Asthma Care Quality Improvement: 

A Workbook for State Action 

Prepared by: 

Karen Ho, M.H.S. 

Rosanna M. Coffey, Ph.D. 

DonnaRae Castillo, M.A. 

U.S. Department of Health and Human Services 

Agency for Healthcare Research and Quality 

Rockville, Maryland 

www.ahrq.hhs.gov 

AHRQ Publication No. 06-0012-2 

April 2006
Acknowledgments 

Karen Ho and Rosanna M. Coffey are with Thomson Medstat; DonnaRae Castillo is with the 

Agency for Healthcare Research and Quality. The authors acknowledge the contributions of 

David M. Adamson, Ph.D., formerly of Thomson Medstat, to the planning and development of 

the initial draft and Barbara Kass-Bartelmes, M.P.H., of the Agency for Healthcare Research and 

Quality, for advice and consultation on readability and utility of this product. 

____________________________________________________________________________________ 

This document is in the public domain within the United States only and may be used and reproduced 

without permission. AHRQ appreciates citation as to source and the suggested format is below. Foreign 

countries and users who want to distribute content on a global basis in electronic form or print should 

submit specific permission requests for use to: info@ahrq.gov 

Ho K, Coffey RM, Castillo D. Asthma Care Quality Improvement: A Workbook for State Action.

Rockville, MD: Agency for Healthcare Research and Quality, Department of Health and Human Services; 

April 2006. AHRQ Pub. No. 06-0012-2. 

ii 
Foreword 

Asthma Care Quality Improvement: A Workbook for State Action and its complementary 

Resource Guide were developed by the Agency for Healthcare Research and Quality (AHRQ) as 

learning tools for all State officials who want to improve the quality of health care. In 

conjunction with the Resource Guide, which uses State-level data on asthma care from the 2004

National Healthcare Quality Report, this Workbook is designed to help States assess the quality 

of care in their States and fashion quality improvement strategies suited to State conditions. 

The Workbook and its complementary Resource Guide can serve as tools for those who work on 

quality improvement to use in sharing their expertise, ideas, knowledge, and solutions. The 

various modules are intended for different users. Senior leaders, for example, may want to focus 

on making the case for asthma quality improvement, incorporating a State-led framework into 

their improvement strategy, and taking action; program staff need to provide the measures and 

data necessary to implement the quality improvement plan. The goal is that everyone work as a 

team and, thereby, improve the quality of asthma care in their State. 

If you have any comments or questions on this Workbook or its complementary Resource Guide, 

please contact the AHRQ Center for Quality Improvement and Patient Safety, 540 Gaither Road, 

Suite 3000, Rockville, MD 20850 (phone: 301/427-1734; email: dwight.mcneill@ahrq.hhs.gov). 

iii
Contents

Introduction......................................................................................................................................1 

Module 1: Making the Case for Asthma Care Quality Improvement .............................................3

Module 2: A Framework for State-Led Quality Improvement......................................................10 

Module 3: Learning From Current State Quality Improvement Efforts........................................18 

Module 4: Measuring Quality of Care for Asthma........................................................................21 

Module 5: Moving Ahead – Implications for State Action ...........................................................32 

A Final Note...................................................................................................................................35 

iv 
Introduction 

The Need for Asthma Quality Improvement 

As protectors of the public’s health, State governments play a vital role in preventing asthma and 

controlling its consequences. Most States have some public resources invested in asthma

prevention, monitoring, and care programs, although the level of investment may vary from State 

to State. As health care purchasers, States are responsible for ensuring that the health care they 

pay for on behalf of State employees, Medicaid clients, and other recipients meet standards of 

quality. 

There are a number of reasons why States may want to take a closer look at improving quality of 

care for asthma, including: 

• The increased prevalence of asthma, especially among children and adolescents. 

• The disparities between various racial and ethnic groups in diagnosis and quality of asthma

care. 

• Interventions and treatment that can successfully control the disease and prevent attacks. 

• The high health care cost of uncontrolled asthma and the potential for return on investment 

for purchasers, including State Medicaid agencies, through asthma quality improvement. 

See Module 1 of the Resource Guide for more information on these topics. 

Aim and Scope of This Workbook 

The aim of this Workbook is to help State leaders develop information to support health care 

quality improvement. Its written exercises should help State leaders begin to think about an 

effective partnership for an initiative, assembly of available data for their State, questions to raise 

about interpretation of the data, and quality improvement techniques. It also should help readers 

apply information and concepts from the Resource Guide to their own States. 

Upon completion of the Workbook, State leaders will be able to: 

• Understand the key factors that determine whether there is a need for an asthma care 

quality improvement in their State (i.e., “make the case”). 

• Identify partners to plan, develop, and support a quality improvement strategy for asthma. 

• Identify national, public-private, Federal, State, and local resources and activities related 

to asthma quality improvement. 

• Identify appropriate asthma data sources and measures and develop estimates from data 

for assessing the State’s performance in providing asthma care. 

• Identify opportunities to contribute to improving asthma care quality. 

This Workbook is a start for State leaders interested in learning about quality improvement for 

asthma care. The actual planning, implementation, tracking, and evaluation of an asthma care 

quality improvement program will go well beyond this Workbook and its companion Resource 

Guide. Carrying out such a program will require a team of experts: State leaders and agency 

staff, program staff, topic experts, researchers, health specialists, statisticians, data collection 

experts, evaluation researchers, and representatives from stakeholder groups. 

 1
Who Should Use This Workbook 

This workbook is intended for multiple users:

• State elected leaders—governors and legislators (and their staffs) who provide leadership on 

health policy. 

• State executive branch officials—State health departments, asthma prevention and control 

program leaders, Medicaid officials, benefit managers for State employees, and their staffs. 

• Nongovernmental State and local health care leaders—professional societies, provider 

associations, hospital associations, quality improvement organizations, voluntary health 

organizations, health plans, business coalitions, community organizations, and consumer 

groups. 

How To Use This Workbook 

Although this Workbook can be completed by one individual, it would be a time-consuming task. 

Furthermore, few State leaders may be equipped to answer all of the questions. Therefore, State 

leaders may want to enlist the help of staff and others who will eventually become part of the 

quality improvement team that will develop, implement, and evaluate an asthma care quality 

improvement program. 

