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Managing Child Asthma - ISSUEBrief


									Center for Prevention

and Health Services

        ISSUE                                                                                                     May 2005

        Managing Child Asthma:
        Prevention and Treatment
                Asthma is a chronic disease that affects between 17–20 million Americans including
                nearly seven million children and adolescents. Asthma is a respiratory disease that
                causes inflammation and irritation in the lining of tubes that carry air to the lungs.
                This prevents air from reaching the lungs properly and makes breathing difficult.
                                                                   When the tubes are chronically inflamed they
                                                                   become oversensitive and hyperactive, which can
        Table of Contents:                                         lead to spasms. It is the spasms of the airways that
                                                                   cause the most recognizable symptoms of asthma
        Asthma.................................................. 1
        Childhood Asthma................................. 1
                                                                   such as wheezing, coughing, chest tightness and
        Risk Factors for Asthma........................ 3          shortness of breath. While some degree of
        Economic Implications of                                   inflammation is always present in people with
         Childhood Asthma............................... 3         chronic asthma, the degree of inflammation —
        Racial and Ethnic                                          and thus the symptoms — vary. Untreated asthma
         Disparities in Asthma.......................... 5         or exacerbated asthma (called an asthma attack or
        Healthy People 2010 Goals....................6             an acute asthma episode) can be fatal. Each year
        Managing Childhood Asthma................. 6
                                                                   5,000 people, including nearly 400 people under
        Medication Management.......................8
        Self-Care and Lifestyle                                    the age of 25, die from asthma.2
        What Physicians Can Do to Improve
         Asthma Management.......................... 9                 Childhood Asthma
        What Employers Can Do to Improve
         Asthma Management.......................... 10                Asthma usually begins in childhood. It is the most
        Actionable Strategies for Employers...... 11                   common chronic condition among children and
        What Parents and Caregivers                                    affects approximately 10%–15% of all grade-
         Can Do to Improve Asthma
                                                                       school age children in the United States.3 The first
         Management ...................................... 13
        Summary............................................... 14      symptoms of asthma begin early in life; 50–80%
        Asthma Management:                                             of children with asthma experienced their first
         An Employer Case Study..................... 15                symptoms before the age of 5.4
        Citations................................................ 18
                                                                  May 2005 ISSUE       Brief 2

                                                    If a child dies from asthma it’s one
Despite a growing body of information               death too many.
about the causes and complications of                                 Seymour Williams, MD
                                                                      Medical Epidemiologist (CDC)
asthma, the number of children with
asthma in the United States is
increasing. In fact, the number of
people with asthma in the United States has doubled over the past 15 years.5 In some
parts of the country, the amount of illness, restricted activity and disability due to asthma
is also increasing.6 Alarmingly, the death rate of asthma for children under the age of 19
has increased 80% since 1980.7

Every hour…
        • 213 people go to an ER for an asthma attack, accounting for 1/4 of all
          emergency room visits in the United States.
        • 53 people are hospitalized for asthma

Each day…
       • 28,000 people visit a physician for asthma
       • 15 people die of asthma

Each year…
        • 10 million people visit a physician regarding asthma
        • 500,000 people are hospitalized for asthma28

Asthma is controllable. Child deaths resulting from asthma are almost entirely preventable.
With appropriate medication use and minor lifestyle modifications, most children with
asthma can lead normal lives.

Quick Facts on Childhood Asthma
        • 6.3 million children under the age of 18 have asthma, representing almost
          1/3 of people with asthma.29
         • 44% of all asthma hospitalizations are for children.30
    3 ISSUE                    Brief May 2005

                           Risk Factors for Asthma
                           While the ultimate cause of asthma is not known, research suggests that there are multiple
                           risk factors for developing asthma. Risk factors associated with asthma include low birth
                           weight, perinatal exposure to tobacco smoke, a family history of asthma, allergies and
                           certain viral respiratory infections.8

                           Research suggests that how early and how frequently a child is exposed to animals and other
                           children influence his/her risk of developing asthma. Children who live with pets, several
                           siblings or who were in childcare during their first year of life are less likely to develop
                           asthma than are other children.9 While the relationship between these exposures and asthma
                           has not been fully explained, researchers believe that early life exposure to dander (from
                           pets), pollen and infections (from other children) may spur immune system response that
                           later protects children from developing allergic responses to these same exposures.

                           Once a child has asthma however, exposure to pets and pollen is no longer protective and
                           may in fact exacerbate symptoms. Children with asthma are especially sensitive to colds,
                           flu and viral infections. And asthma is exacerbated by allergens such as dander from
                           animals, dust mites, pollen, exercise, untreated medical conditions such as rhinitis,
                           sinusitis or reflux disorders, stress and strong emotional expressions such as crying or
                           laughing.10 New evidence also shows that exposure to cockroaches is especially dangerous
                           for asthmatic children.

