Module 1: Making the Case for Asthma Care Quality Improvement
Asthma is a serious chronic respiratory illness that affects a growing number of Americans. According to the National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS), 16.2 million adults and 6.7 million children had asthma in 2007, a substantial increase over the prior two decades (CDC, 2009). It is also a costly disease that can seriously impair normal functioning, and it erodes the quality of life for those who have it, as well as their caregivers (Ford, 2003).
Key Ideas in Module 1:
- The number of Americans diagnosed with asthma has grown dramatically in recent years, especially among children and adolescents.
- The cost burden of uncontrolled asthma can be substantial.
- Asthma disproportionately affects African Americans, children, and low-income individuals.
- Quality of care received by people with asthma can vary widely across States and population groups.
- Interventions and treatment can successfully control the disease and prevent attacks.
- There is potential for return on investment for purchasers and the health care system as a whole through asthma quality improvement.
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The Need for Asthma Care Quality Improvement
Many factors suggest that efforts to improve the quality of asthma care are warranted:
- Increased prevalence of asthma, especially among children and adolescents.
- The high health care cost of uncontrolled asthma.
- The disparities among various socioeconomic, racial, and ethnic groups in how carefully they are diagnosed and treated.
- Variation in interventions and treatment that can successfully manage the disease and prevent attacks.
These points are discussed in more detail in the following sections.
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What Is Asthma and How Is It Treated?
Asthma is a chronic inflammatory disorder of the airways. Such inflammation can cause recurring episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. During an asthma attack, the airways that carry oxygen to the lungs become inflamed and swollen, the muscles surrounding the airways tighten, and mucus collects, making it harder to push air out of the lungs. Although asthma triggers are not the cause of asthma itself, they may exacerbate an asthma attack.
The most common triggers of asthma attacks are respiratory infections, especially colds. Other triggers include various irritants such as second-hand tobacco smoke, dust mites, air pollution, cockroaches, furry pets, mold, stress, exercise, and changes in the weather.
Treatment. The goal of asthma treatment is to reduce underlying inflammation and decrease the daily symptom burden by preventing asthma attacks from recurring. High quality asthma care minimizes the need for emergency care or hospitalization. There are several components of high quality asthma care recommended by the Clinical Guidelines of the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute (NHLBI):
- Component 1: Measures of Assessment and Monitoring. Initial assessment and diagnosis of asthma is extremely important to determine appropriate treatment based on the patient's level of asthma severity.
- Component 2: Control Factors Contributing to Asthma Severity. Controlling asthma triggers and reducing exposure to environmental allergens and irritants help limit asthma severity. Thus, treatment and prevention of co-occurring respiratory and other conditions (such as rhinitis, sinusitis, chronic obstructive pulmonary disease, and gastroesophageal reflux disease) should be considered.
- Component 3: Pharmacologic Therapy. Medications should be prescribed according to the severity of the patient's asthma, and medication use should be monitored. Two classes of medications are involved: long-term medications (inhaled corticosteroids [ICS]) to control the inflammatory process of persistent asthma and quick-relief medications (beta-agonists) to treat symptoms and attacks. The objective is to maintain control with ICS and to avoid attacks and the need for emergency treatment.
- Component 4: Education for a Partnership in Asthma Care. Patients and their families play an important role in their asthma care. They need to understand how to monitor their symptoms, what to do during an asthma attack, and how to use their medications appropriately. People with asthma must learn to "manage" their condition so as to avoid triggers and anticipate problems.
Source: National Heart, Lung, and Blood Institute, 2007.
Cases of asthma have increased dramatically in recent decades. The growth of asthma cases in the United States has been labeled an "epidemic" (RAND, 2002). Information gathered by the Centers for Disease Control and Prevention (CDC) from 1980 to 1996 shows that the number of Americans with self-reported asthma more than doubled during that time, from almost 7 million to over 14 million (CDC, 2007a).1
Especially troubling are the rates of increase among children: over that 16-year period, asthma prevalence among children under age 5 increased 115 percent. For children between 5 and 14, prevalence increased 81 percent (CDC, 2007b). Figure 1.1 (25 KB) shows the rising trend for children 0-17 and the same for all ages, until 1996. The CDC surveillance survey questions changed in 1997 and began to track asthma attacks in the past 12 months. This modification should reflect more closely changes in the quality of care and self-management practices of people with chronic asthma, especially when compared with the number of people who say they currently have asthma, a statistic which has been collected since 2001. Table 1.1 shows the increase in lifetime asthma prevalence by State between 2000 and 2004. Even in that short period, asthma prevalence increased fairly steadily for nearly all States.