The user should first read the Executive Summary and Introduction of the Resource Guide for 

an overview of the National Healthcare Quality Report. This report—produced annually by the 

Agency for Healthcare Research and Quality (AHRQ), along with its companion National 

Healthcare Disparities Report—serves as the basis for measures and data used in the Resource 

Guide and this Workbook. Modules in the Resource Guide are mirrored in this Workbook; and, 

based on the State leader’s interests, needs, and role in developing a quality improvement 

program, users will want to focus on different modules such as: 

Senior leaders 

• Module 1—Making the Case for Asthma Care Quality Improvement 

• Module 2—A Framework for State-Led Quality Improvement 

• Module 3—Learning From Current State Quality Improvement Efforts 

• Module 5—Moving Ahead – Implications for State Action 

Staff specialists (all of above plus the following) 

• Module 4—Measuring Quality of Care for Asthma

Modules 1, 2, and 3 might be completed by different individuals or groups of individuals to 

gather and assess information to create a quality improvement team and strategy specific to the 

State’s needs. Module 4 provides guidance on available measures and how to use and interpret 

them in a quality improvement program. Module 5 will help State leaders assess their strengths 

and weaknesses in instituting improvement in health care quality. 

2 
Module 1: Making the Case for Asthma Care Quality 

Improvement

Learning Objectives 

Upon completion of Module 1, the user(s) will be able to: 

1. Assess the need for asthma care quality improvement in the State. Consolidating

available information will help State leaders “make the case” for improvement in asthma

care by showing why it should be a priority. 

2. Estimate the cost of asthma care statewide and for Medicaid. Estimating the total 

costs of asthma care is an important part of understanding the need for quality 

improvement in the State.

3. Estimate a State’s potential cost savings by using targeted disease management and 

reducing pediatric hospitalizations for asthma. Estimating the potential savings for 

Medicaid and for the State by improving asthma management and reducing avoidable 

hospitalizations is a vital part of making the case for asthma care quality improvement.

1. Assess the need for asthma care quality improvement in the State. 

Read “The Need for Asthma Care Quality Improvement” and “The Quality Improvement 

Opportunity (pages 5-18) in the Resource Guide to learn about important reasons for addressing 

asthma and quality of care for asthma—increased prevalence, high cost, racial/ethnic and income

disparities, and treatment variations—as well as the potential for return on investment through 

quality improvement in asthma care. 

a. Look at Table 1.1 on page 10 to see how asthma prevalence (cases for every 100 people) 

has changed from 2000 to 2003. In Maryland in 2000, for example, 10.6 percent of the 

population had been diagnosed with asthma at some point in their lifetime, similar to the national 

average of 10.5 percent; in 2003, Maryland’s lifetime asthma prevalence was 12.3 percent, 

higher than the national average of 11.7 percent. The lifetime asthma prevalence rates in Table 

1.1 are from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Prevalence 

System (BRFSS). 

1) What was the asthma prevalence in your State in 2000? (Table 1.1) ________ 

2) What was the asthma prevalence in your State in 2003? (Table 1.1) _________ 

3) Has the prevalence increased in your State since 2000? _____________ 

4) How does your State compare with the national average? ____________ 

b. Asthma prevalence may vary among subgroups of the population in your State (such as 

by age, racial or ethnic group, or income). As an example, look at Table E.3 (page 117) in 

Appendix E of the Resource Guide to find the current prevalence of asthma by State among 

adults by age group (18-64 and 65 and older) in 2003. 

 3
1) What was the current asthma prevalence for all adults in your State in 2003? (Table E.3) 

__________ 

How does your State compare with: the national average? _______ the top decile of States 

average? ________ the bottom decile of States average? _________ 

Note: The States in the “top decile” (1/10th) are the States that have the lowest average of 

asthma prevalence. The States in the “bottom decile” are the States with the highest average of 

asthma prevalence. 

 

2) What was the current asthma prevalence for age 18-64 in your State in 2003? (Table E.3) 

 _________ 

How does your State compare with: the national average? ________ the top decile of States 

average? ________ the bottom decile of States average? _________ 

 

3) What was the current asthma prevalence for age 65 and older in your State in 2003?

(Table E.3) ________ 

How does your State compare with: the national average? ______ the top decile of States 

average? _______ the bottom decile of States average? ________ 

4) Are there other groups (racial, ethnic, low income, etc.) in your State for which you have 

asthma prevalence data from your State health data agency? 

___________________________________________________________________________ 

c. Look at Table 1.2 (page 11) in the Resource Guide. This shows the hospitalization rate 

for asthma (admissions per 100,000 population) by State for different age groups. This is an 

important quality improvement measure because many hospital visits for asthma can be avoided 

with high quality outpatient care. Knowing your State’s rate compared to the national average 

may help determine whether asthma care quality improvement, especially as it affects the cost 

for asthma care, should be a priority in your State. Find your State and write your State’s rate for 

each age group in the table below. 

If your State is not listed in Table 1.2, or if your State collects its own hospitalization data for 

asthma, contact your State health data agency for these rates and write them in the table below. 

Hospital admissions for asthma

per 100,00 population among-- U.S. rate Best-in-class rate 

Your State’s 

rate 

 Children under age 18 188.6 72.3 

 Adults age 18-64 112.8 60.2 

 Adults age 65 and older 170.6 118.2 

1) How does your State compare with the U.S. rate? ___________________________ 

4 
2) “Best-in-class” States have lower rates of avoidable hospitalizations for asthma. How 

does your State compare with the best-in-class averages for the three age groups above? 

___________________________________________________________________________ 

___________________________________________________________________________ 

3) What do you see as the potential for quality improvement in this measure in your State?

____________________________________________________________________________ 

____________________________________________________________________________ 

2. Estimate the cost of asthma care statewide and for Medicaid. 

Read “Estimating the Costs of Asthma Care and Potential Savings From Quality Improvement” 

(pages 18-23) in the Resource Guide to learn about estimating direct and indirect costs of asthma

statewide and for Medicaid. Direct costs are expenditures associated with asthma treatment: 

routine services, treatment of complications, and medical conditions attributable to asthma. 

