Better Outcomes at Lower Cost - American College of Allergy ...

Asthma Managementand the Allergist:Better Outcomesat Lower Cost

Editors: Michael B. Foggs, MD, and Bradley E. Chipps, MDReviewed by theACAAI Managed Care and Health Plans Committee:Andrew P. Hope, MD, Stephen A. Imbeau, MD,J. Allen Meadows, MD, John I. Moissidis, MD,Frederic K. Renold, MD, William F. Schoenwetter, MD,David D. Tanner, MD, Dexter W. Walcott, MD, andAndrew G. Weinstein, MD©2009 American College of Allergy, Asthma & Immunology

SummaryAsthma is among the most common of chronicdiseases, and one of the most difficult tomanage. Despite dramatic advances indiagnosis, treatments and overall management,the incidence of the disease has increasedsignificantly over the years and vast numbersof asthma patients – including a disproportionatenumber of children – do not receive adequatecare to control their disease.As asthma specialists, allergists haveconsistently shown that they can provideeffective, economical asthma management.Asthma patients under the care of an allergisthave better outcomes at lower cost because of:• fewer emergency care visits• fewer hospitalizations• reduced lengths of hospital stays• fewer sick care office visits• fewer days missed from work or school• increased productivity in their work andpersonal lives• greater satisfaction with their care• an improved quality of lifeIn addition, early diagnosis and aggressive careof asthma can prevent the scarring, irreversiblelung disease and disability that may result fromunder-treated asthma.This report reviews the current state of asthmacare, its economic consequences, widelyaccepted standards of care and studies thatdemonstrate the superior outcomes of allergistprovidedcare.Scope of the AsthmaEpidemicAsthma is a chronic inflammation of the lung’sairways characterized by a cough, shortness ofbreath and wheezing. In severe cases theairways contract and the patient cannot getenough air into the lungs. The disease affects300 million people worldwide, including22 million in the United States. About6.5 million of those affected are children. Morethan 4,000 people in the United States die ofasthma each year, nearly 50 percent of whomare age 65 or older. [1,2] Asthma prevalence ishigher in children (8.5 percent) than in adults(6.7 percent), and higher in females(8.1 percent) than in males (6.2 percent). Thedisease disproportionately affects blacks(9.2 percent) compared to whites (6.9 percent),and especially black children (12.5 percent)compared to white children (7.7 percent). [2]Asthma management is a key component ofthe Healthy People 2010 objectives of theU.S. Department of Health and HumanServices. The agency has declared asthma anational epidemic and called for ActionAgainst Asthma, a strategic plan to assesscurrent efforts to combat the disease and setpriorities for the future. [3]Curbing the asthma epidemic, preventingneedless suffering and premature deaths, andcontrolling runaway costs of treating thedisease are priorities for the nation’s healthcare policymakers and the nation’s allergists.1

Impact of AsthmaThe most recent surveillance survey conductedby the National Centers for Disease Controland Prevention (CDC) reports that amongpersons with current asthma, more than55 percent or 12.2 million reported one ormore asthma attacks during the preceding year. [1]The economic impact of the disease issubstantial. In 2007, the total annual cost forasthma management was $19.7 billion [4] – upfrom $12.7 billion in 1998. [5] Much of theexpense of asthma is attributed to costs thatcan be avoided or reduced when the disease iscontrolled. According to the most current data,asthma accounts for:• more than 14.7 million physician office andhospital outpatient department visits• 1.8 million emergency department (ED) visits• almost one-half million hospitalizations,including 198,000 for children 17 and under• more than 10 million lost work days• nearly 13 million lost school days [1]Direct health care expenditures such asphysician visits, hospitalization and emergencyservices, medications and other interventionswere estimated in 2007 to be $14.7 billion.Of these, hospital care accounted for$4.7 billion, physician services for $3.8 billionand pharmaceuticals for $6.2 billion. Indirectcosts such as decreased worker productivityand days lost from work by adults who haveasthma or care for children with asthma, andother losses were an estimated $5 billion. [4]Pharmaceuticals, hospital admissions and nonemergencydepartment ambulatory visits were thelargest component of direct costs. Eighty-ninepercent of indirect costs were due to totalcessation of work and loss of entire work days. [6]Among children, the economic impact of thedisease is much the same. Using data from theMedical Expenditure Panel Survey, researchersestimated the direct and indirect costs ofasthma in 2.52 million school-age childrenbeing treated for asthma in 1996. All costswere calculated in 2003 dollars. The study inthis population found:• The total annual economic impact of asthmawas more than $1.7 billion.• Direct medical expenditures – includingprescribed medications, hospital inpatientand outpatient care, emergency departmentand physician office visits – were $401 perchild per year, or a total of more than$1 billion.• The children with treated asthma had14.5 million days of school absence. Theirparents’ lost work productivity taking careof the children was estimated to be$719 million.• Deaths of school-age children were 211,accounting for $264.7 million in lost lifetimeearnings.• The total societal cost was $1.9 billion, or$791 per child per year. [7]In one study of 401 adults with asthma, thetotal per-person annual disease costs averaged$4,912. Costs were $2,646 for persons withmild asthma, $4,530 for those with moderateasthma and $12,813 for severe asthma. Directcosts accounted for 65 percent ($3,180) of theaverage cost per person, and indirect costs forthe remaining 35 percent ($1,732).2

Asthma in America• Affects 22 million people,including 6.5 million children• Costs $19.7 billion/year:$14.7 billion in direct costs$ 5 billion in indirect costs• 14.7 million physician/outpatient visits• 1.8 million emergencydepartment visits• Nearly one-half millionhospitalizations• 10 million lost work days• 13 million lost school daysSources: Centers for Disease Control and PreventionNational Institutes of HealthA National PriorityIn response to the alarming increase in theprevalence of asthma and the rapid rise inexpenditures associated with the disease, anexpert panel was convened by the NationalInstitutes of Health (NIH) National Heart,Lung and Blood Institute (NHLBI) in 1991and again in 1997, 2002 and 2007, to developand update consensus Guidelines for the careof patients with asthma. Based on the latestclinical evidence, the updated Guidelines placespecial emphasis on the importance of asthmacontrol, a stepwise approach to asthmamanagement and early diagnosis andintervention. [8] A primary objective of the2007 Guidelines is educating patients andphysicians about new standards of care fortreating asthma, and the special training,clinical expertise and support services requiredto control the disease.Setting the New Standard of CareThe aggressive therapy recommended in theNIH Guidelines includes ongoing and frequentinteractions with medical personnel to monitorthe disease, written treatment plans, andeducation and support services. Thesemeasures have been shown to control thedisease over the long term and prevent orsignificantly decrease the frequency of acuteasthma attacks and the high costs ofemergency room care, hospitalization, frequentphysician interventions and time lost fromwork, school or other activities.According to the Guidelines, people withasthma should expect:• no or few asthma symptoms, even at night orafter exercise• prevention of all or most asthma attacks• participation in all activities, includingexercise• no emergency room visits or hospital stays• less need for quick-relief medicines• no or few side effects from asthma medicinesBuilding on the NIH Guidelines, allergists havedeveloped practice parameters and otherasthma disease management resources thataugment the federal governmentrecommendations. [9-10]3

$16,000$14,000$12,000$14,212Costs arehighest whenasthma isuncontrolled2002 dollars). The TENOR study is a threeyear,multicenter, observational study of patientswith severe or difficult-to-treat asthma. [11]Cost per patient per year4$10,000$8,000$6,000$4,000$2,000$0Uncontrolled$6,452T reatment CostsSource: Sullivan, et al. Allergy. 2007ControlledCompliance with the GuidelinesRemains PoorUnfortunately, more than 15 years afterpublication of the first NIH Guidelines, amajority of today’s patients continue to receivesubstandard care. Too often asthma patientsreceive health care services from providers whohave little specialized training or knowledge ofrecent advances in asthma diseasemanagement. Many outdated approaches toasthma treatment are still practiced.This was vividly shown in the multicenterEpidemiology and Natural History of AsthmaOutcome and Treatment Regimens (TENOR)study, which found that 83 percent of nearly4,000 patients had uncontrolled asthma,16 percent had inconsistent control and only1.3 percent were controlled. Costs foruncontrolled patients were more than doublethose of controlled patients throughout thestudy ($14,212 versus $6,452, adjusted toAsthma was uncontrolled in 85 percent ofinner-city students with asthma in Little Rock,Ark., based on the presence of symptoms andthe need for rescue medicines, as reported bythe University of Arkansas. According to the study:• 50 percent of the children with active asthmahad been treated in the emergency departmentat least twice in the previous two years• 52 percent said they often had to limit theiractivities• 29 percent reported nighttime symptoms onceor more per week• 17 percent reported missing five or more daysof school per year because of asthma. [12]An analysis of treatments for more than 24,000Medicaid recipients with asthma in Kentuckyfound that nonadherence to NIH Guidelineswas prevalent. Fewer than 40 percent ofpatients received a rescue medication and fewerthan 10 percent were regular users of inhaledcorticosteroids – treatment strategiesemphasized as standards of care in theGuidelines. Nonadherence was associated withan increase in exacerbations of asthma thatresulted in hospitalizations. [13]An analysis of 24,000 Medicaidrecipients with asthma foundnonadherence to NIH Guidelineswas prevalent:• Fewer than 40 percentreceived a rescue medication• Fewer than 10 percent wereregular users of inhaledcorticosteroidsSource: Piecoro. Health Serv Res. 2001.

