CHEAR Unit, Division of General Pediatrics, University of Michigan
Identifying Opportunities for Improvement
in Pediatric Asthma Management
Kevin Dombkowski, DrPH, MS
June 25, 2005
Background
•
Asthma management is of great importance given
high prevalence, morbidity, and mortality
•
National Committee on Quality Assurance (NCQA)
HEDIS looks at one dimension of asthma care:
“use of appropriate medications”
•
Quality assessments are reported at the aggregate
plan level
1
Background
•
•
National Asthma Education and Prevention
Program (NAEPP) provides guidance on key
clinical activities for quality asthma care:
1.
Appropriate pharmacotherapy
2.
Asthma assessment and monitoring
3.
Control of factors contributing to asthma severity
4.
Education
Despite longstanding availability of NAEPP
guidelines, wide variation in adherence exists
2
Background
•
It is unclear whether:
–
a single measure accurately portrays asthma
management for plan enrollees
–
a plan’s aggregate quality assessments reflect
performance throughout the areas in which it
operates
3
Objectives
1. Characterize pediatric asthma care
among Medicaid beneficiaries
2. Describe how measures of health plan
performance may vary between
geographic areas
3. Assess alternate measures of asthma
management
4
Objectives
• Two perspectives:
• variation between plans, contrasting the
performance of plans operating in similar
geographic areas; and
• variation within plans, comparing outcomes
for enrollees within the same plan, but
living in different geographic areas
5
Methods
• Study Design: Retrospective analysis of
Michigan Medicaid administrative claims from
2002-2003
• Study Population:
– 5-18 yrs. old
– continuously enrolled in Medicaid
– classified as having persistent asthma using
HEDIS criteria in 2002 and 2003
6
Methods
•
•
Outcomes measured (2003):
•
1+ asthma controller medication dispensing event
•
1+ outpatient visit
•
1+ asthma ED visit
•
influenza vaccination
Classified into 4 geographic regions
7
Northern
Southeast
Southwest
Urban
0
35
70
140
210
280
Miles
Methods
Statistical analyses:
• Summaries of proportions and 95%
confidence intervals
• Rankings for each outcome by:
– plan
– plan and region
9
Study Population
5-18 yrs. old
with persistent asthma
5,792
Fee-for-Service
Enrollees
1,345 (23%)
Changed
Health Plan
168 (3%)
Other Health
Insurance
309 (5%)
5-18 yrs. old
with persistent asthma
in same health plan
3,970 (69%)
30 Plan / Region pairs
n = 3,780
10
Study Population
Characteristic
n= 3,970
5-9 Yrs.
36%
10-14 Yrs.
46%
15-21 Yrs.
18%
Male
59%
White
36%
Black
59%
All Others
5%
Urban
44%
Northern
15%
Southeast
22%
Southwest
19%
11
Results
Outcome
%
Range (%)
Asthma controller medications
75
66 - 88
12
Results
Outcome
%
Range (%)
Asthma controller medications
75
66 - 88
Outpatient visits
83
73 - 95
13
Results
Outcome
%
Range (%)
Asthma controller medications
75
66 - 88
Outpatient visits
83
73 - 95
Asthma ED visits
28
11 - 53
14
Results
Outcome
%
Range (%)
Asthma controller medications
75
66 - 88
Outpatient visits
83
73 - 95
Asthma ED visits
28
11 - 53
Influenza vaccination
17
3 - 46
15
Long-Term Controller Medications, 2003
100%
90%
% with Controller Medications
80%
70%
60%
50%
40%
30%
20%
10%
0%
E
R
M
A
L
H
K
J
F
N
O
G
Plan
Statewide mean
P
Q
B
C
I
D
Proportion with Asthma ED Use, 2003
100%
90%
% with 1+ Asthma ED Visit
80%
70%
60%
50%
40%
30%
20%
10%
0%
N
M
L
K
P
O
D
E
J
H
I
F
Plan
Statewide mean
G
C
A
R
B
Q
Long-Term Controller Medications, 2003
100%
Proportion with 1 or more Prescription
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
R
A G F
B C
Urban
I
Q D
P M G D
Northern
F
Q H A B C O D
Southeast
Region mean
I
E O L
K
N A G D
Southwest
Long-Term Controller Medications, 2003
100%
Proportion with 1 or more Prescription
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
R A G F
B C
Urban
I
Q D
P M G D
Northern
F
Q H A B C
O D
Southeast
Region mean
I
E
O L
K
N A G D
Southwest
Long-Term Controller Medications, 2003
100%
Proportion with 1 or more Prescription
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
R
A G F
B C
Urban
I
Q D
P M G D
Northern
F
Q H A B C O D
Southeast
Region mean
I
E O L
K
N A G D
Southwest
Asthma Medications Rx
Outpatient Visits
Asthma ED Visits
Plan mean
Ur
ba
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Proportion of Enrollees with each Outcome
Asthma Management Indicators - Plan "D"
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Influenza Vaccination
Limitations
• Severity of asthma not based on
objective clinical criteria
• Claims data subject to completeness
and accuracy of reported information
22
Conclusions
• Health plans may have a diverse profile
of outcomes across a state
• Aggregate measures may not
adequately describe plan experiences
• Multiple outcomes measures may
provide a more comprehensive
assessment of plan performance
23
Implications
• Regional profiles of outcomes may reveal
opportunities for plans to:
– identify and prioritize areas in greatest need of
asthma quality improvement initiatives
– gauge the adequacy of existing provider networks
in local areas
• Scope of asthma performance measurement
can be broadened using administrative claims
data
24