Module 5: Moving Ahead—Implications for State Action

This module draws implications for States to move forward with their own asthma care quality improvement initiatives. States need to go beyond generic resources and tailor efforts to their individual needs; specifically, they need to gather more localized data and involve key partners.

Asthma is a chronic condition that presents a compelling case for quality improvement:

• Asthma is becoming more prevalent. Estimates show that the number of Americans with asthma nearly doubled between 1980 and 1996. In 2007, nearly 30 million Americans reported suffering from asthma at some time in their lives.
• Substantial disparities exist in diagnoses and quality of asthma care. Data from the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) show wide variations in quality for asthma across States and also across different socioeconomic, racial, and ethnic groups.
• Asthma cannot be cured but is highly treatable. It can be controlled and managed through a range of interventions and treatments that prevent attacks and allow people with asthma to function normally. Often the disease can be self managed, allowing people with asthma to avoid costly hospitalizations or procedures.
• Asthma is costly to treat. Families with an asthmatic child reported spending nearly three times as much annually on health care as families with a non-asthmatic child. In 2007, asthma's total estimated cost for the total burden of the illness (including health care services and other lost abilities) was about $9.7 billion.

Thus, there is potential for a substantial return on investment for purchasers and the health care system as a whole through asthma quality improvement.

Essential Elements in State-Led Quality Improvement

This Resource Guide offers a model for States to undertake a systematic effort to improve the quality of asthma care within their jurisdictions. State leaders can contribute essential elements to the process of asthma care quality improvement. These elements include the following:

• Providing leadership and vision. Quality improvement requires leadership. Whether initiatives are developing locally, statewide or nationally, effective leadership is essential to quality improvement. It will not emerge without a champion who can provide leadership to help organizations and individuals develop a shared vision and common goals for health care quality. Leadership must be a catalyst for others to become involved in developing shared vision and goals for improving health care quality.
• Forming partnerships and collaborations. In addition to leadership and vision, partnerships and collaborations are vital to improving quality. Health care quality is the product of many different parts of the health care system but ultimately must affect what happens in the community, the patient environment, and the clinical setting. Thus, all groups that affect patient care should participate in quality improvement efforts. Health care professionals and providers need to establish systems that deliver appropriate, quality care consistently; patients need to demand and participate in the best available care; and purchasers must demand and pay for the highest quality, most cost-effective delivery of care. Consumer groups with interest in asthma can be powerful allies for change and a source of expertise. State health department staff and other asthma care experts from private-sector organizations can provide support and expertise for State initiatives.
• Initiating measurement and reporting. A key step for State action is measuring quality. This step involves defining quality standards, identifying measures of those standards, finding available benchmarks, locating data that pertain to the State, perhaps collecting new data, and using data to track how well the health care system is performing and how well pilot interventions are working. Benchmarks and comparison data provide a mechanism for assessing how well the State is doing and how well any given health plan or provider is doing in a selected area of care. In order to improve, the health care system must have data robust enough to estimate a given set of measures of health care quality. As part of a systematic improvement initiative, States will need to go beyond generic resources and develop a comprehensive, State-specific picture of asthma care. Doing so will enable States to identify specific quality problems in their own communities and tailor specific solutions. Results then must be made available to enable purchasers and consumers to make meaningful decisions based on the performance of various providers.
• Assisting planning and goal setting. State quality improvement initiatives should involve development of an action plan with specific goals for quality improvement in the State. The action plan must include timelines for specific steps and deliverables to help ensure that all partners move together. The plan should include specific responsibilities and benefits for as many project partners as possible to ensure commitment and continued involvement.
• Assuring evaluation and accountability. After establishing partnerships with committed leaders and a common vision and goals, developing measures, collecting and analyzing data, and setting goals, there also is a need for evaluation of both health system performance and accountability for health care quality. Evaluation allows partners to identify the most troublesome areas and devote resources and attention to those areas where improvement is needed. Evaluation also enables recognition of areas where there is solid performance or conduct improvement over time. It may require some technical input and expertise, but it is an important component of the quality improvement process. Without evaluation, impact of the program will be unknown and future direction for the program will be haphazard.
• Creating incentives. Although reporting data on performance is often enough to spur low performers toward improvement, tying rewards to high performance is also needed. The American health care system typically pays providers for the level, not the quality, of services delivered. However, States—as large health care purchasers—are in a position to offer financial incentives for providers to deliver quality care. For example, State programs can include bonuses and rewards for physicians who follow evidence-based guidelines in delivering asthma care.
• Spreading the change statewide. It is important for States to develop and implement ways to spread quality improvement in asthma statewide. This involves planning an effective tracking system, collecting and analyzing data, and drawing conclusions. State leaders must differentiate between sound conclusions and inconclusive findings and use this information to further the asthma quality improvement effort and to address other health care issues.

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States Have a Way Forward—A Final Note

This Resource Guide has attempted to demonstrate for State leaders the need for quality improvement in asthma. Much has been done, but data from the NHQR show that much remains to be done to achieve quality care for all people with asthma.

By reviewing and analyzing the information in this Resource Guide, assessing the local context, and designing an asthma quality improvement strategy, State leaders can identify opportunities to make a difference in the quality of care their constituents receive. The experiences of States that have implemented quality improvement for asthma care provide valuable insights into what can be accomplished through innovative, visionary efforts by State leaders.

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