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The Breathmobile Improves the Asthma Medication Ratio and Decreases Emergency Department Utilization
Tricia Morphew, MSc; Wendy Altamirano, MPH, MBA; Stanley L. Bassin, EdD; and Stanley P. Galant, MD
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The Breathmobile Improves the Asthma Medication Ratio and Decreases Emergency Department Utilization

Tricia Morphew, MSc; Wendy Altamirano, MPH, MBA; Stanley L. Bassin, EdD; and Stanley P. Galant, MD
An examination of the asthma medication ratio (≥0.50) as an informative metric in program evaluation and for healthcare organizations to measure quality of care provided to patients with asthma.

An Asthma Medication Ratio (AMR) of ≥0.50 has gained recognition as a metric related to improved asthma outcomes. The goals of this study were to evaluate asthma outcomes in relation to this threshold in Hispanic children with high-risk asthma and to compare the effectiveness of the Breathmobile (BM) program with usual care (UC), utilizing the AMR-related emergency department utilization (ED) rate.

Study Design: Healthcare utilization and prescription claims recorded January 1, 2011, to June 23, 2014, were evaluated pre- versus post year in 164 Medicaid-enrolled children, aged 2 to 18 years, with high-risk persistent asthma (BM group: n = 72; UC group: n = 92).

Methods: High risk was defined by ≥2 oral corticosteroid fills, or ≥2 ED visits (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0-493.9) or ≥1 IP stay (ICD-9-CM codes 493.0-493.9) in the pre-year. Poisson regression was utilized to compare asthma outcomes pre- versus post year in BM and UC groups and to describe the average number of ED days per 100 patients treated in relation to AMR.

Results: An AMR of ≥0.50 versus <0.50 was related to 49% fewer ED visits (P <.05). BM proved to be more effective than UC in increasing the percent who achieved an AMR ≥0.50 from a baseline of 47.2% to 80.6% versus 50.0% to 65.2% post year, respectively. This difference was reflected in the significant 52% reduction in average number of ED visits post year for the BM cohort versus 13% for the UC cohort.

Conclusions: View achievement of the AMR ≥0.50 as an informative metric in program evaluation and for healthcare organizations to measure the quality of care provided to high-risk patients with asthma.

Am J Manag Care. 2017;23(4):e120-e126
Takeaway Points

An asthma medication ratio (AMR) of at least 0.50 reflects emergency department (ED) utilization and demonstrates superiority of using the Breathmobile (BM) compared with usual care (UC) in Hispanic children with high-risk persistent asthma.
  • The AMR is an effective metric for assessing quality of care provided to asthmatic patients.
  • Patients achieving an AMR ≥0.50 versus <0.50 had 49% fewer ED visits, P <.05.
  • BM proved to be more effective than UC in increasing the percent of patients who achieved ≥0.50 from a baseline of 47.2% to 80.6% versus 50.0% to 65.2% post year, respectively.
  • This AMR difference was reflected in the 52% reduction in ED visits post year in the BM cohort compared with 13% in the UC cohort.
Asthma, one of the most common chronic diseases in children, is estimated to affect more than 10 million children younger than 18 years in the United States.1 In those younger than 15 years, asthma exacerbations result in approximately 640,000 emergency department (ED) visits and 128,000 inpatient (IP) stays annually.2,3 Lifetime total direct medical costs of asthma per annual birth cohort are estimated at $3.2 billion.4 In addition, asthma is the leading cause of school absenteeism.5,6 African American and Hispanic children are disproportionately affected by relatively high morbidity rates.7-12 Morbidity is particularly common among those living in poverty, with poor access to medical care, and in those receiving public insurance.5,8,11,13 For example, Medicaid-covered children typically have poorer asthma control, greater underutilization of long-term controller medication compared with those receiving commercial insurance, and more frequent ED visits and IP stays.14-16

As a result of these poor outcomes, efforts have been made to determine quality-of-care metrics that could predict future exacerbations in order to improve asthma management. These efforts led the National Committee for Quality Assurance to develop the Use of the Appropriate Medication for People with Asthma Metric as part of the Health Effectiveness and Data Information Set (HEDIS) to measure the quality of care provided to patients with asthma by healthcare organizations.17 There are 3 HEDIS measures that assess asthma care for those with persistent asthma.18 The initial asthma measure, reported in the year 2000, assessed the percentage of patients with persistent asthma who were prescribed at least 1 canister of controller medication in the measurement year. This idea has been examined by several studies, which failed to demonstrate a correlation of this measure with improved asthma outcomes.14,18-20 A second asthma HEDIS measure, the Medication Management for People with Asthma (MMA), first publicly reported in 2013, calculates the percentage of asthma controller medication adherence rate per treatment period and was reported in a recent study to not relate to improved asthma outcomes.18 The third HEDIS asthma measure, the Asthma Medication Ratio (AMR), has been shown to correlate with improved asthma outcomes in children and adults,14,21-24 and is currently being used as a quality-of-care metric to assess healthcare programs. However, potential variability in the AMR related to age, ethnicity/race, asthma severity, and type of insurance suggested to us the need for further evaluation in our population of Medicaid-insured Hispanic children with high-risk persistent asthma.

A program utilizing mobile clinics, the Breathmobile (BM) program, has previously demonstrated improvement in asthma control and reduction in healthcare utilization by providing access to preventative asthma care to underserved children.25-28 However, these studies had limited ability to examine improvement relative to a comparator group and by utilization of claims data.

We were fortunate to collaborate with the Medicaid program in Orange County, California, called CalOptima. They gave us the opportunity to access encounter and pharmacy claims data in order to evaluate asthma morbidity, use of oral corticosteroids (OCS), and AMR scores. In addition, we were able to compare those receiving BM care with a usual care (UC) group. The first goal of this study was to evaluate the AMR as a measure for determining improved asthma outcomes. The second goal was to evaluate the effectiveness of the BM healthcare program by comparing BM care with UC using the AMR quality improvement measure, as well as determining healthcare utilization rates in our population of Hispanic children with high-risk persistent asthma.