When To Refer toan AllergistAccording to the NIH Guidelines [8],patients should be referred to aspecialist if they:• have asthma symptoms every dayand often at night that cause themto limit their activities• have had a life-threatening asthmaattack• do not meet the goals of asthmatreatment after three to six months,or their doctor believes they are notresponding to current treatment• have symptoms that are unusual orhard to diagnose• have co-existing conditions such assevere hay fever or sinusitis thatcomplicate asthma or its diagnosis• need more tests to find out moreabout their asthma and the causesof symptoms• need more help and instruction ontreatment plans, medicines orasthma triggers• might be helped by allergyshots• need oral corticosteroid therapy orhigh-dose inhaled corticosteroids• have taken oral corticosteroids more thantwice in one year• have stayed in a hospital because of asthma• need help to identify asthma triggersAn asthma specialist also is recommended forchildren ages 0-4 who have asthma symptomsevery day and three to four nights or more amonth. Seeing a specialist also should beconsidered for children who have symptomsthree days or more a week and one to twonights a month.The NIH Guidelines forreferral to an asthma specialistare in general accord withrecommendations of the AmericanCollege of Allergy, Asthma andImmunology (ACAAI), theAmerican Academy of Allergy,Asthma and Immunology (AAAAI)and the Joint Council of Allergy,Asthma and Immunology (JCAAI),and are endorsed by the Allergy-Immunology Subsection of theAmerican Academy of Pediatrics(AAP).The recommendations of theseprofessional medical societiesfurther state that referral to aspecialist is indicated when:• the diagnosis of asthma is indoubt• the patient asks for a consultationDespite this expert consensus, thereferral patterns of general practiceand primary care physiciansfrequently differ from acceptedguidelines. A survey of 407pediatricians and familyphysicians found that theircriteria for referral to anasthma specialist did notconform to the NIH Guidelines. [14]Another study of primary care physiciansfound that the likelihood of appropriatereferral depended on whether the physicianhad taken a rotation in allergy/immunologyduring training. Among those who had sometraining in allergic diseases such as asthma,nearly 78 percent had referred patients to anallergist, compared with 46 percent who wereless educated about allergic conditions. [15]5

Asthma TreatmentOutcomesWith their years of specialty training andclinical experience in asthma management,allergists are more likely to follow the state-ofthe-arttreatment plans that improve outcomesand reduce costs, and to adhere to practiceguidelines that experts agree are the standardof care. Numerous clinical studies confirm thatspecialists are more likely than non-specialiststo manage asthma based on the latest clinicalstudy findings, to identify and implementprocedures to reduce allergy triggers for thedisease, and to follow consensus guidelines. Itis well documented that asthma care deliveredunder the supervision of an allergist results inimproved outcomes and more effective use ofhealthcare resources. For example:• A survey of 1,954 patients and their 1,078physicians enrolled in 12 managed careorganizations analyzed the relationshipbetween physician specialty and treatmentoutcomes, using indicators from the NIHGuidelines as outcome measures. Asthmacare provided by specialists was consistentlyassociated with better patient outcomesacross a range of relevant indicatorscompared to care provided by generalists.The patients of allergists reported:– fewer hospitalizations and emergencyroom visits for asthma– higher ratings for the quality of care– fewer restrictions in activities because ofasthma symptoms– improved physical functioning [16]• A comparative evaluation of 301 worker’scompensation claimants with work-relatedasthma found that only 36.9 percent weretreated by specialists, either initially orthrough the course of their claim. Fewer thanhalf of the workers had received an objectiveevaluation of pulmonary function. Thosetreated by specialists were significantly morelikely to have received diagnostic testing(82.9 percent) compared to those treated bygeneralists (20 percent). [17]• In a random sample of 3,568 patients withpersistent asthma enrolled in a healthmaintenance organization, 1,079 patientswho were treated by asthma specialistsreported significantly higher general physicaland asthma-specific quality of life, fewerasthma control problems, fewer severesymptoms, higher satisfaction with care andgreater self-management knowledge,compared with 1,679 patients followed byprimary care physicians. Patients of allergistswere less likely to be hospitalized, haveunscheduled visits for their asthma or tooveruse beta-agonist medications. [18] Inrelated studies, the researchers found thateffective management strategies are associatedwith better asthma control, even afteraccounting for high-risk characteristics. Inthese studies, asthma specialist care wasindependently associated with better diseasecontrol. [19-20]• A study from Johns Hopkins Universityfound that children enrolled in two managedcare organizations were significantly lesslikely to be treated according to NIHGuidelines if their asthma was managed by aprimary care physician, compared tomanagement by an asthma specialist. Therewere major differences between the two typesof care at all levels, with specialists receivinghigher scores for the appropriate use ofmedications, patient education, assessment andmonitoring of asthma, and control of riskfactors that make a child’s asthma worse. [21]• A Canadian study underscores the problemof inappropriate medication use. Of 6,254asthma patients age 65 or older who werehospitalized for asthma, 2,495 (40 percent)did not receive a prescription for inhaledcorticosteroid therapy – a mainstay of asthma6

control according to NIH Guidelines – afterfollow-up of 90 days post-discharge. Thepatients of asthma specialists weresignificantly more likely to receive therecommended therapy compared to thepatients of general physicians. [22]• A survey of parents of 1,648 Medicaidinsuredchildren with asthma enrolled in fivemanaged care plans found widespreadunderuse of controller medications. Treatmentby an allergist was associated with moreappropriate use of these medications. [23]• A study of more than 2,300 children withasthma in the Massachusetts Medicaidprogram found that children in a staff-modelhealth maintenance organization (HMO)were nearly twice as likely to receivespecialist care as those in a state-administeredprimary care case manager plan.Consequently, the children in the HMO wereonly 54 percent as likely to require anemergency department visit or hospitalization,only half as likely to meet nationaldefinitions for persistent asthma and nearlythree times as likely to receive timely followupcare. [24]Because of these benefits, administrators ofmany health care plans and managed careorganizations strive to involve allergists inasthma care. When managed aggressively by aspecialist, asthma does not have to be a lifethreateningor disabling disease. In mostpatients, the condition can be controlled sothat acute asthma attacks are avoided.Use of HealthcareResourcesHospitalizationsNumber of HospitalizationsResearch shows that many of the nearly onehalfmillion hospital admissions [2] for asthmacould be avoided if patients received specialistcare.1201008060402077%reduction inhospitalizationswith asthmaspecialists0Non-SpecialistCareSpecialistCareASTHMAHOSPITALIZATIONSSource: National Jewish Medical and Research Center.Medical Scientific Update. 1998.7

In a Washington University School of Medicineand Barnes Jewish Hospital study, nearly 100adults hospitalized for asthma and a history offrequent health care use were randomized toreceive specialty care or general care for sixmonths. There was a 60 percent reduction inhospitalizations in the group receiving specialtycare, and readmissions for asthma werereduced by 54 percent. [25]Care coordinated through an asthma center bya multispecialty team of experts at the LaheyClinic Medical Center in Burlington, Mass.,resulted in an 89 percent decrease in hospitaladmissions among 125 patients with difficultto-controlasthma. [26]A study of adults with moderate-to-severeasthma documented a 77 percent decrease inhospitalization after patients completed acourse of outpatient treatment in a specialtyasthma care center, compared to their rates ofhospitalization in the six months prior to theprogram. [27]Emergency Room VisitsPatients who are cared for by asthmaspecialists require fewer emergency room visits.A study of 9,608 patients, ages 3 to 64 years,enrolled in a large health maintenanceorganization found that dispensing of seven ormore canisters of inhaled corticosteroidscombined with care by an asthma specialistwere both independently associated with alower risk of emergency asthma care. [20] In astudy of children with asthma, emergencydepartment use was significantly less amongthose who saw an allergist. [28] And, in arandomized study of more than 2,000 children,those who had routine access to allergist carewere only 54 percent as likely to requireemergency services compared with childrentreated by primary care providers. [24]In a study of individuals with severe asthma,the average annual number of emergency roomvisits was 3.45 for each patient enrolled in aspecialty allergy clinic, compared to 6.1 visitsfor patients who were not enrolled. [29]Another study found a 76 percent reduction inemergency visits after comprehensive treatmentin a specialty allergy center. [26]Sick Care Office VisitsDespite the availability of new therapies andmedications that can prevent asthma attacks,many patients are still showing up foremergency services to treat uncontrolledexacerbations of the disease. Each year, thereare 1.8 million emergency department visits forasthma. [2] Clinical studies document thatemergency visits are frequently the result ofpoor asthma management. [20, 28]Annually in America, about 14.7 millionphysician office and outpatient clinic visits arefor the treatment of asthma. [1]Supervision of care by an allergist can reducethe number of sick care office visits for asthmapatients. A study of patients with moderate-tosevereasthma in a Kaiser Permanente health8

