Learning Objectives: Upon completion of Module 3, the user(s) will be able to: Use the quality improvement framework to identify various national and State approaches to ast

Asthma Care Quality Improvement: Workbook

Learning Objectives

Upon completion of Module 4, the user(s) will be able to:

  1. Understand quality measures and how measures of process and outcome can be used to track the quality of asthma care. This will help identify gaps in case, how closing them can improve health status, and how measures can be used as a basis for setting goals.
  2. Inventory available data systems and other resources to use in developing State or local estimates. A data systems inventory will identify existing data sources and collection mechanisms that might be adapted or enhanced to track quality improvement.
  3. Define "benchmark" as a measurement tool and understand how to identify appropriate benchmarks when developing quality improvement goals. Comparing a State's performance with national or other benchmarks will provide a clearer understanding of the State's level of asthma care and any potential need for change.
  4. List various sociodemographic, behavioral, and environmental factors that must be considered in setting quality improvement goals. Many factors outside the health care system can affect quality of asthma care processes and outcomes.
  5. Using appropriate benchmarks, draft goals for a State quality improvement effort.

In the Resource Guide, go to Quality Measurement and Multiple Dimensions of Quality for Asthma Care, including selecting process and outcome measures for these dimensions of care.

1. Understand quality measures and how measures of process and outcome can be used to track the quality of asthma care.

  1. Examine the diagram in the Resource Guide

    1. What does the diagram tell you about daily use of medications by people with asthma (a process measure) and number of hospitalizations for asthma (an outcome measure)?

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    2. How would increasing daily use of medications by people with asthma improve asthma outcomes?

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  2. Review Table 4.1 and Appendix D in the Resource Guide to learn about additional process and outcome measures and other dimensions of asthma care management. For many of the measures, special surveys or data collection efforts may be required. Does your State collect data for any of these measures?

    Process measures (such as medication use, management plans, self-management, planned care):

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    Outcome measures (such as symptom burden, work or school days lost, asthma hospitalizations): 

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    Other measures (such as access to care through insurance, asthma prevalence):

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2. Inventory available data systems and other resources to use in developing State or local estimates.

Go to Data Sources for Asthma Quality of Care in Module 4, Appendix E, and Appendix F in the Resource Guide. These sections present information on sources of measures and data for asthma care, including data limitations and State estimates for various measures.

  1. Begin an inventory list of the data sources available for your State below. You may wish to write down any questions or concerns you have about these data sources on the grid—items about which you need to contact data resource experts in your State. Place a "X" if data are available for your State.
    Data sourceXQuestions/notes
    Behavioral Risk Factor Surveillance System—CDC  
    Healthcare Cost and Utilization Project—AHRQ  
    HEDIS® data from the National Committee for Quality Assurance (available by region only)  
    National Asthma Survey—CDC  
    Other CDC surveys  
    State vital statistics  
    Special disease registries  
    Statewide hospital discharge data  
    Medicaid health provider reimbursement claims  
    State employee health benefits claims  
    Census population data  
    Area Resource File—HRSA  
    Kaiser Family Foundation  
    Other statewide or local sources (school, occupational health, environmental assessments, etc.)  
    Other setting-specific sources (hospitals, community health centers, primary care practices, etc.)  
    State and local initiatives from other States  

  2. Review your answers to questions 1.b and 2.a above. Can you identify any gaps in information or resources that you believe are important for assessing asthma care in your State? How will you address them?

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3. Define "benchmark" as a measurement tool and understand how to identify appropriate benchmarks when developing quality improvement goals.

Go to Using Benchmarks to Develop State Performance Estimates and Appendix G in the Resource Guide to find information on benchmarks and examples of how States may use them in quality improvement. Benchmarks are values that can be used as markers for measuring performance. Common benchmarks are national or regional averages, individual State rates, or best-in-class (top 10 percent of States) averages.

  1. Review your answers to question 1c in Module 1 where you compared your State with the national and best-in-class averages for asthma hospitalization rates. How did you assess your State's performance against these benchmarks?

