Asthma Disease Management Demonstration Project:

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1 Asthma Disease Management Demonstration Project: Using EMS Health Coaches May Decrease Emergency Department Revisits, Length of Hospital Admissions and Costs Michael T. Hilton, MD Jan 13, 2012 NAEMSP Annual Meeting Disclosures Employer: UPMC Graduate Medical Education Grants for this study: None Grants provided to CTSI: CTSI contribution was made possible by Grant Number 2UL1 RR from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH. Acknowledgements Kelly Close, MD, MPH Christian Martin-Gill, MD, MPH Jonathan Lever, MPH, NREMT-P Dan Swayze, DrPH, MBA, MEMS Melissa Saul and Dennis WIckline of the Clinical and Translational Science Insitute (CTSI) of the University of Pittsburgh 1

2 Approximately million adults in the United States have asthma million people yearly having an acute exacerbation. 2 Annually, asthma accounts for 1.7 million emergency department visits, 456,000 hospitalizations, and 4,000 deaths. Introduction Asthma is primarily patient-controlled Introduction Asthma is primarily patient-controlled - Interpretation of physiological testing peak-flow meter 2

3 Introduction Asthma is primarily patient-controlled - Interpretation of physiological testing - Recognition of disease state early exacerbation Introduction Asthma is primarily patient-controlled - Interpretation of physiological testing - Recognition of disease state - Titration of short term rescue medications -- albuterol Introduction Asthma is primarily patient-controlled - Interpretation of physiological testing - Recognition of disease state - Titration of short term rescue medications Asthma is ideal for patient-focused education intervention 3

4 Asthma Education programs Computer-based self-education programs 4,5 Asthma Education programs Computer-based self-education programs 4,5 Self-education brochures 6 Asthma Education programs Computer-based self-education programs 4,5 Self-education brochures 6 Small groups 7,8 4

5 Asthma Education programs Computer-based self-education programs 4,5 Self-education brochures 6 Small groups 7,8 In-home asthma disease management programs 9-2 Asthma Education programs Computer-based self-education programs 4,5 Self-education brochures 6 Small groups 7,8 In-home asthma disease management programs 9-2 Variable effectiveness Asthma Education programs Computer-based self-education programs 4,5 Self-education brochures 6 Small groups 7,8 In-home asthma disease management programs 9-2 Some have been shown to be cost-effective, others are not cost-effective 5

6 Asthma Education programs Computer-based self-education programs 4,5 Self-education brochures 6 Small groups 7,8 In-home asthma disease management programs 9-2 None of them have been performed by emergency medical service (EMS) providers EMS Providers EMS providers are an under-utilized community-based healthcare workforce EMS providers are accustomed to house calls EMS providers are well-distributed EMS providers are cheap - salaries range from 1/2 to 1/3 those of nurses (median hourly wage $12.54 vs. $26.28) 30 Overhead expenses already covered EMS Providers EMS providers are an under-utilized community-based healthcare workforce EMS providers are increasingly being considered to provide health promotion and disease management programs 31 6

7 Non-traditional EMS roles Promote injury prevention through homebased infant and child safety evaluations, 32 Screen older community members who may be at risk for falls Screen adults in need of vaccinations 32,34 Administer vaccinations 35 Non-traditional EMS roles Promote injury prevention through homebased infant and child safety evaluations, 32 Screen older community members who may be at risk for falls Screen adults in need of vaccinations 32,34 Administer vaccinations 35 However, there is no literature on the use of EMS providers as health coaches for asthma disease management In summary Asthma is ideal for patient-focused education intervention 7

8 In summary No asthma education intervention has been performed by emergency medical service (EMS) providers In summary EMS providers are increasingly being considered to provide health promotion and disease management programs In summary There is no literature on the use of EMS providers as health coaches for asthma disease management 8

9 Purpose and Hypothesis To determine the feasibility and potential impact of using EMS providers as health coaches for patients with asthma We hypothesized that this EMS provider-led intervention would decrease ED visits, hospital admissions, hospital length of stay (LOS), and hospital-related costs Program Description Created by Emed Health in 2005 Based on best practice guidelines Voluntary recruitment of EMS providers who were trained in: - peak-flow meter use - environmental trigger assessment - asthma action plan coordination with the patient s primary care physician - asthma medication instruction - smoking cessation and prescription medication assistance. Program Description Based in Braddock - 35% live below the poverty level - 69% are under-represented minorities 40 Patients were voluntarily recruited after identification via an electronic medical record review after discharge years - Asthma was one of the first three discharge diagnoses - ED visit or admission from July 1, 2005 to April 1, Uninsured or on Medicaid 9