                           Economic Burden of Asthma 1980–2004                                 Implications of
                                   (Adults and Children)
                                                                                               Childhood Asthma
                      20                                                                       Children with chronic
Billions of Dollars

                      15                                                                       conditions like asthma are
                                                                                               heavy users of costly health
                                                                                               care services such as inpatient
                       5                                                                       hospital care, emergency room
                       0                                                                       services and medications.11
                             1980     1985      1990      1994     1998      2000      2004    Children with asthma use
                                                          Year                                 substantially more medical
                      Note: Data for 2004 is a projected estimate.                             services than do children
                      Source: Data for 1980–1985 from Weiss et al (1992), data for 1990–1998
                      from Weiss et al (2001), data for 2000 from the Asthma and Allergy       without asthma, including 3.5
                      Foundation of America (2001), and data for 2004 from the Asthma and      times as many hospitalizations,
                      Allergy Foundation of America (2004).31
                                                                                               3.1 times as many medication
                                                                                               prescriptions and 1.9 times as
                                                                                               many physician office visits.12
                                                                   May 2005 ISSUE      Brief 4

                                                        Asthma drains the nation’s health
                                                        care budget. Time, energy and money
      Each year, asthma results in 5,000 deaths         are being spent in hospitals and
                                                        emergency departments where services
      among children and adults, 500,000
                                                        are expensive and do not address long-
      hospitalizations, 1.6 million emergency           term reduction of symptoms. Although
      room visits and 10 million physician              appropriate management of people with
      office visits.13 In 2000, spending for            asthma should decrease the overall cost
      asthma-related care exceeded $14.5                of the disease to society, the most
      billion, including $10 billion in direct          important benefit would be the improved
      medical costs and $5 billion in indirect          health and well-being of people with
      costs.14 The Asthma and Allergy                   asthma and their families.
      Foundation of America estimates that                                        Seymour Williams, MD
                                                                                  Medical Epidemiologist, CDC
      asthma costs will reach $18 billion by

     The direct cost of treating childhood asthma is estimated at $3.2 billion annually.16
     Children with untreated or poorly managed asthma are responsible for a disproportionate
     amount of this cost; each year $1.56 billion is spent on hospital-based care and $295
     million is spent on emergency room care for children with poorly controlled asthma.17
                                                       Asthma also exacts costs from families.
                                                       Research shows that the average family of
• Asthma is the 4th leading cause                      an asthmatic child spends between 5.5%
  of absenteeism for adults, and is                    and 14.5% of its total income on
  responsible for 15 million lost workdays             treating their child’s condition.18The
  each year, at a cost to employers of                 overuse of emergency services for asthma
  nearly $3 billion in lost productivity.              is a major cost concern. Children with
• Asthma is the leading cause of                       appropriately managed asthma should
  absence from school for children                     not use emergency services frequently, if
  ages 5–17. The average child with                    at all. Appropriate asthma management
  asthma will miss eight school days each              rests on routine primary care monitoring,
  year due to their condition.                         appropriate medication use and self-care
                                                       practices. For more information see
                                                       Managing Asthma on page 6.

      Disability, Days of Restricted Activity and Lost Productivity
      Asthma is the major cause of restricted activity, bed days and school absence for children
      and adolescents. A child with asthma experiences an average of 11.7 days of restricted
      activity each year and misses approximately eight days of school.19 Each year in the United
      States, 14.7 million school days are lost due to asthma.20

      When children miss school, parents and caregivers frequently must take time off work to
      care for them in the home. Between 1990 and 2000 the costs associated with the time
                          5 ISSUE                   Brief May 2005

                                                                                                             Whenever you see health
                                                                                                             disparities, it is an opportunity
                                                adults lost from work due to a child sick                    to do better.
                                                from asthma increased by 88%.21 And in                                           Seymour Williams, MD
                                                                                                                                 Medical Epidemiologist, CDC
                                                1994, the last year for which there is data,
                                                children ages 5–17 missed 11.8 million
                                                school days, costing employers $957 million
                                                for parents/caregivers’ lost work time.22

                                                Racial and Ethnic Disparities in Asthma
                                                                                                              Asthma disproportionately affects
                                                 Racial Disparities in Asthma ER Visits                       minority children in the United
                                                                                                              States, especially African-American
                                       300                                                                    children in urban communities.
                 Per 10,000 Children

                                       250                                                                    Asthma is 26% more prevalent
                                       200                                                                    among African-American children
                                       150                                                                    than White children, and African-
                                       100                                                                    American children experience
                                        50                                                                    more severe disability due to their
                                                                                                              symptoms than do White
                                                              Whites                           Blacks
                                                                       Emergency Room Visits
                                                                                                              children.23 African-American
                                                                                                              children are also three to four
                               Source: National Hospital Ambulatory Medical Care Survey (NHAMCS) (2004).32
                                                                                                              times as likely to be hospitalized
                                                                                                              due to asthma than are White
                                                                                                              children. African-Americans of all
                                                                                                              ages are three times as likely than
                                                                                                              are Whites to die from asthma.24
                                                 Racial Disparities in Asthma Deaths
                                                                                                              The reasons for these disparities
                                                                                                              are complex. Minority families,
                                                                                                              especially those who live in inner-
Per 1,000,000 Children

