Disease management program for asthma: baseline assessment of resource use.

Resource use by asthma patients was assessed as a step in the development of a disease management program by a university teaching hospital, a health maintenance organization (HMO), and a national pharmacy benefit management company (PBM). Medication profiles and medical records were reviewed for all HMO patients who had a diagnosis of asthma and a pharmacy claim for an asthma-related drug in 1993; patients with chronic obstructive pulmonary disease were excluded. These 656 patients' use of health care resources (outpatient clinic visits, emergency room and urgent care visits, hospital admissions, and, the associated costs were determined, as were variances from the PBM's clinical guidelines for asthma. Members 0-4 years of age had the most outpatient and emergency/urgent care visits and the most hospital admissions. Forty-four of the patients received high-dose beta-agonist therapy, and 20 of these patients did not receive either an inhaled anti-inflammatory drug or a short course of corticosteroids. The 44 patients had more outpatient clinic and emergency room/urgent care visits, more admissions, and greater total health care costs than the other patients with asthma. The asthma patients' mean health care cost in 1993 was $203, compared with $110 for all enrollees in the HMO. For patients with high use of beta-agonists, the mean cost was nearly three times that for the other asthma patients. The baseline review of resource use identified aspects of medication use that were at variance with treatment guidelines for asthma patients.

Patient-centered care: the jury is still out.

The patient-centered care model needs to retain a central focus on the patient. Process and system interfaces are key areas where alignment on behalf of the patient is required. Often, the current system is out of control. Departmental infrastructure and the need for resource reallocation must be assessed. No blueprint exists for implementing patient-centered care, although many incremental patient-focused initiatives are already underway. Impact on patients must be the balancing factor.

Quality and outcome: pharmacy's professional imperative.

Societal forces behind the increased use of outcomes to measure the quality of health care are described, and continuous improvement of outcomes as a goal for pharmacy is discussed. Consumerism, the demands of the aging American population, and problems of access to care for many Americans have helped to bring about an examination of quality. The effectiveness of clinical decision-making methods has been challenged. The Joint Commission on Accreditation of Healthcare Organizations now seeks to examine whether quality care is being provided, rather than whether the capacity exists to provide it. Inspection against criteria to determine quality will be superseded by a goal of continuous improvement. Traditional drug-use evaluation needs to go beyond collection of data and confrontation of noncompliant prescribing. Multidisciplinary quality improvement efforts should focus on patient outcomes; the goal should be to prevent all errors, rather than to not exceed some tolerable rate of errors. Pharmacists and risk managers should share information. Documentation of quality assurance efforts will be required. Drug-use evaluations should include assessment for therapeutic failure. Pharmacy quality improvement efforts can improve patient care and expand the pharmacist's role on the health-care team.

Ensuring quality in a pharmacy department.

An action plan for QA can guide a pharmacy department through reappraisal of existing QA activities and implementation of a QA plan that documents the activities of the department, focuses on the patient, and meets the requirements of reviewers external to the department. The involvement of line-level personnel along with a commitment from department managers must operate in conjunction with each other to sustain the effort. Documentation should be a byproduct of activities already performed. Survey readiness should improve and very little lead time should be required for an on-site visit.