PEDIATRIC ASTHMA

Refining an Effort With Annual Barrier Analysis

With asthma consistently one of the top three reasons for pediatric hospitalization in this plan, it has been a focus of improvement efforts in the pediatric department since 1987. Despite implementing practice guideline distribution and practitioner and parental education, the plan felt that there was still a huge opportunity to improve care. It decided to embark on a more formal quality improvement activity to optimize asthma care for children.

Of the approximately 15 million people in the United Sates afflicted with asthma, it is estimated that two to five million are children. Once out of ten children will have an asthmatic episode by age 17. Asthma has a profound effect on the lifestyle of children affected by the disease. Several studies suggest that the incidence of asthma is rapidly rising. Hospital admission for asthma can be avoided in many cases with optimal outpatient care.

The plan felt that it could reduce hospital admissions for its pediatric members. It embarked on a systematic and repetitive plan of barrier analysis and interventions.

The targeted population consisted of continuously enrolled children aged 2 to 19 years receiving asthma medications. Pharmacy data were used to identify children dispensed bronchodilators, theophylline, cromolyn sodium, or inhaled corticosteroids.

The plan selected five measures. Table 1 shows the baseline performance.

The health plan utilized HEDIS 2.0 (and 2.5) methodology for the first two measures - admission and readmission rates.

The other three measures that looked at emergency room visits, urgent care center visits, and primary care physician (PCP) visits were developed by the health plan. For these measures, the plan calculated the rates per thousand members under the age of 17 years. (The plan chose this age band because it was much easier to extract from the data system.)

The plan established a benchmark and goal of less than 1.0% for its first performance measure - hospital admission rate. A benchmark and goal were not established for the remaining four measures.

The health plan initially used brainstorming to determine barriers to good asthma care. A key barrier was felt to be the use of multiple providers with poor coordination of care. Each provider assumed that someone else was managing their patients' asthma. The analysis also identified:

• lack of appropriate asthma treatment in the school setting
• language barriers
• parents not taking the appropriate steps to treat episodes of acute asthma
• inconsistencies in the advice provided to parents
• limited locations for asthma educational classes
• limited access to peak flow meters, spacers, and nebulizers
• failure of some practitioners to prescribe spacers, nebulizers, or appropriate medications
• financial barriers to attending asthma educational sessions
• no system for monitoring compliance and providing feedback to providers
• incomplete documentation of the disease, treatments, and patient responses

The plan's interventions were designed to be wide ranging. The plan initially focused on access and educational issues to address the identified barriers and to deal with all the potential stakeholders in the effort.

To address access issues, the plan:

• made spacers, peak flow meters, and nebulizers a covered benefit available through pharmacies
• issued free copayment coupons to parents for attending asthma classes
• developed educational materials in Spanish

To address education for parents, members, and providers, the plan:

• initiated a school nurse educational effort
• updated and distributed guidelines to primary care physicians (PCPs)
• monitored PCP compliance with guidelines and provided feedback to outliers
• implemented physician education seminars

COMMUNITY OUTREACH The plan found it extremely difficult to work with the school districts to train their school nurses. Many nurses were threatened by or disinterested in educational sessions. School nurses repeatedly rebuffed the plan's overtures, citing medical liability concerns. To avoid these problems, the plan suggested that other plans attempt to involve a senior school nurse early in the initiative planning process.

The first remeasurement using 1994 data was encouraging; all five measures showed a statistically significant improvement as shown in Table 2.

The plan analyzed barriers to further improvement and initiated new interventions:

• created an asthma newsletter for members
• increased the number of venues for educational classes
• produced an instruction video on asthma care for patients
• made available a commercial program that featured multiple language interpreters via telephone. The plan installed numerous new phone lines in the pediatric and urgent care areas to allow the use of this service
• continued to distribute clinical practice guidelines, measure compliance, and feedback results to the PCPs

SELF EFFICACY The decrease in PCP outpatient visits was not expected. The decreased rate of PCP office visits, emergency room, and urgent care visits may all be attributable to the increasing ability of the family to effectively manage the care of asthma at home.

The results of the second remeasurement, using 1995 data, did not show a statistically significant change in admission or readmission rate. The ER visit, urgent visit, and PCP visit measures actually showed a significant increase, as displayed in Table 3.

In 1996, the plan's barrier analysis indicated that copays represented a financial barrier to educational session attendance. It therefore adjusted copays for member educational classes.

Concerned that some barriers, such as fragmentation of care, disproportionately affected its Medicaid population, the plan decided to track the Medicaid population separately. With asthma management guidelines changing, some practitioners were not up to date. The health plan held physician and nurse educational sessions at least quarterly at all 15 of its clinics.

PEER LEADERSHIP The plan found that the most effective way to encourage the use of guidelines was to use supportive physicians as teachers for other doctors. The same approach worked for patients' in-group educational sessions. Both member and provider sessions worked best when there was already a peer using the program who could describe its benefits and pitfalls.

The 1996 data produced mixed results. There was no statistically significant change in admissions, readmissions, or urgent visit rates. The ER rate showed a significant decrease from the prior year, while the PCP visit rate showed a significant increase.

UNDERSTANDING VARIATION The ER, urgent care, and PCP visit rates fluctuated throughout this activity. The plan was unable to satisfactorily explain these variations. Although it is possible that the variations are simply due to random factors, the size of the changes makes it unlikely. More data, such as pollen counts or the severity of the flu season, would be needed to really understand the cause of these fluctuations. Attempting to influence variations that are not understood is called tampering with the process.

This initiative has continued with strong interventions aimed at overcoming specific barriers. The plan has combined its pediatric and adult asthma management teams to share knowledge. It has implemented a system in pharmacy to flag beta agonist refills for patients not on inhaled steroids, or when patients refill their beta agonist more than once a month.

The plan continues its educational and practice guideline efforts, and is investigating linking its program to other national efforts.