                                        8                                                                     cities, are more likely to be
                                        7                                                                     exposed to some allergens such as
                                        5                                                                     cockroaches, tobacco smoke and
                                        4                                                                     nitrogen dioxide emitted by
                                        2                                                                     unvented stoves and heating
                                        1                                                                     appliances.25 Minorities may also
                                                Non-Hispanic Whites    Non-Hispanic Blacks      Hispanics
                                                                                                              have greater difficulty in accessing
                                                                                                              medical care, medication and
                                       Source: National Vital            Asthma Deaths
                                                                                                              other treatments that help control
                                       Statistic System (NVSS);                                               asthma. Genetic differences may
                                                                                                              also play a role.
                                                             May 2005 ISSUE     Brief         6

Racial and ethnic disparities in asthma, like all areas of health care, represent an
opportunity to promote the quality of care. The United States Department of Health and
Human Services (DHHS), Office of Disease Prevention and Health Promotion sets
national goals for health improvement each decade. These goals, most recently published
as Healthy People 2010, include specific objectives for asthma care. These objectives are
aimed at reducing the amount of morbidity and mortality associated with asthma
improving patient knowledge about asthma, and encouraging physician compliance with
treatment guidelines.

Healthy People 2010 Goals


         • Asthma-related deaths, hospitalizations for asthma, hospital emergency room
           visits for asthma and limitations among persons with asthma.

         • The proportion of persons with asthma who receive formal patient
           education including information about community and self-help resources,
           as an essential part of the management of their condition;
         • The proportion of persons with asthma who receive appropriate asthma
           care according to the NAEP guidelines.34

Managing Childhood Asthma
Asthma can be successfully managed with medications, a healthy lifestyle and self-care
practices such as allergen avoidance. Managing asthma can be a time-consuming and
burdensome regimen, especially for children. Remembering to take multiple medications
and avoiding allergens can be difficult. Thus, when a child is diagnosed with asthma it is
particularly important to involve both the child and family in treatment planning and
patient education so that they have the knowledge, motivation and ability to practice
self-care. It is critical that parents, other caregivers and children know the factors that
exacerbate asthma, how to avoid them and what measures to take in case an asthma
attack occurs. Physicians, health plans, benefit managers and health promotion
program personnel can all play a role in educating and supporting families affected
by asthma.
7 ISSUEBrief            May 2005

   When asthma is under control, a child should be free — or mostly free — of symptoms,
   have the ability to participate in normal activities, not have any asthma attacks that
   require medical attention and not miss school or other important activities due to illness.

   Childhood Asthma Control Equals:
            •   No difficulty with breathing, wheezing, coughing or tightness in the chest.
            •   No waking up at night because of asthma symptoms.
            •   No asthma attacks that require immediate medical attention.
            •   Normal or near normal lung function.
            •   The ability to conduct normal activities, including play, sports and exercise.
            •   No absences from school or other important activities.
            •   No missed time from work or other activities for the parent/caregiver.

   Asthma Control Requires:

            • A daily management plan that details regular medications and other
              measures used to keep asthma under control. This plan should be written in
              clear language that lay adults can understand and that the child can explain if
            • An action plan that describes what actions to take when an asthma attack
              occurs. This information should include what medications to take (including
              dosing and administration information), when to call a parent or caregiver if
              he/she is not present and when to contact a physician or go to the emergency
              room. The action plan should also include information on what activities
              (such as exercise) the child should not participate in after an asthma attack.
              The child should know the action plan and be able to explain it to an adult.
            • Both the daily management plan and the action plan should be in written
              form. Copies should be distributed to teachers, coaches, babysitters or others
              who spend time with the child. The parent or caregiver should go over these
              instructions verbally with each individual so they are sure that the individual
              understands and is comfortable with the plan.
            • If the child is too young (under five) to understand what to do in case of an
              asthma attack and can not communicate well enough to explain his/her plan
              to an adult, consider having the child wear an medical ID bracelet that will
              alert adults and emergency personnel to the child’s condition. Include the
              medications the child is on, any allergies the child may have, a parent or
              caregiver’s phone number, the physician’s phone number and the phone
              number of an alternate emergency contact.
                                                          May 2005 ISSUE     Brief         8

Medication Management
Medication management is a critical component of asthma care. Most children and
adolescents with asthma will need to take two different types of medications: controller
medications (also called preventive or maintenance medications) and rescue medications
(also called quick-relief or fast-acting medications).

Controller medications work over a period of time to reduce the amount of
inflammation in the airways. This helps prevent asthma symptoms from occurring and
reduces that chance of a severe asthma episode.

