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Relationship between process quality measures and acute care utilization for people with asthma enrolled in Medicaid

Yong P, Werner RM. Relationship between process quality measures and acute care utilization for people with asthma enrolled in Medicaid. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.


Research Objective: As controller medications for asthma prevent exacerbations, whether or not patients appropriately receive these medications is currently used as a HEDIS quality measure. However, prior studies of this measure suggest that receipt of controller medications is associated with higher rates of asthma exacerbations, possibly due to unmeasured disease severity. While alternative measures have been proposed to try to account for differences in disease severity, little is known whether these alternative measures are predictive of clinical outcomes. The objective of this study was to compare the association between quality measures and asthma exacerbations among Medicaid beneficiaries for three quality measures: the current HEDIS asthma metric of receipt of at least 1 controller medication in a calendar year and 2 recently proposed asthma quality metrics. Study Design: We performed a retrospective cohort study of Medicaid beneficiaries with persistent asthma, as defined by HEDIS criteria using outpatient, inpatient and pharmacy service use for asthma in 2001 - 2002 in California and New York. We assessed 3 asthma quality metrics for each beneficiary in 2002: 1) the current HEDIS measure of filling at least 1 controller medication prescription; 2) filling at least 4 controller medication prescriptions; and 3) a controller-to-total asthma medication ratio of at least 0.5. The first comparison metric assesses whether those with asthma receive at least 4 controller medication dispensings in a calendar year. The second comparison metric is a controller-to-total (controller plus short-term reliever) asthma medication ratio of at least 0.5, which may better reflect control of asthma symptoms as those with well-controlled disease will need less short-term reliever medication and thus will have a higher ratio. We calculated the odds of having an asthma exacerbation (defined as an emergency department [ED] use or hospitalization for asthma) in 2003 as a function of performance on each of the quality metrics, adjusting for race, sex, age and prior use of acute care services for asthma. Population Studied: 50,505 persistent asthmatics in CA (52.3%) and NY (47.2%). Principal Findings: Those who obtained at least 1 or at least 4 controller medications had increased likelihood of poor outcomes (adjusted ORs 1.46 [95% CI 1.34 - 1.59] and 1.19 [95% CI 1.12 - 1.26], respectively). In contrast, beneficiaries meeting the controller-to-total asthma medication ratio measure were 19.1% less likely to utilize acute care services (adjusted OR 0.81 [95% CI 0.76 - 0.86]). Conclusions: A higher controller-to-total asthma medication ratio was predictive of lower likelihood of subsequent ED visits and hospitalizations for asthma, whereas assessing number of prescription dispensings for controller medications predicted higher odds of acute care utilization regardless of the number filled. Implications for Policy, Delivery or Practice: While appropriate treatment of asthma using controller medications is an important component of high quality care, quality metrics based on this process of care vary in their association with clinical outcomes. Adequate assessment of quality of care for asthma should include process measures that are predictive of good clinical outcomes.

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