Table Of Content

EXECUTIVESUMMARY ChildhoodasthmaImposesaheavyburdenonhealthcare resourcesandonfamilies.LowIncomechildrenusemoreurgentcarefor asthmathanotherpopulations. InanInterimReporttoCongressin1992, HCFAreportedthatpediatricasthmawasthehighestvolumenon- pregnancyrelatedconditiontreatedonaninpatientbasisinthenon-elderly Medicaidpopulation,accountingfor12%oftheseadmissions. TheReport estimatedthatadmissionratesforpediatricasthmawere75%higherinthe Medicaidpopulationthaninthenon-Medicaidpopulation.In1990-91,the CoordinatingCommitteeoftheNationalAsthmaEducationProgram (NAEP)convenedanexpertpaneltodevelopguidelinesforthediagnosis andmanagementofasthma.Theystated"Withappropriatetherapy, patientswithasthmacanexpecttocontroltheirsymptoms,preventmost acuteexacerbations,maintaintheactivitylevelstheydesire,andattain nearnormallungfunction". The1991 NAEPexpertpanelreportwaspart ofaneffortto"bridgethegapbetweenresearchandpractice"inasthma care,andwaswidelydistributedamongphysicians. Anupdatedpanel reportwasproducedin1997. Thefirstpurposeofthisstudywastoexaminewhetherasthma medicationregimesforchildrencoveredbyMedicaidareincompliance withtherecommendationsmadebytheNIHconsensusNationalAsthma EducationProjectin1991. Using1994-1995Medicaidclaims,we examinedcomplianceintwostates,AlabamaandMichigan,andassessed thegeneralizabilityofourobservationsconcerningasthmamedication utilizationacrossstates.Wealsoassessedwhetherfeaturesofachild's healthcareutilizationwereassociatedwithcomplianceornon-compliance withasthmamedicationregimes. Inaddition,weexaminedexpenditures ondifferenttypesofasthmacareinthetwostates,andexploredwhether expendituresonmedicationssubstituteforexpendituresonurgentor routinemedicalcare. Thesecondpurposeofthisstudywastoassesstheaccuracyof Medicaidclaimsdatacomparedtomedicalrecordsdataforidentifying problemsinthepharmaceuticaltreatmentofasthma. Weselectedasmall sampleofchildreninAlabamawithasthmain1995,andrequestedfullyear ambulatoryandinpatientrecordsforthetimeperiodextendingfrom Jclaaniumasryon1,be1h9a9l4fotfotMhaerscehch3i1ld,r1e9n.95Wferocmomalplaorfetdheseplreocvtideedreslwehmoenftislefdrom theabstractedrecordtocorrespondingMedicaidclaimsfiledforcareonthe samedate,or,inthecaseofmedications,fortwelvemonthsfollowingthe dateofcare. Wereportheretheextenttowhichconclusionsaboutthe contentofachild'scareimputedfromMedicaidclaimscorrespondto 1 r conclusionsreachedbasedonrecordreview. Wepayparticularattention towhetherclaimsfiledforprescriptionmedicationsreflectprescriptions recordedinmedicalrecords. Thethirdpurposeofthisstudywastouseclaimsdatatosimulatea letterremindersystemthatwouldnotifyphysiciansifclaimsdataindicated deficienciesinmedicationsandothertypesofcarprovidedtochildrenwith asthma. Weexaminedwhetherthephysiciansassociatedwithcare problemsareasmallorlargesegmentofallphysiciansprovidingcareto childrenwithasthma,andweassesswhethercarefragmentationwould limittheabilityofphysiciansreceivingreminderstocontactandalterthe careoftheirpatients. Thestudyused1993-1995Medicaidclaimsdatafromthestatesof Alabama(acquireddirectlyfromthestate)andMichigan(acquiredfromthe HealthCareFinancingAdministration'sresearchfiles)toidentifytwo cohortsofchildren,ages2-13years,treatedforasthma,whowere continuouslyenrolledduringtheyear.Weincludedinthecohortchildren whohadreceivedatleastoneasthmadiagnosis(ICD9code493)recorded