Some common medications include:
       • Inhaled corticosteroids (some brand names: AeroBid, Azmacort, Flovent,
         Pulmicort, Vanceril, etc.)
        • Cromolyn (brand name: Intal)
        • Nedocromil (brand name: Tilade)
        • Anti-leukotrienes (brand names: Accolate, Singulair, Zyflo)
        • Theophylline (brand names: Slo-bid, Theo-Dur, Theo-24, Uni-Dur)
        • Serevent (inhaled long-acting Beta2-agonist)

Rescue medications work immediately to relieve asthma symptoms during an asthma
episode. Quick-acting bronchodilators such as Beta2-agonists are the most commonly
prescribed type of rescue medication. These drugs are usually administered through an
inhaler or nebulizer and help to loosen the muscles surrounding inflamed airways.

Some common medications include:
       • Albuterol, Pirbuterol, Levalbuterol or Bitolterol (inhaled short-acting
        • Atrovent (anticholinergic)
        • Prednisone, prednisolone (oral steroids)

Self-Care and Lifestyle Modifications
In addition to medication use and regular physician check-ups, children and adolescents
with asthma can successfully control their asthma symptoms through lifestyle
modifications that reduce or eliminate their expose to allergens and irritants. To learn
more about allergens and irritants please see What Parents and Caregivers Can Do to
Improve Asthma Management on page 13.
9 ISSUE Brief          May 2005

  A healthy diet, moderate physical activity and other health promotion activities can help
  bolster a child’s immune system and protect them from colds, flus and viral infections,
  which can exacerbate asthma symptoms.

  What Physicians Can Do to Improve Asthma
  Asthma management requires a physician’s care. Regular primary care check-ups are
  critical in order for a physician to monitor a patient’s severity of asthma and to modify
  his/her medication regiment accordingly. Medical management can prevent emergency
  room use and the use of rescue medications by reducing both the number and the severity
  of acute asthma episodes a child or adolescent will experience in a given year.

  The Centers for Disease Control (CDC) and the National Asthma Education and
  Prevention Program (NAEP) recommend that physicians treating asthma:

  Assess and monitor the patient
            • Establish asthma diagnosis
            • Classify the severity of asthma
            • Schedule a routine follow-up exam
            • Assess the need for referral to specialty care

  Control factors contributing to asthma severity
            • Recommend measures to control asthma trigger
            • Treat or prevent co-morbid conditions

  Maintain a medication plan
           • Prescribe medications according to severity
            • Monitor use of B2-agonist drugs

  Educate the child, family and other caregivers such as daycare providers, babysitters,
  school nurses, teachers, coaches, etc. to follow a written asthma management plan
           • Develop a written asthma management plan that includes information on
              daily management activities and how to handle an asthma attack
            • Provide education on patient self-management35
                                                          May 2005 ISSUE      Brief           10

What Employers Can Do to Improve Asthma

Support Parents and Caregivers Through Benefit Design and Disease
Management Programs
Parents and caregivers play a crucial role in the health of asthmatic children. Depending
on the age of the child, parents may be responsible for purchasing and administering
medication, organizing routine and urgent medical care and preventing asthma attacks
through modifying risk factors. Parents need education and support in order to be able to
effectively carry out these important tasks. Worksite health promotion programs and
employee education can help parents learn to better monitor their child’s asthma.

Children and their parents face many challenges in asthma management. Employers,
through creative benefit design and health promotion activities, can help parents find
solutions to these challenges.

Many children have difficulty remembering to take their medications on time. They may
get sidetracked and forget about the medication, actively try to avoid taking it because
they dislike it or don’t think it is important or they may not have access to their
medication when they are away from home.
        • Solution: Provide employees with kid-friendly information they can use to
          educate their children on the importance of medication use. Ensure that
          easy-to-take medications are available through your formulary. For example,
          it is important to cover controller and rescue medications as available, in pill,
          inhaler and nebulizer form.

Access to Care
Health facilities are quickly disappearing from public schools. This means that during the
school day, children with asthma usually do not have access to an adult trained in asthma
management. They may also lack access to their medications.
        • Solution: Provide your employees with education materials on how to talk to
          their child’s teacher, principal, gym teacher, etc. about their needs. If the
          child is old enough to be responsible for taking his/her own medication,
          encourage your employees to provide their child with medication to keep in
          his/her desk or coat in case of an emergency. Also, encourage pharmacies
          participating in your plans to counsel children and their parents on the
          appropriate use of asthma medications.
11 ISSUE              May 2005

      Financial Barriers
      Some parents of asthmatic children may have difficulty affording the multiple medications
      and physician co-pays their child’s care requires, as well as the many household changes
      recommended by experts to prevent asthma attacks.
              • Solution: To facilitate medication compliance, consider reducing or
                eliminating co-pays or co-insurance on asthma medication and primary care
                treatment. Also, consider subsidizing (or providing as an incentive for
                participation in a disease management or education program) some of the
                non-medical devices children with asthma use to protect themselves from
                allergens. Mattress and pillow case covers, air vent filters and dehumidifiers
                are examples of such products.