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  2. Go to Asthma Benchmarks for States in the Resource Guide for six measures for which national and best-in-class benchmarks were calculated. These include four asthma process measures (routine care, medication use, advice to quit smoking, and flu shots) and two asthma outcome measures (urgent care and emergency room visits). These benchmarks are listed in Table 4.2 of the Resource Guide and reproduced in the table below.
    1. Go to Appendix Table E.1 in the Resource Guide; this table lists national and best-in-class averages for selected BRFSS measures by State, including the six measures below. Locate the values for your State and write them in the blanks. (If your State is not listed in Appendix Table E.1, or if your State collects its own data for these measures, contact your State health data agency for these percentages and write them in the table below.) Subtract your State average from the best-in-class average to assess how many percentage points your State must improve to be a top performer. Note on the last two measures, a lower value is better.
      MeasureU.S. average (%)Best-in-class average (%)Your State (%)Best-in-class average minus your State average (+/-)
      Planned/routine care for asthma (2 visits in past 12 months)28.340.4  
      Advice to quite smoking82.287.9  
      Flu shot (in past 12 months)40.353.3  
      Medication use for asthma (in past month)71.175.3  
      Urgent care visit (in past 12 months)28.119.4  
      Emergency room visit (in past 12 months)17.712.2  

    2. How does your State compare to the national and best-in-class averages for these measures? 

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  3. Review Figure 4.1 in the Resource Guide, which illustrates the national and best-in-class averages for these six measures and the range of variation among States in the four regions. Examples of how four individual States compare against benchmarks on some of these measures are shown in Figure 4.2Figure 4.3Figure 4.4, and Figure 4.5 in the Resource Guide.

    Again using Appendix Table E.1 (or your own State data), select two States with some characteristics similar to your State and write their values for these six measures in the following table. Subtract the percentages for each of these others States from your percentages. Write the differences below; check off measures for which your State is performing better than State A and/or State B.

    MeasureState A (%)Your State minus State A (points different)Better than State A
    X
    State B (%)Your State minus State B (points different)Better than State B
    X
    Planned/routine care for asthma (2 visits in past 12 months)      
    Advice to quit smoking      
    Flu shot (in past 12 months)      
    Medication use for asthma (in past month)      
    Urgent care visit (in past 12 months)      
    Emergency room visit (in past 12 months)      

  4. It is important to know whether a State's results are significantly different from the benchmark from a statistical standpoint. (Refer to Appendix H in theResource Guide for further information on statistical significance.) Look at your answers to question 3b above; then go to Appendix Table E.1.
    1. Are any of the percentages for your State significantly above the national average (as indicated by a + sign next to the value for your State in Appendix Table E.1)? Which ones? 

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    2. Are any of the percentages for your State significantly below the national average (as indicated by a − sign next to the value for your State in Appendix Table E.1)? Which ones?

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    3. Are any of the percentages for your State within the best-in-class range and thus not significantly different from the best-in-class average (as indicated by a † sign next to the value for your State Appendix Table E.1)? Which ones?
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  5. Using your answers to question 3d above, together with the discussion of four States of the Resource Guide as examples, write a similar analysis of your State's results. On which measures is your State doing well? In what areas could you improve?
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4. List various sociodemographic, behavioral, and environmental factors that must be considered in setting quality improvement goals.

Go to Factors That Affect Quality of Asthma Care in the Resource Guide. A State's performance on quality measures may be affected by a number of factors, including poor access to health care, high proportions of subgroups with no insurance, cultural attitudes toward health care providers, etc. In addition State or employer decisions regarding coverage policies may affect the way providers deliver care. For example, certain asthma medications may not be reimbursed by a patient's health plan, and so the patient may have to pay out of pocket for certain prescribed medication and may not be able to afford them. There are also factors over which States have little or no control, such as asthma prevalence and population characteristics. (To find additional information on measures for some of these factors, such as percentage of population uninsured, you can use the Henry J. Kaiser Family Foundation Web site on State health facts at http://www.statehealthfacts.org.)

  1. What characteristics of your State, its infrastructure, and your State's population might help to account for your answers to questions 3d and 3e above? For example, does your State have a substantial Medicaid population or large numbers of uninsured persons, racial or ethnic minorities, people with less than a high school education, or other vulnerable groups? 
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  2. What other issues or concerns might affect your State's performance in asthma care? Are there additional factors that you and your team need to consider in determining your starting point and setting initial goals for quality improvement in asthma care?
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5. Using appropriate benchmarks, draft goals for a State quality improvement effort.

  1. Look at your answers to question 1c in Module 1 and question 3a-3d in Module 4 on how your State compares with benchmarks on the asthma measures presented here. (If necessary, also review Benchmarks and Appendix G in the Resource Guide for a discussion of types of benchmarks and why different benchmarks might be chosen in different circumstances.)

