Contributed Commentary by Kim Collison
February 5, 2019 | For those of us working in clinical laboratories, promoting ourselves and our services doesn’t come naturally. Yet, as the healthcare system moves from fee-for-service to value-based care we must do our part to be advocates for new diagnostic tests that can help the model mature and become more efficient and effective. Aiding in the early diagnosis of asthma is one example of how we can help to meet the Triple Aim goals to improve patient experience of care, improve the health of populations, and reduce the per capita costs of care.
According to a supplement that published in 2011 in American Journal of Managed Care (AJMC), Asthma morbidity and mortality encompass 15 million doctor office visits annually. The disease continues to be a burden for sufferers and their families and a major driver of healthcare costs. The good news is that better outcomes are possible when asthma and its trigger allergens are identified early, and laboratories are critical to that process.
Diagnostic Testing And Interpretation Of The Results
Given the direct link between allergies and asthma, it’s critical that a patient’s allergic triggers are identified early in the diagnostic process. In vitro testing is a proven solution for assessing allergen-specific immunoglobulin E (specific IgE) sensitization. The blood tests are accurate and can be ordered by a primary care clinician during a routine exam. But unfortunately, these blood tests are often underutilized by healthcare professionals. Sometimes costs are a barrier, but according to one study, while allergy trigger testing for high-risk asthma patients requires resources, the cumulative cost of poorly controlled asthma (ED visits, hospital visits, extended stays, etc.) can well exceed the cost of taking this proactive approach (DOI: 10.1111/j.1398-9995.2006.01254.x).
Equally important is helping clinicians interpret allergen specific IgE test results. A study that looked at five different specific IgE test procedures using the average standardized slope coefficient (ASSC) from 12,708 samples found that the ImmunoCAP system produced quantitative specific IgE results over a large range with precision and accuracy, and performed well when compared to the standard of an ideal assay. Specific IgE values >0.10 kUA/L indicate sensitization, and increased values correlate with increased probability of symptoms. Ranking a patient's respiratory allergen quantitative results from highest to lowest can help prioritize targets for environmental control.
The lab’s role in asthma treatment plans
Patients with asthma who have allergy testing are significantly more likely to employ preventive strategies—such as having an asthma treatment plan, avoiding triggers, and taking medication as prescribed—than patients who haven’t been tested (DOI: 10.1056/NEJMoa032097). Clinicians can use the results of allergen-specific IgE testing to customize treatment plans and engage patients in their own care, providing personalized medicine at its best.
Additionally, specific IgE testing is reproducible. Quality control measures and the sensitivity measured with specific IgE testing on Phadia instruments is universal throughout any laboratory running the test. The same cannot be said for skin testing. Physicians may interpret the results of a skin test differently and allergen extracts and devices used in the procedure could be manufactured by several different companies, without standardization, leading to variations in the diagnosis and ultimately the patient’s treatment plan. It’s the lab professional’s job to ensure clinicians understand the different testing options so healthcare providers can ultimately provide a fast and accurate diagnosis and subsequent treatment plan for each patient.
Insights from laboratory data
Across healthcare, data are already helping us understand how certain patients can benefit from certain treatments. The more data laboratories produce—and share—the better able we are to predict outcomes and prescribe care plans that reduce the systemwide costs of managing asthma. Allergy evaluations are a key part of this process.
Using laboratory data as well as billing and ICD-10 codes, including prescription data, we can help identify those with asthma and flag certain high-risk patients, according to asthma guidelines. This enables the identification of patients who are candidates for appropriate diagnostic testing. The data obtained in the diagnostic practice and clinical care can be tracked over time to measure progress toward the Triple Aim goals.
The value of laboratory services in enhanced asthma management
The Asthma and Allergy Task Force, a group of 11 healthcare professionals supported by Thermo Fisher Scientific that met in person and remotely over a period of 20 months to develop recommendations for enhanced asthma management, acknowledged that asthma care often misses the improvements that result from identification, assessment, and management of allergic triggers in accordance with guideline-based asthma management. This gap in care represents an opportunity for promoting the value of laboratory services. Allergy trigger testing for people with asthma requires resources, but poorly controlled asthma is expensive in terms of emergency department visits, hospitalizations (inpatient and intensive care) and extended stays. According to The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) cohort study, a single case of uncontrolled asthma can cost $5,963 per year, double the cost for a patient whose asthma symptoms are controlled. (DOI: 10.1016/j.jaci.2012.04.014).
Final Thoughts
We need to step away from the comfort of our labs to educate the specialists and primary care clinicians we work with and to become advocates for allergic trigger management in asthma care. We must also remember that people involved in care management and quality improvement can benefit from opportunities to integrate the use of laboratory results into their quality improvement initiatives. Let’s embrace our position as professionals who can make a difference in asthma outcomes by working toward closing the current care gap.
Kim Collison, , MSA, MT(ASCP) is the Director, Pathology and Laboratory Services, Spectrum Health Hospitals, Grand Rapids, Michigan. Kim successfully builds and maintains collaborative relationships with physician and service line leaders through highly visible participation in quality and operation teams. Kim holds a Master of Science in Health Service Administration and is an ASCP certified Medical Technologist. She can be reached at Kim.Collison@spectrumhealth.org.