onaclaimforamedicalencounterduringtheyear. Wealsoincluded childrenwhohadnotreceivedanactualasthmadiagnosis,butwhohad claimsformedicalencountersonthreeseparatedaysduringthe identificationyearwhichrepresentedasthma-likesymptoms. Forthestudy ofmedicationandhealthcareutilization,weconcentratedouranalysison thecohortofchildrenwithasthmaineachstateidentifiedin1994,following theirutilizationexperiencesin1995.Thistimelagwasbuiltinsothatwe wouldbemorelikelytobeassessingutilizationaftertheusualtreatment patternfortheconditioninthischildhadbeenestablished.Theentire cohortofchildrenwithasthmain1994whoremainedcontinuouslyenrolled inMedicaidthrough1995included2554childreninAlabamaand8634 childreninMichigan. Thebasepopulationofchildrenwhowere continuouslyenrolledthrough1994and1995was78,658inAlabamaand 222,031inMichigan,yieldingatreatedasthmaprevalencerateof3.2%in Alabamaand3.9%inMichiganforthisstudycohort. Claimsfiledforprescriptiondrugswereusedtoidentifyfouraspects ofmedicationtreatmentforasthmawhichareproblematicrelativetothe NAEPasthmatreatmentguidelinesthatwerecurrentatthetime.Thefirst problemwastheoccurrenceofatimeperiodwhenanactiveprescription forabeta-agonist,atreatmentfortheacutesymptomsofasthma,wasnot availabletoachildwithasthma. Availabilitywasassessedbasedonthe timingoffilledandrefilledprescriptions. Thesecondproblemoccurredifa childoveragesixhadaclaimfortheoralformofthismedication,since guidelinesadviseuseoftheinhaledformasmoreeffectiveandusableby 2 thisagegroup. Thethirdproblemweidentifiedwaslimitedtochildrenclassifiedas havingmoresevereasthma,definedbasedonpreviousutilizationofurgent careorpreventiveasthmamedications.Theoccurrenceofatimeperiod withoutanactiveprescriptionforapreventivemedication,eitherinhaled cromolynsodium,inhaledcorticosteroidsororaltheophylline,was consideredtobeaproblemforchildrenwithmoresevereasthma. Finally,previousresearchusingAlabamaMedicaiddatahad indicatedthatsomechildrenwithasthmadiagnosesoccasionallyfilled prescriptionsfornarcoticcoughmedications. Weconsideredthistobea treatmentproblem,sincesuchmedicationsuppressesrespiratory response,andcouldbedangerousforachildwithreactiveainwaydisease. InthecourseofconductingthisstudywefoundthattheMichiganMedicaid programdoesnotprovidecoveragefornarcoticcoughmedicines. Thus analysisoftheoccurrenceofthisproblemislimitedtoAlabama. Ourmajorfindingsoncompliancewithasthmamedicationregimes wereasfollows: Medicationcostsaccountedfornearlyonethirdofexpendituresonasthma forchildrenages2-13coveredbyMedicaidinMichiganandAlabamain 1995. Prescriptionsformedicationsforthetreatmentofacutesymptomsof asthmawerefilledbyabout85%ofthechildrenwithasthmaineach state,whileprescriptionsformedicationsforthepreventionofasthma exacerbations,werefilledbyabout43%ofchildreninbothstates, including81%ofthosewithmoderateorsevereasthma. Onlyabout14%ofthosewithmildasthmaand7%ofthosewithsevere asthmamaintainactiveprescriptionsforappropriatemedicationsover thecourseofthewholeyear. Urgentambulatoryorinpatientcarewasusedby13%(Michigan)to17% (Alabama)ofthepopulationduring1995,andwasmorecommonly usedbychildrenwithgreaterexpendituresandmoreavailabilityof medicationsthanbyotherchildrenwithasthma. Providingtherecommendedamountofasthmamedicationcoverageall yearforallchildrenintheseMedicaidcohortswouldincreasetotal expendituresforchildrenwithmildasthmabyaboutone-third,and wouldnearlydoublecurrentexpendituresforchildrenwithmoderateor 3 severeA-st/lfnA-. Tke-ie.