Allergycosteffectivenessslides r4132004
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Asthma patients cared for by allergists have significantly better health outcomes and lower healthcare costs compared to those cared for by primary care physicians alone. Allergists achieve fewer emergency visits, hospitalizations, and missed days of work/school for asthma patients. Their specialized training in accurately diagnosing asthma triggers and treating sensitivities results in improved disease management and reduced acute care utilization. As a result, the costs of caring for asthma patients is substantially lower when an allergist is involved in their treatment.
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Allergycosteffectivenessslides r4132004
- 1. Cost Effectiveness of Allergy Care
- 2. Asthma Patients Cared for by Allergists Have: • Fewer emergency care visits • Fewer hospitalizations • Reduced length of hospital stays
- 3. Asthma Patients Cared for by Allergists Have: • Fewer sick care office visits • Fewer days missed – school or work Increased productivity in work and personal lives Fewer sick days =
- 4. Asthma Patients Cared for by Allergists Have: • Greater satisfaction with their care • Improved quality of care • All of this supported by peer reviewed literature
- 5. Asthma in the United States • 17 million Americans have asthma • Prevalence rose 42% in 1982 – 1992 • Prevalence higher in children, i.e. - 4-6 million pediatric asthmatic case • 1.5 million ER visits and 460,000 hospitalization in 1992
- 6. Cost of Asthma Care Direct Medical Expenditures Cost $M Hospital Care: In-Patient- $2054.6 Emergency- $546.3 Out-patient- $722.6 Physician’s Services: In-patient care- $110.9 Office visits- Prescriptions- $724.7 $3188.1 All direct expenditures $7365.3 Weiss and Sullivan JACI 2001
- 7. Indirect Cost of Asthma CareIndirect Cost of Asthma Care Indirect Costs Costs $M School days lost $1,107.3 Loss of work (outside employment) • Men $415.0 • Women $1,128.2 Housekeeping $841.7 Mortality $1,813.9 Total indirect costs $5,306.0 All Costs: $12,671.3 Weiss and Sullivan J Allergy Clin Immunol 2001
- 8. Allergist ManagementAllergist Management • Primary care for 1 year • Allergy evaluation + 1 year follow up • Reduced: - Sick care office: 308 to 169 (45%) - Acute care: 266 to 118 (55%) - Hospitalizations: 34 to 11 (67%) - Hospital days: 4 to 2.5 • Cost savings $145,500 All the above results are statistically significant Westley CR et al All Ast Proc 1997;18, 15
- 9. Missed Work and SchoolMissed Work and School Days Due to AsthmaDays Due to Asthma • Care in multi-disciplinary asthma center: • Hospitalization frequency decrease 77.4% • Emergency department visits decreased 71.80% • 80% decrease in missed work days • 65% decrease in school absences NJC – Medical Scientific Update 1998 McDonald RJ ACCP Meeting (ABS) 1999
- 10. Asthma Care Provided byAsthma Care Provided by Allergists as Compared toAllergists as Compared to GeneralistsGeneralists • Fewer hospitalizations and emergency room visits (OR 0.63) • Better ratings for quality of care • Fewer restrictions in activities (OR 0.57) • Improved physical functioning (P<than .001) Wu AW et al, Archives of Int Med 2001
- 11. Impact of Allergist CareImpact of Allergist Care • 125 adults with at least one hospitalization or more than two ED visits in 6 months before entry • Refer to Asthma Center for care • Decrease emergency visits 74-17 (76% decrease) • Decrease hospitalizations 38-4 (98% decrease) Villanueva AC et al Abstract ACCP October 2000
- 12. In-Patient CostIn-Patient Cost Reductions Asthma CareReductions Asthma Care Provided by AllergyProvided by Allergy SpecialistsSpecialists • 125 patients – hospitalizations decreased from 38 to 4 • Total hospital costs decreased from $192,926 to $20,308. • Total emergency department costs decreased from $34,706 to $7,973. Villanueva AC et al Abstract ACCP 2000
