What Can One Asthma Study Teach You About Improving Patient Care In Your Hospital System?

By Dr. Inderpal Randhawa
August 21, 2019

Asthma is an extremely prevalent condition. The CDC estimates it affects 7.7% of adults and 8.4% of children.[i] And the disease state itself hasn’t improved much over the last two decades. While mortality rates in the US have decreased some this century, hospitalization rates have remained relatively steady.[ii],[iii]  Asthma remains a large public health problem.

For many years, the National Institutes of Health have encouraged healthcare providers to not look at asthma as a monolith. The disease is more than one thing, and not all patients can be treated the same way. The call to action is clear: there should be more methodology built into the treatment of asthma. Despite this, there haven’t been many large-scale studies conducted on the most severe forms of asthma—such as status asthmaticus—that are likely to land patients in an ICU or hospital setting.

I’m the division co-chief at Miller Children’s Hospital Long Beach, the sixth-largest children’s hospital in the nation. We have the largest pulmonary division in California. That means me and my research team are in a position to see a lot of complex disease dynamics at play. When you bear witness to the diversity of what asthma is as a disease, you start to ask questions.

lungs 944557_960_720Some of those questions led me and my team to look at unexamined gaps in the treatment of asthma, such as the role of allergic disease in the atopic profile of severe asthma. In a sense, it’s a form of a biomarker. To say someone is “allergic” is not in itself a biomarker, but if you go a step further and identify a set of blood tests that are consistent within a group that could predict the level of risk, that would be deemed a biomarker.

It’s this thinking—rooted in a desire to make not only an economic impact, but a patient impact—that inspired our recent study.

The Study

Our study, Allergy Evaluation During Hospitalized Asthma Improves Disease Management Outcomes, published this May in SN Comprehensive Clinical Medicine, analyzed the efficacy of objective parameters to determine post-hospitalization asthma treatment. To date, no other study had done so. We compared post-hospitalization outcomes of hospitalized asthmatics who underwent objective allergy and lung function testing to a cohort which did not.[iv]

The results of the study were clear: serum allergy evaluation by sIgE had a positive impact in terms of ER visits, systemic steroid use, and hospitalizations1. Here are more details on the key findings:

  • Serum allergy evaluation by sIgE testing reduced the hazard of an ER visit and systemic corticosteroids requirement by half in mild asthmatics (p < 0.05).

  • The average time to next ER visit was almost one year in the allergy-tested group compared to < 6 months in the no-test group.

  • Blood-based allergy evaluation as part of inpatient asthma treatment was shown to improve disease management specifically in time to next ER and/or exacerbation and systemic corticosteroids requirement in patients with mild disease.

  • In more severe adolescent asthmatics, sIgE testing appeared protective against future hospitalization.

You can [read the full study here]

Simplifying Complex Problems

One clear takeaway from this study is that all healthcare providers should be utilizing specific IgE blood testing for their asthma patients. That includes general practitioners, family medicine doctors, pediatricians, internal medicine doctors, and their midlevel providers.

Simply put, it’s impossible for specialists to be the only people treating these patients. If you have one out of four children, for example, who have asthma, there are simply not enough allergists or pulmonologists to treat them. There are roughly 4500 allergists and 1000 pediatric pulmonologists in the nation.[v],[vi] How can 5500 people potentially cover tens of millions of Americans?

This issue extends far beyond asthma and into the treatment and management of other prevalent conditions. And solving this issue isn’t a simple one-and-done. Non-specialists can hear all day long about the value of adding sIgE testing to their management of asthma patients, but as we all know, medicine is complex. It’s not easy for providers to make the best decisions when it’s just fly by the seat of their pants—there needs to be algorithms, or decision trees, in place for them to follow.

Continuing with the asthma example, a reliable way to manage asthma in general is to start by giving non-specialist practitioners an idea of how to identify subtypes of asthmatics. Once they have a subtype, that subtype should be treated in a unique way based on identifiable markers.

At my hospital, which is one of the few JCAHO Asthma Centers of Excellence in the nation, we have spent many years building better decision trees for our providers to follow. We identify patients as mild, moderate, or severe, and then ensure that the patients categorized as moderate-to-severe undergo very specific sets of testing and monitoring. This is all enabled by decision trees based on markers.

When following the decision trees, our providers put those patients on therapy based on those decisions. Eventually, this turns into a sequence of events that can lead to improved results—but only if all the players are involved. The ICU, the hospital, the ER, the community clinics, and the specialty clinics all need to talk to each other—that’s what we’ve built at our hospital over the last decade.

Conclusion

Ultimately, the discussion I want to propagate with our study is the value things like algorithms and decision trees can provide to non-specialist healthcare practitioners and large hospital systems. Having these frameworks in place makes more research like our study, which produced such impactful results, feasible. Using the framework we’ve built over the past decade, our goal is to develop a “super-specialty” clinic for difficult asthma cases. If we can identify and allocate these high-risk patients into a subpopulation, they can be treated at a much better rate of function, which would result in the best health outcomes for those patients and the most savings for the healthcare system.

References: 

[i]https://www.cdc.gov/nchs/fastats/asthma.htm

[ii] https://www.cdc.gov/asthma/asthma_stats/asthma_underlying_death.html

[iii] https://www.hcup-us.ahrq.gov/reports/statbriefs/sb169-Asthma-Trends-Hospital-Stays.pdf

[iv] Brock, J.P., Nussbaum, E., Morphew, T.L. et al. SN Compr. Clin. Med. (2019) 1: 328. https://doi.org/10.1007/s42399-019-0044-9

[v] https://www.aamc.org/data/workforce/reports/492556/1-1-chart.html

[vi] https://www.thoracic.org/professionals/career-development/residents-medical-students/choosing-pediatric-pulmonology.php

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