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