Quality Measures

In 1997, the National Asthma Education and Prevention Program (NAEPP) published asthma guidelines. The guidelines were revised in 2002. NAEPP's recommendations focus on four areas of asthma care: diagnosis of asthma and establishing a partnership with patient, reduction of inflammation, symptoms, and exacerbation, monitoring asthma over time, and prompt treatment of asthma episodes.

The specific recommendations from the guidelines that will be measured include the following:

Severity of patient's asthma documented by a clinician
Performance of asthma management services, such as peak flow expiratory flow rates (PEFR) or pulmonary function tests (PFT's) monitoring, referrals to specialists, and allergy evaluations
Documentation of interim history, asthma triggers, or inquiries regarding smoking exposure
Whether asthma patients or their parents/caregivers receive general asthma education regarding management of exacerbation or avoidance of triggers, use of peak flow meters, and metered dose inhalers
Types of medications prescribed for the patient and determine the appropriateness based on the severity of patient's asthma
Whether asthmatic patients/parents/ or caregivers receive written asthma management plans

A1: Long-term Control Agent Indicator

Proportion of patients with persistent asthma who are being treated by one of several classes of agents that are considered "long-term control agents". These are inhaled steroids, cromolyn sodium/nedocromil, or leukotriene modifiers.
- Persistent asthma is defined in 5 different ways. Denominator is all patients in registry who have persistent asthma. Numerator is all patients with documentation of being on long-term control agents at least one time during review period
  - Persistent 1- Hospitalization or emergency department visit during study start and end dates
  - Persistent 2- Four or more visits for asthma during study start and end dates
  - Persistent 3- Physician or clinician asthma severity documentation of mild, moderate or severe persistent asthma during study start and end dates
  - Persistent 4- Documentation of National Asthma Education Prevention Program asthma symptoms on any of the visits for asthma during study start and end dates. These include the following:
    - Daytime symptoms occur 3 or more times a week (NAEPP)
    - Night-time symptoms occur 3 or more times a month (NAEPP)
    - Continual symptoms lasting days (NAEPP)
    - FEV1 less than 80% of predicted value (NAEPP)
    - PEFR less than 80% of personal best or nomogram (IPRO)
  - Persistent 5- Documentation of either Persistent 1, 2, 3, or 4

A2: General Patient Education Indicator

Proportion of all eligible registry patients who have evidence of any education being provided to a patient from any health care provider
- Inclusions: Education must be geared toward the treatment of management of asthma which would include mention of any of the following: when to increase medication, when to call for help, when to visit ER, how to avoid triggers, using a PEFR, how to manage condition during acute illness (e.g. increase fluids during URIs). Also include any progress notes, which indicate patient was instructed in asthma medication usage, e.g. "use proventil prior to exercising" or "call if symptoms worsen".
- Exclusions: Information given only on when to schedule a return visit. Information unrelated to asthma. Medications were noted without indication that patient was given any guidance respect to their use.

A3: Asthma Management Plan Indicator

Proportion of eligible registry patients for whom there is documentation, at any time during the abstraction period, that a written asthma management plan was provided either to the patient or the patient's caregiver OR at a minimum, specific written instructions on under what conditions the patient's doctor should be contacted or the patient should go to the emergency room:
- Inclusions: Copy of asthma management plan on record OR written note by provider documenting having given the patient/parent/caregiver written asthma management instructions. Instructions can include when to use PEFR or change medications in response to a change in patient symptoms &/or when to contact a physician &/or when to go directly to the emergency room
- Exclusions: Documentation of verbal directions given to patient/parent/caregiver without documentation of written directions being given to patient/parent/caregiver

A4: Home Peak Expiratory Flow Rate Indicator

Proportion of eligible registry patient who have documentation, at any time during the abstraction period, of any instruction regarding the home use of a PEFR or actual home use of a PEFR
- Inclusion: Any notation that the patient or caregiver received instruction in home use PEFR or management of results. Notation of PEFR being performed at home with or without documented results
- Exclusion: NONE

A5: Office Peak Expiratory Flow Rate (PEFR) pulmonary Function Test (PFT) Indicator

Proportion of eligible registry patients who have documentation, at any time during the abstraction period, of office use of a PEFR or results from formal pulmonary function testing
- Inclusions: Any notation documenting "peak flow", FEVI, expiratory flow rate, tidal volume, forced expiratory flow rate, PFT or report from a pulmonary function laboratory
- Exclusions: NONE

A6: General Trigger History Indicator

Proportion of eligible registry patients who have documentation, at any time during the abstraction period, that inquiry was made regarding potential trigger(s).
- Inclusions: Common triggers include a variety of environmental allergens and irritants (e.g., pollen, grass, ragweed, mold, pets, rodents, dust mites, cold air, smoke, pollutants, or weather changes). Documentation of any other factor that may precipitate an asthma attack, e.g., emotional factors, infections or exercise OR documentation when symptoms increase (e.g., night wheezing, seasonal changes). Patient self-report is acceptable. This could occur at any time during the measurement period or listed on the patient's intake history and physical examination within the last two years
- Exclusions: Notation of no known allergies, "NKA".

A7: Specific Smoking History Indicator

Proportion of eligible registry patients who have documentation, at any time during the abstraction period that an inquiry was made concerning patient exposure to second hand smoke and/or if the patient smokes.
- Inclusions: Any notation documenting question(s) regarding smoke exposure or smoking. Patient self-report is acceptable.
- Exclusions: NONE

A8: Metered Dose Inhaler Skills Indicator

Proportion of eligible registry patients who have documentation, at any time during the abstraction period, that the patient is using a MDI and there is documentation of specific patient training in MDI
- Inclusion: among those patients who are using a metered dose inhaler-chart review evidence of training performed by the clinician at any time during the measurement period. This includes MDI-use instructions and/or MDI demonstration by the clinician and/or demonstration of MDI use by the patient with corrective training as needed by the clinician.
- Exclusion: Patient not on an MDI

A9: Explicit Assessment of Asthma Severity Indicator

Proportion of eligible registry patients who have documentation, at any time during the review period, of a physician, physician assistant or nurse practitioner statement regarding the patient's symptoms that coincides with NAEPP terminology of persistent asthma.
- Inclusion: Intermittent asthma, mild persistent or mild asthma, moderate persistent or moderate asthma, severe persistent or severe asthma.

A10: Symptoms of Patient's Asthma Severity

Proportion of eligible registry patients who have documentation, at any time during the review period, of a physician, physician assistant or nurse practitioner statement regarding the patient's symptoms that coincides with NAEPP terminology of persistent asthma
- Inclusion: Documentation of any of the following symptoms:
  - Daytime symptoms occur 3 or more times per week. For example, patient noted to have episodes of coughing for 3 or more times in a week
  - Nighttime symptoms occur 3 or more times a month. For example, patient noted to be waking up with wheezing for the last 2 weeks
  - Continual symptoms lasting days. For example, patient noted to have a cough for the last 2 weeks or for the past 2 days, wheezing has continued and treatments offer little relief
  - FEV 1 less that or equal to 80% of predicted value. Documentation in progress notes, consults notes, or spirometry results or recording of FEV1, documented values for patient to be less that or equal to 80% of patient's predicted value

PEFR less that 80% of personal best or nomogram. Documentation in progress notes, consults notes, or peak expiratory flow rate results or recordings documented values for patient to be less than 80% of patient's predicted value.