Specialists provide better outcomes at lower cost
Referral in moderate-to-severe cases works best
It sounds like a dream come true: better outcomes for lower costs. But a compilation of 21 studies over the past few years shows a clear trend: Asthma patients under the care of an allergist have fewer and shorter hospitalizations, fewer crises associated with the disease, and better work productivity — all at substantial cost savings, as shown in a booklet produced by the American College of Allergy, Asthma and Immunology (ACAAI) in Arlington Heights, IL.
The booklet includes abstracts of studies published in the past nine years and shows a strong body of evidence the aggressive management of asthma by specialists has these dramatic results:
- 67% fewer hospitalizations;
- 38% shorter hospital stays;
- 63% fewer return visits to the hospital;
- 50% fewer emergency department visits;
- 45% fewer sick care office visits;
- 33% reduction in lost time from work or school;
- up to 95% reduction in hospitalization costs per capita.
The ACAAI maintains that allergists can achieve such results because "their training and experience enables them to accurately diagnose the disease, aggressively treat it, and maintain disease control through patient education about self-care."
"We have interest in the pathophysiological mechanisms of the disease. Mostly we do the research on it and report on the newest findings. We stay on the cutting edge," says Stanley Fineman, MD, MBA, a member of the ACAAI’s board of regents, the organization’s managed care committee co-chairman, and a practicing allergist at the Atlanta Allergy and Asthma Clinic.
Fineman says the document published by the ACAAI is not meant as a slam to primary care physicians. "They can do a lot for most patients," he says. "But for some, an allergist can do better." The bottom line: Primary care providers should refer asthma patients who have difficulty controlling their disease, if it is affecting the patients’ quality of life, and when the disease is moderate to severe and more medication is indicated, he adds.
"Asthma specialists are more likely than primary care physicians to adhere to current management guidelines and prescribe inhaled steroids that are associated with decreased asthma mortality rates,"says Edward M. Zoratti, MD, senior staff specialist in allergy and clinical immunology at the Henry Ford Health System in Detroit.
He says it’s important to involve the specialist with controlling the disease, not just to deal with emergency situations. "Asthma is a chronic disease and our goal should not be just to treat asthma episodes but to help patients manage their asthma and maintain good health."
Members of minority groups with asthma are less likely to be under the care of a specialist, adds Zoratti, who authored a study on how minorities with asthma use the hospital and ED.
Norman Edelman, MD, a spokesman for the American Lung Association and vice president for Health Sciences at the State University of New York at Stony Brook, agrees that specialist care is clearly warranted for patients with moderately severe to severe asthma. "But the patient who wheezes in the spring and fall and who has no hospitalizations or emergency room visits can be perfectly well managed by primary care physicians," he says.
Specialist vs. generalist
"The general impression is that a primary care physician tends to give a standard dosage of medications for chronic illness across the board. A specialist has a lot more experience with drugs and knows how far he can push it," He explains.
Both Edelman and Fineman say caregivers often can agree the primary care doctor will oversee disease management, while the specialist will be visited occasionally to help monitor the disease or to help deal with a recent exacerbation.
It sounds like a simple plan. But unless the strategy gets mapped out, many patients will not go to a specialist for these types of visits. Asthma patients sometimes tend to be complacent, Edelman says. "If you ask a patient how he’s feeling, he’ll usually say, OK,’ but when you keep asking the questions, you’ll often find his quality of life has been dramatically affected and that his disease is out of control. Not to refer that patient is a disservice to him."
He also suggests capitation may be partly responsible for the primary care physicians’ reluctance to refer patients to specialists. "The primary care physician gets a fee, and it costs him to refer out to a specialist."
Fineman notes capitation can be a double-edged sword. While it may help to create an incentive to reduce the number of specialist referrals, it can bring patients through the specialist’s door when they have had trouble with their disease. "In some plans, managed care helps facilitate the referral by automatically sending patients to us when they have an emergency room visit," he says.
[Contact Stanley Fineman at (770) 428-4477 and Norman Edelman at (516) 444-2080.
Single copies of the ACAAI booklet The Role of the Allergist in the Cost-Effective Treatment of Asthma are available free from: ACAAI, 85 W. Algonquin Road, Suite 550, Arlington Heights, IL 60005.]
The Numbers Add Up
Annually, asthma causes:
o 10.4 million physician visits;
o 468,000 hospitalizations;
o 1.8 million emergency department visits;
o 3 million lost work days;
o 10 million missed school days;
o $3.6 to $5.1 billion per year in direct health care costs;
o an estimated $2.5 billion in indirect costs.
When to Refer
The expert panel from the National Institutes of Health in Bethesda, MD, recommends asthma patients be referred to a specialist when they:
- are children under the age of 3;
- are children who are beginning daily long-term therapy;
- have difficulty achieving or maintaining control of their condition;
- have had a life-threatening asthma attack;
- are not meeting the goals of asthma therapy after three to six months of treatment, or are not responding to current therapy;
- have symptoms that are unusual or difficult to diagnose;
- have other conditions such as severe hay fever or sinusitis that complicate their asthma or their diagnosis;
- need additional diagnostic tests to determine the severity of their asthma and what causes their asthma symptoms;
- require additional education or guidance on the complications of therapy, adhering to their treatment plan, or avoiding triggers;
- are candidates for immunotherapy;
- have severe persistent asthma;
- require continuous oral corticosteroid therapy or high-dose inhaled corticosteroids, or have taken more than two bursts of oral corticosteroids in one year.
Referral to a specialist also is indicated when:
- The patient’s asthma is unstable, or the response to therapy is limited, incomplete, or very slow and poor control interferes with the patient’s quality of life.
- Identification is required for allergens or other environmental factors that may be triggering the patient’s disease.
- Co-existing illnesses or their treatment complicate the management of asthma.
- The diagnosis of asthma is in doubt.
- There is concern about side effects that have occurred or may occur with asthma medications.
- The patient asks for a consultation.
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