- 13. In-Patient Cost ReductionsIn-Patient Cost Reductions For Asthma Care Provided byFor Asthma Care Provided by Allergy SpecialistsAllergy Specialists • Per patient hospital costs decreased 95% – $40,253 → $1,926 – 19 patients with a history of intubations for status asthmaticus – Follow up one year after intubation in allergy clinic – Patient hospital costs decreased 95% ($40,253 to $1,926.00)
- 14. Emergency Room Follow-UpEmergency Room Follow-Up :: Allergists vs PCP in an HMOAllergists vs PCP in an HMO • All ER visits for acute asthma – alternating referral of allergists vs. PCP for follow-up • Blind review of medical records for next 6 months • 50% decrease in asthma ER relapses for allergy patients (P=0.017) • Greater use of inhaled steroids for allergist’s patients (P<.000001) • 75% decrease nocturnal awakenings for allergy patients (P<.000001) Zeiger et al JACI 1991
- 15. Reduction in Acute Care CostsReduction in Acute Care Costs when Treated by Allergywhen Treated by Allergy SpecialistsSpecialists • 207 patients – Mail survey • One year before and one year after 1 intervention • Total cost savings per patient: $4,155.00 Gaioni SJ et al Am J MGD Care 1996 Number of Patients Cost Savings HospitalizatioHospitalizatio nn 157-35157-35 $724,070.$724,070. ED VisitsED Visits 233-63233-63 $136,000.$136,000.
- 16. Allergic Rhinitis, BHR andAllergic Rhinitis, BHR and Asthma Immunotherapy asAsthma Immunotherapy as TreatmentTreatment andand PreventionPrevention 0 100 200 300 400 500 600 700 800 PD20FEV1,mg Baseline Year 1 Year 2 Placebo SIT In Normal Range Placebo: 0 SIT: 50% In Normal Range Placebo: 0 SIT: 50% Grembiale R. Am J Respir Crit Care Med 2000; 162:2048-52
- 17. Effect of Specialty CareEffect of Specialty Care Bukstein DA, Luskin Annals of Allergy. 1997 0 1 2 3 4 5 6 7 8 Hospital/ 100 Hospital stay Hospital days/ 100 ED visits/ 100 Allergist: follow ed PCP only Allergist: not follow ed
- 18. Improved Outcomes:Improved Outcomes: ExplanationsExplanations AllergistAllergist PCPPCP Anti-inflammatory: β-agonist (SA) 1.6:1 0.46:1 Anti-inflammatory adherence 67% 39% No refill after 1st 8% 25% Bukstein DA, Luskin AT. 1997
- 19. ““Why can’t we just have PCPs doWhy can’t we just have PCPs do it?it?
- 20. Delivery of Asthma Care -Delivery of Asthma Care - What is Known •Aspects of asthma guidelines are effective •Most caregivers know, but do not follow, guidelines •Patients receiving proper recommendations generally don’t follow them
- 21. Primary Care andPrimary Care and Asthma GuidelinesAsthma Guidelines 91 72 99 50 0 10 20 30 40 50 60 70 80 90 100 %Physicians Heard of Guidelines Read Guidelines Found Useful Written Action Plan Finklestein, Pediatrics, 2000
- 22. Pediatrician Non-Pediatrician Non- Adherence to AsthmaAdherence to Asthma GuidelinesGuidelines• 455 pediatricians responded to survey of adherence to guidelines • 81% had access to a copy of the guidelines • 64% were “adequately familiar” with the guidelines • Rate of adherence to different guideline components (self reported) vary from 39%-53%.
- 23. ““Can’t we just send the worstCan’t we just send the worst ones to the allergist?”ones to the allergist?”
- 24. Specify the TargetSpecify the Target PopulationsPopulations The 20-80 RuleThe 20-80 RuleThe 20-80 RuleThe 20-80 Rule 2% = Severe $25,000 / yr + 18% = Episodic $2,500 / yr 80% = “Healthy” $250 / yr 20% of members 80% of costs
- 25. Specify the TargetSpecify the Target PopulationsPopulations Pitfall of the 20-80 RulePitfall of the 20-80 Rule This Year Next Year High Cost Low Cost Member
- 26. Reasons for AllergistsReasons for Allergists Provided Cost-EffectiveProvided Cost-Effective OutcomesOutcomes • Accurate diagnosis of disease type and severity • Identified external triggers including allergens – advise on avoidance • Immunotherapy (allergy shots) to decrease sensitivity to allergic triggers
- 27. Asthma Patients CaredAsthma Patients Cared For by Allergists Have:For by Allergists Have: • Fewer emergency care visits • Few hospitalizations • Reduced length of hospital stays • Fewer sick care office visits • Fewer days missed – school or work • Increased productivity in work and personal lives THUS LOWER YOUR COST!