^^^tioniUexye-n^tumcml^notWreamjje^'hi^ <(ecreA-5e5invtr^mtc^-re.usej^crtkesecfiil^ren,sincetke(i4,^iti<'n(\.l expendituresarelargerthanthecurrentamountsspentonsuchcare. EffortstoprovidecareforchildrenwithasthmacoveredbyMedicaidthat meetthecurrentrecommendationsforasthmatreatmentwillrequirethe investmentofadditionalfundsandcannotbeexpectedtogenerate largedollarsavings. Basedoncurrentpracticerecommendations, however,theycanbeexpectedtoimprovethefunctionalstatusofthese children. Severalcharacteristicsofchildrenandaspectsoftheircareusewere predictiveofgapsinmedicationavailability. Childrenwerelesslikelyto havegapsinmedicationavailabilityiftheyhadmoresevereasthma,if theywerefrequentusersofasthmaambulatorycare,andiftheirmost recentasthmavisitwasspecificallycodedwiththediagnosisofasthma ontheclaim. ChildreneligibleforMedicaidbecausetheyreceived SupplementalSocialSecurityforsomeotherformofdisabilitywerealso lesslikelytohavegapsinasthmamedicationavailability. Ambulatorycareinoutpatienthospitalsettings,urgentcareandinpatient carewereallassociatedwithlatergapsinmedicationavailability.These findingsallreinforceastandardassumptionofasthmacare,whichis thatcareprovidedinurgent-orientedsettingsisnotconducivetoon- going,appropriate,prevention-orientedtreatmentofthecondition. Childrenwhosawthesamephysicianthroughout1995werealsomore likelytohavegapsinmedicationavailabilitythanthosewhosawmore physicians. Thismayrepresenttheabsenceofareferraltoaspecialist forthesechildren,butitalsosuggeststhatsomephysiciansmaynotbe familiarwithcurrentstandardtreatmentsforasthma. Useofhospitalbasedcare,urgentcareandnocareatallweremore commonforblackandotherurbanchildrenthanforwhiteandrural childreninbothstates. Controllingforthesefactors,andalsofor asthmaseverityanddiagnosticaccuracy,wefoundthatblackchildren andthoselivinginurbanareaswereactuallylesslikelythanother childrentohavegapsinmedicationavailability. Theywerealsoless likelytofillprescriptionsfornarcoticcoughmedications. Thissuggests thatthetreatmentdeficienciesoftenreportedforthesechildrenare moreafunctionofthecaresystemstheyusethanspecificallyafunction oftheirdemographiccharacteristics. 4 Atthesametime,thereweresomeindicationsthattheblackandother childreninourcohorts,whowerethosewhosoughtcareforasthmain 1994,hadmoreseveremanifestationsoftheconditionthanwhite children. PrevalenceratesamongMedicaideligibleswerelowerforthis group,averageseverityrateswerehigherandfewerofthemreturned forcarein1995. Thissuggeststhattheremaybemoreblackandother childrenthanwhitechildrencoveredbyMedicaidwhohavesymptoms ofrelativelymildasthma,butwhodonotreceivethebenefitsofasthma medicationsandroutinecare. Ourmajorfindingsonthecon-espondencebetweenMedicaidclaimsand medicalrecorddatawereasfollows: Muchofthedatathatwouldbeneededforassessmentsofasthmaseverity orencounterurgencywasnotactuallydocumentedinthemedical recordswereviewed. Thesmallsetofdataelementsavailableinclaimsdataforusein measuringasthmaurgencyandseverityareactuallymeasuresof serviceutilization,ratherthanmeasuresofhealthstatus. Theclaims dataelementsidentifyurgentasthmaencountersaccurately,butthey donotidentifyalloftheurgentasthmaencountersthatactually occurredforthispopulation,becauseMedicaidclaimswerenot submittedforeveryinstanceofnebulizedmedicationprovisionreported