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Identifying Opportunities for Improvement in Pediatric Asthma Management
Kevin Dombkowski, DrPH, MS
June 25, 2005
CHEAR Unit, Division of General Pediatrics, University of Michigan
2
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
3
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
4
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
5
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
6
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
7
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
8
Methods
• Outcomes measured (2003):• 1+ asthma controller medication dispensing event
• 1+ outpatient visit
• 1+ asthma ED visit
• influenza vaccination
• Classified into 4 geographic regions
0 70 140 210 28035Miles
Southwest Southeast
Northern
Urban
10
Methods
Statistical analyses:
• Summaries of proportions and 95% confidence intervals
• Rankings for each outcome by:– plan – plan and region
11
Study Population
5-18 yrs. old with persistent asthma
5,792
Fee-for-Service Enrollees
1,345 (23%)
5-18 yrs. old with persistent asthma
in same health plan3,970 (69%)
Changed Health Plan
168 (3%)
Other Health Insurance
309 (5%)
30 Plan / Region pairsn = 3,780
12
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%
13
Results
Outcome % Range (%)
Asthma controller medications 75 66 - 88
14
Results
Outcome % Range (%)
Asthma controller medications 75 66 - 88
Outpatient visits 83 73 - 95
15
Results
Outcome % Range (%)
Asthma controller medications 75 66 - 88
Outpatient visits 83 73 - 95
Asthma ED visits 28 11 - 53
16
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
Long-Term Controller Medications, 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
E R M A L H K J F N O G P Q B C I D
Plan
% w
ith
Co
ntr
olle
r M
ed
ica
tio
ns
Statewide mean
Proportion with Asthma ED Use, 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
N M L K P O D E J H I F G C A R B Q
Plan
% w
ith
1+
As
thm
a E
D V
isit
Statewide mean
Region mean
Long-Term Controller Medications, 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
R A G F B C I Q D P M G D F Q H A B C O D I E O L K N A G D
Urban Northern Southeast Southwest
Pro
po
rtio
n w
ith
1 o
r m
ore
Pre
sc
rip
tio
n
Region mean
Long-Term Controller Medications, 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
R A G F B C I Q D P M G D F Q H A B C O D I E O L K N A G D
Urban Northern Southeast Southwest
Pro
po
rtio
n w
ith
1 o
r m
ore
Pre
sc
rip
tio
n
Region mean
Long-Term Controller Medications, 2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
R A G F B C I Q D P M G D F Q H A B C O D I E O L K N A G D
Urban Northern Southeast Southwest
Pro
po
rtio
n w
ith
1 o
r m
ore
Pre
sc
rip
tio
n
Plan mean
Asthma Management Indicators - Plan "D"
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Urban
Norther
n
South
east
South
west
Urban
Norther
n
South
east
South
west
Urban
Norther
n
South
east
South
west
Urban
Norther
n
South
east
South
west
Asthma Medications Rx Outpatient Visits Asthma ED Visits Influenza Vaccination
Pro
po
rtio
n o
f E
nro
llee
s w
ith
ea
ch
Ou
tco
me
23
Limitations
• Severity of asthma not based on objective clinical criteria
• Claims data subject to completeness and accuracy of reported information
24
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
25
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