Number of Visits35030025020015010045%reduction insick careoffice visitswith asthmaspecialistsNumber of Lost Days1,2001,00080060040077%reductionin time lostfrom workor schoolwith asthmaspecialtycare502000Non-SpecialistCareSpecialistCare0Non-SpecialistCareSpecialistCareASTHMA SICK CAREOFFICE VISITSSource: Westley, et al. Allergy Asthma Proc. 1997.LOST WORK/SCHOOLDAYS DUE TO ASTHMASource: Castro, et al. Am J Respir Critical Care Med. 2003.plan in Denver found sick care office visitswere reduced by 45 percent in patients whoreceived follow-up care from an allergist for atleast one year. [30]Missed Days from Work or SchoolAggressive management of asthma by anallergist also can reduce the estimated10 million work days and 13 million schooldays missed each year because of asthma. [1]One study reported that adult patientsaveraged an 80 percent reduction in missedwork days, and children had 65 percent fewerabsent days from school after receiving care ina multidisciplinary asthma center. [27] Anotherstudy randomly assigned nearly 100 adultswho had a history of frequent health care toreceive either specialty care or general care forsix months. The general care group had 1,040days of lost work or school, compared to 246days for those assigned to specialty care. Thespecialty care group had direct and indirectcost savings of $6,462 per patient. [25]Patient Satisfaction andQuality of LifePatients who receive asthma care from anallergist experience improved emotional andphysical well being, and are more satisfiedwith their physician and with the quality oftheir general medical care.9

In a survey of nearly 400 patients treated in alarge health maintenance organization,significant quality of life improvements werereported by patients treated by allergists,compared to those treated by generalists or inthe emergency department. Improvements wereseen in physical function, emotion, pain reliefand general health. [31]In a suburban private practice, patients weresurveyed after the initiation of an asthmamanagement program that was supervised by anasthma specialist. The patients reported significantimprovements in their ability to participate inactivities, their emotional well being and in thecontrol of asthma symptoms. [32]Asthma Treatment CostsNumerous studies have shown that aggressivemanagement and treatment of asthma by anallergist not only produces better healthoutcomes, but also can reduce costs related tothe disease.For example, one large, urban specialty asthmacenter estimated that specialty care reducedinsurance claims for asthma-related services by45 percent to 80 percent. [27]In a study sponsored by the Asthma andAllergy Foundation of America, a 54 percentincrease in the cost of asthma care wasdocumented between 1985 and 1994 while, atthe same time, deaths from the disease rose by41 percent. The increased costs reflected asteep rise in medication costs, yet nine out of10 prescriptions were for “rescue” medicationsto manage severe asthma attacks, rather thanfor inhaled corticosteroids used to prevent suchattacks. The study’s authors concluded that theresults indicated that many patients were notbeing treated according to establishedguidelines. [33]Even when asthma patients attend frequentclinic programs offering intensive specialtyservices, costs are saved in the long-term byreducing the number of emergency room visitsand other acute care interventions. In onecenter, a savings of $137 per patient per yearwas realized among patients who madefrequent, regular visits to a comprehensiveallergy clinic, compared to patients who wentless frequently to an emergency room fortreatment of acute asthma symptoms. [29]Other research has documented that the servicesin specialty clinics result in a higher quality ofcare, including strategies to help patients controltheir disease and reduce the incidence of acutesymptoms that require hospitalization oremergency room services. [34]Failure to control asthma has a particularlyhigh price. It has been estimated that morethan 80 percent of all resources expended forasthma treatment is used by 20 percent ofpatients whose disease is not adequatelycontrolled. [35]HospitalizationsAsthma is responsible for nearly one-halfmillion hospital admissions annually, whichcost an estimated $4.7 billion. [4] Patientsunder the care of allergists are hospitalized lessoften for asthma symptoms and have shorterlengths of stay, which can dramatically lowerthe cost of inpatient asthma care.In a retrospective study of 70 patients withmoderate-to-severe asthma, decreasedhospitalizations after evaluation by an allergistcontributed to an overall savings of $145,500,or $2,100 per patient. [30] In another study ofpatients requiring intubation for asthma,enrollment in an intervention programsupervised by asthma specialists saw perpatienthospital costs reduced 95 percent from$40,253 to $1,926. [36]10

Emergency Room VisitsInpatient Care Costs$50K$40K$30K$20K$10K$40,25395%reductionfor inpatientcare costswith asthmaspecialists$1,926The most recent data on the cost of emergencyroom visits for asthma is estimated to be morethan $546 million annually. [5]In a study of 207 asthma patients treated byspecialists at one Midwest asthma center,reductions in hospitalizations and emergencyroom visits were substantial, representing anannual cost savings of $2,714 per patient –more than $560,000. [32] Another studyreported a fall in emergency department visitsfrom 74 to 17, and cost reductions of $34,706to $7,973, for 125 patients after they enrolledin a specialty asthma clinic. [26]$0Non-SpecialistCareSpecialistCareASTHMA CAREHOSPITAL INPA TIENTCOST SAVINGSSource: Doan, et al. Ann Allergy Asthma Immunol. 1996.$35K$30K$25K$34,70677%reduction inemergencyroom costswith asthmaspecialistsYet another study of 125 patients showed thatthe number of hospitalizations decreased from38 to four, and the costs of inpatient caredropped from $192,926 to $20,308, after thepatients were enrolled in a specialty allergyclinic. [26]ER Costs$20K$15K$10K$7,973There was a 60 percent reduction in totalhospitalizations in a study of nearly 100 adultswho were enrolled in a specialty asthmaprogram. The study also found a markedreduction in lost work or school days, anddocumented a savings of $6,462 per patientover a six-month period. [25]$5K$0Non-SpecialistCareSpecialistCareASTHMA CAREEMERGENCY ROOMCOST SAVINGSSource: Villanueva, et al.American College of Chest Physicians Annual Meeting 2000.11

Indirect CostsDays missed from work for adults withasthma, or those who must stay home to carefor children with asthma, are estimated to costmore than $5 billion annually. Asthma is aleading cause of missed school days amongchildren, causing an estimated 13 millionabsences each year [1]. In one survey of adultswith asthma prior to enrollment in an asthmamanagement program, a total of 194 daysmissed from work were reported by 78patients. Care by an allergist or other asthmaspecialist reduced lost days from work orschool by 80 percent or more. [27] In anotherstudy, nearly 100 patients enrolled in aspecialty intervention program reduced lostwork or school days to 246 over a six-monthperiod,compared to 1,040 days for patientswho did not receive specialty care. [25]How Allergists AchieveHigh-Quality, Cost-EffectiveOutcomesSociety in general, health plan administrators,group plan purchasers and – most importantly –patients benefit when asthma care is managed byan allergist. With their specialty training,knowledge and experience, allergists can:Accurately diagnose the disease, its types,subtypes and severityThe blockage of airways caused by asthma canbe intermittent, so a patient with asthma mayhave symptoms of the disease and yet appearto have normal lung function during a routinephysician visit. The allergist can performspecialized tests such as a methacholine orexercise challenge to confirm a diagnosis ofasthma. These tests are particularly helpful indiagnosing the cause of exercise-inducedshortness-of-breath. The allergist is an expertin determining if symptoms are due to asthmaor to another medical condition.Identify the role of external factors,including allergens that can trigger anasthma attack, and advise patients on howto avoid their asthma triggersMany people with asthma are allergic to oneor more things that trigger their asthmasymptoms. The allergist performs tests toidentify an individual’s asthma triggers andhelps patients develop a plan to avoid orminimize exposure to the allergens thatcontribute to the disease.Administer immunotherapy, or “allergyshots,” to reduce sensitivity to allergytriggersAllergy immunotherapy is indicated for peoplewith allergic asthma who:• have symptoms that are not adequatelyrelieved by asthma medications• are unable to avoid the allergens that triggertheir disease• have unacceptable side effects from asthmamedications• have not responded well to asthmamedications, or need to avoid long-termmedication use.In some cases, immunotherapy also canprevent children with nasal allergies or otherrisk factors from developing asthma.Use current best practice standards todevelop and implement aggressivetreatment plans that focus on asthmacontrolThe allergist understands that each patientwith asthma is unique and requires a treatmentplan tailored to individual needs. Allergistswork with patients to develop self-help plansthat include at-home instructions for assessingasthma control, how to deal with asthma12

