Improving Asthma Care: An Update for Managed Care Achieving Optimal Outcomes

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1 Improving Asthma Care: An Update for Managed Care Achieving Optimal Outcomes Aidan A. Long, MD Clinical Director, Allergy and Immunology Massachusetts General Hospital Faculty Information Presenter: Aidan A. Long, MD Clinical Director, Allergy and Immunology Massachusetts General Hospital Boston, Massachusetts Moderator: Nikhil Patel, RPh, PharmD Director, Scientific Affairs Pharmacy Times Office of Continuing Professional Education This activity is supported by an educational grant from Merck & Co, Inc. 2 Educational Objectives After completing this activity, the participant should be able to: Describe the significance of unmet needs among people with asthma and elucidate contributing factors to poor asthma control Discuss the pharmacoeconomics of asthma therapy as it relates to clinical outcomes Identify strategies for improving asthma control The contents of this webinar may include information regarding the use of products that may be inconsistent with or outside the approved labeling for these products in the United States. Physicians should note that the use of these products outside current approved labeling is considered experimental and are advised to consult prescribing information for these products. 3 1

2 Disclosures According to the disclosure policies of the University of Cincinnati and Pharmacy Times Office of Continuing Professional Education, faculty, editors, managers, and other individuals who are in a position to control content are required to disclose any relevant financial relationships with relevant commercial companies related to this activity. All relevant conflicts of interest that are identified are reviewed for potential conflicts of interest. If a conflict is identified, it is the responsibility of the University of Cincinnati and Pharmacy Times Office of Continuing Professional Education to initiate a mechanism to resolve the conflict(s). The existence of these interests or relationships is not viewed as implying bias or decreasing the value of the presentation. All educational materials are reviewed for fair balance, scientific objectivity of studies reported, and levels of evidence. Aidan A. Long, MD, reports expert testimony for GlaxoSmithKline. The planning staff from the University of Cincinnati, The American Journal of Managed Care, and the Pharmacy Times Office of Continuing Professional Education have no relevant financial relationships to disclose. 4 Physician Accreditation Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the University of Cincinnati. The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation The University of Cincinnati designates this enduring material activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. 5 Pharmacy Accreditation Pharmacy Times Office of Continuing Professional Education is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program is approved for 1 contact hour (0.1 CEU) under the ACPE universal program number H01-P. PThe program is available for CE credit through May 25, Type of Activity: Application-based. 6 2

3 Improving Asthma Care: An Update for Managed Care Achieving Optimal Outcomes Send discussion questions to Content Overview The burden and impact of (uncontrolled) asthma Barriers to optimal asthma management Strategies to improve asthma outcomes 8 The Burden and Impact of (Uncontrolled) Asthma Send discussion questions to CEINFO@pharmacytimes.com 3

4 Prevalence of Asthma Approximately 23.3 million Americans (7.8% of the population) There were 3447 deaths due to asthma in 2007 Affects all races, sexes, and ages, in all regions More common in the South, in females, in non-hispanic whites, and in 18 to 44 year olds American Lung Association. Trends in asthma morbidity and mortality. Published Accessed March 9, Akinbami LJ, et al. Asthma prevalence, health care use, and mortality: United States, National health statistics reports; No. 32. Hyattsville, MD: National Center for Health Statistics; Prevalence of Asthma American Lung Association. Trends in asthma morbidity and mortality. Published Accessed March 9, Healthcare Utilization Due to Asthma It is estimated that in 2009, 52% of those with current asthma had attacks and were at risk for emergency department (ED) visits or hospitalization In 2007, there were 1.75 million ED visits and 456,000 hospitalizations due to asthma In 2007, 13.9 million visits for asthma were made to private physician offices and 1.4 million visits were made to hospital outpatient departments Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, Nat Health Stat Report. 2011;12(32):

5 Utilization and Mortality Due to Asthma Female vs Male Other vs White Total ambulatory visit 0.96 Emergency department visit Hospitalization Death 0.89 Black vs White <18 years vs 18 years A rate ratio of 1.0 (dashed line) indicates equal rates between the groups being compared. Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, Nat Health Stat Report. 2011;12(32): The Economic Burden of Asthma Direct and indirect medical costs total $20.7 billion Direct medical costs total $15.6B $5.5B for hospital care $5.9B for prescription care $4.2B for physician care Indirect medical costs add another $5.1B $3.1B related to comorbidity and complications $2.0B associated with mortality American Lung Association. Trends in asthma morbidity and mortality. Published Accessed March 9, Lost Productivity Due to Asthma According to the National Health Statistics Report on asthma prevalence, health care use, and mortality ( ): Of children 15 to 17 years of age with at least 1 asthma attack in the previous year: Almost 60% had at least 1 missed day of school due to asthma in the past year 5.5% reported activity limitations due to asthma Of adults with at least 1 asthma attack in the previous year: Almost 34% missed at least 1 day of work due to asthma in the past year 6% of working adults and 27% of non working adults reported that breathing problems caused activity limitations Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, Nat Health Stat Report. 2011;12(32):

