Portions of this review (c) 2006 Brian Altonen 

A Study of an Asthma-related Risk Assessment Method applied to a Medicaid Managed Care Population

 A common HEDIS and NCQA topic for institutions to evaluate how effective preventive care is for individuals with a moderate to severe form of asthma.  The HEDIS/NCQA protocols for such a study tend to divide these individuals into three separate age categories: 5 to 9 years of age, 10 to 17, and 18 to 45.   Individuals over the age of 45 may be evaluated as well, but due to typical population health behaviors and the related statistics, many individuals who might potentially be identifiable as asthmatics are in fact suffering from COPD and other forms of respiratory distress that have nothing to do with asthma-related cause and effect events.  These cases typically include such conditions as emphysema due to long-term smoking, a cystic fibrosis history, bronchiectasis brought on by a long history of pulmonary infection, allergy-induced conditions mimicking asthma non-asthma related causes such as plant, animal and other environmental allergens, and chemically and  genetically-induced respiratory distress syndromes related to one or more structural or histological changes in pulmonary tissue thereby impacting normal respiratory activities and pulmonary function testing results.

The HEDIS/NCQA method uses the following risk indicators to identify high risk cases:  4+ visits per year for asthma related reasons, 1+ visits during the past year in an ED/ER or UC setting due specifically to asthma-related problems, and/or the need for hospitalization due to an asthma related event.  The individuals identified based on these features must have a claims history indicating that one or more of the above events took place within the past twelve to fifteen months, and a history of diagnosis of asthma indicated by at least one visit in which the ICD (473.xx) was attached to the visit’s claim record.  In most cases, an individual with just one visit related to a possible asthma-related event will not be placed on the listing of potential candidates for this review of ongoing care management of asthma.  Those eligible for this review will usually have a second or back-up diagnosis of the same, sometimes extending back to one of the first visits.  In cases where just one diagnosis is documented, and the appropriate medications demonstrate a clear history of asthma-related respiratory care, and/or one or more visits are assigned a visit code which defines the visit type as asthma/COPD related, one can usually continue on with a review of this case until other factors result in the removal of this person from the list of asthmatics being researched.

The next step taken with this research is to study the preventive behaviors these patients and their providers are engaged in.   This stage in the analysis is typically focused upon medication regimens, including a review of whether or not the patients are on some long-term bronchodilator therapy for asthma, usually applied in stages for preventive purposes as well as for reactive purposes (the result of an asthmatic attack).  But the most important indicator as to whether or not preventive activities are engaged in is determining whether or not the patient is using some form of steroid medication directed towards preventing the inflammatory response linked to severe asthmatic attacks.  The ongoing use of standard oral steroidal medications in this case, such as to deal with RA or some other inflammatory condition, may not suffice in this case.  The steroidal produce prescribed to asthmatic patients must be of the type that is approved for use in asthma-related preventive therapy typically, this means that the source of the steroid is some sort of combination asthma prevention product, or some sort of single steroid product aimed at providing the same benefits.  On occasion, the administration of leukotrienes has been accepted for a steroid substitute in some measures taken on prevention of asthma-related events. But for the most part, these agents are measured separately regarding their administration to asthmatic patients, usually added to the count of steroid-related treatment programs for som but not all program measures.   

Since NCQA requires two measures be taken for a particular program to be developed and considered valid, the other measure for asthmatics is typically either a review of their visits per year to a PCP in order to reassess and update therapeutic measures being taken to prevent severe asthma-related events, or simply a review of their engagement in the other asthma-related protocols such as the completion of a risk assessment survey or participation in a preventive care well visit for asthma at least once during the measurement year.  Currently, the use of leukotrienes for treating high risk asthmatics has not been a focus of this part of the study due to the low incidence of use of such products and their varied applications due to the manner in which they work, yet this is one common measurement taken when evaluating the treatment of chronic asthma.   Receiving a flu or pneumonia shot is another common measure due to the potential for pulmonary function related morbidity effects due to these two infectious diseases.  Whether or not an asthmatic smokes (tobacco or non-tobacco) is also measured, but is a measure that typically is hard to change the results for and so not added to most QIAs and PIPs.

