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A Health Maintenance Organization Experience

Antonio P. Legorreta, MD, MPH; Jennifer Christian-Herman, PhD; Richard D. O'Connor, MD; Malik M. Hasan, MD; Reaburn Evans, MD; Kwan-Moon Leung, PhD

Arch Intern Med. 1998;158:457-464.

Background  To improve asthma disease management, the National Asthma Education Program (NAEP) Expert Panel published Guidelines for the Diagnosis and Management of Asthma in 1991.

Objectives  To compare the current status of asthma disease management among patients in a large health maintenance organization with the NAEP guidelines and to identify the factors that may be associated with medical care (eg, emergency department visits and hospital admissions) and adherence to the guidelines.

Methods  Analyses of 1996 survey data from 5580 members with asthma (age range, 14 to 65 years) covered by a major health maintenance organization in California (Health Net).

Results  In general, adherence to NAEP guidelines was poor. Seventy-two percent of respondents with severe asthma reported having a steroid inhaler, and of those, only 54% used it daily. Only 26% of respondents reported having a peak flowmeter, and of those, only 16% used it daily. Age (older), duration of asthma (longer), increasing current severity of disease, and treatment by an asthma specialist correlated with daily use of inhaled steroids. Ethnicity (African American and Hispanic) correlated negatively with inhaled steroid use but positively with emergency department visits and hospital admissions for asthma. Increasing age and treatment by an asthma specialist were also identified as common factors significantly related to the daily use of a peak flowmeter and, interestingly, to overuse of ₂-agonist metered-dose inhalers.

Conclusions  Although the NAEP guidelines were published 7 years ago, compliance with the guidelines was low. It was especially poor for use of preventive medication and routine peak-flow measurement. Furthermore, the results showed that asthma specialists provided more thorough care than did primary care physicians in treating patients with asthma. Combining the results of the regression analyses revealed that some of the variation in rates of emergency department visits and hospitalizations among some subpopulations can be explained by the underuse of preventive medication. This study serves the goal of documenting the quality of care and services currently provided to patients with asthma through a large health maintenance organization and provides baseline information that can be used to design and assess effective population-based asthma disease management intervention programs.

From the Quality Initiatives Division, Health Net, Woodland Hills, Calif (Drs Legorreta, Christian-Herman, Hasan, and Leung); the Division of Asthma, Allergy, and Clinical Immunology, Sharp Rees-Stealy Medical Group, and the Division of Immunology and Allergy, University of California, San Diego (Dr O'Connor); Integrated Therapeutics Group, Schering-Plough, Kenilworth, NJ (Dr Evans); the Department of Community Medicine, Mount Sinai School of Medicine, New York, NY (Dr Legorreta); and the Department of Biostatistics, UCLA, University of California, Los Angeles (Dr Leung).

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