inthemedicalrecords.Thusclaimsdatapresentanaccuratepictureof thecontentofcareforsomeencounters,butdonotidentifytheextentto whichatypeofcareoccursinthepopulation. Childreninthispopulationwithclaimsforasthmagenerallydohave asthma,accordingtotheirmedicalrecords. Accuracyofcasefindingis withclaimsisenhancedwhenthebroaderdiagnosticcategoryof asthma-likerespiratorydiagnosesIsused,andwhenclaimsforan entireperiodoftime,ratherthanjustasingleencounter,are considered. Comparisonofmedicalrecordsandclaimsshowedthat60%of documentedasthmaprescriptionswerefilledwithinoneweekand30% wereneverfilled. Furtherwefoundthatabout37%offilledasthma prescriptionswereundocumentedinmedicalrecords. Thusinasense, claimsdataareabettermeasureofmedicationavailabilitythanmedical records. However,itisamistaketoconcludethattheabsenceofa claimforanappropriateasthmamedicationortheabsenceofmedical recordsdocumentationindicatesaprescribingfailureonthepartofthe physician. 5 Weconcludethatclaims-basedcontentofcareindicatorsareusefulfor identifyingarangeofqualityproblems,includingabsenceofappropriate medications,failuretoaccuratelydiagnosetheconditionandfailureto providefollow-upcareafterurgentepisodes. Claimsbaseddatadonot identifyeverycaseoftheseproblemsthatoccurs. Itisnotpossibleto ascertainfromclaimsdatawhetherthequalityproblemisdotoprovider actions,documentationproblemsortotheactionsofasthmapatients andtheirfamilies. Ourmajorfindingsfromthesimulationofaletterremindersystemusing claimsdatawereasfollows: Problemcare,asdefinedhereandidentifiedusingadministrativedata,is quitecommonforchildrenwithasthmacoveredbyMedicaid,affecting overonehalfofallchildrenseeninonemonth,inbothAlabamaand Michigan. Thephysiciansprovidingproblemcaretothesechildren includeoverhalfofthephysiciansprovidingcareinthesamplemonthin bothAlabamaandMichigan.Thus,itisnotthecasethatproblem asthmacareisanisolatedphenomenon,foreitherpatientsor physicians. Inbothstates,over70%ofthephysiciansassociatedwithproblemcare weretreatingpatientstheyhadseenbefore,andover70%ofthese physiciansseethesesamepatientsagain. Ofallthechildren,newand establishedpatients,whoareseenbythesephysiciansinonemonth, overhalfareseenagainduringthecourseoftheyear. Thusitisnot thecasethatmostchildrenwithproblemasthmacarelosetouchwith theirphysiciansovertime. Underthesecircumstances,aletterremindersystemcouldhavea relativelylargeaffectonthecareofchildrenwithasthma,providingthe messagewasclearandrecommendedactionswhichphysicianscould realisticallyaccomplish. Claimsdatacouldbeusedtoprovide physicianswithahistoryofthetimesthatchildrenhadbeenseenfor asthma-likesymptomsinthepast,thussupplementingpatienthistories whichmayormaynothavebeentakenbyphysicians,andmaynotbe accurate. Claimsdatacouldalsoinformphysiciansaboutwhether familiesfilledprescriptionsthatwerewrittenafterthechildreceived care. Suchinformationcouldbeusedbyphysiciansasareference,if andwhenachildreturnedforcare,butpreferablytheinformationwould beusedtoreachouttofamiliesandencouragethemtobeseenfor 6 routine,preventionorientedasthmacare. INTRODUCTION BACKGROUND:COMPLIANCEWITHASTHMACARE RECOMMENDATIONS ChildhoodasthmaImposesaheavyburdenonhealthcare resourcesandonfamilies.Itcausesmoreschoolabsenteeismandlimited activitythananyotherchronicillnessinchildhood(FridayandFireman 