symptoms and when to seek help for anasthma attack.Maintain disease control through a multifacetedapproach that includes prevention,appropriate use of medications and otherinterventions to prevent asthmasymptoms, and promote ongoing patienteducation and self-care strategiesThe most successful asthma control resultsfrom a partnership between patient andphysician. The allergist is uniquely qualified towork with patients to ensure proper use oflong-term controller medications, avoid overrelianceon quick-relief medications andprevent the hospitalizations, emergency roomvisits, days lost from work or school and otherdebilitating and expensive outcomes associatedwith poorly controlled asthma.Prevent serious consequences of asthmaFor persons who have required emergency careor hospitalization for asthma, care by anallergist can reduce the need for these acutecare services. Compared to care provided bygeneral medical professionals, the allergist ismore likely to educate the patient in selfmanagement,including the use of writtenasthma action plans and of peak flow metersto enhance asthma control.Aggressive Asthma Management:The Standard of CareUntil 1991, it was the consensus of physiciansthat asthma therapy should be conservativeand medications introduced one at a time, withdosage increases only when the conditionworsened. Contrasted to this are the currentevidence-based guidelines stipulating thatasthma should be diagnosed as early aspossible and treated aggressively while it is stillmild. Otherwise it may worsen and causepermanent scarring and irreversible remodelingof the lungs’ airways. [8]The disease should be treated with multiplemedications, if necessary, to control symptomsas soon as they appear. Allergists, with theirextensive experience using these medications,are able to prescribe them properly for theindividual patient. Aggressive therapy shouldbe initiated at the onset to establish immediatecontrol of symptoms. The therapy then may bestepped down as the patient’s conditionimproves. An allergy history, physical examand skin tests may be needed to identifyfactors triggering asthma exacerbations.Although the costs of the initial therapy maybe high, they are outweighed by significantlong-term health benefits and cost savings. [26]A study of medical treatments for 1,574patients enrolled in a managedcare plan found that the bestmanagers of asthma are specialistswho tend to be very aggressivewith diagnostics, therapies and theallocation of time to counsel thepatient. The study found that thecosts of care were about the sameor less than the care given bynonspecialists, and outcomes anddisease control were significantlyimproved for the patients treatedby specialists. [37]13

New Perspectives on AsthmaAs more is learned about asthma, researchersare discovering that the disease is far morecomplex than previously thought and consistsof several subtypes, such as allergic asthma,exercise-induced asthma, asthma related tobacterial or fungal infections and asthma in theelderly. Each type can have different symptomsor triggers, and each requires a differentapproach to diagnosis and treatment. Allergists,based on extensive experience in treating allforms of the disease, understand its complexitiesand know that it is crucial to distinguish amongdifferent types. They can assess the severity ofeach case and develop case-specific action plansthat have the greatest likelihood of success withindividual patients.The Emerging Role of NewTreatments and PreventionsAllergists are uniquely qualified to ensure thatpatients have access to the latest treatment andsymptom control strategies to keep their asthmacontrolled.• Allergists, with their specialized knowledgeof the relationship between environmentalpollutants and allergens, as well as thedisease and the mechanisms of allergicreactions, have the training and clinicalexperience to deal effectively with thesefactors.• Allergists promote asthma self-managementskills to assist people in eliminating ordecreasing exposure to asthma “triggers.” [38]• Allergists are more likely than generalists toprovide authoritative information to healthcare providers, families and other caregivers.[13, 39-40]• Allergies are specialists at immunotherapy or“allergy shots” that can reduce sensitivity tothe allergens that trigger asthma attacks, andsignificantly reduce the severity of thedisease. [41] Immunotherapy also can preventthe development of asthma in some childrenwith seasonal allergies. [42]Allergists are involved in clinical trials to testother promising techniques, such as the use ofmonoclonal antibodies to inhibit theinflammatory process that leads to asthma.They usually are the first clinicians to becomeaware of and implement proven newtreatments.14

Specialty Care of Asthmain Health Plansuse of asthma medications a key indicator inevaluating the quality of managed careprograms. [44]Even PCPs increasingly aredemanding a greater say inreferring patients to specialistswhen the disease is severe,atypical or requires specializedknowledge for optimummanagement. [45]As asthma management becomes moresophisticated, health care plans are seeking acompetitive edge through programs thatoptimize patient health education, symptomcontrol and aggressive treatment that avoidssevere exacerbations of the disease. Plans withgoals of reducing participant turnover and thatemphasize lifestyle change are most successfulat satisfying patients and reducing costs. In areview of health care trends prepared forManaged Care Medicine, asthma managementwas chosen as a model for the new strategy ofmanaged care. [43] “Asthma is a healthproblem that pays large dividends if a properfront-end investment is made in patienteducation and preventive care,” the authornoted. “Such an intervention can significantlyimprove symptom control and reduce hospitaland emergency room use . . . . The PCP[primary care physician] should have aconsulting relationship with an allergyspecialist who can perform any part of theinitial evaluation for asthma or diseasemanagement that the PCP is not able to provide.”Managed care organizations have an addedmotivation to optimize asthma management.The National Committee for QualityAssurance (NCQA) has made the appropriateAsthma specialists also arespreading the word toconsumers. The AmericanCollege of Asthma, Allergy andImmunotherapy (ACAAI), forexample, has launched aneducation campaign to help consumersevaluate allergy and asthma benefits in healthplans. When individuals with allergies orasthma enroll in a health plan – or have anannual open enrollment period for changingplans – the ACAAI provides a Checklist as aguide to determine whether an employee’sinsurance options allow:• access to specialists for diagnosis of asthmaand other allergic diseases• ongoing management for specialist care ofasthma and allergies• unlimited visits to specialist care for asthmaand allergies• access to diagnostic tests for asthma andallergies• access to medications and tests prescribed byspecialists, including immunotherapy or“allergy shots”• consultation and/or management by aspecialist without co-payments that aregreater than those for generalist care.15

ConclusionA substantial and growing body of publishedclinical data and other, economic researchshows significant differences in treatmentoutcomes and costs between asthma care thatis managed by generalists who have nospecialty training in the complexities ofasthma, and disease management that is underthe direction of an allergist.An evidence-based review of the literatureindicates that aggressive management ofasthma by a specialist improves outcomes forpatients, lowers overall treatment costs forpayers, and reduces the indirect costs tosociety. Specialty care results in fewerhospitalizations and other emergencyinterventions, fewer missed days from work orschool, and significantly enhanced health andquality of life for those who suffer fromasthma.Despite all this, some health care plans todaystill place obstacles in front of patients seekingreferral to an asthma specialist, even whenreferral to a specialist is recommended in theNIH Guidelines and other national consensusrecommendations. [46-47] The result isconservative or sporadic treatment that allowsdisease progression, airway remodeling andpermanent damage to the lungs. Inadequatemanagement of asthma also results inincreased hospitalizations, emergency care andother high-priced interventions, and adds tothe number of days missed from work orschool.As more is learned about the mechanisms ofasthma and its risk factors, and as newtherapies are developed, the allergist can beexpected to be at the forefront helping tocontrol disease severity and diminish itsprogression.16

