A randomized controlled trial of a pediatric asthma outreach program,☆☆,

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Abstract

Background: Previous studies have shown that asthma education and case management may reduce asthma emergency care, hospitalizations, and expenditures. Objective: We sought to study the effect of an asthma outreach program (AOP), a team-based, case-management intervention, on emergency ward (EW) and hospital use. Methods: Fifty-seven patients aged 1 to 15 years with the diagnosis of asthma based on the usual clinical practice criteria who were continuously enrolled in a staff-model health maintenance organization for a period of at least 2 consecutive years were randomized into 2 intervention groups. The control group received a single intensive asthma education intervention, and the AOP group received the same initial education but then was followed-up by an asthma case management nurse throughout the intervention period. Results: EW visits, hospitalizations, and total outside-of-health-plan expenditures (consisting of EW and hospital expenses, as well as miscellaneous costs, such as ambulance, durable medical equipment, tertiary referrals, and home care) were assessed from claims filed for a year before and after enrollment. Control group patients experienced significant reductions in EW visits (39%), hospitalizations (43%), and outside-of-health-plan costs (28%), possibly as a result of the baseline educational intervention received by all enrolled patients, in conjunction with regression to the mean. AOP group patients experienced significant reductions in EW visits, (73%, P = .0002), hospitalizations (84%, P = .0012), and outside-of-health-plan use (82%, P < .0001). When compared with the control group, AOP group patients demonstrated additional significant reductions in EW visits (57%, P < .05), hospitalizations (75%, P < .05), and outside-of-health-plan use (71%, P < .001). Estimates of direct savings to the health plan ranged from $7.69 to $11.67 for every dollar spent on the AOP nurse’s salary, depending on assumptions. Conclusions: Asthma patients in a staff-model health maintenance organization decreased their resource use between 57% to 75% by participation in an AOP as compared with a randomized control group receiving only an educational intervention. Substantial savings were achieved compared with the cost of the AOP nurse. (J Allergy Clin Immunol 1999;103:436-40.)

Section snippets

METHODS

A total of 57 pediatric patients with asthma between the age of 1 and 15 years were enrolled in this phase of the AOP. Patients less than 12 months of age at randomization who had wheezing for the first time or who had the eventual diagnosis of bronchopulmonary dysplasia were excluded. Patients were selected from predominately urban health centers of the Health Centers Division of Harvard Pilgrim Health Care, a large health maintenance organization in New England. This study was approved by the

RESULTS

Fifty-seven patients were enrolled in this randomized trial as defined above. A total of 18 patients were recruited from the hospitalization list, with 9 being randomized into the “control” group (group H, Table I) and an equal number into the AOP group (group H, Table II).An additional 39 patients were obtained by referral from pediatricians and were randomized independently into the “control” (group R, Table I) and AOP (group R, Table II) groups. As expected, the patients derived from the

DISCUSSION

The before and after intervention results for the AOP group are similar to those obtained in our previously reported uncontrolled trial.10 In that study we did not have a control group and therefore had no effective way to estimate the influence of natural regression to the mean or what effect the result of identifying patients as high risk (by their pediatrician or because of the patients’ EW use or hospitalizations) would have on subsequent use. We have independent observations on a similar

Acknowledgements

We thank all the pediatricians who referred patients to the project and cared for those who were randomized to the control group.

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Supported in part by the Harvard Pilgrim Health Care Foundation.

☆☆

Reprint requests: Dirk K. Greineder, MD, PhD, Department of Allergy, Harvard Pilgrim Health Care, 133 Brookline Ave, Boston, MA 02215.

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