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Identifying Children at Risk of Asthma Exacerbations: Beyond HEDIS

Jonathan Hatoun, MD, MPH, MS; Emily K. Trudell, MPH; and Louis Vernacchio, MD, MS
Analysis of insurance claims reveals that criteria other than the Healthcare Effectiveness Data and Information Set (HEDIS) persistent asthma definition can identify more at-risk patients with reasonable loss of specificity.
DISCUSSION

Creating disease-specific patient registries for population health initiatives increasingly requires organizations to “think outside the problem list” to find patients at risk. This work demonstrates such an approach for pediatric asthma using a claims-based definition of asthma that can efficiently identify patients at risk of an asthma exacerbation with reasonably high sensitivity and specificity. Our definition No. 18, which identifies patients with 1 or more paid claims for a clinician visit with asthma or wheeze as a diagnosis in the past 2 years, had the largest AUC—substantially larger than that of the formal HEDIS definition for persistent asthma.

The HEDIS definition can be useful in defining the denominator for certain quality measures, such as the asthma medication ratio, or as a research definition, but it identifies just a small and very high-risk population of children with asthma and excludes many children who will go on to suffer an exacerbation in the coming 12 months. Indeed, in our sample, the formal HEDIS definition excluded 80% of children who suffered an exacerbation in the measurement year. The HEDIS-identified cohort of patients in this study made up just 1.5% of the entire population, far below the established population prevalence estimates for pediatric asthma, such as the CDC’s estimate of pediatric asthma prevalence nationally (8.6%)8 or in Massachusetts (9.8%),9 and even further below the school-reported prevalence in Massachusetts (10.9%).10 In order to approach such population estimates, a broader definition is needed. Our definition No. 18 had the largest AUC but identified a cohort representing 17.0% of the total population, well above the population estimates. An individual organization balancing the desire to identify all patients at risk of an asthma exacerbation with the need for judicious allocation of resources may choose to use an alternative definition that is more or less sensitive, depending on its resource availability.

Increasingly, organizations are taking a proactive approach to managing patients with asthma by reaching out to their families to optimize preventive strategies, educate about the importance of adherence to an action plan, promote influenza vaccination, and reduce environmental triggers, among other evidence-based strategies.2,11,12 The cost of proactively managing at-risk children with asthma is high. Nonetheless, if applied to the right population of children with asthma, costly interventions can provide a positive return on investment.13 Building an accurate registry of patients with asthma for population health management purposes is difficult due to the inherent unpredictability of the disease, however. A claims-based identification rule may be optimal, because relying on provider memory is inaccurate,14 and assuming that any documented respiratory complaint represents asthma overestimates the desired population.15

Although any loss of specificity from the HEDIS definition means that a larger proportion of the patients identified will not actually go on to have an exacerbation, there are clear benefits to a more inclusive identification definition that promotes outreach to a larger but still substantially at-risk population. There may be long-term benefits that are difficult to quantify for families who receive asthma education and mitigate environmental triggers in the home, such as by reducing exposure to environmental tobacco smoke. Given that genetic factors contribute to the development of asthma,2 such interventions can also benefit siblings. Additionally, missing fewer school days and workdays benefits families in innumerable ways.

Limitations

This study does not help clinicians determine which children with wheeze will go on to become patients with persistent asthma, and it was not designed to assess the economic impact of an expanded registry of patients with asthma. Using a claims database also has the limitation of relying on assigned visit diagnoses to summarize nuanced clinical situations and lacks valuable demographic information. Although our study used ICD-9 codes because of the time period of our data, the current International Classification of Diseases, Tenth Revision (ICD-10) convention offers a more refined spectrum of asthma codes that incorporate severity, which could more accurately determine a patient’s risk. Although this analysis used a 2-year lookback period, it is effectively a cross-sectional study. A longitudinal approach may further refine the performance of various definitions, but the time period in this analysis adequately accounts for seasonal variation, and analyses of more recent data were limited by the conversion to ICD-10 coding in fall 2015.

CONCLUSIONS

In order to monitor and further characterize the patients in our network with asthma at risk of exacerbation, we have begun to use a definition of asthma that identifies patients with asthma or wheezing as any diagnosis on a paid insurance claim in the preceding 2 years (definition No. 18). This definition may serve as a more appropriate criterion for inclusion into the denominator of certain quality measures for children with asthma compared with the HEDIS definition of persistent asthma. Work is ongoing to determine which characteristics of patients with asthma portend a greater likelihood of an asthma exacerbation and what the relative contributions of these factors are to a patient’s risk of exacerbation.

Author Affiliations: Pediatric Physicians’ Organization at Children’s (JH, EKT, LV), Brookline, MA; Division of General Pediatrics, Boston Children’s Hospital (JH, LV), Boston, MA.

Source of Funding: This study was funded by internal funds of the Pediatric Physicians’ Organization at Children’s. No outside funding was used for this study.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JH, EKT, LV); acquisition of data (JH, EKT, LV); analysis and interpretation of data (JH, EKT, LV); drafting of the manuscript (JH, EKT, LV); critical revision of the manuscript for important intellectual content (JH, EKT, LV); and statistical analysis (JH, EKT, LV).

Address Correspondence to: Jonathan Hatoun, MD, MPH, MS, Pediatric Physicians’ Organization at Children’s, 77 Pond Ave, Ste 205C, Brookline, MA 02445. Email: jonathan.hatoun@childrens.harvard.edu.
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