One way to get useful data on patient outcomes is to develop performance indicators, identify all the information that needs collecting, lay siege to computer systems and chart bunkers in search of the data, and crunch the results into a clinical study.
Another way is just to ask patients how they're doing. Then tabulate the answers.
A collaboration of 13 major employers and 16 managed-care organizations (See chart, p. 41) has generated a study on asthma that relied on simple questionnaires to produce hard evidence of how the condition is being managed.
Asthma is the first condition examined in the Outcomes Management System Project, organized by the Managed Care Health Association, a Washington-based consortium of employers involved with managed-care plans.
The project is coordinated by the Health Outcomes Institute of Bloomington, Minn., which devised the questionnaire-based outcomes measures. The Johns Hopkins University School of Hygiene and Public Health is providing technical consultation.
The 16 managed-care participants first contacted 8,640 patients with two or more encounters or hospitalizations for asthma during the previous two years. The 6,645 responding patients named 3,749 physicians, who received questionnaires to distribute for each patient and were asked to complete practice evaluations.
Employers got some eye-opening news about how asthma is being managed.
"People with asthma have not been informed and educated about two or three specific tools that are important to dealing with asthma," said Helen Darling, director of value management strategies at Xerox Corp. "It confirms there is a lot more suboptimal care out there than I would like to think."
Management of asthma at home generally consists of inhaling a corticosteroid medication and faithfully checking up on breathing capacity.
The corticosteroid is a preventive and moderating measure in controlling symptoms of moderate-to-severe asthma.
And use of a peak flow meter keeps patients "more attuned to what their body is telling them about their asthma" by monitoring airflow through their lungs, said Terri Foley, the project's manager at the Health Outcomes Institute.
On average, 74% of severe and 65% of moderate asthmatics reported having steroid inhalers. Only 57% said they use the inhaler daily as recommended. As for self-monitoring, 30% of severe asthmatics and 25% of moderate asthmatics said they had a peak flow meter.
Instead of keeping up with the ounce-of-prevention routine, asthmatics sometimes relied too heavily on another type of inhalant-a bronchodilator-that provides rapid relief but isn't supposed to be used more than four times a day.
The report found room for improvement in asthma care through increased prescribing of corticosteroids and home peak flow meters, while also discouraging excessive use of bronchodilators.
A patient's ability to avoid precipitating an asthma attack and to follow a treatment plan at home are important in managing the condition, but only about half the patients reported knowing all they should about what makes their asthma worse.
And it all translated to lost time and canceled activity, the adverse outcomes of inadequate treatment. Among severe asthmatics who were employed, 50% reported they had missed work, school or a usual activity during the month leading up to the questionnaire, and 24% reported modifying their activities.
The good news,though, is that the report targeted specific areas for immediate intervention with significant payoff in better care, said Debra Hughey, director of value management strategies for Blue Cross and Blue Shield of Missouri/St. Louis.
Identifying certain "leverage points" in the treatment process, such as education and medication improvements, "are going to give you the biggest bang for your buck," Hughey said.
Besides type of treatment, the report showed that type of provider also made a big difference. Patients seen by specialists were more likely to be treated in compliance with published guidelines, consider themselves better prepared to manage their condition and report greater satisfaction with quality of care.
The suggestion that specialists are doing a better job calls for health plans to do a better job of getting asthmatics to specialists or training primary-care physicians to pick up on what the specialists are doing, said Darling.
Just focusing on severe asthmatics can cut into healthcare costs. According to the National Jewish Center in Denver, only about 4% of asthmatics are rated severe, but they account for about half the total cost of treating asthma.
Severe asthmatics were overrepresented in the outcomes project, at 42%, because a large part of the sample was drawn from hospitalizations and emergency visits, the report said.
Now that the project's baseline survey has documented the substantial impact of asthma on people's lives and ability to function, other surveys will assess how important patient knowledge and treatment compliance are on outcomes, including workdays lost and overall health status, the report said.
The project also plans to start studying coronary disease in late 1995 and add to the condition list over time. The goal, Foley said, is to refine the process of documenting effective treatment, use the data to stimulate productive intervention and improve outcomes.
That's a component now missing from such performance-measurement initiatives as the Health Plan Employer Data and Information Set.
The HEDIS program seeks to evaluate managed-care plans according to 160 indicators in the areas of clinical quality, finances, enrollment stability and use of resources. But the version released in 1993, HEDIS 2.0, did not attempt to uncover whether the indicators actually translated to better outcomes.
"When we tried to include that, the plans said they didn't have the data," Darling said. "But when we get to HEDIS 3.0, that's exactly the kinds of measures we want to include."
Health plans are now evaluated on such preventive activities as mammograms and Pap tests, but high rates have only a presumed effect on outcomes. "We don't want to measure the number of mammograms; we want to measure the stage where cancer is screened and treated," Darling said.