References1. Centers for Disease Control and Prevention; Asthma Prevalence, Health Care Use and Mortality:United States, 2003-2005; National Center for Health Statistics; November 2006. Available fromURL: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/ashtma03-05/asthma03-05.htm.2. Centers for Disease Control and Prevention; National Surveillance for Asthma – United States,1980-2004; MMWR; Oct. 19, 2007;56(SS08):1-14;18-54.3. Action Against Asthma. A Strategic Plan for the Department of Health and Human Services.May 2000.4. Morbidity and Mortality: 2007 Chart Book on Cardiovascular, Lung and Blood Diseases.National Institutes of Health, National Heart, Lung and Blood Institute. June 2007.5. Weiss KB, Sullivan SD. The health economics of asthma and rhinitis. I. Assessing the economicimpact. J Allergy Clin Immunol. 2001;107(1):3-8.6. Cisternas MG, Blanc PD, Yen IH, Katz PP, Earnest G, et al. A comprehensive study of the directand indirect costs of adult asthma. J Allergy Clin Immunol. 2003;111(6):1212-1218.7. Wang LY, Zhong Y, Wheeler L. Direct and indirect costs of asthma in school-age children.Prev Chronic Dis. 2005;2(1). Available from URL: http://www.cdc.gov/pcd/issues/2005/jan/04_0053.htm.8. National Heart, Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosisand Management of Asthma 2007. Bethesda, Md: National Institutes of Health; Aug. 2007.NIH Publication No. 07-4051.9. Li JT, Oppenheimer J, Bernstein IL, Nicklas RA, eds. Attaining optimal asthma control: apractice parameter. J Allergy Clin Immunol. 2005;116(5):S3-S11.10. Leung D, Schatz M., eds Consultation and referral guidelines citing the evidence: How theallergist-immunologist can help. J Allergy Clin Immunol. 2006;117(2):S495-S23.11. Sullivan SD, Rasouliyan L, Russo PA, Kamath T, Chipps BE for the TENOR Study Group.Extent, patterns, and burden of uncontrolled disease in severe or difficult-to-treat asthma. Allergy.2007;62(2):126-133.12. Vargas PA, Simpson PM, Bushmiaer M, Goel R, Jones CA, et al. Symptoms profile and asthmacontrol in school-age children. Ann Allergy Asthma Immunol. 2006;96:787-793.13. Piecoro LT, Potoski M, Talbert JC, Doherty DE. Asthma prevalence, cost, and adherence withexpert guidelines on the utilization of health care services and costs in a state Medicaidpopulation. Health Serv Res. 2001;36(2):357-371.14. Finkelstein JA, Lozano P, Shulruff R, Inui TS, Soumerai SB, Ng M, Weiss KB. Self-reportedphysician practices for children with asthma: Are national guidelines followed? Pediatrics.2000;106(4):886-896.15. Baptist AP, Baldwin JL. Physician attitudes, opinions, and referral patterns: comparisons of thosewho have and have not taken an allergy/immunology rotation. Ann Allergy Asthma Immunol.2004;93:227-231.16. Wu AW, Young Y, Skinner EA, et al. Quality of care and outcomes of adults with asthma treatedby specialists and generalists in managed care. Arch Intern Med. 2001;161:2554-2560.17. Curwick CC, Bonauto DK, Adams DA. Use of objective testing in the diagnosis of work-relatedasthma by physician specialty. Ann Allergy Asthma Immunol. 2006;97:546-550.18. Schatz M, Zeiger RS, Mosen D, Apter AJ, Vollmer WM, et al. Improved asthma outcomes fromallergy specialist care: A population-based cross-sectional analysis. J Allergy Clin Immunol.2005;116(6):1307-1313.19. Schatz M, Zeiger RS, Vollmer WM, Mosen D, Cook EF. Determinants of future long-termasthma control. J Allergy Clin Immunol. 2006;148(5):1048-1053.17

1820. Schatz M, Cook EF, Nakahiro R, Petitti D. Inhaled corticosteroids and allergy specialty carereduce emergency hospital use for asthma. J Allergy Clin Immunol. 2003;111(3):503-508.21. Diette GB, Skinner EA, Nguyen, TT, et al. Comparison of quality of care by specialist andgeneralist physicians as usual source of asthma care for children. Pediatrics. 2001;108(2):432-437.22. Sin DD, Tu JV. Underuse of inhaled steroid therapy in elderly patients with asthma. Chest.2001;119:720-725.23. Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medicationsamong Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002;156:562-567.24. Shields AE, Comstock C, Finkelstein JA, Weiss KB. Comparing asthma care provided toMedicaid-enrolled children in a primary care case manager plan and a staff model HMO.Ambul Pediatr. 2003;3(5):253-262.25. Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthmaintervention program prevents readmissions in high healthcare users. Am J Respir Critical CareMed. 2003;168:1095-1099.26. Villanueva AG, Mitchell L, Ponticelli D, Levine AS. Effectiveness of an asthma center inimproving care and reducing costs in patients with difficult-to-control asthma. Abstractpresentation, the American College of Chest Physicians annual meeting, October 2000.27. National Jewish Medical and Research Center; Outcomes prove asthma treatment programsimprove disease management and control costs. Medical Scientific Update Publication.Vol. 15, No. 3, Winter 1998.28. Lafata JE, Xi H, Divine G. Risk factors for emergency department use among children withasthma using primary care in a managed care environment. Ambul Pediatr. 2002;2(4):268-275.29. Moore CM, Ahmed I, Mouallem R, et al. Care of asthma: allergy clinic versus emergency room.Ann Allergy Asthma Immunol. 1997;78:373-380.30. Westley CR, Spiecher B, Starr L, et al. Cost effectiveness of an allergy consultation in themanagement of asthma. Allergy Asthma Proc. 1997;18(1):15-18.31. Vollmer WM, O’Hollaren M, Ettinger KM, et al. Specialty differences in the management ofasthma. A cross-sectional assessment of allergists’ patients and generalists’ patients in a largeHMO. Arch Intern Med. 1997;157:1201-1208.32. Gaioni SJ, Korenblat-Hanin M, Fisher EB, Korenblat P. Treatment outcomes in an outpatientasthma center: retrospective questionnaire data. Amer J Managed Care. 1996;2:999-1008.33. Moon MA. Costs of asthma care up by 54% in 10-year period. Family Practice News. Oct. 1, 2000.34. Mahr TA, Evans R. Allergist influence on asthma care. Ann Allergy Asthma Immunol.1993;71:115-120.35. Smith DH, Malone DC, Lawson KA, et al. A national estimate of the economic costs of asthma.Am J Respir Crit Care Med. 1997;156:787-793.36. Doan T, Grammer LC, Yarnold PR, et al. An intervention program to reduce the hospitalizationcost of asthmatic patients requiring intubation. Ann Allergy Asthma Immunol. 1996;76:513-518.37. Nyman JA, Hillson S, Stoner T, DeVries A. Do specialists order too many tests? The case ofallergists and pediatric asthma. Ann Allergy Asthma Immunol. 1997;79:496-502.38. Zeiger RS, Schatz M. Effect of allergist intervention on patient-centered and societal outcomes:allergists as leaders, innovators, and educators. J Allergy Clin Immunol. 2000;106(6):995-1018.39. Taylor DM, Auble TE, Calhoun WJ, et al. Current outpatient management of asthma showspoor compliance with international consensus guidelines. Chest. 1999;116:1638-1645.

40. Legorreta AP, Christian-Herman J, O’Connor RD, Hassan MM, Evans R, Leung KM.Compliance with national asthma management guidelines and specialty care: A healthmaintenance organization experience. Arch Intern Med. 1998;158:457-464.41. Abramson MJ, Puy RM, Weiner JM. Allergy immunotherapy for asthma. Cochrane DatabaseSyst Rev. 2000;2:CD001186.42. Moller C, Dreborg S, Hosne AF, et al. Pollen immunotherapy reduces the development of asthmain children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol.2002;109(2):251-256.43. Keenan JM. Optimizing health: asthma management as a model for the new managed care.Managed Care Med. Nov-Dec 1995;20-28.44. National Committee for Quality Assurance; The state of managed care quality, 2000; NCQA’sState of Managed Care Quality Report.45. More power to you: Some managed care organizations are loosening the reins a little. DrugTopics, Jan. 3, 2000.46. Mitchell JB, Khatustky G, Swignonsky NL. Impact of the Oregon Health Plan on children withspecial health care needs. Pediatrics. 2001;107(4):736-743.47. Moy JN, Grant EN, Turner-Roan K, et al. Asthma care practices, perceptions and beliefs ofChicago-area asthma specialists. Chest. 1999;116:154S-162S.Abstracts of Outcome and Cost StudiesAbramson MJ, Puy RM, Weiner JM. Allergy immunotherapy for asthma. Cochrane Database Syst Rev.2000;2:CD001186.Conclusion: Immunotherapy may reduce asthma symptoms and use of asthma medications.Specific findings: A review of 54 trials was conducted to assess the effects of allergen-specific immunotherapyfor asthma. Overall, patients receiving immunotherapy experienced a significant reduction in asthmasymptoms and medication use compared to those randomized to placebo.Baptist AP, Baldwin JL. Physician attitudes, opinions, and referral patterns: comparisons of those who have andhave not taken an allergy/immunology rotation. Ann Allergy Asthma Immunol. 2004;93:227-231.Conclusion: There are significant differences in the attitudes, opinions and referral patterns betweenphysicians who have and have not taken an allergy/immunology rotation.Specific findings: A questionnaire completed anonymously by 227 primary care physicians found that thosewho had taken an A/I rotation were more likely to feel they knew the types of cases seen by an allergistcompared to those who had not taken an A/I rotation (75.9 percent vs. 33.3 percent), to feel they knew anadequate amount about A/I (59.3 percent vs. 19.5 percent), to view immunotherapy as effective (70.0 percentvs. 52.3 percent) and to have referred a patient to an allergist (77.8 percent vs. 46.0 percent).Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthma intervention programprevents readmissions in high healthcare users. Am J Respir Critical Care Med. 2003;168:1095-1099.Conclusion: A brief intervention program focusing on high health care users with asthma resulted inimproved asthma control, reduced hospital use and substantial cost savings.Specific findings: A total of 96 adult subjects, hospitalized with an asthma exacerbation who had a history offrequent health care use, were randomized to care by an asthma specialist or a generalist for six months.There was a 60 percent reduction in total hospitalizations, a 54 percent reduction in readmissions for asthmaand a marked reduction in lost work or school days (246 vs. 1,040 days) in the intervention group comparedto the control group. Care by an asthma specialist resulted in a savings of $6,462 per patient.19