Indirect costs are additional costs of living or the lost opportunities that affect individuals 

because they have asthma: the cost of dealing with disability, lost wages and productivity, 

premature death, and so on. 

a. Look at Table 1.3 on page 20 of the Resource Guide. It lists current asthma prevalence 

and direct and indirect cost estimates for asthma by State. Find your State’s estimates and list 

here. 

Direct cost of asthma to your State = $__________ 

Indirect cost of asthma to your State = $__________ 

Total estimated asthma costs to your State = $__________ 

Asthma prevalence in your State = __________ 

Average cost to your State per person with asthma = $__________ 

(Divide State’s total costs by State’s asthma prevalence) 

b. Next compare your State estimates for the total population to estimates for neighboring 

States in your region. Again using Table 1.3 on page 20 of the Resource Guide, find the figures 

for your State and the two States with similar characteristics to yours and write them in the 

blanks below. How does your State compare?

Your State State A State B 

Asthma prevalence 

Total asthma cost 

Average cost per person

(divide total cost by prevalence) 

Cost difference (+/-) 

 5
c. Look at Table 1.4 on page 21 of the Resource Guide. It gives the Medicaid population 

with asthma and the estimated costs to each State’s Medicaid program for three age groups: 0-17, 

18-64, and 65 and older. Find your State’s Medicaid population and estimated Medicaid 

spending on asthma for the three age groups and list them in the first column below. Calculate 

the cost per person by dividing the estimated expense by the estimated Medicaid population with 

asthma. Make the same type of comparisons for the Medicaid population between your State and 

the two States you used in question 2b above. 

Note: Do you have estimates for asthma care costs from your State health department or 

Medicaid program office that are better than those listed in Table 1.4? _________________ 

If so, use them here. Your own State estimates for spending on asthma care would be more 

accurate than these derived through national studies and more generalized assumptions. 

Medicaid population Your State State A State B 

Age 0-18

Population with asthma

Estimated expense

Average cost per person 

(divide expense by 

population) 

Age 19-64

Population with asthma

Estimated expense

Average cost per person 

(divide expense by 

population) 

Age 65 and older 

Population with asthma

Estimated expense

Average cost per person 

(divide expense by 

population) 

d. Look at Appendix B, Tables B.1-B.6 (pages 85-90) in the Resource Guide. These tables 

show estimated numbers of people in racial/ethnic subgroups of the Medicaid population with 

asthma by age group and estimated Medicaid spending for asthma for these groups. Fill in the 

blanks in the following table below with figures for your State and two comparable States. 

6 
 Medicaid eligibles with asthma

Population group Age 0-18 Age 19-64 Age 65 

and older 

Estimated Medicaid 

spending 

Your State: 

White

Black

American Indian/ 

Alaska Native 

Asian

Hispanic

Other

State A: 

White

Black

American Indian/ 

Alaska Native 

Asian

Hispanic

Other

State B: 

White

Black

American Indian/ 

Alaska Native 

Asian

Hispanic

Other

1) Does your State have large numbers of these subgroups with asthma? How much of your 

Medicaid spending is devoted to asthma care for these groups? 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

______________________________________________________________________________

____________________________________________________________________________ 

2) Can you use the figures in Appendix Tables B.1-B.6 to help make the case for asthma care 

quality improvement in your State? 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

______________________________________________________________________________

____________________________________________________________________________ 

 7
3. Estimate a State’s potential cost savings by using targeted disease management and 

reducing pediatric hospitalizations for asthma. 

a. Look at pages 22-23 of the Resource Guide to see the results from a calculation of 

potential Medicaid savings from an asthma disease management program based on the Virginia 

Health Outcomes Partnership (VHOP) experiment. 

1) Call your Medicaid program office to find your State’s spending for emergency 

department visits for Medicaid (see step 1, below), the number of Medicaid claims for 

emergency department visits (step 2), and the number of physicians participating in primary care 

case management who might accept training in asthma management (step 6). Use your State data 

to fill in the blanks to develop a “ballpark” estimate of how much might be saved in Medicaid 

costs with a similar asthma disease management intervention. 

Note: These estimates assume that you would have results similar to those of Virginia (see page 

22 of the Resource Guide) and that your State has not already implemented a training program

for physicians treating Medicaid recipients with asthma. Your results will vary depending on the 

size of your Medicaid program and the scale of the intervention your State might undertake. 

Steps for Estimating Potential Medicaid Savings From an Asthma Disease Management Program

Step Your State 

 1. Total annual spending for emergency department visits for asthma preintervention for Medicaid recipients 

 2. Total annual number of Medicaid claims for emergency department visits 

 3. Payment per claim: Divide step 1 by step 2 

 4. Emergency visit reduction factor: Adjusted to four quarters and to exclude 

added costs per physician and added drug prescribing (both included below; see 

steps 7 and 8) 

 0.06 

 5. Emergency care visit annual saving after training physicians: Multiply step 

1 by step 4 

 6. Number of physicians participating in primary care case management who 

might accept training in asthma management 

 7. Asthma drug cost: Multiply step 6 by $180 per physician per year 

 8. Program training costs: Multiply step 6 by $235 per physician 

 9. Total drug and training costs: Add steps 7 and 8 

10. Total Medicaid savings: Subtract step 9 from step 5 

11. Savings per Medicaid claim: Divide step 10 by step 2 

Source: Estimates derived from Rossiter LF, Whitehurst-Cook MY, Small RE, et al. The impact of disease 

management on outcomes and cost of care: a study of low-income asthma patients. Inquiry 2000;37:188-202. 

Note: Based on the VHOP experiment, for purposes of step 6, assume that one-third of Medicaid participating

physicians in any disease management program would accept training in asthma management. See Rossiter et al. for 

further detail on derivation of the emergency visit reduction factor, asthma drug cost, and program training cost. In

addition, percent savings per claim can be calculated by dividing step 11 by step 3. 

8 
2) How do these potential Medicaid savings for asthma care compare with other disease 

management programs in your State? Do these figures help make a case for asthma care quality 

improvement for your Medicaid program? 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

b. Look at pages 23-24 in the Resource Guide to see results from a calculation of potential 

savings for Massachusetts from reducing avoidable hospitalizations for pediatric asthma. 

1) Follow the steps below to develop a “ballpark” estimate of how much your State might 

save by reducing excess hospitalizations for pediatric asthma. 

