With reimbursement increasingly tied to quality measures and other metrics, the question of whether best practices actually produce improved outcomes has taken on greater importance for clinicians and their patients.
Guidelines from the National Heart, Lung, and Blood Institute (NHLBI) offer recommendations for managing asthma, guidance on medications, recommendations on patient education in settings beyond the physician's office, and advice for controlling environmental factors that can cause asthma symptoms. Does adherence to these guidelines in the context of the Patient Centered Medical Home (PCMH) lead to improvements in asthma outcomes?
During a session at the 2014 Annual Meeting of the American Academy of Allergy, Asthma & Immunology, held February 28 — March 4, 2014, in San Diego, CA, Richard W. Honsinger, MD, Director of the Los Alamos Medical Care Clinic in New Mexico, argued that adherence to the guidelines would lead to improved outcomes in this setting, while Harvey L. Leo, MD, who is a pediatric allergist from Allergy and Immunology Associates in Ann Arbor, MI, argued that overall outcomes have not improved significantly, especially for minority patients.
Honsinger gave the background to the debate by reviewing the various versions and iterations of the NHLBI Guideline for the Diagnosis and Treatment of Asthma, the latest version of which was released in 2007. The guidelines recommend a stepwise approach for the long-term management of asthma.
Principles governing the administration, the standards of care, and best practices for Patient Centered Medical Homes (PCMH) were initiated in 1967 by the American Academy of Pediatrics (AAP) and subsequently further developed by various organizations that came on board; namely the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association. Their “Joint Principles of the Patient-Centered Medical Home” also date from 2007.
Other interested parties include the National Committee for Quality Assurance (founded in 1990), and its utilization of the Health Effectiveness Data and Information Set (HEDIS), various accreditation and certification programs, and the PCMH Recognition Program (2011). The current situation is influenced by provisions of the Patient Protection and Affordable Care Act of 2010 (ACA), which include quality measures. ACA objectives are supported by the availability of grants administered by the non-governmental Patient Centered Outcomes Research Institute (PCORI), which has processed 79 submissions for grants, including eight approved for asthma in the amount of $23 million.
According to Honsinger, a major impediment to the implementation of optimum long-term care for asthma patients is the unsatisfactory state of communications between primary care physicians (PCP) and specialists. Surveys have shown that PCPs are dissatisfied with the feedback from specialists about their referred patients and vice versa regarding follow-up. A Specialty Practice Program has been developed that incorporates a standardized Basic Referral Form with templates for immunodeficiency diseases and for asthma.
In presenting the case refuting the claim that adherence to the NHLBI guideline leads to improved asthma outcomes, Leo drew attention to quality measurements such as absolute costs, individual costs, hospitalization rates, and adherence to medication.
Asthma is a disease that commonly develops in childhood. It is especially prevalent in minorities (9.6% overall prevalence but over 17% in African Americans). African Americans with asthma, both children and adults, massively gravitate towards the emergency room for care. Asthma and other respiratory conditions have the third highest hospitalization rate in the nation.
Leo presented graphs that strikingly showed that, while there were some signs of an improvement in asthma outcomes over the years of study, there were major discrepancies in outcomes between Caucasian patients and Hispanic/Latino patients and African Americans, who had by far the worst outcomes.
In rebuttal, Honsinger acknowledged the situation was far from satisfactory and conceded that, so far, there were no clear signs that the use of PCMHs had led to decreased costs. However, he argued that if the NHLBI guideline has not had an effect it is because it has not been properly implemented. For him, the difference between the outcomes for black versus white patients illustrated the point that socially disadvantaged patients need implementation of the ACA and proposed changes to the Medical Sustainable Growth Rate (SGR) legislation to obtain the necessary insurance coverage and access to appropriate treatment. Honsinger gave an illustration of how the Alaskan Native Medical Center used the PCMH approach to improve asthma outcomes in their population.
Leo’s rebuttal focused on the need for the guidelines to address the big differences between outcomes in the black, Hispanic and white populations and the corresponding rates of medication adherence, hospitalizations and deaths.