Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) performance with outcomes of enrollees with diabetes

A primer on quality measurement and reporting in pharmacy benefit plans

Pharmacy benefit plans in the United States are evaluated on quality measures and other requirements of the government and accrediting organizations. This primer describes the roles of key organizations involved in measuring and reporting quality in pharmacy benefit plans and explains the methods that pharmacy benefit plans use to promote quality of medication use.

Implications of Patient-Reported Outcome Measures among patients with recently diagnosed type 2 diabetes

BACKGROUND

For the past two decades, the assessment of the quality of diabetes care has mostly relied on clinical quality indicators. These have not included Patient-Reported Outcome Measures (PROMs) which provide information on outcomes deemed valuable by patients. We aimed to examine the potential utility of PROMs in type 2 diabetes care and to study the association of PROMs with patients' characteristics and clinical quality indicators.

METHODS

A cross-sectional survey of recently (≤ 4 years) diagnosed patients with type 2 diabetes (n = 392) in the setting of a large health plan. PROMs were based on two well-validated questionnaires, the Problem Areas in Diabetes (PAID) one-page questionnaire that measures diabetes-related distress, and the ten item PROMIS-10 global health questionnaire that measures general health. Additional items were added following a previous qualitative study among Israeli patients with diabetes. The survey was carried out using phone interviews, and data collected were linked to the electronic medical records. Multivariable regression models were used to assess the associations of socio-demographic variables and clinical quality indicators with the PROMs.

RESULTS

About a fifth of participants (22%) had high diabetes-related distress (PAID score ≥ 40), a third reported that they did not feel confident in self-management of diabetes and about a third reported having sexual dysfunction. Women, younger patients, and those with a low education level (≤ 12 years) reported worse general health, were more likely to experience high diabetes-related distress, and to have low confidence in diabetes self-management. Interestingly, performance of all seven diabetes quality indicators was associated with worse general health and high diabetes-related distress. Of note, levels of glycated hemoglobin, LDL-cholesterol, or blood pressure were not associated with PROMs.

CONCLUSIONS

PROMs provide important information on patient self-reported health status and are likely to reflect aspects of the quality of care that are not otherwise available to clinicians. Thus, the use of PROMs has the potential to expand the evaluation of diabetes care and promote patient-centered care. We recommend that policy-makers in the Ministry of Health and health maintenance organizations implement PROMs for assessing and improving the care for patients with type 2 diabetes.

Impact of Diabetes Prevention Guideline Adoption on Health Outcomes: A Pragmatic Implementation Trial

Limited research exists to evaluate nutrition guideline impact on clinical practice and patient health outcomes. In this study we investigate (1) the impact of guideline training on the implementation of the diabetes prevention Evidence-Based Nutrition Practice Guideline (EBNPG), and (2) the relationship between EBNPG congruence and resulting health outcomes in patients with prediabetes. We conducted an implementation study in which registered dietitian nutritionists (RDNs) provided nutrition care with 3-month follow-up to 102 pre-diabetes patients before and after a professional training on the implementation of the Diabetes Prevention EBNPG. Using the RDNs' Nutrition Care Process (NCP) documentation, we measured percent guideline congruence and health outcomes (body weight, waist circumference, fasting glucose, glycosylated hemoglobin), and modeled health outcomes. Guideline congruence improved after training by 4.3% (P < 0.05). However, no significant associations were observed between guideline training, or guideline congruence and health outcomes. Our model showed a reduction in waist circumference (2.1 ± 0.92 cm; P = 0.023), and body weight (-1.78 ± 0.55 kg; P = 0.001) throughout the course of the study. Training of nutrition professionals improved congruence to EBNPG for Diabetes Prevention. Nevertheless, improved guideline congruence did not impact related health outcomes. Standard care including nutrition intervention resulted in body weight and waist circumference reductions. Future research needs to further address the impact of evidence-based guidelines on outcomes in all areas of practice.

The Value of Laboratory Information Augmenting a Managed Care Organization's Comprehensive Diabetes Care Efforts in New Mexico

BACKGROUND

The National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set on Comprehensive Diabetes Care requires patients with diabetes obtain a hemoglobin A1c (Hb A1c) and urine albumin-to-creatinine ratio (ACR) test every year. To improve these measures, managed care organizations (MCOs) rely on claim and prescription data to identify members for care management. TriCore Reference Laboratories collaborated with Blue Cross Blue Shield of New Mexico (BCBSNM) to determine if laboratory information would augment BCBSNM's diabetes care management services.

