Asthma Disease Management
Demonstration Project:
Using EMS Health Coaches May
Decrease Emergency Department
Revisits, Length of Hospital
Admissions and Costs
Michael T. Hilton, MD
Jan 13, 2012
NAEMSP Annual Meeting
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Disclosures
• Employer: UPMC Graduate Medical Education
• Grants for this study: None
• Grants provided to CTSI: CTSI contribution was
made possible by Grant Number 2UL1 RR02415306 from the National Center for Research
Resources (NCRR), a component of the National
Institutes of Health (NIH), and NIH Roadmap for
Medical Research. The contents of this
presentation are solely the responsibility of the
authors and do not necessarily represent the official
view of NCRR or NIH.
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Acknowledgements
•
•
•
•
Kelly Close, MD, MPH
Christian Martin-Gill, MD, MPH
Jonathan Lever, MPH, NREMT-P
Dan Swayze, DrPH, MBA, MEMS
• Melissa Saul and Dennis WIckline of the
Clinical and Translational Science Insitute
(CTSI) of the University of Pittsburgh
University of Pittsburgh School of Medicine - Department of Emergency Medicine
1
• Approximately 17.5 – 23.3 million adults in the
United States have asthma1
• 2.7 million people yearly having an acute
exacerbation.2
• Annually, asthma accounts for 1.7 million
emergency department visits, 456,000
hospitalizations, and 4,000 deaths.
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Introduction
• Asthma is primarily patient-controlled
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Introduction
• Asthma is primarily patient-controlled
- Interpretation of physiological testing – peak-flow
meter
University of Pittsburgh School of Medicine - Department of Emergency Medicine
2
Introduction
• Asthma is primarily patient-controlled
- Interpretation of physiological testing
- Recognition of disease state – early exacerbation
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Introduction
• Asthma is primarily patient-controlled
- Interpretation of physiological testing
- Recognition of disease state
- Titration of short term rescue medications -albuterol
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Introduction
• Asthma is primarily patient-controlled
- Interpretation of physiological testing
- Recognition of disease state
- Titration of short term rescue medications
• Asthma is ideal for patient-focused education
intervention
University of Pittsburgh School of Medicine - Department of Emergency Medicine
3
Asthma Education programs
• Computer-based self-education programs 4,5
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Asthma Education programs
• Computer-based self-education programs 4,5
• Self-education brochures6
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Asthma Education programs
• Computer-based self-education programs 4,5
• Self-education brochures6
• Small groups7,8
University of Pittsburgh School of Medicine - Department of Emergency Medicine
4
Asthma Education programs
•
•
•
•
Computer-based self-education programs 4,5
Self-education brochures6
Small groups7,8
In-home asthma disease management
programs 9-2
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Asthma Education programs
•
•
•
•
Computer-based self-education programs 4,5
Self-education brochures6
Small groups7,8
In-home asthma disease management
programs 9-2
• Variable effectiveness
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Asthma Education programs
•
•
•
•
Computer-based self-education programs 4,5
Self-education brochures6
Small groups7,8
In-home asthma disease management
programs 9-2
• Some have been shown to be cost-effective,
others are not cost-effective
University of Pittsburgh School of Medicine - Department of Emergency Medicine
5
Asthma Education programs
•
•
•
•
Computer-based self-education programs 4,5
Self-education brochures6
Small groups7,8
In-home asthma disease management
programs 9-2
• None of them have been performed by
emergency medical service (EMS) providers
University of Pittsburgh School of Medicine - Department of Emergency Medicine
EMS Providers
• EMS providers are an under-utilized
community-based healthcare workforce
• EMS providers are accustomed to “house
calls”
• EMS providers are well-distributed
• EMS providers are cheap
- salaries range from 1/2 to 1/3 those of nurses
(median hourly wage $12.54 vs. $26.28)30
• Overhead expenses already covered
University of Pittsburgh School of Medicine - Department of Emergency Medicine
EMS Providers
• EMS providers are an under-utilized
community-based healthcare workforce
• EMS providers are increasingly being
considered to provide health promotion and
disease management programs 31
University of Pittsburgh School of Medicine - Department of Emergency Medicine
6
Non-traditional EMS roles
• Promote injury prevention through homebased infant and child safety evaluations,32
• Screen older community members who
may be at risk for falls
• Screen adults in need of vaccinations32,34
• Administer vaccinations35
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Non-traditional EMS roles
• Promote injury prevention through homebased infant and child safety evaluations,32
• Screen older community members who
may be at risk for falls
• Screen adults in need of vaccinations32,34
• Administer vaccinations35
• However, there is no literature on the use
of EMS providers as health coaches for
asthma disease management
University of Pittsburgh School of Medicine - Department of Emergency Medicine
In summary…
• Asthma is ideal for patient-focused education
intervention
University of Pittsburgh School of Medicine - Department of Emergency Medicine
7
In summary…
• No asthma education intervention has been
performed by emergency medical service
(EMS) providers
University of Pittsburgh School of Medicine - Department of Emergency Medicine
In summary…
• EMS providers are increasingly being
