Flunking Asthma? When HEDIS Takes the ACT

Published Online: August 01, 2008
Kaiser G. Lim, MD; Ashok M. Patel, MD; James M. Naessens, ScD; James T. Li, MD, PhD; Gerald W. Volcheck, MD; Amy E. Wagie, BS; Felicity B. Enders, PhD; and Timothy J. Beebe, PhD

Objective: To test several patient-oriented asthma outcome measures and the Healthcare Effectiveness Data and Information Set (HEDIS) measure of appropriate medication for persistent asthma to determine the most useful quality indicator of asthma care.

Design: Prospective mail survey of adult employees and dependents with asthma.

Methods: The medical and pharmacy claims of all subjects from 12 months before and after the survey were abstracted. Outcomes measures included the Asthma Control Test (ACT), workday loss, unscheduled healthcare utilization (emergency department and inpatient care), and satisfaction with care.

Results: Although 81% of all responders had wellcontrolled asthma, persistent asthma was uncontrolled in 28%. Only 64.5% received appropriate controller medication. Well-controlled asthma is associated with a high degree of satisfaction, less workday loss, fewer prednisone bursts, and minimal unscheduled healthcare utilization. Except for a reduced incidence of more than 2 oral corticosteroid dispensings (6.4% vs 13.6%, P = .012), compliance with the HEDIS appropriate medication for asthma was not positively associated with any of the patient-centered outcomes studied.

Conclusions: Asthma control was the most useful patient outcome quality indicator in this study. Compliance with the HEDIS asthma measure in this population was not associated with a better patient-oriented outcome. This finding may be different with different levels of asthma control. The positive association between well-controlled asthma and patient satisfaction, minimal unscheduled healthcare utilization, and low workday loss suggests that asthma control as measured by ACT may be a better performance measure in asthma.

(Am J Manag Care. 2008;14(8):487-494)

Asthma control has emerged as a summary outcome of several disease dimensions, including disease severity, medical therapy, and patient compliance, and may be the primary indicator of high-quality asthma care.

The Asthma Control Test is a clinical tool to guide therapy and is positively associated with better patient outcomes.

Compliance with the HEDIS asthma measure is not favorably associated with relevant patient-oriented outcomes.

Healthcare providers and organizations have responded to the public demand for excellence in medical care1,2 by reporting performance based on disease-specific quality indicators. There are many types of quality indicators,3 and the choice is crucial because what is measured should be important to patients, payers, and providers. Which quality indicator is adopted influences the tactical approach or focus of healthcare providers and organizations. Physicians are skeptical of performance measures because of previous experience with inadequately calibrated and poorly validated measurements.4,5 This is especially true if the quality indicator chosen is variably linked to better patient outcome. Most physicians subscribe to the “I believe, therefore I practice” philosophy.6

Asthma is one of the priority chronic diseases earmarked for quality improvement.7 The Healthcare Effectiveness Data and Information Set (HEDIS) asthma measure8-10 is a “process of care” measure (ie, appropriate controller medication prescription for patients with persistent asthma). It is controversial because compliance with the HEDIS measure has never been prospectively linked to a better health outcome for the patients.11-15 The current scientific literature has shifted focus from severity categorization to asthma control as an outcome measure.16-20 Other relevant patient-oriented outcomes cited have included patient satisfaction,21-23 unscheduled healthcare utilization, asthma-related quality of life,24-26 and workday loss.27 We sought to assess which quality indicators are most useful for quality improvement in asthma care in our institution.

The Mayo Clinic Rochester (MCR) is a multispecialty practice that self-insures employees and dependents. A cross-sectional survey was conducted to simultaneously measure asthma control, patient satisfaction, healthcare utilization, and workday loss, and to determine the effectiveness of the HEDIS asthma measure. Our survey was limited to our employees and dependents (primary care patients for practical reasons, because we had access to full claims data regardless of where they received their care). We investigated medication and healthcare use by using actual pharmacy and billing claims submitted. Patients were categorized according to the HEDIS definition of persistent asthma, and severity risk adjustment was performed by medication intensity scale.28

Study Population
The eligible study cohort was identified by using the Rochester Medical Index database.29 The Rochester Medical Index classified asthma patients’ problems by using an internal coding system based on the Hospital Adaptation of the International Classification of Diseases, Eighth Revision. Patients’ problem lists were refined by applying a second database with International Classification of Diseases, Ninth Revision codes from billing data for clinic and hospital visits (see eAppendix Table A at www.ajmc.com). The resulting dataset was cross-referenced to a personnel and billing database to identify participants who were MCR employees, including retirees and/or dependents. All MCR employees and dependents more than 17 years of age at the time of the first mailing on May 5, 2005, with physician- diagnosed asthma were considered eligible. The dataset was further refined by including only active subjects (defined as those with any billing for medical care in the last 5 years) because many trainees and dependents of employees may have moved out of the Rochester area. The survey was posted to all eligible subjects. Seven subjects were found to have died before the initial posting of the survey, leaving 3137 subjects eligible for participation.

