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Disparity in LDL-C Testing of Dually Enrolled Patients with Diabetes Patient and Practitioner Factors

Disparity in LDL-C Testing of Dually Enrolled Patients with Diabetes Patient and Practitioner Factors Ruth Medak, MD Senior Clinical Coordinator OMPRO AHQA Technical Conference Analytic Methodologies Track 11:10 am, February 1, 2002 Project Goal

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Disparity in LDL-C Testing of Dually Enrolled Patients with Diabetes Patient and Practitioner Factors

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  1. Disparity in LDL-C Testing of Dually Enrolled Patients with DiabetesPatient and Practitioner Factors Ruth Medak, MD Senior Clinical Coordinator OMPRO AHQA Technical Conference Analytic Methodologies Track 11:10 am, February 1, 2002

  2. Project Goal • Investigate causes of performance disparities in diabetes indicator tests between • Dually enrolled:Oregon patients on Medicare FFS + Medicaid • Non-dually enrolled:Oregon patients on Medicare FFS • Design and implement interventions based on factors

  3. Performance Disparity in Diabetes Indicator Tests for Oregon Medicare FFS Patients • Significant disparity in LDL-C testing (12.2%) between dually enrolled and non-dually enrolled Oregon Medicare FFS patients with diabetes • No significant disparity in HbA1c testing • Significant disparity in dilated eye exams (7.5% —below CMS threshold) Data source: 1997–1998 Oregon Medicare FFS diabetes claims

  4. Project Design Interviews + baseline medical record abstraction Hypothesis development Intervention development Intervention implementation Remeasurement(medical record abstraction and claims)

  5. Semistructured Interviewsand Medical Records Abstraction Sampling criteria: physicians with >5 DE and >10 NDE patients Sample: 40 physicians Recruited: 18 physicians Interviewed: 16 physicians Records abstracted: 244 patients of 15 physicians* 5 diabetes specialists 6 general internists 4 family physicians *1 physician withdrew following the interview

  6. Semistructured Interviews Fifteen physicians and staff • use of lipid testing guidelines • lipid testing practices • barriers to testing • characteristics of dually enrolled and non-dually enrolled patients with diabetes • use of diabetes management systems

  7. Baseline Measurement: Retrospective Medical Record Abstraction 66 DE records and 178 NDE records abstracted • test dates and results • blood pressure • hyperlipidemia treatment • use of systems • patient comorbidities • patient behavior (missed appointments,treatment refusal, etc.)

  8. Analytic Methods • Combination of qualitative and quantitative methods • Results from semi-structured interviews analyzed using Nud*Ist qualitative software • Results from medical record data abstraction analyzed using MS Access and SPSS • Statistical analysis: Chi-square test was used to check for statistically significant differences between variables at the α=0.05 level of significance

  9. Results: Practitioner Interviews LDL-C testing goals • compatible with CMS quality indicators and ADA guidelines Reasons not to test • advanced terminal illness • normal LDL-C without medications • patient indifference to treatment Patient indifference • perceived as common among to treatment Medicaid patients • most physicians not discouraged by initial patient indifference regarding glycemic and lipid treatment

  10. Results: Practitioner Interviews (continued) Delegation • no standing order protocol for LDL-C testing • most reported referring patients to nurse educator or CDE for education Systems approach • 7 of 15 reported use of flow sheet • 10 of 15 reported obtaining lab prior to visit more often than not • 10 of 15 reported using flow sheet or obtaining lab prior to visit

  11. Results: Performance in LDL-C and HbA1c Testing for DE and NDE Patients of Interviewed Physicians • Significant disparity (23.4%) in LDL-C testing between dually enrolled and non-dually enrolled patients with diabetes • No significant disparity in HbA1c testing Data source: March 1, 1999–February 28, 2001 medical record abstraction

  12. Results: Factors Associated with Dually Enrolled Patients Medicare patients with Medicaid coverage: • More likely than patients without Medicaid coverage to have • mobility limitation • nephropathy • insulin therapy • psychiatric disorder

  13. Results: Patient Factors Associated with LDL-C Testing For the aggregate sample: • Less likely to receive testing • mobility limitation • nephropathy Although some patient factors were significantly more common among DE patients, no significant association was found with LDL-C testing disparity between DE and NDE

  14. Results: Use of a System (Flow Sheet or Planned Visit) Diabetes specialists were significantly more likely to use systems Use of a diabetes management system was not significantly more likely to be found in the charts of non-dually enrolled patients Aggregate Data source: March 1, 1999–February 28, 2001 medical record abstraction

  15. Results: LDL-C Tests Among Patients Whose Charts Show Use of a System, by Patient Coverage • Use of a diabetes management system was significantly associated with LDL-C testing • aggregate • non-dually enrolled patients Data source: March 1, 1999–February 28, 2001 medical record abstraction

  16. Results: LDL-C Tests Among Patients Whose Charts Show Use of a System, by Provider Type No significant performance difference between specialists and nonspecialists Data source: March 1, 1999-February 28, 2001 medical record abstraction

  17. Conclusions from Interviews and Chart Abstraction The interviews and abstracted chart data did not explain the disparity in LDL-C testing between dually enrolled and non-dually enrolled patients with diabetes.

  18. Conclusions from Interviews and Chart Abstraction(continued) Factors associated with receivinga biennial LDL-C test: • documented diagnosis of hyperlipidemia • treatment by a diabetes specialist • use of a diabetes management system Factors associated with not receivinga biennial LDL-C test: • mobility limitations • nephropathy

  19. Hypothesis for Intervention Implementation of a patient management system will lead to increased LDL-C testing of both dually enrolled and non-dually enrolled patients with diabetes • Implementation may not reduce LDL-C testing disparity between dually enrolled and non-dually enrolled patients with diabetes

  20. Intervention: Tools • Data support for systems change • Practitioner-specific performance data (automatically generated) • Flow sheet • Electronic registry • Planned visit concept paper • Systems change concept paper

  21. Intervention: Participants and Methods Participants • Project participants • Additional target practitioners treating 25% of Oregon Medicare FFS dually enrolled patients Methods • Detailing visits to project participants • Detailing visits to 1/3 to 1/2 of target practitioners • Mail packets to remaining target practitioners

  22. Remeasurement Interim measurements Medical record abstractions* • laboratory tests and results • blood pressure • use of systems Final measurement Medicare FFS claims data CY 2001–2002 *5–6 months after interviews and 5–6 months after intervention

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