identifying opportunities for improvement in pediatric asthma management kevin dombkowski, drph, ms...

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