MANAGING ASTHMA: Keys to Delivering Value-Based Care

Asthma is a common chronic disorder of the airways characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness to constructing stimuli, and underlying inflammation. The inter­action of these features determines the clinical manifestation and severity of asthma. The devel­opment of asthma appears to involve the interplay between host factors (particularly genetics) and environmental exposures that occur at a crucial time in the development of the immune system.1

A 2013 report from the Centers for Disease Con­trol and Prevention shows that asthma affects an estimated 25.9 million Americans, of which 7.1 million are children. During 2001 to 2011, the number of individuals with asthma increased by 28%. In 2010, asthma accounted for 3404 deaths, 439,400 hospitalizations, 1.8 million emergency department visits, and 14.2 million physician office visits. Furthermore, asthma prevalence is highest among adults 18 to 24 years of age (10.3%), adult females (10.7%), and multirace and black adults (15.1% and 10.8%, respectively).2

Economic Impact of Asthma

Asthma’s prevalence places a significant eco­nomic burden on society, providers, and payers. The total annual cost of asthma was $56 billion in 2007, translating to $50.1 billion in direct costs (hospitalizations is the single largest portion of this cost) and $5.9 billion in indirect costs from lost earnings due to illness or death.2,3 Studies have examined the economic burden of asthma in the United States and in managed care settings. Based on data from the 2008 to 2010 Medical Expenditure Panel Surveys, Sullivan et al4 found that individuals with asthma and markers of uncontrolled asthma had higher medical expenditures ($4423), greater utilization of services (eg, emergency visits were 1.8-fold greater), and decreased productivity attributable to unemployment, work absentee­ism, and activity limitations compared to those without asthma.

 In a real-world managed care study, Zeiger et al5 looked at the clinical and economic burden of patients with severe uncontrolled asthma (SUA). Patients with SUA exhibited significantly more asthma exacerbations and short-acting beta₂- agonist use, and higher all-cause and asthma-related costs than patients with non-SUA. The adjusted asthma-related average direct cost per patient at follow-up was significantly higher for SUA than non-SUA ($2325 vs $1261, respectively) with an incremental cost of $1056 (95% confidence inter­val [CI], $907-$1205). Asthma drugs accounted for the major difference (incremental cost of $848/patient; 95% CI, $737-$959).

Diagnosis and Treatment

A key to delivering value-based care is to establish a diagnosis of asthma as early as possible. Clinicians should start by determining that symptoms of recurrent episodes of airflow obstruc­tion or airway hyperresponsiveness are present via a detailed medical history and physical examination. Table 1 provides key symptom indicators for con­sidering a diagnosis of asthma. The presence of multiple key indicators increases the probability of asthma; however, spirometry is needed to es­tablish a diagnosis.1

 The National Asthma Education and Prevention Program (NAEPP) guidelines has classified asthma severity in 4 stages: intermittent, mild persistent, moderate persistent, and severe persistent. Table 2 outlines the NAEPP staging criteria for classify­ing asthma and initiating therapy in patients age 5 to 11 and age ≥12. Achieving and maintaining asthma care requires 4 components of care1:

• Assessment and monitoring

• Education for a partnership in care

• Control of environmental factors and comorbid conditions that af­fect asthma

• Medications

Medications for asthma are catego­rized into 2 general classes: long-term control medication and quick-relief medications. When choosing drug therapy, clinicians need to consider general mechanisms and the role of medication in therapy, delivery, devic­es, and safety. The NAEPP guidelines recommend a stepwise approach for managing asthma that dovetails with managed care’s mandate of delivering cost-effective care. It starts with the use of inhaled corticosteroid (ICS) monotherapy as the first line of treatment for persistent asthma (mild, moderate, and severe) across all age groups. For patients whose asthma is not adequately con­trolled on low-dose ICS monotherapy, clinicians should consider a medium-dose ICS monotherapy or adding a long-acting beta-agonist to the low-dose ICS regimen.1

Despite treatment according to current guide­lines, patients with asthma remain symptomatic. In the US, the Asthma Control Characteristics and Prevalence Survey Studies reported the preva­lence of uncontrolled asthma was 58% and 46% in adult and pediatric patients, respectively.6 Poorly controlled asthma puts patients at risk of future exacerbations and thus has a significant impact on patients’ lifestyles and on the use of health care resources and health care expenditures.

