Appendix D: Asthma Measures (continued)

Asthma Care Quality Improvement: A Resource Guide for State Action

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

Type of measureVariants of the measure definitionAge groupGeographic scopeSource1
Provider Care (Process)Severity Assessment—spirometryPatients with newly diagnosed asthma (moderate or severe) reported to have spirometry as part of their evaluationAllCityCASI
Physicians monitoring spirometry or peak flow during office visitsAllCityCASI
Percent of people with asthma who have had a spirometry measurement.AllStateOregon
Severity Assessment—spirometry accessPhysicians reporting access to spirometry:
—Spirometer in office
—Referral to an asthma specialist who performs spirometry
—No access to spirometry
AllCityCASI
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
AllCityCASI
Severity Assessment—peak flow et al.Patients with newly diagnosed asthma (moderate or severe) reported to have daily peak flow as part of their evaluationAllCityCASI
Peak flow measurement at ED dischargeAllCityCASI
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
AllCityCASI
Doctor visitPercent of people with persistent asthma who have been seen by a medical practitioner for asthma in the last 12 monthsAllStateOregon
Percent of members with persistent asthma who have at least one preventive/ambulatory visit with a primary care physician, pulmonologist, or allergistAllState health
plans
MQIC
Medications—corticosteroidsPhysicians prescribing inhaled steroid (for patients <5 years old, for patients > 5 years old) for patients with moderate persistent symptomsAllCityCASI
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)
AllCityCASI
Medications after ED visitAfter ED visit percentage of patients given:
—Prescription for systemic steroids
—Prescription for inhaled steroids/cromolyn
—Prescription for antibiotics
AllCityCASI
Medications—inhalerPatients with moderate or severe asthma prescribed a corticosteroid inhalerAllCityCASI
Patients with asthma for whom any type of metered-dose inhaler is prescribedAllCityCASI
During ED visit, formal training in use of metered-dose inhaler, spacerAllCityCASI
Percent of people with persistent asthma who have at least one filled prescription for a daily inhaled anti-inflammatory medicationAllStateOregon
Percent of people with persistent asthma who use more than one canister of a short-acting inhaled bronchodilator every two months for one year.AllStateOregon
Written asthma plansPatients with moderate or severe persistent asthma for whom written treatment plans are routinely developedAllCityCASI
Percent of people with asthma who have a written asthma action planAllStateOregon
Asthma educationPercent of people with asthma who have documentation of asthma educationAllStateOregon
Physicians' approach to asthma education.
Techniques listed: form education program, informal education delivered by nurse or physician, other, do not provide asthma education
AllCityCASI
During ED visit:
—Formal asthma education by physician or nurse
—Written asthma educational material
AllCityCASI
Percent of people with persistent asthma who have received education about their triggers and how to reduce their exposure to themAllStateOregon
NAEPP guidelinesPhysicians 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)
AllCityCASI
Consultation with asthma specialistPhysician’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 oldAllCityCASI
Percent of people hospitalized for asthma who are seen by an asthma specialist within one month of the hospital discharge dateAllStateOregon
Acute exacerbationsPatients 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
AllCityCASI
Preventive care—flu vaccinePercent of people with persistent asthma who have received an influenza immunization in the last 12 monthsAllStateOregon
Preventive care—allergen testingPercent of people with persistent non-seasonal asthma who have received allergen testingAllStateOregon
Hospital Care (Process)Standards of care—hospitalWhether a hospital is using the following hospital-wide:
—Currently using NAEPP guidelines
—Currently using critical pathways
AllCityCASI
Standards of care—ICUWhether the hospital is using the following in ICU:
—Currently using guidelines
—Currently using critical pathways
AllCityCASI
Standards of care—bedsideWhether care at bedside includes: nebulization, peak flow monitoring, peak flow instruction, evaluation of inhaler technique, inhaled anti-inflammatories, asthma educationAllCityCASI
Community-based care at hospitalsPercent 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
AllCityCASI
Emergency Department Care (Process)Assessment in EDWhether 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
AllCityCASI
Treatment in ED1. 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)
AllCityCASI
Follow up after ED visitPercent of patients given a specific followup appointmentAllCityCASI
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 dateAllStateOregon
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 visitAllStateOregon
Managed Care Organizations (Enabling factors)Management1. MCOs offering an asthma education program
2. MCOs offering an asthma case management program
3. MCOs offering an asthma disease management program
AllCityCASI
BenefitsAsthma-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
AllCityCASI
Patient Care—ProcessAsthma knowledgeReported 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.AllStateOregon
Percent of people with asthma who affirm receipt of information about asthma and treatment techniques.AllStateOregon
Percent of people with asthma who report high levels of confidence in understanding and using this information.AllStateOregon
Percent of people with asthma who report behavior consistent with having received and understood this information.AllStateOregon
Environmental triggersPercent 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
AllStateOregon
Mortality (Outcome)Mortality ratesMortality rates:
—By age and gender
—By borough
ChildrenCityNYCCAI
Avoidable events (Outcome)Emergency/Urgent careEmergency department visits per 1000 members with asthma.AllState health plansMQIC
Relapse ratePercentage of asthma patients estimated to relapse within 7 days.AllCityCASI
HospitalizationsHospitalization 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
ChildrenCityNYCCAI
Other dimensions (Prevalence)PrevalenceSelf-reported lifetime prevalence for adults age 18 and over:
—By age
—By race/ethnicity
—By borough
—By neighborhood
ChildrenCityNYCCAI
School-based prevalence:
—By gender
—By income (ZIP code areas)
—By borough
—By neighborhood
ChildrenCityNYCCAI
Other dimensions (Behavior)SmokingPercent of people with asthma who currently do not smoke cigarettes.AllStateOregon
Percent of non-smokers with asthma who are not exposed to tobacco smoke in the home.AllStateOregon

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)

Return to Contents
Proceed to Next Section

Current as of September 2009
Internet Citation: Appendix D: Asthma Measures (continued): Asthma Care Quality Improvement: A Resource Guide for State Action. September 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/asthmaqual/asthmacare/appendix-d2.html