Asthma management has also been facilitated by the adoption of ED observation units, which allow hospitals to monitor patients for up to 23 hours without inpatient admission. Typically, payers have been supportive of observation units for patients with acute asthma exacerbations under the assumption that close monitoring in the outpatient setting will lead to improved quality of care, less hospitalizations, and perhaps fewer recurrences.⁶ There is evidence to suggest that ED observation units have resulted in improved patient satisfaction and cost-savings; one study found that the cost of monitoring a patient in an observation setting is approximately half of the cost of monitoring the same patient in an inpatient setting.^7,8 Overall, advances in asthma management have been positive for payers as well as for patients. The appropriate prescribing of controller medications have led to substantially improved disease control and reduced daily burden for patients. Furthermore, improved adherence to asthma control medications has been shown to reduce healthcare-related utilization and costs.⁷ Despite improvements in asthma care, however, a number of key unmet needs remain. First, in the clinical practice guidelines promulgated by the National Heart, Lung, and Blood Institute, which have not been revised since 2007 but are due to be updated in 2015, treatment recommendations are based on symptomatology rather than on diagnostic criteria.⁹ This is important because differential diagnoses of respiratory conditions continue to pose a challenge for clinicians, especially when trying to differentiate between asthma, “chronic bronchitis,” and chronic obstructive pulmonary disease in adults. In addition, a substantial number of patients are nonadherent to their controller medications—as prescribed or at all.⁷ This is surprising given the minimal financial barriers to drugs in the category because of generic availability; some payers that have implemented value-based insurance designs charge minimal or zero copays for generic asthma control medications. Ultimately, however, asthma management is predominantly driven by the patient–provider relationship. Nevertheless, health plans seek to identify high-risk patients who take multiple rescue medications without a controller medication, often referring these patients to outreach programs by case management professionals. In addition, payers also engage in population health efforts, which may include the development and dissemination of asthma self-management tools for their members with asthma. They may also work with their network providers to raise awareness about validated patient assessment tools. Similar to other chronic conditions, the future of asthma care will likely bring new opportunities to personalize patient care as more gene-based targeted therapies are developed and commercialized. More efficient, simpler drug delivery systems may also facilitate improved compliance to asthma medications and minimize the burden for patients and their families. To demonstrate value, these technologic and therapeutic enhancements will need to contribute to better cost-effective asthma management and improved patient outcomes.

References

1. Andrews AL, Simpson AN, Basco WT Jr, et al. Asthma medication ratio predicts emergency department visits and hospitalizations in children with asthma. Medicare Medicaid Res Rev. 2013;3:E1-E10.
2. Asthma and Allergy Foundation of America. Asthma facts and figures. www.aafa.org/display.cfm?sub=42&id=8. Accessed November 29, 2014.
3. Centers for Disease Control and Prevention. Asthma facts: CDC’s national asthma control program grantees. July 2013. www.cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf. Accessed November 29, 2014.
4. National Committee for Quality Assurance. Summary table of measures, product lines and changes. www.ncqa.org/Portals/0/HEDISQM/HEDIS2014/List_of_HEDIS_2014_Measures.pdf. Accessed November 29, 2014.
5. Erickson CD, Splett PL, Mullett SS, et al. The healthy learner model for student chronic condition management—part II: the asthma initiative. J Sch Nurs. 2006;22:319-329.
6. Downey C. EDTUs (emergency diagnostic and treatment units): last line of defense against costly inpatient stays. Manag Care. 2001;10:44-46.
7. National Committee for Quality Assurance. Improving quality and patient experience: the state of health care quality 2013. October 2013. www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf. Accessed November 29, 2014.
8. Baugh CW, Venkatesh AK, Hilton JA, et al. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31:2314-2323.
9. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). NIH Publication No. 07-4051. Bethesda, MD: US Department of Health & Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program; 2007.

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