Performance improvement inclusion criteria for clinic patients were based on active status in the clinic. Active patients were defined as patients with at least 2 clinic visits and a clinic visit within 3 months of an ED visit or admission. The 3-month cutoff was chosen based on several criteria. First, most patients referred to the clinic were categorized as either not well controlled (NWC) or very poorly controlled (VPC) and required at least a 2- to 4-week follow-up based on guidelines. Second, patients who were categorized as well controlled (WC) were scheduled for clinic visits every 3 months for regular follow-up.
Using all ICD-9 codes for asthma, RPMS VGEN was used to find the number of ED visits and admissions that occurred with asthma as the primary diagnosis from both clinic and nonclinic patients. The inclusion criteria were then applied to the clinic patients, and those not meeting these criteria were returned to the nonclinic pool of patients.
Cost analysis was evaluated based on the results of a random selection of 20 patients from 2009 and 2010 ED and hospital visits at the NNMC. These numbers were averaged to determine ED and admission costs. Length of admission stay was determined from a RPMS VGEN search for each clinic and nonclinic patient admission.
Determination of the level of control was based on the 2007 national asthma guidelines. The guidelines state that the level of control can be determined by either asthma symptoms or by peak flow evaluation. 19 Because of the language barrier that sometimes arises with the treated population, the use of symptom-based evaluation has been observationally superior to providing peak flow meters for home use. At each visit, patients were interviewed using tables from the asthma guidelines. Table 2 is an abbreviated portion of the guidelines representing the assessment tool used by the clinic. The level of control was determined by selecting the column with the highest severity of impairment. 19
All patients seen at the clinic were tracked in a database, and their current level of control was documented at each visit. To determine the level of control, the database was reviewed, and those patients with > 1 visit were included in the analysis. The levels of control from the first visit to the most recent visit were compared.
Patient surveys were completed at each visit. These surveys included questions to assist the pharmacy provider in classifying the level of control, patient satisfaction with asthma care, and patient perception of asthma control. Approval from the Navajo Area Institutional Review Board was obtained for data publication. Odds ratios were used to determine the impact of the clinic, using a 95% confidence interval.
Results
For the review period, 2,997 patients were coded as having some form of asthma, resulting in 12,739 asthma visits within the medical center.
ED Visits and Hospital Admissions
Of these 2,997 patients, 301 visited the ED between 2010 and 2011 with 22 being active asthma clinic patients. These 22 active clinic patients accounted for 31 ED visits. The remaining 279 patients had 428 visits with a total of 459 ED visits from clinic and nonclinic patients. Sixty patients were hospitalized for asthma with 7 of them active asthma clinic patients. The 7 clinic patients admitted accounted for 8 admissions. There is a statistical significance in total ED visits and admissions as well as for individual patients (Table 3).