10 Program Description Visit 1 Visit 2 Asthma Management Initial Questionnaire Peak flow meter Asthma Attack Booklet Review peak flow readings Asthma Action Plan Asthma Home Environment Evaluation Trigger Survey Visit 3 Visit 4 Review environmental trigger mitigation strategies Asthma Action Plan Asthma Management Final Questionnaire Smoking cessation program referral Prescription for Prednisone if needed $50 gift certificate Methods Approved by the University of Pittsburgh IRB Retrospective, case-controlled study The study subjects were all patients who completed the intervention by taking part in all four home visits. Matched control cases were initially identified by: - having one ED visit or hospitalization for asthma between July 1, 2005 to April 1, uninsured or Medicaid insurance status - final hospital disposition of being discharged to home Methods Controls were then matched to the intervention participants based on the following criteria in order of priority: - age (within 5 years) - sex, race/ethnicity - marital status, - severity of illness (asthma) using a modified Charlson score. 41,42 10

11 Methods Intervention period - from the first home visit - to the date when all four home visits were completed. Outcome data - collected for any visit to a UPMC hospital for which asthma was one of the top three diagnoses Methods Data was collected - for the six months before the intervention period - for the six months after the the intervention period The data collected included - # of ED visits - # of inpatient admissions - hospital length of stay (LOS) - associated costs Data Analysis A cost analysis compared hospital visits during the time periods - excluded one participant outlier and his control due to the performance of major procedures unrelated to asthma (including pacemaker insertion) during one hospitalization. All data were analyzed by descriptive statistics 11

12 Results 44 people initially screened 24 enrolled in home visits 2 dropped-out and 1 died - one due to lack of interest - one due to having a premature baby - one participant died at seven months of unrelated causes. 21 participants (87.5%) completed the program Results - Demographic characteristics of participants and matched controls Intervention Group Control Group (N=21) (N=21) Age (years, mean) 44.4 ± ± 13.8 Gender (female) 17 (0.81) 17 (0.81) Race -black 12 (0.57) 9 (0.43) -white 9 (0.43) 10 (0.48) -other 0 2 (0.10) Marital Status - single 16 (0.76) 15 (0.71) - married 4 (0.19) 5 (0.24) - unknown 1 (0.05) 1 (0.05) Charleson Score 1.3 ± 0.78, ± 0.78, 1-4 (mean, range Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % 12

13 Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % 13

14 Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % Results Before After Change % Change Emergency Department Visits (n) - Study group 16 7 (9) (56.5%) - Control group % Inpatient Hospitalization (n) - Study group % - Control group % Admission Length of Stay (days) - Study group (4) (25.0%) - Control group % Hospital Costs - Study group $28, 272 $13, 969 ($14, 303) (50.6%) - Control group $39,554 $63, 626 $24, % 14

15 Results The intervention group had Results The intervention group had - fewer ED visits 7 vs. 16 Results The intervention group had - fewer ED visits - a shorter cumulative inpatient LOS 12 days vs. 16 days 15

16 Results The intervention group had - fewer ED visits - a shorter cumulative inpatient LOS - no change in the number of inpatient admission 3 in both periods Results Conversely, the control group had Results Conversely, the control group had increased ED visits 15 vs. 8 16

17 Results Conversely, the control group had increased ED visits increased inpatient LOS 32 days vs. 27 days Discussion Although limited by sample size, this study demonstrates - trend toward decreased ED visits - trend toward decreased hospital admission LOS for visits related to asthma exacerbation - trend toward decreased hospital related costs after completing the EMS-led intervention Discussion The number of admissions was similar between the two groups Suggests that the intervention - may have the greatest influence in decreasing mild to moderate exacerbations - those that lead to outpatient emergency department visits The effect on more severe exacerbations that require admission may be less pronounced 17

18 Discussion Suggests that the intervention helps educate participants on how to more effectively prevent and manage their symptoms - limiting the number of exacerbations that require additional treatment in a healthcare setting Discussion Significant implications for health systems and insurers - EMS provider-led home interventions help to improve the health status of asthma patients postdischarge - EMS provider-led home interventions lower associated health care costs for patients who are often frequent users of health care facilities Discussion Enrolled patients in one hospital system One socioeconomic group Outcome data from one hospital system Low enrollment in the program leading to. - small sample size 18

19 Conclusion This study analyzed a novel intervention utilizing EMS providers as health coaches for a home-based asthma disease management program This study provides preliminary support of the use of EMS providers as health coaches for asthma disease management but additional research is needed Questions? 19

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