special report Asthma: Better Outcome at Lower Cost? The Role of the Expert in the Care System* Thaddeus Bartter, MD, FCCP; and Melvin R. Pratter, MD, FCCP Asthma is a common disease for which morbidity and mortality have been increasing. This despite advances in the scientific understanding of asthma and in the pharmacologic armamentarium available to treat it. The dichotomy between knowledge and outcomes led us to review asthma from a systems perspective. We have presented data first to document failure in the current system of care and then to examine factors associated with improved outcomes. We found a disparity in outcome and costs when care given by experts was contrasted with care given by generalists. We conclude that "expert-based" care systems are superior from the perspective both of the patient and of the insurer; medical outcomes are better at lower overall cost. Managed care companies are in a unique position to identify asthmatics and to shift them from generalist to expert-based care when appro¬ priate. (CHEST 1996; 110:1589-96) Key words: asthma; clinical outcomes; expert care; managed care Abbreviations: ED=emergency department TPhe prevalence, morbidity, and associated economic -"- costs of asthma are increasing at an alarming rate. This has occurred despite ever-increasing knowledge about the pathophysiologic condition of asthma and despite the development of more specific and effective drugs. In this review, we will part from the traditional (and necessary) approach of which medicines to use and when to use them and consider instead the ques¬ tion of whether there are aspects of delivery of care in the current health-care system that may be contribut¬ ing to the suboptimal outcomes experienced by many asthmatics. Information was obtained from a Medline search of relevant articles from the last 10 years plus earlier references culled from those articles. To answer this question, we will examine first evidence of dysfunction in the current system of care and then aspects ofthe current system that seem more likely to result in a better outcome than others. We will frame the problem by reviewing some ofthe major literature about asthma management. We will **From the Division of Pulmonary and Critical Care Medicine, UMDNJ/Robert Wood Johnson Medical School at Camden, Camden NJ. Manuscript received January 16, 1996; revision accepted July 24. Reprint requests: Dr Pratter, 3 Cooper Plaza Suite 312, Camden, NJ 08103. concentrate on the available literature that deals with expert vs generalist care. The Problem It is estimated that asthma affects between 7 and 20 million Americans.1"3 Although this may reflect in part increased recognition of the disease, the evidence clearly demonstrates a true increase in the prevalence of patients with symptomatic asthma.1 Both the morbidity and the economic cost of asthma are huge. A published estimate put the total costs (di¬ rect and indirect) of asthma in the United States in 1990 at $6.2 billion per year.4 The largest direct cost was that of hospitalization. The study cited 463,500 hospitalizations for asthma per year at an annual cost of $1 billion. The cost of medications was the second largest direct cost at $700 million. Emergency depart¬ ment (ED) visits, about 1.81 million visits per year, were more frequent than physician office visits, 1.5 million per year, and incurred significantly greater cost, estimated at $200.3 million per year. The largest indi¬ rect cost, $700 million, came from the costs associated with missed school days for children. Estimated loss of income from premature deaths accounted for $680 million. Asthma mortality is on the rise. A number of reports CHEST /110 / 6 / DECEMBER, 1996 1589 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21740/ on 06/06/2017