Note: These estimates assume that you would have results similar to those of Massachusetts (see 

page 24 of the Resource Guide). Your results may vary. In addition, the cost of implementing a 

quality improvement program to reduce hospitalizations is not included in the calculation below. 

Steps for Estimating Potential Savings From Reducing Excess Pediatric Asthma Hospitalizations 

* Step 6 was calculated by multiplying the national mean charge per pediatric asthma hospitalization ($5,888) by the 

national cost-to-charge ratio for these hospitalizations (0.44) using data from the 2001 HCUP Nationwide Inpatient

Sample. (Information on HCUP data and tools is available on the HCUP Web site at http://www.hcup-us.ahrq.gov 

or via email at hcup@ahrq.gov.) States may use their own State estimates on pediatric asthma hospitalizations if 

available. 

Step Your State 

 1. Hospital admission rate for pediatric asthma per 100,000 population under 

age 18 (Table 1.2 in the Resource Guide) 

 2. Estimated population under age 18 in State (Census, 2000; available at 

http://www.census.gov/popest/states/asrh/SC-est2004-02.html) 

 3. Number of pediatric asthma hospital admissions: Multiply step 1 by step 2 

 4. Percent of pediatric asthma hospital admissions to be reduced to achieve 

best-in-class (Table 1.2 in the Resource Guide) 

 5. Number of hospital admissions for pediatric asthma to reduce (excess 

hospitalizations): Multiply step 3 by step 4 

6. Mean cost for pediatric asthma hospitalization* $2,590.72

7. Total cost of all pediatric asthma hospitalizations in State: Multiply step 3 

by step 6 

8. Total cost of excess pediatric asthma hospitalizations in State: Multiply step 

5 by step 6 

9. Potential cost savings from reducing excess hospitalizations: Subtract step 8 

from step 7 

2) Look at your potential cost savings from reducing excess hospitalizations. Can these 

potential savings help to make a case for asthma care quality improvement in your State? 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________

 9
Module 2: A Framework for State-Led Quality Improvement 

Learning Objectives 

Upon completion of Module 2, the user(s) will be able to: 

1. Define the State’s role in the asthma care quality improvement process and 

develop activities using a Plan-Do-Assess approach. States can play a strategic 

role in quality improvement by providing leadership, working in partnership, and 

implementing quality improvement to achieve better care for people with asthma.

2. Identify appropriate resources to help States reach their improvement goals. 

States need to locate available resources to use in quality improvement efforts.

1. Define the State’s role in the asthma care quality improvement process and develop 

activities using a Plan-Do-Assess approach. 

a. Read pages 26-35 in the Resource Guide. These sections discuss the State’s role in 

fostering quality improvement in health care, present existing improvement models, and a define 

a new framework for asthma care quality improvement and a leadership role for States. 

1) What existing programs in your State can you use to gather information on quality 

improvement? Do you have previous quality improvement programs at the State or community 

level which you can use to begin planning your asthma improvement efforts? Who in your State 

might be able to provide this information (such as experts in asthma, asthma care, and quality 

improvement)? _________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

2) Are there ongoing provider networks already involved in quality improvement in your State 

that might serve as the basis of a statewide quality improvement initiative for asthma care?

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

3) What do you envision as the State’s key leadership role in leveraging these existing programs 

and networks for asthma care quality improvement?____________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

10 
b. General and clinical models of quality improvement are described on pages 27-31 of the 

Resource Guide. These models require collaboration in planning, setting goals, establishing 

appropriate measures, designing and implementing changes, gathering and analyzing data, and 

interpreting the results. What features of these models seem particularly relevant to your State? 

Plan-Do-Study-Act model:________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

______________________________________________________________________________ 

IHI model: ____________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________

___________________________________________________________________________ 

______________________________________________________________________________ 

Chronic Care model: ____________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Federal models: ________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

c. “A New Framework for State-Led Quality Improvement” that uses elements of these 

models is described on pages 31-35 of the Resource Guide and illustrated in Figures 2.1-2.3. 

This framework adapts the Plan-Do-Study-Act model into a Plan-Do-Assess improvement 

process comprising three stages: (1) provide leadership; (2) work in partnership; and (3) 

implement improvement. The State takes a lead role in each stage. 

1) Stage 1: Provide leadership. A key part of this stage is championing the need for improving 

care and creating a quality improvement vision. 

Plan: Are there members of your staff with experience in quality improvement who can help 

plan this effort and identify potential partners? _____________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________

___________________________________________________________________________ 

 

 11
What other State officials can you call upon to collaborate in leading the asthma care quality 

improvement effort? Consider the governor, other elected officials, the Medicaid program

director, health department director, school superintendent, social services director, and 

others whose programs serve large numbers of State residents with asthma. 

___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 

Can you identify ways to incorporate the case for asthma care quality improvement that you 

assembled in Module 1 into your planning efforts?__________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

Do: What is the best way to convene parties interested in improving asthma care? Are there 

existing advisory bodies or workgroups? Who are the key stakeholders that you would want 

to include? (These might be community organizations, providers, health plans, employers 

and other larger purchasers, as well as consumers.) _________________________________ 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ 

 ___________________________________________________________________________ 

 

Can you identify resources to help develop networks that support this effort in your State?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ 

___________________________________________________________________________ 

Assess: How do you assess your planning efforts at this stage? Have you established an 

environment and partnerships with stakeholders that will foster quality improvement?

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ 

What adjustments might be necessary?___________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

12 
(2) Stage 2: Work in partnership. This stage relies on the collaborative efforts of key 

stakeholders to develop a strategy, plan activities, develop possible solutions, and assess the 

potential pros and cons of these solutions before major implementation campaigns are begun. 

Plan: The Centers for Disease Control and Prevention supports asthma programs in many States 

through its National Asthma Control Program. (The CDC Web site has information and a 

link to these programs at www.cdc.gov/asthma.) Does your State already have an asthma

plan that identifies problems/issues to consider and goals to address in developing a quality 

improvement strategy? Are there established processes in place that you can use or adapt?

