The Role of Pest Control in Effective Asthma Management: A Business Case

1. The Role of Pest Control in Effective Asthma Management:A Business Case Authors: Molly Brett and Laurie Stillman Presented by: Molly Brett, The Medical Foundation

2. Acknowledgements Produced by the Asthma Regional Council for the Boston Public Health Commission�s Healthy Pest-Free Housing Initiative. Funded by the W.K. Kellogg Foundation and the US EPA. Special thanks to Margaret Reid and Emily Litonjua at the Boston Public Health Commission for their guidance.

3. Megan�s presentation sets a great stage for mine, because she provided you with a good deal of the background information regarding the health risks of pest allergens and the potential clinical benefits of multifacated allergen reduction efforts.Megan�s presentation sets a great stage for mine, because she provided you with a good deal of the background information regarding the health risks of pest allergens and the potential clinical benefits of multifacated allergen reduction efforts.

4. Establishing a business case in the health care sector So, to begin, there is an industry standard that governs the way that a business case can be established in the health care sector. The literatuer describes two ways of making a case � Document cost savings realized by investing in the intervention OR Demonstrate that the intervention is �cost-effective:� (That is, the cost of a new service is reasonable relative to costs of standard services, given the health benefits realized by the intervention) In ARC�s business case for asthma education and environmental interventions, an analysis of the cost literature for in-home environmental interventions concludes that the interventions are cost-effective, meaning, again, that the cost is reasonable for the outcomes gained. [1] Leatherman S, Berwick D, Iles D et al. The business case for quality: case studies and an analysis. Health Affairs. 2003; 22 (2): 17-30. So, to begin, there is an industry standard that governs the way that a business case can be established in the health care sector. The literatuer describes two ways of making a case � Document cost savings realized by investing in the intervention OR Demonstrate that the intervention is �cost-effective:� (That is, the cost of a new service is reasonable relative to costs of standard services, given the health benefits realized by the intervention) In ARC�s business case for asthma education and environmental interventions, an analysis of the cost literature for in-home environmental interventions concludes that the interventions are cost-effective, meaning, again, that the cost is reasonable for the outcomes gained. [1] Leatherman S, Berwick D, Iles D et al. The business case for quality: case studies and an analysis. Health Affairs. 2003; 22 (2): 17-30.

5. Overview To establish a business case, we will show that IPM� Offers significant health benefits for asthma patients Is reasonable: IPM costs less than many medications and hospital visits for allergic asthma Is a warranted intervention for certain high-risk asthma patients In this business case for IPM, we are demonstrating that IPM is cost effective. To da We are presenting a range of possibilities rather than a specific service In this business case for IPM, we are demonstrating that IPM is cost effective. To da We are presenting a range of possibilities rather than a specific service

6. Pests cause and exacerbate asthma The biz case for IPM is grounded in research showing that pests � 3 x - immediately sets up the possibility that the health sector stands to save money (in the form of payment for hospitalizations) by providing these interventions. The biz case for IPM is grounded in research showing that pests � 3 x - immediately sets up the possibility that the health sector stands to save money (in the form of payment for hospitalizations) by providing these interventions.

7. Pest control recommended among best practices for asthma management Skin testing or in vitro testing to determine sensitivity Multifaceted, comprehensive approach to allergen-avoidance for sensitized patients (IPM methods) For mouse allergen: block access; use low-toxicity pesticides and traps; vacuum and clean. For cockroach allergen: properly store food and garbage; use poison baits, boric acid, and traps. [1] National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma, full report 2007. NIH Publication No. 08-4051. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute, August 2007. For mouse allergen: block access; use low-toxicity pesticides and traps; vacuum and clean. For cockroach allergen: properly store food and garbage; use poison baits, boric acid, and traps. [1] National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma, full report 2007. NIH Publication No. 08-4051. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute, August 2007.