Population and Design

CalOptima generated an annual list of insured children eligible for participation in the BM program. Parents of eligible children were contacted and offered care. Those who agreed to participate were designated the BM cohort; those who did not, the UC cohort. The reasons for not enrolling in the BM cohort included: unable to contact family (>50%), family preference, those who were scheduled to be seen but did not show up to their appointment, and children who had received care with an asthma specialist in the previous 12 months. All patients were offered the CalOptima disease management intervention prior to referral to the BM program. The intervention included reminder letters for tests and recommended immunizations, quarterly screening and monitoring by a disease management coordinator, quarterly educational paper mailings reviewing self-management techniques, and a list of self-management classes. Patients were referred for care in the BM program from July 2011 to April 2013. Eligibility criteria specific to this study included: being 18 years or younger, diagnosis of asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0-493.9) documented in encounter data, and being considered high risk. The criteria for being considered high risk are: persistent asthma as defined by HEDIS criteria 29 and validated in the article by Schatz et al,30 ≥2 courses of OCS, and/or ≥2 ED visits (ICD-9-CM codes 493.0-493.9), and/or ≥1 IP stay (ICD-9-CM codes 493.0-493.9) in the previous 12 months. Other criteria included Hispanic ethnicity and a measurable AMR over the study period. Continuous CalOptima coverage during the entire study period was also required.

Encounter and prescription claims recorded from January 1, 2011, to June 23, 2014, in an electronic health record system utilized by CalOptima were abstracted for 164 children who met study eligibility criteria (n = 72 BM group and n = 92 UC group). Encounter claims data included age, gender, race, date of service, location of visit, diagnosis code(s), Current Procedural Terminology code, place of service, and whether patient had continuous insurance coverage. Prescription (Rx) claims data included date filled, label name, drug type, and days supplied. National Drug Codes identifying asthma medications and the label name specified in the claim line were evaluated to qualify medication prescribed (Rx) as a reliever, controller, or oral corticosteroid for the purposes of calculating HEDIS AMR ([number of controllers Rx] ÷ [number of controllers Rx + number of relievers Rx]) during respective annual evaluation periods. Claims data were aggregated on an exposure period basis (pre- and post year) to determine total number of defined events. Exposure time for patients in the BM group was determined from date of initial BM visit. In the UC group, pre- and postyear claims data were provided by CalOptima. This protocol was reviewed and approved by the Children’s Hospital of Orange County Institutional Review Board.


Study population characteristics were described in terms of valid percent of patients with a defined trait and the significance of between-intervention group (UC vs BM) differences assessed by χ2 test statistic.

AMR was calculated in pre- and postyear periods and described in terms of average value and percentage of members with an AMR ≥0.50. Increased percentage of patients with AMR ≥0.50 in the post compared with the pre-period was assessed for significance using McNemar’s test. Correspondence of AMR to ED visits, IP stays, and OCS fills was evaluated using Poisson regression with adjustment for patient age, gender, intervention group, and time period. Inclusion of an interaction effect between group and time determined significance of intervention group differentials in average medication fills. In SAS version 9.2 (SAS Institute Inc, Cary, North Carolina), PROC GENMOD with repeated statement was run to produce robust standard errors for the Poisson regression coefficients, controlling for potential overdispersion. In terms of reduced healthcare utilization, intervention group differentials were nonsignificant, but the small number of events (particularly IP stays) and sample size were factors impacting power to detect significance of interaction effect (results not shown). Calculation of incidence rate ratios (IRRs) were offset by patient-level exposure time for outcomes investigated per person-year in the BM group (pre- vs post period: retrospective look-back up to 365 days from initial BM visit vs elapsed time from initial BM visit to 365 days later or to cohort data end point [whichever occurred first]). Poisson regression analyses were performed using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina) while remaining analyses utilized SPSS version 18.0 (SPSS Inc, Chicago, Illinois).


Patient Characteristics

In the BM group, 65.3% were male and the average age was 7.1 years with 27.8% under 5 years, 54.2% aged 5 to 11 years, and 18.1% aged 12 to 18 years (Table 1). The UC group was similar in age and gender composition; however, the percentage of patients in the BM group who required an ED visit (pre-year) was slightly higher than observed in the UC group (37.5% vs 23.9%; P = .059). Prior to enrollment in the BM program, 47.2% of high-risk patients met HEDIS criteria (AMR ≥0.50). The percentage was similar in the UC group (50.0%), P =.724. Nearly all patients in both groups reported OCS fills pre-year (98.6% in BM and 98.9% in UC group) and most had been prescribed at least 1 controller medication (86.1% and 80.4%, respectively). In terms of engagement in the BM program, 74% of patients had at least 3 visits to the program with a median time from baseline to third visit of 71 days (interquartile range: 57-107 days) by the study endpoint.

HEDIS AMR Related to ED Visit Rate

Achieving an AMR ≥0.50 corresponded to 49% fewer ED visits per 100 patients treated, after adjustment for age, gender, intervention group, and time period (P = .018) (Figure 1). Average number of ED days per 100 patients ranged from 50 in high-risk patients not using any controller medication (AMR = 0.00) down to an estimated 19 days in those using controller medication(s) without the requirement of relievers (AMR = 1.00). Each 0.10 increase in AMR resulted in 9% fewer ED days (P = .059). AMR did not show a statistically significant relationship to OCS fills and IP stays during the concurrent period (P >.05) (data not shown).

Reduced Healthcare Utilization and Improved Pharmacological Outcomes

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