 __________________________________________________________________________ 

 __________________________________________________________________________ 

 __________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 

What does the quality improvement team envision as the starting point? For example, do you 

want to improve the quality of care among the entire population or among vulnerable 

subgroups you have identified? Do you want to focus on quality of care in physician 

practices? Do you want to focus on reducing asthma hospitalizations? Is there more than one 

priority to which the team wants to commit at this point? _____________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 

What steps need to be taken to design an initial intervention that addresses your priority 

area(s)?____________________________________________________________________ 

___________________________________________________________________________ 

 ___________________________________________________________________________

___________________________________________________________________________ 

 ___________________________________________________________________________ 

Do: How will the proposed intervention be tested? Is there existing evidence from the literature 

or from your key stakeholders you can use? Can you or other stakeholders conduct a small 

pilot study to get data? 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ 

___________________________________________________________________________ 

Which measures will be used to determine whether the proposed intervention is successful? 

What experts that you have identified can you contact for information on these measures?

___________________________________________________________________________

 13
___________________________________________________________________________

___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

Assess: What do the results of the test show? Who can you call on to help interpret the results?

Is there something else you might need to do to gather more data? 

___________________________________________________________________________ 

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________ 

 ___________________________________________________________________________ 

Does analysis of the results seem to suggest that the quality improvement partnership needs 

to modify the intervention or find another solution? (Perhaps your analysis indicates that you 

may need to add measures to improve documentation of how well asthma care is provided in 

your State.) Or has another problem or critical issue emerged that you believe should be 

addressed instead? 

 ___________________________________________________________________________ 

 ___________________________________________________________________________

___________________________________________________________________________ 

 ___________________________________________________________________________ 

 

3) Stage 3: Implement improvement. This stage relies on the partnership to bring about change 

statewide and evaluate its outcomes. 

Plan: What are the steps needed to implement the asthma quality improvement intervention 

statewide? Specify the roles and responsibilities that each partner in the quality improvement 

team has agreed to take on to bring about this change. _______________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

Do: What are the methods and mechanisms the quality improvement team will use to spread the 

change to providers and others in the State? For example will you use an advertising 

campaign, training programs, community outreach, other vehicles, or combinations? 

___________________________________________________________________________ 

___________________________________________________________________________

___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

How will you measure the impact of this effort to spread change on patients and providers? 

 __________________________________________________________________________ 

14 
 ___________________________________________________________________________

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

 ___________________________________________________________________________ 

Assess: How will the team evaluate the outcomes of the quality improvement effort, both 

successes and shortcomings? Is there a plan for modifying the intervention, based on 

ongoing evaluation, to assure continuous quality improvement? 

__________________________________________________________________________ 

 __________________________________________________________________________ 

 __________________________________________________________________________ 

 __________________________________________________________________________ 

 __________________________________________________________________________ 

2. Identify appropriate resources to help States reach their improvement goals. 

Read “Information Resources for Quality Improvement (pages 35-37) in the Resource Guide for 

a listing of some Federal programs and resources on quality improvement and quality of care, 

including asthma care. 

a. Is your State using any of these resources? If so, how well have they worked for you?

_____________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

b. Visit the Web sites of the resources listed below. Jot down any ideas to help you plan, 

implement, and evaluate an asthma care quality improvement program. 

• Institute for Healthcare Improvement (IHI model): www.ihi.org 

Ideas: ________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 

______________________________________________________________________________ 

• Improving Chronic Illness Care (Chronic Care model) : www.improvingchronicare.org/ 

Ideas: ________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

• National Healthcare Quality and Disparities Reports: www.qualitytools.ahrq.gov 

 15
Ideas: ________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________ 

______________________________________________________________________________ 

• State resources from the NHQR: www.qualitytools.ahrq.gov/qualityreport/2005/state 

Ideas: ________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________ 

______________________________________________________________________________ 

• Healthcare Cost and Utilization Project databases: www.hcup-us.ahrq.gov 

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

___________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

• AHRQ evidence reports: www.ahrq.gov/clinic/epcix.htm 

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________ 

______________________________________________________________________________ 

Diabetes quality improvement tool: www.ahrq.gov/qual/diabqualoc.htm 

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________ 

• National Quality Measures Clearinghouse: www.qualitymeasures.ahrq.gov

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 

• Behavioral Risk Factor Surveillance System: www.cdc.gov/brfss

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

16 
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 

• National Asthma Control Program: www.cdc.gov/asthma/NACP.htm

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

___________________________________________________________________________ 

• National Asthma Survey: www.cdc.gov/nchs/about/major/slaits/nsa.htm

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 

• National Asthma Education and Prevention Program: www.nhlbi.nih.gov/about/naepp 

Ideas:_________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________ 

 17
Module 3: Learning From Current State Quality Improvement 

Efforts

 

Learning Objectives: 

Upon completion of Module 3, the user(s) will be able to: 

1. Use the quality improvement framework to identify various national and State 

approaches to asthma care quality improvement. Many States have quality 

improvement programs that can be used or modified to serve as resources for 

informing State-specific quality improvement initiatives for asthma. 

2. Start an inventory of your State’s quality improvement resources. Building on 

others’ activities, identify those initiatives already underway in your State that might 

provide models, staff, or additional resources for a statewide improvement effort. 

1. Use the quality improvement framework to identify various national and State 

approaches to asthma care quality improvement. 

Read pages 39-47 on “Current State Efforts To Improve the Quality of Asthma Care” in the 

Resource Guide for examples of programs that reflect the three stages of the quality 

improvement framework: provide leadership, work in partnership, and implement improvement. 

a. What leadership approaches of other States seem particularly relevant to your State? 

These might include identifying “champions” for asthma quality improvement as well as 

advisory bodies, workgroups, and coalitions to help pull the overall effort together. 

_____________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

b. What types of State practices seem to offer the best opportunities for leveraging 

partnerships to advance asthma care quality improvement? What can you learn from States that 

have worked in partnership with others (within and outside health care settings) to develop and 

implement quality improvement plans, promote guidelines, or improve their ability to measure 

and monitor quality?_____________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

18 
c. Which State programs would be most useful as examples for implementing an asthma

quality improvement effort? Are there specific categories of activities that seem most relevant to 

your State’s quality improvement initiative (such as self-management, patient/public education, 

provider training, or disease management)? __________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

2. Start an inventory of your State’s quality improvement programs and resources. 

Review Appendix C (pages 92-103) in the Resource Guide for a list of over 100 asthma quality 

improvement programs in 12 areas and Web links for more information on each program. 

a. Inventory your own State quality improvement activities related to asthma. Use the 

categories listed in Appendix C (see page 92 of the Resource Guide) to organize your inventory. 

