DIABETIC RETINAL EXAMS

Education, Reminders, Cost and Convenience

With the addition of a Medicare risk product, this plan saw its population of diabetics increase by over 40 percent during the two-year period covered by this activity. Despite an ongoing diabetes disease management program, the plan had only been able to demonstrate a 3 percent increase in the rate of diabetic eye exams over the previous three years.

Twenty-four thousand Americans go blind from diabetes each year. [1] People with diabetes are 25 times as likely to develop blindness as are individuals without diabetes. Diabetic retinopathy is the leading cause of new-onset blindness in working-age people in the United States. In addition, diabetics are at higher risk for optic neuropathy and cataracts. [2]

Timely laser treatment can reduce the risk of severe vision loss by 90 percent. [3]

Nationwide HEDIS results suggest that, if all health plans could improve their diabetic eye exam rates to a benchmark rate of 66.4 percent, 3,400 fewer people would become blind each year. [4]

Using pharmacy data, this plan determined that 4.7 percent of its population was diabetic, a higher prevalence than seen in sister plans in other geographic areas.

With the cost of care for members with diabetes at three times that of the plan's general membership, this plan renewed its efforts to improve its rate of diabetic retinal exams.

The health plan used pharmacy codes (following HEDIS 3.0 specifications) to identify diabetics age 31 and older. Gestational diabetes and diet-controlled diabetes were excluded.

Staff from both clinical and claims areas managed this project.

The plan used the HEDIS 3.0 measure for Diabetic Retinal Exams as its performance measure. Administrative data were used to calculate the number of members in the target population who received a retinal exam during the year.

Baseline performance, based on 1996 data, showed a rate of 60 percent. A sister plan in another geographic region reported a rate of 75.4 percent, and the plan used this number as its benchmark.

Considering baseline performance and the benchmark rate, the plan set a goal of 65 percent.

In-house QI staff worked together with employed medical staff to ascertain possible barriers to diabetic eye care.

Among the barriers uncovered:

• High rate of membership turnover
• Delays in educational programs
• Providers not educated about screening recommendations
• Patient noncompliance
• Co-pays for eye exams

GROUP DECISION-MAKING METHODS This health plan used the Delphi technique to obtain consensus regarding possible barriers. This process involves the use of a series of revised and increasingly specific questionnaires to achieve consensus. After each questionnaire, group results are fed back to the respondents. Because respondents do not meet face to face, they are not influenced by the personalities of other participants. The drawback? The process can be time consuming, and does not offer the opportunity to share ideas.

Based on the barriers it had identified, the plan decided that the most effective strategy to obtain improvement would be to educate and remind its members about the importance of diabetic retinal exams in a way that would also remind their primary care providers.

The plan refined its diabetic tracking program, which identified members not seen by an ophthalmologist or optometrist in the past year. Each medical office had a call-back program to contact these patients and schedule appointments, and the frequency of this outreach to patients was increased from quarterly to monthly.

It was hoped that the presence of the call-back program in their offices would have an impact on providers, and reinforce their appreciation of the importance of the plan's eye exam recommendations.

Member education also included two newsletter articles on diabetes and two-hour diabetes education classes offered four times each month.

The first remeasurement, based on data from 1997, was divided into measures for the commercial and Medicare populations. The commercial rate of diabetic retinal exams was 54 percent, with Medicare showing a rate of 57 percent. Both rates were less than that seen in the previous year's baseline measurement of the entire population.

In analyzing why the rates had declined, the plan found that, while membership had increased by 20 percent, the overall diabetic population had increased by 27 percent from the previous year.

Besides continuing previous interventions such as education, the plan added several new interventions.

PHARMACY CARE The pharmacy department was recognized as an important contact point between diabetic members and the health plan. The plan implemented a reminder system that used a note included with each refill of a diabetic prescription. The note informed patients of both the need for annual eye exams, and the information needed to schedule an appointment.

The plan piloted cooperative group visits. These featured a 90-minute educational session in conjunction with an appointment with a practitioner either before or after the group session. The plan hired a diabetic case manager to help identify high-risk diabetics and collaborate with PCPs on their care.

Several changes were made to the plan's diabetic tracking program. In addition to enhancing software, a number of plan personnel cooperated in outreach efforts. Administrative staff in the plan's call center performed monthly outreach to patients needing eye exams. Medical office nursing staff began rescheduling patients who had failed to keep their appointments. Optometrists began calling patients to remind them a day or two in advance of their appointments.

The member co-pay for diabetic retinal exams was waived.

The second remeasurement, based on 1998 data, showed a commercial diabetic exam rate of 69 percent, and a Medicare rate of 81 percent. These rates represented statistically significant improvements. In addition, the plan had surpassed the goal it had set for eye exams.

The plan has continued its diabetic disease management program. The diabetic tracking registry has been improved, with better maintenance and additional data. New measures such as HbA1c screening rates and levels have been added. Optometry services have been relocated to those medical offices with the greatest diabetic caseloads. The plan has sustained the impact of this activity, reporting a 71 percent rate for diabetic eye exams in 1999.

[1] - National Committee for Quality Assurance, State of Managed Care Quality 2000 (Washington, D.C.: National Committee for Quality Assurance, 2000), 37.

[2] - "Information Statement: Eye Care for People with Diabetes Mellitus," In MEDEM [online database of American Academy of Opthalmology]. [cited January 30, 2001]. Available from www.medem.com; INTERNET.

[3] - Ibid

[4] - National Committee for Quality Assurance, State of Managed Care Quality 2000 (Washington, D.C.: National Committee for Quality Assurance, 2000), 37.