Asthma Care Quality Improvement

Appendix D: Asthma Measures (continued)

Table D.2. State and Local Asthma Measures: Four Selected Quality Improvement Initiatives

Type of measure Variants of the measure definition Age group Geographic scope Source1
Provider Care (Process) Severity Assessment—spirometry Patients with newly diagnosed asthma (moderate or severe) reported to have spirometry as part of their evaluation All City CASI
Physicians monitoring spirometry or peak flow during office visits All City CASI
Percent of people with asthma who have had a spirometry measurement. All State Oregon
Severity Assessment—spirometry access Physicians reporting access to spirometry:
—Spirometer in office
—Referral to an asthma specialist who performs spirometry
—No access to spirometry
All City CASI
For specialists:
Patients with newly diagnosed asthma (moderate or severe) reported to have selected diagnostic techniques as part of their evaluation (percents). Techniques listed: spirometry, chest radiograph, skin testing or radioallergosorbent testing, sinus radiographs, trial of daily peak flow monitoring, sputum examination and stain for eosinophilia
All City CASI
Severity Assessment—peak flow et al. Patients with newly diagnosed asthma (moderate or severe) reported to have daily peak flow as part of their evaluation All City CASI
Peak flow measurement at ED discharge All City CASI
Physicians monitoring:
Techniques listed: spirometry or peak flow during office visits, frequency of wheeze/cough, frequency of beta 2-agonist use, activity levels, frequency of disturbed sleep due to asthma symptoms, loss of work/school days due to asthma, spirometry or peak flow, direct observation of inhaler technique, peak flow diary review
     
Percent of physicians using peak flow or PFTI:
—Acutely symptomatic patient (never, rarely, sometime, often)
—Asymptomatic patient (never, rarely, sometimes, often)
     
Patients with newly diagnosed asthma (moderate or severe) reported to have selected diagnostic techniques as part of their evaluation.