6 The State of Asthma Management The treatment goal is to achieve asthma control by: Reducing impairment Reducing risk Unfortunately, not all patients achieve this goal Asthma Insight and Management Survey (2009): Telephone interview of 2500 patients with current asthma Interviewees questioned regarding frequency of asthma symptoms and control/management of asthma in the preceding 4-week period As many as 42% of asthma patients surveyed were poorly or not well controlled and reported experiencing symptoms daily (16%), most days per week (11%), or 2 or more days per week (15%) National Asthma Education and Prevention Program, National Heart, Lung, and Blood Institute. Expert Panel report 3: guidelines for the diagnosis and management of asthma. Full report Murphy K, Meltzer EO, Nathan RA, Blaiss M, Stoloff S. Ann Allergy Asthma Immunol. 2010;105(suppl 5):A50. Abstract P Economic Implications of Poor Asthma Control Navaratnam et al (2010) reviewed claim data from patients with mild asthma Patients categorized as high control/high adherence or low control/low adherence High control/high adherence group vs low control/low adherence Fewer asthma treatment days (ie, medical visits with asthma-related ICD-9 codes): 2.9 vs 3.9 Lower overall charges per patient per year: $2655 vs $3345 Navaratnam P, Friedman H, Urdaneta E. The impact of adherence and disease control on resource use and charges in patients with mild asthma managed on inhaled corticosteroid agents. Patient Prefer Adherence. 2010;4: Economic Implications of Poor Asthma Control (cont) Annual Charges, $ a P Navaratnam P, Friedman H, Urdaneta E. The impact of adherence and disease control on resource use and charges in patients with mild asthma managed on inhaled corticosteroid agents. Patient Prefer Adherence. 2010;4:

7 Barriers to Optimal Asthma Management Send discussion questions to Barriers to Optimal Asthma Management: Overview The most common causes of uncontrolled asthma are poor treatment adherence and insufficient knowledge on the patient s part More than 50% of asthma patients are noncompliant with therapy Cochrane GM, Horne R, Chavez P. Compliance in asthma. Respir Med. 1999;93(11): Vanelli M, Adler S, Vermilyea J. Moving beyond market share. In Vivo: The Business and Medicine Report. 2002;20(3): Reasons Patients Identify for Not Taking Their Asthma Medications Fear of side effects Belief that the medication does not help or is not necessary Patient belief that their illness is not serious Sense of only intermittent itt t need for medication Concern that the medication will lose effectiveness over time Inconvenience of medication use Cost of medication Dislike of provider Bender BG, Long AA, et al. Ann Allergy Asthma Immunol. 2007;98:

8 Factors Associated With Nonadherence: Gaps in Prescriber Knowledge Stelmach et al (2007) evaluated residents (n = 239) regarding maintenance treatment of asthma and the technique for using metered dose inhalers 76% identified the correct medication 30% adequately performed the inhalation technique Stelmach R, Robles-Ribeiro PG, Ribeiro M, Oliveira JC, Scalabrini A, Cukier A. Incorrect application technique of metered dose inhalers by internal medicine residents: impact of exposure to a practical situation. J Asthma. 2007;44(9): Factors Associated With Nonadherence: Underestimation of Severity of Symptoms Both patients and physicians tend to underestimate the severity of symptoms 39% to 70% of patients report that their asthma is well controlled even when they are experiencing moderate symptoms This leads to underprescribing and underuse of controller medication Rabe KF, Adachi M, Lai CK, et al. Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys. J Allergy Clin Immunol. 2004;114(1): Strategies to Improve Asthma Outcomes Send discussion questions to CEINFO@pharmacytimes.com 8

9 Addressing Knowledge Gaps Many of the identified reasons for poor adherence may be corrected by appropriate educational intervention Asthma educators can help bridge knowledge gaps 25 Treatment Guidelines: EPR-Recommended Recommended Education for Partnership Asthma self-management education is essential Issue an action plan for daily management Patients should be taught how to recognize deterioration Regularly review basic facts, medication roles and uses, and symptom control Develop a partnership with patient and family Encourage adherence; take note of patient s preferences National Asthma Education and Prevention Program, National Heart, Lung, and Blood Institute. Expert Panel report 3: guidelines for the diagnosis and management of asthma. Full report Risk Identification Smith et al (2005) categorized patents with severe asthma as compliant (n = 41) or poorly compliant (n = 92) Poorly compliant patients had: Increased self-reported asthma, medication use, time off work, symptoms, and medical center visits Decreased asthma-specific quality of life Poorer self-management Higher physical and psychological comorbidities Difficult social and economic circumstances and younger age Smith JR, Mildenhall S, Noble M, Mugford M, Shepstone L, Harrison BD. Clinician-assessed poor compliance identifies adults with severe asthma who are at risk of adverse outcomes. J Asthma. 2005;42(6):

