To the Editor:

“Asthma Days: An Approach to Planned Asthma Care” [October 2004, page 43] left me feeling that I was reading the first chapter of what may become a really good book. Dr. Kurtis Elward and his colleagues have taken the courageous step of trying something new in the care of asthma patients and then exposing their results to critics like me.

Beginnings are always messy, as the old saying goes, and the published report asks as many questions as it answers. I would like to thank Dr. Elward for providing me with the following information, which adds context to his published report: Family Medicine of Albemarle is a three-physician practice (now adding a fourth) with 1.5 FTE physician assistants and a patient population of about 10,000. The project began with identifying patients with asthma who had not visited the practice in the previous year. They also included some who had been seen more recently but not often enough to meet their asthma care needs. The intent was to improve the effectiveness of asthma care through a structured, focused program of evaluation, education and fine-tuning of treatment.

Dr. Elward’s report indicates that the initial Asthma Days generated increased revenue, but it does not provide parallel data on the staff, overhead and material costs that would have been incurred if his associates had lacked free time to conduct the program. Also, we generally assume that increased expenses for tests and medicines are justified by their benefit to patients, but the correlation between price and benefit is sometimes weak, and the continuing explosion in health care costs puts a burden on us to think seriously about the financial impact of our approaches to patient care.

Did the program reach the people it should have reached? Sixty percent of patients invited to attend the first round of Asthma Days did so. Of these, 65 percent attended at least one timely follow-up visit. It would be instructive to find out who the non-attenders were: Persons with only mild, infrequent bronchospasm? Hardcore noncompliers? Timid people who are reluctant to talk about their problem in public? There may be a need to reach out to some non-attenders, perhaps by telephone, to identify and address their concerns.

One final question for consideration: Did the program improve outcomes? Simple “happiness scores” and unsolicited comments aren’t enough. The evaluation process might look at emergency department visit rates, calls for rescue medicine prescriptions, serial peak flow rate measurements and days lost from work or school. It would also be good to demonstrate that Asthma Days participation helps patients enough that they feel less burdened by their disorder and more in control of it.

There is room for improvement in any program, and Dr. Elward’s is no exception. However, the foresight he has demonstrated in establishing such a program leaves me with little doubt that he will continue to fine-tune it over time.

As yet another old saying goes, the turtle never gets anywhere until he sticks his neck out. We need more family physicians like Dr. Elward and his associates, who will ask the right questions and then pursue the answers diligently.

Author’s response:

I appreciated the interest shown in “Asthma Days” and the keen attention to the essential questions we as family physicians face in developing clinical quality improvement ideas. The article was not intended to be a research study, and many of the details of interest to Dr. Gillette lie outside the scope of the article. However, I would like to respond to several important questions.

First, the only additional costs for the program were the mailings ($1 each) and three nurse orientation/training meetings that were held at noon. The program was designed to fit into normal patient care hours.

Second, we did not increase expenses for patients as a result of the program. We provided the standard of care according to evidence-based medicine and national guidelines, not by performing excessive testing. This approach helped us do for asthma what all studies should: decrease costs for a population of patients.

I also share concerns about making people “feel good” without improving their care. In fact, as the article mentions, in addition to happiness scores, rates of classification and prescriptions of inhaled steroids were markedly increased.

We are developing a more formal evaluation of the Asthma Days concept, one which I hope will address the excellent questions raised and, more important, better define ways to enhance the care of our patients with asthma.