Asthma Care Quality Improvement
Improving the quality of health care in America remains a widely shared national objective. The ultimate goal of quality improvement is to close the gap between current practice and best practice as defined by the medical community. Closing this gap can contribute to improved health care in a number of ways: reduced costs, more efficient care delivery, fewer complications, and better quality of life for patients.
The National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) published annually by AHRQ provide extensive research and data on the extent of health care quality gaps as well as national benchmarks for quality. This Resource Guide draws on the NHQR and the NHDR to support State-level efforts to improve the quality of care for asthma. It is an update to the second Resource Guide and Workbook published by AHRQ; the first Resource Guide and Workbook addressed diabetes quality of care. This Resource Guide combines the data assembled for the NHQR and other sources with a variety of background, analysis, and policy information on asthma.
Why Should States Make Asthma a Priority?
Asthma is a chronic condition that affects the lungs and is characterized by episodes of wheezing, breathlessness, chest tightness, and coughing. 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 in and out of the lungs. These episodes are usually the result of exposure to asthma "triggers." These include infections such as colds and bronchitis; irritants such as second-hand tobacco smoke, dust mites, air pollution, and cockroach debris; other allergens such as furry pets and mold; and other triggers such as stress, exercise, and abrupt changes in the weather.
The prevalence of asthma among Americans has nearly doubled in the past two decades. In 2007, 29.3 million people had been diagnosed with asthma at some point in their lives and nearly 23 million people stated they currently had asthma (CDC, 2009; Pleis and Lucas, 2009).
Asthma is also a costly disease: the estimated cost of asthma was $19.7 billion in 2007. This total is composed of direct costs—estimated at $14.7 billion from physician visits, hospital stays, and medications—and indirect costs—estimated at $5 billion from lost work days, school absenteeism, and lost earnings (ALA, 2009).
For several years, asthma has been a target for quality improvement efforts by States and other health care entities because of the following:
- Increased prevalence of asthma, especially among children and adolescents.
- Disparities between socioeconomic groups and between racial/ethnic groups in terms of diagnoses and quality of asthma care.
- A range of interventions and treatments that can successfully manage the disease and prevent attacks.
- High health care cost of uncontrolled asthma and the potential for a positive return on investment for purchasers and the health care system as a whole through asthma quality improvement.
Data from the NHQR and NHDR demonstrate that there are wide variations in quality of care for asthma across States and across different socioeconomic strata and racial and ethnic groups.
Why and How To Use This Resource Guide
State leaders can play a central role in leading asthma care quality improvement. This Resource Guide is designed to equip them with information resources and a model for taking action.
Purpose of the Resource Guide
The purpose of this Resource Guide and companion Workbook is to assist State policymakers and others in planning and implementing a State-level quality improvement initiative for improving asthma care.
Specifically, the Resource Guide:
- Describes the need for improvement in quality of care for asthma and the potential for returns on State investments.
- Offers a model for how State leaders can lead efforts to improve asthma care quality, along with examples of State-level activities underway.
- Presents examples of current State-led efforts to improve asthma care.
- Presents the multiple dimensions within which health care quality for asthma can be measured, examines metrics for assessing State performance, and provides data from the NHQR and other data sources on asthma to help inform State decisionmaking.
Audiences for This Resource Guide
Quality health care is delivered by providers in clinical settings. Thus, quality improvement ultimately needs to influence what happens in a doctor's office, hospital, or clinic. Even so, State leaders and policymakers can have an enormous impact on health care:
- They can articulate a vision that inspires action and change.
- They can involve strategic partners and champions who can reach the front lines of health care.
- They can assemble information that focuses the attention of health care providers at the local level, just as the NHQR does at the national and State levels.
- They can enable health care improvement strategies to be tailored more skillfully for State and local health care markets.
As purchasers and regulators, States can supply incentives for providers to make the changes necessary to improve the quality of health care. Thus, the main audiences for this Resource Guide include:
- State elected leaders—Governors and legislators (and their staffs) who provide leadership on health policy.
- State executive branch officials—Executive office appointees and career staff charged with taking action on important health issues, such as State health department and State Medicaid officials.
- Nongovernmental State and local health care leaders—Members of professional societies, provider associations, quality improvement organizations, voluntary health organizations, health plans, hospital associations, business coalitions, community organizations, consumer groups, and others who want to stimulate action on health care quality improvement at the State level.
Organization of This Resource Guide
This Resource Guide is divided into five modules. To assist readers in finding the information they need, the beginning of each module previews the contents and highlights key ideas. Each module ends with a summary and synthesis to demonstrate how to use the module and how to move to the next step. Also, a resource list for further reading and a discussion of associated appendixes are included where applicable.
State leaders in different parts of State government have different roles in quality improvement. This Resource Guide is addressed to State leaders, who have key contributions to make to the quality improvement process. Users can skip to the sections that are most relevant and appropriate for them.
The modules are organized as follows:
- Module 1: Making the Case for Asthma Care Quality Improvement—describes both the need and opportunity for quality improvement in asthma care. The module answers the following questions: What is asthma? What are current trends in the prevalence of asthma and the cost burden for people with asthma? What opportunities exist for improving care and outcomes for people with asthma and reducing the cost of asthma care?
- Module 2: A Framework for State-Led Quality Improvement—presents an operational approach for leaders to use in their quality improvement efforts. Synthesized from existing models of health care quality improvement, the framework outlines a leadership role for States in setting goals for improvement, convening partners, designing interventions, and assessing their impact through careful measurement and data analysis.
- Module 3: Learning From Current State Quality Improvement Efforts—examines current State efforts to improve the quality of care for asthma. This module summarizes various approaches to asthma quality improvement as they relate to championing quality, creating partnerships, planning for change, implementing the vision, evaluating effectiveness, and spreading success. It also highlights State activities underway at each stage of quality improvement.
- Module 4: Measuring Quality of Care for Asthma—examines measures and data issues that affect asthma care quality and improvement. This module describes current measurement issues and current metrics for assessing asthma care quality and examines a variety of data sources that State leaders can use to assess the quality of care in their States. It provides specific benchmarks of process and outcome measures from the NHQR and the Behavioral Risk Factor Surveillance System (BRFSS) on asthma care. An analysis using BRFSS data from four States—Maryland, Michigan, New Jersey, and Vermont—presents concrete examples of how one can draw conclusions from the data that can spur local action. Finally, the module shows how to derive estimates from available data to fill data gaps for particular States. These include examples for estimating the direct and indirect costs of asthma, Medicaid spending for each State, and cost effectiveness of an asthma intervention for Medicaid primary care case management programs.
- Module 5: Moving Ahead—Implications for State Action—describes how State leaders can initiate a public policy-focused quality improvement effort for asthma care. This module describes specific steps that States can take in each of the three basic areas of activity: lead, partner, and improve.
Supplementary information on data sources and other resources for State leaders as they address asthma care quality improvement are provided in the appendixes.
A complementary Workbook mirrors the five modules presented in this Resource Guide and provides a set of exercises and more detailed instructions on how State leaders can find and develop their own State data for asthma care quality improvement.
Overall, this Resource Guide and its companion Workbook are designed to be a complete manual for State leaders at all levels interested in improving the quality of care for asthma in their States.