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Quality improvement for asthma care: The asthma care return-on-investment calculator

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On December 6, 2007, Ginger Carls gave an overview of the Asthma Return on Investment (ROI) Calculator at the State Healthcare Quality Improvement Workshop. This is the text version of the event's slide presentation. Please select the following link to access the slides: (PowerPoint® File, 764 KB).

Slides: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20

Slide 1: Quality improvement for asthma care: The asthma care return-on-investment calculator

Ginger Smith Carls, M.A.,
Thomson Healthcare (Medstat)
State Healthcare Quality Improvement Workshop:
Tools You Can Use to Make a Difference
December 6-7, 2007

On the top of the slide are the logos for the Department of Health & Human Services and the AHRQ logo. The Department of Health & Human Services logo is an artistic image of an eagle with the outlined profile of faces. The AHRQ logo reads, "AHRQ — Agency for Healthcare Research and Quality: Advancing Excellence in Health Care,"

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Slide 2: Agenda

  • What is the Asthma Care Return-on-Investment calculator?
  • Background
    • Definitions
    • Key issues
    • How can the calculator help evaluate asthma care programs? What does it provide?
  • How does the calculator work?
  • Features of the calculator
  • Summary of literature review
  • Conclusions
  • Resources

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Slide 3: What is the Asthma Care ROI Calculator?

  • Purpose
    • Help state policy makers and health plans estimate financial returns on asthma quality improvement programs.
  • Why developed?
    • Most studies don't address financial impact, rather clinical and use impacts only.
    • Clinical or use impacts need to be translated into costs or savings.
  • How are estimates generated?
    • Combine clinical evidence about impacts on utilization with separate cost data to estimate financial impact.

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Slide 4: Background: definitions

  • Asthma care programs typically follow NAEPP (National Asthma Education and Prevention Program) guidelines.
    • Patient education
    • Provider activities
  • Financial metrics

Return on Investment (ROI) = Savings/Program Cost = $1 break even
Net Present Value (NPV) = Savings minus Program Cost = $0 break even

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Slide 5: Background: cost vs. quality

  • Programs that improve quality of asthma care may or may not reduce total medical care costs. Beneath the text is a visual equation with graphics. Reducing hospitalization and increasing prescription medicine equals a question mark.

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Slide 6: Background: program evaluation methods

  • Regression to the mean bias.
    • Sick patients may get better over time, even without the program.
    • To be successful, a program must "beat" the regression to the mean bias.

A graphic indicates that if the program cohort reduces hospitalizations by 60% and the control cohort reduces hospitalizations by 20%, the true effect of the program is a 40% reduction in hospitalizations.

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Slide 7: How does the calculator work?

  • 72,777 participants who average 0.25 ED visits per year lead to 18,194 annual visits to ER.
  • Asthma program reduces hospitalizations by 30%, leading to 5,458 visits to ER saved.
  • Each visit costs $88 leads to $480,304 saved.

Repeat for each component asthma-related costs.
Compare change in medical care expenditures with program cost.

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Slide 8: How does the calculator work?

Cost components

  • Asthma-related medical care
    • Emergency department visits
    • Hospital stays
    • Outpatient visits
    • Medications
    • Ancillary testing
  • Productivity
    • Missed school or work days

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Slide 9: Data sources

  1. Population demographics.
    • Medicaid (CMS 2003).
    • Employer sponsored health insurance (CPS 2003-2005).
    • State employees (BLS 2003-2005).
  2. Large, nationwide, medical claims database (MarketScan™)
    • Prevalence rates.
    • Utilization and costs for asthma patients.
  3. Literature review (52 studies)
    • Impact of asthma care programs.
    • Cost to implement asthma care programs.
  4. You!
    • Virtually all data used by the model can be changed by the user.

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Slide 10: Calculator features

  • Ability to examine how the following factors may change financial impact of program.
    • Who is included in the program.
      • Children, adults, or both.
      • All asthma patients, or only those with persistent asthma.
      • Medicaid, employer-sponsored insurance, or state employees.
    • What benefits are counted?
      • Only medical care savings or also include productivity gains?
    • Length of the program.
    • Cost to implement the program.
  • Options to describe benefits and costs from a third-party payer or society perspective.

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Slide 11: Calculator features

  • Ability to choose the research design to use in estimating savings.
    • Studies without a control group.
      • Use as a benchmark for preliminary results.
    • Studies with a control group.
      • Shows expected true savings.
    • Comparisons between study designs can be used to assess magnitude of regression to the mean bias.

Underneath the text is a large yellow arrow pointing to the following text: Use calculator in planning, monitoring and/or evaluative phases of an asthma care program.

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Slide 12: Steps in the ROI calculator

This slide shows a series of steps in the ROI calculator. The steps include:

  1. Describe population.
  2. Estimate number of participants.
  3. Estimate baseline utilization or missed work days.
  4. Estimate impact of the asthma program.
  5. Estimate program cost.

In all five steps, the user chooses between default data and user data. Meta-analysis occurs at steps 4 and 5.

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Slide 13: Results from the literature review

Savings more likely for some populations than others, depending on the component of care. For example:

  • Interventions on people with persistent asthma (versus all asthma) had:
    • Higher savings on ED visits and outpatient visits.
    • Similar savings on missed work/school days.
    • Lower savings on hospitalizations.
    • Smaller increases in medication costs (so higher savings).

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Slide 14: Results from the literature review

  • Interventions on Medicaid populations (versus other coverage) had:
    • Higher savings on hospitalizations, outpatient visits, missed work/school days.
    • Lower savings on ED visits.
  • Interventions on children (versus adults) had:
    • Higher savings on outpatient visits and asthma medications.
    • Lower savings on ED visits, hospitalizations, and missed work/school days.
  • Controlled studies showed lower savings than non-controlled studies.

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Slide 15: Results from literature

  • Few studies reported program cost; those that did reported a wide range (7 studies).
    • Average of $395 dollars per patient per year.
    • Low of $81 for automated educational mailing to general populations.
    • High of $989 per year, targeted to highest cost patients.

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Slide 16: Results from literature

  • Few studies reported the impact on asthma medication use (10 studies).
    • Studies without a control group reported larger increases in medication costs.
    • Studies with a control group reported smaller increases in medication costs.
    • Baseline asthma medication costs varied a great deal, suggesting different cost and utilization settings.
    • Recent increase in use of drug formularies and availability of generics may result in lower increases in medication cost than reported by some of the older studies included in our review.

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Slide 17: Conclusions

What kinds of programs are more likely to find savings?

Programs that:

  • Target patients who use the emergency department and hospital for asthma care.
  • Target children.
  • Target Medicaid program.

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Slide 18: Conclusions

What are the key drivers of ROI?

  • Decrease in costs due to hospitalizations.
  • Increase in medication use.
  • Cost to implement the program.

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Slide 19: Conclusions

What can the asthma care calculator do?

  • Help plan, monitor and evaluate financial impact of asthma care programs.
  • Summarizes published evidence on financial impact of asthma care programs.

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Slide 20: Resources

  • Breakout sessions
    • Policy implications
    • Hands-on-Training
  • Handouts
    • Screen shots example
  • Detailed report available on request
    • Documents methods, definitions used for the default baseline data
    • List of studies included in the literature review
  • Send questions, suggestions and stories about the use of the calculator to:
    Ginger Carls ( or
    Rosanna Coffey (

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