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The American Journal of Managed Care May 2005
Economic Analysis of Targeting Chemotherapy Using a 21-Gene RT-PCR Assay in Lymph-Node"Negative, Estrogen-Receptor"Positive, Early-Stage Breast Cancer
John Hornberger, MD; Leon E. Cosler, PhD, RPh; and Gary H. Lyman, MD, MPH, FRCP (Edin)
Determinants of Compliance With Statin Therapy and Low-Density Lipoprotein Cholesterol Goal Attainment in a Managed Care Population
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Validity of the HEDIS Criteria to Identify Children With Persistent Asthma and Sustained High Utilization
Anne L. Fuhlbrigge, MD; Vincent J. Carey, PhD; Jonathan A. Finkelstein, MD, MPH; Paula Lozano, MD, MPH; Thomas S. Inui, ScM, MD; Scott T. Weiss, MD; and Kevin B. Weiss, MD

Validity of the HEDIS Criteria to Identify Children With Persistent Asthma and Sustained High Utilization

Anne L. Fuhlbrigge, MD; Vincent J. Carey, PhD; Jonathan A. Finkelstein, MD, MPH; Paula Lozano, MD, MPH; Thomas S. Inui, ScM, MD; Scott T. Weiss, MD; and Kevin B. Weiss, MD

Background: The most widely used performance measure for asthma, the Health Plan Employer Data and Information Set (HEDIS), has been criticized because the delay between classification (year 1) and assessment of medication dispensing (year 2) may produce a "misalignment"and weaken the validity of the measure.

Objective: To examine whether a previously observed association between the HEDIS performance measure and asthma-related emergency department visits is robust when the period between the classification and outcome assessment is evaluated during a 2-year period as defined.

Methods: Children (N = 2766) aged 3 to 15 years enrolled in 1 of 3 managed care organizations with at least 1 asthma diagnosis listed for a hospitalization, an emergency department visit, or an ambulatory encounter and at least 2 consecutive years of data for analysis from July 1996 through June 1999 were identified.

Results: Children did not consistently meet the HEDIS criteria for persistent asthma, and 24% to 28% of children did not requalify in year 2 of observation. Multivariate regression models showed that a protective relationship between controller medication dispensing and asthma-related emergency department visits was no longer seen among children meeting the HEDIS criteria for persistent asthma when the total period of observation is extended to 2 years (odds ratio, 0.7; 95% confidence interval, 0.4-1.2).

Conclusions: Our results suggest that the variable nature of asthma may affect how the HEDIS performance measure should be used for assessing quality of care. The period between identification of the target population and performance assessment should be closely related in time.

(Am J Manag Care. 2005;11:325-330)

The Guidelines for the Diagnosis and Treatment of Asthma developed by the National Asthma Education and Prevention Program1 have been widely disseminated to help achieve more uniform management and improve disease outcomes. However, variations in asthma management practices persist, and asthma continues to impose a burden on society,2 with a high proportion of asthma-related morbidity concentrated in identifiable subpopulations.3 Targeting disease- specific intervention to the individuals at highest risk allows efficient use of healthcare resources and has been shown to be effective.4 Managed care organizations (MCOs) have attempted to use performance measures as a way to reduce variation and to monitor and identify suboptimal management practices through the use of performance measures.

The most widely used performance measure for asthma is the "use of appropriate medications for people with asthma,"which is one of the many measures included in the Health Plan Employer Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance to evaluate the performance of health plans. This measure is computed as the proportion of people who filled at least 1 prescription for a controller medication among those identified as likely to have persistent asthma. Persons are classified as having persistent asthma based on data from year 1, while the assessment of controller dispensing is assessed based on data from year 2. However, performance measures, in general, have been criticized as having unintended negative effects on care by "overlooking important dimensions of quality not captured by these performance measures."5,p575 In addition, specific aspects of the HEDIS asthma measure have been criticized.5 Because the HEDIS asthma measure relies solely on automated data (ie, no reports of symptom frequency or pulmonary function data), the denominator (the subpopulation of individuals with persistent asthma) can only be estimated. Second, the HEDIS asthma measure requires data from 2 consecutive years for evaluation; subjects are classified as having persistent asthma using data from year 1, while the HEDIS performance measure, the proportion with controller medication dispensing among the individuals identified as having persistent asthma, is evaluated using data from year 2. The potential misclassification of subjects with persistent asthma and the delay between classification (year 1) and performance assessment (year 2), producing a "misalignment,"may weaken the validity of the measure.5 A third criticism is that the HEDIS measure does not emphasize the regular use of controller medications. For persons who truly have persistent asthma, the single dispensing of a controller medication during a 12-month period is inadequate.

The Pediatric Asthma Care Patient Outcomes Research Team, in a clinical trial assessing the effectiveness and cost-effectiveness of strategies to implement asthma guidelines,6 previously evaluated the ability of the HEDIS performance measure to identify individuals at increased risk of future adverse asthma-related events. The prior analysis demonstrated that, among children defined by the HEDIS criteria as having persistent asthma, identification of children who have been dispensed a controller medication can help stratify children based on their risk of future adverse events.7 In this analysis, we sought to extend these results to examine the criticisms of the HEDIS measure. Does the misalignment between the period of identifying children with persistent asthma and the period of performance assessment in the HEDIS performance measure affect its ability to identify children with persistent asthma and sustained high utilization?

METHODS

Study Sites

Provider profiling is now widely practiced in many managed healthcare systems.8 We based our analysis within 3 large geographically diverse managed care systems.

