Health Plan Employer Data and Information Set (HEDIS(R)) Criteria to Determine the Quality of Asthma Care in Children: What Are the Limitations?

The Health Plan Employer Data and Information Set (HEDIS(R)) of the National Committee for Quality Assurance is a set of standardized performance measures, the goal of which is to enable purchasers and consumers to evaluate the quality of different health plans. The HEDIS(R) `Use of Appropriate Medications for People with Asthma' measure assesses the presence of an asthma controller medication dispensing in patients who meet healthcare utilization criteria that suggest persistent asthma. The HEDIS(R) asthma measure has been criticized on the basis of poor sensitivity and specificity for identifying persistent asthma because just one asthma controller medication dispensing is unlikely to be effective, and because asthma controller medications are not all the same. Meeting the HEDIS(R) criteria may be associated with reductions in asthma crisis care in more adherent population groups; however, in less adherent populations, a paradoxical increase in asthma crisis care has been observed. The `asthma medication ratio' of anti-inflammatory divided by (anti-inflammatory plus bronchodilator) canister dispensings has been proposed as an alternative quality-of-care measure, and improvements in the ratio are associated with a reduction in asthma crises. However, this measure has been criticized because of the difficulty in determining dose equivalence among various medications and delivery systems. Medication-based measures of asthma care quality, although associated with clinically important outcomes, may also create adverse incentives for overtreatment. In addition, medication-based measures only assess the level of asthma control indirectly and neglect important parameters of asthma care, including identification and control of asthma triggers, stepping down medication when asthma is well controlled, and the development of a patient/doctor partnership. Although there is utility to medication-based measures of asthma care quality, we need to be cognizant of the limitations of medication-based measures. Many items that affect asthma control, such as air quality, housing quality, and involuntary smoke exposure, reflect choices of our society. From a societal perspective, quality of care for the uninsured/intermittently insured is as important as for the continuously enrolled. Asthma control reflects not only the quality of medical care delivered, but also broader aspects of the health of our society. Perhaps the future of asthma quality assessment is not just about physician and health plan performance but also about the performance of our communities and nations in protecting the respiratory health of the most vulnerable.