Eye examinations for VA patients with diabetes: standardizing performance measures

Sensitivity and specificity of digital retinal imaging for screening diabetic retinopathy

AIMS

To assess the effectiveness of a non-mydriatic digital camera (45 degrees -30 degrees photographs) compared with the reference method for screening diabetic retinopathy.

METHODS

Type 1 and 2 diabetic patients (n = 773; 1546 eyes) underwent screening for diabetic retinopathy in a prospective observational study. Hospital-based non-mydriatic digital retinal imaging by a consultant specialist in retinal diseases was compared with slit-lamp biomicroscopy and indirect ophthalmoscopy through dilated pupils, as a gold standard, previously performed in a community health centre by another consultant specialist in retinal diseases. The main outcome measures were sensitivity and specificity of screening methods and prevalence of diabetic retinopathy.

RESULTS

The prevalence of any form of diabetic retinopathy was 42.4% (n = 328); the prevalence of sight-threatening including macular oedema and proliferative retinopathy was 9.6% (n = 74). Sensitivity of detection of any diabetic retinopathy by digital imaging was 92% (95% confidence interval 90, 94). Specificity of detection of any diabetic retinopathy was 96% (95, 98). The predictive value of the negative tests was 94% and of a positive test 95%. For sight-threatening retinopathy digital imaging had a sensitivity of 100%.

CONCLUSIONS

A high sensitivity and specificity are essential for an effective screening programme. These results confirm digital retinal imaging with a non-mydriatic camera as an effective option in community-based screening programmes for diabetic retinopathy.

Diabetes care among veteran women with disability

OBJECTIVE

The primary objective of this study was to analyze predictors of diabetes care consistent with performance standards among women Veterans Health Administration (VHA) clinic users with disability enrollment status.

METHODS

This is a retrospective cohort study using VHA and Medicare files of VHA clinic users with diabetes. Diabetes care measures consisted of annual testing for hemoglobin A(1c) (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and poor HbA(1c) (>9%) and LDL-C (> or =130 mg/dL) control in fiscal year 2000. Chi-square tests and logistic regressions were used to assess subgroup differences in diabetes care. Independent variables included demographic characteristics and physical and psychiatric comorbidities.

POPULATION

Study population was based on veteran women <65 years of age who used VHA clinics; we identified 2,344 women as having coexisting disability and diabetes and 2,766 women with diabetes and without disability.

FINDINGS

Among veteran women with diabetes and disability, 65% received > or =1 HbA(1c) test, and 54% received a LDL-C test; 25% and 30% had poor HbA(1c) and LDL-C control, respectively. In logistic regressions, none of the independent variables had significant effects on poor HbA(1c) or LDL-C control, except that African Americans were more likely to have poor HbA(1c) control than whites. Significant age effects were noted in rates of HbA(1c) and LDL testing. Comparison of diabetes care measures between women with and without disability indicated that those with disability were more likely to receive HbA(1c) and LDL-C tests; no significant differences in HbA(1c) and LDL-C control were noted.

CONCLUSIONS

Disability status of women veterans was not a barrier to diabetes care consistent with performance standards. Our findings suggest that to improve diabetes care, subgroup-specific interventions, rather than a global approach, are warranted.

Clinical Improvement Associated with Conformance to HEDIS-Based Depression Care

BACKGROUND

Employers recently requested a valid metric of depression treatment quality. Such an indicator needs to measure the proportion of the population in need who receive high-quality care, and to predict clinical improvement.

METHODS

We constructed an administrative database indicator derived from HEDIS criteria for antidepressant medication management, and tested it in 230 employed patients in five health plans.

RESULTS

Indicator rates were 7.0% in the population in need. Conformance to indicator criteria in this population was associated with 23.0% improvement in depression severity over 1 year (p = .02).

CONCLUSIONS

Administrative database indicators that predict clinical improvement are a very rare accomplishment. Existing depression indicators may need to be calculated for the population in need to provide a valid metric for employer purchasers.

Causes of preventable visual loss in type 2 diabetes mellitus: an evaluation of suboptimally timed retinal photocoagulation

To examine circumstances surrounding suboptimally timed retinal photocoagulation, we reviewed the medical records of 238 patients who had received photocoagulation for diabetic retinopathy at one of three large referral centers. Forty-three percent (95% confidence interval, 36% to 49%) of cases were rated as probably or definitely suboptimally timed (i.e., patient could have benefited from earlier photocoagulation). About one third of cases were due to patients going many years without screening (> 3 years), and two thirds were associated with surveillance problems (failures to achieve close follow-up for known retinopathy). We found that suboptimal timing of photocoagulation was common but was not due to patients going between 13 and 36 months between screening visits, suggesting that current performance measures, which focus on annual retinal examinations, may be requiring wasteful care while not addressing a major quality problem.

