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2003 National Healthcare Quality Report

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Chapter 3. Effectiveness (Continued)

Respiratory Diseases

Contents

Background and Impact
How the NHQR Measures Respiratory Disease Quality of Care
How the Nation Is Doing
What We Don't Know
What Can Be Done
List of Measures
References

Key Findings:

  • The percentages of "high risk" individuals who reported having had influenza and pneumonia vaccinations are 20.8% and 15.4%, respectively. Rates are higher for elderly individuals on these same measures (65% and 54%, respectively).
  • More than 80% of Medicare enrollees hospitalized with pneumonia have blood cultures taken before antibiotic administration, have their initial antibiotic within 8 hours of hospital arrival, and have antibiotics consistent with current clinical guidelines.
  • Nearly one-third of children and adults are not prescribed primary therapy medications to control their asthma.
  • Rates of child admissions for asthma are 29.5 per 10,000, more than twice that of adults (12.5 per 10,000).

Background and Impact

Respiratory disease encompasses a broad array of illnesses that affect an increasing number of Americans. As recently as 1980, chronic lower respiratory diseases and influenza and pneumonia did not even appear in the top 10 causes of death in the United States. In 1999, they were the fourth and seventh leading causes of death, respectively.1 Respiratory diseases are also among the leading causes for hospital admissions nationally, and pneumonia treatment costs in the United States top $9.7 billion.2 For children, pneumonia is one of the leading causes of hospital admission; and among the elderly, pneumonia admissions have increased 18% since 1988.3

Asthma is another important disease. More than 25 million Americans have been told by a provider that they have asthma.4 Recent data show continuing increases in asthma-related hospitalizations, emergency department visits, and deaths, especially among minority populations.5

Tuberculosis (TB) continues to be a national priority condition. After several years of TB resurgence, the number of cases is at an all-time low.6 In fact, TB has declined tenfold since 1953 when CDC began tracking incidence of the disease.

One of the key reasons respiratory diseases are important for national quality measurement is because they can be treated and managed effectively. The conditions presented in this report are either infectious diseases that may be controlled through immunization or drug therapies, or they are chronic diseases that may be managed with proper primary care and medication.

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How the NHQR Measures Respiratory Disease Quality of Care

Measures of quality of care for respiratory illnesses presented in this report fall into the following categories (see full list of measures at end of section):

  • Preventing influenza through targeted immunization.
  • Preventing and treating pneumonia.
  • Managing asthma.
  • Reducing overprescription of antibiotics for the common cold.i
  • Treating TB.

All of the aspects of care discussed in this section have been identified as HHS priorities for quality improvement.7

One measurement area discussed here is inappropriate care. Articles in both the popular and professional press have focused on rising rates of antibiotic ineffectiveness and drug-resistant infections.8,9,10,11 Reducing antibiotic overuse is a national priority through CDC's National Campaign for Appropriate Antibiotic Use.12


i Antibiotics are bacterial or fungal metabolites that inhibit the growth of other bacteria or fungi. Some are used clinically against infections, but others are anticancer or immunosuppressive drugs. The measure in this report looked at the use of antibiotics for nasal pharyngeal infections, acute upper respiratory infection, and chronic rhinitis.


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How the Nation Is Doingii

Drug resistance and the emergence of new strains of certain infectious respiratory diseases, as well as increases in the prevalence of certain chronic lung illnesses, continue to be of concern. Improvement in the delivery of care is possible.

Managing Asthma

The number of people with asthma has more than doubled in the past 15 years; and even if rates were to stabilize at their current numbers, asthma would remain a serious public health issue.13 Direct health care costs for asthma in the United States total more than $8.1 billion annually, and indirect costs associated with lost productivity add another $4.6 billion. Moreover, inpatient hospital services for asthma represent a major medical expenditure nationally at more than $3.5 billion annually.14 Although death from asthma is almost always preventable if care is sought in a timely fashion, more than 4,600 people died of the condition nationwide in 1999.15 In addition, datac show that:

  • Children age 17 and under are much more likely to be admitted to a hospital for asthma than are adults (29.5 per 10,000 versus 12.3 per 10,000).
  • Black children in America are nearly twice as likely to be admitted to a hospital for asthma as white children.
  • According to national estimates from NCQA's HEDIS® data, nearly a third of children and adults are not receiving primary therapy medicationsiv to control their asthma.

