DIABETIC RETINAL EXAMS

Repeating Member Outreach for Success

Diabetes is the leading cause of adult blindness in the United States. Studies suggest that early intervention could decrease the incidence of diabetes-related blindness by 45%. When this health plan realized that only one out of seven of its diabetic members was receiving an annual eye exam, it realized that there was a pressing need to improve.

An analysis of this plan's hospital admissions revealed that its rate of hospital admissions related to diabetes mellitus was more than twice the rate projected by actuarial tables. The plan felt that this was a strong indication that there was opportunity to improve the overall care that its diabetic members received. Better care of diabetes offers enormous opportunities for quality-of-life improvements. The plan began its efforts to improve quality of life for its diabetic patients by concentrating on improving its eye care services. Ultimately, this activity became part of a comprehensive disease management program for diabetic patients.

HEDIS 2.5 (and 3.0) methodology was used throughout the activity. The target population for this activity consisted of all diabetic members aged 31 years and older. The plan used claims, encounter, and pharmacy data to identify its population of diabetic patients. The performance measure selected was the percentage of diabetic patients who had received an annual retinal exam from an eye care professional. The hybrid method (using encounter and medical record data) was used to calculate this rate from a random sample of the diabetic population.

Baseline measurement, using 1995 data, revealed that only 16.1% of the plan's diabetic members had received an annual retinal exam.

As a benchmark, the health plan averaged the 1995 NCQA Quality Compass national rates of 42% for HMOs and 38% for POS plans to arrive at a combined rate of 40%. The plan used this benchmark to set its performance goal of 40%.

This plan conducted a barrier analysis by brainstorming with providers and performing member telephone surveys. The plan identified that a major barrier was related to the requirement that a referral be obtained prior to visiting an eye care specialist.

HEALTH PLAN BENEFITS The plan's research showed that referral requirements were a major barrier to patients getting an annual eye exam. This issue affected all members, not only members with diabetes. The ''hassle factor'' can be a big issue for patients and practitioners alike. Even if patients are wrong about a need for a referral, the perception that they need one may be a significant barrier. Overcoming this requires not only benefit restructuring but also good communication to members about their benefits.

The plan discovered other causes for the low rate of reported eye exams:

• eye exams were underreported in the data because eye care was poorly documented
• few referrals were made to ophthalmologists or optometrists by primary care physicians (PCPs)
• diabetic members did not perceive the need for an annual dilated eye exam

The first intervention implemented by the plan was to eliminate the referral requirement for eye care. A mailing to all members informed them of the new self-referral benefit.

The plan also contracted with a new eye care vendor, providing a new network of optometrists, general ophthalmologists, and ophthalmologic specialists. It developed a collaborative approach with the new vendor to improve member compliance. American Diabetes Association guidelines and educational materials were mailed to diabetic patients, along with information about the new vendor.

The plan initiated a telephone survey of patients with diabetes in an effort to learn more about diabetic care and to raise the awareness of patients with diabetes about what constituted appropriate care. The same sample selected to perform the HEDIS measurement was used for the telephone survey.

SURVEY QUESTIONS

• Have you had a history and physical exam in the last year?
• Have you had a retinal exam annually by an ophthalmologist or optometrist?
• Was there an inspection of your skin, particularly your injection sites?
• Was there an assessment of your feet, including an assessment for numbness and tingling?
• Did your history and physical exam include a measurement of height, weight, blood pressure and pulses, including leg pulses?
• Does your doctor review your medications and provide educational information about your disease?
• Does your doctor check your glycosylated hemoglobin (HbA1c) twice a year?
• Have you had a urinalysis done in the past year for sugar and albumin?

Subsequently, a mailing was sent to all diabetic members outlining general diabetic health maintenance and the need for annual eye exams.

CORPORATE RESOURCES The plan relied on corporate support from its parent company for the resources needed to implement this initiative. The corporate office provided the plan with support for data analysis and large-scale mailings to members and practitioners. This assistance at the corporate level allowed the plan to focus its local resources on planning and implementation of health fairs, newsletter articles, provider education, and telephone outreach to members.

Remeasurement, using 1996 data, demonstrated an annual diabetic retinal exam rate of 30.2%. This increase was statistically significant.

Two persistent barriers were identified as a result of analyzing the member survey and remeasurement results:

• poor documentation of eye care in PCPs' medical records
• lack of member knowledge regarding appropriate diabetic management

As a result, several new interventions were initiated by the plan.

The plan mailed educational materials on diabetes, disease management guidelines for diabetes, and practice-specific survey results to PCPs. Each PCP was informed of the identity of his or her patients who participated in the survey.

The plan also sponsored a CME program for PCPs where new educational materials were disseminated. Invitations were specifically targeted to PCPs with a large diabetic patient population. Continuing education credits and meals were provided at no cost. To foster good attendance, the health plan coupled this with a recreational activity.

New enrollment materials were produced by the plan to once again emphasize members' ability to self-refer for vision care.

Remeasurement, using 1997 data, showed a compliance rate of 35.3%.

The plan has continued its initiatives directed at diabetic members. Those who did not have an eye examination received reminder mailings asking them to schedule an appointment. The plan continued to mail information to all diabetic members reinforcing the importance of eye exams and the ability to self-refer.

Those diabetic members who had still not undergone annual eye examination by late 1998 were contacted by telephone and offered assistance in scheduling eye care appointments. This initiative was facilitated by collaboration between the health plan and the eye care vendor. The vendor provided blocks of appointment time to enable the health plan to schedule appointments during their telephone conversations with members. The vendor also offered evening and weekend hours at selected sites. The health plan shared this information with its members.

The plan distributed updated clinical guidelines and a list of diabetic members who have not had an annual eye examination to its PCPs.

Preliminary data showed that compliance rose to 48.5% in 1998. These results suggest that these additional interventions had an impact.

While the performance goal has been attained, the plan continues to work to increase compliance with annual diabetic retinal examinations as a component of a comprehensive diabetes disease management program.