Profiling quality of diabetes care in a Veterans Affairs Healthcare System

Profiling care on the basis of standard sets of measures has been extensively studied in the inpatient setting. However, less attention has been given to profiling outpatient care. The purpose of this study was to determine the influence of case-mix adjustment when profiling care for persons with diabetes. This is a cross-sectional study using medical and pharmacy data. Four process and 3 outcomes measures were used to assess the quality of care provided between 4 outpatient clinics. Diabetics were predominantly elderly (mean = 66 years), married (61%), white (73%), males (96%), with high body mass index (31 +/- 6.3 kg/m2), and mean comorbidity score of 4.2 +/- 1.8 conditions. Screening for hemoglobin A1c (HbA1c) and microalbuminuria was frequently performed in all clinics. However, 61% (n = 1697) and 36% (n = 254) of study patients had not undergone foot or eye examinations during the study period, respectively. Approximately 27% (n = 408), 41% (n = 643), and 26% (n = 515) of the study patients had poor glycemic, renal function, and lipid control, respectively. Significant differences (P < .05) in poor HbA1c and creatinine clearance rates between the clinics were observed after adjusting for patient case-mix. No differences between the clinics in cholesterol levels were observed after adjusting for patient case-mix. Overall, these clinics performed well in process of care measures, except for foot screening. After adjusting for patient case-mix, significant disparities between the clinics were observed with respect to glycemic control and renal function measures, whereas differences were nullified with respect to cardiovascular outcome measure.

Use of electronic medical record data for quality improvement in schizophrenia treatment

An understanding of the strengths and limitations of automated data is valuable when using administrative or clinical databases to monitor and improve the quality of health care. This study discusses the feasibility and validity of using data electronically extracted from the Veterans Health Administration (VHA) computer database (VistA) to monitor guideline performance for inpatient and outpatient treatment of schizophrenia. The authors also discuss preliminary results and their experience in applying these methods to monitor antipsychotic prescribing using the South Central VA Healthcare Network (SCVAHCN) Data Warehouse as a tool for quality improvement.

VHA enrollees' health care coverage and use of care

The authors examined health care coverage for Veterans' Health Administration (VHA) enrollees and how their reliance on VHA care varies by coverage, using the largest and most detailed survey of veterans using VHA services ever conducted. The results showed that a majority of veterans who use VHA services have alternative health care coverage and that most of them use both VHA and non-VHA health care. The findings have important implications for quality of care and coordination of care.

Comparing clinical automated, medical record, and hybrid data sources for diabetes quality measures

BACKGROUND

Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined.

METHODS

Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use.

RESULTS

Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record-based measures but would have required about 50% fewer chart reviews.

CONCLUSIONS

Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.

Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities

OBJECTIVE

To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases.

DATA SOURCES/STUDY SETTING

Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998.

STUDY DESIGN

This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use.

DATA COLLECTION/EXTRACTION METHODS

A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities.

PRINCIPAL FINDINGS

There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability.

CONCLUSIONS

little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions.

Preventive health care measures before and after start of renal replacement therapy

OBJECTIVE

To describe utilization of preventive health care measures in patients with chronic kidney disease (CKD), both in the year prior to onset of renal replacement therapy (RRT), and in the first year of RRT.

METHODS

We identified a large cohort of patients with CKD in the New Jersey Medicaid and Medicare programs with fixed enrollment into the cohort at 1 year prior to RRT. We applied commonly used quality assurance instruments (Health Plan Employer Data and Information Set measures) and defined levels and correlates of use of preventive care measures before and after RRT. These included mammography, Pap smear testing, prostate cancer screening, diabetic eye exams, and glycosylated hemoglobin testing (HbA1c). We employed logistic regression models with adjustment for age, race, gender, comorbidity, timing of first nephrologist contact, socioeconomic status, and calendar year of first RRT.

RESULTS

Overall, screening rates were low with the exception of diabetic eye exams. Prostate cancer screening, diabetic eye exams, and HbA1c testing were performed less often after onset of RRT compared to the year before (P < .05). Although screening rates before RRT improved considerably over the period of observation for these measures (P < .05), this was not the case once patients were on RRT.

CONCLUSIONS

Preventive health care interventions remain underutilized among RRT patients. Greater attention to such preventive measures could lead to significant improvements in the health status of such vulnerable patients. Thus, quality improvement of the general health care for patients on RRT should become a priority in renal health policy.

The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography

PURPOSE

To evaluate single-field digital monochromatic nonmydriatic fundus photography as an adjunct in the screening of diabetic retinopathy.

DESIGN

Prospective, comparative, observational case series.

METHODS

Patients with type I and type II diabetes mellitus (n = 197) were sequentially evaluated by three different techniques: single-field digital monochromatic nonmydriatic photography; dilated ophthalmoscopy by an ophthalmologist; and seven Early Treatment Diabetic Retinopathy Study (ETDRS) standardized 35-mm color stereoscopic mydriatic images. The seven stereoscopic color photographs served as the reference standard and were compared with either ophthalmoscopy or a single digital photograph transmitted electronically to a reading site. Levels of agreement were determined by kappa analyses. The sensitivity and specificity of the three methods were compared based on a threshold for referral to further ophthalmologic evaluation (ETDRS level > or =35).

RESULTS

There was highly significant agreement (kappa = 0.97, P =.0001) between the degree of retinopathy detected by a single nonmydriatic monochromatic digital photograph and that seen in seven standard 35-mm color stereoscopic mydriatic fields. The sensitivity of digital photography compared with color photography was 78%, with a specificity of 86%. Agreement was poor (kappa = 0.40, P =.0001) between mydriatic ophthalmoscopy and the seven-field standard 35-mm color photographs. Sensitivity of ophthalmoscopy compared with color photography was 34%, with a specificity of 100%.

CONCLUSION

A single nonmydriatic monochromatic wide-field digital photograph of the disk and macula was more sensitive for diabetic retinopathy screening than mydriatic ophthalmoscopy, the currently accepted screening method. When adjudicated by standard seven-field color photographs, the higher sensitivity of digital photography primarily reflected the reduced sensitivity of ophthalmoscopy in detecting early retinopathy.