      Actionable Strategies for Employers
      To ensure that your company is doing the most it can to help employees manage asthma,
      use the following checklist to “keep tabs” on the recommended prevention and treatment
      strategies your health plans and health promotion programs offer:

      Health Plans
              • Ensure that health plans are appropriately screening, diagnosing, treating and
                managing children with asthma.
              • Ensure that your formularies include a wide range of asthma medications and
                equipment (inhalers, nebulizers, etc).
              • Free flu shots to children with asthma. Flu shots protect children (especially
                in children under the age of five26) from getting some of the respiratory
                viruses that can exacerbate asthma symptoms.
              • Incorporate smoking cessation programs into existing pre-natal programs if
                not already present. Women who smoke during their pregnancies are more
                likely to deliver low-birth weight babies and babies with respiratory problems.
                Such infants are at an increased risk of asthma and other complications.
                                                       May 2005 ISSUE      Brief           12

Health Benefit Design
       • Craft benefit plans to encourage the appropriate use of services and discourage
         the inappropriate use of services.
        -    Offer reduced co-pays for regular primary care asthma check-ups.
        -    Cover one or more respiratory therapist counseling sessions per
             year to allow children with asthma to receive education and
             assistance on medication use and symptom monitoring.
         -   Cover non-medical durable goods required for asthma self-care
             such as mattress and pillowcase covers and dehumidifiers.
       • Develop innovative strategies to reward treatment compliance.
        -    Offer reduced medication co-pays to beneficiaries who use their
             medications consistently and correctly (this can be measured by
             number of prescriptions filled on time, etc).

Health Promotion Programs or Worksite Wellness Events
       • Educate your employees about childhood asthma at health fairs or through
         employee health education materials. Consider sending out a brief patient
         education leaflet inside health plan enrollment material or other mailings.
       • Support smoking cessation programs for your employees. Because second-
         hand smoke is an allergen for children with asthma, eliminating tobacco
         smoke in the home can greatly improve child health.
       • Ensure that your worksite has clean and safe air and is asthma-friendly by
         banning smoking at and around the worksite and reducing or eliminating
         sources of mold and mildew.
       • Asthma prevention measures recommended for the workplace parallel those
         measures that should be taken in the home — use regular maintenance
         activities such as cockroach control, leak prevention, heating/cooling system
         cleaning and window sealing and use them as teaching tools to model
         appropriate prevention activities for your employees.
13 ISSUE  Brief            May 2005

  What Parents and Caregivers Can Do to Improve Asthma
  Prevent Asthma Symptoms and Acute Episodes by Limiting a Child’s
  Exposure to Allergens and Irritants
  Because indoor and outdoor allergens can intensify asthma symptoms and lead to an
  asthma attack, it is especially important to decrease an asthmatic child’s exposure to
  allergens. Parents and caregivers can improve the health of asthmatic children by reducing
  or eliminating these common allergens:

  Animal dander from household pets
         • Remove animals that have dander (such as dogs and cats) from the home. If this
           is not possible, make sure that the animal does not sleep or play in the child’s
         • If pets are present, put air filters over all of the vents and air ducts in the child’s

  Dust mites
         • Encase the child’s mattress and pillow in an allergen-proof cover. These are
           available at most department stores and are relatively inexpensive.
         • Wash his/her sheets each week in hot water (>130F).
         • Don’t let the child sleep on upholstered furniture.
         • If possible, remove wall-to-wall carpeting from the child’s bedroom.

         • Control roaches with poison bait, boric acid or traps.
  Pollens and outdoor molds
          • Limit the child’s outdoor activity during peak allergen season, especially during
            the afternoons.
          • Keep car windows rolled up when driving during peak allergy season.
  Indoor molds
          • Fix water leaks, clean moldy surfaces and prevent indoor mold growth by
            properly sealing windows.
          • Avoid using vaporizers.
          • Keep humidity at <50%.

  Tobacco smoke
           • Make sure that the child is not exposed to secondhand smoke in the home,
             restaurants or at friends’ or relatives’ houses.
  Indoor and outdoor pollutants and irritants
           • Limit your child’s expose to wood burning stoves, fireplaces, campfires and
             un-vented stoves or heaters.
           • Reduce your child’s expose to cleaning agents, perfumes and other irritating vapors.27
                                                                      May 2005 ISSUE         Brief             14

The appropriate management of asthma is essential to safeguard the health of children
and control medical costs. Untreated or under-treated asthma can be a debilitating disease
in children resulting in restricted activity, significant complications and in some cases,
death. Asthma is responsible for more lost school days among children ages five to 17
than any other illness. And it is also a major cause of lost work time for caregivers. While
children’s health conditions are usually not seen as major cost-drivers, the costs associated
with asthma are sobering. Each year, $3.2 billion dollars are spent on direct medical
expenses for children with asthma. The bulk of this cost could be avoided with
appropriate disease management, medication compliance and self-care practices.

