Process quality measures and asthma exacerbations in the Medicaid population

doi:10.1016/j.jaci.2009.07.027

Journal of Allergy and Clinical Immunology

Volume 124, Issue 5, November 2009, Pages 961-966

https://doi.org/10.1016/j.jaci.2009.07.027 Get rights and content

Background

Asthma quality assessment often focuses on controller medication use, yet claims-based studies find conflicting associations between this care process and clinical outcomes.

Objective

We sought to compare the association between 3 controller-based quality measures and asthma exacerbations to gain better understanding of how processes of care are related to clinical outcomes.

Methods

Identifying a cohort of Medicaid beneficiaries with persistent asthma by using Healthcare Effectiveness Data and Information Set (HEDIS) criteria for asthma in 2001–2002 in California and New York, we assessed 3 asthma quality metrics in 2002: (1) the current HEDIS measure of at least 1 controller medication filling; (2) at least 4 controller medication prescription fillings; and (3) a controller-to-total asthma medication ratio of at least 0.5. We calculated the odds of having an asthma exacerbation in 2003 as a function of performance on each quality metric, adjusting for race, sex, age, and prior outpatient and acute care use for asthma.

Results

Of 90,909 subjects with persistent asthma in California (48.1%) and New York (51.9%), those who obtained at least 1 or at least 4 controller medications had increased likelihood of poor outcomes (adjusted odds ratios, 1.80 [95% CI, 1.73–1.87] and 1.44 [95% CI 1.40–1.48], respectively). Beneficiaries meeting the controller-to-total asthma medication ratio measure were 23.0% less likely to have exacerbations (adjusted odds ratio, 0.77 [95% CI, 0.75-0.80]).

Conclusions

A higher controller medication ratio indicated a lower likelihood of asthma exacerbations, whereas assessing the number of controller medication–dispensing events was associated with a higher odds of exacerbation.

Section snippets

Methods

To compare the association between quality metrics and asthma exacerbations among Medicaid beneficiaries, we defined a cohort of subjects with persistent asthma in 2001 and 2002, measured the quality of care each beneficiary received in 2002, and then tested whether patients who received care measured as high quality were less likely to have subsequent asthma exacerbations in 2003 (Fig 1).

Cohort characteristic

More than 90,000 Medicaid beneficiaries, of whom 57,032 (62.7%) were female, met the criteria for persistent asthma (Table II). The mean age of the cohort was 33.9 years (SD, 17.2 years). Approximately one third of the beneficiaries were white (33.6%), and almost one quarter were either black (22.0%) or Hispanic (23.0%). Forty-eight percent resided in California, and 52% resided in New York. Approximately 14.0% of included patients had a Charlson index of 0 points. Seventy-six percent of the

Discussion

This study compared the association of 3 asthma process-of-care quality measures with clinical asthma outcomes. Our analyses found that in a population including both pediatric and adult subjects with persistent asthma, the filling of either at least 1 or 4 asthma controller medication prescriptions by Medicaid beneficiaries was associated with a higher likelihood of future ED visits, hospital admissions, and oral steroid–dispensing events for asthma. In contrast, those beneficiaries with a

References (28)

E.W. Gelfand et al.
Use of the HEDIS for measuring and improving the quality of asthma care
Ann Allergy Asthma Immunol
(2006)
R.A. Pauwels et al.
Early intervention with budesonide in mild persistent asthma: a randomized, double-blind trial
Lancet
(2003)
M. Samnaliev et al.
Comparative evaluation of two asthma care quality measures among Medicaid beneficiaries
Chest
(2009)
W.E. Berger et al.
The utility of the HEDIS asthma measure to predict asthma-related outcomes
Ann Allergy Asthma Immunol
(2004)
M. Schatz et al.
Asthma quality of care markers using administrative data
Chest
(2005)
M. Schatz et al.
Inhaled corticosteroids and allergy specialty care reduce emergency hospital use for asthma
J Allergy Clin Immunol
(2003)
M. Schatz et al.
The controller-to-total asthma medication ratio is associated with patient-centered as well as utilization outcomes
Chest
(2006)
M.E. Charlson et al.
A new method of classifying prognostic co-morbidity in longitudinal studies: development and validation
J Chron Dis
(1987)
M. Schatz et al.
American College of Allergy, Asthma and Immunology Task Force; American Academy of Allergy, Asthma and Immunology Task Force. Asthma quality-of-care measures using administrative data: relationships to subsequent exacerbations in multiple databases
Ann Allergy Asthma Immunol
(2008)
American Lung Association: Epidemiology and Statistics Unit. 2007. Trends in asthma morbidity and mortality. Available...

