Published online May 2, 2005
PEDIATRICS
Vol. 115
No. 5
May 2005, pp.
1453
(doi:10.1542/peds.2005-0071)
Limits of the Health Plan Employer Data Information Set (HEDIS) Criteria in Determining Asthma Severity for Children, Applied to an Impoverished, Urban Population
Sarah C. Armstrong, MD
Hollis Seunarine, MD, FAAFP
Jai Medical Center
Baltimore, MD 21212
To the Editor.—
The Cabana et al1 article in the October 2004 issue of Pediatrics, which compares the National Heart, Lung, and Blood Institute recommendations for treatment of pediatric asthma with the quality-of-asthma-care measure developed by the Health Plan Employer Data Set (HEDIS), effectively addresses the limitations of standardized guidelines. The HEDIS asthma measure identifies health plan members with "persistent" asthma if there was 1 emergency-department (ED) visit or inpatient discharge listing asthma as the primary diagnosis, 
4 outpatient asthma visits with 2 medication-dispensing events, or 4 medication-dispensing events in the year before evaluation. To pass the measure, members with "persistent" asthma must fill a prescription for a qualifying medication (inhaled steroid, leukotriene modifier, etc) in the year of evaluation. Medicaid programs currently use HEDIS criteria to compare state health plans, offering incentives for high scores and disincentives for poor scores.
The population selected in the Cabana et al study represents a variety of demographics; however, only 13% are Medicaid participants.1 The asthma burden is disproportionately carried by the poor black population, which is seen most strikingly in rates of hospitalizations and mortality. In a review published by Akinbami and Schoendorf,2 non-Hispanic black children were >3 times as likely to be hospitalized and >4 times as likely to die from asthma as their white counterparts.
We conducted a retrospective chart review at our Baltimore City–based community health facility to evaluate the effectiveness of the HEDIS criteria in an impoverished, urban population. All patients received regular medical care at 1 of the Jai Medical Systems facilities in Baltimore City between January 2002 and November 2004. Approximately 15% of all the pediatric patients at the clinic have a diagnosis of asthma, more than twice the national average. All patients are eligible for medical assistance.
Our sample included 43 children 5 to 18 years old: 100% were black, 56% were male, and 70% were between the ages of 10 and 18 years. All patients met criteria for "persistent" asthma according to the HEDIS asthma measure. According to physician documentation in the chart, 1 (2%) had outgrown asthma, 3 (7%) had exercise-induced asthma, and 20 (47%) had mild intermittent asthma. Of the 19 remaining patients, 16 (37%) had mild persistent and 3 (7%) had moderate persistent disease. No patients were classified as severe. Of the 19 patients with persistent asthma, 16 had been given a prescription or office sample for an inhaled corticosteroid within the past year but are currently failing the measure. None of the patients were admitted to a hospital with a diagnosis of asthma in the past year, and only 4 (9%) had a single ED visit.
In an all-black, urban, underserved community setting, the HEDIS asthma measure overclassified the severity of pediatric asthma in more than half of the cases reviewed. The lack of hospitalizations and ED visits shows that ours is not a group of severely asthmatic children. In an urban, impoverished population, the HEDIS asthma measure seems even less specific for identifying chronic asthma than in the mixed socioeconomic population of the Cabana et al study. HEDIS uses automated reporting data such as the number of ß-agonist refills in a year, number of ED visits, and pharmacy data. These markers of severity may not be appropriate for the urban poor, because the ED is overused, prescriptions are misplaced, and drug samples are often used. If providers inappropriately modify their treatment standards to improve HEDIS scores, it may lead to overmedication. The HEDIS asthma measure needs to be revised before we can follow its recommendations safely. Meanwhile, we still need a tool to identify and treat those children with asthma who are not receiving adequate treatment.
REFERENCES
- Cabana M, Slish K, Nan B, Clark N. Limits of the HEDIS criteria in determining asthma severity for children.
Pediatrics. 2004;114
:1049
–1055[Abstract/Free Full Text]
- Akinbami L, Schoendorf K. Trends in childhood asthma: prevalence, health care utilization, and mortality.
Pediatrics. 2002;110
:315
–322[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
