Failure of Administrative Data to Guide Asthma Care

Rationale: Asthma is a chronic inflammatory disease of the airways that is very common (7.9% of Canadians over the age of 12). Despite numerous clinical guidelines, education events and administrative data reviews, there has been little change to the way asthma is managed in the Canadian health care system for nearly 30 years. We evaluated, through the Physician Learning Program (PLP) in Alberta, possible reasons why administrative datasets have not been able to provide meaningful information to adjust health policy.

Asthma is a prevalent disease for which numerous clinical guidelines, educational events and administrative data reviews have been implemented to guide asthma care. However, despite these resources being readily available to health care workers (HCWs) and administrators, it has not significantly changed the way in which asthma is managed in the Canadian health care system since the first Canadian guidelines were introduced in 1989. Numerous clinical guidelines and educational events have been implemented over this period; however, regional, provincial and national administrative datasets have been unable to assist health care providers [1,2,3]. Consequently, significant morbidity and mortality rates of asthma patients continue to cost the health care system.
The cost of respiratory diseases, excluding lung cancer, account for the fourth largest health care cost in Canada [4]. The direct costs of asthma are estimated at $600 million per year. Asthma leads not only to direct costs from services such as physician visits, emergency visits, diagnostic tests and drug costs, but also to indirect costs from sources such as lost time from work [5].
According to Statistics Canada, in 2014, 8.1% of Canadians (2.9 million) 12 years of age and older reported having had a diagnosis of asthma from a health professional [6]. This disease accrues a mortality of 500 adults each year and is responsible for 20% of school absences in Canada [7].
Multiple publications over the past 15 years have indicated that 1 in 3 physician-diagnosed asthma cases are not in fact, asthma [10,11]. This includes over 700,000 Canadians who may be misdiagnosed with asthma. The diagnosis of asthma, which may become a lifelong label, should not be made in the absence of timely pulmonary physiologic testing (i.e. spirometry, pulmonary function tests [PFTs]) and airway challenge tests in conjunction with appropriate respiratory symptoms [8,9]. However, although the Canadian Respiratory Guidelines have outlined best practices for treatment of asthma, a Canadian study found that only 39% of physicians surveyed made treatment recommendations based on the Canadian Respiratory Guidelines [10]. A Nova Scotia study found that only 52.2% of their 90 selfreferred participants who had a diagnosis of asthma reported having received pulmonary function testing, and 62% of the participants were being treated with long-term asthma medications despite not meeting the combined clinical and physiological test criteria for a diagnosis of asthma [11].
Spirometry is a simple, cost effective test used in the diagnosis of respiratory diseases. This physiologic testing is essential in asthma diagnosis; however, it should never be used as a stand-alone diagnostic test. It must be taken into consideration after a thorough clinical pre-test likelihood is evaluated [21]. If diagnosis is made without spirometry testing, contradictory to the Canadian Respiratory Guidelines, asthma misdiagnosis may occur. Diagnosis of asthma may result in patients being prescribed medications, and if based on an incorrect diagnosis, this could be dangerous, unnecessary and costly to both the patient and the health care system. There are also side effects associated with some of the prescription medications used for asthma; for example, β2agonists have been found to increase cardiovascular death, and therefore pose a risk for individuals with cardiovascular disease [17]. Owing to the potential for unnecessary financial burden and health risks, it is important to ensure that an accurate diagnosis of asthma is made and managed correctly.

Introduction
Spectrum | InterdIScIplInary undergraduate reSearch for spirometry was noted. Figure 2 shows the available respiratory testing data in Alberta, using the spirometry testing code 03.38C Health Service

Methods
The PLP Process The unique asthma diagnostic codes for newly diagnosed asthma were employed between 14660 and 16928 times, yet spirometry was only billed for between 6798 and 10323 times or roughly half as often as the asthma diagnostic codes.

Discussion
Our study showed that Alberta's current system to capture pulmonary physiology as assessed by the PLP is not adequate. We used provincial asthma data on pulmonary function testing performed between 2005 and 2011, along with data on asthma diagnosis made during the same time period.
Due to problems with data extraction caused by inconsistencies in physician and PFT lab billing as well as differences in billing between private and public labs, the project was never completed.
Pulmonary physiology, in addition to a detailed history, is essential to the diagnosis of asthma.
Asthma overdiagnosis poses health services concerns which can be impacted by pulmonary physiology testing, and where testing is done [18]. The current process for interpretation of pulmonary physiology is coordinated through the CPSA and involves four levels. To perform and report lung function tests, physicians must obtain CPSA approval as at least a level II physician, which requires a specialist in respiratory medicine, internal medicine, anesthesia or pediatrics to receive training for one month in a lab that performs 500 level III studies each year, unless it is being performed as office spirometry [13,14].  is caused by their ability to limit disclosure of business information [16]. Secondly, for-profit laboratories pose a challenge to integration of health care information since in some provinces they fall under separate administrative structure, have different payment structure and separate data networks [16]. Potential inconsistencies in information disclosure in private labs may also contribute to knowledge gaps, and further affect the way data is managed in Alberta.
The PLP is not the first to encounter problems gathering reliable data from healthcare databases and this challenge is not unique to Alberta, or even We have found that the current administrative system is in need of improvement to better link private for-profit PFT labs in conjunction with private not-for-profit PFT labs (i.e. AHS), into a common administrative database such that the province of Alberta has more robust data gathering capacity for quality assurance /quality control reviews related to asthma.
Spectrum | InterdIScIplInary undergraduate reSearch