AHRQ Research on Caring for Children With Asthma
Translating Research Into Practice
Asthma is the most common chronic disease among U.S. children, affecting 4.8 million of America's 70 million children under age 18. Medical evidence, however, shows asthma can be treated effectively. The National Asthma Education and Prevention Program (NAEPP) recommends that children with persistent asthma use daily drug therapy to prevent airway swelling and, if an asthma attack occurs, to ease airway constriction. Consistent treatment at home and school can prevent attacks and minimize the need for emergency hospital care. To date, however, medical knowledge has not been enough to ensure that children get basic, high-quality asthma care.
In 1995, children were hospitalized for treatment of asthma nearly 170,000 times at a total cost of about $387 million. The debilitating effects of this condition cause 10 million missed school days each year. If we know which treatments work, why are these costly health problems so common? What more can be done to ensure basic routine care for children with asthma?
Researchers supported by the Agency for Healthcare Research and Quality (AHRQ, formerly known as the Agency for Health Care Policy and Research) have been working to find answers to these questions. These investigators are:
- Testing specific strategies to improve care.
- Embarking on new studies to understand how particular health plan policies and clinical practices can hinder or promote high-quality, cost-effective care.
By using findings from the AHRQ-funded research described below, clinicians, families, and other decisionmakers can translate medical knowledge into better everyday care for children with asthma.
Understanding the Problem
Although asthma is a pervasive problem, it does not affect all groups of children equally. Poor children are at especially high risk of hospitalization for asthma. In 1995, half of all pediatric asthma hospitalizations were for children who were either covered by Medicaid or uninsured.
Boys and African-American children are also at higher-than-average risk of being affected by this disease. In a study of middle-class children, 14 percent of boys and 12 percent of African-American children were diagnosed with asthma, compared with 5 percent of girls and 6 percent of white children.
Among preschool children with asthma, whites are 3 times as likely as blacks and over 10 times as likely as Hispanics to receive routine drug treatment to prevent future attacks.
Strengthening Primary Care
Many hospitalizations might be avoided if children diagnosed with asthma received adequate primary care. One group of researchers compared children hospitalized for asthma in three cities. They found that children in Boston, where rates of hospitalization are high, were only one-third as likely as children in Rochester, NY, to be on maintenance drug therapy, which helps prevent asthma attacks.
African-American and Hispanic children appear to be at especially high risk of receiving inadequate preventive treatment for asthma attacks. In one study, African-American children were 30 percent more likely than white children to be treated for asthma only in hospital emergency departments. Another study of preschool children hospitalized for asthma found that only 7 percent of blacks and 2 percent of Hispanics, compared with 21 percent of white children, were prescribed routine drug treatment to prevent future hospitalizations.
Improving Quality of Care
Systematic improvements in quality of care are based on accurate measurement which takes into account effects important to children and families. Valid, sensitive measures allow strategies that lead to real improvements to be reliably identified, while those with no or illusory effects can be abandoned.
One AHRQ project has contributed to the development of a new measure of quality to be used in the most recent version of the Health Plan Employer Data and Information Set, HEDIS 2000. HEDIS measures are widely used to evaluate the quality of health plans. This particular measure will track use of long-term control medications in children and adults with asthma. Another project is developing and testing several quality indicators of appropriate care for adults suffering from acute asthma attacks. These measures could be tested for their applicability to children.
Bringing Research to Every Day Practice
Despite considerable expert consensus and evidence on which practices will lead to better care for children with asthma, those practices are far from universal. Findings from one project will help clinicians and parents better manage childhood asthma by testing an approach for implementing the NAEPP asthma care guidelines mentioned earlier. Investigators are assessing whether this approach can improve prescribing practices, as well as measuring the costs and health benefits associated with adopting the guidelines. The research team also has tested new measures, such as number of symptom-free days, to identify how treatments affect children's daily lives.
AHRQ research has contributed to a new measure that will monitor patients' use of long-term drugs to control asthma. Such measures are widely employed to evaluate health plan quality.
New Research Directions
Many asthmatic children, including many whose care is covered by Medicaid, are now enrolled in managed care plans. To improve the quality of care for these children, plan managers, payers, families, and other decisionmakers need to know how specific policies and practices affect their care. Current AHRQ-funded investigations are aimed at addressing this information need.
AHRQ, the American Association of Health Plans Foundation, and in part, the Health Resources and Services Administration, are funding several research teams in a 3-year research effort to investigate how particular managed care policies and practices affect the quality of care for patients living with chronic illnesses, including asthma. For example:
- Researchers in one study are examining how 2,700 poor children with asthma in California, Massachusetts, and Washington are receiving their Medicaid-reimbursed care through managed care. Among other questions, this study will examine whether features such as asthma disease management programs improve self-care and health outcomes.
- Two sets of investigators—one studying children in Maryland's Medicaid program and one looking at children in the Florida Healthy Kids program—are assessing how specific organizational policies either restrict or enable access to particular services for children with asthma and other chronic diseases who are enrolled in public programs.
- In another study, researchers are examining how structural characteristics, incentives, and quality assurance efforts of managed care plans in Washington State affect the quality of care for chronically ill children.
Emergency Department Use
Investigators studying children with respiratory problems who are enrolled in managed care plans are relating emergency department use by patients to characteristics of their primary care practice, such as availability of after-hours care. By doing so, these researchers hope to identify problems in access to primary care that can be addressed to decrease the need to seek services from the emergency room.
New Models of Care
In 1999, AHRQ funded several studies that investigate various methods of service delivery and financing and their effect on quality of pediatric asthma care. These include:
- An assessment of the effects of using school-based health centers (SBHCs) in delivering primary care to children with asthma in the Bronx, NY. The outcomes of three different treatment strategies will be compared by various measures, including child's school performance, health status, life style restrictions, and cost.
- An evaluation of how the specific features of a State children's health insurance program—New York State's Child Health Plus (CHPlus)—affect access, use, and quality of care for low-income children with asthma. Key comparisons include those across four types of CHPlus plans, three age groups, three ethnic/racial groups, and four geographic areas.
- A study of the impact of an office-based quality improvement strategy compared with "usual care" in the management of pediatric asthma in different practices in the same integrated health care delivery system. Researchers will examine how this strategy affects processes, outcomes, and costs of asthma care.