Cisternas MG, Blanc PD, Yen IH, Katz PP, Earnest G, et al. A comprehensive study of the direct and indirect costsof adult asthma. J Allergy Clin Immunol. 2003;111(6):1212-1218.Conclusion: Asthma-related costs are substantial and are driven largely by pharmaceuticals and work loss.Specific findings: In a study of 401 adults with asthma, total per-person annual costs of asthma averaged$4,912, with direct costs accounting for $3,180 (65 percent) and indirect costs $1,732 (35 percent). Thelargest components of direct costs were pharmaceuticals, hospital admissions and non-emergency departmentambulatory visits. Total cessation of work and the loss of entire work days accounted for 89 percent ofindirect costs. Total per-person costs were $2,646, $4,530 and $12,813 for persons reporting mild, moderateand severe asthma, respectively.Curwick CC, Bonauto DK, Adams DA. Use of objective testing in the diagnosis of work-related asthma byphysician specialty. Ann Allergy Asthma Immunol. 2006;97:546-550.Conclusion: Appropriate diagnostic care received by workers with work-related asthma may be lacking, andphysicians who have questions about diagnostic procedures should consider referral to a specialist.Specific findings: A comparative evaluation of 301 workers’ compensation claimants with work-relatedasthma found that only 36.9 percent were treated by specialists and less than half the claimants(43.2 percent) had received an objective evaluation of pulmonary function. Claimants treated by specialistswere significantly more likely to have received diagnostic testing during evaluation of their disease than thosetreated solely by generalists (82.9 percent vs. 20.0 percent).Diette GB, Skinner EA, Nguyen, TT, et al. Comparison of quality of care by specialist and generalist physicians asusual source of asthma care for children. Pediatrics. 2001;108(2):432-437.Conclusion: Asthma care in children in two large managed care organizations was more likely to beconsistent with national guidelines when a specialist was the primary provider.Specific findings: A cross-sectional study of 260 children with asthma reviewed four domains of patient care,including patient education, control of factors contributing to asthma symptoms, periodic physiologicassessment and monitoring, and proper use of medications. In all four domains, care provided by a specialistwas more likely to be consistent with guidelines. The greatest differences between specialist and generalistdisease management were in the use of controller medications, having had a pulmonary function test andhaving been told about asthma triggers and how to avoid them.Doan T, Grammer LC, Yarnold PR, et al. An intervention program to reduce the hospitalization cost of asthmaticpatients requiring intubation. Ann Allergy Asthma Immunol. 1996;76:513-518.Conclusion: An intervention program that included education, specialist care, regular outpatient visits andaccess to an emergency call service significantly reduced the cost of asthma care in patients intubated forasthma.Specific findings: In a study of nine patients, the mean total cost of care decreased from $43,066 the yearbefore the intervention to $4,914 the year after. Inpatient hospitalization costs decreased from $40,253 to$1,926. The costs of emergency services, outpatient services and medicines did not change significantly.Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaidinsuredchildren with asthma. Arch Pediatr Adolesc Med. 2002;156:562-567.Conclusion: Medicaid-insured children who receive action plans, have follow-up visits or specialtyconsultations are less likely to be symptomatic underusers of controller medications.Specific findings: Telephone surveys conducted with parents of children and adolescents aged 2 to 16 yearswith asthma who were enrolled in one of five managed care plans found widespread underuse of medicationsthat control asthma symptoms. Having seen an asthma specialist was a factor associated with lower rates ofunderuse.20

Finkelstein JA, Lozano P, Shulruff R, Inui TS, Soumerai SB, Ng M, Weiss KB. Self-reported physician practices forchildren with asthma: Are national guidelines followed? Pediatrics. 2000;106(4):886-896.Conclusion: Most children’s physicians report having read and adopted the National Asthma Education andPrevention Program guideline recommendations for asthma treatment, but criteria for referral to an asthmaspecialist often differed from those of the guidelines. Opportunities for improvement also exist in areas suchas the use of written care plans, optimizing anti-inflammatory medications and providing routine follow up.Specific findings: In a survey, 407 pediatricians and family physicians reported criteria for referral to anasthma specialist that differed from national guidelines when it came to managing more severe patientswithout input from an asthma specialist. Family physicians were more likely than pediatricians to refer achild after a single hospitalization, two to three emergency department visits, two disease exacerbations, orwhen the child was under age 3 and required daily medications.Gaioni SJ, Korenblat-Hanin M, Fisher EB, Korenblat P. Treatment outcomes in an outpatient asthma center:retrospective questionnaire data. Amer J Managed Care. 1996;2:999-1008.Conclusion: Aggressive treatment at an asthma center had a positive and significant impact on asthma healthoutcomes and health system cost savings.Specific findings: Treatment at an asthma specialty center resulted in a 78 percent reduction inhospitalizations, a 73 percent reduction in emergency room visits and a 48 percent reduction in unscheduledphysician visits, according to a survey of 207 patients who had been treated at the center for at least one year.Overall net savings in medical system use was estimated to be $2,714 per patient per year, for a total savingsof more than $560,000. Other improvements included decreases in severe shortness of breath from 48 percentto 15 percent, frequent depressed mood from 32 percent to 13 percent, and severe interference with dailyactivities from 31 percent to 11 percent. Patients also noted an increase from 48 percent to 96 percent inknowledge of self care for asthma, and from 21 percent to 78 percent in satisfaction with professional asthma care.Keenan JM. Optimizing health: asthma management as a model for the new managed care. Managed Care Med.Nov.-Dec. 1995;20-28.Conclusion: Aggressive and consistent implementation of the new asthma management clinical guidelines isan excellent way for managed care organizations to optimize the health of their community of patients.Specific findings: Asthma management is studied as a model to illustrate the individual and populationbenefits of optimizing health care. Based on a review of the available literature, the author concludes thatimplementation of intervention programs in compliance with existing guidelines will provide immediate andtangible clinical and cost benefits.Lafata JE, Xi H, Divine G. Risk factors for emergency department use among children with asthma using primarycare in a managed care environment. Ambul Pediatr. 2002;2(4):268-275.Conclusion: Encouraging routine primary care visits and referral to an allergist may reduce emergencydepartment use among children with asthma.Specific findings: Children with asthma aged 5-14 treated by pediatricians in a large group practice werefollowed for two years. Emergency department use tended to be less among children who saw an allergist.Legorreta AP, Christian-Herman J, O'Connor RD, Hassan MM, Evans R, Leung KM. Compliance with nationalasthma management guidelines and specialty care: a health maintenance organization experience. Arch InternMed. 1998;158:457-464.Conclusion: Although the National Asthma Education and Prevention Program expert panel guidelines forthe diagnosis and management of asthma were initially published in 1991, a survey of a major CaliforniaHMO found compliance with the guidelines low. The results showed that asthma specialists provided morethorough care than did primary care physicians in treating patients with asthma.21