Defining Risk

To define risk for a patient with asthma, two scores need to be developed to determine the degree of proactiveness the patient/PCP combination undertake due to the patient’s condition [the proactive score], and the degree to which the patient alone responds to his/her asthma-related problems, condition or visits [the reactive score].

In terms of defining this risk indicator, each of the following measures are used to predefine whether or not an individual eligible for HEDIS/NCQA reviews needs to be evaluated and scored for this study.

The first set of scores are defined by HEDIS/NCQA.  Each is considered an indicator of high risk, and when occurring in combination may be used to rank each of these complying with these claims history based upon the numbers of times each of these high risk events took place during the past year:

  1. 4+ regular office visits for asthma-related reasons [1 point for 4, 1.5  for 5 visits, 2 for 6 visits, etc.]
  2. 1+ ED visit(s) for an asthma-related reason [1 point for each]
  3. 1+ UC visit(s) for an asthma-related reason [1 point for each]

 

There are several other behaviors that should be measured in order to evaluate the success of a given asthma preventive care program.    These measures focus on both the patient and the PCP, and provide a more complete review of the overall disease prevention process engaged in by a particular program.  Those measures related to the individual with asthma include reviews of:

  1. engagement in preventive rather than reactive asthma-related care visits, at least once per year [1 point, proactive],
  2. engagement by the patient in determining whether or not specific environmental features exist within the home and work settings, completing separate specialized surveys used to measure each of these risk indicators [1 point, proactive; 1-5 points reactive of 1+ possible causes are identified.]

 

At the provider level, activities engaged in clinically can be assessed and statistically evaluated for the following preventive activities a PCP should be engaged in.  Some of these are measures made of lifestyle-related decisions made by asthmatics, which are known to increase their risk of long-term problems due to asthma history.  Since a number of these processes are more proactive in nature, they are categorized as such and considered preventive measures more than reactive measures. engaged in with the goal of improving QOL and reducing morbidity and mortality rates for chronic asthmatics.

  1. The completion of a listing of overall medication history performed at least once per year, as part of the Asthma care management visit the patient is involved with [1 point, proactive].
  2. The completion of a survey tool by the PCP and patient, used to measure overall risk for asthma and the level of severity for this state based on the past two years worth of history involving ER/UC/IH visits and stays, the types of medication prescribed as used, with an evaluation of amounts used per year or month for each of the two main groups of asthma medication, and whether or not the patient is making use of a leukotriene to prevent the onset of asthma related events [1 point, proactive].
  3. The documentation as to whether or not a nebulizer is used [1 point, proactive].
  4. Evidence for use of a tobacco smoking product [1 point, proactive]
  5. Evidence for use and/or history or a non-tobacco smoking product [1 point, proactive]
  6. Evidence for an annual flu shot [1 point, proactive]
  7. Evidence for an annual pneumonia shot [1 point, proactive]
  8. Documentation as to whether or not a history of exercised induced asthma exists [1 point, proactive].

 

An additional series of evaluations can be made of activities engaged in by both the PCP and the patient involving other departments.  These include the processes used to review  each of the following states of the patient based on their personal medical history.  These measures may be either proactive or reactive in nature.  The latter, more demographic like measurements serve as indicators of risk related to lifestyle and uncontrollable living conditions histories.  These are considered to be human environmental features that are not necessarily controllable by the patient alone, but serve as important indicators of cases that may be considered exceptionally high risk cases in need of more targeted management activities, engaged in as part of a long-term treatment practice.

