IMPROVING PEDIATRIC ASTHMA OUTCOMES

Systematically Strengthening Interventions

Asthma remains the most common chronic disease in children. With an estimated 4.8 million children affected in the United States, the prevalence of asthma has continued to increase. Despite improved diagnosis and the availability of potent drugs, asthma continues to make kids sick.

The plan found that 4 percent of its members age 2 to 17 carried a diagnosis of asthma in 1996. With hospitalization rate 54 percent higher than the national average, asthma was the number one pediatric volume diagnosis, and in the top 10 high cost diagnoses for the total member population.

This health plan took a thoughtful approach to improving pediatric asthma outcomes, starting with the development of a planned budget for the initiative. The plan systematically embarked on study design, barrier analysis and implementation, and it used support from a corporate parent. The plan utilized survey data at each step of the process to assess the effectiveness of current interventions and the need for new ones. Over a two-year period, it was able to decrease pediatric hospitalizations and emergency room visits, as well as increase the appropriate use of anti-inflammatory medications.

Encounter data were searched for each paid claim for an inpatient admission or emergency room visit with a primary or secondary diagnosis of asthma (ICD-9 CM 493.xx). A Pharmacy claim for an "anti-asthmatic" drug according to the Medi-Span Therapeutic Classification System was also used to identify children with asthma. Together, encounter and pharmacy data identified a population of 1,575 asthma patients age 2 to 17.

The plan chose three performance measures: two utilization measures and a process measure. The utilization measures were inpatient admissions and emergency room visits (both required a principal diagnosis of asthma). The plan calculated a rate per thousand members using the formula:

(Encounters per month) x 12 x 1,000 (Total member months for commercial members < 18 years)

For its process measure, the plan looked at the treatment of moderately severe childhood asthma. It first defined asthmatics of moderate severity as those receiving more than one beta agonist prescription a month. It then determined the number of these moderately severe asthmatics who also received a prescription for an inhaled anti-inflammatory medicine or a leukotriene modifier.

Baseline performance, based on 1996 data, showed a hospitalization rate of 3.02/1,000 members, an emergency room visit rate of 1.5/1,000 members, and a 44.7 percent rate of usage for anti- inflammatory medications in moderately severe pediatric asthma patients.

The plan set a hospitalization goal of 1.6/1,000 members, based on the goal from the U.S. Public Health Service. It also set a goal of 1.2/1,000 members for ER visits, and a goal of 60 percent for the use of anti-inflammatory medications.

Two committees conducted brainstorming sessions to identify barriers to care. One was a multidisciplinary committee composed of QI, Pharmacy, Network Management and Member Services staff. The other was an advisory council composed of practicing pediatricians. They were guided by baseline data as well as results of a survey of caregivers of asthma patients. A medical education vendor contracted by a corporate parent performed this survey. The survey data showed that caregivers lacked confidence in recognizing and avoiding episode triggers.

QI IS A TEAM EFFORT One of the secrets of a successful quality improvement activity is making sure that you have the right team. The multidisciplinary asthma committee was the first of its kind in this organization, and provided a template for future initiatives. Involvement of physicians in all aspects of the project produced opinion leaders who worked to change physician attitudes and practices.

In July 1997, the plan identified three barriers to be addressed:

• Practitioners lacked knowledge of National Heart, Lung, and Blood Institute (NHLBI) guideline recommendations for the use of anti-inflammatory medications
• Practitioners lacked knowledge of the latest overall recommendations for the treatment of asthma
• Members lacked knowledge of asthma and its self-management

The plan began to consider interventions that would specifically address the identified barriers. It chose its interventions based on the clinical literature, experience from sister plans, and the availability of resources from the corporate parent organization.

The effort began with an article on asthma in the member newsletter. A business reply card was included that allowed a member to request:

• A survey that assessed the caregiver's knowledge of asthma and its treatment (included in QP Tool )
• An educational kit consisting of a 20-minute video and a 50-page booklet
• A stop smoking brochure

Surveys and the offer of the educational kit were also mailed to the parents of pediatric members utilizing one or more beta agonist prescriptions per month, and those on multiple medications. Follow-up surveys were sent to those who received educational kits, to assess their satisfaction and level of knowledge concerning asthma and its management.

Another newletter article during the year focused on the allergic triggers in asthma.

Physicians were informed of the plan's asthma management program and how to refer their patients. They participated in the development of a clinical practice guideline on the management of asthma. Local pediatric pulmonologists provided their input, and the guideline was distributed to all PCPs. PCPs who had patients recently hospitalized for asthma received a mailing from the plan's medical director with information on the patient's medication and hospital utilization.

