Correlation of care process measures with childhood asthma exacerbations.

OBJECTIVE: We sought to define processes of pediatric asthma care identifiable through administrative data that correlate with asthma exacerbations for use in quality improvement. METHODS: Commercially insured children aged 5 to 17 years from the Pediatric Physicians' Organization at Children's, an independent practice association affiliated with Boston Children's Hospital, with persistent asthma in 2008, 2009, or 2010 were identified. The correlations of various process measures with asthma exacerbations, defined as hospitalizations or emergency department visits for asthma or outpatient visits for asthma with an oral steroid prescription, were analyzed by using logistic regression. RESULTS: Significant correlations were found between filling 0 vs ≥ 1 controller medications in all years (relative risk [RR] 3.35, 2.11, and 2.71 in 2008, 2009, and 2010, respectively) although only 4% of subjects overall filled no controller medications. The asthma medication ratio (controller prescriptions divided by total asthma prescriptions) was also associated with exacerbations, with the lowest 2 quartiles having a lower risk compared with the highest in all years (RR 2.27, 2.45, and 2.39 for the lowest; RR 2.10, 2.02, and 2.65 for the second quartile in 2008, 2009, and 2010, respectively). CONCLUSIONS: Filling 0 vs ≥ 1 controllers and the asthma medication ratio correlated with asthma exacerbations. Although both might serve as quality improvement metrics for pediatric asthma, we favor the asthma medication ratio because it applies to a broader range of children with asthma and better reflects the recommended clinical approach for children with persistent asthma.

Ambulatory subspecialty visits in a large pediatric primary care network.

OBJECTIVE: To determine patterns of subspecialty utilization within a pediatric primary care network. DATA SOURCES/STUDY SETTING: Paid claims from a large not-for-profit health plan for patients of The Pediatric Physicians' Organization at Children's, a network of private pediatric practices affiliated with Children's Hospital Boston. PRINCIPAL FINDINGS: The subspecialty visit rate was 1.01 visits per subject-year. In 2007, 56.8 percent of subjects had no subspecialty visits, whereas 4.2 percent had ≥ 5 visits; the corresponding figures in 2008 were 54.1 and 4.5 percent, respectively. The most frequently visited subspecialties were Ophthalmology, Orthopedics, Dermatology, Otorhinolaryngology, and Allergy/Immunology. Visit rates varied sevenfold by practice. CONCLUSIONS: Wide practice variability in pediatric subspecialty utilization suggests an opportunity for reducing unnecessary visits. Better integration between primary care and the most commonly used subspecialties will be needed to meaningfully reduce unnecessary visits and enhance value.