In the grid that follows, fill in what you know about groups in your State already assembled 

around asthma and asthma care; place a check (9) if this activity is ongoing. If you know of 

other asthma-related activities that might not seem to fit within the categories listed below, jot 

them down in the lines after the inventory. 

 

 Asthma-Related Quality Improvement Programs in Your State, by Type of Activity 

Type of activity 9 Name of program 

Program 

contact 

Advisory bodies/councils/workgroups 

 

Coalitions (networks) 

 

Collaboratives 

Cross-agency work 

 

Data measurement and reporting 

 19
Type of activity 9 Name of program 

Program 

contact 

Developing/enforcing guidelines 

Disease management 

Minority and rural outreach 

 

Public service/education efforts 

 

Self-management 

 

Provider training 

 

Use of technology 

 

Other: _______________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

b. Review your answers to questions 1a, 1b, and 1c above. Are there asthma-related 

activities for which you and your quality improvement team see a need but which do not appear 

in your inventory? Who might you contact to get more information on how to address this need? 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

20 
Module 4: Measuring Quality of Care for Asthma 

Learning Objectives

Upon completion of Module 4, the user(s) will be able to: 

1. Understand quality measures and how measures of process and outcome can be used 

to track the quality of asthma care. This will help identify gaps in care, how closing

them can improve health status, and how measures can be used as a basis for setting goals. 

2. Inventory available data systems and other resources to use in developing State or

local estimates. A data systems inventory will identify existing data sources and 

collection mechanisms that might be adapted or enhanced to track quality improvement. 

3. Define “benchmark” as a measurement tool and understand how to identify 

appropriate benchmarks when developing quality improvement goals. Comparing a 

State’s performance with national or other benchmarks will provide a clearer 

understanding of the State’s level of asthma care and any potential need for change. 

4. List various sociodemographic, behavioral, and environmental factors that must be 

considered in setting quality improvement goals. Many factors outside the health care 

system can affect quality of asthma care processes and outcomes. 

5. Using appropriate benchmarks, draft goals for a State quality improvement effort. 

Read pages 49-55 in the Resource Guide on quality measurement and dimensions of care for 

asthma, including selecting process and outcome measures for these dimensions of care. 

1. Understand quality measures and how measures of process and outcome can be used to 

track the quality of asthma care. 

a. Look at the diagram on page 51 of the Resource Guide. 

1) What does the diagram tell you about daily use of medications by people with asthma (a 

process measure) and number of hospitalizations for asthma (an outcome measure)?

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

______________________________________________________________________________ 

2) How would increasing daily use of medications by people with asthma improve asthma

outcomes?_____________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________

______________________________________________________________________________ 

 21
b. Review Table 4.1 (pages 53-55) and Appendix D (pages 104-112) in the Resource Guide

to learn about additional process and outcome measures and other dimensions of asthma care 

management. For many of the measures, special surveys or data collection efforts may be 

required. Does your State collect data for any of these measures?

Process measures (such as medication use, management plans, self-management, planned care): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Outcome measures (such as symptom burden, work or school days lost, asthma hospitalizations): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Other measures (such as access to care through insurance, asthma prevalence):_______________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

2. Inventory available data systems and other resources to use in developing State or local 

estimates. 

Review pages 55-59 in Module 4 and Appendixes E and F (pages 113-131 and 132-138, 

respectively) in the Resource Guide. These sections present information on sources of measures 

and data for asthma care, including data limitations and State estimates for various measures. 

a. Begin an inventory list of the data sources available for your State below. You may wish 

to write down any questions or concerns you have about these data sources on the grid—items

about which you need to contact data resource experts in your State. Place a check (9) if data 

are available for your State. 

Data source 9 Questions/notes 

Behavioral Risk Factor Surveillance 

System - CDC 

Healthcare Cost and Utilization 

Project - AHRQ 

HEDIS® data from the National 

Committee for Quality Assurance 

(available by region only) 

22 
National Asthma Survey - CDC 

Other CDC surveys 

State vital statistics 

Special disease registries 

Statewide hospital discharge data 

Medicaid health provider 

reimbursement claims

State employee health benefits 

claims

Census population data 

Area Resource File – HRSA 

Kaiser Family Foundation 

Other statewide or local sources 

(school, occupational health, 

environmental assessments, etc.) 

Other setting-specific sources 

(hospitals, community health 

centers, primary care practices, etc.) 

State and local initiatives from other 

States 

b. Review your answers to questions 1.b and 2.a above. Can you identify any gaps in 

information or resources that you believe are important for assessing asthma care in your State?

How will you address them?_______________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

 23
______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

3. Define “benchmark” as a measurement tool and understand how to identify 

appropriate benchmarks when developing quality improvement goals.

Read pages 59-66 and Appendix G (pages 139-140) in the Resource Guide on benchmarks and 

examples of how States may use them in quality improvement. Benchmarks are values that can 

be used as markers for measuring performance. Common benchmarks are national or regional 

averages, individual State rates, or best-in-class (top 10 percent of States) averages. 

a. Review your answers to question 1c in Module 1 where you compared your State with 

the national and best-in-class averages for asthma hospitalization rates. How did you assess your 

State’s performance against these benchmarks? _______________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

b. Page 60 of the Resource Guide lists six measures from BRFSS for which national and 

best-in-class benchmarks were calculated. These include four asthma process measures (routine 

care, medication use, advice to quit smoking, and flu shots) and two asthma outcome measures 

(urgent care and emergency room visits). These benchmarks are listed in Table 4.2 (page 56) of 

the Resource Guide and reproduced in the table below. 

1) Go to Appendix Table E.1 (page 115) in the Resource Guide; this table lists national and 

best-in-class averages for selected BRFSS measures by State, including the six measures below. 

Locate the values for your State and write them in the blanks. (If your State is not listed in 

Appendix Table E.1, or if your State collects its own data for these measures, contact your State 

health data agency for these percentages and write them in the table below.) Subtract your State 

average from the best-in-class average to assess how many percentage points your State must 

improve to be a top performer. Note on the last two measures, a lower value is better. 