8. Traditional methods of pest control can be dangerous for asthma patients Pesticides, like pests, can cause and trigger asthma: California toddlers exposed to insecticides were over twice as likely to develop asthma Pesticides cause muscles lining airway to contract, restricting airflow and initiating or aggravating asthma attacks IPM is better for asthma patients than trad pest control methods for two main reasons: First - Pesticides also linked to damage to the respiratory and nervous systems, injury to the reproductive organs, dysfunction of the immune and endocrine systems, birth defects, and cancer. [1] Salam MT, Li YF, Langholz B, Gilliland FD. Early-life environmental risk factors for asthma: findings from the Children�s Health Study. Environmental Health Perspectective. 2004; 112(6): 760-765. [2] Field M. Asthma: the Breathtaking Disease. The Magazine of Johns Hopkins Bloomberg School Of Public Health. Fall 2002. Accessed 11/14/08: http://www.jhsph.edu/publichealthnews/magazine/archive/ Mag_Fall02/Asthma.html [3] National Research Council. Pesticides in the Diets of Infants and Children. Washington: National Academy Press, 1993. IPM is better for asthma patients than trad pest control methods for two main reasons: First - Pesticides also linked to damage to the respiratory and nervous systems, injury to the reproductive organs, dysfunction of the immune and endocrine systems, birth defects, and cancer. [1] Salam MT, Li YF, Langholz B, Gilliland FD. Early-life environmental risk factors for asthma: findings from the Children�s Health Study. Environmental Health Perspectective. 2004; 112(6): 760-765. [2] Field M. Asthma: the Breathtaking Disease. The Magazine of Johns Hopkins Bloomberg School Of Public Health. Fall 2002. Accessed 11/14/08: http://www.jhsph.edu/publichealthnews/magazine/archive/ Mag_Fall02/Asthma.html [3] National Research Council. Pesticides in the Diets of Infants and Children. Washington: National Academy Press, 1993.

9. Second � IPM works, whereas traditional methods often do not - Which should be quite an important consideration for anyone considerng paying for pest control. Megan already went over some of the most recent research showign that IPm can reduce cockroach and mouse populations below clinically relevant thresholds � or below the level that can cause asthma attacks.Second � IPM works, whereas traditional methods often do not - Which should be quite an important consideration for anyone considerng paying for pest control. Megan already went over some of the most recent research showign that IPm can reduce cockroach and mouse populations below clinically relevant thresholds � or below the level that can cause asthma attacks.

10. Multifaceted interventions:The Inner-City Asthma Intervention Conducted multifaceted two-year in-home intervention Along with other components, the intervention included IPM education, services, and supplies tailored to the patient�s sensitization and pest exposures.

11. Multifaceted Interventions:Seattle-King County Healthy Homes Project Krieger et al., 2005 1-year environmental intervention in households of low-income children with persistent asthma As part of the multifaceted intervention, participants received instruction in & demonstration of IPM methods, and supplies [1] Krieger, JW Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: A Randomized, Controlled Trial of a Community Health Worker Intervention to Decrease Exposure to Indoor Asthma Triggers. American Journal of Public Health. 2005; 95 (4): 652-59. [2] Krieger JW, Takaro TK, Allen C et al. The Seattle-King County healthy homes project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environmental Health Perspectives. 2002; 110 (suppl. 2): 311-322. [1] Krieger, JW Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: A Randomized, Controlled Trial of a Community Health Worker Intervention to Decrease Exposure to Indoor Asthma Triggers. American Journal of Public Health. 2005; 95 (4): 652-59. [2] Krieger JW, Takaro TK, Allen C et al. The Seattle-King County healthy homes project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environmental Health Perspectives. 2002; 110 (suppl. 2): 311-322.

12. Costs of IPM: The New England Healthy Homes Project HUD-funded demonstration project in Boston, MA (2003) implemented by ARC and BPHC Tailored interventions in homes of children with asthma (selected services from menu of options according to household needs) Health benefits included reduced use of quick relief medicines and fewer emergency department visits for asthma The two studies just described estimated the total costs of comprehensive home-based environmental interventions that addressed a number environmental asthma triggers (e.g. dust mites, pets, mold, and environmental tobacco smoke) in addition to cockroach and rodent allergens; no published studies have quantified the cost-effectiveness of IPM alone. Data that isolates the cost of professional IPM services provides a significantly lower cost estimate than the more comprehensive package. * Regular IPM consisted of one or two visits by an experienced IPM professional. In expanded IPM, the unit and any adjacent infested units were treated, along with the common area, basement, and or exterior of the property. The two studies just described estimated the total costs of comprehensive home-based environmental interventions that addressed a number environmental asthma triggers (e.g. dust mites, pets, mold, and environmental tobacco smoke) in addition to cockroach and rodent allergens; no published studies have quantified the cost-effectiveness of IPM alone. Data that isolates the cost of professional IPM services provides a significantly lower cost estimate than the more comprehensive package. * Regular IPM consisted of one or two visits by an experienced IPM professional. In expanded IPM, the unit and any adjacent infested units were treated, along with the common area, basement, and or exterior of the property.

