Evaluation of a medicaid asthma disease management program

Chronic disease management programmes for adults with asthma

BACKGROUND

The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education.

OBJECTIVES

To evaluate the effectiveness of chronic disease management programmes for adults with asthma.

SEARCH METHODS

Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months.

DATA COLLECTION AND ANALYSIS

After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs).

MAIN RESULTS

A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes.

AUTHORS' CONCLUSIONS

There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

The differences in health care utilization between Medical Aid and health insurance: a longitudinal study using propensity score matching

Study Objectives

Health care utilization has progressively increased, especially among Medical Aid beneficiaries in South Korea. The Medical Aid classifies beneficiaries into two categories, type 1 and 2, on the basis of being incapable (those under 18 or over 65 years of age, or disabled) or capable of working, respectively. Medical Aid has a high possibility for health care utilization due to high coverage level. In South Korea, the national health insurance (NHI) achieved very short time to establish coverage for the entire Korean population. However there there remaine a number of problems to be solved. Therefore, the objective of this study was to investigate the differences in health care utilization between Medical Aid beneficiaries and Health Insurance beneficiaries.

Methods & Design

Data were collected from the Korean Welfare Panel Study from 2008 to 2012 using propensity score matching. Of the 2,316 research subjects, 579 had Medical Aid and 1,737 had health insurance. We also analyzed three dependent variables: days spent in the hospital, number of outpatient visits, and hospitalizations per year. Analysis of variance and longitudinal data analysis were used.

Results

The number of outpatient visits was 1.431 times higher (p<0.0001) in Medical Aid beneficiaries, the number of hospitalizations per year was 1.604 times higher (p<0.0001) in Medical Aid beneficiaries, and the number of days spent in the hospital per year was 1.282 times higher (p<0.268) for Medical Aid beneficiaries than in individuals with Health Insurance. Medical Aid patients had a 0.874 times lower frequency of having an unmet needs due to economic barrier (95% confidence interval: 0.662-1.156).

Conclusions

Health insurance coverage has an impact on health care utilization. More health care utilization among Medical Aid beneficiaries appears to have a high possibility of a moral hazard risk under the Health Insurance program. Therefore, the moral hazard for Medical Aid beneficiaries should be avoided.