The increase in asthma prevalence and its costs to the American health care system have caused concern among health care policymakers and providers. In recent years, there has been considerable attention paid to effective medical management and patient education programs based on clinical guidelines. Research has shown that these programs reduce the use of emergency services and improve quality of life for people with asthma.16,17,18,19

Despite the increase in asthma prevalence, there are gains in effective management of asthma. Although even the best primary care may not necessarily avoid hospitalizations, hospital admissions for asthma can be used as one measure of timely and effective primary care. Data from both the National Hospital Discharge Survey (NHDS) and the Healthcare Cost and Utilization Project show improvements in the rate of admissions for asthma. Between 1994 and 2000, these admissions have decreased between 10% and 20% for adults according to NHDS and HCUP figures.

Reducing Overprescription of Antibiotics for the Common Cold

In 1996, the National Center for Health Statistics estimated that viral respiratory tract infections accounted for more than 20 million lost workdays for adults and 21 million lost school days for children annually.20 Too often, these viral infections are being inappropriately treated with antibiotics, a practice that has contributed to the development of drug-resistant strains of bacteria. As a result, a nationwide campaign to reduce antimicrobial resistance has been launched,21 and the Food and Drug Administration has promulgated new rules on labeling of antibiotics.22 Addressing the problem of overprescription of antibiotics is difficult, as patient preferences for these prescriptions exist.23 Some research has suggested that levels of antibiotic prescriptions are underreported.11 In addition to the problem of drug-resistance, the inappropriate use of antibiotics has implications for private and public health care spending in physician offices, outpatient clinics, and emergency departments.24 Despite the attention paid to overprescription of antibiotics, data indicate that there is still room for improvement in this area.

  • There has not been any recent statistically significant improvement in the rate of inappropriate antibiotic prescriptions for the common cold (1997 to 1998 vs. 1999 to 2000.)v
  • Visits by children under age 17 are twice as likely to result in inappropriate antibiotic prescriptions as visits by adults (see Figure 13).

Preventing Influenza and Preventing and Treating Pneumonia

State and/or regional data are not available for all respiratory disease measures tracked in this report. However, for a number of respiratory illness measures, such as immunizations for influenza, there are data on national performance across the regions of the country. Twenty States had scores of 90% or better for immunizing seniors against the flu, according to 2001 data from the Behavioral Risk Factor Surveillance System.25,vi

The HHS/CMS Quality Improvement Organization program for Medicare enrollees has defined basic quality for the treatment of pneumonia at the hospital level. National performance is excellent on measures such as the percentage of patients who have their blood cultures taken prior to the administration of antibiotics, receive the initial dose of antibiotics within 8 hours of hospital arrival, and receive the correct antibiotics, according to current standard of practice, for their condition. For each of these measures, national performance is greater than 80%. However, performance on the percentage of patients with pneumonia who receive a flu or pneumonia screeningvii or immunization prior to hospital discharge is still below 30% for both measures.


ii Adjusting for known contributing factors, such as gender, age, and insurance status (multivariate analysis) would allow for more detailed exploration of the data, but this generally was not feasible for this report. Any adjustments that were done are noted in the detailed tables. The data presented in this report do not imply causation.
iii Data on hospitalizations for asthma in the NHQR come from the National Hospital Discharge Survey, 2000 (available at: http://www.cdc.gov/nchs/products/pubs/pubd/ad/321-330/ad329.htm). Additional data analysis carried out for the report from the HCUP also highlights that the poorest as well as the youngest children are most at risk for being hospitalized for asthma.
iv Primary therapy medications are defined by the NCQA as inhaled corticosteroids.
v However, there have been declines in such prescriptions by office-based physicians. See Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA 2001;286(10):1181-6, and McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA 2002;287(23):3096-102.
vi Note that because the Behavioral Risk Factor Surveillance System is a household survey, estimates for the elderly exclude immunization of those in nursing homes.
vii More information on this screening measure is available in the Measure Specifications Appendix as well as from the Centers for Medicare & Medicaid Services.