Techniques listed: spirometry, chest radiograph, skin testing or radioallergosorbent testing, sinus radiographs, trial of daily peak flow monitoring, sputum examination and stain for eosinophilia, sinus radiographs, CT of the sinuses, MRI of the sinuses, nasal speculum examination, rhinolaryngoscopy, upper GI for gastroesophageal reflux disease (GERD), esophogeal pH testing for GERD
All City CASI
Doctor visit Percent of people with persistent asthma who have been seen by a medical practitioner for asthma in the last 12 months All State Oregon
Percent of members with persistent asthma who have at least one preventive/ambulatory visit with a primary care physician, pulmonologist, or allergist All State health
plans
MQIC
Medications—corticosteroids Physicians prescribing inhaled steroid (for patients <5 years old, for patients > 5 years old) for patients with moderate persistent symptoms All City CASI
Others listed:
—Oral beta-agonist (for patients <5 years old, for patients > 5 years old)
—Inhaled beta-agonist (for patients <5 years old, for patients > 5 years old)
—Theophylline (for patients <5 years old, for patients > 5 years old)
—Systemic steroid (for patients <5 years old, for patients > 5 years old)
—Inhaled steroid (for patients <5 years old, for patients > 5 years old)
—Cromolyn or nedocromil (for patients <5 years old, for patients > 5 years old)
All City CASI
Medications after ED visit After ED visit percentage of patients given:
—Prescription for systemic steroids
—Prescription for inhaled steroids/cromolyn
—Prescription for antibiotics
All City CASI
Medications—inhaler Patients with moderate or severe asthma prescribed a corticosteroid inhaler All City CASI
Patients with asthma for whom any type of metered-dose inhaler is prescribed All City CASI
During ED visit, formal training in use of metered-dose inhaler, spacer All City CASI
Percent of people with persistent asthma who have at least one filled prescription for a daily inhaled anti-inflammatory medication All State Oregon
Percent of people with persistent asthma who use more than one canister of a short-acting inhaled bronchodilator every two months for one year. All State Oregon
Written asthma plans Patients with moderate or severe persistent asthma for whom written treatment plans are routinely developed All City CASI
Percent of people with asthma who have a written asthma action plan All State Oregon
Asthma education Percent of people with asthma who have documentation of asthma education All State Oregon
Physicians' approach to asthma education.
Techniques listed: form education program, informal education delivered by nurse or physician, other, do not provide asthma education
All City CASI
During ED visit:
—Formal asthma education by physician or nurse
—Written asthma educational material
All City CASI
Percent of people with persistent asthma who have received education about their triggers and how to reduce their exposure to them All State Oregon
NAEPP guidelines Physicians and NAEPP guidelines:
—Heard of NAEPP guidelines (yes/no)
—Think NAEPP guidelines are useful (extremely useful,
somewhat useful, not very useful, no use at all)
All City CASI
Consultation with asthma specialist Physician’s likelihood of initiating a consultation with an asthma specialist based on the following event or criteria: hospitalization for asthma, an emergency department visit for asthma, multiple medications with continued symptoms, a life-threatening asthma episode, all patients with mild persistent asthma, all patients with moderate persistent asthma, all patients with severe persistent asthma, atypical signs or symptoms, for a diagnosis in child <3 years old All City CASI
Percent of people hospitalized for asthma who are seen by an asthma specialist within one month of the hospital discharge date All State Oregon
Acute exacerbations Patients who call practice for an acute (not life-threatening) exacerbation are usually:
—Told to go to the emergency department
—Provided with a same-day office appointment
—Scheduled for an appointment within the week
—Other
All City CASI
Preventive care—flu vaccine Percent of people with persistent asthma who have received an influenza immunization in the last 12 months All State Oregon
Preventive care—allergen testing Percent of people with persistent non-seasonal asthma who have received allergen testing All State Oregon
Hospital Care (Process) Standards of care—hospital Whether a hospital is using the following hospital-wide:
—Currently using NAEPP guidelines
—Currently using critical pathways
All City CASI
Standards of care—ICU Whether the hospital is using the following in ICU:
—Currently using guidelines
—Currently using critical pathways
All City CASI
Standards of care—bedside Whether care at bedside includes: nebulization, peak flow monitoring, peak flow instruction, evaluation of inhaler technique, inhaled anti-inflammatories, asthma education All City CASI
Community-based care at hospitals Percent of hospitals that have:
1. Formal asthma education in outpatient setting
2. Utilization review for asthma
3. Clinical case management program for asthma
4. Home visits as part of asthma management
5. Community-based asthma screening
6. Community-based adult asthma education programs
7. Community-based pediatric asthma education programs
8. School-based asthma education programs
All City CASI
Emergency Department Care (Process) Assessment in ED Whether assessment in the ED includes:
1. PEFR measurement as part of initial assessment
2. PEFR measurement to document improvement after treatment
3. Pulse oximetry as part of initial assessment
4. Pulse oximetry to document improvement after treatment
5. Arterial blood gas as part of initial assessment
6. Arterial blood gas as part of assessment of severe cases
7. Chest radiograph for patients wheezing for the first time
8. Chest radiograph for patients with wheezing and fever
9. Chest radiograph when diagnosis of asthma is in doubt
All City CASI
Treatment in ED 1. Average time asthma patients spent in ED
2. Average time asthma patients spent in ED before disposition
3. Percentage of patients receiving:
—IV or po steroids used within the first hour
—IV or po steroids used at any time during ED care
—Theophylline therapy at any time during ED care
—Supplemental oxygen at any time during ED care
—Treatment for >4 hours
4. Percentage of EDs reporting:
—Availability of respiratory therapy, both day and night
—The first medication given for asthma attack (beta-agonist by nebulizer, beta-agonist by metered-dose inhaler)
All City CASI
Follow up after ED visit Percent of patients given a specific followup appointment All City CASI
Percent of people with one emergency department visit for asthma who are seen by a medical practitioner within one month of the emergency department visit date All State Oregon
Percent of people with two emergency department visits for asthma in 12 months who are seen by an asthma specialist within one month of the most recent emergency department visit All State Oregon
Managed Care Organizations (Enabling factors) Management 1. MCOs offering an asthma education program
2. MCOs offering an asthma case management program
3. MCOs offering an asthma disease management program
All City CASI
Benefits Asthma-specific covered benefits:
—Medications
—Spacer devices
—Peak flow meters
—Nebulizers
—Asthma education
—Pillow/mattress covers
—Smoking cessation programs
—Smoking cessation medication
—HEPA filter/cleaner
—Dehumidifier
—Home assessment
All City CASI
Patient Care—Process Asthma knowledge Reported as percentage sampled who answered the question correctly:
1. Asthma cannot be cured
2. Vaporizer is good treatment
3. Asthma limits exercise
4. Need for asymptomatic asthma visits
5. Common reason for school absences
6. Asthma runs in families
7. Asthma is mainly an emotional illness
8. Asthma resolves if attacks stop
9. Where to go for treatment
10. Asthma onset always in childhood
11. Signs: shortness of breath
12. Signs: chest tightness
13. Signs: severe headaches
14. Signs: nocturnal cough
15. Signs: wheezing with exercise
16. Triggers: furry pets
17. Triggers: mosquito bites
18. Triggers: dampness
19. Triggers: cockroaches
20. Triggers: poor diet
21. Triggers pollen
22. Hospitalizations are preventable
23. Symptoms are preventable
24. Adequacy of OTC medications
25. Asthma is a serious disease
26. Asthma care is expensive
27. See doctor immediately for attack
28. Appropriateness of ED for treatment
29. Addiction to asthma medicines
30. Overprotective mothers and asthma
     