S. Hennessy et al.

Medicaid databases

National Committee on Quality Assurance. Available at: http://www.ncqa.org. Accessed April 13,...

N.C. Barnes et al.

Effect of leukotriene receptor antagonist therapy on the risk of asthma exacerbations in patients with mild to moderate asthma: an integrated analysis of zafirlukast trials

Thorax

(2000)

C.A. Camargo et al.

Association between common asthma therapies and recurrent asthma exacerbations in children enrolled in a state Medicaid plan

Am J Health Syst Pharm

(2007)

Cited by (28)

The HEDIS Medication Management for People with Asthma measure is not associated with improved asthma outcomes
2019, Journal of Allergy and Clinical Immunology: In Practice
Can asthma be well controlled with NAEPP guideline care in morbidly obese children? The Breathmobile
2019, Annals of Allergy, Asthma and Immunology
Obesity is thought to be associated with poor asthma control, increased health resource utilization, and reduced responsiveness to inhaled corticosteroids.
Based on previous experience, our hypothesis was that by improved access to comprehensive guideline care, outcomes in normal weight would be comparable in obese children with asthma.
This was a retrospective cohort study of predominately Hispanic children (3-18 years of age) in underserved areas of Orange County, California, who enrolled in the Breathmobile Program from 2003 to 2012. Outcomes were examined by using Cox regression and generalized estimating equations analyses, adjusted for potential confounding factors.
Clinical outcomes in more than 1,200 children followed up for a mean of 6 visits (standard deviation [SD] = 2.2) across 403 days (SD = 112) were improved, on average, regardless of body mass index (BMI). Morbidly obese (MOB) patients were able to achieve significant reductions of approximately 60% or more in report of emergency department (ED) visits, hospitalizations, school absenteeism, usual exercise limitations, and exacerbations to levels that were comparable those of normal weight (NW) patients. The importance of close follow-up, particularly for the MOB patient, was evidenced by achieving 80% cumulative probability of well controlled asthma by visit 3, similar to patients in lower BMI risk groups with good adherence, when the visit interval did not exceed 90 days. These outcomes were achieved across all BMI groups with similar mean step of therapy, adjusted for severity (P < .001).
Access to effective community-based care where trust, education, and continuity of care consistent with National Asthma Education and Prevention Program (NAEPP) guidelines is possible, as demonstrated by the Breathmobile Program, can provide an opportunity for children with asthma in all BMI categories to achieve well-controlled disease.
Pediatric asthma medication therapy management through community pharmacy and primary care collaboration
2016, Journal of the American Pharmacists Association
To design and implement a collaborative medication therapy management (MTM) program targeting pediatric patients with high-risk asthma in a community pharmacy.
Underserved inner city of Cincinnati, OH.
A large national grocery store chain pharmacy and an academic hospital developed a partnership aimed at improving asthma care for shared patients. An interdisciplinary project team was formed, including 2 clinical pharmacists, 1 pharmacy district clinical coordinator, 1 pharmacy division clinical coordinator, 1 associate professor at a college of pharmacy, 1 pharmacy resident, and 3 pediatric physicians. This pilot project involved 2 Kroger Pharmacy sites and Cincinnati Children's Hospital Medical Center's (CCHMC) 3 pediatric primary care centers.
Kroger and CCHMC staff identified shared high-risk asthma patients (those cared for at the included primary care centers who used Kroger for their medication fills) with the use of information from validated symptom assessments (Asthma Control Test), refill history, and recent health care utilization. Community pharmacists recruited jointly identified patients and provided a targeted MTM intervention. Education focused on asthma diagnosis, types of asthma medications, appropriate medication administration, and environmental triggers. Pharmacists suggested medication changes to prescribers via facsimile. Pharmacists followed up with patients in 30 days to assess asthma control, provide additional education, and propose further recommendations.
Outcomes evaluated included the average number of recommendations made to patients and prescribers and acceptance rates for each of those measures.
Six patients completed the project. Pharmacists provided an average of 3.7 recommendations to each patient and 1.5 to prescribers for each patient; 77.3% and 100% recommendations were accepted, respectively.
This pilot project describes the design and implementation of a pharmacist-physician collaborative program for high-risk pediatric asthma patients. The greatest outcome of this project was the formation of a collaborative team between pharmacists and physicians that continues to work together on additional family-centered initiatives.
The HEDIS medication management for people with asthma measure is not related to improved asthma outcomes
2015, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
Compliance with the original “one-controller-per-year” HEDIS asthma measure actually correlates with an increased risk for asthma-related adverse events, even when adjusted for baseline asthma medication use and demographic characteristics.6,7,11 In contrast, compliance with the HEDIS AMR measure correlates with improved asthma outcomes in both children and adults.6-11 The relationship between asthma outcomes and compliance with the HEDIS MMA measure has not been previously studied.
