Medical Foundation, risk patients, environmental interventions, HEPA filters, IPM services, HEPA vacuums, asthma education, Lowell Laurie Stillman, asthma, Regional Council Asthma, Outdoor allergens, Business Case, Polly Hoppin, asthma severity, EPA, Private Foundations, Director of Health Policy, Health Sector Care, Washington Street, ARC, Contact Information Laurie Stillman, Asthma Regional Council of New England, Federal Grants, Health Sector, funding sources, Local Health Departments, direct and indirect costs, Housing Authorities, Asthma costs, NIH
Investing in Best Practices for Asthma: A Business Case A program of The Medical Foundation Produced by Dr. Polly Hoppin & Molly Jacobs/UMass Lowell Laurie Stillman, Asthma Regional Council
Asthma Big National Problem IN New England
: -One in Ten adults and children currently have asthma -One in Seven adults and children have been given asthma diagnosis in lifetime -Low income, Hispanic and black population
s have severest burden
Best Practices for Asthma Management NAEPP Guidelines Outlines 4 Components: 1) The use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy; 2) Comprehensive pharmacologic therapy for long-term management and to manage asthma exacerbations; 3) Environmental control of measures to avoid or eliminate factors that contribute to asthma severity; and 4) Patient Education
that fosters a partnership among the patient, family, and clinicians. PROBLEM: THE MEDICAL ESTABLISHMENT FAILS TO HEED LAST TWO RECOMMENDATIONS.
Environmental Triggers in the Home
Allergens Cat* & Dog Dander Cockroaches* ** Dust mites** Molds* Outdoor allergens
Irritants ETS* ** (preschool) Indoor/outdoor fumes Wood burning stoves Cleaning agents Fragrances (candles & sprays)
Pests and Asthma Asthma and the Home Environment (HUD 2006) · Asthmatics living in low income, urban housing have patterns of specific sensitivities that differ from other populations, with a higher frequency of sensitivity to cockroaches, mice, and molds and less frequent sensitivity to cats, dogs, and house dust mites 1 ·The 2004 NIH "Inner City
Asthma Study", conducted in 7 U.S. cities, found that: -By reducing cockroach and dust mite allergens, asthma symptoms improve -Cockroach exposure and sensitivity predominated in the Northeast, whereas dust-mite exposure and sensitivity were predominant in southern and northwestern cities 2
Who Is Currently Paying? z Federal Grants (HUD, EPA, NIH) z State and Local Health Departments z Housing Authorities z Local Coalitions/CBOs z Some Private Foundations PROBLEM: These funding sources
are not sustainable
Why Should the Health Sector Care?
Asthma costs well over $16 billion in direct and indirect costs. Over 70% of those costs are born by the health care
Figure 1: Distribution of Asthma Costs in the US (2004): $16.1 Billion in Total Costs7
Prescriptions, 31.1% Physician Services, 18.0% Outpatient, 2.1% ER visit, 3.2%
Morbidity, 18.0% School Days Lost, 9.3% Lost Work Days, 8.8% Mortality, 10.6% Hospital Inpatient, 17.1%
ICMnodsiortesrcttality Direct CEoRstsvisit
How Do We Convince Health Sector to Pay for Best Practices? ESTABLISH A BUSINESS CASE z Demonstrating savings (ROI) Savings from reduced health expenditure
s outweigh the cost of the program 2. Demonstrating cost effectiveness Investments in a new service are reasonable in comparison with standard treatment given value of health benefit
Health Sector Stands to Improve Asthma Outcomes at Reasonable Cost Up front investments in best practices demonstrate: *Cost savings associated with the provision of discrete asthma education services-particularly to high-risk patients. *Cost effectiveness for providing environmental interventions in the home to the same population.
The Evidence on Education z Hundreds of studies show health effectiveness z 16 rigorous studies examined cost outcomes z Settings and staffing varied z Content similar, including triggers z statistically significant
outcomes: Fewer ED visits & hospitalizations; improved quality of life z ROI realized, especially in high risk populations
Benefits of Environmental Interventions z Numerous research studies show home-based EI improves asthma outcomes z All RCT studies include: - Extensive education re. trigger avoidance - Basic pest abatement - Vacuum cleaner (HEPA) - Smoking cessation z Some RCT studies include: - Professional pest control
- Professional mold abatement
The Evidence on E.I.: IT'S COST EFFECTIVE z Examined cost per symptom free day gains using an "incremental cost ratio" paradigm z 2 rigorous studies examined costs (RCTs) Cost Range: $2-$48 SDG z Standard pharmacotherapy $7.50 inhaled corticosteroid; $11.3 budesonide; $523 Xolair for SDG.
Conclusion 1 Rigorously designed research studies and Program Evaluation
s conclude that asthma education and environmental assessment, services and supplies, delivered in the clinical setting and in the home, reduce symptoms and improve quality of life at a reasonable cost and when targeted appropriately, may result in net cost savings to payers who invest in them.
Conclusion 2 z Cockroaches, ETS and Cats are largest offenders z More Expensive Supplies and Services, such as HEPA filters, HEPA vacuums, and IPM services should be given to the highest risk patients, who have demonstrated allergy sensitization. z Research does not break out cost effectiveness of individual interventions.
Conclusion 3 z Who Receives: Patients should be stratified by severity: Mild persistent; moderate and severe z Who Provides: The cost evaluation literature suggests that providers other than physicians-- including nurses, respiratory therapists, asthma educators, Social Work
ers, community health workers, and environmental counselors--can effectively provide asthma education and environmental interventions
HOLGATE at BHA Cost Analysis
Contractor IPM Coordinators Contactor call-backs Training Stipends Door Sweeps + Installation for all units Subtotal Contract/ Direct Labor/Supplies IPM training * Subtotal Start Up Costs TOTAL COSTS EXCLUDING BHA LABOR Building Manager Hours/Year Building Manager Costs/Year ($24/hr) BHA Custodian Hours/Year BHA Custodian Costs/Year ($18/hr) TOTAL COSTS WITH BHA LABOR
IPM YR 1 $10,720 $2,930 $125 $809
TRADITIONAL $3,459 $240
IPM YR 3** $6,428
$14,584 $2,000 $2,000
$16,584 12 $288 52 $936 $17,808
$3,699 52 $1,248 104 $1,872 $6,819
$6,428 12 $216 $6,644
Contact Information Laurie Stillman, Executive Director of the Asthma Regional Council of New England (ARC) and Director of Health Policy and Advocacy c/o The Medical Foundation 622 Washington Street, 2nd fl Dorchester, MA 02124 (617) 451-0049x 504 [email protected]
P Hoppin, M Jacobs, L Stillman