Specific findings: Survey data were analyzed for 5,580 asthma patients covered by Health Net in California in1996. Of respondents with severe asthma, 72 percent reported having a steroid inhaler, but only 54 percentused it daily. The patients of specialists were more likely to have a steroid inhaler and peak flow meter and touse them daily. Specialists also provided more patient education on how to prevent and control asthmaattacks.Mahr TA, Evans R. Allergist influence on asthma care. Ann Allergy Asthma Immunol. 1993;71:115-120.Conclusion: Follow-up care by an allergist after hospitalization for asthma resulted in a decrease insubsequent hospitalizations and emergency room visits.Specific findings: The retrospective study compared 83 patients who received asthma follow-up care by anallergist and 40 patients who received care from a non-allergist after hospitalization. Of patients whoreceived follow-up care by an allergist, 13 percent were subsequently hospitalized, compared to 35 percenttreated by non-allergists, and 18 percent of the allergist patients had emergency room visits compared to 47percent treated by non-allergists. There were significant increases in use of all medications and devices in thegroup treated by allergists.Mitchell JB, Khatustsky G, Swigonsky NL, et al. Impact of the Oregon Health Plan on children with special healthcare needs. Pediatrics. 2001;107(4):736-743.Conclusion: Children with disabilities in managed care plans did not experience any more difficulty accessingneeded specialty care than did those without special health care needs. Children with asthma, however, hadhigher levels of unmet need.Specific findings: Three groups of children, ages 1 to 17 were sampled: 205 children with disabilities whoreceived Supplemental Security Income (SSI), 410 children with asthma and 351 children without specialhealth care needs. Almost one-fifth of the children with disabilities and one-eighth of children with asthmawere reported to be in fair or poor health. Access problems were rare, however a high proportion of childrenwith asthma reported unmet needs for specialist care and children with asthma were not eligible for the sameconsumer protections afforded SSI children by Oregon. The authors concluded that if states want to enroll allchildren with special health needs into managed care programs, they must develop mechanisms for identifyingsuch children and ensuring that they receive medically necessary services.Moller C, Dreborg S, Hosne AF, et al. Pollen immunotherapy reduces the development of asthma in children withseasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol. 2002;109(2):251-256.Conclusion: Immunotherapy can reduce the development of asthma in children with seasonalrhinoconjunctivitis.Specific findings: More than 200 children ages 6 to 14 with moderate-to-severe hay fever symptoms wereenrolled in the study. At the start of the study, none of the children reported an asthma diagnosis requiringdaily treatment, however 20 percent had mild asthma symptoms during the pollen season(s). Among thosewithout asthma, the children actively treated with immunotherapy had significantly fewer asthma symptomsafter three years as evaluated by clinical diagnosis.Moore CM, Ahmed I, Mouallem R, et al. Care of asthma: allergy clinic versus emergency room. Ann AllergyAsthma Immunol. 1997;78:373-380.Conclusion: The decreased morbidity of asthma and cost of care for the allergy clinic patients, compared tothe emergency room patients, are likely due to the care given in the allergy-immunology clinic.Specific findings: Fifty emergency room patients and 25 allergy clinic patients were studied. The data showedno demographic or socioeconomic differences between the two groups. However, the clinic group hadsignificantly less nocturnal cough and sleep interruption, and fewer missed school and emergency room visits,resulting in approximate average savings of $137 per patient per year.Moy JN, Grant EN, Turner-Roan K, et al. Asthma care practices, perceptions, and beliefs of Chicago-area asthmaspecialists. Chest. 1999;116:154S-162S.Conclusion: Asthma specialists in the Chicago area are providing asthma care that is, in many ways,consistent with national guidelines. However, there are also important differences in asthma care between22

two subspecialty groups: allergists and pulmonologists. The effect of these differences on the management ofpersons with asthma is not known.Specific findings: A survey was mailed to a sample of asthma specialists (allergists or pulmonologists) in theChicago area. A total of 113 eligible surveys were returned (response rate, 72.0 percent). Ninety-nine percentof the respondents indicated they would prescribe inhaled corticosteroids for patients 5 years of age or olderwith moderate persistent asthma, and 85.5 percent would prescribe them for patients younger than 5 yearsold. The respondents reported that 71.2 percent of their patients with moderate or severe persistent asthmawere routinely given written treatment plans. The use of these plans was reported more frequently by allergiststhan pulmonologists (77.6 percent vs. 58.9 percent). Nearly half of the respondents were involved in thedevelopment of hospital-based asthma programs; fewer (14.9 percent) were involved in developing asthmaprograms for managed care organizations. A majority (63.4 percent) of the physicians had given a formalprofessional education presentation on asthma in the past year. A majority of the respondents who care forpatients under managed care contracts reported that these patients have encountered barriers to access inseeking specialty care.Nyman JA, Hillson S, Stoner T, DeVries A. Do specialists order too many tests? The case of allergists and pediatricasthma. Ann Allergy Asthma Immunol 1997;79:496-502.Conclusion: Allergists’ test-intensive practice style is cost-effective.Specific findings: A review of 1,574 pediatric asthma cases in a large health plan found that cases managed byallergists were no more costly than those managed by non-allergists, despite the fact that the allergists orderedsignificantly more tests and required more office visits than non-allergists. Patients treated by allergistsexperienced fewer hospitalizations and emergency room visits resulting in cost-savings due to improvedoutcomes and disease control.Piecoro LT, Potoski M, Talbert JC, Doherty DE. Asthma prevalence, cost, and adherence with expert guidelines onthe utilization of health care services and costs in a state Medicaid population. Health Serv Res. 2001;36(2):357-371.Conclusion: A review of asthma prevalence and utilization of health services in a Kentucky Medicaidpopulation found that widespread nonadherence to the National Asthma Education Program expert panelguidelines was associated with an increase in asthma exacerbations that resulted in hospitalizations.Specific findings: Of 530,000 Medicaid recipients, 24,365 (4.6 percent) were identified as having asthma.Average annual per-person asthma-related costs ($616) accounted for less than 20 percent of total per-personhealth care costs ($3,645). Less than 40 percent of the patients received a prescription for a rescue medicationand fewer than 10 percent of the patients who received daily inhaled short-acting beta-2 agonists were regularusers of inhaled steroids. Nonadherence to the guidelines was associated with an increased risk of an asthmarelatedhospitalization.Schatz M, Cook EF, Nakahiro R, Petitti D. Inhaled corticosteroids and allergy specialty care reduce emergencyhospital use for asthma. J Allergy Clin Immunol. 2003;111(3):503-508.Conclusion: Asthma care by allergy specialists and increased use of inhaled corticosteroids reduce use ofemergency hospital services.Specific findings: More than 9,600 asthmatic patients 3 to 64 years of age were identified from an electronicdatabase of a large health maintenance organization. Dispensing of seven or more canisters of inhaledcorticosteroids (ICs) annually and care by an allergy specialist were independently associated with reducedemergency hospital care. Patients with allergy specialist care were more likely than those without specialty careto receive seven or more dispensations of ICs.Schatz M, Zeiger RS, Mosen D, Apter AJ, Vollmer WM, et al. Improved asthma outcomes from allergy specialistcare: A population-based cross-sectional analysis. J Allergy Clin Immunol. 2005;116(6):1307-1313.Conclusion: Allergist care is associated with a wide range of improved outcomes in asthmatic patientscompared with care provided by primary care providers.23

Specific findings: In a random sample of 3,568 patients with persistent asthma, patients of allergists reportedsignificantly higher general physical and asthma-specific quality of life, fewer asthma control problems andsevere symptoms, higher satisfaction with care and greater self-management knowledge, compared with thosewhose disease was managed by primary care providers. Patients of allergists were less likely to require anasthma hospitalization, unscheduled office visit or to overuse beta agonists, and were more likely to havereceived inhaled steroids during the past year.Schatz M, Zeiger RS, Vollmer WM, Mosen D, Cook EF. Determinants of future long-term asthma control. JAllergy Clin Immunol. 2006;148(5):1048-1053.Conclusion: Effective management strategies are associated with improved asthma control, even afteraccounting for characteristics that put patients at high risk for poor control.Specific findings: Poor asthma control was associated with greater use of oral corticosteroids, unscheduledmedical visits in the prior year, prior asthma hospitalizations, smoking, chronic obstructive pulmonary disease,male sex, black race and lower educational level. Better control in high-risk patients was associated withregular inhaled corticosteroids, long-acting beta agonists and asthma specialist care.Shields AE, Comstock C, Finkelstein JA, Weiss KB. Comparing asthma care provided to Medicaid-enrolled childrenin a primary care case manager plan and a staff model HMO. Ambul Pediatr. 2003;3(5):253-262.Conclusion: Children enrolled in a staff model HMO that provided greater access to asthma specialists wereless likely to require emergency department visits or hospitalization, or to meet federal criteria for persistentasthma, compared to patients in a primary care case manager plan (PCCM) that provided less access tospecialist care.Specific findings: In a study of 2,365 children with asthma in the Massachusetts Medicaid program, childrenin the HMO were only 54 percent as likely as those in the PCCM plan to experience an asthma emergencydepartment visit or hospitalization, only half as likely to meet the NCQA definition for persistent asthma andonly 32 percent as likely to have prior emergency department visits or hospitalizations. Children in the HMOwere 2.9 times as likely to receive timely follow-up care and 1.8 times as likely to receive a specialist visitduring the year.Sin DD, Tu JV. Underuse of inhaled steroid therapy in elderly patients with asthma. Chest. 2001;119:720-725.Conclusion: Despite their proven efficacy, inhaled steroids are underused in the elderly asthmatic population,with patients of primary-care physicians less likely to receive the therapy than patients of specialists.Specific findings: Of the 6,254 Ontario, Canada, patients age 65 and older who experienced a recent acuteexacerbation of asthma, 2,495 patients (40 percent) did not receive inhaled steroid therapy within 90 days ofdischarge from their initial hospitalization for asthma. Nonreceipt of inhaled steroid therapy was particularlyprominent in older patients with multiple comorbidities. Moreover, those who received care from primary carephysicians were less likely to receive inhaled steroid therapy, compared to those who received care from specialists.Smith DH, Malone DC, Lawson KA, et al. A national estimate of the economic costs of asthma. Am J Respir CritCare Med. 1997;156:787-793.Conclusion: Future asthma research and intervention efforts directed at reducing hospitalization and providingbetter care for high-risk asthma patients could help to decrease health care resource use and provide cost savings.Specific findings: Based on an analysis of the 1987 National Medical Expenditure Survey, the total estimatedannual cost of asthma is $5.8 billion, with hospitalization accounting for half of all expenditures. More than80 percent of resources were used by 20 percent of the population. The estimated annual per patient cost forhigh-risk patients was $2,584, compared to $140 for the rest of the sample.Sullivan SD, Rasouliyan L, Russo PA, Kamath T, Chipps BE for the TENOR Study Group. Extent, patterns, andburden of uncontrolled disease in severe or difficult-to-treat asthma. Allergy. 2007;62(2):126-133.Conclusion: This multi-center study found that few severe or difficult-to-treat asthma patients achieved controlover a two-year period, and the economic consequence of uncontrolled disease is substantial.24

