Transcript Putting Excellent Asthma Care Within Reach

Better Asthma Care, Better Health and
Lower Costs – Is it possible?
Data, Decision-Making and Improving Outcomes
Paul Foreman, PhD, MS, MA
University of Missouri, School of Medicine
Project Director, Asthma Ready® Communities
Child Health, Pulmonary Medicine and Allergy
[email protected]
®
July 11, 2012
Disclosure
Dr. Foreman will not discuss off label or
experimental use of medications or devices.
He has no commercial relationships to
disclose. His research and presentations have
not been supported by pharmaceutical
companies or equipment vendors.
®
just do it.
®
Background
Charges to insurers result in rich data sets that
can define cost-efficient clinical services, identify
high risk children who require special care and
support evaluation of educational interventions.
This presentation will illustrate the usefulness of
Medicaid administrative claims data analysis and
will describe emerging asthma applications that
use claims data.
®
Claims Data Explained
Insurers receive bills from health care
providers, pharmacies, hospitals, durable
medical equipment companies and others
who deliver covered products or services to
beneficiaries. These charges are collectively
called “administrative claims.”
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March 26, 2012
Electronic Access to Claims
Insurers are beginning to provide electronic
access to claims records to allow clinicians and
others to more accurately assess adherence, risk
and control. Clinical histories and interview data
often DO NOT agree with claims data. Asthma
care is best guided by evaluating claims data
along side other data sources.
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March 26, 2012
just do it.
®
just do it.
®
just do it.
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Medication Related Problems
Analysis of claims data is being used to
identify 17 asthma management and
medication-related problems by Missouri
Medicaid. These problems are automatically
detected by a logic engine and the
pharmacist is notified at the time of
dispensing a medication that a problem
exists.
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March 26, 2012
Medication Related Problems (2)
The pharmacist is given the option of accepting
an encounter to address the problem. An
assessment and counseling guide is provided to
structure the encounter and pharmacist’s
documentation. If completed within 90 days the
pharmacist is reimbursed (99605,6,7) in 15
minute increments up to one hour a month for
medication therapy management.
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March 26, 2012
Medication Related Problems (3)
Examples of MRPs include:
1) low rate of ICS refills
2) albuterol dispensed > 3 times in 6 months
3) No spirometry in 3 years
4) Recent ER visit for asthma
5) >one oral steroid burst in 12 months
http://mediasuite.multicastmedia.com/player.php?v=al80y67g
®
March 26, 2012
just do it.
New, Compelling Asthma Outcome Variables
• ACD
Acute Care Day Score
ACD is defined as the number of days
of acute care for asthma in a given time period
If ACD = 6
– 6 ER visits
– 6 inpatient days or
– 3 ER visits & 3 inpatient days
®
just do it.
New, Compelling Asthma Outcome Variables
• POPT
– Proportion (P) of Outpatient
visits (OP) to Total visits (T)
including OP, ER visits &
inpatient days
– expressed from 0 to1
– where
• “0” is the worst case
scenario
(no outpatient visits, all asthma encounters
are in acute care settings)
• “1” is the best case
scenario (only OP visits)
Example
1 OP visit and 9 ER visits
1 OP / 1 OP + 9 ER =
0.1 POPT
Or
Only 10% of asthma encounters
were outpatient visits
®
just do it.
New, Compelling Asthma Outcome Variables
• DPR Daily Possession Rate
• Average daily amount of drug (i.e., inhaled corticosteroids)
available over a dispensing interval
• Charting ACD, POPT & DPR to model opportunities for
family member, PCP and school nurse messaging
• These claims data are available within one month of
event for timely actions
®
just do it.
New, Compelling Asthma Outcome Variables
• DPR charts change trajectory of care
• Micrograms of asthma medication and EPR3 ICS dose
ranges are plotted on the y axis by EPR3 guidelines
–
by age, sub-therapeutic, low, medium, high or very high
• Asthma ACD (ED and IP days) are plotted on the x axis
(time)
• POPT is calculated and displayed. DPR graphed by
actual dispensing interval, by year & 90 day
• Trajectory of delivered asthma health care can be
analyzed and appropriate interventions prompted by
messaging members, PCPs and school nurses
®
just do it.
Sub-therapeutic doses of ICS,
low PopT, high ACD, high
SABA
just do it.
Two ER visits,
starts ICS,
SABA use drops
just do it.
ACD =1 (ED visit),
high SABA, PopT = 0.83,
TUAC participation, medium dose ICS
Three Critical Data Sources
1) Clinicians
2) Claims
3) Interventions
a) pharmacists
b) school nurses
c) clinic-based educators
d) in-home trigger reduction specialists
http://asthma.esgn.tv/school_nurse_visit
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March 26, 2012
Educator Assessment (ACE©)
1) Custom assessment scan form
2) Before and after playing the ACE© DVD
3) Incorporates CARAT (Childhood Asthma
Risk Assessment Tool)
4) For “very poorly controlled asthma”
®
March 26, 2012
Educator Assessment (ACE©)
®
March 26, 2012
just do it.