METHOD

In January 2018, BCBSNM provided its Medicaid enrollment file to TriCore for identifying members and determining their diabetes status by evaluating their recent Hb A1c results. Of the 6,138 members with diabetes, a random sample of 600 was extracted, and half were provided to BCBSNM to perform care management from January 18 to May 1, 2018. Completion of Hb A1c and ACR were measured.

RESULTS

Significantly more (P = 0.03) study group members (25%) than control group members (18%) received an Hb A1c test. The study group (14%) also received more ACR tests than the control group (9%; P = 0.07). We then calculated the monetary penalty to which New Mexico Medicaid MCOs are subject, leading to the identification of additional value ($3,693,000) that clinical laboratories provide beyond the cost per test.

CONCLUSION

Clinical laboratories play a critical role in healthcare, and this article demonstrates an approach for laboratories to collaborate with MCOs in their care management efforts. In addition, we calculate the value of this novel collaboration, which may play an integral role in laboratories' pursuit of value-based care.

Patient Dissatisfaction With Primary Care and Nonurgent Emergency Department Use

A well-functioning primary care system will have the capacity to provide timely, adequate, and effective care for patients to avoid nonurgent emergency department (ED) use. This study advances academic discussion by examining whether patient negative experiences during their encounter with a primary care physician (PCP) are associated with nonurgent ED use nationwide in the United States. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. The independent measures were patient perceptions of PCPs' communication and care quality in 2010. The multivariate logit model was employed to analyze the nonurgent ED use as opposed to no ED use in 2011, after controlling for age, gender, race and ethnicity, rural/urban location, marital status, and education levels in 2010. All predictors were treated as dummy variables. We employed the lagged time effect and controlled health status to account for the endogeneity between outcomes and the main independent variables. The weights and variance were adjusted using the survey procedures to yield nationally representative results. The study sample consisted of 5242 adults, which represented 131 317 908 weighted people in the total population. While the measure of patient satisfaction with providers' communication was not associated with nonurgent ED use (P = .750), patient perceived poor and intermediary levels of primary care quality had higher odds of a nonurgent ED visit (OR = 1.75, P = .049, and OR = 1.48, P = .050, respectively) compared with high levels of care quality. For PCPs, endeavors may be considered in improving health care quality to reduce nonurgent ED use. Whenever possible, PCPs' efforts may want to be devoted to both communication and care quality to improve patients' health outcomes and satisfaction and to reduce nonurgent ED use.

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

High-cost sharing policies and non-urgent emergency department visits

PURPOSE

The purpose of this paper is to examine whether high-cost-sharing ambulatory care policies affect non-urgent emergency department (ED) care utilization differently among individuals with and without chronic conditions.

DESIGN/METHODOLOGY/APPROACH

This retrospective cohort study used 2010-2011 US Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model and survey procedures were employed. Time lag effect was used to address endogeneity concerns.

FINDINGS

The sample included 4,347 individuals. Difference in non-urgent ED visits log odds between high- and low-cost-sharing policies was not significantly different between chronically ill and non-chronically ill individuals ( β=-0.48, p=0.42). Sensitivity analysis with 15 and 25 percent cost-sharing levels also generated consistent insignificant results ( p=0.33 and p=0.31, respectively). Ambulatory care incidence rates were not significantly different between high- and low-cost-sharing groups among chronically ill people (incidence rate ratio=0.849, p=0.069).

PRACTICAL IMPLICATIONS

High-cost-sharing ambulatory care policies were not associated with increased non-urgent ED care utilization among chronically ill and healthy people. The chronically ill patients may have retained sizable ambulatory care that was necessary to maintain their health. Health plans or employers may consider low-level cost-sharing policies for ambulatory care among chronically ill enrollees or employees.

ORIGINALITY/VALUE

Findings contribute to insurance benefit design; i.e., whether high-cost-sharing ambulatory care policies should be implemented among chronically ill enrollees to maintain their health and save costs for health plans.

A patient-centred intervention to improve the management of multimorbidity in general practice: the 3D RCT

Background

People with multimorbidity experience impaired quality of life, poor health and a burden from treatment. Their care is often disease-focused rather than patient-centred and tailored to their individual needs.

Objective

To implement and evaluate a patient-centred intervention to improve the management of patients with multimorbidity in general practice.

