Science Behind the Issues

A payer, provider, and nonprofit organization were partners in a multistate quality improvement project that included promoting guidelines-based medical management for asthma among primary care providers (PCPs). Payer data were used to identify clinics serving patients with asthma at higher risk for ED visits or hospitalizations and to track health outcomes. The project reduced asthma-related ED visits by 55% and asthma-related hospitalizations by 56%. Return on investment was $2.40 per $1.00 invested.³²

In a study involving more than 4,000 Medicaid recipients (adults and children) in a large metropolitan area, a program trained health care providers on the NAEPP Guidelines and used claims data to deliver provider-specific feedback at 6-month intervals. This program was shown to reduce asthma-related ED visits by 41%. Return on investment was $3.00–$4.00 per $1.00 spent.³³

In a study of 3,298 urban children (primarily Medicaid or State Children’s Health Insurance Program [S-CHIP] participants), when PCPs used the NAEPP Guidelines to determine asthma severity and then developed a written asthma plan with corresponding medications, participating children had 20% fewer symptom days, along with 13% fewer ED visits, compared with a control group. Program start-up costs in the first year were $29 per child, but annual operating costs in years 2 and 3 decreased to about $10 per child. For years 2 and 3, estimated return on investment for Medicaid managed care plans was $3.58 per $1.00 spent.³⁴

Among PCPs who participated in a citywide asthma management program for 3,748 urban children (89% were Medicaid or S-CHIP participants), provider adherence to NAEPP Guidelines for prescribing anti-inflammatory controller medication increased from 38% to 96%. Among participating patients, medication fills for inhaled corticosteroids increased by 25%. Asthma-related ED visits decreased by 27%, hospitalizations by 35%, and outpatient visits by 19%.³⁵

In 1998–2000, researchers conducted a randomized, controlled clinical trial involving 937 children (5 to 11 years old) with moderate or severe asthma (most of whom had Medicaid, Medicaid managed care, or were uninsured) from seven U.S. inner-city urban areas. This trial evaluated the effect of collecting information from children’s caregivers about their children’s asthma through bimonthly telephone calls and then communicating this information to their PCPs. PCPs received bimonthly, patient-specific, computer-generated letters summarizing each child’s asthma symptoms, health care use, and medication use; if appropriate, the letters also provided recommendations regarding the appropriateness of changes in asthma medication regimens based on NAEPP Guidelines. Researchers observed a 24% drop in asthma-related ED visits with the intervention, saving $337 per child in the first year.³⁶

In a randomized trial involving 870 children with asthma (more than 70% had commercial insurance) and 101 PCPs in 10 regions of the United States, researchers studied the effect of providing PCPs with two interactive seminar sessions (2.5 hours each) that reviewed NAEPP Guidelines, communication skills, and key educational messages. The study found that patients of physicians who received the intervention had a 46% decrease in days limited by asthma symptoms (8.5 versus 15.6 days), as well as a 45% decrease in asthma-related ED visits (0.30 versus 0.55 visits per year).³⁷

A randomized trial involving 546 people with asthma aged 12–20 years in multiple U.S. inner-city areas (>50% had annual household incomes <$15,000) showed that medical management consistent with NAEPP Guidelines dramatically reduced asthma symptom days (5.6 vs. 2.3 days, a 59% reduction) within 3 weeks and also reduced asthma exacerbations by 49% over the course of the 1-year treatment period.^38,39

An analysis of commercial claims data from 8,834 U.S. children revealed that higher out-of-pocket costs for asthma medications were associated with a reduction in medication use and higher rates of asthma hospitalization among children aged 5–18 years.⁴⁸

Review of pharmacy claims data from 2,023 patients enrolled in a health maintenance organization showed that first-time prescriptions for asthma medications were less likely to be filled (within 30 days of the prescription date) by patients with above-average copays (i.e., more $12 in this study).⁴⁹

In an analysis of commercial claims data from 40,784 patients with asthma aged 12–64 years, those whose average monthly medication copayment costs increased by more than $5 experienced a significant decline in average annual days of medication supplied. Furthermore, a copayment increase of more than $5 per month was associated with more asthma-related outpatient and ED visits among persons with asthma who used leukotriene receptor antagonists or a combination of inhaled corticosteroids plus long-acting beta agonists than among those using similar medications whose copayments increased less than $5 per month.⁵⁰

A systematic review of interventions at the patient, provider, or systems level to improve medication adherence among U.S. adults found that shared (provider–patient) decision making to produce treatment regimens that accommodated patients’ goals and preferences could improve adherence.^51,52 Researchers identified asthma self-management education (including, but not limited to, the timing and use of asthma medications and how to handle signs and symptoms of worsening asthma) as an effective tool for improving adherence to medication regimens.⁵³

A systematic review of interventions to improve health care provider adherence to asthma treatment guidelines showed that prescriptions for controller medications could be increased by decision support (interventions designed to support health care provider decision-making), feedback and audit (providing performance data to health care providers about their quality of care), and clinical pharmacy support (targeting pharmacists’ delivery of care).⁵⁴

A review of the health and economic evidence for intensive asthma self-management education identified nine U.S. programs that provided this education and reported return on investment (ROI).⁸¹ Asthma self-management education was typically provided through one or more group sessions, but a few programs offered individual instruction either face-to-face or by telephone. Eight of the nine programs reported a positive ROI (i.e., more than $1 return per $1 invested) for all or some participants. Among these eight programs, one program achieved a positive ROI only among participants with more than one hospitalization, and one program achieved a positive ROI when its participants had more than two unscheduled asthma visits prior to program enrollment. Estimated time to achieve ROI ranged from 1 to 3 years. An additional 18 U.S. programs provided asthma self-management education and reported economic outcomes but not ROI.

A systematic review of interventions to improve adherence to self-administered medications found that asthma self-management education had the strongest evidence for improving adherence to medication regimens among the 10 chronic conditions studied.⁸²

A systematic review of asthma self-management education found that multifaceted interventions (i.e., those that explicitly addressed patient, provider, and organizational factors) most consistently improved clinical outcomes.⁸³ The authors highlighted the importance of patient education programs supported by regular reviews and ongoing evaluation of effectiveness.

A systematic review found that providing clinical decision-making support to health care providers or clinical pharmacy support (i.e., targeting pharmacists’ delivery of care) could help increase health care providers’ provision of asthma self-management education to patients.⁸⁴

A review of the health and economic evidence for asthma home visits identified 17 U.S. home visit programs that reported ROI.¹⁰⁷ Approximately one-third of these programs involved health plans; most were in urban areas. Fifteen of the 17 programs reported a positive ROI (i.e., more than $1 return per $1 invested) for all or some participants; among the programs that reported a positive ROI for participants, one program observed a positive ROI among children less than 6 years old. Median estimated time to achieve ROI was 3 years. An additional 25 U.S. home visit programs reported economic outcomes but not ROI.

Similarly, a systematic review of 13 cost-benefit or cost-effectiveness studies found that home-based, multi-trigger, multicomponent programs for treating asthma provide value (e.g., by reducing medical care costs or missed school and work days) for dollars spent on the interventions. Benefıt-cost ratios ranged from $5.30–14.00 per $1.00 spent.¹⁰⁸