Asthma care quality for children with minority-serving providers.

OBJECTIVE: To compare asthma care quality for children with and without minority-serving providers. DESIGN: Cross-sectional telephone survey of parents, linked with a mailed survey of their children's providers. SETTING: A Medicaid-predominant health plan and multispecialty provider group in Massachusetts. PARTICIPANTS: A total of 563 children with persistent asthma, identified by claims and encounter data. Main Exposure Whether the child's provider was minority serving (>25% of patients black or Latino). Outcomes Parent report of whether the child had (1) ever received inhaled steroids, (2) received influenza vaccination during the past season, and (3) received an asthma action plan in the past year. RESULTS: In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not statistically significantly different for children with minority-serving providers (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63-2.64), or for Latino vs white children (OR, 1.76; 95% CI, 0.74-4.18); odds were increased for children receiving care in community health centers (OR, 4.88; 95% CI, 1.70-14.02) or hospital clinics (OR, 4.53; 95% CI, 1.09-18.92) vs multispecialty practices. Such differences were not seen for influenza vaccinations or action plans. CONCLUSIONS: Children with persistent asthma are less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics. Practice setting mediated initially observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations or asthma action plans.

The immunization delivery effectiveness assessment score: a better immunization measure?

BACKGROUND: Childhood immunization measures, such as the Health Employer Data Information Set (HEDIS) or the National Immunization Survey, assess the percentage of children up-to-date for a specified series of vaccinations. In particular, the HEDIS assesses immunization delivery to children enrolled in managed care organizations (MCO). Such measures do not assess the timeliness of immunization delivery with reference to recommended age standards. To achieve maximal protection against vaccine-preventable diseases, children should receive all immunizations within recommended age intervals-fully "on-time." OBJECTIVE: The Immunization Delivery Effectiveness Assessment (IDEA) is a novel immunization measure that assesses, on a continuous scale, the timeliness of administration of each vaccination with reference to recommended age intervals. Specifically we ask: 1) Do absolute immunization rates differ between HEDIS and IDEA? 2) Does relative MCO performance differ when assessed by the 2 performance measures? 3) How well do MCOs perform relative to the standard of fully on-time immunization? The health services implications of using the timeliness standard to assess childhood immunization delivery is discussed. METHODS: A vaccine-dose IDEA score was developed for each of the 14 vaccination events in the 4:3:1:3:3 combination series (4 diphtheria-pertussis-tetanus:3 polio:1 measles-mumps-rubella:3 Haemophilus influenzae type B:3 hepatitis B). Assessing the actual age of administration with reference to the recommended age of administration generates the vaccine-dose IDEA score. A child's composite IDEA score is obtained by averaging the 14 vaccine-dose IDEA scores. These composite IDEA scores, when averaged among children sampled within the MCO, constitute the MCO's immunization score. SETTING: Retrospective analysis of childhood immunization datasets from a convenience sample of 6 MCOs in 5 states. RESULTS: HEDIS rates ranged from 57% to 75%. IDEA scores ranged from 80% to 90%. Relative rankings of MCO immunization performance were different using HEDIS rates and IDEA scores, respectively. At most, 16% of children in any of these MCOs received all of their immunizations fully on-time. From 47% to 77% of children experienced at least 3 delayed immunizations. CONCLUSIONS: An immunization measure based on timeliness of administration yields both absolute and relative differences in MCO childhood immunization performance when compared with HEDIS rates. By assessing delivery of each component vaccination, the IDEA score permits more detailed analysis of immunization patterns within an MCO and focuses improvement efforts.

Stratifying asthma populations by medication use: how you count counts.

BACKGROUND: Asthma disease management programs typically use pharmacy data to identify high-risk individuals for outreach. Provider-directed pharmacy profiling seeks to identify physicians whose prescribing of recommended asthma medication is suboptimal. Both strategies require an accurate approach to counting prescribed asthma medication. OBJECTIVE: We compare two methods for counting the use of bronchodilators and inhaled anti-inflammatory medication. One approach uses simple counts of dispensed medication. An alternative, canister-equivalent method standardizes these medications on the basis of variation in both potency and medication-days supplied per prescription. We evaluate whether these alternative methods yield different population risk profiles when applied to managed care enrollees who have asthma and to the physicians treating them. METHODS: Retrospective cohort study of patterns of medication use by asthmatic patients receiving care within a group-model health maintenance organization and prescribing of asthma medications by the physicians treating them. RESULTS: Each method yields a different risk profile of the patient and physician populations, respectively. Relative to simple counts, the canister-equivalent method results in a 40% increase in the population identified as having high bronchodilator use and chronic anti-inflammatory medication use. On the physician-level, the mean anti-inflammatory:bronchodilator ratio (AIF:BD) was 1.50 by the canister-equivalent method compared with 1.08 by the simple-count method. When stratified by each method, 36% of physicians were assigned to different quartiles of anti-inflammatory:bronchodilator ratio. CONCLUSIONS: A novel canister-equivalent method for counting dispensed asthma medications yields different risk profiles compared with simple counts of asthma medications. Asthma disease management programs should consider alternative approaches to improve the accuracy of risk profiling based on patterns of medication use.