Pharmacist Management of Adult Asthma at an Indian Health Service Facility

According to the Centers for Disease Control and Prevention, asthma prevalence in the U.S. increased between 2001 and 2010 and is now at its highest level. In 2010, about 25.7 million people had asthma: 18.7 million adults (8%) and 7 million children (9%). Despite well-known treatment options, asthma continues to be poorly controlled. In 2009 there were 1.6 million emergency department (ED) visits, 497,300 hospitalizations, and 3,404 deaths related to asthma. Additionally, in 2008 the disease affected attendance at school and work with 10.5 million and 14.2 million missed school days and workdays, respectively.^1-5

The American Indian and Alaska Native (AIAN) populations have not escaped the realities of asthma. According to a 2010 report of the National Center for Health Statistics, AIAN populations also have a high prevalence of asthma at 14.2%. This percentage is much higher than that of the general population.¹

Over the past decade, pharmacists have expanded their roles from educators to clinicians with prescriptive authority in various settings. The greatest success has been seen with anticoagulation clinics, both clinically and financially.^6-10 Pharmacists have also demonstrated positive outcomes when involved in cardiovascular clinics.^11-13

Additionally, pharmacists have been involved with asthma clinics as both educators and prescribers with favorable results clinically and economically.^14-16 A study from Taiwan done by Chan and Wang indicated that pharmacist asthma interventions in an outpatient setting improved the quality of care, reduced cost, and relieved stress on general medical resources.¹⁷ Another study indicated that education by a community pharmacist can improve asthma control in a self-managed program.¹⁸

In 2007, an asthma medication use evaluation (MUE) was completed at the Northern Navajo Medical Center (NNMC) in Shiprock, New Mexico. The results of the MUE concluded that asthma statistics for the local population differed from that of the national data (Table 1). Overall, the Navajo population served by the NNMC had a lower incidence of asthma but a higher rate of hospital admissions and ED visits.

One of the primary focus points for the MUE was short-acting beta agonist (SABA) refills. According to national guidelines, using a SABA 2 or more times per week (not for exercise-induced bronchospasms) would indicate a patient was not well controlled.¹⁹ This use equates to 2 refills of SABA per year. The MUE found that 51% of patients had ≥ 3 refills per year, and 38% of patients had 4 or more refills per year. Based on asthma prevalence and SABA history, it was determined that a specialty clinic could have a positive impact on asthma care.

This study addresses how a specialized adult asthma clinic managed by pharmacists with physician oversight can improve asthma outcomes. Since January 2010, the NNMC has had a program in place and has experienced a concurrent substantial drop in asthma-related ED visits and admissions, an improved level of control, and a decreased cost burden to the facility.

Methods

A retrospective chart review was completed on all patients currently enrolled in the clinic. The Resource and Patient Management System Visit General Retrieval (RPMS VGEN), Electronic Health Record, and the asthma clinic database were used to evaluate patients. The evaluation period began January 1, 2010, and ended December 31, 2011.

Performance improvement inclusion criteria for clinic patients were based on active status in the clinic. Active patients were defined as patients with at least 2 clinic visits and a clinic visit within 3 months of an ED visit or admission. The 3-month cutoff was chosen based on several criteria. First, most patients referred to the clinic were categorized as either not well controlled (NWC) or very poorly controlled (VPC) and required at least a 2- to 4-week follow-up based on guidelines. Second, patients who were categorized as well controlled (WC) were scheduled for clinic visits every 3 months for regular follow-up.

Using all ICD-9 codes for asthma, RPMS VGEN was used to find the number of ED visits and admissions that occurred with asthma as the primary diagnosis from both clinic and nonclinic patients. The inclusion criteria were then applied to the clinic patients, and those not meeting these criteria were returned to the nonclinic pool of patients.

Cost analysis was evaluated based on the results of a random selection of 20 patients from 2009 and 2010 ED and hospital visits at the NNMC. These numbers were averaged to determine ED and admission costs. Length of admission stay was determined from a RPMS VGEN search for each clinic and nonclinic patient admission.

Determination of the level of control was based on the 2007 national asthma guidelines. The guidelines state that the level of control can be determined by either asthma symptoms or by peak flow evaluation.¹⁹ Because of the language barrier that sometimes arises with the treated population, the use of symptom-based evaluation has been observationally superior to providing peak flow meters for home use. At each visit, patients were interviewed using tables from the asthma guidelines. Table 2 is an abbreviated portion of the guidelines representing the assessment tool used by the clinic. The level of control was determined by selecting the column with the highest severity of impairment.¹⁹