Editor's Notes
- This program will show that facilitating allergists care will save insurance carrier costs because of fewer emergency care visits, few hospitalizations and for those who are hospitalized, fewer hospital days.
- In addition, patients with asthma, cared for by allergists, have fewer acute or sick care visits. In addition to lower costs of office visits, there is greater productivity and better attendance at school thus providing a double benefit.
- We can demonstrate all of the claims we have made by examining supporting documentation in the medical literature. Consumer satisfaction is a major benefit of the improved care allergists provide.
- Asthma is a fairly common disease affecting 17 million Americans and increasing in frequency. In 1992, there were 1.5 million emergency department visits and 460,000 hospitalizations. Both of these statistics can be substantially decreased with significant carrier savings, by allowing ready access-to-care by an allergist. Most asthmatics are treated by primary care physicians and the prevalence of expensive asthma treatment in hospitals including both ER visits and hospitalizations should be reduced through consultation with an asthma specialist.
- Asthma is an expensive disease in terms of direct costs, usually covered by insurance. In the year 2000, in-patient hospital care cost over 2 billion dollars; emergency care - half billion; and hospital out-patient care - $700 million. Overall direct costs exceeded 7 billion dollars.
- Although direct costs are more easily measured, the indirect cost of asthma is over 70% more than the direct costs!
- Let’s look at how adding care by an allergist can reduce some of the costs. Records of 70 patients with moderate to severe bronchial asthma were reviewed. These patients had been under the care of their primary care physician only for one year and then had follow-up care by an allergist for at least one year. The requirements for entering the study were a history of at least two emergency visits and/or one hospitalization before the allergy evaluation. The result of this study shows that the number of sick care visits was reduced by 45% and the number of hospitalizations by 67%. The overall cost savings for the 70 patients were $145,500.
- In a study of patients with moderate to severe bronchial asthma in the 6-month prior to and 12 months after treatment at National Jewish Center data, revealed a 77.4% decrease in hospitalizations and 71.8% decrease in emergency department visits along with comparable reductions in missed school and work days.
- A mail survey of 1954 adult asthma patients enrolled in 12 managed care organizations and 1078 matched physicians was done. The study compared outcome results one year later looking at care provided by generalists as compared to allergists. The results of this study showed that patients of allergists had to be hospitalized or have ED visits (OR 0.63) or were significantly less likely to cancel activities (OR .057). These patients also rated physician communication and overall quality of care significantly higher when they were under the care of an allergist.
- Asthma care centers can provide improved outcomes for those patients who utilize ER and hospital excessively.
- In the same study, the authors show that referral of 125 patients (of one hospitalization or two or more emergency department visits) to an asthma center, also resulted in a decrease in hospitalizations from 38-4 with a decrease in total hospital costs of $192,926 before referral to $20,308 after referral. Also, the total emergency department costs decreased from $34,706 to $7,973 after asthma clinic intervention.
- Nine patients with a history of intubation for status asthmaticus were followed in an allergy clinic for at least one year after intubation. Medical costs of asthma were determined for the one year before and one year after intervention. Costs for in-patient hospital care decreased from $40,253 to $1,926.00 (P&lt;.001) per patient.
- A mail survey of 207 patients with bronchial asthma seen in the University Hospital Asthma Center compared hospitalizations, ED visits, and unscheduled physician visits for one year before and one year after the intervention. Results show a decrease in hospitalization of 78%; a decrease in emergency department visits of 73%; a reduction of and unscheduled physician visits of 48%. The reduction in hospitalizations for one year after intervention as compared to the year before intervention went from 157-35 with a total savings of $724,070 dollars ($3,488.00) Emergency department visits decreased for a 233-63 with total savings of $136,000. ($637.00 per patient). The total one year savings, on a per patient basis, was $4,155.00.