Employers can play a key role in facilitating the appropriate management of asthma. By
carefully crafting benefit plans, employers can encourage medication compliance and the
consistent use of primary care treatment (rather than emergency service use). By offering
programs that teach parents and children how to prevent and manage asthma symptoms,
employers can reduce the number of acute asthma episodes a child will experience in a
given year. Together, medication compliance and symptom management will lower total
medical costs for children with asthma and improve the quality of life for children
struggling with this chronic disease.

Additional Resources for Information on Asthma:
The Allergy and Asthma Foundation of America
Provides information on educational programs, research, and support groups for families dealing with
asthma. It also provides an asthma education and support hotline.

The American Academy of Allergy, Asthma, & Immunology
Provides an A-Z guide of allergens, a medication guide for asthma treatment, a kid-friendly website with
education modules for children with asthma, and other resources.

The American Lung Association
Provides information on asthma and asthma treatment methods including an interactive decision support
tool, called NexProfiler that helps individuals understand clinical information. NexProfiler provides users
with a personalized treatment options report tailored to his/her diagnosis that details the pros and cons of
each treatment, side effects, questions to ask the physician, and links to summaries of clinical studies.

The Centers for Disease Control and Prevention (CDC)
Provides detailed information on the causes and contributors to asthma, the epidemiology of asthma, and
recommendations for asthma care.
15 ISSUE   Brief          May 2005

    Asthma Management: An Employer Case Study

    H-E-B Grocery Uses a Creative Benefit Structure to Encourage Asthma
    Medication Compliance

    H. E. Butt Grocery (H-E-B) was recently named in the Forbes Top 10 List of privately
    held companies in the United States, with estimated revenues of just over $11 billion.
    H-E-B has 55,000 employees and owns more than 350 supermarkets throughout the
    Southern United States. H-E-B also owns and operates several food manufacturing and
    distribution centers. The H-E-B employee population is largely Hispanic, with an average
    age of 34 years, and average income of less than $35,000.

    H-E-B is dedicated to the health of its partners, the term H-E-B uses for its employees.
    The Benefits staff has developed a series of innovative programs to help partners improve
    their health status by better managing their chronic conditions. To promote employee
    health and productivity H-E-B offers a comprehensive health promotion program:
    “Healthy at H-E-B: Partners Wellness Program.” This program is available to all H-E-B
    employees and their families.

                                                      Due to its prevalence within the
                                                      employee population and its impact of
Why Did H-E-B Grocery Choose to                       productivity, asthma is a major concern
Target Asthma?                                        for H-E-B. H-E-B offers an asthma
                                                      disease management program to assist
• The prevalence of asthma is high, and               its partners and their dependents
  is increasing.                                      struggling with asthma. The program
• The costs associated with asthma are
                                                      offers coordinated care, nurse coaching
  high, yet the cost drivers (ER visits,              and patient education services.
  hospitalizations, urgent care and
  death) are largely preventable with                 Despite the availability of H-E-B’s
  appropriate disease management.                     disease management program for
                                                      asthma, benefit managers found that
• Treatment guidelines are not being                  employees and dependents were using
  followed and, subsequently, patients                asthma medications incorrectly and
  are not receiving high-quality care.                inconsistently. The inappropriate use of
  Further, medication adherence                       drugs was driving up health care costs
  problems limit the efficacy of treatment.
                                                      and negatively impacting employees’
                                                          May 2005 ISSUE      Brief            16

H-E-B’s experience is not unique. Many adults and children with asthma use their
medications incorrectly — meaning they take them less frequently than prescribed, at a
lower dose than prescribed or in a manner not prescribed. And some fail to use controller
medications at all. Research shows that while the majority (62%) of physician office visits
related to asthma care result in the recommendation of a prescription medication, many
patients fail to fill these medications and few use them as directed. For example, of people
who receive a prescription medication from their doctor to treat asthma:
         • 18% fail to fill the script.
         • 26% delay filling the script.
         • 21% stop the medicine sooner than advised.
         • 30% take less frequently than prescribed.
         • 14% take a smaller dose than prescribed.

H-E-B Grocery’s Solution
Concerned that partners and dependents were not using asthma medications and health
services appropriately, H-E-B Grocery decided to investigate the causes of medication
non-compliance. H-E-B found that asthma medication costs were a barrier to compliance
for many of their lower-income employees.

In 2005, H-E-B will launch a company-wide pilot research project to examine the effects
of lowering medication costs and co-pays for asthma treatment. H-E-B hopes that by
lowering treatment costs, employees would better adhere to their medication regiments.
The appropriate use of medication would improve the overall health of employees by
reducing the number of acute asthma attacks experienced and by alleviating symptoms.
Better disease management would in turn reduce employee reliance on urgent care and
emergency department services, reduce hospitalization rates, reduce absenteeism and
increase productivity.