    1. To begin your quality improvement effort, which benchmarks for the following measures would you select for your State? Place a "X" in the blank of the measure you select. If you check "Other benchmark" for your State, describe it (for example, a regional average).
      MeasureU.S. average (X)Best-in-class average (X)Other benchmark (describe)
      Planned/routine care for asthma (2 visits in past 12 months)   
      Advice to quite smoking   
      Flu shot (in past 12 months)   
      Medication use for asthma (in past month)   
      Urgent care visit (in past 12 months)   
      Emergency room visit (in past 12 months)   
      Asthma hospitalization rate (per 100,000):   
      • Children
         
      • Adults <65
         
      • Adults 65+
         

    2. For each measure, why did you select that benchmark? Write your reasons below.

      Planned/routine care for asthma (2 visits in past 12 months):
      Advice to quit smoking:
      Flu shot (in past 12 months):
      Medication use for asthma (in past month):
      Urgent care visit (in past 12 months):
      Emergency room visit (in past 12 months):
      Asthma hospitalization rate (per 100,000):
      • Children
      • Adults <65
      • Adults 65+

    3. Set a preliminary goal to reach the benchmark for the measures you have selected. The following are some examples of goal statements:
      • Increase the percent of adults with asthma who receive a planned care visit for asthma once every 6 months to the level of the best in class average—40.4 percent—within 2 years. (The specifics on these measures (e.g., which measures and period of time to reach the goal) should be established by your quality improvement team).
      • Increase use of inhaled corticosteroids medication for adults with persistent asthma to the level of use on average across the Nation—71.1 percent of adults with asthma—within 2 years.
      • Increase the percent of adults with asthma who receive flu vaccinations to the best-in-class average—53.3 percent—within 2 years. (An aggressive program might set an even higher goal or tighter time frame.)
      • Reduce the hospitalization rate for asthma to the best-in-class averages (for children, 72.3 per 100,000) and for adults under age 65, 60.2 per 100,000).
      • Identify the barriers to obtaining planned/routine care visits, smoking cessation counseling, or flu vaccinations.

      What are the preliminary goals for the following?

      Planned/routine care for asthma (2 visits in past 12 months):

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      Advice to quit smoking: 

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      Flu shot (in past 12 months):

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      Medication use for asthma (in past month):

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      Urgent care visit (in past 12 months):

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      Emergency room visit (in past 12 months):

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      Asthma hospitalization rate (per 100,000):

        Children

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        Adults <65

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        Adults 65+

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  2. You may want to go beyond the measures listed above. Refer to Appendix E in the Resource Guide for additional BRFSS asthma measures you may want to consider in your quality improvement effort. Some of these measures are listed below. Are any of these measures appropriate for your State? Note those you want to investigate further.

    Asthma attacks/episodes (in past 12 months):

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    Limited activity days (in past 12 months):

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    No sleep difficulty due to asthma (in past month):

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    Doctor visit for asthma (in past 12 months):

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    Asthma symptom-free days (in past 2 weeks):

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    Asthma symptoms everyday (in past 2 weeks):

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    Other:

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Guidance for Setting Goals:

  • Consider this goal setting exercise as preliminary to enhance your understanding.(Stakeholders who will become partners and champions of the initiative must have a part in goal setting for the program. Clinicians in your community who are experts in asthma care may want to enhance the goals listed above. Only by engaging local experts will the goals reflect the circumstances that the community faces and be more likely to be supported by leaders in the health care community.)
  • Note whether your State is extremely low, close to the national averages, or within the best-in-class averages. Your position relative to these benchmarks will indicate how far your State must go to be among the best performing health care systems. Do you want to set long-range and short-range goals?
  • Remember that you will have to identify and address the underlying issues that affect your State's position.
  • The measures featured here are only a subset of the meaningful goals and are not necessarily the only goals for asthma quality improvement in your State. (Refer to Appendix D and Appendix E in the Resource Guide for additional asthma measures.)
  • As you move through the planning process and discover new information, you can come back and change your goals to reflect your new knowledge.
  • Your quality improvement program for asthma care should ultimately be designed to reach the goals set by the full quality improvement team.

Source: Adapted from B. Kass. Diabetes Care Quality Improvement: A Workbook for State Action. Rockville, MD: Agency for Healthcare Research and Quality, 2004.

Page last reviewed April 2013
Internet Citation: Learning Objectives: Upon completion of Module 3, the user(s) will be able to: Use the quality improvement framework to identify various national and State approaches to ast: Asthma Care Quality Improvement: Workbook. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/asthmaqual/asthmawkbk/asthmawkbkmod4.html