Design

Pragmatic, cluster randomised controlled trial with parallel process and economic evaluations. Practices were centrally randomised by a statistician blind to practice identifiers, using a computer-generated algorithm.

Setting

Thirty-three general practices in three areas of England and Scotland.

Participants

Practices had at least 4500 patients and two general practitioners (GPs) and used the EMIS (Egton Medical Information Systems) computer system. Patients were aged ≥ 18 years with three or more long-term conditions.

Interventions

The 3D (Dimensions of health, Depression and Drugs) intervention was designed to offer patients continuity of care with a named GP, replacing separate reviews of each long-term condition with comprehensive reviews every 6 months. These focused on individualising care to address patients’ main problems, attention to quality of life, depression and polypharmacy and on disease control and agreeing treatment plans. Control practices provided usual care.

Outcome measures

Primary outcome – health-related quality of life (assessed using the EuroQol-5 Dimensions, five-level version) after 15 months. Secondary outcomes – measures of illness burden, treatment burden and patient-centred care. We assessed cost-effectiveness from a NHS and a social care perspective.

Results

Thirty-three practices (1546 patients) were randomised from May to December 2015 [16 practices (797 patients) to the 3D intervention, 17 practices (749 patients) to usual care]. All participants were included in the primary outcome analysis by imputing missing data. There was no evidence of difference between trial arms in health-related quality of life {adjusted difference in means 0.00 [95% confidence interval (CI) –0.02 to 0.02]; p = 0.93}, illness burden or treatment burden. However, patients reported significant benefits from the 3D intervention in all measures of patient-centred care. Qualitative data suggested that both patients and staff welcomed having more time, continuity of care and the patient-centred approach. The economic analysis found no meaningful differences between the intervention and usual care in either quality-adjusted life-years [(QALYs) adjusted mean QALY difference 0.007, 95% CI –0.009 to 0.023] or costs (adjusted mean difference £126, 95% CI –£739 to £991), with wide uncertainty around point estimates. The cost-effectiveness acceptability curve suggested that the intervention was unlikely to be either more or less cost-effective than usual care. Seventy-eight patients died (46 in the intervention arm and 32 in the usual-care arm), with no evidence of difference between trial arms; no deaths appeared to be associated with the intervention.

Limitations

In this pragmatic trial, the implementation of the intervention was incomplete: 49% of patients received two 3D reviews over 15 months, whereas 75% received at least one review.

Conclusions

The 3D approach reflected international consensus about how to improve care for multimorbidity. Although it achieved the aim of providing more patient-centred care, this was not associated with benefits in quality of life, illness burden or treatment burden. The intervention was no more or less cost-effective than usual care. Modifications to the 3D approach might improve its effectiveness. Evaluation is needed based on whole-system change over a longer period of time.

Trial registration

Current Controlled Trials ISRCTN06180958.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.

Importance of an alternative approach to measuring quality in a volume-to-value world: a case study of diabetes care

Background

To develop a statistical tool that allows practitioners and/or their practice managers to easily select the relevant range in which volume and value are maximised.

Methods

Data for the study were based on 55 primary care practices that participated in the Colorado Improving Performance in Practice programme in 2014. We used two composite variables including the volume of processes of care variables listed in Diabetes Practice Guidelines and value (quality) as measured by changes in the intermediate outcomes. We assessed volume/value trade-offs using a multilevel model with a time-varying covariate partitioned into a between-practice and within-practice effect.

Results

The study revealed a strong linear relationship between volume and value (P<0.0001). Specifically, practices with an above-average volume of care as measured by their process of care scores also had above-average quality outcomes (expected value 57; average volume 49.48) as quantified by their intermediate outcome scores. Additionally, in those months when practices provided a volume of care that exceeded their average process of care score, further improvements occurred in quality as measured by intermediate outcome scores (P<0.0001).

Conclusion

Such findings suggest an inherent linkage between volume of care and quality. This statistical approach, if provided as an app containing an easy-to-use statistical calculator, will allow practice managers and clinicians to systematically identify volume/quality trade-offs, thereby reducing undertreatment and/or overtreatment among patients with chronicities.

Germain A, Egede LE. Trends in sex differences in the receipt of quality of care indicators among adults with diabetes: United States 2002-2011

BACKGROUND

Evidence suggests disparities in quality of care (QoC) indicators based on sex exist in adults diagnosed with diabetes; however, this research is limited. Therefore, the objective of this research study was to assess differences in QOC indicators in a nationally representative sample of men and women with diabetes.

