Cost Effectiveness of Allergy Care

Asthma Patients Cared for by Allergists Have: Fewer emergency care visits Fewer hospitalizations Reduced length of hospital stays Fewer emergency care visits Fewer hospitalizations Reduced length of hospital stays

Asthma Patients Cared for by Allergists Have: Fewer sick care office visits Fewer days missed – school or work Fewer sick care office visits Fewer days missed – school or work Increased productivity in work and personal lives Fewer sick days =

Asthma Patients Cared for by Allergists Have: Greater satisfaction with their care Improved quality of care All of this supported by peer reviewed literature Greater satisfaction with their care Improved quality of care All of this supported by peer reviewed literature

Asthma in the United States 17 million Americans have asthma Prevalence rose 42% in 1982 – 1992 Prevalence higher in children, i.e million pediatric asthmatic case 1.5 million ER visits and 460,000hospitalization in million Americans have asthma Prevalence rose 42% in 1982 – 1992 Prevalence higher in children, i.e million pediatric asthmatic case 1.5 million ER visits and 460,000hospitalization in 1992

Cost of Asthma Care Direct Medical ExpendituresCost $M Hospital Care: In-Patient-$ Emergency-$546.3 Out-patient-$722.6 Physician’s Services: In-patient care-$110.9 Office visits- Prescriptions- $724.7 $ All direct expenditures$ Weiss and Sullivan JACI 2001

Indirect Cost of Asthma Care Indirect CostsCosts $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

Allergist 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 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

Missed Work and School Days 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 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

Asthma Care Provided by Allergists as Compared to Generalists 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) 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

Impact 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 (76% decrease) Decrease hospitalizations 38-4 (98% decrease)  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 (76% decrease) Decrease hospitalizations 38-4 (98% decrease) Villanueva AC et al Abstract ACCP October 2000

In-Patient Cost Reductions Asthma Care Provided by Allergy Specialists 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, 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

In-Patient Cost Reductions For Asthma Care Provided by Allergy 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) Doan T et al Ann Allergy Immunology 1996 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) Doan T et al Ann Allergy Immunology 1996

Emergency Room Follow-Up: Allergists 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< ) 75% decrease nocturnal awakenings for allergy patients (P< ) Zeiger et al JACI 1991 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< ) 75% decrease nocturnal awakenings for allergy patients (P< ) Zeiger et al JACI 1991

Reduction in Acute Care Costs when Treated by Allergy Specialists 207 patients – Mail survey One year before and one year after 1 intervention Total cost savings per patient: $4, patients – Mail survey One year before and one year after 1 intervention Total cost savings per patient: $4, Gaioni SJ et al Am J MGD Care 1996 Number of PatientsCost Savings Hospitalization157-35$724,070. ED Visits $136,000.

Allergic Rhinitis, BHR and Asthma Immunotherapy as Treatment and Prevention In Normal Range Placebo: 0 SIT: 50% In Normal Range Placebo: 0 SIT: 50% Grembiale R. Am J Respir Crit Care Med 2000; 162:

Effect of Specialty Care Bukstein DA, Luskin Annals of Allergy. 1997

Improved Outcomes: Explanations Allergist PCP Allergist PCP Anti-inflammatory:  -agonist (SA) 1.6:1 0.46:1 Anti-inflammatory adherence67%39% No refill after 1st8%25% Bukstein DA, Luskin AT Allergist PCP Allergist PCP Anti-inflammatory:  -agonist (SA) 1.6:1 0.46:1 Anti-inflammatory adherence67%39% No refill after 1st8%25% Bukstein DA, Luskin AT. 1997

“Why can’t we just have PCPs do it? Can’t we teach them how?” “Why can’t we just have PCPs do it? Can’t we teach them how?”

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 Aspects of asthma guidelines are effective Most caregivers know, but do not follow, guidelines Patients receiving proper recommendations generally don’t follow them

Primary Care and Asthma Guidelines Finklestein, Pediatrics, 2000

Pediatrician Non-Adherence to Asthma Guidelines 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%. 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%.

“Can’t we just send the worst ones to the allergist?”

Specify the Target Populations The Rule 2% = Severe $25,000 / yr + 18% = Episodic $2,500 / yr 80% = “Healthy” $250 / yr 20% of members 20% of members 80% of costs 80% of costs

Specify the Target Populations Pitfall of the Rule This Year Next Year High Cost Low Cost Member

Reasons for Allergists Provided Cost-Effective Outcomes Accurate diagnosis of disease type and severity Identified external triggers including allergens – advise on avoidance Immunotherapy (allergy shots) to decrease sensitivity to allergic triggers Accurate diagnosis of disease type and severity Identified external triggers including allergens – advise on avoidance Immunotherapy (allergy shots) to decrease sensitivity to allergic triggers

Asthma Patients Cared 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 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!