Clinicians Assess Impairment & Risk
just do it.
School nurses assess impairment & risk
just do it.
School
Nurse
Messages
PCP
just do it.
School Nurse Messages PCP (continued)
• Objective measures of airflow by digital flow meter : FEV1 (% predicted, personal
best, and % change with quick relief medicine)
• Objective measurement of Inhalation technique : inspiratory flow rate and
inspiratory flow time
• Medication Adherence by Student Report – using a Respiratory Inhaler Poster
Chart : What medicines are available at home? How many missed doses of control
medicine? Using a spacer with inhaled MDI medicines?
• Impairment by Student Report : Activity limitation or sleep disruption due to
breathing problems?
•Tobacco Smoke Exposure by Student Report
•Form encourages provider to fax updated asthma action plan to school
just do it.
Calculate
percent
predicted
FEV1 and
peak flow
just do it.
School
Nurse
TUAC
Follow-Up
Formfurther
actions
just do it.
School Nurse Actions – Levels of Communication
• Send home a Student Asthma Status Report Form: Inform family of asthma
events at school – includes subjective and objective measures, encourage
communication/follow up with provider
• Called and talked to the family about their child’s asthma assessment
findings
• Met face-to-face with this family to discuss their child’s asthma care at
home and school
• Completed and sent a “School Nurse Report of Student Asthma
Assessments” to (name of health care provider)
•Provided an ICS Star Chart to promote inhaled corticosteroid (ICS) adherence
just do it.
Intervention Data Messaging Capacity
• Initial TUAC assessments are analyzed by EPR3
algorithms to suggest additional assessments
and interventions by the school nurse
Well
Controlled
• Children are categorized into three zone
classifications of EPR3→
• Parents and PCPs are alerted by school nurse
regarding findings in timely manner
• All clinical interventions are collaborative with
goal of moving children into the GREEN zone
over time. An expert support system is
needed to provide resources, analysis and
messaging (ARC)
Not Well
Controlled
Very Poorly
Controlled
guided by data
Medicaid (MoHealth Net Data Project)
Persistent asthma ages 6-18
140,000
Medicaid Leading Prescribed Asthma Medication by
Number of Claims, Missouri
132,641
120,000
•
36.4% received inhaled corticosteroids
and national average is 79.8%
(Arellano, et al, 2011)
100,000
79,730
80,000
53,451
60,000
40,000
26,191
20,000
•
0
24.0% ICS medication possession ratio
(MPR) adherence for all ages (SFY 2010)
SA Beta
Agonists
Leukotriene Inhaled Steroid
Inhaled
Modifiers
Combo
Corticosteriods
ICS Medication Possession Ratio Medicaid Population
with Persistent Asthma, Missouri
• $ 2574 paid for medication per
persistent asthmatic child annually
Percent
40
30
• Poor ICS medication use and
adherence contributes to acute care
utilization
20
35.59
37.29
22.45
23.44
13.14
13.85
37.38
23.97
Marginal and
Adherent 61%
or greater
13.25
Adherence
81% - 100%
10
0
*Missouri Department of Social Services, Mo Health Net
2008
2009
2010
Marginal
Adherence
61% - 80%
just do it.
Changing Cost Outcomes for Missouri Children with Asthma:
MO Health Net Data Project Collaboration
• Per member per month (PMPM) costs for children ages 5-18 identified
with persistent asthma was $1,497 for 6,577 participants in 2010.
• Per member per month costs for children ages 5-18 was $1044 for 134
patients of an EPR3-compliant practice in 2010.
• EPR3-treated group costs were 9.6% higher for ICS medication costs
and 17% higher costs for treating co-morbid conditions when
compared to population mean.
• However the total asthma direct costs were 4.7% lower for EPR3treated group.
• Remarkably, total asthma medication costs were 33% lower and total
cost of care was 30% lower for the EPR3-treated patient group.
just do it.
IMPACT Asthma Kids© Care
Background
• Asthma Ready® Clinics and Medical Homes
- clinic staff including physicians, nurse practitioners, nurses,
receptionists/billing clerks and respiratory therapists receive asthma
standardized medical management curricula, equipment & protocols
(EPR3 compliant care)
• Asthma Ready® Schools
- School nurses trained, standardized curricula
- School assessments and interventions are based on EPR3 guidelines
- Actionable data are documented and sent to the parents and PCP
(should be in real time)
®
just do it.