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What We Don't Know

Respiratory disease is one of the areas within the NHQR framework in which there is consensus on what constitutes good quality of care. We know that immunization reduces the rate of influenza infection and pneumonia. We know how to properly treat patients with pneumonia. We know what medications currently work best for managing asthma, and we know how to control the spread of TB.26,27,28

There are gaps in our ability and knowledge on how best to diagnose and treat respiratory diseases. For example, management of multi-drug resistant TB is a growing challenge in this country. A significant push will be needed to realize the potential for quality improvement in prevention and treatment of all respiratory diseases. Nationally, more information is needed on:

  • Efforts toward quality improvement — whether locally by individual hospitals, or nationally through programs such as the Medicare QIO program — have shown results.29,30 Ways to expand these gains to other populations and settings need to be explored.
  • Without systematic and consistent use of evidence-based guidelines in practice, performance will continue to lag behind knowledge in managing asthma, upper respiratory infection, and in some areas, pneumonia.
  • Short-term research that emphasizes drug efficacy trials predominates the literature on asthma. More information is needed that can support clinical decisionmaking on the intensity of treatment, optimization of medication regimens, and utility of disease management interventions for various asthma populations.28

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What Can Be Done

Improving quality of care for patients with respiratory disease should be the goal of any quality measurement effort such as this report. We need to understand where we are doing well and where we are doing poorly; for instance, examining existing data to better understand why some areas of the country do better than others at delivering respiratory disease care. HCUP, which tracks national and State data for a variety of quality measures, is one such source of State data. A first look at some State analyses for asthma quality of care is presented in Figure 14.

State Variation in Admission Rates for Childhood Asthma

Admissions for childhood asthma vary widely across the Nation. Several State data sources shared with AHRQ their rates of admission for pediatric asthma — potentially preventable hospitalizations. While this is not a complete or random sample of States, the rates differ by almost two-and-a-half times from the lowest to the highest among these States. The States shown here (see Note) are part of AHRQ's Federal-State-Industry partnership, known as the Healthcare Cost and Utilization Project , which combines States' hospital discharge records into a uniform database to make such insights possible. The U.S. rate is based on the Nationwide Inpatient Sample, a sample of hospitals from 28 HCUP States weighted to a national estimate.

What causes the differences in these preventable hospitalizations? Undoubtedly many factors, including prevalence of the disease; severity of the condition when presented to the doctor; different approaches by physicians to treating asthma in community settings and judgments about when to hospitalize; differential access to hospital beds, emergency rooms, and health care professionals; income levels; availability of insurance and effective disease management programs; environmental risk and behavioral factors (such as second-hand smoke levels) among populations; and education about the warning signs of disease, prevention, and when to consult a doctor. Also, HCUP relies on State-specific data collection methods, which may contribute to the differences. These potential factors need further study.

Better use of data to understand variation and causes behind unfavorable respiratory illness outcomes is one component of efforts to improve quality of care for these illnesses. Another component is the dissemination of best practices in respiratory illness. In addressing TB, screening and treatment for latent TB infection (LTBI) have been key components of the national strategy for TB elimination in the United States for more than 35 years. Updated guidelines, issued in 2000, urge public health programs to direct TB screening activities toward populations most at risk for LTBI and TB.

The Virginia Department of Health has advocated screening and treatment of LTBI as a TB control strategy for many years. In 1998, approximately 90,000 people were screened for TB infection by local health departments in Virginia; only an estimated 40% belonged to high-risk groups. The remaining low-risk individuals were screened primarily due to requirements established by State or local regulation or private employers. From 1999 to 2002, the Virginia Division of TB Control led a successful, statewide initiative to establish risk-based, targeted tuberculin testing as the official TB screening policy for all State agencies throughout the Commonwealth of Virginia. As a result of these efforts, testing of individuals at low risk for TB infection or disease was dramatically reduced, as evidenced by the results below:

  • Between FY 2000 and FY 2002, there was a 39.8% (69,569 versus 41,913 tests) decrease in the number of tuberculin skin tests administered statewide. Thirty of the 35 local districts reported decreases in the number of tests administered.
  • As a consequence of this policy change, use of State-funded chest radiography services declined by 88%, resulting in an annual cost savings of nearly $175,000 compared with FY 1998.
  • Over this same time period, the percentage of positive results among those tested increased from 3.4% to 6.1%, suggesting that the targeted testing policy has improved the efficiency of screening.31