METHODS

Cross-sectional study of 17,702 men and women (≥18 years of age) with diabetes from the 2002-2011 Medical Expenditure Panel Survey Household Component. Sex was the main predictor variable, and the dependent variables were five binary indicators to measure QOC, which included testing of hemoglobin A1c, examining feet annually, getting eyes dilated, checking blood pressure, and visiting the doctor annually. Sample demographics by sex were assessed. Unadjusted analyses were computed for descriptive statistics by sex and proportions of QOC indicators over time. Logistic regression evaluated associations between QOC indicators and sex, while controlling for sociodemographic characteristics, time, and comorbid conditions.

RESULTS

Approximately 44% and 56% of the sample was comprised of men and women, respectively. Unadjusted analyses showed significant differences in A1c testing (p < 0.001) and foot examinations (p = 0.002) for the entire sample, and significant differences in A1c testing (p = 0.027), foot examinations (p = 0.01), and dilated eye exams (p = 0.026) among men and A1c testing (p < 0.001) among women overtime. Adjusted analyses found women to be significantly more likely to have dilated eye examinations during a given year (OR = 1.14; 95% CI 1.04, 1.24), to get their blood pressure checked by a doctor in a given year (OR = 1.44; 95% CI 1.13, 1.84), and to visit a doctor annually (OR = 1.39; 95% CI 1.22, 1.58) compared to men.

CONCLUSIONS

In this sample of adults with diabetes, women had significantly higher odds of receiving quality of care compared to men. These findings suggest the importance of educating patients about appropriate metrics of diabetes management, especially men, and the need for continuous empowerment of women to receive proper and optimal care. Additional research is needed to identify causes and reduce sex and gender disparities associated with diabetes quality of care.

How do high cost-sharing policies for physician care affect inpatient care use and costs among people with chronic disease?

Rapidly rising health care costs continue to be a significant concern in the United States. High cost-sharing strategies thus have been widely used to address rising health care costs. Since high cost-sharing policies can reduce needed care as well as unneeded care use, it raises the concern whether these policies for physician care are a good strategy for controlling costs among chronically ill patients, especially whether utilization and costs in inpatient care will increase in response. This study examined whether high cost sharing in physician care affects inpatient care utilization and costs differently between individuals with and without chronic conditions. Findings from this study will contribute to the insurance benefit design that can control care utilization and save costs of chronically ill individuals. Prior studies suffered from gaps that limit both internal validity and external validity of their findings. This study has its unique contributions by filling these gaps jointly. The study used data from the 2007 Medical Expenditure Panel Survey, a nationally representative sample, with a cross-sectional study design. Instrumental variable technique was used to address the endogeneity between health care utilization and cost-sharing levels. We used negative binomial regression to analyze the count data and generalized linear models for costs data. To account for national survey sampling design, weight and variance were adjusted. The study compared the effects of high cost-sharing policies on inpatient care utilization and costs between individuals with and without chronic conditions to answer the research question. The final study sample consisted of 4523 individuals; among them, 752 had hospitalizations. The multivariate analysis demonstrated consistent patterns. Compared with low cost-sharing policies, high cost-sharing policies for physician care were not associated with a greater increase in inpatient care utilization (P = .86 for chronically ill people and P = .67 for healthy people, respectively) and costs (P = .38 for chronically ill people and P = .68 for healthy people, respectively). The sensitivity analysis with a 10% cost-sharing level also generated consistent insignificant results for both chronically ill and healthy groups. Relative to nonchronically ill individuals, chronically ill individuals may increase their utilization and expenditures of inpatient care to a similar extent in response to increased physician care cost sharing. This may be due to cost pressure from inpatient care and short observation window. Although this study did not find evidence that high cost-sharing policies for physician care increase inpatient care differently for individuals with and without chronic conditions, interpretation of this finding should be cautious. It is possible that in the long run, these sick people would demonstrate substantial demands for medical care and there could be a total cost increase for health plans ultimately. Health plans need to be cautious of policies for chronically ill enrollees.

Is Access to and Use of Patient Perceived Patient-Centered Medical Homes Associated With Reduced Nonurgent Emergency Department Use?

