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

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)

4. Project Design

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

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 a=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

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

15. Results: LDL-C Tests Among Patients Whose Charts Show Use of a System, by Patient Coverage

16. No significant performance difference between specialists and nonspecialists Results: LDL-C Tests Among Patients Whose Charts Show Use of a System, by Provider Type

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 receiving a biennial LDL-C test: documented diagnosis of hyperlipidemia treatment by a diabetes specialist use of a diabetes management system Factors associated with not receiving a 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

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