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List of Measures

Respiratory Diseases

Measure Title National State
Immunization, influenza:
Process: % of high risk individuals (e.g., COPD) age 18-64 who received an influenza vaccination in the past 12 months Table 1.69a (00) Table 1.69b (01)
Process: % of individuals age 65 and over who received an influenza vaccination in the past 12 months Table 1.70a (00) Table 1.70b (01)
Process: % of institutionalized adults (people in long-term care or nursing homes) who received an influenza vaccination in past 12 months Table 1.71a (99)  
Table 1.71b (97) N/A
Outcome: Hospital admissions for immunization-preventable influenza per 100,000 population Table 1.72 (00) N/A
Immunization, pneumonia:
Process: % of high risk individuals (e.g., COPD) age 18-64 who ever received a pneumococcal vaccination Table 1.73a (00) Table 1.73b (01)
Process: % of individuals age 65 and over who ever received a pneumococcal vaccination Table 1.74a (00) Table 1.74b (01)
Process: % of institutionalized adults (people in long-term care or nursing homes) who ever received a pneumococcal vaccination Table 1.75a (99)  
Table 1.75b (97) N/A
Treatment of pneumonia:
Process: % of patients with pneumonia who have blood cultures collected before antibiotics are administered Table 1.76a Table 1.76b
Process: % of patients with pneumonia who receive the initial antibiotic dose within 8 hours of hospital arrival Table 1.77a Table 1.77b
Process: % of patients with pneumonia who receive the initial antibiotic consistent with current recommendations Table 1.78a Table 1.78b
Process: % of patients with pneumonia who receive influenza screening or vaccination Table 1.79a Table 1.79b
Process: % of patients with pneumonia who receive pneumococcal screening or vaccination Table 1.80a Table 1.80b
Treatment of URI:
Process: % of visits where an antibiotic is prescribed for the diagnosis of a common cold, children and adults Table 1.81a (9900)  
Table 1.81b (9899)  
Table 1.81c (9798) N/A
Management of asthma:
Process: % of people with persistent asthma who are prescribed medications acceptable as primary therapy for long-term control of asthma (inhaled corticosteroids) Table 1.82 (00) N/A
Outcome: Hospital admissions for pediatric asthma per 10,000 population under age 18 h Table 1.83a (nhds00)  
Table 1.83b (nhds99)  
Table 1.83c (nhds 98) N/A
Outcome: Hospital admissions for asthma per 10,000 population age 18-64viii Table 1.84a (nhds00)  
Table 1.84b (nhds99)  
Table 1.84c (nhds 98) N/A
Outcome: Hospital admissions for asthma per 100,000 population age 65+ Table 1.85 (00) N/A
Treatment of TB:
Process: % of TB patients that complete a curative course of TB treatment within 12 months of initiation of treatment Table 1.86a (99)  
Table 1.86b (98) N/A

Note: See Tables Appendix for tables listed above.

viii This measure is one for which two comparable national data sources exist—the National Hospital Discharge Survey and the Healthcare Cost and Utilization Project. Both data sources present information on potentially preventable hospital admissions with some slight variation in the measure specifications for individual measures. This report relied on Healthy People 2010 measure specifications to determine which data source should be used in the report for individual measures. More information is available in the Measure Specifications Appendix. More information on the NHDS is available at http://www.cdc.gov/nchs/about/major/hdasd/nhds.htm. More information on HCUP and the AHRQ Quality Indicators is available at www.ahrq.gov/data/hcup and www.qualityindicators.ahrq.gov, respectively.


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References

1 National Center for Health Statistics. Health, United States, 2002. Hyattsville, MD: Public Health Service; 2002. Table 32.

2 Rhew DC. Quality indicators for the management of pneumonia in vulnerable elders. Ann Intern Med 2001;135(8 Pt 2):736-43.

3 American Lung Association. Morbidity and mortality: pneumonia, influenza and acute respiratory conditions. New York: American Lung Association; 2002.

