Module 4: Measuring Quality of Care for Asthma
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.
- Examine the diagram in the Resource Guide.
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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______________________________________________________________________________ How would increasing daily use of medications by people with
asthma improve asthma outcomes?
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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.
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 source |
X |
Questions/notes |
| Behavioral Risk Factor Surveillance System—CDC |
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| Healthcare Cost and Utilization Project—AHRQ |
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| HEDIS® data from the National Committee
for Quality Assurance (available by region only) |
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| National Asthma Survey—CDC |
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| Other CDC surveys |
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| State vital statistics |
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| Special disease registries |
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| Statewide hospital discharge data |
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| Medicaid health provider reimbursement
claims |
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| State employee health benefits claims |
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| Census population data |
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| Area Resource File—HRSA |
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| Kaiser Family Foundation |
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| Other statewide or local sources (school, occupational health,
environmental assessments, etc.) |
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| Other setting-specific sources (hospitals,
community health centers, primary care practices, etc.) |
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| State and local initiatives from other States |
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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.
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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______________________________________________________________________________ -
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.
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.
| Measure |
U.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) |
28.3 |
40.4 |
|
|
| Advice to quite smoking |
82.2 |
87.9 |
|
|
| Flu shot (in past 12 months) |
40.3 |
53.3 |
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|
| Medication use for asthma (in past month) |
71.1 |
75.3 |
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|
| Urgent care visit (in past 12 months) |
28.1 |
19.4 |
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|
| Emergency room visit (in past 12 months) |
17.7 |
12.2 |
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|
How does your State compare to the national and best-in-class
averages for these measures?
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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 4.2,
Figure 4.3,
Figure 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.
| Measure |
State 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) |
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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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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 the Resource Guide for further information on statistical significance.) Look
at your answers to question 3b above; then go to
Appendix Table E.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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_____________________________________________________________________________ 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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_____________________________________________________________________________ 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 in
Appendix Table E.1)? Which ones?
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_____________________________________________________________________________ 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.)
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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_____________________________________________________________________________ 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.
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.)
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).
| Measure |
U.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 |
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|
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| Flu shot (in past 12 months) |
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|
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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):
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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): |
|
|
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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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______________________________________________________________________________ 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. |
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