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Project Goal. Investigate causes of performance disparities in diabetes indicator tests betweenDually enrolled: Oregon patients on Medicare FFS MedicaidNon-dually enrolled: Oregon patients on Medicare FFSDesign and implement interventions based on factors. Performance Disparity in Diabetes Indicator Tests for Oregon Medicare FFS Patients.
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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)
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 20012002