4 Krauss N. Statistical brief #13: asthma treatment: use of medications and devices, 2000. Rockville, MD: Agency for Healthcare Research and Quality; 2003.

5 National Heart, Lung, and Blood Institute. Strategy for addressing health disparities FY 2002 2006. Available at: http://www.nhlbi.nih.gov/resources/docs/plandisp.htm. Accessed October 29, 2003.

6 Centers for Disease Control and Prevention. Reported tuberculosis in the United States, 2002. 2002. Available at: http://www.cdc.gov/nchstp/tb/surv/surv2002/PDF/total.pdf. Accessed January 15, 2004.

7 Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001. JAMA 2003;289(3):305-12.

8 Schmid R. Strep strains becoming more resistant to drugs; experts caution against antibiotic overuse. The Washington Post (from the Associated Press) 2003 Mar 10;Sect. A:09.

9 Rubin R. Colds uncommonly costly. USA Today 2003 Feb 25;Sect. 9:D.

10 Manning A. Microbes eat away at antibiotics. USA Today 2002 Sep 30;Sect. 6:D.

11 Cantrell R, Young AF, Martin BC. Antibiotic prescribing in ambulatory care settings for adults with colds, upper respiratory tract infections, and bronchitis. Clin Ther 2002;24(1):170-82.

12 Centers for Disease Control and Prevention. Promoting appropriate antibiotic use in the community home page. Available at: http://www.cdc.gov/drugresistance/community/#campaign. Accessed November 10, 2003.

13 U.S. Department of Health and Human Services. Action against asthma: a strategic plan for the Department of Health and Human Services. 2000.

14 American Lung Association. Trends in asthma morbidity and mortality; 2002 Mar.

15 Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma--United States, 1980-1999. MMWR Surveill Summ 2002;51(1):1-13.

16 Clark NM, Feldman CH, Evans D, et al. The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 1986;78(1 Pt 1):108-15.

17 Goodman DC, Lozano P, Stukel TA, et al. Has asthma medication use in children become more frequent, more appropriate, or both? Pediatrics 1999;104(2 Pt 1):187-94.

18 Warman KL, Silver EJ, McCourt MP, et al. How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? National Heart, Lung, and Blood Institute. Pediatrics 1999;103(2):422-7.

19 Laumann JM, Bjornson DC. Comparing asthma treatment with guidelines. Annals of Pharmacotherapy 1998;32(12):1290-1294.

20 Adams P, Hendershot G, Marano M. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 10 1999;200:59-66.

21 Centers for Disease Control and Prevention. Campaign to prevent antimicrobial resistance in healthcare settings. Available at: http://www.cdc.gov/drugresistance/healthcare/default.htm. Accessed November 14, 2003.

22 Food and Drug Administration. FDA publishes final rule to require labeling about antibiotic resistance [Press Release]. 2003 Feb 5.

23 Scott JG, Cohen D, DiCicco-Bloom B, et al. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract 2001;50(10):853-8.

24 Mainous AG, 3rd, Hueston WJ. The cost of antibiotics in treating upper respiratory tract infections in a medicaid population. Arch Fam Med 1998;7(1):45-9.

25 Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: Centers for Disease Control and Prevention; 2001. Available at: http://www.cdc.gov/brfss/technical_infodata/surveydata/2001.htm. Accessed January 15, 2004.

26 Guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute. National Asthma Education Program. Expert Panel Report. J Allergy Clin Immunol 1991;88(3 Pt 2):425-534.

27 National Asthma Education and Prevention Program Expert Panel Report. Guidelines for the diagnosis and management of asthma — update on selected topics 2002. 2002.

28 Aronson N, Lefevre F, Piper M, et al. Management of chronic asthma. Evidence Report/Technology Assessment Number 44. 2001 Sep. AHRQ Publication No. 01-E044. Available at: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=erta44. Accessed January 2, 2004.

29 Chu LA, Bratzler DW, Lewis RJ, et al. Improving the quality of care for patients with pneumonia in very small hospitals. Arch Intern Med 2003;163(3):326-32.

30 Institute for Healthcare Improvement. Asthma training manual. Boston, MA: Institute for Healthcare Improvement; 2002.

31 U.S. Department of Health and Human Services. Risk-based tuberculosis screening in Virginia. 2003.

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