Asthma is a growing public health threat. Its prevalence. A Home-Based Asthma Education Program in Managed Medicaid ASTHMA EDUCATION

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1 A Home-Based Asthma Education Program in Managed Medicaid Christopher L. Vojta, MD, MBA, Miguel A. Amaya, MPH, Kevin Browngoehl, MD, Kenneth D. Coburn, MD, MPH, and Deneen D. Vojta, MD Objective: To assess the effectiveness of a home-based asthma education program in a Medicaid managed care population. Design: Randomized controlled clinical trial. Setting and participants: 121 adult members (aged 18 to 45 years) of a Philadelphia-based Medicaid health maintenance organization (HMO) with asthma and at risk for poor outcomes based on previous health resource utilization. Intervention: A nurse-led educational program comprising 4 home visits; control patients received usual care. Outcome measures: Emergency department (ED) visits and hospital admissions over a 6-month period. Results: ED visits dropped by at least 25% and hospitalizations dropped by at least 51% for patients in both the intervention and control groups during the 6 months after enrollment. Completion rates for the program were 20% for females and 0% for males. Conclusion: A home-based educational intervention was not superior to usual asthma care in an urban Medicaid population. In addition, acceptance of this type of program is extremely low among both males and females. Future disease management programs should be sensitive to patient preferences for non home-based interventions and incorporate these into their design. Asthma is a growing public health threat. Its prevalence has increased approximately 75% in the past decade, from 30.7 to 53.8 per thousand, with hospitalization rates increasing 17% between 1990 and 1993 [1]. African Americans suffer disproportionately, experiencing mortality and hospitalization rates at least 3 times as high as those of whites [2]. In the United States, the disease accounts for approximately 1% of total health care expenditures [3]. Despite these daunting figures, there is widespread agreement that with optimal management, most asthmarelated morbidity can be prevented. Headrick and colleagues [4] and Blainey and colleagues [5] have estimated that half of all asthma mortality is preventable and that most hospitalizations could be avoided with proper medical care. As a result, health care providers and managed care organizations have invested significant resources in programs aimed at improving the care of asthmatics. The results of these programs have been mixed. In the United States, Bolton et al [6] reported that for adult asthmatics seen in the emergency department (ED), 3 group education sessions led to decreased ED utilization, with visits decreasing from 39 to 16 per 100 subjects. Among the urban poor, Kelso et al [7] and Mayo et al [8] reported success in reducing ED visits and hospitalizations among indigent African Americans and Hispanics, respectively. In contrast, 3 other studies [9 11] found that intensive educational programs provided no additional benefit over traditional care in decreasing utilization and improving outcomes. In 1995, Health Partners of Philadelphia, a Medicaid health maintenance organization (HMO), initiated a pilot study to evaluate the effectiveness of a nurse-based patient education program for medical assistance recipients diagnosed with asthma. The program was developed based on review of pharmacy data that showed few asthmatic members receiving optimal therapy and the belief that education could enhance compliance with appropriate medications and improve outcomes. Thirty high-risk asthmatics (members who had experienced at least 3 ED visits and/or 2 inpatient visits in the previous 12 months) were enrolled in the study and randomized to either the intervention or control group. The 13 patients who received the educational intervention of 4 educational visits experienced 30% reductions in ED visits and hospital admissions over the next year. As a result of this success, Health Partners expanded the program Christopher L. Vojta, MD, MBA, Fellow, Division of Geriatric Medicine, University of Pennsylvania Health System, Philadelphia, PA; Miguel A. Amaya, MPH, Director, Disease Management, Health Partners, Inc., Philadelphia, PA; Kevin Browngoehl, MD, Medical Director, Quality Management, Health Partners, Inc.; Kenneth D. Coburn, MD, MPH, Senior Vice President, Executive Medical Director, Chief Quality Officer, PennCARE, Allentown, PA; and Deneen D. Vojta, MD, Senior Vice President and Chief Medical Officer, Health Partners, Inc. 30 JCOM November/December 1999 Vol. 6, No. 10