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How Is Asthma Diagnosed and Severity Assessed?
Diagnosing asthma and assessing asthma severity are important first steps to quality asthma care. Clinical guidelines for the diagnosis and treatment of asthma were comprehensively updated in 2007. Diagnosing asthma can be difficult and, as a result, it may at times be mislabeled as other problems. Below are steps recommended by NHLBI Clinical Guidelines to diagnose asthma and classify its severity.
Methods for diagnosing asthma. The first step in providing quality asthma care is to make a correct diagnosis. Clinical judgment is required because signs and symptoms vary widely from patient to patient as well as within each patient over time.
To establish the diagnosis of asthma, the clinician must determine that:
- Episodic symptoms of airflow obstruction or hyperresponsiveness are present.
- Airflow obstruction is at least partially reversible.
- Alternative diagnoses are excluded.
No one test or set of tests is appropriate for every patient. Usually, a detailed medical history, a physical exam focusing on the upper respiratory tract, chest, and skin; and spirometry to demonstrate reversibility of airflow obstruction will enable a clinician to see a pattern of symptoms and history of recurrent episodes and rule out other conditions. Additional tests may be done to evaluate alternative diagnoses, identify triggers, assess severity, and investigate potential complications.
Classifying asthma severity. At the initial visit, the physician should assign the patient to a severity grade to help guide medication decisions. The severity classifications are based on the frequency of the patient's symptoms and his or her lung function measurements. The characteristics noted in the chart below are general and may overlap because asthma is highly variable. In addition, the patient's severity classification may change over time. The severity of the patient's asthma should be rechecked at every visit.
Severity is currently divided into four levels, as shown in the following table:
|Classification of Asthma Severity
||Days with Symptoms
||Nights with Symptoms
||FEV1a or PEFa
Percentage Predicted Normal
||PEF Variability Between Morning and Night Test
||>1 night per week
||>2 days per week but
<1 time per day
|>2 nights per month
||<2 days per week
||<2 nights per month
a. For adults and children over 5 years who can use a spirometer or peak flow meter, the percentage predicted values for forced expiratory volume in 1 second (FEV1) and percentage of personal best for peak expiratory flow (PEF) (NHLBI, 2003).
Barriers to diagnosis and severity assessment. Improving asthma care quality requires
understanding how asthma is diagnosed and assessed. Asthma care depends on initial assessments and monitoring to determine appropriate care. Patients or their caregivers must be able to give detailed descriptions of frequency and severity of symptoms which are sometimes difficult to recognize. Also, diagnosing asthma in children is difficult because diagnosis may be unclear until recurrence of signs and symptoms is established (NHLBI, 2003). Thus, some patients who actually have asthma may be assessed as having other conditions and may remain untreated until diagnosed accurately. Access to quality lung function testing is often unavailable. These barriers must be addressed to improve asthma care quality.
What is causing this upsurge in asthma cases? Because doctors are still unsure why some people develop asthma while others do not, further research is needed to identify the exact causes of asthma. Such research is underway at the Environmental Protection Agency, National Institutes of Health, Centers for Disease Control and Prevention, and elsewhere. Risk factors—including genetic predisposition and early exposure to irritants—may contribute, but are certainly not the only reasons for the increase. Even without pinpointing the cause, however, efforts to improve the quality of care for asthma can help control the severity of the condition.
1 Changes in survey design over time make it impossible to compare current data with data collected before 1996.
Uncontrolled asthma is costly to treat. In recent economic analyses of asthma commissioned by the American Lung Association, the estimated annual cost of asthma in 2004 was $16.1 billion and in 2007 was $19.7 billion (ALA, 2005, and ALA, 2009). These analyses evaluated both direct costs including physician visits, hospital stays, and medications, as well as indirect costs such as lost work days, school absenteeism, and lost earnings ($14.7 billion direct and $5 billion indirect, respectively). Included in the estimates (ALA, 2005) were:
- 444,000 hospitalizations.
- 1.2 million hospital outpatient department visits.
- 1.7 million emergency room visits.
- 10.6 million doctor office visits.
