Cost Effectiveness of Allergy Care

Asthma Patients Cared for by Allergists Have:• Fewer emergency care visits• Fewer

hospitalizations• Reduced length

of hospital stays

Asthma Patients Cared for by Allergists Have:• Fewer sick care off ice visits• Fewer days missed –

school or workIncreased productivity in work and personal l ives

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 l i terature

Asthma in the United States• 17 mill ion Americans have asthma• Prevalence rose 42% in 1982 – 1992• Prevalence higher in children, i.e. - 4-6 mill ion pediatric asthmatic case

• 1.5 mill ion ER visits and460,000 hospitalization

in 1992

Cost of Asthma CareDirect 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 Sull ivan JACI 2001

Indirect Cost of Asthma CareIndirect Cost of Asthma CareIndirect Costs Costs $MSchool days lost $1,107.3Loss of work (outside employment)

• Men $415.0• Women $1,128.2Housekeeping $841.7Mortal ity $1,813.9Total indirect costs $5,306.0All Costs: $12,671.3

Weiss and Sull ivan J Allergy Clin Immunol 2001

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

signif icantWestley CR et al All Ast Proc 1997;18, 15

Missed Work and School Missed 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 Scientif ic Update 1998 McDonald RJ ACCP Meeting (ABS) 1999

Asthma Care Provided by Asthma Care Provided by Allergists as Compared to Allergists as Compared to GeneralistsGeneralists• Fewer hospitalizations and

emergency room visits (OR 0.63)• Better ratings for quality of care• Fewer restrictions in activit ies (OR

0.57)• Improved physical functioning

(P<than .001)

Wu AW et al, Archives of Int Med 2001

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 hospital izations 38-4

(98% decrease)

Villanueva AC et al Abstract ACCP October 2000

In-Patient Cost In-Patient Cost Reductions Asthma Care Reductions Asthma Care Provided by Allergy Provided by Allergy Special istsSpecial ists

• 125 patients – hospitalizations decreased from38 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 In-Patient Cost Reductions For Asthma Care Provided by For Asthma Care Provided by Allergy Special istsAllergy Special ists

• 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-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

Reduction in Acute Care Costs Reduction in Acute Care Costs when Treated by Allergy when Treated by Allergy SpecialistsSpecialists• 207 patients – Mail survey• One year before and one year after 1intervention• Total cost savings per patient: $4,155.00

Gaioni SJ et al Am J MGD Care 1996

Number of Patients Cost SavingsHospitalizatioHospitalizationn

157-35157-35 $724,070.$724,070.

ED VisitsED Visits 233-63233-63 $136,000.$136,000.

Allergic Rhinit is, BHR and Allergic Rhinit is, BHR and Asthma Immunotherapy as Asthma Immunotherapy as Treatment Treatment and and PreventionPrevention

0100200300400500600700800

PD20

FEV 1

,mg

Baseline Year 1 Year 2

Placebo SITIn Normal RangePlacebo: 0SIT: 50%

In Normal RangePlacebo: 0SIT: 50%

Grembiale R. Am J Respir Crit Care Med 2000; 162:2048-52

Effect of Specialty CareEffect of Specialty Care

Bukstein DA, Luskin Annals of Allergy. 1997

0

12

34

567

8

Hospit al/ 100 Hospit al stay Hospitaldays/ 100

ED visit s/ 100

Allergist : fol low ed

PCP only

Al lergist : notfol low ed

Improved Outcomes: Improved Outcomes: ExplanationsExplanations

Allergist Allergist PCP PCP Anti- inflammatory: β-agonist (SA) 1.6:1 0.46:1

Anti- inflammatoryadherence 67% 39%

No refi l l after 1st 8% 25%

Bukstein DA, Luskin AT. 1997

““ Why can’t we just have PCPs do Why can’t we just have PCPs do it? i t?

Can’t we teach them how?”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

Primary Care and Primary Care and Asthma GuidelinesAsthma Guidelines

91

72

99

50

0102030405060708090

100

% P

hysi

cian

s

Heard ofGuidelines

ReadGuidelines

FoundUseful

Writ t enAct ion Plan

Finklestein, Pediatrics, 2000

Pediatrician Non-Pediatrician Non-Adherence to Asthma Adherence 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%.

““Can’t we just send the worst Can’t we just send the worst

ones to the allergist?”ones to the allergist?”

Specify the Target Specify 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

Specify the Target Specify the Target PopulationsPopulations

Pitfall of the 20-80 RulePitfall of the 20-80 Rule

This Year Next Year

High Cost

Low Cost Member

Reasons for Allergists Reasons for Allergists Provided Cost-Effective Provided 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

Asthma Patients Cared Asthma 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 l ives

THUS LOWER YOUR COST!