Vol. 11 •Issue 3 • Page 48
Identifying Gaps in Asthma CarE
Looking in the mirror to pinpoint potential problems in how you provide asthma care can be an uncomfortable process. Instead of searching for medical errors, comparing your current clinical practices with quality indicators may be less emotionally charged and easier to accomplish.
Developing quality indicators based on outcomes with clear clinical relevance should enhance clinicians’ willingness to address gaps in care, to participate in identifying root causes and to create practical solutions that enhance the quality of care they provide.
Quality indicators require a review of medical records. Reading the records of only 30 to 40 patients with asthma often will reveal areas to target for improvement. The following six quality indicators can be traced quickly back to an asthma care step directly related to an outcome that matters to patients, their families or clinicians.
• Quality indicator No. 1: What percentage of patients over 3 years of age with an ICD-9 code of 493 (asthma) has diagnoses other than asthma Ð such as reactive airway disease, wheezy bronchitis, chronic bronchitis or whatever the label du jour is in a community — documented in the medical record?
Inaccurate or incomplete diagnoses are common problems in asthma care. A review of 200 medical records of children with asthma in Rochester, Minn., revealed more than 30 percent had diagnoses that fluctuated from asthma to reactive airway disease and back over a period of five or more years of office, emergency department and urgent care visits.1
This wavering is unfortunate because proper asthma management and self-management are based on a clear diagnosis understood by the clinician and patient. In addition, patients whose diagnosis fluctuates from reactive airway disease to wheezy bronchitis to asthma may decide the medical community can’t make a decision about their condition.
Labels do matter. Calling asthma reactive airway disease or wheezy bronchitis or chronic bronchitis can affect therapy adherence and the patient’s and family’s response to an attack. People often perceive the label of reactive airway disease to signify a less serious condition, one that may not require immediate or urgent attention or chronic daily medications. Providing a clear and consistent name for the condition can be the first step in preventing miscommunication.
• Quality indicator No. 2: What percentage of patient medical records includes a quantification of daytime and nighttime symptoms?
A second common problem in asthma evaluation is incomplete identification and documentation of a patient’s symptoms. Because both severity scoring and the initial selection of therapy are based on symptoms, knowing and recording them is paramount to beginning appropriate therapy.
Asthma severity classification is based on the frequency and duration of daytime and nighttime symptoms as well as FEV1.2 Yet review of primary care practices’ medical records of more than 1,000 children and adolescents with asthma throughout the United States revealed that only 30 percent of the records had any documentation of the frequency and duration of daytime or nighttime symptoms. In fact, nighttime symptoms were mentioned only in 10 percent of the records.3 Spirometry or peak flow measurements were available in only 15 percent.
Without symptoms information, there’s no basis to initiate medical therapy or decide if it’s adequate. Symptom frequency should be available for a baseline period. The level of asthma severity can’t be defined and long-term therapy can’t be guided by knowing only the frequency and duration of symptoms during attacks or exacerbations.
• Quality indicator No. 3: What percentage of medical records documents absenteeism? What percentage of medical records addresses ability to participate in play and recreation?
Knowing when to step up or step down therapy requires information about symptoms and the patient’s daily life. For instance, how often has a child missed school or a parent missed work due to asthma? Has the mother had to quit work to be available to care for her child? How often does an adult with asthma attend work but perform at a lower level of productiveness?
A surprising number of medical records don’t record absenteeism from work or school. Even fewer identify the frequency of missed sports .activities or changes in recreation plans or reduced levels of play due to asthma symptoms. It’s your responsibility to ask and to document the response.
• Quality indicator No. 4: What percentage of medical records has some indication that allergens and triggers have been discussed or identified?
Knowledge of allergens and asthma triggers is important for the control of many patients’ asthma. Yet review of medical records showed that less than 10 percent of people with asthma have specific discussions with their physicians about allergens and asthma triggers or an indication of an allergy evaluation.1
All patients with persistent asthma should have some exploration of the potential allergic basis of their disease,3 such as documentation of the presence or absence of allergy-related symptoms, discussion of the seasonal variation in asthma symptoms, or a referral to an allergist for a more extensive evaluation. Lack of attention to triggers and allergens is likely to result in inadequate control and possibly to overmedication.
• Quality indicator No. 5: What percentage of patients has documented asthma education including observation of inhaler technique?
Asthma education appears to enhance self-management skills and reduce urgent and emergency visits for asthma.4 Something as seemingly simple as having patients demonstrate proper inhaler technique can have a significant effect on medication management.4
• Quality indicator No. 6: What percentage of patients has a scheduled follow-up visit after an urgent care or emergency department visit or a hospitalization?
While an asthma attack may prove a good moment to educate, patients’ attention may be limited during a crisis. Therefore, asthma education will likely require a scheduled follow-up visit.
Using these simple quality indicators can develop a basis for asthma care discussions with almost any clinician.
Dr. Yawn is director of research at the Olmsted Medical Center, Rochester, Minn.
For a list of references, call Sharlene Sephton at (610) 278-1400, ext. 1324, or visit www.Respiratory-care-sleep-medicine.advanceweb.com/mrreflist.html.