DIABETES CARE MANAGEMENT

Aggressive Interventions Leading to Incremental Improvement

Diabetes affects 16 million Americans. Almost one out of every five people age 65 or older has diabetes. Death rates among middle-aged people with diabetes have been found to be twice as high as those of middle-aged people without diabetes. Diabetes is associated with a wide range of complications, including heart disease, hypertension, kidney disease, amputation, stroke and other disorders of the nervous system.

Results from the Diabetes Control and Complications Trial showed that intensive therapy delays the onset of diabetes-related complications, and slows their progression in insulin-dependent diabetics.

With the plan readily able to identify approximately 3 percent of its population as diabetic, it felt a need to encourage and monitor compliance with established treatment standards. In 1996, the plan formed a cross-departmental team. Its mission: minimize the complications affecting plan members with diabetes.

Members were identified as diabetic on the basis of two claims with separate dates of service with any of the following:

• ICD-9-CM diagnosis of diabetes
• CPT-4 code for glucose monitoring
• Prescription for insulin or an oral hypoglycemic agent

The targeted population included all identified diabetics who were plan members at both the beginning and end of the year.

The plan selected a multidisciplinary work group of QM, IS, data analysis, care coordination, pharmacy and disease management staff to manage the project.

The work group selected three performance measures. It looked first at the percentage of targeted members who had received at least one HbA1c test during the reporting year. It also looked at the rate of lipid panel testing among those targeted members age 21 and older. Finally, it looked at the percentage of targeted members over age 31 who had received at least one retinal exam during the reporting year.

Baseline performance, based on June 1995 to May 1996 data, showed a rate of 61.9 percent for HbA1c testing, 46.7 percent for lipid panel testing, and 29.0 percent for retinal examination.

Based on this performance, the work group set one- and two-year goals for improvement. The plan set goals for may 1997 of 65 percent for HbA1c testing, 50 percent for lipid panel testing and 60 percent for retinal examination. Goals to be reached by May 1998 were 100 percent for HbA1c testing, 100 percent for lipid panel testing, and 70 percent for retinal examination.

ZERO DEFECTS MINDSET Though the work group realized that it would be necessary to take incremental steps to achieve 100 percent rates, it felt that the literature on the importance of the American Diabetes Association standards for HbA1c and lipid testing was strong enough to prevent it from settling for anything less than 100 percent as a long-term goal.

The work group not only conducted its own brainstorming session to identify barriers to care, it also convened a number of focus groups. Focus groups of PCPs, endocrinologists, diabetes educators, nutritionists and pharmacists provided insights into the obstacles interfering with members' control over diabetes.

Among the barriers uncovered:

• Varying degrees of knowledge about ADA standards of care and steps to prevent complications; both members and physicians were in need of education
• Poor member and practitioner understanding of health plan benefits with regard to diabetes
• A utilization management policy that denied referrals from PCPs to ophthalmologists for routine retinal exams
• No existing mechanism to focus attention on high risk diabetic members
• Lack of member motivation for self-care and reluctance to test blood sugar.

In designing interventions, the work group tried to consider all the identified barriers. Once again, it used focus groups of PCPs, endocrinologist, diabetes educators, nutritionists and pharmacists. It gave top priority to interventions they believed would have the greatest impact, and then to those that could be implemented quickly and easily.

Educational efforts went forward on both practitioner and member fronts. A diabetes educator presented seven physician forums featuring CME credit. Six kick of sessions were held for members. These featured health risk appraisals and presentations on eye disease and nutrition.

MEASURING THE IMPACT OF INTERVENTIONS One of the strengths of this QIA was the effort spent in trying to identify obstacles and tailor interventions. This effort was continued in the plan's efforts to measure the effect of individual interventions. For instance, member education sessions were evaluated by surveying participants. The satisfaction rate for eye disease sessions was 94 percent, and the nutrition session earned a 98 percent satisfaction rating. About 30 percent of the participants subsequently made a change in at least one behavior related to controlling their diabetes.

