1. 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. 1 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. 2 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. 3 Background It is unclear whether: –a single measure accurately portrays asthma management for plan enrollees –a plans aggregate quality assessments reflect performance throughout the areas in which it operates

5. 4 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. 5 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. 6 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. 7 Methods Outcomes measured (2003): 1+ asthma controller medication dispensing event 1+ outpatient visit 1+ asthma ED visit influenza vaccination Classified into 4 geographic regions

9. Southwest Southeast Northern Urban

10. 9 Methods Statistical analyses: Summaries of proportions and 95% confidence intervals Rankings for each outcome by: –plan –plan and region

11. 10 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 plan 3,970 (69%) Changed Health Plan 168 (3%) Other Health Insurance 309 (5%) 30 Plan / Region pairs n = 3,780

12. 11 Study Population Characteristicn= 3,970 5-9 Yrs.36% 10-14 Yrs.46% 15-21 Yrs.18% Male59% White36% Black59% All Others5% Urban44% Northern15% Southeast22% Southwest19%

13. 12 Results Outcome%Range (%) Asthma controller medications7566 - 88

14. 13 Results Outcome%Range (%) Asthma controller medications7566 - 88 Outpatient visits8373 - 95

15. 14 Results Outcome%Range (%) Asthma controller medications7566 - 88 Outpatient visits8373 - 95 Asthma ED visits2811 - 53

16. 15 Results Outcome%Range (%) Asthma controller medications7566 - 88 Outpatient visits8373 - 95 Asthma ED visits2811 - 53 Influenza vaccination173 - 46

17. Statewide mean

19. Region mean

22. Plan mean

23. 22 Limitations Severity of asthma not based on objective clinical criteria Claims data subject to completeness and accuracy of reported information

24. 23 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. 24 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