2 ORIGINAL RESEARCH Table 1. Characteristics of Study Subjects Intervention Control Group Group Characteristic (n = 62) (n = 59) P value Mean age, yr (SD) 32.2 (8.1) 32.4 (8.2) 0.89 Sex Male 12.9% 13.5% 0.91 Female 87.1% 86.5% Race African American 67.2% 66.1% 0.98 Hispanic 21.3% 23.7% 0.79 Other 11.5% 10.2% 0.64 Preintervention utilization ED visits (SD) 1.27 (1.63) 1.18 (1.50) 0.76 Hospitalizations (SD) 0.56 (1.09) 0.59 (0.72) 0.86 ED = emergency department; SD = standard deviation. to all members in This study evaluates the effectiveness of this full-scale intervention. Methods All adult HMO members between 18 and 45 years of age who experienced 3 or more ED visits and/or 2 hospitalizations related to asthma over a 12-month period were randomized to either the intervention or control group between October 1996 and April Each month, the Health Partners claims database was used to identify all patients with a claim containing an ICD-9 code for asthma (493.*) and to analyze the prior 12-month utilization for such individuals. Administrative data are generally accurate when used for billing and can be used to accurately identify patients with asthma [12]. Patients who met eligibility criteria were randomized to either the intervention or control group on a monthly basis. Patients assigned to the intervention group were referred to 1 of 2 home health agencies that had been contracted to provide 4 home-based educational sessions and a postintervention evaluation 6 months later assessing health status and quality of life. These agencies were chosen based on their experience working with urban Medicaid clients. They were paid for each successfully completed home visit and recevied a bonus for each patient who successfully completed all 4 home visits. Control group patients received their usual asthma care. Patients who disenrolled from Health Partners during the study were included if there was reasonable assumption that they would re-enroll within the next 6 months. The study was powered to detect utilization differences of 30% based on an alpha of 0.05 and a beta of 0.2. Assuming a 50% attrition rate, the study had the power to detect utilization differences of 50% based on the same alpha and beta. Table 2. Compliance with Program Completed: Total (%) Males (%) Females (%) Enrollment 62 (100%) 8 (100%) 54 (100%) First home visit 28 (45.2%) 3 (37.5%) 25 (46.3%) Second home visit 24 (38.7%) 3 (37.5%) 21 (38.8%) Third home visit 18 (29.0%) 1 (12.5%) 17 (31.5%) Fourth home visit 11 (17.7%) 0 (0%) 11 (20.3%) The educational intervention consisted of home-based visits by a trained nurse. The visits encompassed assessment of the patients knowledge of asthma and medication compliance, recommendations to the physician and patient regarding possible medication changes, teaching of proper medication use and peak flow monitoring, and identification and avoidance of asthma triggers. The program was developed using standards published by the National Heart, Lung, and Blood Institute [13] as well as based on review of the literature. Emphasis was placed on preventing acute exacerbations with the use of daily inhaled corticosteroids, use of β agonists as needed, and addressing trigger exposure with β agonists. Patients were given peak flow meters and taught proper use and response to readings. Inhaler technique was observed, and proper technique was taught if necessary. At the end of each visit, patients were given selfassessment quizzes as well as written care plans. The assessment was designed to measure disease knowledge and skills (peak flow meter, nebulizer, and medication use and compliance). Patient competency was scored at the first and last visit on a 4-point scale: 1 = not competent; 2 = minimally competent; 3 = substantially competent; and 4 = competent. Inpatient admissions and ED visits among the intervention and control groups were followed for 6 months prior to and 6 months after the intervention. Logistic regression was used to test for baseline differences between intervention and usual care groups. Because outcomes data are often skewed, nonparametric statistical tests were used for the analyses. Changes in ED visits, hospitalizations, and asthma scores were subjected to the Sign or Kruskal-Wallis test. All statistical calculations were done with Stata Version 5.0 software. Results The basic characteristics of the intervention and control groups are presented in Table 1. The mean age for both groups was 32 years; 85% of both groups were female. African Americans and Hispanics made up over 85% of each group, reflecting the overall Medicaid population in Philadelphia. Both control and intervention groups had similar utilization profiles in the 6 months prior to the study. Vol. 6, No. 10 JCOM November/December