Measure 

U.S. 

average 

(%) 

Bestin-class 

average 

(%) 

Your 

State 

(%) 

Best-in-class 

average minus 

your State 

average (+/-) 

Planned/routine care for asthma (2 visits in 

past 12 months) 28.3 40.4

Advice to quite smoking 82.2 87.9 

Flu shot (in past 12 months) 40.3 53.3

Medication use for asthma (in past month) 71.1 75.3

Urgent care visit (in past 12 months) 28.1 19.4

Emergency room visit (in past 12 months) 17.7 12.2

24 
2) How does your State compare to the national and best-in-class averages for these measures? 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

c. Look at Figure 4.1 (page 61) in the Resource Guide, which illustrates the national and 

best-in-class averages for these six measures and the range of variation among States in the four 

regions. Examples of how four individual States compare against benchmarks on some of these 

measures are shown in Figures 4.2-4.5 (pages 62-65) in the Resource Guide. 

Again using Appendix Table E.1 (or your own State data), select two States with some 

characteristics similar to your State and write their values for these six measures in the following 

table. Subtract the percentages for each of these others States from your percentages. Write the 

differences below; check off measures for which your State is performing better than State A 

and/or State B. 

Measure 

State A 

(%) 

Your State 

minus 

State A 

(points 

different) 

Better 

than 

State A 

9 State B 

(%) 

Your State 

minus 

State B 

(points 

different) 

Better 

than 

State B 

9

Planned/routine care 

for asthma (2 visits in 

past 12 months) 

Advice to quit 

smoking 

Flu shot (in past 12 

months) 

Medication use for 

asthma (in past 

month) 

Urgent care visit (in 

past 12 months) 

Emergency room

visit (in past 12 

months) 

d. It is important to know whether a State’s results are significantly different from the 

benchmark from a statistical standpoint. (Refer to Appendix H on pages 141-143 of the 

Resource Guide for further information on statistical significance.) Look at your answers to 

question 3b above; then go to Appendix Table E.1 on page 115 of the Resource Guide. 

 

 25
 1) Are any of the percentages for your State significantly above the national average (as 

indicated by a + sign next to the value for your State in Appendix Table E.1)? Which ones? 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

2) Are any of the percentages for your State significantly below the national average (as 

indicated by a − sign next to the value for your State in Appendix Table E.1)? Which ones?

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

3) Are any of the percentages for your State within the best-in-class range and thus not 

significantly different from the best-in-class average (as indicated by a † sign next to the value 

for your State in Appendix Table E.1)? Which ones?

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

e. Using your answers to question 3d above, together with the discussion of four States on 

pages 62-66 of the Resource Guide as examples, write a similar analysis of your State’s results. 

On which measures is your State doing well? In what areas could you improve?

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

4. List various sociodemographic, behavioral, and environmental factors that must be 

considered in setting quality improvement goals. 

Review pages 66-70 of the Resource Guide on the factors that affect asthma quality of care. A 

State’s performance on quality measures may be affected by a number of factors, including poor 

access to health care, high proportions of subgroups with no insurance, cultural attitudes toward 

26 
health care providers, etc. In addition State or employer decisions regarding coverage policies 

may affect the way providers deliver care. For example, certain asthma medications may not be 

reimbursed by a patient’s health plan, and so the patient may have to pay out of pocket for 

certain prescribed medication and may not be able to afford them. There are also factors over 

which States have little or no control, such as asthma prevalence and population characteristics. 

(To find additional information on measures for some of these factors, such as percentage of

population uninsured, you can use the Henry J. Kaiser Family Foundation Web site on State 

health facts at http://www.statehealthfacts.org.) 

a. What characteristics of your State, its infrastructure, and your State’s population might 

help to account for your answers to questions 3d and 3e above? For example, does your State 

have a substantial Medicaid population or large numbers of uninsured persons, racial or ethnic 

minorities, people with less than a high school education, or other vulnerable groups? 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

b. What other issues or concerns might affect your State’s performance in asthma care? Are 

there additional factors that you and your team need to consider in determining your starting 

point and setting initial goals for quality improvement in asthma care?_____________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

5. Using appropriate benchmarks, draft goals for a State quality improvement effort. 

a. Look at your answers to question 1c in Module 1 and question 3a-3d in Module 4 on how 

your State compares with benchmarks on the asthma measures presented here. (If necessary, also 

review pages 59-60 and Appendix G in the Resource Guide for a discussion of types of 

benchmarks and why different benchmarks might be chosen in different circumstances.) 

1) To begin your quality improvement effort, which benchmarks for the following measures 

would you select for your State? Place a check (9) in the blank of the measure you select. If you 

check “Other benchmark” for your State, describe it (for example, a regional average). 

 27
Measure 

U.S. average 

(9) 

Best-in-class 

average (9) 

Other 

benchmark

(describe) 

Planned/routine care for asthma (2 visits in 

past 12 months) 

Advice to quite smoking 

Flu shot (in past 12 months) 

Medication use for asthma (in past month) 

Urgent care visit (in past 12 months) 

Emergency room visit (in past 12 months) 

Asthma hospitalization rate (per 100,000): 

◦ Children 

◦ Adults <65 

◦ Adults 65+ 

2) For each measure, why did you select that benchmark? Write your reasons below. 

___________________________________________________________________________________ 

Planned/routine care for asthma (2 visits in past 12 months): 

Advice to quit smoking: 

Flu shot (in past 12 months): 

Medication use for asthma (in past month): 

Urgent care visit (in past 12 months): 

Emergency room visit (in past 12 months): 

Asthma hospitalization rate (per 100,000): 

◦ Children 

◦ Adults <65 

◦ Adults 65+ 

3) Set a preliminary goal to reach the benchmark for the measures you have selected. The 

following are some examples of goal statements: 

• Increase the percent of adults with asthma who receive a planned care visit for asthma once 

every 6 months to the level of the best in class average—40.4 percent—within 2 years. (The 

28 
specifics on these measures (e.g., which measures and period of time to reach the goal) 

should be established by your quality improvement team). 

• Increase use of inhaled corticosteroids medication for adults with persistent asthma to the 

level of use on average across the Nation—71.1 percent of adults with asthma—within 2 

years. 