Specific findings: The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens(TENOR) study found that 83 percent of asthma patients had uncontrolled disease, 16 percent hadinconsistent control and 1.3 percent were controlled. Controlled patients experienced fewer work or schoolabsences and less health care resource use than uncontrolled patients. Costs for uncontrolled patients weremore than double those of controlled patients throughout the study ($14,212 vs. $6,452, adjusted to 2002 dollars).Taylor DM, Auble DE, Calhoun WJ, et al. Current outpatient management of asthma shows poor compliancewith international consensus guidelines. Chest. 1999; 116:1638-1645Conclusion: The outpatient management of most asthma patients requiring emergency room care does notcomply with consensus treatment guidelines, and patient knowledge of asthma is poor.Specific findings: A prospective, researcher-administered questionnaire was used to evaluate 85 patientsrequiring emergency room treatment for asthma. The majority of the patients were not managed incompliance with expert guidelines, with 62 percent under treated with medications and 87 percent having nowritten plan of action. Only 28 percent of the severe asthmatics were treated by asthma specialists, far shortof the 100 percent recommended by the guidelines. Knowledge of the disease and proper medication use alsowas low.Vargas PA, Simpson PM, Bushmiaer M, Goel R, Jones CA, et al. Symptoms profile and asthma control in schoolagechildren. Ann Allergy Asthma Immunol. 2006;96:787-793.Conclusion: Asthma was uncontrolled in 85 percent of inner-city students with asthma in Little Rock, Ark.,based on the presence of symptoms and the need for rescue medicines.Specific findings: Half of the children with active asthma had been treated in the emergency department atleast twice in the previous two years, 52 percent often had to limit their activities, 29 percent reportednighttime symptoms once or more per week and 17 percent reported missing five or more days of school peryear because of asthma.Villanueva AG, Mitchell L, Ponticelli D, Levine AS. Effectiveness of an asthma center in improving care andreducing costs in patients with difficult-to-control asthma. Abstract presentation. American College of ChestPhysicians annual meeting. Oct. 2000.Conclusion: A multi-disciplinary team specializing in the treatment of patients with difficult-to-control asthmacan affect substantial cost savings while improving quality of care.Specific findings: A review of 125 patients receiving care in an asthma center (AC) found high patientsatisfaction, a significant reduction in the number of inhaled beta agonist prescriptions filled relative to thenumber of inhaled steroid prescriptions filled, large reductions in emergency room (ER) and hospitalutilization and resultant decrease in cost. The number of hospitalizations was 38 before AC vs. four afterAC (89 percent reduction). The mean cost of the initial AC visit was $770. The cost of ER care totaled $34,706before AC vs. $7,973 after AC. The cost of inpatient care totaled $192,926 before AC vs. $20,308 after AC.Vollmer WM, O’Hollaren M, Ettinger KM, et al. Specialty differences in the management of asthma. A crosssectionalassessment of allergists’ patients and generalists’ patients in a large HMO. Arch Intern Med.1997;157:1201-1208.Conclusion: Specialist care was found to be of benefit to asthma patients in a large HMO. The allergists’patients conformed more closely to national asthma management guidelines and reported better quality of lifethan did the patients of generalists.Specific findings: Nearly 400 patients ages 15-55 with physician-diagnosed asthma were studied. Patientsreceiving their primary asthma care from an allergist were considerably more likely to report using inhaledanti-inflammatory agents, oral steroids and regular breathing medications to control their asthma. Allergists’patients were more likely to have asthma exacerbations treated in a clinic rather than an emergency room andreported significantly improved quality of life.25

Wang LY, Zhong Y, Wheeler L. Direct and indirect costs of asthma in school-age children. Prev Chronic Dis.2005;2(1). Available from URL: http://www.cdc.gov/pcd/issues/2005/jan/04_0053.htm.Conclusion: The economic impact of asthma on school-age children, families and society is immense, andmore public health efforts to better control asthma in children are needed.Specific findings: An estimated 2.52 million children ages 5-17 years were treated for asthma in 1996. Thetotal economic impact of asthma in school-age children was nearly $2 billion, or $791 per child with asthma.Costs were calculated in 2003 dollars.Weiss KB, Sullivan SD. The health economics of asthma and rhinitis. I. Assessing the economic impact. J AllergyClin Immunol. 2001;107(1):3-8.Conclusion: Cost-of-illness studies of asthma and allergic rhinitis suggest that these conditions represent alarge burden to society, both nationally and internationally. The largest direct medical expenditure ismedications, and indirect costs associated with the disease also are significant.Specific findings: The economic burden of asthma and rhinitis are examined in terms of how resources areallocated to the care of persons with the conditions. In 1998, asthma in the United States accounted for anestimated $12.7 billion annually. Similarly, in 1994, allergic rhinitis was estimated to cost $1.2 billion. Mostof the costs for these conditions are attributed to direct medical expenditures, with medications emerging asthe single largest cost component. Indirect costs also represent an important social effect. While cost-of-illnessstudies help to characterize the economic burden, comparative economic studies evaluate the value of newand existing strategies for clinical care.Westley CR, Spiecher B, Starr L, et al. Cost effectiveness of an allergy consultation in the management of asthma.Allergy Asthma Proc. 1997;18:15-18.Conclusion: Referral to an allergist reduced the cost of asthma care by $2,100 per patient.Specific findings: The retrospective study evaluated the outcomes and treatment costs for 70 moderate-tosevereasthma patients treated in a Kaiser Permanente health plan in Denver. All patients were followed for atleast one year by a primary care physician prior to evaluation and follow-up by a specialist for at least oneyear. Findings after the evaluation and follow-up with a specialist included a 67 percent decrease in thenumber of hospitalizations, a decrease in average hospital days from 4 to 2.5, a 45 percent decrease in sickcare office visits and a 55 percent decrease in emergency room visits. Estimated cost savings for the 70patients was $145,500.Wu AW, Young Y, Skinner EA, et al. Quality of care and outcomes of adults with asthma treated by specialists andgeneralists in managed care. Arch Intern Med. 2001;161:2554-2560.Conclusion: In a managed health care setting, physicians’ specialty training and self-reported expertise intreating asthma were related to better patient-reported care and outcomes.Specific findings: Based on a survey of 1,954 adult asthma patients enrolled in 12 managed care organizationsand their 1,078 corresponding physicians, significant differences were noted for patients of specialists andgeneralist physicians. Compared with patients of generalists, outcomes for patients of allergists weresignificantly better with regard to canceled activities, hospitalizations and emergency department visits forasthma, quality of care ratings and physical functioning.Zeiger RS, Schatz M. Effect of allergist intervention on patient-centered and societal outcomes: allergists asleaders, innovators, and educators. J Allergy Clin Immunol. 2000;106(6)995-1018.Conclusion: Allergist educators, comprising academic and practicing allergists, supported by allied healthprofessionals, national associations and affiliated lay organizations, provide comprehensive education andimprove patient-centered and societal outcomes.Specific findings: Allergy as a specialty is a major leader in developing effective strategies to confront theepidemic of atopic disorders and allergists have made major contributions to the understanding of the riskfactors, immunology, pathophysiology, immunomodulation, and prevention of atopic and immunologicdisorders. Allergist epidemiologists and clinicians have helped develop and implement national andinternational guidelines in the recognition, management and prevention of asthma and rhinitis.26

When To Refer to an AllergistPatients should be referred to an asthma specialist if they:• have asthma symptoms every day and often at night that cause themto limit their activities• have had a life-threatening asthma attack• do not meet the goals of asthma treatment after three to six months,or their doctor believes they are not responding to current treatment• have symptoms that are unusual or hard to diagnose• have co-existing conditions such as severe hay fever or sinusitis thatcomplicate asthma or its diagnosis• need more tests to find out more about their asthma and the causes ofsymptoms• need more help and instruction on treatment plans, medicines orasthma triggers• might be helped by allergy shots• need oral corticosteroid therapy or high-dose inhaled corticosteroids• have taken oral corticosteroids more than twice in one year• have stayed in a hospital because of asthma• need help to identify asthma triggers• have had a diagnosis of asthma that is in doubt• request a consultation or referral85 W. Algonquin Road, Suite 550Arlington Heights, IL 60005(847) 427-1200 FAX (847) 427-1294