3 Table 3. Per-Member Utilization Before and After Intervention Preintervention Postintervention Change P Value n (SD) ED visits over 6 months Intervention group 1.27 (1.63) 0.74 (1.40) 0.53 (1.40) Control group 1.18 (1.50) 0.45 (0.77) 0.73 (1.31) < Hospitalizations over 6 months Intervention group 0.56 (1.63) 0.27 (1.40) 0.29 (1.09) Control group 0.59 (0.72) 0.15 (0.41) 0.44 (0.79) < ED = emergency department; SD = standard deviation. Table 4. Asthma Competency Pre- and Postintervention Mean Mean Preintervention Postintervention Subjects Score (SD) Score (SD) P Value Completed initial 3.3 (0.8) N/A self-assessment only (n = 7) Completed pre- and 3.2 (0.8) 3.7 (0.4) < postintervention assessments (n = 15) N/A = not applicable; SD = standard deviation. Compliance with the program was poor (Table 2). Less than 50% of the patients who were eligible actually participated in the program. Only 20% of females completed all 4 educational sessions. Although there were few males in the program, no male completed all 4 visits. Of the 34 eligible patients who did not complete an initial visit, 3 refused to participate and 31 were unable to be located. Reasons reported for dropping out of the program after the first visit included failure to keep appointments and perceived lack of need for further education. Utilization rates in both the intervention and control groups dropped significantly (Table 3). The intervention group experienced a 42% reduction in ED visits (from an average per-member rate of 1.27 to 0.74) and a 52% reduction in hospitalizations (from an average per-member rate of 0.56 to 0.27) over the 6-month follow-up. The usual care group experienced even larger declines in utilization: a 62% reduction in ED visits (from an average per-member rate of 1.18 to 0.45) and a 75% decline in hospitalizations (from an average per-member rate of 0.59 to 0.15). The magnitude of the differences between the intervention and usual care groups was not statastically significant (Sign test, ED visits P = 0.21, hospitalizations P = 0.19). Subanalysis of patients who actually participated revealed no consistent differences between those in the intervention group who completed 1 or more visits and those in the intervention group who were not locatable. For the 34 patients in the intervention group who failed to receive even 1 visit, inpatient utilization dropped by 0.2 admissions and ED visits dropped by 0.54 visits over the follow-up period. Those who completed at least 1 visit experienced on average 0.40 fewer inpatient admissions and 0.51 ED visits. Stratification of results by number of visits completed, age, sex, and race similarly failed to show any consistent differences in utilization patterns. Of the 28 patients who received at least 1 visit, 22 agreed to participate in the self-assessment section of the study. Of these, 7 completed an initial self-assessment only and 15 completed both pre- and postintervention assessments. Average assessment scores are depicted in Table 4. The mean preintervention score for all participants was 3.3, and scores did not differ significantly between those who agreed to a postintervention assessment and those who did not. For the 15 subjects who completed the postintervention assessment, mean scores increased to 3.7, a statistically significant 0.5 increase. Thus, those who actually participated had knowledge and skills that were between substantial and competent, and these scores increased with the intervention. Discussion The need for appropriate management of asthma remains high, but compliance with published guidelines is low, especially in the at-risk Medicaid population. In 1 HMO, only 26% of moderate to severe asthmatics possessed peak flow meters and only 16% used them daily [14]. The educational program tested in this study makes clear how difficult the challenge is to design successful programs. Overall, despite a very successful pilot program, the educational intervention did not do better than usual care in decreasing ED utilization and hospitalizations over the 6-month follow-up. Patients in both groups exhibited decreases in ED utilization and hospitalizations that were significant and not different from each 32 JCOM November/December 1999 Vol. 6, No. 10

4 ORIGINAL RESEARCH other. In a similar study, Cote et al [15] reported the same phenomenon. It is possible, therefore, that when asthmatic patients experience significant contact with the health care system, they may manifest improved outcomes over a relatively short time-course. Our results also highlight the importance of robust study design in critically evaluating the efficacy of specific care management interventions among specific populations. Most reports in the literature on this subject are nonrandomized, uncontrolled observational pre/post comparisons of clinical and utilization measures. Very often high-risk populations are selected for participation on the basis of a recent increase in their use of medical services. This approach makes subsequent observations subject to the regression-to-themean phenomenon. As in our study, the use of a randomly selected control group can eliminate this bias. Although some may be uncomfortable providing some patients but not others with care management services during such trials, in many circumstances such an approach may be the best means to optimize the quality and cost of care while providing consumers with sound information about such services. There were several limitations to our study. First, the follow-up period was limited to 6 months, possibly masking a long-term effect of an educational program. Given the low compliance with the educational intervention, however, it would be difficult to imagine a substantial effect over a longer time period. Nevertheless, we will report on 1-year data in the future. Second, we are not sure why