• Increase the percent of adults with asthma who receive flu vaccinations to the best-in-class 

average—53.3 percent—within 2 years. (An aggressive program might set an even higher 

goal or tighter time frame.) 

• Reduce the hospitalization rate for asthma to the best-in-class averages (for children, 72.3 per 

100,000) and for adults under age 65, 60.2 per 100,000). 

• Identify the barriers to obtaining planned/routine care visits, smoking cessation counseling, 

or flu vaccinations. 

What are the preliminary goals for the following?

Planned/routine care for asthma (2 visits in past 12 months): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Advice to quit smoking: 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Flu shot (in past 12 months): 

_____________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Medication use for asthma (in past month): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Urgent care visit (in past 12 months): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Emergency room visit (in past 12 months): 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

Asthma hospitalization rate (per 100,000): 

 Children______________________________________________________________________ 

______________________________________________________________________________ 

 Adults <65____________________________________________________________________ 

______________________________________________________________________________ 

 Adults 65+____________________________________________________________________ 

______________________________________________________________________________ 

 29
b. You may want to go beyond the measures listed above. Refer to Appendix E (pages 113-

131) in the Resource Guide for additional BRFSS asthma measures you may want to consider in 

your quality improvement effort. Some of these measures are listed below. Are any of these 

measures appropriate for your State? Note those you want to investigate further. 

Asthma attacks/episodes (in past 12 months): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Limited activity days (in past 12 months): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

No sleep difficulty due to asthma (in past month): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Doctor visit for asthma (in past 12 months): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Asthma symptom-free days (in past 2 weeks): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Asthma symptoms everyday (in past 2 weeks): 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

Other: 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

_____________________________________________________________________________ 

30 
Guidance for Setting Goals:

• Consider this goal setting exercise as preliminary to enhance your understanding.

(Stakeholders who will become partners and champions of the initiative must have a 

part in goal setting for the program. Clinicians in your community who are experts 

in asthma care may want to enhance the goals listed above. Only by engaging local 

experts will the goals reflect the circumstances that the community faces and be 

more likely to be supported by leaders in the health care community.) 

• Note whether your State is extremely low, close to the national averages, or within 

the best-in-class averages. Your position relative to these benchmarks will indicate 

how far your State must go to be among the best performing health care systems. Do 

you want to set long-range and short-range goals?

• Remember that you will have to identify and address the underlying issues that 

affect your State’s position. 

• The measures featured here are only a subset of the meaningful goals and are not 

necessarily the only goals for asthma quality improvement in your State. (Refer to 

Appendixes D and E in the Resource Guide for additional asthma measures.) 

• As you move through the planning process and discover new information, you can 

come back and change your goals to reflect your new knowledge. 

• Your quality improvement program for asthma care should ultimately be designed to 

reach the goals set by the full quality improvement team. 

Source: Adapted from B. Kass. Diabetes Care Quality Improvement: A Workbook for State Action. 

Rockville, MD: Agency for Healthcare Research and Quality, 2004. 

 31
Module 5: Moving Ahead – Implications for State Action 

Learning Objective

Upon completion of Module 5, the user(s) will be able to: 

1. Summarize the essential elements in planning and implementing asthma care quality 

improvement in your State. In undertaking a systematic effort to improve the quality of 

asthma care, State leaders must provide vision, involve key partners, set goals specific to State 

needs and resources, and develop a strategy to measure improvement and identify gaps. 

1. Summarize the essential elements for an asthma care quality improvement effort in 

your State. 

Read pages 74-76 in the Resource Guide which discusses the essential elements of developing 

and implementing a State action plan. Note your strengths and any needs in these areas: 

a. Providing leadership and vision. Identify leaders to champion the quality improvement 

effort and develop a common vision for improving asthma care. 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

b. Forming partnerships and collaborations. Identify key stakeholders and strategic partners 

in quality improvement; recruit other groups—public and private, formal and informal—to 

further the effort (such as policy staff, asthma care experts, Medicaid or other health program

staff, data and program evaluation experts, and other networks, workgroups and coalitions). 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

32 
c. Identifying measures and data sources. Identify data and other information resources that 

will support an asthma quality improvement effort as well as any gaps in data and measures. 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

d. Assisting planning and goal setting. Based on the needs identified and the data resources 

and quality measures available, set initial goals for asthma care quality improvement. 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

e. Assuring evaluation and accountability. Determine the purpose, goals/objectives, and 

intended users of the evaluation; the methods to be used in gathering, analyzing, and interpreting 

the results; and any potential limitations of the information. 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

f. Creating incentives. Explore ways to reward providers for delivery of high-quality care, 

such as financial incentives, bonus awards, or other incentive programs. 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

 33
______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

g. Spreading the change statewide. Disseminate lessons learned and best practices beyond 

the quality improvement team to spread improvements in asthma care throughout the State. 

Strengths/needs:________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

______________________________________________________________________________ 

34 
A Final Note

By answering the questions in this Workbook, you have used the Plan-Do-Assess approach to 

determine your State’s needs and available resources, identify measures to be used, set initial 

goals, and begin considering an evaluation strategy for quality improvement; now you are ready 

to take action. The goal of improving asthma care quality in your State may at first seem

overwhelming. Yet, with small, smart steps, you can make that happen. 

 

Assemble your staff or your network of State leaders and discuss the idea. Most likely you will 

want them to read the Resource Guide, do the exercises in this Workbook, and prepare some

ideas for a preliminary plan even before you meet. Identifying and recruiting public and private 

partners for health care quality improvement—other State agencies, purchasers, provider groups, 

consumers, and experts who fill in the gaps in your knowledge—is critical. Find out who the 

change agents for health care quality are in your State. 

Any work plan must be shared with key stakeholders who may modify it in slight or drastic 

ways. A preliminary plan sets the stage for discussion and interaction with health care providers 

and policymakers. Flexibility within these interactions will be important to making progress and 

implementing improvement statewide. 

Remember, without committed leadership and involvement of professionals at the forefront of 

health care, there can be no quality enhancement. As we have noted throughout this Workbook

as well as in the Resource Guide, the full stakeholder group should be involved in designing the 

goals, approach, details of implementation, evaluation plan, and strategy for spreading 

change. Only with an effective team will the health care system in your State be able to change 

and provide better care for residents. 

 35