The degree to which a patient’s asthma is con­trolled may be related to disease treatment and, or severity. Asthma may also be affected by other contributing factors including comorbidities such as allergic rhinitis and gastroesophageal reflux, poor treatment adherence, incorrect inhaler technique, allergen exposure, or concurrent smoking.7

Therefore, there is an ongoing need for improve­ment in the management and control of asthma. Emerging therapeutic options are currently in development and undergoing clinical trials for the treatment of symptomatic asthma. These include anti-interleukin agents, chemoattractant receptor-homologous molecules expressed on T-helper type 2 lymphocyte antagonists, phosphodiesterase-4 inhibitors, and long-acting muscarinic antagonists.7

 Asthma Education

Asthma self-management education is crucial to reducing asthma-related adverse health effects. Education also improves quality of life by reduc­ing urgent care visits, emergency department visits, hospitalizations, and health care costs. To maximize delivery of value-based care, clinicians should provide asthma self-management educa­tion to patients with asthma and their families or caregivers. In addition, patients with asthma (particularly for patients with moderate to severe persistent asthma, a history of severe exacerba­tions, or poorly controlled asthma) should receive a written action plan that includes instructions for daily asthma management and for recognizing and handling worsening asthma.1,2

Furthermore, clinicians should integrate asthma self-management education into all aspects of asthma care. It should:1

• Begin at the time of diagnosis and continue through follow-up care

• Involve all members of the health care team

• Occur at all points of care where health care professionals interact with asthma patients

• Use a variety of educational strategies to reach individuals who have varying levels of health literacy and learning styles

• Incorporate individualized case/care man­agement by trained health care professionals who have poorly controlled asthma and have recurrent visits to the emergency department or hospital

 Although there is no cure for asthma, asthma can be controlled with appropriate medical care, ad­dressing environmental factors that cause worsening symptoms, helping patients learn self-management skills, and long-term monitoring to assess, control, and adjust therapy accordingly.1 Asthma remains a prevalent and challenging health issue that contin­ues to be an economic burden on society, managed care, and payers. Therefore, collaboration among all stakeholders is critical in managing asthma to reduce health care utilization and costs.—Eileen Koutnik Fotopoulos

References

1. National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Full Report 2007. National Asthma Education and Prevention Program. US Department of Health & Human Services; National Institutes of Health. https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf. Accessed October 25, 2015.

2. Centers for Disease Control and Prevention. Asthma Facts—CDC’s National Asthma Control Program Grantees. July 2013. www.cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf. Accessed October 25, 2015.

3. Asthma and Allergy Foundation of America website. Asthma facts and figures. www.aafa.org/

display.cfm?id=9&sub=42. Accessed October 25, 2015.

4. Sullivan PW, Slejko JF, Ghushchyan VH, et al. The relationship between asthma, asthma control and economic outcomes in the United States. J Asthma. 2014;51(7):769-778.

5. Zeiger RS, Schatz M, Dalal AA, et al. Utilization and costs of severe uncontrolled asthma in a managed-care setting [published online ahead of print October 2, 2015]. J Allergy Clin Immunol Pract. DOI:10.1016/j.jaip.2015.08.003.

6. Stanford RH, Gilsenan AW, Ziemiecki R, et al. Predictors of uncontrolled asthma in adult and pediatric patients: analysis of the Asthma Control Characteristics and Prevalence Survey Studies (ACCESS). J Asthma. 2010;47(3):257-262.

7. McIvor RA. Emerging therapeutic options for the treatment of patients with symptomatic asthma. Ann Allergy Asthma Immunol. 2015;115(4):265-271.