1988,Gergenetal1988,Newachecketal1986).Using1985data,Weiss, Gergen,andHodgson(1992)estimatedthedirectmedicalcostsofasthma, excludingmedicationcosts,forUSchildrenunderage18yearsat$465.1 millionperyear.Intheiranalysis,medicationcostsforadultsandchildren togetheraccountedfornearly30%ofalldirectcosts.Indirectcostswere valuedatanadditional$825.1million. Atatimewhenhospitalizationrates formostchildhoodillnessesdeclined,thehospitalizationrateforasthma increased(GergenandWeiss1990,Mullallyetal1984). Datafromthe NationalHealthInterviewSurveyshowa33%increaseintheprevalenceof childhoodasthmafrom1981to1988(TaylorandNewacheck1992).In additiontodiseaseprevalenceandhospitalutilization,mortalityratesfor asthmahavebeenincreasing,particularlyamongurban,poorandminority individuals(LangandPolansky1994,WeissandWagoner1990). Lowincomechildrenusemoreurgentcareforasthmathanother populations. InanInterimReporttoCongressin1992,HCFAreportedthat pediatricasthmawasthehighestvolumenon-pregnancyrelatedcondition treatedonaninpatientbasisinthenon-elderlyMedicaidpopulation, accountingfor12%oftheseadmissions. TheReportestimatedthat admissionratesforpediatricasthmawere75%higherintheMedicaid populationthaninthenon-Medicaidpopulation(HCFAOfficeofResearch, 1992,page3-14).HalfonandNewacheck(1993)comparedpoorchildren withasthmatonon-poorchildrenwithasthmaandfoundpoorchildrenhad fewerdoctorvisits,hadmoreandlongerhospitalizations,andweremuch morelikelytouseanEmergencyDepartmentwhenevertheyweresick. Wissowetal(1988)foundasthmahospitalizationratesweremuchhigher forMedicaid-enrolledchildrenthanforchildrenwhosecarewaspaidforby othersources. Murray,StangandTierney(1997)andLozano,McConnell andKoepsell(1995)bothreportthatinnercityAfricanAmericanchildren usemorecareinurgentambulatoryandinpatientsettingsthanwhite children,whileAllandOsberg(1998)reportverylowratesoffollow-up visitsafterhospitalizationsforasthmaamonglowincomechildren.In addition, Bosco,Gerstman,andTomita(1993)reportedthatmanychildren withasthmaintheMichiganMedicaidpopulationfrom1980to1986failed 8 toreceiveeffectivedrugs,andmanyreceivedatypeofmedicationthen listedbytheFDAaslacl^ingsubstantialevidenceofeffectiveness. In1990-91,theCoordinatingCommitteeoftheNationalAsthma EducationProgram(NAEP)convenedanexpertpaneltodevelop guidelinesforthediagnosisandmanagementofasthma.Theystated"With appropriatetherapy,patientswithasthmacanexpecttocontroltheir symptoms,preventmostacuteexacerbations,maintaintheactivitylevels theydesire,andattainnearnormallungfunction"(NHLBI1991). The1991 NAEPexpertpanelreportwaspartofaneffortto"bridgethegapbetween researchandpractice"inasthmacare,andwaswidelydistributedamong physicians.Thisworkwasupdatedin1997(NHLBI1997). Thefirstpurposeofthisstudywastoexaminewhether medicationregimesforchildrencoveredbyMedicaidarein compliancewiththerecommendationsmadebytheNAEP. Using Medicaidclaims,weexaminedtheexperienceoftwostates,Alabamaand Michigan,inparttoassessthegeneralizabilityofourobservations concerningmedicationutilization. Inaddition,theAlabamaMedicaid programcoversasignificantnumberofAfricanAmericanchildrenlivingin ruralareas,whileMichigan'sAfricanAmericanMedicaidpopulationforthe mostpartresidesinurbanareas. Thedifferingdemographicsinthetwo statesallowedustoassesswhethertheobsen/ationsmadeinotherstudies caroencreeranlliyngonclayrcehaurtialcitzeartiisotniacmoofnthgeAcfarriecainnAlmaergreicuarnbacnhialrderaesn.wiWtheaasltshoma