A new Healthcare Effectiveness Data and Information Set (HEDIS) asthma quality-of-care measure designed to quantify patient adherence to asthma controller medication has been implemented. The relationship between this measure and asthma outcomes is unknown.
To examine the relationship between the HEDIS Medication Management for people with Asthma (MMA) measure and asthma outcomes.
Administrative data identified 30,040 patients who met HEDIS criteria for persistent asthma during 2012. These patients were classified as compliant or noncompliant with the MMA measure at the 75% and 50% threshold, respectively. The association between MMA compliance in 2012 and asthma outcomes in 2013 was determined.
Patients who were 75% or 50% MMA compliant in 2012 showed no clinically meaningful difference in asthma-related hospitalizations, emergency department visits, or rescue inhaler dispensing in 2013 compared with those who were noncompliant. Stepwise comparison of patients who were 75% or more, 50% to 74%, and less than 50% MMA compliant showed no meaningful difference in asthma outcomes between groups.
Compliance with the HEDIS MMA measure is not related to improvement in the asthma outcomes assessed (rescue inhaler dispensing, asthma-coded hospitalizations, or asthma-coded emergency department visits).
Comparative outcomes of leukotriene receptor antagonists and long-acting b-agonists as add-on therapy in asthmatic patients: A population-based study
2013, Journal of Allergy and Clinical Immunology
Recent evidence suggests that the use of leukotriene receptor antagonists (LTRAs) in addition to inhaled corticosteroids (ICSs) in asthmatic patients provides comparable benefits to the addition of long-acting β-agonists (LABAs) to ICSs.
We sought to compare, in a unified framework, adherence, outcomes, and costs associated with ICS+LTRA versus ICS+LABA as step-up therapies for asthma.
Using the administrative databases of British Columbia, Canada (years 1997-2007), we created a propensity score-matched sample of asthmatic patients (12-45 years old) receiving ICS+LTRA therapy versus ICS+LABA therapy after a period of monotherapy with an ICS. We compared the outcomes using 2 analyses: an intention-to-treat (ITT) analysis that followed subjects for a fixed period of 2 years and an uninterrupted treatment analysis that followed subjects for as long as they continuously dispensed their index medications.
The matched cohort consisted of 1032 subjects in each group (mean age at entry, 27.4 years; 52.5% female). Adherence, which was defined as the proportion of days covered, was higher in the ICS+LABA group compared with the ICS+LTRA group. In both the ITT and uninterrupted treatment analyses, use of ICS+LTRA therapy was associated with more asthma-related outpatient visits, asthma-related medication dispensations, and dispensation of reliever medications. Dispensation of oral corticosteroids and rate of asthma exacerbations were higher in the ICS+LTRA group in the uninterrupted treatment analysis but not in the ITT analysis.
In a real-world clinical setting subjects were more adherent to ICS+LABA therapy than ICS+LTRA therapy. ICS+LABA therapy seems to be more effective than ICS+LTRA therapy in the management of asthma, regardless of adherence.
Effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma
2012, Journal of Allergy and Clinical Immunology
Citation Excerpt :
Nonadherence to controller medication use in asthmatic patients has been directly related to poor outcomes, such as ED visits and hospitalizations.39 Conversely, previous database analyses have found that patients with persistent asthma who have a medication refill pattern reflecting a higher (>0.5) controller/total asthma medication ratio (defined as the number of controllers dispensed divided by the total number of controllers plus SABAs refilled) were less likely to have exacerbations.40-42 The results of this analysis appear to contradict in 2 important ways this prior work.
Health care costs increase in patients with more severe asthma, but the effect of asthma exacerbations on costs among patients with more severe asthma has not been quantified.
This study compared direct health care costs between patients with moderate/severe persistent asthma with and without exacerbations.
Patients who had an asthma diagnosis (International Classification of Diseases–ninth revision–Clinical Modification code 493.x), were 12 to 64 years old, and were receiving controller therapy were identified from a large administrative claims database. Patients were categorized as having moderate/severe persistent asthma and were further evaluated for exacerbations during a 12-month exacerbation identification period. Patients with 1 or more exacerbations (asthma-related inpatient or emergency department visit or corticosteroid prescription) were matched to patients without exacerbations on demographic characteristics and asthma severity. Total and asthma-related health care costs during the 1-year study period after the exacerbation index date were calculated.
Patients with exacerbations had significantly higher total health care costs ($9223 vs $5011, P < .0001) and asthma-related costs ($1740 vs $847, P < .0001). The cost differences remained significant after controlling for patient differences by using multivariate models. Patients with exacerbations (n = 3830) had higher rates of sinusitis, allergy-related diagnoses or medications, pneumonia, and mental disorders and higher average Charlson Comorbidity Index scores at baseline. Patients with exacerbations filled their prescriptions for controllers more often and had higher asthma-related drug costs.
Patients with moderate/severe persistent asthma who had exacerbations had higher total and asthma-related health care costs than those without exacerbations. Moreover, controller medication use was higher in patients with exacerbations.