Percent of people with asthma who has knowledge of asthma medication use and what do in case of an exacerbation. All State Oregon
Percent of people with asthma who affirm receipt of information about asthma and treatment techniques. All State Oregon
Percent of people with asthma who report high levels of confidence in understanding and using this information. All State Oregon
Percent of people with asthma who report behavior consistent with having received and understood this information. All State Oregon
Environmental triggers Percent of people with persistent asthma with documentation they have been asked at least once about home and occupational exposures to:
—Dust-mites
—Animal allergens
—Tobacco smoke
—Exercise-induced bronchospasm
All State Oregon
Mortality (Outcome) Mortality rates Mortality rates:
—By age and gender
—By borough
Children City NYCCAI
Avoidable events (Outcome) Emergency/Urgent care Emergency department visits per 1000 members with asthma. All State health plans MQIC
Relapse rate Percentage of asthma patients estimated to relapse within 7 days. All City CASI
Hospitalizations Hospitalization rates:
—By age
—Comparison of New York City to New York State
—Trends 1990-2000
—Distribution by age group
—Leading causes of hospitalizations in children 0-14
—By age and gender
—By income (ZIP code areas)
—Distribution by payer
—Total charges by payer
—Average length of stay
—By borough
—By neighborhood
—By ZIP code
—By month and age
Children City NYCCAI
Other dimensions (Prevalence) Prevalence Self-reported lifetime prevalence for adults age 18 and over:
—By age
—By race/ethnicity
—By borough
—By neighborhood
Children City NYCCAI
School-based prevalence:
—By gender
—By income (ZIP code areas)
—By borough
—By neighborhood
Children City NYCCAI
Other dimensions (Behavior) Smoking Percent of people with asthma who currently do not smoke cigarettes. All State Oregon
Percent of non-smokers with asthma who are not exposed to tobacco smoke in the home. All State Oregon

1 Key to Sources:
CASI = Chicago Asthma Surveillance Initiative (Weiss KB, Grant EN. The Chicago Asthma Surveillance Initiative: As
Oregon = Guide to Improving Asthma Care in Oregon (Oregon Health Division, 2005; http://www.dhs.state.or.us/publichealth/asthma/guideor.cfm)
MQIC = Michigan Quality Improvement Initiative Guideline: Management of Persistent Asthma (MQIC, 2005; http://www.mqic.org/meas.htm)
NYCCAI = New York City Childhood Asthma Initiative (Garg, et al, 2003)

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Page last reviewed October 2014
Internet Citation: Appendix D: Asthma Measures (continued). October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/asthmaqual/asthmacare/appendix-d2.html