assessedwhetherfeaturesofachild'shealthcareutilizationwere associatedwithcomplianceornon-compliancewithmedicationregimes. In addition,weexaminedexpendituresondifferenttypesofasthmacarein thetwostates,andexploredwhetherexpendituresonmedications substituteforexpendituresonurgentorroutinemedicalcare. BACKGROUND: VALIDATIONOFCLAIMSDATA Oneapproachtomonitoringmedicationuseandotheraspectsof healthcarequalityisafocusedstudy,whichexaminesmedicalrecordsand otherprimarydocumentationforasub-sampleofthepopulationtoassess whetherappropriatecareforaconditionisbeingprovided. TheHealth CareFinancingAdministration'sQualityAssuranceReformInitiative (QUARI)project,whichadaptedqualityofcareprinciplesandpracticesfor usewithMedicaidmanagedcare,recommendedthatfocusedstudiesof qualityofcareforchildrenwithasthmabeusedtoevaluatethequalityof careprovidedbymanagedcareorganizationsservingthispopulation (NCQA1994). 9 Analternativetomedicalrecordsstudiesforassessingthequalityof medicalcareprovidedtothepopulationistheuseofadministrativedata, suchasthatprovidedbyinsuranceclaims. Thestrengthsofadministrative datacomparedtomedicalrecordsdataarethattheycanbeusedtoreview thecareprovidedbymultipleentitiestothesameindividuals,andtoreview careacrossanentirepopulation,ratherthanasub-sample(Scholleetal 1996). Administrativedataarealsofasterandlesscostlytocollectand examinethanmedicalrecorddata (Weineretal1990,Parenteetal1995, Steinbergetal1990). Themajorweaknessesoftheuseofadministrative dataforexaminingqualityofcarearetheabsenceofclinicaldetailabout thenatureofthemedicalproblemanduncertaintyabouttheaccuracyof claimsdataindescribingthecontentofmedicalcareencounters(Steinberg etal1990,lezzonietal1998). Inthecaseofmedicationmonitoring, prescriptionsthatarewrittenbyphysiciansbutnotfilledbypatientsdonot generateadministrativerecords. Inthatcase,administrativedatamaybea usefulmeasureofgapsinmedicationtreatment(SteinerandProchazka 1997,RayandGriffen1989),butnotagoodmeasureofthecontentof careprovidedbyphysicians.Atthesametime,themedicalrecordsdata usedforfocusedstudiesthemselvesdonotalwaysincludethedesirable informationabouttheclinicalproblemandthenatureoftreatment(Stange etal1998). Thesecondpurposeofthisstudywastoassesstheaccuracy ofMedicaidclaimsdataforidentifyingproblemsinthepharmaceutical treatmentofasthmabycomparingclaimsdatatomedicalrecorddata. WeselectedasmallsampleofchildreninAlabamawithasthmain1995, andrequestedfullyearambulatoryandinpatientrecordsfromallofthe physiciansandhospitalswhofiledclaimsonbehalfofthesechildrenforthe timeperiodextendingfromJanuary1,1994 toMarch31,1995. The records,bearingonlystudyidentificationnumbers,weresubmittedtothe AlabamaQualityAssuranceFoundation(thestate'sPhysicianReview Organization)forabstraction. Wecomparedselectedelementsfromthe abstractedrecordtocorrespondingMedicaidclaimsfiledforcareonthe samedate,or,inthecaseofmedications,fortwelvemonthsfollowingthe dateofcare. Wereportheretheextenttowhichconclusionsaboutthe contentofachild'scareimputedfromMedicaidclaimscorrespondto conclusionsreachedbasedonmedicalrecordreview. Wepayparticular attentiontowhetherclaimsfiledforprescriptionmedicationsreflect prescriptionsrecordedinmedicalrecords. BACKGOUND: EFFECTIVENESSOFREMINDERSYSTEMS Bydefinition,drugutilizationreviewisasystematicprocessfor reviewingpatternsofmedicationuseforapopulationagainst 10