Gasping for a breath
Fighting for breath is a common occurrence during the early spring or fall seasons for many San Antonians. Allergies abound in the Alamo City—oak pollen in the spring and mountain cedar in the fall. And for asthmatics, gasping for air in this allergy-laden city can be frightening.
In a pilot study in the Department of Respiratory Care, Dr. David Shelledy and colleagues provide hope for a large percentage of asthmatics. They’ve shown that it may be more effective to use an in-home asthma disease management program (ADMP) provided by respiratory therapists.
"Savings amount to about $8,000 in hospitalization costs for the pilot study data with the asthma management program provided by respiratory therapists," said Dr. Shelledy. "While asthma incidence in San Antonio is similar to other parts of the country, asthma is on the rise among children."
Comparing a 12-month pre-education period and the 12 months after introduction of the ADMP with 19 children, the researchers showed that intensive care unit days dropped from 3.53 to .26 days and the associated cost fell from $3,368 to $329; the number of emergency room visits declined from 4.16 to .63 and the cost fell from $1,455 to $221; the number of physician office visits went from 6.37 to 2.21 with the cost falling from $318 to $105; and the number of school days missed fell to 6.69 from 19.53.
Asthma is the most common pediatric chronic disease in this country, affecting nearly 5 million children and adolescents, 1.5 million of whom are less than 5 years of age. Each year, about 200,000 asthmatic children are hospitalized and 5,000 children with asthma die. The most disturbing fact is asthma is increasing, according to a 1999 article in the Journal of the American Medical Association.
"The number of kids with asthma under 4 years of age has increased 160 percent in the years 1980 to 1995, and in the same period increased 75 percent in children between 5 to 14 years of age," the article stated.
The economic costs are enormous. Asthma is responsible for 10.4 million physician office visits every year, according to the article, and one-third of these are by patients under the age of 18. Hospitals annually record 570,000 emergency department visits for asthmatic disorders in children under 15 years of age. Direct treatment costs of pediatric asthma approach $2 billion annually.
What about adult asthmatics? Dr. Terry LeGrand, also in the Department of Respiratory Care, Dr. Shelledy and colleagues are conducting a study to evaluate the role of the in-home ADMP, which will use three groups of adult asthma patients, age 18-64. These patients are high risk based on the number of times they have gone to the emergency room and the number of hospitalizations for treatment of acute asthma exacerbations during the previous year.
"We believe that increasing the asthma patients’ knowledge base with regard to implementing a detailed action plan will facilitate compliance with self-management treatment regimens and reduce the number of visits to the emergency department (ED)," said Dr. Shelledy, about the study funded by the American Association for Respiratory Care. "A respiratory therapist, in conjunction with a physician, initiates the asthma action plan."
While each asthmatic patient’s plan is tailored for his or her needs, some of the common information that’s needed includes knowing what triggers an attack. Triggers include pollen, common to the Alamo City, molds, humidity, fumes, cats, dogs, cold air, chest infections, dust and dust mites. Detailing the times of symptoms, medication and dosage are also part of the plan.
"Acute asthma exacerbations account for a significant number of hospitalizations each year and contribute to the rising cost of health care," said Dr. Shelledy. "In 1990, the cost of illness related to asthma was approximately $6.2 billion, with 43 percent of its impact associated with ED visits and hospitalizations."
The figures are stark enough to prompt the Health Science Center team to better educate asthma sufferers. More than the standard consultations are needed, said Dr. Shelledy.
"The reality is patients require far more information about disease management than can be effectively communicated during a clinical appointment," said Dr. Shelledy, about the current adult study that has 100 patients enrolled. "The primary objective is to determine if an in-home ADMP provided by respiratory care practitioners (RCP) can improve patient outcomes and reduce cost of care when compared to home care provided by nurses or standard care in a physician’s office."
A secondary objective will be to determine if the in-home ADMP by RCPs can improve pulmonary function, patient satisfaction and quality of life. The adult study will use three groups. Members of the control group will return to their regular physicians for routine follow-up after hospital discharge. Group two members will receive routine home visits provided by home health agency nurses. For group three, the intervention group, an ADMP will be implemented using respiratory therapists to deliver the program.