Publications

Although inhaled corticosteroid (ICS) use is associated with a decreased risk of hospitalization for asthma, the impact of ICS on the risk of life-threatening asthma exacerbation is less clear. The effect of ICS and inhaled beta agonist (IBA) dispensing on the risk of intensive care unit admission for asthma, a surrogate for life-threatening exacerbation, is evaluated. Using computerized International classification of diseases (ICD)-9 discharge diagnoses, a cohort of all 2,344 adult Northern California members of a health maintenance organization hospitalized for asthma over a 2-yr period were identified. Computerized pharmacy data was used to ascertain asthma medications dispensed during the 3-,6-, and 12-month intervals preceding index hospitalization for asthma. During the 3-months preceding hospitalization, a minority of subjects had no IBA units dispensed (34%), with 14% receiving low level (1 unit), 20% medium level (2-3 units), and 32% high level (> or = 4 units) therapy. A substantial proportion received no ICS units (55%), whereas 13% had low, 16% medium, and 15% high level therapy. In multiple logistic regression analysis, high level IBA use was associated with a greater risk of intensive care unit (ICU) admission for asthma after controlling for asthma severity. There was no relationship, however, between low or medium level IBA use and ICU admission. Conversely, medium level and high level ICS use were associated with a reduced risk of ICU admission. Analysing 6- and 12-month medication dispensing data, similar risk patterns were observed. Inhaled corticosteroid dispensing was associated with reduced risk of intensive care unit admission among adults hospitalized for asthma, whereas the opposite applied for high dose beta agonist usage. This suggests that ICS prescription to adults with moderate-to-severe asthma could reduce the risk of life-threatening exacerbation.

BACKGROUND

Multidisciplinary disease management programs (MDMP) have demonstrated reduced hospitalizations in motivated pretransplant heart failure populations, but little is known about their effectiveness in largely indigent patients who are not transplant candidates.

METHODS AND RESULTS

We studied 35 patients with heart failure with left ventricular ejection fraction (EF) /=2 per year (group A) and 21 patients referred by their primary care physicians because they were difficult to manage (group B). Group A patients were New York Heart Association (NYHA) class III or IV, aged 25 to 87 years (mean 57 +/- 17 SD) and had an EF of 15% to 45% (29% +/- 11%). Group B patients were NYHA class II or III, aged 35 to 86 (57 +/- 16) years and had an EF of 20% to 45% (28% +/- 10%). Data were compared for the year before enrollment in the MDMP and the year afterward. In group A hospital admissions decreased from 33 to 3, a 91% reduction, and NYHA class improved to class II-III (P <.001). In group B hospital admissions decreased from 9 to 0, and NYHA class improved to class I-II (P <.001). When hospital and clinic charges were assessed for both groups, the net savings were $162,000 per year or $4600 per patient.

CONCLUSIONS

A multidisciplinary heart failure program can improve functional status and reduce hospitalization and net costs compared with conventional care in indigent non-transplant candidate patients.