Optimal Asthma Control Data Specifications Final Version December 2009: Updated for Population Identification April 2010 MNCM Measure Description Methodology Rationale Composite measure of the percentage of pediatric and adult patients who have asthma. Optimal care is defined as: - Asthma is well controlled - Patient is not at increased risk of exacerbations - Patient has a current written asthma action/management plan Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Data is submitted via the direct data submission process using MNCM s portal to upload data files. Roughly 7% of adults and children in Minnesota are currently living with asthma. Asthma is a chronic disease associated with familial, infectious, allergenic, socioeconomic, psychosocial and environmental factors. It is not curable but is treatable. Despite improvements in diagnosis and management, and an increased understanding of the epidemiology, immunology, and biology of the disease, asthma prevalence has progressively increased over the past 15 years. In addition, variation in practice from recommended clinical guidelines is evident with only 33% of adult asthma patients in Minnesota reporting in 2005 to having an action plan and 75% reporting instruction on what to do when having an asthma attack. It is up to providers to assess patients, prescribe medications, educate about self-management, help patients identify and mitigate triggers so patients can prevent their exacerbations. Measurement Period Measurement period will be a fixed 12 month period. For the first data collection, data will be collected for dates of service July 1, 2010 June 30, 2011. Medical groups will be requested to submit data to Minnesota Community Measurement beginning on July 11, 2011. Denominator: Patients with asthma Established patients meeting the following criteria: Date of birth on or between 07/01/1960-06/30/2005 (ages 5-50 during the measurement period). Patient has been seen at least two times for asthma (face-to-face with a provider) in the past two years (07/01/2009-06/30/2011) AND patient has had at least one office visit during the measurement period (07/01/2010-06/30/2011). Visits with asthma ICD-9 codes are listed below. Please use the two-year dates of service (07/01/2009 06/30/2011) when querying your practice management or EMR system to allow you to count the number of visits within this time frame. Asthma is defined as any one of the following ICD-9 diagnosis codes, in any position, not just primary. Codes are stated to the minimum specificity required. For example, if a threedigit code is listed, it is valid as a three, four, or five-digit code. Where there is a range of codes, we have listed them in an effort to be clearer. Extrinsic asthma 493.00, 493.01, 493.02 Intrinsic asthma 493.10, 493.11, 493.12 Other forms of asthma 493.80, 493.81, 493.82 Asthma, unspecified 493.90, 493.91, 493.92 Provider specialties included: Family Practice, Internal Medicine, General Practice, Pediatrics, Allergy/Immunology, Pulmonology Include all provider types who manage care: MD, Physician Assistant, Nurse Practitioner, etc. Exclusions Patient was a permanent nursing home resident home during the measurement period 1
MNCM Measure Numerator: Please refer to each data element definition for further instruction on collection. Patient was in hospice at any time during the measurement period Patient died prior to the end of the measurement period Documentation that diagnosis was coded in error Exclude patients with all of the diagnoses below: o COPD (491.2, 493.2, 496, 506.4) o Emphysema (492, 506.4, 518.1, 518.2) o Cystic fibrosis (277.0) o Acute respiratory failure (518.81) Percentage of asthma patients ages 5-50 in the measurement period who meet ALL of the following targets: a) Asthma well-controlled (take the most recent asthma control tool available): Patient has an Asthma Control Test (ACT) score of 20 or above (taken from most recent Asthma Control Test on file) only applicable for patients 12 and older ---OR--- Patient has a Childhood Asthma Control Test (C-ACT) score of 20 or above (taken from most recent C-ACT on file) only applicable for patients 11 and younger ---OR--- Patient has an Asthma Control Questionnaire (ACQ) score of 0.75 or lower (taken from most recent ACQ on file) only applicable for patients 17 and older ---OR--- Patient has an Asthma Therapy Assessment Questionnaire (ATAQ) score of 0 (taken from most recent ATAQ) only applicable for children and adolescents b) Patient not at elevated risk of exacerbation: Patient reports values for all of the following questions (at date of most recent asthma visit): o o Number of emergency department visits not resulting in a hospitalization due to asthma in last 12 months ---AND--- Number of inpatient hospitalizations requiring an overnight stay due to asthma in last 12 months The total number of emergency department visits and hospitalizations due to asthma must be less than 2. c) Patient has been educated about his or her asthma and self-management of the condition and also has a written asthma management plan present (created or reviewed and revised within the measurement period): Patient has a written asthma management plan in the chart with the following documented: o Plan contains information on medication doses and purposes of these medications o Plan contains information on how to recognize and what to do during an exacerbation o Plan contains information on the patient s triggers 2
