Asthma outcomes focus on function
Most asthma management programs focus on such outcomes measures as utilization of medical services, and with good reason: The direct costs of asthma were estimated at $6.2 billion in 1990. Those costs included direct medical expenditures such as inpatient and outpatient care, emergency room visits, doctor visits, and medications.
However, employers face additional costs in terms of lost productivity. When Glaxo Wellcome in Research Triangle Park, NC, designed outcomes measures for its asthma management program, it went beyond utilization and looked at productivity and ability to perform activities of daily living. "Too many programs focus on the effectiveness of medical interventions without looking at what patients report as outcomes," says John E. Paul, PhD, director of clinical economics and outcomes assessment. "It’s important to focus on the total impact of the disease on the patient." (For Glaxo’s measures, see charts, at right and on p. 11.)
"Managed care organizations can use these results to sell asthma management programs to employers," says Deborah O. Lucas, MPH, manager of clinical economics and outcomes assessment for Glaxo. Imagine being able to report results like these from Glaxo’s six-month data of 137 patients in its asthma management program:
• 68.3% reported some or a lot of difficulty in daily indoor or outdoor work at baseline, compared with 41.9% at three months follow-up and 37.7% at six months.
• 69.8% reported some or a lot of limitations in physical activities at baseline, compared with 41.9% at three months follow-up and 47.3% at six.
Glaxo’s Care Management Division’s Asthma Self-Management Program (ASMP) offers eight weekly sessions using a behavioral modification support group model. Taught by nurses, case managers, pharmacists, and respiratory therapists, it covers asthma management, the nature of asthma medications, attack prevention and management, solving problems, relapse prevention, and communicating with health care providers.
ASMP patients complete a questionnaire during the first session for baseline data prior to any asthma education. In addition to that questionnaire, patients are given one on medical history and previous health care utilization to bring home and return at the next session. They complete the same questionnaire at the last session. "We then begin following patients quarterly from the date of their last class," Lucas says. Three- and six-month follow-up surveys are conducted by interactive voice response (IVR) system, she says. "However, we contract with a third-party data vendor to contact patients who don’t respond to the IVR. We have an overall response rate of 90%."
Glaxo also mails patients surveys at 12 months. "We also use the third-party vendor to contact patients who didn’t mail back their questionnaires by phone," Lucas says, adding that Glaxo is just now completing an analysis of 12-month data for early ASMP graduates.
"We consider the three-, six-, and 12-month follow-up contacts themselves as part of the intervention," Paul says. "The follow-up questionnaires are as much for learning reinforcement as for data collection. If we asked patients whether or not they are using their metered dose inhaler or keeping a diary of asthma triggers, we believe the mere asking will serve as a trigger for renewed positive behaviors." He says Glaxo relies on standardized, validated outcomes measurement tools. "There’s a whole body of measures available in the literature. Using standardized measures allows disease management programs to accurately compare their outcomes to those of other programs."
Glaxo hopes to measure next whether self- confidence is a strong predictor of positive outcomes in asthma management, Lucas says. "We have built the whole concept of self-confidence into the program. We feel strongly that if patients believe they know how to manage their asthma, it will reduce serious complications and improve outcomes. We don’t have any data for that, yet, but we’ve designed the instruments to measure it and plan to capture that data in the future."
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