Group Health Cooperative of Puget Sound. Group Health Cooperative of Puget Sound is a centralized group-model health maintenance organization. At the time of the study, it was the sixth largest nonprofit health maintenance organization in the nation, serving an estimated 383 000 members in the Puget Sound area.

Harvard Pilgrim Health Care. Harvard Pilgrim Health Care (HPHC) is a mixed-model managed care organization (MCO) concentrated in eastern Massachusetts. At the time of the study, HPHC had a staff-model component and a network practice component. The Pediatric Asthma Care Patient Outcomes Research Team trial was conducted in HPHC network practices. Each of these network practices was affiliated with several health insurers or MCOs in addition to HPHC. Therefore, a second MCO, Blue Cross Blue Shield of Massachusetts, was enlisted to increase the number of children per practice under analysis.

Rush-Prudential Health Plans, Chicago. Rush-Prudential Health Plans enrolled an estimated 350 000 members at the time of the study. Rush-Prudential Health Plans had a staff-model component and an independent practice association model component.

Automated claims and pharmacy data were collected as part of the Pediatric Asthma Care Patient Outcomes Research Team trial from each of the 3 study sites. All 3 MCOs maintain computerized information systems that capture basic demographic data and claims files for all hospitalizations and emergency department (ED) visits. Automated pharmacy records contain detailed information on prescriptions dispensed at outpatient pharmacies. Approval for this study was obtained from institutional review boards at each of the participating institutions.

Study Population

The source population for this study consisted of children aged 3 to 15 years enrolled in 1 of the 3 study MCOs with at least 1 asthma diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification codes 493.00-493.99) listed for a hospitalization, an ED visit, or an ambulatory encounter during a 3-year period from July 1996 through June 1999. In addition, study subjects had to have continuous enrollment for the 12-month study period, prepaid prescription drug coverage, and at least 1 dispensing of an asthma medication. Approximately 90% of all members have prepaid drug coverage that provides up to a month's supply of medicine for a nominal payment. For this analysis, the study population was further limited to children with 2 consecutive years of data available.

The HEDIS Denominator The HEDIS denominator is the subpopulation of children meeting the HEDIS criteria for persistent asthma. Children are included if they meet 1 of 4 criteria based on medication dispensing or healthcare utilization; each criteria is assessed during a 12-month period:

  1. At least 4 asthma medication dispensing events, or
  2. At least 1 ED visit with asthma as the principal diagnosis, or
  3. At least 1 hospital admission with asthma as the principal diagnosis, or
  4. At least 4 ambulatory visits with asthma as the principal diagnosis and at least 2 asthma medication dispensing events.

In addition to the 4 criteria, the absolute level of β-agonist dispensing has been independently associated with the risk of asthma-related hospitalizations and ED visits.9 Therefore, we refined the HEDIS denominator by stratifying the level of β-agonist dispensing. The HEDIS high reliever subpopulation included children who met the HEDIS criteria for persistent asthma and had at least 4 β-agonist dispensings per person-year, while the HEDIS low reliever subpopulation included children who met the HEDIS criteria for persistent asthma and had fewer than 4 β-agonist dispensings per person-year.

Classification Using Pharmacy Data

Automated medical records were inspected for type and quantity of asthma pharmacotherapy provided during each 1-year period. Asthma controller therapy was defined to include inhaled corticosteroids, inhaled cromolyn sodium and nedocromil sodium (referred to as "cromolyn"), and oral antileukotriene and theophylline preparations. Reliever agents included inhaled or pediatric oral reliever preparations such as short-acting β-agonists and anticholinergics but excluded long-acting β-agonists such as salmeterol xinafoate.10 Pharmacy data included initial dispensing and refills of all prescription medications. Salmeterol and oral corticosteroids were not included in this analysis.

For each type of drug, the frequency of dispensing was calculated for each study subject as the sum of the number of canisters or containers of drug dispensed during each 1-year period. Canister equivalents for nebulized reliever agents and inhaled and nebulized anti-inflammatory medications were created on the basis of expected duration of supply with typical dosages. This method corrects for differences in days of medication supplied by various anti-inflammatory preparations at standard doses and by reliever agents formulated as metered-dose inhalers versus a nebulized solution.11 We defined 1 canister equivalent of a reliever agent as 1 canister of albuterol sulfate and considered 2.5 mg of nebulized albuterol as equivalent to 4 puffs of the metered-dose inhaler.11 One dispensing of an oral formulation was treated as 1 canister equivalent regardless of the quantity dispensed. Controller medications were not weighted for potency, as fluticasone propionate accounted for only 5% of controller dispensing, budesonide was not being used during this period, and recommended doses of other inhaled corticosteroids are similar in potency.

The HEDIS Performance Measure

The HEDIS performance measure (version 3.0) identifies the proportion of individuals who have been dispensed a controller medication (yes or no) among subjects meeting the HEDIS criteria for persistent asthma. The performance measure specifies that 2 years of data are necessary for review; the information in year 1 is used to target individuals, and the information in year 2 is then used to assess prescribing practices. Three years of data were available for this project. Therefore, 2 separate cohorts of children with 2 consecutive years of data (cohort 1 with data from years 1-2 and cohort 2 with data from years 2-3) were included in the analysis, and children with all 3 years of data contributed observations to both cohorts.

Emergency Department Visit Outcome Variables

Each MCO maintains computerized files of all office visits, hospitalizations, and ED visits of its members; coded information includes visit dates and International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. All patient data files were linked by scrambled and untraceable patient identification numbers.

 
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