13. Costs of IPM: The New York City Asthma Initiative Program of the NYC Department of Health and Mental Hygiene Funded by the City Council Provides free IPM to asthma patients in three low-income communities Total cost: $400-$500 per unit Intervention includes: 3-hour visit by professional IPM contractor Educational materials Supplies: Flashlights Sponges Soap Plastic food storage containers Intervention includes: 3-hour visit by professional IPM contractor Educational materials Supplies: Flashlights Sponges Soap Plastic food storage containers

14. Average costs: Health care services for allergic asthma So, that establishes a sort of range of costs for possible kinds of IPM interventions, some more ocmprehensive than others, ranging from about $400-1400. Are those costs reasonable relative to the costs of standard services for asthma?So, that establishes a sort of range of costs for possible kinds of IPM interventions, some more ocmprehensive than others, ranging from about $400-1400. Are those costs reasonable relative to the costs of standard services for asthma?

15. Average costs: Medications for allergic asthma In addition, when you think about IPM as something that physicians might recommend when the circumstances warrant it � just like they�d recommend a more intensive course of medication like Xolair � the costs are reasonable as a more intensive intervention.In addition, when you think about IPM as something that physicians might recommend when the circumstances warrant it � just like they�d recommend a more intensive course of medication like Xolair � the costs are reasonable as a more intensive intervention.

16. IPM is cost-effective, and could result in cost savings for payers For certain high-risk asthma patients, the cost of IPM is reasonable relative to costs of standard services, given the health benefits realized by the intervention. With hospital visits for allergic asthma often costing from over $1000 to over $9000, an IPM intervention that results in just one fewer hospital visit could realize cost savings for payer organizations.

17. Assessing patients� risk of allergic asthma exacerbations Asthma severity: Moderate to severe persistent Exposures: Use patient�s medical history to identify allergen exposures that may worsen asthma Sensitivities: Use skin testing or in vitro testing to determine sensitivity Note: If tests determine that a patient is sensitized to some pest allergen, but the patient does not report any exposures, health plans should arrange a home visit by a pest management professional or trained caseworker who can more reliably determine exposures. Assessment for Exposures and Sensitivities For any patient with persistent asthma, providers should use the patient�s medical history to identify allergen exposures that may worsen asthma (see sidebar for assessment tool). Clinicians should follow the NAEPP Guidelines, which advise that for patients with persistent asthma, physicians �use skin testing or in vitro testing to reliably determine sensitivity to perennial indoor inhalant allergens to which the patient is exposed� (165). If tests determine that a patient is sensitized to some pest allergen, but the patient does not report any exposures, health plans should arrange a home visit by a pest management professional or trained caseworker who can more reliably determine exposures. Assessment for Exposures and Sensitivities For any patient with persistent asthma, providers should use the patient�s medical history to identify allergen exposures that may worsen asthma (see sidebar for assessment tool). Clinicians should follow the NAEPP Guidelines, which advise that for patients with persistent asthma, physicians �use skin testing or in vitro testing to reliably determine sensitivity to perennial indoor inhalant allergens to which the patient is exposed� (165). If tests determine that a patient is sensitized to some pest allergen, but the patient does not report any exposures, health plans should arrange a home visit by a pest management professional or trained caseworker who can more reliably determine exposures.