IMPACT Asthma Kids© Care
Background
• Medical Homes and Asthma Ready® Clinics (ARC)
-Comprehensive care in the context of individual, cultural, and
community needs:
ARC address individual patient and family goals each clinic visit and
refers to community partners for continuity of care
-Emphasize education through system-level protocols and
interpersonal interactions:
Asthma Ready Educator uses standardized asthma literacy
education tools for patients and families and validated assessment
protocols for transmitting actionable data
-At the center of the Medical/Health Home are the patient and family
and their relationship with the primary care team
Asthma Ready care is delivered by a team, composed of a clinic
provider and a nurse trained as an asthma educator
®
just do it.
®
School /Clinic Based IMPACT Programs
• Based on dyad approach – clinic and school
district in proximity prepared to deliver care
• Rural and urban school districts identified as
having the highest persistent childhood asthma
rates and level of health risk in Missouri
• Identify targets by matching the zip codes clinic
sites of Federally Qualified Health Centers
(FQHC) and Asthma Ready Clinics (includes
Medical Homes) with local school districts
• School nurses who expressed interest in IMPACT
programs after receiving 2011 Missouri School
Asthma Manual
School
District
Clinic
Child
&Family
®
March 26, 2012
just do it.
Changing Outcomes for Missouri Children with Asthma:
MO Health Net Collaboration
• Identify populations of children suffering from the most severe asthma
– Claims: high ACD, low POPT, sub-therapeutic ICS, higher cost of care
– School: exacerbations, low FEV1, high impairment, high absenteeism
• Train local school and clinic (including medical homes) dyads in EPR3
guidelines for care using standardized curricula
• Continuously analyze school & claims data to deploy and stratify
interventions to meet their needs and the family circumstances
• Produce actionable data for key providers (Asthma Control Dashboard)
• Track individual and aggregated outcomes and evaluate using
advanced scientific methodology
Asthma Control Dashboard
(Patient 1)
Past 3 years
Past 90 days
Indicator / Measure
Well Controlled
Not Well
Controlled
Very Poorly
Controlled
Inhaled Corticosteroid
Low / Med
High
Sub-therapeutic
Inhalation Technique
Good
Inadequate
Poor
SABA
< 3 / week
> 3 / week
High doses
FEV1
> 80% of personal
best
Or
% Predicted
60% - 80%
< 60%
Impairment Score
None
Some
Lots
Oral Steroid Burst
0 - 1 / year
2 - 3 / year
> 3 year
Acute Care Days
0 - 1 day
2 - 6 days
> 6 days
Cost
< 120%
120% - 200%
> 200%
Summary: This child demonstrates very poorly controlled asthma with possession of sub-therapeutic
amounts of ICS, more than 3 oral steroid bursts, more than 6 days of acute care for asthma and very high
cost of care. Recommendation: Additional clinical encounters, 98960 (ACE) and home trigger reduction.
Asthma Control Dashboard
(Patient 2)
Past 3 years
Past 90 days
Indicator / Measure
Well Controlled
Not Well
Controlled
Very Poorly
Controlled
Inhaled Corticosteroid
Low / Med
High
Sub-therapeutic
Inhalation Technique
Good
Inadequate
Poor
SABA
< 3 / week
> 3 / week
High doses
FEV1
> 80% of personal
best
Or
% Predicted
60% - 80%
< 60%
Impairment Score
None
Some
Lots
Oral Steroid Burst
0 - 1 / year
2 - 3 / year
> 3 year
Acute Care Days
0 - 1 day
2 - 6 days
> 6 days
Cost
< 120%
120% - 200%
> 200%
Summary: This child demonstrates very poorly controlled asthma with evidence of poor inhalation
technique, adequate possession of ICS, 2 oral steroid bursts, 2 days of acute care for asthma and high cost
of care. Recommendation: Consider ACE, 2 tone MDI trainer, spacer, teach target time, and school nurse
contact for more coaching.
Asthma Control Dashboard
(Patient 3)
Past 3 years
Past 90 days
Indicator / Measure
Well Controlled
Not Well
Controlled
Very Poorly
Controlled
Inhaled Corticosteroid
Low / Med
High
Sub-therapeutic
Inhalation Technique
Good
Inadequate
Poor
SABA
< 3 / week
> 3 / week
High doses
FEV1
> 80% of personal
best
Or
% Predicted
60% - 80%
< 60%
Impairment Score
None
Some
Lots
Oral Steroid Burst
0 - 1 / year
2 - 3 / year
> 3 year
Acute Care Days
0 - 1 day
2 - 6 days
> 6 days
Cost
< 120%
120% - 200%
> 200%
Summary: This child demonstrates very poorly controlled asthma with evidence of good inhalation
technique, high ICS, Moderate amount of use of SABA, more than 3 oral steroid bursts, more than 6 days
of acute care for asthma and very high cost of care. Recommendation: Consider CARAT, star chart to
encourage compliance with ICS and school nurse alert for monitoring.
®
just do it.
just do it.
Students Receiving Award for
Finishing Asthma Education
Benjamin Francisco, PhD, PNP, AE-C
Asthma Ready®, University of Missouri