MNCM Measure Workgroup Recommendations to the Community The asthma workgroup considered many potential components for an asthma measure during the measurement development process and would like to recommend the following going forward: 1. The measure should be reviewed in one year to make certain that recommendations continue to match any updates to clinical guidelines. 2. At an annual evaluation, asthma control assessment tools should be re-assessed. If additional tools are validated as acceptable, they should be considered for inclusion. The medical community should consider opportunities to standardize tools going forward. 3. Severity assessment, tobacco use and exposure, spirometry, flu shots and other appropriate vaccinations, medication management, and referrals to specialists are important aspects of asthma management and should be done according to clinical guidelines as needed. 3
MN Community Measurement Measure Impact and Recommendation Document April 2010 Degree of Impact Relevance to Consumers, Employers and Payers Degree of Improvability Degree of Inclusiveness Prevalence with Adults: The Asthma in Minnesota 2008 Epidemiology Report published by the Minnesota Department of Health noted that in 2007: 10.9% of adults in MN reported that they had been told sometime in their lifetime that they had asthma; 7.7% reported that they still had asthma. That translates to an estimated 429,000 Minnesota adults who have a history of asthma and an estimated 303,000 who currently have asthma. 1 Prevalence with Children: In 2006, the MN Behavioral Risk Surveillance System (BRFSS) reported that: 9.5% of children (age 0-17) in Minnesota have been diagnosed with asthma, and 7% were reported to currently have asthma. That translates to an estimated 116,000 Minnesota children with a history of asthma and an estimated 85,000 who currently have asthma. The prevalence of asthma among children has remained stable since 2003. 2 Prevalence Nationally: 12.9% of adults reported being diagnosed with asthma and 8.2% were reported to currently have asthma. This translates to an estimated 22.2 million adults and 6.5 million children. Minnesota costs: The total costs for asthma in Minnesota for 2003 were estimated at $363.9 million, including $208.6 million in direct costs of office visits, ED visits, hospitalizations and medication, and $155.3 in indirect costs of missed school and work days. 3 National costs: In 2004, the economic costs of asthma for the United States were estimated at more than $16 billion. This figure included $4.6 billion in lost productivity. Updated estimates for direct medical expenditures alone in 2007 were $37.2 billion. 4 The societal costs of asthma are acutely felt in the pediatric population with asthma cited as the most frequent cause of pediatric emergency room use and hospital admissions as well as the leading cause of school absences. Asthma is a chronic disease; it is multi-factorial and associated with familial, infectious, allergenic, socioeconomic, psychosocial and environmental factors. It is not curable but is treatable asthma morbidity and mortality are largely preventable. Asthma prevalence has progressively increased over the past 15 years. Asthma is a chronic condition that affects every demographic of the population however it disproportionately affects children, minorities, and persons of lower socioeconomic status. It is known that women in MN are affected more than men. However, between 2000 and 2006, there have been no clear trends in adult asthma prevalence by age group. 5 In 2007, 13.9% of black Minnesotans reported that they currently have asthma, compared to 7.3% for whites. 6 1 MN Department of Health Website. Accessed on-line at: http://www.health.state.mn.us/divs/hpcd/cdee/asthma/research.html. 2 CDC Website. Accessed on-line at: http://www.cdc.gov/brfss 3 Coffey RM, Ho K, et al. Asthma Care Quality Improvement: A Resource Guide for State Action (Prepared by Thomson Medstat and The Council of State Governments under Contract No. 290-00-0004). Rockville, MD, Agency for Healthcare Research and Quality, Department of Health and Human Services; 2006. 4 Kamble S, et.al. Incremental direct spending on asthma in the United States. J Asthma, 2009 Feb; 46(1):73-80. 5 http://www.health.state.mn.us/divs/hpcd/cdee/asthma/research.html 6 http://apps.nccd.cdc.gov/brfss/race.asp?yr=2007&state=mn&qkey=4416&grp=0 4