- 12.8 million in lost school days.
- 1.01 million in lost work days.
The most expensive direct cost was prescription drugs ($6.2 billion) [ALA, 2009]). Although the per-person cost of asthma is not the highest among chronic diseases, asthma and chronic obstructive pulmonary disease together represent the fifth most costly disease for the population at $48.7 billion annually, or nearly 6.4 percent of all health care spending (Soni, 2007).
Much of this economic burden falls on people with asthma and their caregivers—one study found that the average family in the United States spends between 5.5 percent and 14.5 percent of its total income on treating an asthmatic child (HHS, 2003). In addition, payers also pick up a significant amount of the cost. A study published in February 2002 found that the cost to employers of treating someone with asthma was twice that of treating someone without asthma—$5,385 vs. $2,121 (HHS, 2003). Another study (Brodsky, 2002) found that families spend 2½ times more on children with asthma than on children without asthma—$618.42 vs. $248.67 (in 1996 dollars, inflated to 2003 dollars).
As a payer through State Medicaid and State employee health care programs, States have a financial stake in encouraging providers to provide high quality care to plan participants with asthma. Prevention of even a small number of hospitalizations through better management of the disease could affect expenditures significantly.
Children are more likely to be hospitalized for asthma than adults (202 per 100,000 children vs. 102 per 100,000 adults ages 18-64 (Table 1.2). According to a 2006 study, there were 335,000 asthma-related pediatric hospital stays, accounting for 13.5 percent of all pediatric hospitalizations (Stranges, 2008).
Racial, Ethnic, and Income Disparities
Asthma does not affect all groups equally. Asthma is more prevalent among minorities and low income persons, and asthma attack rates and mortality are higher among Blacks compared with Whites (AHRQ, 2008). In addition, Black children in the United States are more than 3½ times as likely to be admitted to a hospital for asthma as White children (AHRQ, 2008, Table 117). Black adults age 18 to 64 are three times as likely to be hospitalized as White adults for asthma (AHRQ, 2008, Table 118a).
The 2005 National Health Interview Survey (CDC, 2006a) showed that:
- Current asthma prevalence is 125 percent higher for Puerto Ricans compared with non-Hispanic Whites. Non-Hispanic Blacks and American Indians and Alaska Natives had 25 percent higher current asthma prevalence compared to non-Hispanic Whites.
- In 2005, Puerto Ricans also had the highest rate of asthma attacks in the previous year, 140 percent higher than non-Hispanic Whites. Blacks had an asthma attack rate about 30 percent higher than non-Hispanic Whites. American Indians and Alaska Natives had an asthma attack rate that was 43 percent higher than non-Hispanic Whites.
- Blacks had an asthma hospitalization rate 240 percent higher than Whites.
In 2003, Puerto Ricans were the most likely to die from asthma and had an asthma death rate more than 360 percent higher than Whites. Blacks had an asthma death rate 200 percent higher than Whites.
There are also significant racial/ethnic disparities among children in asthma status and self-management
practices. A study by Lieu, et al. (2002) showed that Black and Hispanic children have more severe asthma based on number of symptom days, missed school days, and health status scores than White children with similar insurance and socioeconomic status. Black and Hispanic children were also less likely than White children to be using daily inhaled anti-inflammatory medications (28 percent and 22 percent, respectively, compared with 33 percent).
Income also plays a role. Children in poor families are more likely than other children to have been diagnosed with asthma (14.9 vs. 12.6 percent). And, although not all single-parent families are low income, children in single-mother families are more likely to have asthma (17.1 percent) than children from two-parent families (11.4 percent) or than children from single-father families (11.5 percent) (CDC, 2007b).
Another study looking at indoor and outdoor allergies among children with asthma found that Puerto Rican and Black children were at greater risk for multiple allergies. The study found that Puerto Rican children with asthma are up to three times more likely to be allergic to indoor and outdoor allergens than White children with asthma. The study also found that black children with asthma are two to three times more likely to have allergic reactions to outdoor allergens (Celedón, et al., 2004).