A mass mailing to the parents of all identified pediatric asthma patients contained:

• A Functional Status Survey (included in QP Tool )
• Information about the plan's asthma management program
• Educational materials:
• Common questions and answers
• Asthma treatment recommendations
• Asthma daily self-management plan
• Asthma action plan
• Peak flow meter instructions
• Patient diary
• Patient self-assessment sheets

Educational efforts were also focused on case managers. In-service sessions informed them about the physiology of asthma, signs, symptoms, triggers, medications and preventive measures.

CLEAR AND SIMPLE COMMUNICATION The educational materials sent by the health plan were basic and easily understood. Caregivers were instructed to watch the child using an inhaler, and to give praise or correction as needed. They were introduced to the concept that there are two kinds of asthma medicine, "quick relief" and "control." The action plan documented the doctor's instructions on what medicines or steps to take based on the absence or presence and severity of symptoms, and the peak flow rate. The materials stressed the importance of knowing how to manage asthma, and the need to periodically review and update the action plan.

An asthma disease profile was developed to notify PCPs of their identified asthmatic patients, their hospitalization, ER visits, and medication usages (included in QP Tool ). A similar report was developed for medical group medical directors (included in QP Tool ).

A clinical practice guideline based on NHLBI recommendations was developed with input from local pediatric pulmonologists and physician committees. A flow sheet containing minimum practice recommendations was developed and distributed to practitioners (included in QP Tool ).

The first remeasurement, based on 1997 data, documented a hospital admission rate of 2.7/1,000 members - an 11 percent decrease, but not statistically significant. Emergency room visits actually increased to 1.9/1,000 members. The rate of anti-inflammatory medication usage in members with more than one beta agonist per month rose to 48.9 percent, also not statistically significant. The plan had clearly failed to meet its goals, and needed to strengthen its interventions. The plan analyzed the results of its surveys, in which caregivers had been asked about their knowledge of asthma, what they were doing to prevent and control their children's asthma attacks, and the advice and instructions they had been receiving from their children's PCPs. This analysis suggested several continuing barriers:

• PCPs continued unfamiliarity with prescribing guidelines for asthma
• Lack of PCP awareness of asthma educational kits
• Low usage of peak flow meters

Mailings to survey respondents emphasized peak flow meter usage and the plan's smoking cessation program. The plan continued to mail educational kits to members who requested more information.

PCPs were mailed copies of an updated clinical practice guideline, NHLBI recommendations and materials, survey findings, and a listing of their patients who had requested additional information. They also continued to receive the asthma disease profile.

PCPs were also supplied with free peak flow meters for distribution to their patients.

A risk stratification scheme was developed. It classified all asthmatics as Level I (using medication, but not on multiple medications, and without hospital or ER utilization) or Level II (admissions, ER visits or multiple medications).

Level II members were targeted to receive surveys and information on how to obtain and use a peak flow meter.

The member newsletter discussed asthma signs, symptoms and the use of peak flow meters. Members were encouraged to request free asthma kits and flow meters.

The second remeasurement, based on 1998 data, showed a 1.9/1,000 members rate of hospitalization, a 37 percent decrease from baseline. ER visits declined to 1.4/1,000 members. The usage of anti-inflammatory medications increased to 54.6 percent, which was statistically significant using a chi square test (p=0.034). This represented a 22 percent improvement from baseline. Although the plan had not yet met its goals, it had achieved meaningful improvement in both process and outcome.

The health plan continued its efforts during 1999. Mailings to PCPs and patients have continued. Surveys in 1999 have shown the following changes since 1998:

• Ninety-one percent of caregivers have used the provided materials
• Missed school/work days have decreased by 19 percent
• Peak flow meter usage has increased by 24 percent
• Self-efficacy has improved by 22 percent
• Perception of quality of care has increased by 49 percent

CLINICAL OUTREACH In retrospect, would this plan have done anything differently? Knowing the importance of clinician involvement, the plan states it probably would have spent more time visiting practitioners' offices and interacting with physicians and staff.

Perhaps most telling is that every recipient of an asthma education kit stated that he or she would recommend its use to a friend.

The performance measures have continued to show improvement as well. All of the plan's initial goals were met in 1999: Hospitalizations declined to 0.7/1,000 members; ER visits declined to 1.2/1,000 members, and anti-inflammatory usage increased to 60 percent.

The plan gained valuable experience in developing and maintaining this quality initiative. It attributes much of the initiative's success to the multidisciplinary approach and the cultivation of strong clinical champions. Its approach to future initiatives is sure to emphasize these critical success factors.