patients failed to complete the full intervention course. Given the success of the pilot study, this was not anticipated and therefore was not built into the evaluation of the study. Third, we do not have information on long-term process variables such as medication compliance and adequacy of drug delivery technique. Patients who actually participated in the program demonstrated relatively high levels of asthma competency preintervention and postintervention, but their outcomes were not significantly different from those of nonparticipants. Although in some ways it might be enough that outcomes improved so dramatically, ultimately most practitioners still believe that compliance with national treatment guidelines does improve long-term outcomes. Nevertheless, our study revealed several other important aspects of managing patients within a Medicaid population. The program completion rates of 20% and 0% for females and males, respectively, raise doubts about the effectiveness of care management models predicated on home visits in this population. Of the 34 patients who never completed a first visit, 31 were unreachable as a result of incorrect phone numbers or addresses. This highlights the transience often exhibited in our Medicaid population. The dropout rate of over 60% among those who did complete the first home visit highlights the well-documented discomfort that the Medicaid population continues to have with the American health system. Providers will need to ensure that future efforts focus on creating programs acceptable to this group, and if one looks at the evidence in the United States, it appears that the more successful recent programs are centered around provider offices and, perhaps, pharmacists [8,16]. Finally, within this Medicaid population, male asthmatics remain at higher-risk. Even though the outcome measures for males improved, in some cases the postintervention utilization of the ED and hospital remained higher than females preintervention rates of use. In addition, not one male finished the educational program. Ultimately, special efforts will be needed to reach this group if we are to stop the worrisome trends of increased morbidity and mortality. Author addresses: Drs. Vojta: 201 Forrest Ave., Narberth, PA 19072, cvojta@cceb.med.upenn.edu. Dr. Amaya: PO Box 650, Rancho Mirage, CA 92270, mamya@healthcar . com. Dr. Browngoehl: Health Partners, Inc., 841 Chestnut St., Ste. 900, Philadelphia, PA. Dr. Coburn: 3401 Fish Hatchery Rd., Allentown, PA , coburnk.pc@penncare.org. References 1. Lang DM, Polansky M. Patterns of asthma mortality in Philadelphia from 1969 to N Eng J Med 1994;331: Homer CJ. Asthma disease management. N Engl J Med 1997; 337: Barnes PJ, Jonsson B, Klim JB. The costs of asthma. Eur Respir J 1996;9: Headrick L, Crain E, Evans D, Jackson MN, Layman BH, Bogin RM, et al. National Asthma Education and Prevention Program working group report on the quality of asthma care. Am J Respir Crit Care Med 1996;154(3 Pt 2):S Blainey D, Lomas D, Beale A, Partridge M. The cost of acute asthma how much is preventable? Health Trends ; 22: Bolton MB, Tilley BC, Kuder J, Reeves T, Schultz LR. The cost and effectiveness of an education program for adults who have asthma. J Gen Intern Med 1991;6: Kelso TM, Self TH, Rumbak MJ, Stephens MA, Garrett W, Arheart KL. Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics. Am J Emerg Med 1995;13: Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990; 112: Wilson SR, Scamagas P, German DF, Hughes GW, Lulla S, Coss S, et al. Acontrolled trial of two forms of self-management education for adults with asthma. Am J Med 1993;94: Bailey WC, Richards JM, Brooks CM, Soong SJ, Windsor RA, Manzella BA. Arandomized trial to improve self-management practices of adults with asthma. Arch Intern Med 1990;150: Kaupinnen H, Sintonen H, Tukianen H. One-year economic Vol. 6, No. 10 JCOM November/December

5 evaluation of intensive vs conventional patient education and supervision for self-management of new asthmatic patients. Respir Med 1998;92: Chao J, Gillanders WG, Flocke SA, Goodwin MA, Kikano GE, Stange KC. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 1998;47: National Heart, Lung, and Blood Institute, National Asthma Education Program. Expert panel report. Guidelines for the diagnosis and management of asthma. Bethesda (MD): U.S. Department of Health and Human Services; NIH Pub. No Legoretta AP, Christian-Herman J, O Connor RD, Hasan MM, Evans R, Leung KM. Compliance with national asthma management guidelines and specialty care: a health maintenance organization experience. Arch Intern Med 1998;158: Cote J, Cartier A, Robichaud P, Boutin H, Malo J, Rouleau M, et al. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med 1997;155: Wilson SR, Scamagas P, Grado J, Norgaard L, Starr NJ, Eaton S, Pomaville K. The Fresno Asthma Project: a model intervention to control asthma in multiethnic, low-income, innercity communities. Health Educ Behav 1998;25: Copyright 1999 by Turner White Communications Inc., Wayne, PA. All rights reserved. 34 JCOM November/December 1999 Vol. 6, No. 10