The goals of H-E-B’s pharmacy benefit re-design program are to:
         • Promote cost-effective and appropriate medication use.
         • Limit the inappropriate use of medications.
         • Manage drug spending by constraining escalating costs and ensuring
           that H-E-B receives the best ROI possible for the dollars they spend on
           health care.
17 ISSUE Brief            May 2005

   Primary research objective:
   To examine the effects of combining a favorable benefit design with a pharmacy-based
   asthma disease management initiative on asthma adherence to prescribed controller
   medications on selected clinical, economic and humanistic outcomes.

   How might we integrate our disease management programs with our pharmacy
   benefits to create more effective utilization of our health care dollar?

  The program is still in its infancy, but it promises to deliver exciting results. If H-E-B’s
  hypothesis is true, they should expect to realize significant costs savings in the near future
  and have a healthier and happier workforce.

                 Why asthma makes it hard to breathe
                   Air enters the respiratory system
                   from the nose and mouth and
                   travels through the bronchial tubes.

                                                                             In a non-asthmatic person,
                                                                                 the muscles around the
                In the asthmatic person, the                                          bronchial tubes are
                muscles of the bronchial tubes                                     relaxed and the tissue
                tighten and thicken, and the                                             thin, allowing for
                air passages become                                                           easy airflow.
                inflamed and mucus-
                filled, making it
                difficult for air to move.

                   Inflamed bronchial tube
                        of an asthmatic                                           Normal bronchial tube
                                                    Source: American Academy of Allergy, Asthma and Immunology
                                                                             May 2005 ISSUE          Brief               18

1 American Academy of Allergy, Asthma & Immunology (AAAAI) (2004). Pediatric Asthma, Promoting Best Practice:
  Guide for Managing Asthma in Children.
2 Aon Consulting (2002). Evaluating cost-effectiveness and outcomes of asthma treatments: Case studies and assessment
  tools. Contemporary Issues in Clinical Care: Rational Therapy. Aon Consulting: Somerset, NJ
3 American Academy of Pediatrics. Asthma. Accessed 1-13-05.
4 American Academy of Allergy, Asthma & Immunology (AAAAI) (2004). Pediatric Asthma, Promoting Best Practice:
  Guide for Managing Asthma in Children.
5 Williams S. Powell O (2001). Asthma management in the workplace. Business & Health. 18(5); 44.
6 American Academy of Pediatrics. Asthma. Accessed 1-13-05.
7 Asthma and Allergy Foundation of America (AAFA) (2004). Asthma facts and figures. Accessed 2-1-05.
8 American Academy of Allergy, Asthma & Immunology (AAAAI) (2004). Pediatric Asthma, Promoting Best Practice:
  Guide for Managing Asthma in Children.
9 American Academy of Pediatrics. Asthma. Accessed 1-13-05.
10 American Academy of Allergy, Asthma & Immunology (AAAAI) (2004). Pediatric Asthma, Promoting Best Practice:
   Guide for Managing Asthma in Children.
11 ibid
12 Raskin L (2003). Breathing Easy: Solutions in Pediatric Asthma. National Center for Education in Maternal and Child
   Health. Accessed 1-13-05.
13 Asthma and Allergy Foundation of America (AAFA) (2001). A closer look at asthma. The National Pharmaceutical
   Council. Reston, VA.
14 ibid
15 Asthma and Allergy Foundation of America (AAFA) (2004). Asthma facts and figures. Accessed 2-1-05.
16 Raskin L (2003). Breathing Easy: Solutions in Pediatric Asthma. National Center for Education in Maternal and Child
   Health. Accessed 1-13-05.
17 Aon Consulting (2002). Evaluating cost-effectiveness and outcomes of asthma treatments: Case studies and assessment
   tools. Contemporary Issues in Clinical Care: Rational Therapy. Aon Consulting: Somerset, NJ.
18 Aon Consulting (2002). Evaluating cost-effectiveness and outcomes of asthma treatments: Case studies and assessment
   tools. Contemporary Issues in Clinical Care: Rational Therapy. Aon Consulting: Somerset, NJ.
19 Asthma and Allergy Foundation of America (AAFA) (2001). A closer look at asthma. The National Pharmaceutical
   Council. Reston, VA.
20 National Center for Health Statistics (2002). Centers for Disease Control and Prevention.
21 Asthma and Allergy Foundation of America (AAFA) (2001). A closer look at asthma. The National Pharmaceutical
   Council. Reston, VA.
22 Williams S. Powell O (2001). Asthma management in the workplace. Business & Health. 18(5); 44.
23 Asthma and Allergy Foundation of America (AAFA) (2001). A closer look at asthma. The National Pharmaceutical
   Council. Reston, VA.
24 Asthma and Allergy Foundation of America (AAFA) (2001). A closer look at asthma. The National Pharmaceutical
   Council. Reston, VA.
25 ibid
26 American Academy of Allergy, Asthma & Immunology (AAAAI) (2004). Pediatric Asthma, Promoting Best Practice:
  Guide for Managing Asthma in Children.
19 ISSUE    Brief               May 2005

  27 Adapted from Centers for Disease Control and Prevention (CDC)/ National Asthma Education and Prevention Program(NAEP)
    (2003). Key clinical activities for Quality asthma care: Recommendations of the National Asthma Education and Prevention
    Program. Morbidity and Mortality Weekly Report, (MMWR): Recommendations and Reports. Vol 52. No RR-6. 3-28-03.

