DIABETIC RETINAL EXAMS

Keeping Improvement Simple

Many health plans prioritize quality improvement (QI) activities based on the number of potentially affected members. Others consider the potential impact on the quality or length of life of affected individuals. This health plan felt that diabetes was an important topic based not only on the volume of affected members, but also because of the enormous potential that exists to prevent complications of the disease.

As a participant in NCQA's Report Card Pilot project, this plan discovered that only about a third of its members with diabetes were receiving annual eye exams. The plan decided that improvement was not only feasible, but also necessary.

HEDIS 2.0 (and as they became available, HEDIS 2.5 and 3.0) methodology was used throughout this activity. The targeted population consisted of all patients with diabetes aged 31 to 64 years. The plan used pharmacy, claims, and encounter data to identify this population. Patients with diabetes were defined as those members who had received insulin or oral hypoglycemic agents, or who had a claim submitted with an ICD-9-CM diagnosis of diabetes, diabetic polyneuropathy, diabetic retinopathy, or diabetic cataract. The plan used one performance measure: the percentage of patients with diabetes who had received an annual retinal screening exam. The plan used the hybrid method of chart review and claims data to identify members who had received a retinal exam.

Data from 1994 revealed a baseline performance of 32%. The plan used information from the 1995 NCQA Quality Compass to identify its benchmarks. It reported a national average of 36.7% and a regional average of 31.8% for annual diabetic retinal exams. Although the plan's baseline measurements were in the benchmark range, it thought that this was well below what it could achieve. It established an aggressive performance goal of 65%.

A true barrier analysis was not conducted by the plan for this initiative; however, discussions with providers indicated that members and providers were not aware of the importance of the retinal exam for patients with diabetes.

INFORMATION SYSTEMS This plan encountered substantial difficulty in retrieving data from its information/claims system. Although the information systems had been used previously for financial purposes, this was one of the first initiatives the plan undertook that sought to extract administrative information about medical care. Numerous data runs were required before the plan achieved what it determined to be an effective and accurate approach to data extraction. Close collaboration with both local and corporate information systems departments enabled the plan to overcome this barrier.

The plan concentrated its initial efforts on educating members and practitioners. Educational interventions included articles about the importance of eye examinations for patients with diabetes in its practitioner and member newsletters. In addition, it implemented CME programs for primary care physicians (PCPs).

The plan also engaged in two main active interventions:

• it provided lists of noncompliant patients to PCPs
• it sent letters directly to noncompliant members; these letters urged members to request referral for an eye examination from their PCP, and provided education regarding the importance of eye exams

OUTSOURCING Extensive work was required to coordinate interventions so that they were appropriately sequenced. The management of multiple large mailings was a challenge the plan successfully met by contracting with a fulfillment center for assistance with mailings. This ensured that mailings were sent on schedule without disruption of the day-to-day work of the QI department staff. Also, the outsourcing allowed the plan to increase its internal QI staffing levels gradually, over the course of the study.

Remeasurement, using 1995 data, showed a compliance rate of 39.3%, a substantial increase over the baseline measurement.

These results were encouraging: the plan concluded that the interventions implemented to date were effective. However, physician feedback suggested that some of the members who received referrals did not have an eye exam as instructed. Therefore, the plan decided to intensify its direct outreach to members.

During 1996 the plan strengthened the initiatives it already had in place:

• the plan's contacts and reminders to members with diabetes were intensified
• to support a comprehensive diabetic care initiative, coverage was expanded for diabetic supplies such as glucometers and test strips
• letters and postcards were sent to members with diabetes - twice to all patients, and twice more to noncompliant patients - stressing the importance of annual eye exams
• letters were sent to PCPs that included personalized lists of noncompliant patients

The plan also continued its CME programs for PCPs.

Though shy of its goal, the plan was very gratified to learn that compliance with diabetic eye exams increased to 49.4% in calendar year 1996, a significant improvement of 17 percentage points over the baseline measurement of 1994.

CME ATTENDANCE Initially the plan scheduled CME programs during hours thought to be convenient to doctors, but attendance was disappointingly low. In studying the problem, the plan noted that solo and small group practices had the lowest attendance, while attendance was higher for larger groups. Consequently, the plan focused its subsequent CME interventions on larger group practice settings, frequently using a brown bag lunch approach. This produced greater attendance.

Providers of the plan continue to report that a substantial number of diabetic patients are given referrals but do not follow through with eye examinations. The plan has contracted with an ophthalmology network that has the capability of providing retinal photography with a special camera that eliminates the need for pupil dilation, which many patients find inconvenient. The network has collaborated on an outreach program in an effort to further increase compliance. This campaign focuses on direct outreach by the ophthalmology network to noncompliant members with diabetes, offering appointments that include the use of the new camera's technology.

This initiative provides a good example of progressive improvement using simple tools and widely available methods. Although the interventions may not be unique, meaningful improvement was accomplished through multiple patient reminders, physician and member education, and most of all, persistence.