Intervention and Treatment Variation
Clinical guidelines for care—including developing an asthma management plan with physicians, eliminating or decreasing exposure to triggers, and proper use of medications—offer people with asthma a way of minimizing its effects on daily living, avoiding hospitalizations, and reducing trips to the emergency room. Data gathered in national surveys, however, show that many people do not have control of their asthma:
- The 2004 National Healthcare Quality Report (NHQR) reported that, according to national estimates from the National Committee for Quality Assurance Health Plan Employer Data and Information Set (HEDIS®), nearly a third of children and adults suffering from persistent asthma are not receiving inhaled corticosteroids to control their asthma (AHRQ, 2004b).
- Although most asthma deaths are preventable if care is received in time, 4,055 deaths were attributed to asthma in 2003 (CDC, 2006a).
- The Medical Expenditure Panel Survey determined that only one-third of respondents with asthma in 2002 used a peak flow meter recommended at that time to self-monitor the severity of their asthma (MEPS, 2002).
There is also considerable variation from State to State in the care received by people with asthma. The following chart and table show two of the asthma measures that are available nationwide—hospitalizations for asthma and use of inhaled corticosteroids—with data for States grouped by region to allow for regional comparisons.2 Comparisons can also be made across all States to the national average and the best-in-class average (the 10 percent of States with the best value). The percentage of people receiving specific, recommended services and the percentage difference between the lowest and the highest performing State vary by service.3
The use of the most expensive service—inpatient care—varies three to five times across the
States and shows variation within each region, especially for children (Figure 1.2 (36 KB) and Table 1.2). For every 100,000 State adult residents age 18 to 64, from 36 to 156 people will be admitted to the hospital with asthma. For every 100,000 State child residents, from 65 to 345 children will be admitted (HCUP, 2004). Little of the variation in hospitalizations is likely to be due to differences in asthma prevalence across States (Table 1.1). Asthma prevalence rates only ranged from 10.5 to 16.3 percent across the States represented in the HCUP data. Thus, the top State in terms of prevalence has 55 percent more residents with asthma than the bottom State. Contrast that with the top State in terms of pediatric hospitalizations, which has 429 percent more children admitted to the hospital during a year than the State with the lowest hospitalization rate for children.
Use of inhaled corticosteroids by people with persistent asthma—measured from health plan claims across regions—varied from 2001 to 2003 as shown below:
|No. of plans
||No. of plans
|| || ||
Note: All means are weighted by the eligible populations of the plans.
Source: National Committee for Quality Assurance, HEDIS data from The State of Healthcare Quality, 2004.
This variation suggests possible bias in terms of which plans report fully or which are regional versus national plans. Because of the large difference between reporting and non-reporting plans, full reporting might change the above regional estimates significantly. These regional 2003 HEDIS averages compare with the national average of 69.6 percent from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) and the best-in-class State average of 76.5 percent for use of this important type of medication.
Regardless of data sources (State-run surveys, claims for payment, or hospital discharges) and regardless of differences in asthma prevalence, there is considerable variation in asthma care. These figures illustrate this variation across States and regions for asthma measures. This variation suggests room for improvement for many States. The States with the best rates on the asthma measures—the best-in-class States—provide examples of quality performance that is achievable. However, even the best results may leave room for improvement.
2 U.S. Census regions are: Northeast=CT, ME, MA, NH, RI, VT, NJ, NY, PA); Midwest=IN, IL, MI, OH, WI, IA, KS, MN, MO, NE, ND, SD; South=DE, DC, FL, GA, MD, NC, SC, VA, WV, AL, KY, MS, TN, AR, LA, OK, TX; West=AZ, CO, ID, NM, MT, UT, NV, WY, AK, CA, HI, OR, WA.
3 For example, BRFSS data for 2004 show that receipt of flu shots among adults with asthma varied by State from 22 percent to 62 percent, a difference of 40 percentage points, while the proportion of adults who had an emergency room visit for asthma ranged from 9 percent to 41 percent, a difference of 32 percentage points. Regional and State variation is discussed further in Module 4: Measuring Quality of Care for Asthma.
Implications for State Policy
Disparities in the prevalence and management of asthma and in quality of care have important implications for States and the public sector more generally. Care for low income individuals who are hospitalized is often financed by public sources such as Medicaid and uncompensated care funds. Ensuring effective care can help people with asthma remain healthy and productive, prevent attacks, and reduce health care costs.
These differences are important for two reasons as States undertake asthma quality improvement initiatives. First, the racial, ethnic, and socioeconomic makeup of a given State influences the prevalence of asthma in the State. Second, improvement in quality of care may require targeted efforts to minority and low income groups in order to be successful.
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