Fit with National, Regional, and Local Priorities Performance Variation Existing Measures at a National and Local Level New Measure Development Enhance the patient/ provider relationship Three bodies have released clinical guidelines updated in the past several years. The Global Initiative for Asthma (GINA) was last updated in 2008, the National Asthma Education and Prevention Program Expert Panel Report 3 (NAEPP-EPR3) was last updated in 2007, and the Institute for Clinical Systems Improvement (ICSI) was last updated in 2008. The guidelines have many similarities and all three guideline sets discuss the importance of the following: Assessment of severity Using stepwise approach to treatment Using asthma control as the primary goal of therapy Distinguishing between asthma impairment (frequency and intensity of symptoms) and risk (potential for exacerbations) Education and creating a patient-provider partnership Control (or elimination) of environmental factors and co-morbid conditions that affect asthma Comprehensive pharmacologic therapy Assessment, management, and treatment asthma exacerbations MNCM first reported asthma care in 2004. The (HEDIS) measure is the percentage of patients age 5-56 with persistent asthma who were appropriately prescribed medication. In 2004, MN Community Measurement reported medical group average was 74%; in the 2006 Quality Report the medical group average was 91%, an increase of 17 percentage points. For the past three years (2006-2008) the medical group average has remained steady at 92%. Results from an Asthma Callback Survey, developed by the CDC and administered in conjunction with the MN BRFSS survey in 2005, asthma self-management skills may be compromised. While 61% of adult persons with asthma in Minnesota reported that they had been taught to recognize the early signs of an asthma attack and 75% reported that they had been taught how to respond to an asthma attack, only 8% had taken a class on asthma management, only 33% had ever had an asthma management plan and only 47% had been taught how to monitor peak flow. Various guidelines consistently highlight the importance of patient self knowledge and self efficacy in the management of asthma and a large body of evidence documents that asthma self management education is effective in improving outcomes including reductions on hospitalizations, urgent care and ED visits. There are many existing asthma measures available from the following national and local organizations: - National Committee for Quality Assurance (NCQA) - National Quality Forum (NQF) - Institute for Clinical Systems Improvement (ICSI) - American Medical Association (AMA) Physician Consortium for Process Improvement (PCPI) - CMS s Physician Quality Reporting Initiative (PQRI) - Minnesota health plans: Medica, Blue Cross Blue Shield of MN, etc. Existing measures were catalogued and reviewed by the technical advisory committee during the measure development process. Due to the stability of the measure currently captured by MN Community Measurement and the release of updated clinical guidelines, the development of a new measure that more appropriately defines and measures asthma care in Minnesota was undertaken. A group of community stakeholders met to develop a new measure. The group identified the need to have a patientcentered direct-data submission measure with a focus on outcomes that impact the patient s experience and control. All meeting materials, a list of workgroup members, and other documentation is available on request from Minnesota Community Measurement staff. The workgroup discussed the relationship between the patient and the provider throughout the development process. In particular, much thought was given to the application and use of the asthma control test/tool versus the provider s assessment of symptom criteria, the recall ability and 5
importance for providers to assess risk by asking patients about emergency department and hospital use, and the importance of provider education with patients and the use of a written asthma plan. Recommendation Feasibility (resources, barriers, culture) The asthma workgroup drafted a recommendation for a new measure that went before the Reporting Advisory Committee (RAC) in October of 2009. RAC approved a recommendation for the new measure as follows: Asthma control experience Patient reports that over the last several weeks his or her asthma has been well controlled. Providers will submit the results from a validated assessment control tool which may be one of the following: the Asthma Control Test (ACT or Child ACT), the Asthma Control Questionnaire (ACQ), or the Asthma Therapy Assessment Questionnaire (ATAQ). Asthma risk experience A patient s past health care use provides information on potential for future exacerbations. The provider will report the patient s response to utilization of the hospital and emergency department to treat an asthma exacerbation in the past 12 months. Education and written asthma management plans - Patient received education and a written asthma management plan (created / reviewed and revised within the measurement period) with the following documented: Information on medication doses and purpose of the medications, information on how to recognize and what to do during an exacerbation, and information on triggers The measure will apply to both primary care providers and specialists treating asthma. The components will be collected and submitted via direct data submission requiring some medical groups and clinics to develop systems to collect and submit this data. The Board of Directors approved the asthma measure with the changes noted above in December of 2010. 6