DIABETIC RETINAL EXAMS

Managing Disease With Teams and Technology

Diabetes is a high-risk disease that affects millions of people. Many of the complications associated with diabetes can be detected early and treated. For example, the incidence of diabetes-related blindness can be decreased with early identification and intervention through retinal screening. In addition, this plan decided to focus on eye care for patients with diabetes because of a very practical consideration: it had a clinical "champion." It was fortunate that one of its doctors displayed a strong interest in moving this initiative forward.

The plan used HEDIS 2.0 (and as they were released, HEDIS 2.5 and 3.0) methodology throughout this initiative. The targeted population consisted of patients with diabetes 31 to 64 years of age. The plan used pharmacy data to identify its patients with diabetes. All members who received insulin or oral hypoglycemic agents were included. The performance measure selected for the activity was the percentage of patients with diabetes that received a dilated retinal examination or retinal photograph during the last 12 months. The plan used claims data to measure its performance.

Baseline performance measurement, using 1993 data, demonstrated an annual diabetic retinal screening rate of 42%. No goals or benchmarks were established at this time. However, in 1996, the plan established a benchmark of 79% based on results achieved by a sister plan. Using this benchmark, the plan set a performance goal of 75% in 1996.

Analysis of the baseline data revealed a number of barriers that might inhibit the performance of a diabetic retinal exam:

• physicians were neglecting to recommend retinal screening exams
• there were no reminder systems for physicians and patients
• patients needed a referral for eye care
• even patients with a referral often neglected to make an appointment for eye care
• many patients with diabetes didn't have a designated primary care physician (PCP)

PATIENT-DOCTOR RELATIONSHIP The plan thought that the absence of a patient relationship with a PCP might have created a lack of accountability. The plan felt that a strong relationship would result in the reinforcement of the need for regular screening exams. Although patients who received a recommendation and a referral from their PCP didn't always follow up to actually make an appointment for an eye exam, this patient-PCP relationship appeared to be a critical first step in the eye care process.

The plan convened a multidisciplinary team for diabetic care. This group consisted of office staff, RNs, physicians, and pharmacists. It was charged with looking at processes of care and developing and implementing strategies to improve retinal screening rates. The group committed to meet at least one day each month.

In autumn 1993, the plan distributed the first patient-specific quarterly reports to physicians. These reports contained information about each patient's last visit date, the glycosylated hemoglobin (HbA1c) level, and the date of the last ophthalmology referral.

Quarterly newsletters were sent to providers and staff covering topics relating to diabetic care such as guidelines for diabetic eye exams. In the spring of 1994, an article in quarterly member publication addressed diabetes care management and promoted group educational classes. In addition, steps were taken to ensure that all patients with diabetes were assigned to a PCP.

Remeasurement, using 1994 data, showed that 42.8% of the member population with diabetes received an annual eye exam. This rate was essentially unchanged from the baseline performance.

The plan continued to distribute quarterly reports to PCPs of patients who had not received retinal exams. These reports were linked to a member outreach telephone program. Office staff and diabetes educators called members to remind them about necessary medical care, and assisted them in scheduling appointments. The plan held CME programs that emphasized diabetic retinal screening.

The plan conducted a barrier analysis. This identified three key logistical issues that had yet to be addressed:

• requiring that patients travel to a different location to have an eye exam
• requiring that patients schedule appointments with an ophthalmologist for a screening exam
• requiring an additional copayment for retinal screening exams

1995 data for diabetic retinal screening showed a statistically significant increase to 51.3%.

As a result of the remeasurement and previously identified barriers, the plan developed a new model of diabetes management. The new model used diabetes care teams. Each care team was physically located in a primary care clinic, and consisted of specifically trained RNs and LPNs who worked with the PCP, the pharmacist, and the member to coordinate and manage care.

The plan developed and distributed a set of standard protocols and orders to assist the diabetes care teams. A diabetes registry was developed to provide a repository of patient information. Specific tools were developed to allow for risk stratification based on glycemic control.

Each care team was assigned a total of 600 to 800 patients and was responsible for all aspects of primary care for these patients. Member outreach efforts began with member mailings: during their birth months, members were reminded to schedule a preventive screening visit that would include a foot exam, retinal screening, lab work, and counseling.

To remove cost as a barrier to care, the plan eliminated all copayments for these preventive screening visits.

The plan purchased nonmydriatic cameras to take retinal photographs. LPNs on the diabetes care team were trained in the use of these cameras. The pictures were then sent out to board-certified ophthalmologists for grading.

ONE-STOP SHOPPING This plan devoted significant resources to the purchase of the nonmydriatic cameras, and the training of LPNs in their use. These cameras allowed the plan to eliminate patient referrals to ophthalmologists for the screening exams. In addition, patients no longer needed to schedule a separate appointment for eye care. This innovative use of technology created a "one-stop shopping" system that removed a major logistical barrier.

The plan rolled out the diabetes care team concept to three plan regions in a stepwise fashion between June 1996 and February 1997.

Remeasurement, using 1996 data, showed an increase from 51.3% to 54.6%. This represented a statistically significant improvement.

The plan's staff focused on refining its diabetes registry and its educational efforts for providers.

With the help of information systems support, the plan's staff identified and addressed issues such as inaccurate and incomplete data in the diabetes registry.

With the formation of the diabetes care teams, it seemed that the PCPs no longer felt accountable for referrals to the team or to an ophthalmologist for services. In an effort to promote accountability among the PCPs, the plan initiated ongoing educational efforts. PCPs were kept informed about the diabetes care team's activities and member outreach efforts. They continued to receive patient-specific information detailing retinal screening status.

Remeasurement, using data from the first six months of 1997, demonstrated a rate of 32.8%. This translated into an annualized rate of 65.6%, which would represent a significant improvement.

In 1998, the plan completed its remeasurement of 1997 data with results showing a 71% screening rate, which exceeded the projected annualized rate of 65.6%.

The plan learned that with the implementation of the diabetes care teams, PCPs began to assume that retinal photographs were being taken on all patients. Some had stopped referring members to the diabetes care teams or to ophthalmology. Given that the diabetes care teams had encounters with less than 50% of the population by mid-1997, this left a significant portion of the population untouched by the new retinal screening process. Ongoing educational efforts continue to stress the PCP's role in education, management, and referral to the care teams.

The plan's constant midcourse corrections were the key to the success of this effort. Constant refinements and new ideas helped the plan implement strong interventions, notably the team concept and the use of retinal cameras.