Mailings to members began with identified diabetics. Letters signed by the plan medical director urged members to receive HbA1c tests, lipid panels and retinal exams. The letters also helped explain the plan's health benefit provisions. Eventually, reminder notices were sent to members (and their physicians) if they still lacked any of these three tests. Over 4,000 letters were sent (samples of these mailings are included in QP Tool ).

CAMPAIGNING FOR CHANGE One of the major obstacles to eye care, the policy to deny referrals from PCPs to ophthalmologists, was taken on by the plan's director of pharmacy, who successfully lobbied for a change in this policy. A process was implemented in which designated codes would trigger approval of these referrals.

Finally, the work group decided that it needed to focus attention on areas of need reported by the members themselves. And it wanted to measure the impact of the plan's diabetes care program on health status. For these reasons, it obtained baseline measurements using a mailed functional status instrument based on the SF-36 to 4,617 plan members with diabetes.

The first measurement, based on data from June 1996 to May 1997, showed a statistically significant improvement in HbA1c testing with a rise to 66.5 percent. However, lipid panel performance remained flat at 46.9 percent, and only slight progress was made toward the retinal exam goal with a rate of 30.9 percent - not a statistically significant improvement.

The plan confronted these data by performing a drill-down analysis. Members who had received reminders increased their retinal exam rate by 8.4 percentage points, while members who did not receive reminders actually showed a decrease in exam rates of 6.1 percentage points. Similarly, lipid panel reminders increased the rate of screening among their recipients by 30.3 percentage points, while members without these reminders showed a decrease of 0.3 percentage points.

In response to these findings, the work group's efforts focused on increasing the number of members receiving reminders. They addressed information issues that caused delays in sending reminders to newly identified or newly enrolled members and their physicians. By increasing the frequency of communications, the plan hoped to minimize the number of members who didn't get a prompt reminder, and scheduled reminder mailings on an ongoing basis with no gaps.

IENT EMPOWERMENT Member education efforts used a model of patient empowerment. Diabetes educators worked with a nationally recognized expert on patient empowerment. Some participants were so excited that they wished to become facilitators. The educators trained them to lead their own sessions. Together with the community nurses, they ultimately trained other members.

A community-based stress management session featured a blood glucose monitor exchange where members could obtain more accurate monitors at no cost.

A number of other community-based sessions focuses on plan benefit coverage, eye exams, self-monitoring and carbohydrate consumption. These sessions were spaced throughout the year, and dovetailed with articles in member newsletters.

Physician recognition featured the ADA program for certification for the treatment of patients with diabetes.

EARLY ADOPTERS Although the certification program was ultimately dropped due to poor attendance, 14 physicians attended introductory sessions, and six eventually became certified. These physicians served as champions of the program, helping to get ''buy in'' from other clinicians.

The second remeasurement, based on June 1997 to May 1998 data, showed statistically significant increases in all the measures. HbA1c screening rose to 70.6 percent; lipid panels to 49.7 percent, and retinal exams to 31.6 percent.

The retinal measure fell well short of the health plan's goal, but the plan met their short-term goals on the other measures.

The health plan continued its efforts, focusing again on improving the frequency, timing and consistency of interventions.

It offered a chance to win a $100 gift certificate at a local department store for members completing retinal examinations.

It formed a Disease Management Steering Committee to integrate efforts by plan staff, members and physicians across chronic illnesses instead of taking a more fragmented approach. It was discovered that some barriers and interventions were highly relevant to several chronic conditions.

Subsequent evaluations yielded encouraging results. Perhaps most gratifying was the results of the repeat health status assessment survey, performed in 1999. Almost 70 percent of the members surveyed completed and returned the form. Despite the progressive nature of diabetes, member health status had shown statistically significant improvement on the visual disturbance index, and four other indices showed improvement that did not reach the level of statistical significance. Only one index, the leg index, showed a significant decrease.

The plan notes that careful planning, the use of a variety of interventions, the inclusion of the right players (particularly diabetes educators) and listening to its membership are key success factors in its continuing journey to reduce complications in diabetic patients.