Pharmacist Management of Adult Asthma at an Indian Health Service Facility

The financial impact of asthma was evident with the 2010 to 2011 cost for ED visits and hospital admissions at $265,928. Asthma clinic patients made up only 8% ($21,155) of this cost and yielded an annual cost savings of $24,352. Obviously, the 8% was a direct result of the number of nonclinic vs clinic patients. However, the cost savings of $24,352 was independent of patient numbers and was calculated directly from patients pre- and postenrollment. The potential savings if all current nonclinic patients were enrolled in the clinic was $85,405 annually.

The savings was only direct cost and did not include indirect costs related to asthma, such as lost work/school days, impact on employer productivity, and so forth. This was calculated after applying the 75% and 60% reduction in ED and hospital costs. As more patients are enrolled in the clinic, the potential cost could become an actual cost savings, based on the assumption that the 75% and 60% reduction stays constant (Figure). Over 1 year, the actual savings of the clinic makes up for 31% of the current ED visits from nonclinic patients. With the addition of the potential savings, the clinic could almost negate the money that is currently spent on asthma care.

Clinic data indicated a positive impact on level of control. Of those patients with 3 or more visits to the asthma clinic, 59% had some form of improvement. Fifteen of those patients (23%) had the biggest improvement: from VPC to WC. While any form of improvement is beneficial, a jump of this magnitude in so many patients is extremely encouraging. Thirty percent of the patients had no change in level of control. Of these, 14% were WC, so it would be hoped that no change would occur. Eleven patients remained at suboptimal control. The most concerning control data were those patients who lost control of their asthma during the 2-year period.

Chronic nonadherence from a select number of clinic patients seemed to be a major problem. Thirty-one ED visits were from 22 patients, and the 8 admissions were from 7 patients. Of the 22 ED patients, 82% had poor adherence to asthma medications. The hospital data were similar with 6 out of the total 7 (86%) clinic patients reporting poor medication adherence. Additionally, the majority of patients with a decrease in level of control since enrolling in the clinic had a history of poor medication adherence (4 of 7 patients).

In rating the level of asthma care, patients indicated they received the same level of care after enrollment as they did before enrollment. Most of the care given before the clinic was by primary care providers (PCPs), the ED, and urgent care providers. Since the patients rated the level of care equal, it would suggest that pharmacists were providing the same level of care as were these providers, at least from a patient standpoint. Overall, patients were satisfied with their level of control. Most patients were satisfied at enrollment and did not have a change of opinion throughout the study period, and a large number showed increased satisfaction. The patients who showed a decrease in satisfaction of asthma control were those patients who also had no improvement in actual control. Most of these patients stayed at the VPC level. About half these same patients had a history of noncompliance.

There is significant concern regarding those patients who continue to believe they are better controlled than what the guidelines indicate. Sixteen patients moved from VPC to NWC per the guidelines. Thirteen of these patients now believe that their asthma is WC. This belief places the patients at risk for a severe asthma exacerbation. Patients who believe they are WC may be less likely to self-medicate with albuterol or seek medical help during the initial stages of an exacerbation. These patients will need further education to bring their personal perceptions and actual asthma control together.

Conclusions

Based on clinical results it seems that the NNMC Adult Asthma Clinic has made a positive impact on asthma care. Additionally, significant reduction in the financial burden to the facility is achievable. The results, both clinically and statistically significant, indicate the impact a specialty clinic can provide. Specialty clinics, pharmacy or otherwise, have a history of providing positive outcomes.

As previously noted, no confounding variables were included in the data analysis, which could bias the results, even though data for the same time frame from separate years will reduce some errors. However, there will always be a difference in pollen counts, outbreaks (ie, influenza), temperature changes, and so forth. Such variables should be reduced but not removed completely, based on this performance improvement design. If any of these variables were significantly different, it could alter the results, so a potential weakness is present in this study.