DIABETES MANAGEMENT PROGRAM

Improving Multiple Aspects of Diabetes Care

One of the most common complications of diabetes is diabetic retinopathy, a leading cause of blindness. A key to successful early intervention is annual retinal screening of patients with diabetes. The American Diabetes Association (ADA) recommends annual eye evaluations starting from the time of diagnosis in patients older than 30 years of age, and after a five-year duration of diabetes in patients aged 12 to 30 years. The ADA also recommends annual cholesterol profiles, serum creatinine determinations, urinalyses, semiannual foot exams, and glycosylated hemoglobin (HbA1c) tests.

This plan decided to embark on a diabetes-focused quality initiative. The objective would be to reduce the excessive morbidity related to diabetes - especially diabetic complications such as retinopathy - in its members. The plan began with the HEDIS-specified focus on eye examinations, and added its own measures of compliance to ADA recommendations to create a comprehensive diabetes management program.

HEDIS 2.5 (and 3.0) methodology was used in this activity. The targeted population consisted of continuously enrolled patients with diabetes aged 31 to 64 years. The plan identified this population using pharmacy data. All members who were dispensed insulin or an oral hypoglycemic agent were included. The initiative began with one performance measure, the percentage of patients with diabetes who had a dilated retinal ophthalmoscopic examination performed by an eye care professional during the reporting year. Baseline performance was measured using the hybrid methodology of claims data and chart review for the entire population of patients with diabetes.

Using 1994 data, the baseline performance for the rate of annual diabetic retinal examination was established as 35.8%. The plan identified the NCQA Report Card Pilot Project average score of 48%, and selected the 1996 Regional Quality Compass best score of 42.7% as its benchmark.

With its baseline performance and the HEDIS benchmarks in mind, the plan established a performance goal of 55% for 1996 and a second-step goal of 60% for 1997.

Using a fishbone diagram, the plan identified numerous potential barriers:

• inadequate patient education
• patient noncompliance with preventive guidelines
• patients who did not access the health care system
• lack of PCP referral to an eye care specialist
• lack of understanding by practitioners of the current definition of diabetes
• lack of knowledge of current clinical practice guidelines
• identifying patients with diabetes
• lack of an automated reminder system for practitioners and patients
• lack of coordination of care for patients with diabetes

The plan took a wide range of specific interventions. It began by developing a multidisciplinary committee, including a representative from an outside vendor, to manage the initiative.

The plan began to implement its interventions by focusing on member education/outreach, data-sharing with physicians, and general organizational needs. Many of these interventions were designed to help physicians participate in the initiative.

The member-specific interventions included a letter to members with diabetes regarding the importance of regular eye exams and an article in the member magazine focusing on retinal exams for patients with diabetes. (Examples of member mailings used throughout the activity are in QP Tool .) The plan contracted for diabetic member educations.

Providers also received letters regarding the importance of retinal eye exams. In these letters, the plan provided a chart sticker to flag members with diabetes. (Examples of provider mailings used throughout the activity are in QP Tool .)

In preparation for future interventions, the plan charged the diabetes QI team - consisting of physician representatives from pediatrics, OB/GYN, internal medicine, neurology, and family practice - to create a gestational diabetes protocol.

The first remeasurement, on a random sample using 1995 data, indicated that the rate of diabetic retinal examination had risen significantly to 43.3%.

The plan focused its interventions for 1996 on guidelines and protocols to help physicians. Diabetes practice and referral guidelines were revised and sent to PCPs in June, and an article on gestational diabetes protocols was highlighted in a physician newsletter. A medical record flow sheet for diabetes was developed to assist providers with tracking care. Three CME teleconferences relating to the care of diabetes were offered to providers.

The activity was expanded to include four new performance measures. The plan added measures for the percentage of diabetic patients who received an:

• annual foot exam
• annual test for proteinuria
• annual cholesterol test
• annual HbA1c test

BEYOND HEDIS Like many health plans, this plan started this activity with a chosen HEDIS measure. However, it moved beyond HEDIS by adding measures that looked at other important aspects of diabetic care. The broader focus resulted in additional meaningful improvements in the quality of care rendered to its members with diabetes.

The second remeasurement of annual retinal exams, using a random sample and data from 1996, indicated that the rate of diabetic retinal examination using HEDIS 2.5 methodology was 45.6%. The plan also used HEDIS 3.0 methodology to facilitate comparisons with future years. The HEDIS 3.0 rate was 50.1%. This was not statistically different from the prior year.

Baseline measures were obtained from the same random sample for the four new measures (shown in Table 1)

Although the plan did not identify any benchmarks for these new measures, it set performance goals for the four new measures of five percentage points over baseline.

Following its analysis, the plan sent a questionnaire to all members with diabetes, along with a reminder encouraging them to have a dilated retinal examination. The purpose of the questionnaire was to identify barriers in the management of diabetes and to provide education, as well as assess the member's knowledge of diabetes management. (There were 40 members who returned the questionnaire and indicated that they had not had an annual dilated eye exam. These members were called by the plan and offered an appointment in order to facilitate access.) Members identified two new barriers to good diabetic care through this survey:

• glucose test strips were not a covered benefit
• educational offerings in one geographic area were inadequate

As a result, the plan expanded its educational offerings in the identified underserved area.

The plan began working on a process to cover glucose test strips, but encountered significant internal resistance from its legal and corporate benefits departments.

Additionally, the plan implemented a number of other interventions targeted at members with diabetes:

• a brochure on HbA1c monitoring was sent to members
• a letter was sent to members regarding educational services and screening guidelines (see QP Tool )
• weight management and exercise classes were offered and promoted to members

There was an aggressive effort to contact PCPs and educate them on the diabetes program.

QUALITY CHAMPIONS The chairperson of the diabetes committee contacted specialty providers personally and visited high-volume offices in the IPA network to provide details about the program. Committee members were also very active in their participation. The chairperson considered this activity to be a personal mission. Staff felt that this was a key reason for the success of this initiative.

Provider education continued to expand. All PCPs were sent letters informing them of the baseline diabetes audit results, and the year-to-year comparison of the compliance rate, with encouraging statements regarding increased compliance. (Sample letters are included in QP Tool .) The plan continued to provide a list of compliant and noncompliant members to the physicians. Other interventions highlighted during this year included:

• an article in the physician newsletter on how to obtain patient educational materials
• a physician education meeting on diabetes management
• an article on diabetic education in the physician newsletter
• an article on new diabetic medications in the physician newsletter
• updated chart stickers and list of members with diabetes sent to all PCPs
• nursing staff education sessions
• development and promotion of a foot clinic form (sample form in QP Tool )

Remeasurement of retinal exam rates for 1997, now using only HEDIS 3.0 methodology, demonstrated a rate of 53.3%. This was not statistically different from the previous year. Remeasurement of the annual foot exam and proteinuria testing showed significant improvement over the baseline, but small increases in the rate of cholesterol and HbA1c testing were not statistically significant.

In 1998, in addition to maintaining its previous efforts, the plan introduced new interventions. It began using a mobile eye unit for outreach to underserved areas. Unfortunately, member turnout has been low. The effort to give individualized feedback to physicians on their own rates of compliance with the diabetic guidelines, based on the four new measures, has been stymied by data system limitations.

Nevertheless, the multiple strong interventions that this plan implemented over the course of the activity resulted in meaningful improvement in the quality of care rendered to its members with diabetes. The use of comprehensive repeated barrier analysis and the continuous efforts to improve its interventions are especially noteworthy.