- The vertical axis represents airway reactivity as measured by methacholine challenge. 44 patients with allergic rhinitis and bronchial hyper reactivity demonstrated by methacholine, and sensitivity to dust mites were placed on immunotherapy to mite in a double-blind placebo controlled study. After one year the researchers found it took almost three times as much methacholine to get a 20% drop in FEV1 (P&lt; .001). At the end of the study, year two, 50% of the subjects methacholine tests returned to normal. In addition, 9% of the subjects on placebo developed bronchial asthma while no asthma developed in any of the subjects receiving specific immunotherapy.
- Patients were divided into three groups. Group 1 were patients seen and followed with two or more telephone or office visit contacts per year by the allergy group. Group 2 were patients seen by the allergy group in the previous five years, but with less than two contacts per year. Group 3 were patients not seen by the allergy group in the past five years. Patients followed by the allergy group required less utilization of resources for acute uncontrolled disease than patients never seen by the allergy group or those not actively followed. Calculated at $1,000.00 per day for in-patient asthma care and $750.00 per emergency department visit, specialty care would save over $4,500.00 per identified asthmatic patients in a 12-month period. If no other parameter changed, savings in acute care cost to the health plan would approach $65,000.00 if all asthmatics identified in this study had been cared for by the allergy group. In patients seen or followed by two or more contacts with the allergy group, there was a substantial decrease in the emergency department visits and hospital days. Those who were never seen by an allergist, experienced an increase in emergency department visits, which is expected.
- In a review of 150 medical records for each of three groups of patients enrolled in an HMO for use of anti-inflammatory drugs, patients of allergists showed a significantly higher ratio for use and adherence to inhaled corticosteroids as compared to patients who are cared for only by their primary care physician. Primary care physicians patients demonstrated higher rates of β-agonist to inhaled corticosteroid use and a significantly lower compliance rate. Refill rates for the use of inhaled corticosteroids was higher.
- The question is frequency asked whether PCP’s should be trained to follow asthma guidelines and to provide asthma education. We will look at that in the next several slides.
- There is evidence that most caregivers are aware of but do not follow disease treatment guidelines. It is also known that patients receiving proper recommendations generally do not follow those recommendations. We also recognize that patients treated in accordance with asthma guidelines generally do better than those treated without guideline guidance.
- In a study reported in the year 2000 looking at 407 primary care physicians, it was found that while 91% had heard of the asthma guidelines, only 72% had read them, and only 50% provided their patients with written action plans. Written action plans are considered key to compliance with therapy recommendations. In addition, only 21% of the primary care physician used spirometry routinely. Primary care physicians criteria for referral to an allergy specialist were significantly different from the NAEPP and they generally chose to manage more severe patients without asthma specialists’ input. As shown above, this probably increases the costs.
- Although many pediatricians are aware of the 1997 NHLBI Asthma Guidelines, there compliance with various guidelines components ranges from 39%-53%. Among the reasons for non-compliance were lack of agreement with the guidelines and lack of time for guideline components that called for intensive counseling and education. Asthma specialists are trained to provide asthma education and counseling and have the necessary time to provide these services.
- The general rule in asthma care is that 20% of the patients with asthma account for 80% of the costs. It might make sense to send only the 20% most severe asthmatics to the specialists, but…
- …the patient who is in the 80% category this year may well be in the 20% category next year because of progression of the disease. We cannot predict, with any accuracy, what patients should be seen by the allergist and which ones should not.
- We have shown you that allergist care is the most cost effective care. Reasons for this are: Accurate diagnosis and categorization into the proper category in accordance with guidelines, this helps to guide the medication approach, which is laid out well in the guidelines. The ability to recognize triggers and counsel on avoidance; and Availability of allergen immunotherapy, which has been shown to reduce costs significantly.
- Patients with asthma, who are cared for by allergists have: Fewer emergency department visits, Few hospitalizations, Reduced length of stay in hospital, Fewer sick care visits, THUS LOWER YOUR COST