considered to provide health promotion and
disease management programs
University of Pittsburgh School of Medicine - Department of Emergency Medicine
In summary…
• There is no literature on the use of EMS
providers as health coaches for asthma
disease management
University of Pittsburgh School of Medicine - Department of Emergency Medicine
8
Purpose and Hypothesis
• To determine the feasibility and potential
impact of using EMS providers as health
coaches for patients with asthma
• We hypothesized that this EMS provider-led
intervention would decrease ED visits,
hospital admissions, hospital length of stay
(LOS), and hospital-related costs
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Program Description
• Created by Emed Health in 2005
• Based on best practice guidelines 36-39
• Voluntary recruitment of EMS providers who
were trained in:
- peak-flow meter use
- environmental trigger assessment
- asthma action plan coordination with the patient’s
primary care physician
- asthma medication instruction
- smoking cessation and prescription medication
assistance.
•
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Program Description
• Based in Braddock
- 35% live below the poverty level
- 69% are under-represented minorities
40
• Patients were voluntarily recruited after
identification via an electronic medical record
review after discharge
- 18-64 years
- Asthma was one of the first three discharge
diagnoses
- ED visit or admission from July 1, 2005 to April 1,
2006
- Uninsured or on Medicaid
University of Pittsburgh School of Medicine - Department of Emergency Medicine
9
Program Description
Visit 1
Asthma Management Initial
Questionnaire
Visit 2
Review peak flow readings
Asthma Action Plan
Peak flow meter
Asthma Attack Booklet
Visit 3
Asthma Home Environment Evaluation
Trigger Survey
Visit 4
Review environmental trigger
mitigation strategies
Asthma Management Final
Questionnaire
Asthma Action Plan
Smoking cessation program referral
Prescription for Prednisone if needed
$50 gift certificate
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Methods
• Approved by the University of Pittsburgh IRB
• Retrospective, case-controlled study
• The study subjects were all patients who
completed the intervention by taking part in all
four home visits.
• Matched control cases were initially identified by:
- having one ED visit or hospitalization for asthma
between July 1, 2005 to April 1, 2006
- uninsured or Medicaid insurance status
- final hospital disposition of being discharged to
home
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Methods
• Controls were then matched to the intervention
participants based on the following criteria in
order of priority:
-
age (within 5 years)
sex, race/ethnicity
marital status,
severity of illness (asthma) using a modified
Charlson score.41,42
University of Pittsburgh School of Medicine - Department of Emergency Medicine
10
Methods
• Intervention period
- from the first home visit
- to the date when all four home visits were
completed.
• Outcome data
- collected for any visit to a UPMC hospital for which
asthma was one of the top three diagnoses
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Methods
• Data was collected
- for the six months before the intervention period
- for the six months after the the intervention period
• The data collected included
-
# of ED visits
# of inpatient admissions
hospital length of stay (LOS)
associated costs
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Data Analysis
• A cost analysis compared hospital visits during
the time periods
- excluded one participant outlier and his control due
to the performance of major procedures unrelated
to asthma (including pacemaker insertion) during
one hospitalization.
• All data were analyzed by descriptive statistics
University of Pittsburgh School of Medicine - Department of Emergency Medicine
11
Results
• 44 people initially screened
• 24 enrolled in home visits
• 2 dropped-out and 1 died
- one due to lack of interest
- one due to having a premature baby
- one participant died at seven months of unrelated
causes.
• 21 participants (87.5%) completed the
program
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results - Demographic characteristics
of participants and matched controls
Intervention Group
(N=21)
Control Group (N=21)
Age (years, mean)
44.4 ± 14.6
43.1 ± 13.8
Gender (female)
17 (0.81)
17 (0.81)
Race
-black
12 (0.57)
9 (0.43)
-white
9 (0.43)
10 (0.48)
-other
0
2 (0.10)
Marital Status
- single
16 (0.76)
15 (0.71)
- married
4 (0.19)
5 (0.24)
- unknown
1 (0.05)
1 (0.05)
Charleson Score
(mean, range
1.3 ± 0.78, 1-4
1.3 ± 0.78 , 1-4
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
Before
After
Change
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
(50.6%)
60.9%
12
Results
Before
After
Change
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
Before
After
Change
(50.6%)
60.9%
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
Before
After
Change
(50.6%)
60.9%
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
(50.6%)
60.9%
13
Results
Before
After
Change
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
Before
After
Change
(50.6%)
60.9%
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
Before
After
Change
(50.6%)
60.9%
% Change
Emergency Department Visits (n)
- Study group
16
7
(9)
(56.5%)
- Control group
8
15
7
87.5%
Inpatient Hospitalization (n)
- Study group
3
3
0
0%
- Control group
6
5
1
16.7%
Admission Length of Stay (days)
- Study group
16
12
(4)
(25.0%)
- Control group
27
23
5
18.5%
$28, 272
$13, 969
($14, 303)
Hospital Costs
- Study group
- Control group
$39,554
$63, 626 $24, 072
University of Pittsburgh School of Medicine - Department of Emergency Medicine
(50.6%)
60.9%
14
Results
• The intervention group had
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
• The intervention group had
- fewer ED visits