18. A framework for decision-making After patients� sensitivities and exposures have been identified in the manner outlined above, health plans can use this information to assign patients to various levels of IPM interventions. In determining for which patients IPM is a sound investment, payers may also consider patients� income level. Low-income patients have higher rates of costly hospitalizations for their asthma,[1] pointing to the need for improved preventive care. In addition, these patients most likely cannot afford IPM services on their own. Recommendations Patients who are diagnosed with moderate or severe persistent asthma and are sensitized AND exposed to one or more pest allergen in the home should receive a referral to a professional integrated pest management provider. For patients who live in low-income households, the literature suggests that it is cost-effective for insurers to reimburse for professional IPM services tailored to the patients� particular allergies and exposures. An asthma educational session that describes the role of pests in developing and triggering asthma is indicated for all asthma patients, but particularly those who are potentially exposed to pest allergens. Education about safely preventing exposure to pest allergens, conducted by health care providers, case managers or community health workers, can avert future pest exposure and sensitization for this moderate-risk population. Low-income asthma patients should be provided with basic pest prevention and management supplies as part of their education. As with any higher-intensity course of treatment, physicians should use their discretion in assessing patients� needs and recommending them to different levels of interventions. [1] Kim H, Kieckhefer GM, Greek AA, Joesch JM, Baydar N. Health care utilization by children with asthma. Preventing Chronic Disease. 2009; 6 (1). Accessed 1/7/2009: http://www.cdc.gov/pcd/issues/2009/jan/07_0199.htm.After patients� sensitivities and exposures have been identified in the manner outlined above, health plans can use this information to assign patients to various levels of IPM interventions. In determining for which patients IPM is a sound investment, payers may also consider patients� income level. Low-income patients have higher rates of costly hospitalizations for their asthma,[1] pointing to the need for improved preventive care. In addition, these patients most likely cannot afford IPM services on their own. Recommendations Patients who are diagnosed with moderate or severe persistent asthma and are sensitized AND exposed to one or more pest allergen in the home should receive a referral to a professional integrated pest management provider. For patients who live in low-income households, the literature suggests that it is cost-effective for insurers to reimburse for professional IPM services tailored to the patients� particular allergies and exposures. An asthma educational session that describes the role of pests in developing and triggering asthma is indicated for all asthma patients, but particularly those who are potentially exposed to pest allergens. Education about safely preventing exposure to pest allergens, conducted by health care providers, case managers or community health workers, can avert future pest exposure and sensitization for this moderate-risk population. Low-income asthma patients should be provided with basic pest prevention and management supplies as part of their education. As with any higher-intensity course of treatment, physicians should use their discretion in assessing patients� needs and recommending them to different levels of interventions.

19. Opportunities & Conclusions Health sector must look for creative, preventive approaches to asthma management IPM should be targeted to specific patients based on their allergen sensitivities and exposures IPM education and services represent a highly promising � though certainly unconventional � approach to improving outcomes for high-risk asthma patients in conjunction with other tailored environmental interventions. 2007: 14.7 billion dollars in direct medical costs2007: 14.7 billion dollars in direct medical costs

20. Appendix: Breaking down the costs of an effective intervention The two studies just described estimated the total costs of comprehensive home-based environmental interventions that addressed a number environmental asthma triggers (e.g. dust mites, pets, mold, and environmental tobacco smoke) in addition to cockroach and rodent allergens; no published studies have quantified the cost-effectiveness of IPM alone. Data that isolates the cost of professional IPM services provides a significantly lower cost estimate than the more comprehensive package.The two studies just described estimated the total costs of comprehensive home-based environmental interventions that addressed a number environmental asthma triggers (e.g. dust mites, pets, mold, and environmental tobacco smoke) in addition to cockroach and rodent allergens; no published studies have quantified the cost-effectiveness of IPM alone. Data that isolates the cost of professional IPM services provides a significantly lower cost estimate than the more comprehensive package.

21. Appendix: Breaking down the costs of an effective intervention The two studies just described estimated the total costs of comprehensive home-based environmental interventions that addressed a number environmental asthma triggers (e.g. dust mites, pets, mold, and environmental tobacco smoke) in addition to cockroach and rodent allergens; no published studies have quantified the cost-effectiveness of IPM alone. Data that isolates the cost of professional IPM services provides a significantly lower cost estimate than the more comprehensive package.The two studies just described estimated the total costs of comprehensive home-based environmental interventions that addressed a number environmental asthma triggers (e.g. dust mites, pets, mold, and environmental tobacco smoke) in addition to cockroach and rodent allergens; no published studies have quantified the cost-effectiveness of IPM alone. Data that isolates the cost of professional IPM services provides a significantly lower cost estimate than the more comprehensive package.