Demographic information on all potential subjects was extracted from the Mayo Clinic Subject Registration Database. Subjects without prior research authorization on record were excluded (n = 49). The survey was conducted with the approval of and in accordance with the policies of the Mayo Clinic Institutional Review Board. The first posting was on May 5, 2005, with a second mailing to nonresponders in July 2005. The study was closed in September 2005.

The medical and pharmacy claims of all eligible subjects were abstracted for the time period from May 2004 through May 2006 to encompass both 12 months before and 12 months after the survey. The pharmacy data included the National Drug Code number, information on dispensing, size of dispensing, number of canisters, and days supply. These were used to compute milligrams per day. The HEDIS definition of persistent asthma,8 the Global Initiative for Asthma (GINA)Medication Intensity Score,30 and the Kaiser Permanente Medication Intensity Scale28 were based on claims data 12 months before the survey and were applied to characterize responders and nonresponders. We used the HEDIS definition of controller medication to classify medications (ie, long-acting bronchodilators were not included). All emergency department (ED) visits and hospitalizations were based on claims data from the previous 12 months before the survey.

Survey Instrument Development
The Mayo Clinic Employee and Dependent Asthma Survey (MEDAS) was developed by a collaborative interdisciplinary team. The resulting MEDAS questionnaire is a 4-page, 29-item survey tool incorporating the Asthma Control Test (ACT; permission obtained from QualityMetric, Lincoln, RI). There were questions regarding tobacco use, current medications, oral corticosteroid use, unscheduled healthcare utilization, workday loss and absenteeism, and satisfaction with access and asthma care in the past 12 months. Satisfaction with access to care, quality of care, and willingness to recommend were scored along a 5-point scale. There are 5 questions in the ACT, with a Likert scale from 1 to 5. The higher the score, the better the asthma control. A cumulative ACT score of ≥20 is the threshold for well-controlled asthma. The workday loss rate is calculated using 260 workdays per person per year.

Statistical Analysis
All continuous variables were presented as mean ± standard deviation and compared between groups with 2 sample t tests. Categorical variables were expressed as actual numbers as well as percentages and analyzed by the χ2 test as appropriate. All statistical tests were 2-sided, and significance was set at P ≤.05. Statistical analysis was performed with SAS statistical software, version 8.1 (SAS Institute Inc., Cary, NC) and S-PLUS version 7.0.6 for Unix (Insightful Corporation, Seattle, WA). The satisfaction indicator was dichotomized to greater satisfaction (very satisfied/somewhat satisfied) versus lesser satisfaction (neither satisfied nor dissatisfied/somewhat dissatisfied/very dissatisfied). The overall care satisfaction was dichotomized to greater satisfaction (excellent/very good) and lesser satisfaction (good/fair/poor). Unscheduled healthcare utilization was defined by ED visit or hospitalization because MCR does not have an urgent care service and the billing data do not discern between different appointment types (ie, unscheduled visit or same-day visit).

Demographic Features of Responders and Nonresponders
There were 1056 responders out of 3137 (33.7%) eligible adult subjects. Most responders were women (70.5%), Caucasian (71.2%), and nonsmokers (95.9%); their mean age was 41 ± 13 years. A comparison of responders with the 2081 nonresponders revealed that the latter were significantly more likely to be men and younger (≤35 years of age) compared with responding counterparts (see Table 1). Many subjects had mixed heritage or did not provide this informaand were marked in the ethnicity category as unknown. Among responders, only 4.1% were current smokers. Only 30% of the total patients met HEDIS criteria for persistent asthma.

Comparison of Responders and Nonresponders: GINA Score Severity, Healthcare Utilization, and Medication Intensity Responders were more likely to meet the HEDIS criteria for persistent asthma than nonresponders (41.1% vs 24.4%, P <.001; Table 2). This difference was driven primarily by the percentage of subjects with 4 or more asthma medications (39.7% vs 23.0%, P <.001). Among potentially eligible subjects who met the HEDIS criteria for persistent asthma, the survey response rate was 46.1%. There was no difference in healthcare utilization (ED, inpatient, or ambulatory care visits) between responders and nonresponders. Responders were significantly more likely to have severe asthma by the GINA Medication Intensity Score (step 4; P <.001). The Kaiser Permanente Medication Intensity Scale did not differ between responders and nonresponders. Only a handful had an excessive requirement for beta agonists or frequent oral corticosteroid use.

The ACT Score Distribution
Among responders, 854 (81%) adults had an ACT score of 20 or higher, with 45.2% having an ACT score of 24 or 25 (see Figure). There was no significant difference in ACT scores between sex and age groups for this cohort (data not shown).

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