7 vs. 16
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
• The intervention group had
- fewer ED visits
- a shorter cumulative inpatient LOS

12 days vs. 16 days
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15
Results
• The intervention group had
- fewer ED visits
- a shorter cumulative inpatient LOS
- no change in the number of inpatient admission

3 in both periods
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
• Conversely, the control group had
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Results
• Conversely, the control group had

increased ED visits

15 vs. 8
University of Pittsburgh School of Medicine - Department of Emergency Medicine
16
Results
• Conversely, the control group had


increased ED visits
increased inpatient LOS

32 days vs. 27 days
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Discussion
• Although limited by sample size, this study
demonstrates
- trend toward decreased ED visits
- trend toward decreased hospital admission LOS
for visits related to asthma exacerbation
- trend toward decreased hospital related costs
• after completing the EMS-led intervention
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Discussion
• The number of admissions was similar
between the two groups
• Suggests that the intervention
- may have the greatest influence in decreasing
mild to moderate exacerbations
- those that lead to outpatient emergency
department visits
• The effect on more severe exacerbations that
require admission may be less pronounced
University of Pittsburgh School of Medicine - Department of Emergency Medicine
17
Discussion
• Suggests that the intervention helps educate
participants on how to more effectively
prevent and manage their symptoms
- limiting the number of exacerbations that require
additional treatment in a healthcare setting
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Discussion
• Significant implications for health systems
and insurers
- EMS provider-led home interventions help to
improve the health status of asthma patients postdischarge
- EMS provider-led home interventions lower
associated health care costs for patients who are
often frequent users of health care facilities
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Discussion
•
•
•
•
Enrolled patients in one hospital system
One socioeconomic group
Outcome data from one hospital system
Low enrollment in the program leading to….
- small sample size
University of Pittsburgh School of Medicine - Department of Emergency Medicine
18
Conclusion
• This study analyzed a novel intervention
utilizing EMS providers as health coaches for
a home-based asthma disease management
program
• This study provides preliminary support of the
use of EMS providers as health coaches for
asthma disease management but additional
research is needed
University of Pittsburgh School of Medicine - Department of Emergency Medicine
Questions?
University of Pittsburgh School of Medicine - Department of Emergency Medicine
19