  Charts, Graphs and Textbox Citations

  28 Williams S. Powell O (2001). Asthma management in the workplace. Business & Health. 18(5); 44; Asthma and Allergy
     Foundation of America (AAFA) (2004). Asthma facts and figures. Accessed 2-1-05.
  29 Atherly A. Williams SG. Redd SC (2003). What is the cost of asthma to employers? Drug Benefit Trends. 15(11); 35-46; Williams
     S. Powell O (2001). Asthma management in the workplace. Business & Health. 18(5); 44.
  30 Asthma and Allergy Foundation of America (AAFA) (2004). Asthma facts and figures. Accessed 2-1-05.
  31 Weiss KB. Sullivan SA. Lyttle CS. (1994). Trends in the costs of asthma in the United States, 1985-1994. Journal of Allergy and
     Clinical Immunology. 45(5):461-472. Asthma and Allergy Foundation of America (AAFA) (2001). A closer look at asthma. The
     National Pharmaceutical Council. Reston, VA. Asthma and Allergy Foundation of America (AAFA) (2004). Asthma facts and
     figures. Accessed 2-1-05.
  32 National Hospital Ambulatory Medical Survey: 2002 Emergency Department Summary. (2004). Prepared by Linda F. Craig &
     Catharine W. Burt. Advance Data from Vital and Health Statistics. 340(18).
  33 National Center for Health Statistics. Center for Disease Control and Prevention.(2002). Asthma prevalence, health care use and
     mortality. Accessed 2-23-05. Akinbami LJ. Schoendorf
     KC (2002). Trends in childhood asthma: Prevalence, health care utilizations and mortality. Pediatrics. 110(2); 315-322.
  34 US Department of Health and Human Services, Healthy People 2010. (2000). 2nd ed. Understanding and Improving Health and
     Objectives for Improving Health (2 vols). Washington DC: US Department of Health and Human Services.
  35 National Asthma Education and Prevention Program (NAEP) (2003). Key clinical activities for Quality asthma care:
     Recommendations of the National Asthma Education and Prevention Program. Morbidity and Mortality Weekly Report
     (MMWR): Recommendations and Reports. Vol 52. No RR-6. March 28, 2003.
            Center for
           Prevention ISSUE
           and Health May 2005
                                Managing Child Asthma:
                                Prevention and Treatment

This issue brief was based, in part, on material presented during The National Business Group on Health’s webinar:
“Improving Childhood Asthma Management: Tools for Employers.” The Center for Prevention and Health Services
would like to thank webinar presenters, Seymour Williams, MD, Medical Epidemiologist in the Air Pollution and
Respiratory Health Branch of the National Center for Environmental Health, Centers for Disease Control and
Prevention and Elizabeth Common, MBA, Corporate Benefits Manager for H-E-B Grocery. We also thank the
Maternal and Child Health Bureau (MCHB) for their generous funding.

The “Improving Childhood Asthma Management: Tools for Employers” webinar and other presentations can be accessed

This issue brief was written by Kathryn Phillips, MPH, Program Analyst in the Center for Prevention and Health
Services at the National Business Group on Health.

About the Center for Prevention and Health Services (CPHS)
The Center houses the Business Group’s projects and resources that relate to the delivery of preventive and other
health services through employer-sponsored health plans and worksite programs. Through the Center, employers can
find practical toolkits to address preventive health and health promotion issues at the worksite. Employers will find
current information and recommendations from federal agencies and professional associations, model programs from
other employers, and the latest clinical and health services research results. In addition, the Center provides
opportunities for employer participation in teleconferences and in-person solutions workshops. Currently, the Center
has initiatives in racial and ethnic disparities in health and health care, terrorism and public health emergency
preparedness, maternal and child health, preventive services, health services research and quality, health and work
performance, benefit design, and wellness programs.

For more information, visit
or contact Kathryn Phillips at

About the National Business Group on Health
The National Business Group on Health, formerly the Washington Business Group on Health, is the national voice
of large employers dedicated to finding innovative and forward-thinking solutions to the nation’s most important
health care issues. The Business Group represents over 200 members, primarily Fortune 500 companies and large
public sector employers, who provide health coverage for approximately 50 million U.S. workers, retirees, and their
families. The Business Group fosters the development of a quality health care delivery system and treatments based on
scientific evidence of effectiveness. The Business Group works with other organizations to promote patient safety and
expand the use of technology assessment to ensure access to superior new technology and the elimination of
ineffective technology.

Helen Darling, President
National Business Group on Health
50 F Street NW, Suite 600 • Washington DC 20001
Phone (202) 628-9320 • Fax (202) 628-9244 •

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