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: P. L. Y. is supported by a training grant from the Philadelphia Veterans Affairs Medical Center and the Robert Wood Johnson Clinical Scholars Program. R. M. W is supported in part by a Veterans Affairs HSR&D Career Development Award. The study was supported by pilot grant funding from the Leonard Davis Institute of Health Economics and resources supported by the Clinical and Translational Science Awards (UL1-RR024134).

: Disclosure of potential conflict of interest: R. M. Werner receives research support from the Institute on Aging, the SGIM Williams Scholar Award, and the Agency for Healthcare Research and Quality and has provided legal consultation/expert witness testimony in cases related to outpatient management of suspected coronary artery disease. P. L. Yong has declared that he has no conflict of interest.

View full text

Asthma and lower airway diseaseProcess quality measures and asthma exacerbations in the Medicaid population

Background

Objective

Methods

Results

Conclusions

Section snippets

Methods

Cohort characteristic

Discussion

Ann Allergy Asthma Immunol

Lancet

Chest

Ann Allergy Asthma Immunol

Chest

J Allergy Clin Immunol

Chest

J Chron Dis

Ann Allergy Asthma Immunol

Medicaid databases

Effect of leukotriene receptor antagonist therapy on the risk of asthma exacerbations in patients with mild to moderate asthma: an integrated analysis of zafirlukast trials

Thorax

Association between common asthma therapies and recurrent asthma exacerbations in children enrolled in a state Medicaid plan

Am J Health Syst Pharm

Asthma and lower airway disease
Process quality measures and asthma exacerbations in the Medicaid population