10 Risk Identification (cont) Anxiety, younger age, unemployment, adverse family circumstances, and the number of welfare benefits were independently associated with poor asthma control Smith et al conclude: Clinicians i i can recognize patients t at risk for poor adherence to treatment and make appropriate adjustments Open dialogue, through clear and direct questions, is an appropriate method for determining whether the proposed treatment regimen is being followed Smith JR, Mildenhall S, Noble M, Mugford M, Shepstone L, Harrison BD. Clinician-assessed poor compliance identifies adults with severe asthma who are at risk of adverse outcomes. J Asthma. 2005;42(6): Self-management Plans Kaya et al (2009) evaluated the impact of peak flow or symptom based self-management plans on asthma control and patient quality of life Data were collected from patients with persistent asthma (n = 63) A standard asthma self-management education program was issued and patients were randomly divided into the peak flow meter or symptom based action plan groups Patients were assessed over 12 months for: Drug compliance, quality of life, psychiatric comorbidities, asthma control and symptoms Kaya Z, Erkan F, Ozkan M, et al. Self-management plans for asthma control and predictors of patient compliance. J Asthma. 2009;46(3): Self-management Plans (cont) In both groups: Emergency visits, antibiotic treatments, systemic corticosteroid use, and unscheduled visits were fewer than the previous year Quality of life measures increased In the peak flow group: Compliance was better Kaya Z, Erkan F, Ozkan M, et al. Self-management plans for asthma control and predictors of patient compliance. J Asthma. 2009;46(3):

11 Self-management Plans (cont) Conclusions: Self-management plans improved illness control and quality of life in asthma patients Use of the peak flow meter and the presence of psychiatric comorbidities can be used to predict compliance with the action plans Kaya Z, Erkan F, Ozkan M, et al. Self-management plans for asthma control and predictors of patient compliance. J Asthma. 2009;46(3): Management Plans: Review of Evidence Cochrane review of written individualized management plans for asthma in children and adults published in 2007 Findings: Insufficient evidence from trials Not possible to conclude whether use of written management plans (peak flow or symptom based plans) alone leads to an improvement in adherence Improvements in outcomes require a comprehensive program that includes education, a written selfmanagement plan, and regular review Toelle BG, Ram FS. Written individualised management plans for asthma in children and adults. Cochrane Database Syst Rev. 2004;(2):CD Disease Management Programs: Easy Breathing Management Program Cloutier et al (2009) assessed the return on investment from the Medicaid managed care plan perspective on a 3-year asthma management program ( Easy Breathing ) among children residing in a poor urban environment (n = 3298) Start-up t costs for the program per child: $28.95 (first year); continuing costs: $10.28 per year Potential return on investment: $3.58 per US$ spent Overall costs declined in children with persistent asthma Overall costs increased in children with intermittent asthma Cloutier MM, Grosse SD, Wakefield DB, Nurmagambetov TA, Brown CM. The economic impact of an urban asthma management program. Am J Manag Care. 2009;15(6):

12 Disease Management Programs: The TRICARE Asthma Management Program Dall et al (2010) examined medical claims of 23,793 military individuals with asthma Individuals enrolled in the TRICARE Disease Management Program had: Reduced annual medical costs by $453 due to: Reduced hospital visits Increased appropriate use of medical exams Improved overall satisfaction, self-managed care, QOL, patient knowledge of asthma outcomes Dall TM, Askarinam Wagner RC, Zhang Y, Yang W, Arday DR, Gantt CJ. Outcomes and lessons learned from evaluating TRICARE s disease management programs. Am J Manag Care. 2010;16(6): Health Plan Provider Cooperation Ramos et al (2009) studied a managed care program designed to reduce costs The care plan: Promoted education and insurance company involvement Focused on patients who accounted for higher medical costs Educated individuals on their condition and environment Results: Reduction in unnecessary medical costs Conclusion: Asthma control is enhanced when health plans and providers cooperate Ramos C, Ciaccio C, Portnoy JM. Asthma control is enhanced when health plans and providers cooperate. Pediatr Ann. 2009; 38(3): Conclusions Asthma has an enormous clinical and economic impact on all stakeholders; suboptimal management increases this burden Many factors can contribute to inadequate management, but prominent are nonadherence and a lack of understanding/education di d ti Improving outcomes is a team effort by all involved: managed care organizations, practitioners, patients, and their carers 36 12

13 Q&A Aidan A. Long, MD Clinical Director, Allergy and Immunology Massachusetts General Hospital Send discussion questions to Improving Asthma Care: An Update for Managed Care Achieving Optimal Outcomes THANK YOU! For any questions regarding this activity, contact: 38 13