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Cultural Competence Policies and Other Predictors of Asthma Care Quality for Medicaid-Insured Children

Tracy A. Lieu, MD, MPH^*,, Jonathan A. Finkelstein, MD, MPH^*,, Paula Lozano, MD, MPH, Angela M. Capra, MA^||, Felicia W. Chi, MPH^||, Nancy Jensvold, MPH^||, Charles P. Quesenberry, PhD^|| and Harold J. Farber, MD^¶

^* Center for Child Health Care Studies, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts
Division of General Pediatrics, Children’s Hospital Boston, Boston, Massachusetts
Center for Health Studies, Group Health Cooperative, and Child Health Institute, Department of Pediatrics, University of Washington, Seattle, Washington
^|| Division of Research, Kaiser Permanente, Oakland, California
^¶ Department of Pediatrics, Kaiser Permanente, Vallejo, California

Objective. More than half of Medicaid enrollees are now in managed care. Scant information exists about which policies of practice sites improve quality of care in managed Medicaid. Children with asthma are a sentinel group for Medicaid quality monitoring because they are at elevated risk for adverse outcomes. The objective of this study was to identify practice-site policies and features associated with quality of care for Medicaid-insured children with asthma.

Methods. A prospective cohort study with 1-year follow-up was conducted in 5 health plans in California, Washington, and Massachusetts. Data were collected via telephone interviews with parents at baseline and 1 year, surveys of practice sites and clinicians, and computerized databases. The practice site survey asked about policies to promote cultural competence, the use of several types of reports to clinicians, support for self-management of asthma, case management and care coordination, and access to and continuity of care. Quality of care was evaluated on the basis of 5 measures: 1) preventive medication underuse based on parent report; 2) the parent’s rating of asthma care; 3) the 1-year change in the child’s asthma physical status based on a standardized measure; 4) preventive medication underprescribing based on computerized data; and 5) the occurrence of a hospital-based episode.

Results. Of the 1663 children in the study population, 67% had persistent asthma at baseline based on parent report of symptoms and medications. At 1-year follow-up, 65% of the children with persistent asthma were underusing preventive medication based on parent report. In multivariate analyses, patients of practice sites with the highest cultural competence scores were less likely to be underusing preventive asthma medications based on parent report at follow-up (odds ratio [OR]: 0.15; 95% confidence interval [CI]: 0.06–0.41 for the highest vs lowest categories) and had better parent ratings of care. The use of asthma reports to clinicians was predictive of less preventive medication underprescribing based on computerized data (OR: 0.33; 95% CI: 0.16–0.69), better parent ratings of care, and better asthma physical status at follow-up. Patients of practice sites with policies to promote access and continuity had less underuse of preventive medications (OR: 0.56; 95% CI: 0.34–0.93). Among the 83 practice sites, the practice site’s size, organizational type, percentage of patients insured by Medicaid, mechanism of payment for specialty care, and other primary care features were not consistently associated with quality measures.

Conclusions. Practice-site policies to promote cultural competence, the use of reports to clinicians, and access and continuity predicted higher quality of care for children with asthma in managed Medicaid.

Key Words: asthma • Medicaid • cultural competence • quality of care

Abbreviations: ACQA, Asthma Care Quality Assessment • ED, emergency department • HMO, health maintenance organization • OR, odds ratio • CI, confidence interval

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