Affiliations: Bellevue, WA
Dr. Stempel is affiliated with Infomed Northwest and the University of Washington.
Correspondence to: David A. Stempel, MD, InfoMed Northwest, Bellevue, WA 98004; e-mail: firstname.lastname@example.org
The measure of a successful guideline implementation is the ability to present data on the improved health status of the population addressed by the recommendations. Performance measures are selected based on their validation and the ability to monitor large populations at a reasonable cost. At the time of the initial National Asthma Education and Prevention Program (NAEPP) guideline in 1991,1 asthma morbidity and mortality were increasing. These trends have plateaued, and the annual mortality from asthma appears to be declining despite the increasing prevalence of the disease. Although these changes appear to be positive, cause and effect need to be demonstrated.
The National Committee on Quality Assurance (NCQA) has developed quality indicators for many disease states including persistent asthma. The NCQA has stated that the use of one or more controller medications is a quality indicator2 for patients with persistent asthma, who were defined as having one or more of the following: one or more asthma-related hospitalizations or emergency department visits; four or more asthma-related medication dispensings; or four or more asthma-related outpatient visits with two or more asthma-related medication dispensings. Patients are qualified with these criteria in year 1 and studied in the following year.
The NAEPP established the following six goals of treatment: three are patient-centric outcomes; one is a physiologic measurement; one assesses resource utilization; and another is the provision of optimal pharmacotherapy.3The NAEPP gives no guidance as to the relative value of each of these goals. Schatz and colleagues4 in this issue of CHEST (see page 43) propose and validate the fact that a ratio of controller medication to total asthma medication of ≥ 0.5 is associated with improved patient-centric outcomes and decreased resource utilization while providing recommended medication.
The NCQA has selected the use of one or more of any asthma controller medication as evidence of good care. Although earlier observational studies5seemed to indicate that this might be a reasonable starting point, it is unclear whether a supply of ≥ 1 month of any controller medication defines good care. Several other studies6–7 have indicated that the consistent use of inhaled corticosteroids was associated with decreased asthma-related hospital care. The presence of a claim for any single controller medication may identify a physician intervention and not the effect of the medication. Alternatively, the selection of any one controller medication may be confounded by a population with less disease severity. The caution of selecting any controller medication is reflected in the 2002 NAEPP guideline, which discusses the value of cromolyn as follows: “However, when data regarding the efficacy of cromolyn recently were systematically reviewed [Tasche et al 20008–], the authors concluded that insufficient evidence existed to conclude that cromolyn had a beneficial effect on maintenance treatment of childhood asthma.”9
Schatz and coworkers10 have previously demonstrated that the ratio of controller medication to total asthma medication use is superior to the NCQA measure of selecting one or more controller medications. The present report4 does not address whether selecting a specific controller medication would alter the results. This article reports that 80% of patients meeting the NCQA enrollment criteria received therapy with inhaled corticosteroids. While nearly 50% of patients received leukotriene modifiers, < 6% received them as their only controller medication. Other controller medications were prescribed to < 5% of patients. Since inhaled corticosteroids are the predominant controller medication in this report, it is uncertain whether the results are driven by the higher use of inhaled corticosteroids or whether these results are generalizable to all controller medications.
The strength of the present article is that it validates the medication ratio measure with three patient-centric outcomes. The four criteria used to assess the asthma medication ratio of ≥ 0.5 in this report were as follows: (1) mini-asthma quality-of-life questionnaire score; (2) patient assessment of asthma control; (3) the use of the asthma outcomes monitoring system; and (4) resource utilization in the inpatient or emergency care setting.4 In this analysis, the medication ratio of ≥ 0.5 was associated with improved outcomes for all four domains. Although the predictive value of the medication ratio is modest, it is higher than that of any controller medication use and demonstrates the validity of this ratio to the patient-centric NAEPP goals.
Schatz and coworkers4,10 have studied the HEDIS performance measure, reviewed the evidence, and developed and then tested an alternative measure for asthma. They have demonstrated that the controller medication to total asthma medication ratio is more predictive of better outcomes than the NCQA criteria for a range of patient-oriented outcomes. A possible limitation of these data are that Kaiser Permanente is a unique health-care delivery system that is able to capture and analyze linked medical and pharmacy data in an efficient and comprehensive manner. This ability may limit the generalizability of these results to other managed care organizations. Albuterol dispensing in other health-care systems may fall under the copayment and not be recorded, and therefore may adversely affect the ability to collect the data needed for determining this ratio. In these settings, alternative measures such as a quantity of controller medication or a pattern of consistent use of controller medications may need to be studied.
The present report did not attempt to validate the NCQA denominator. The criteria established for persistent asthma by the NCQA increases the specificity of identifying a patient with persistent asthma. But asthma is a disease that is associated with the underreporting of symptoms.11The relative importance of increased sensitivity compared to maintaining specificity needs to be studied. A process measure proposed by the National Quality Health Forum12 to assess the level of asthma control (either by quantifying symptoms or performing a validated asthma control test) could be implemented to increase disease recognition and the need for medical intervention. Appropriate identification is required before one can begin to measure appropriate treatment. This proposed measure to assess control addresses a different but equally important issue.
The article in this issue of CHEST by Schatz and colleagues4 reports the development and validation of performance measures for patients with asthma. This measure is appropriate for health-care systems that have access to linked medical and pharmacy claims. Future studies need to focus on refining the definition of adequate controller medication use, the generalizability of the data to other populations, and the need to demonstrate that all patients who are burdened with the symptoms and limitations of asthma receive appropriate care.
Dr. Stempel has served as a consultant and a member of the speaker’s bureau for GlaxoSmithKline.
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