5 Reasons Your Health System Should Consider an Asthma Population Health Initiative

Asthma hurts your patients, community, and bottom line. Here's what you can do about it.

This article appears in the November/December 2018 edition of HealthLeaders magazine.

[Editor's note: In December 2018, after this article was published, Adherium reduced its direct operational presence in the U.S. and is no longer involved in the SmartAirLA initiative.]

How do you tackle a health problem that affects 60,000 underserved children in your community, leads a third of them to the emergency department or urgent care each year, and keeps school-age kids out of the class more than six days annually? You address it with a population health initiative.

SmartAirLA is a program targeting underserved children with asthma located in Los Angeles County. The technological lynchpin is a Bluetooth-enabled smart sensor that attaches to asthma inhalers. The device alerts children to take their meds, tracks usage and location when inhalers are activated, and feeds data to their physicians and parents.

The program emulates a similar initiative in Louisville, Kentucky, that reduced rescue inhaler usage by 82%, led to greater control of symptoms, and inspired municipal and community organizations to reduce pollution in areas where asthma and COPD victims suffer most.

These population health initiatives provide a model for health systems that seek to improve the health status of the communities they serve. While neither program directly involved a hospital, provider organizations and payers stand to greatly benefit from initiatives targeting asthma. Nationwide, medical costs associated with this disease totaled $50.3 billion between 2009–2013, according to the Asthma and Allergy Foundation of America.

Following are five reasons why your health system should consider an asthma population health initiative:

1. Asthma Matters to Health Systems: By the Numbers
 

Asthma presents significant challenges to healthcare. "As the most prevalent chronic illness in children, asthma imposes a major financial burden on many healthcare systems," said Jeffrey H. Silber, MD, PhD, director of the Center for Outcomes Research at the Children's Hospital of Philadelphia, in 2016, commenting on a study he coauthored that appeared in JAMA Pediatrics.

According to the Asthma and Allergy Foundation:

• Asthma accounts for 14.2 million doctor’s office visits, 439,000 discharges from hospital inpatient care, and 1.8 million emergency department visits each year
   
• From 2008–2013, the annual economic cost of asthma was more than $81.9 billion. This figure includes $3 billion in losses due to missed work and school days, and $29 billion due to asthma-related mortality
   
• More than 26 million Americans have asthma including 8.3% of adults and 8.3% of children, affecting 1 in 13 people, according to the Centers for Disease Control and Prevention
   
• Asthma has been increasing since the early 1980s in all age, sex, and racial groups

2. Existing Technology Provides Clinical and Data Backbone
 

The technology behind the program is surprisingly simple to deploy. A plastic sensor snaps around the inhaler patients use to control their symptoms, as well as the rescue inhaler they use during an asthma attack.

Adherium, a digital health technology company based in San Mateo, California, donated the devices SmartAirLA is using in its program. When it's time to take the medication, the sensor, called the Hailie solution, emits an audible signal and an LED light flashes. Patients use whatever medication is prescribed by their physician—an inhaler used daily to control their symptoms, as well as a separate "rescue" inhaler that is activated if an asthma attack occurs. SmartAirLA does not provide the medication.

When either inhaler is activated, Bluetooth technology embedded in the device sends data to an app on the parent's smartphone, as well as to the clinician's web portal. Location is recorded as well. 

The activation data helps parents and providers track compliance. Location data from rescue inhaler activation helps pinpoint where asthma attacks occur. Over time this data is used to produce a heat map, pinpointing troublesome spots that can be correlated to pollution, weather, traffic patterns, and other environmental factors.

But "the technology by itself is not going to solve everything," says Ray Cheung, executive director of SmartAirLA. "How do we use technology to treat a chronic illness and do it in a way … that drives systematic change within the community [and addresses] the social determinants of health?"

3. A Successful Model Has Already Been Deployed
 

SmartAirLA was inspired by a similar program in Kentucky. In 2015 AIR Louisville enrolled 1,147 people in an asthma-reduction initiative that involved collaboration between the Louisville Metro Office of Civic Innovation, the Center for Healthy Air, Water and Soil, and device manufacturer Propeller, with funding from the Robert Wood Johnson Foundation.

One year after the program started:

• Participants experienced an average 82% reduction in asthma rescue inhaler use
   
• 29% of uncontrolled participants gained control of their asthma
   
• On average, participants more than doubled their symptom-free days
   
• Enrollees reported they slept better, with an average 19% increase in symptom-free nights

Rescue medication use occurred more often on days with higher temperatures and higher air pollutant levels. When pollutants exceeded certain limits, associated healthcare costs in Jefferson County totaled $129,000 per day, translating to more than $2.4 million during 2016.

To truly effect change, the initiative went further in a quest to make the air safer to breathe. AIR Louisville created an asthma risk map for each neighborhood, based on environmental conditions. The city is now using this information to influence transportation policy (such as rerouting trucks around these areas), creating new zoning laws to prevent future emissions, and planting more trees in targeted locations.

4. Initiative Can be Refined for Specific Populations
 

"Our initiative is different than AIR Louisville," says Cheung. "We're specifically focused on underserved children that live in the polluted areas. In Los Angeles, we already know where the pollution and asthma are at a ZIP code level. But with the smart inhalers, we can now pinpoint exactly where these asthma attacks are happening."

In April, Los Angeles was rated by the American Lung Association as the city with the highest ozone levels in the country. "Most of that pollution affects underserved communities," says Cheung. "And, according to the Los Angeles Department of Public Health, there are close to 60,000 underserved children who are asthmatics." One-third of those children will end up in the emergency room or urgent care and most are covered by Medicaid. "The burden on the health network and the costs are just enormous," he says.

5. Program Helps Realize the Potential of Population Health
 

Broadly impacting community health is often a goal of population health initiatives, but it is difficult to achieve because it involves cooperation among multiple organizations. Looking at the bigger picture, there are several ways communities benefit from these asthma programs:

• Improved health outcomes due to increased medication adherence by patients and precise data for their physicians, who can better monitor compliance
   
• Opportunities to pinpoint geographic areas most impacted by pollutants and other asthma triggers and the ability to use that information to inform public policy to address environmental factors
   
• Ability to influence dynamics related to education and employment by keeping kids in school and their parents at work

"We know that preventing disease requires intervening at multiple levels: individual, family, community, and in this case, the environment," says Rachel Wick, senior program officer of Blue Shield of California Foundation, which is funding SmartAirLA's initiative with a $250,000 grant. "This project really created that bridge by putting technology in the hands of children and families who need it most—low income children who are exposed to pollution in the environment and possibly at home."

Wick continues, "There's this potential for a really broad environmental health impact if we can get the data to detect where pollution is occurring in communities. Then communities can engage in advocacy to impact air quality. That's the root cause in terms of triggering illness as it relates to asthma and could have a huge impact on population health."