Digital tool reduces ED visit rates for patients with asthma, Medicaid

Key takeaways:

• Patients used a digital asthma self-management program or usual care.
• There were 219 patients on Medicaid and 678 with commercial insurance.
• The Medicaid group had 43% less risk for ED visits.

ANAHEIM, Calif. — A digital asthma self-management program reduced ED visit rates for adults with asthma on Medicaid, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“There are a lot of challenges in home management,” Bronwyn Harris, MD, chief transformation officer at CareEvolution, said during the presentation.

These challenges include a lack of passive measures, poor engagement with symptom tracking, disparities in asthma care between commercial and Medicaid coverage, and limited evidence about the impact of digital tools, she continued.

The study was conducted by the University of California, Irvine, and was designed in collaboration with Elevance Health, the healthcare organization formerly known as Anthem Inc., and Apple Inc. CareEvolution is the study technology partner.

Study design

The randomized, controlled, pragmatic, decentralized trial enrolled 901 adults from 41 states (71% female; mean age, 36.6 years; standard deviation, 10.5 years; range, 18-64 years), with 897 included in prespecified intention-to-treat subgroup analyses.

Bronwyn Harris

“It was a real-world randomized controlled study,” Harris said. “It was fully digital. Invitations went out to patients via email.”

Each patient had a diagnosis of asthma based on claims data as well as an elevated risk for ED visits.

Overall, 347 (39%) had controlled asthma based on an Asthma Control Test (ACT) score of 20 or higher, and 552 (61%) had uncontrolled asthma based on an ACT score of less than 20. Additionally, 352 (39%) had at least one asthma-associated ED visit in the previous 12 months.

Patients also had either commercial insurance (n = 680; 76%) or Medicaid insurance (n = 219; 24%) affiliated with Elevance Health.

“Just by having the Medicaid insurance and having a diagnosis of asthma, they were automatically eligible for the study and considered to be at an elevated risk for an emergency room visit,” Harris said.

Both groups received an Apple Watch and a Beddit Sleep Monitor. Participation incentives included an opportunity to keep these devices in addition to a $25 gift card.

“There were no other incentives, and that was on purpose,” Harris said. “None of these incentives were actually tied to logging symptoms, because we wanted that symptom logging and engagement with the tools to be organic.”

Researchers followed patients for 12 months after randomly assigned them to digital asthma self-management (DASM; n = 450) or usual care (n = 449).

DASM included access to asthma digital tools in addition to usual care, regular study surveys and the collection of claims data. Usual care included routine asthma care, surveys at baseline and at 12 months, and collected claims data, all without any asthma digital tools.

The asthma digital tools included consumer-grade devices for passive biometric monitoring and a smartphone app that logged symptoms and tracked triggers in addition to providing “smart nudging,” which prompted patients to use the tools based on the data they collected, evidence-based education and connections to traditional care.

“This is a fully digital experience,” Harris said. “The results that we saw in the study did not involve having a provider in the loop.”

The user experience

When users engage with the app, Harris said, there is a very clear call to action to complete a daily entry, which is a survey that asks about current symptoms and triggers.

“What severity are your symptoms? What specific symptoms are you having?” Harris said. “Are you waking up at night? Limiting your daily activity or using your rescue inhaler?”

Responses to these questions indicate whether the patient’s asthma is under control, based on clinical guidelines. The app then provides relevant education based on what the patient has logged. Their asthma action plan from their provider can also be stored and viewed within the app.

Additionally, the app asks patients to consider what triggers they may have experienced recently and log them too.

“They may be experiencing something that they might not recognize if they didn’t really think about it in that moment,” Harris said.

If patients do not report any triggers, the app will provide a list of surprise triggers.

“Some patients said this question prompted them to recognize that NSAIDs were a trigger for them,” Harris said.

Every 2 weeks, the app also asks patients if they have missed any medication.

“If someone is missing more than three doses in the past 2 weeks, we’ll ask about what barriers that they’re having to take their medications,” Harris said. “We can then give targeted education based on those barriers.”

The Apple Watch and the Beddit Sleep Monitor provided baseline data for each patient. Metrics include daytime and nighttime resting heart rates, nighttime respiratory rates, awakenings, step counts, and oxygen saturation..

“When there are significant deviations from that baseline, they get a nudge saying that their data are outside their normal level and prompting them to log on, so these data are meant as an engagement hook,” Harris said. Additionally, air quality index (AQI) is obtained based on patient reported zip codes, and patients are notified when the AQI is elevated.

Education includes textual content written at a seventh-grade level and videos that users can browse at any time. Finally, the app can generate 3-month PDF summaries that users can share with providers by printing them out or via digital platforms such as MyChart.

Study results

The 219 patients with Medicaid had a 43% (95% CI, 17%-69%) relative risk reduction in ED visits associated with asthma. These patients included 108 patients in the control group who averaged 0.58 ED visits per year, and 111 in the DASM group who averaged 0.33 visits per year (number needed to treat = 4.1; 95% CI, 0.7-7.5).

The 678 patients in the group with commercial insurance did not display any clinically or statistically significant effect in ED visit rates, including 0.31 for the control group and 0.33 for the DASM group.

Also, Harris said, the intervention group had more patients with zero ED visits compared with the control group (89 vs. 79) in addition to only two patients with more than three visits during the 12-month study period.

“Meanwhile, the control group had seven who had more than three visits and three patients who actually were in the emergency room on average more than every other month,” she said.

Users engaged with the app as well, Harris said. Participants with commercial coverage had medians of 13.7 (interquartile range [IQR], 8-21.3) symptom logs and 27.7 (IQR, 15.3-40.9) app opens each month during the first 3 months. The participants with Medicaid coverage had medians of 12.7 (IQR, 2.5-18.3) system logs and 24 (IQR = 9.3-39.3) app opens each month.

“The majority of participants were going in to the app and then going through those questions to assess control and thinking about triggers,” Harris said, “more than one in every 3 days.”

Next steps

Based on these findings, the researchers concluded that the digital self-management program reduced annual rates of ED visits for adults with asthma who use Medicaid.

However, Harris said, the reasons why the program led to such significant decreases for the Medicaid population but not for the commercial insurance population remain unclear.

“The study team is looking into more data on that,” she said.

For example, Harris asked how many of the ED visits before and after the intervention were avoidable. Perhaps a lack of education and awareness may have impacted the number of ED visits in these populations, she continued.

“By really providing that information, you’re able to bring it down,” Harris said.

Access to care may play a role too, she said.

“You can help someone be educated, understand asthma and understand they’re not controlled,” Harris said. “But if they don’t have access to see a provider, or get the right medication, it’s not going to do anything.”

Harris added that the control group in the commercial population already had a low rate of 0.31 ED visits per participant per year.

“It’s harder to decrease that. That’s already a lower rate,” she said. “There isn’t as much low hanging fruit.”

This population might not have had patients who simply did not understand what an exacerbation was or that they should see a doctor sooner, Harris said.

Additionally, Harris said that patients with Medicaid generally are less likely to see a primary care provider in the previous year.

“If you haven’t seen a primary care provider in a year and you’re having some asthma symptoms, you’re probably going to go to the ED,” she said.

Looking ahead, Harris said that the study team will continue to examine the data, including asthma control and ED visits, in addition to hospitalizations and other costs associated with asthma.

For more information:

Bronwyn Harris, MD, can be reached at bronwyn.harris@careevolution.com.