  1. The patient’s immunological status and allergy-related histories in order to determine the impacts of these types of events on overall health and prognosis, indicated by completion of an age-related allergy history survey.
  2. Continuation of this documentation process, if necessary, in the form of an immunological skin test used to define allergens
  3. Documentation of home pet or animal histories for positive-testing environmental cases
  4. Evidence for discussion of these and other environmental risks with parents and/or patient.
  5. The engagement in pulmonary function testing at least once every two years, and for specific high risk cases, at least once per year.
  6. Documentation of evidence for types I, II, III, and IV reactivity to certain environmental agents [1 point, proactive; optional, based on local environmental conditions and history.]
  7. Documentation of patients overall health and living status based on the following socioeconomic (GINI) indicators:
  8. Estimated family income range (3 scale) based on parental employment history and/or heath care insurer type and history [2,1,0]
  9. Estimated SES group based on address information in relation to census block data (5 scale, 0-4)
  10. Patient’s estimate of degree of exposure to pollutants based on placement of domestic and work settings (scalar, 0-6)
  11. Form of health care coverage (0,1,2::None or limited/minimal, versus Medicaid/Medicare versus Private)
  12. Engaged in other insurer-provided intervention activity related to chronic condition (such as use of hotlines, referral services, recipient of educational materials, provision for free or reduced cost preventive services or activities, involvement with special needs groups, etc., 1 point per activity type)

 

The following table summarizes the scoring based on the use of the above described methodology for reviewing asthma risk, based on claims and medical records data.  It is important to note that this method extend much further than typical HEDIS and NCQA techniques, and is designed for use in identifying reasons for increase risk in order to facilitate the development of more effective prevention related techniques at the interventions level.

There are two ways in which outcomes might go regarding patient behavior.  Values are expected to range from 0 to 50.  Demonstrating an outcome in a single line drawing model, one would place risk to the left (Reactive Scores) and benefits to the right (Proactive scores).  An ideal outcome of course is somewhere to the right of the central fulcrum; the further to the right the better the outcome.  We can measure the reactive side of this measurement tool and compare it with the scores linked to the proactive side.  This single value would be greater than zero for positive test results and negative outcomes for negative test results.  We can also review each on these measures independently, to determine where the first steps need to be taken to have the greatest impact on outcomes then next time such as measurement is taken.  When we related this methodology to standard age-defined techniques used to evaluate the Asthmatics population, we will find for example that each group has a different final score and different imbalance in services and activities provided or engaged in for prevention related purposes.  An ideal outcome will have proactive scores approximating 50 and reactive scores approximately 0.  But in reality it is safe to consider a proactive score of 35 or better to be considered highly productive, a proactive score of 25 to 35 moderately productive, and 15 to 25 fair in terms of productivity.  Scores that are between 15 and -15 (towards the reactive side) represent individuals who are most easily modified so as to prevent unnecessary costs from accumulating due to unexpected asthma related events.  Scores below -15 suggest an individual is most likely of very high risk of becoming a burden to the health care system should adequate preventive and proactive steps not be taken to modify their lifestyles, behaviors, and predisposition for undergoing an asthma-related emergent care event.  

The lower the score is below -15, the more impact financially an intervention will have on the cost to the system as a whole.  This is because these high risk cases already demonstrate a history of high cost events such as hospitalization and the need for urgent/emergent care.   The best approach to dealing with asthmatics identified as being within these various subgroups is to take different intervention steps for managing these various groups.  The borderline groups can be better managed clinically and pharmacologically, the extremely high risk groups require aggressive case management activities as well. 

To interpret outcomes related to these activities, whereas Claims data was used to identify the initial list of members to be monitored for adequate asthma-related preventive care activities, the inpatient and outpatient data has to be used to determine whether or not the appropriate activities and events are taking place in a timely fashion.  Then, by reviewing pharmacy-related data, we can determine what stage the individual is in with regards to risk, and determine whether or not an aggressive change has taken place according to HEDIS/NCQA standards.  The best indicator of the latter is determining whether or not the use of anti-inflammatory medications has increased, and whether or not leukotriene use has increased pro re nata.