This study examined whether access to and use of patient-centered medical home (PCMH) practices is associated with reduced nonurgent emergency department (ED) use, especially among the uninsured population. This retrospective study used 2010-2011 Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model, marginal effect, and survey procedures were employed. A total of 1287 adults had any ED visit in 2011, which represented weighted 29 463 684 people in the population. Reductions in odds of nonurgent ED use between the full PCMH group and the “no regular provider” group was significantly larger for the uninsured group than publicly and privately insured groups (β = −1.70, P = .009, and β = −1.04, P = .040, respectively). Similar results were found between the partial PCMH group and the “no regular provider” group for the uninsured group compared to the public group (β = −1.67, P = .019). PCMH models demonstrate higher odds of reduced nonurgent ED use among uninsured individuals compared to public and private enrollees nationwide.

Challenges and Opportunities in Using Patient-reported Outcomes in Quality Measurement in Rheumatology

Use of patient-reported outcome measures (PROs) in rheumatology research is widespread, but use of PRO data to evaluate the quality of rheumatologic care delivered is less well established. This article reviews the use of PROs in assessing health care quality, and highlights challenges and opportunities specific to their use in rheumatology quality measurement. It first explores other countries' experiences collecting and evaluating national PRO data to assess quality of care. It describes the current use of PROs as quality measures in rheumatology, and frames an agenda for future work supporting development of meaningful quality measures based on PROs.

Quality of Care for Chronic Conditions Among Disabled Medicaid Enrollees: An Evaluation of a 1915 (b) and (c) Waiver Program

IMPORTANCE

Examining the impact of Medicaid-managed care home-based and community-based service (HCBS) alternatives to institutional care is critical given the recent rapid expansion of these models nationally.

OBJECTIVE

We analyzed the effects of STAR+PLUS, a Texas Medicaid-managed care HCBS waiver program for adults with disabilities on the quality of chronic disease care.

DESIGN, SETTING, AND PARTICIPANTS

We compared quality before and after a mandatory transition of disabled Medicaid enrollees older than 21 years from fee-for-service (FFS) or primary care case management (PCCM) to STAR+PLUS in 28 counties, relative to enrollees in counties remaining in the FFS or PCCM models.

MEASURES AND ANALYSIS

Person-level claims and encounter data for 2006-2010 were used to compute adherence to 6 quality measures. With county as the independent sampling unit, we employed a longitudinal linear mixed-model analysis accounting for administrative clustering and geographic and individual factors.

RESULTS

Although quality was similar among programs at baseline, STAR+PLUS enrollees experienced large and sustained improvements in use of β-blockers after discharge for heart attack (49% vs. 81% adherence posttransition; P<0.01) and appropriate use of systemic corticosteroids and bronchodilators after a chronic obstructive pulmonary disease event (39% vs. 68% adherence posttransition; P<0.0001) compared with FFS/PCCM enrollees. No statistically significant effects were identified for quality measures for asthma, diabetes, or cardiovascular disease.

CONCLUSION

In 1 large Medicaid-managed care HCBS program, the quality of chronic disease care linked to acute events improved while that provided during routine encounters appeared unaffected.

Guideline adherence and health outcomes in diabetes mellitus type 2 patients: a cross-sectional study

Background

The complex disease of diabetes mellitus type 2 (T2DM) requires a high standard of quality of care. Clinical practice guidelines define norms for diabetes care that ensure regular monitoring of T2DM patients, including annual diagnostic tests. This study aims to quantify guideline adherence in Dutch general practices providing care to T2DM patients and explores the association between guideline adherence and patients’ health outcomes.

Methods

In this cross-sectional study, we studied 363 T2DM patients in 32 general practices in 2011 and 2012. Guideline adherence was measured by comparing structure and process indicators of care with recommendations in the national diabetes care guideline. Health outcomes included biomedical measures and health behaviours. Data was extracted from medical records. The association between guideline adherence and health outcomes was analysed using hierarchical linear and logistic regression models.

Results

Guideline adherence varied between different recommendations. For example 53% of the practices had a system for collecting patient experience feedback, while 97% had a policy for no-show patients. With regard to process indicators of care, guideline adherence was below 50% for foot, eye and urine albumin examination and high (>85%) for blood pressure, HbA1c and smoking behaviour assessment. Although guideline adherence varied considerably between practices, after adjusting for patient characteristics we found guideline adherence not to be associated with patients’ health outcomes.

Conclusions

Guideline adherence in Dutch general practices offering diabetes care was not optimal. Despite considerable variations between general practices, we found no clear relationship between guideline adherence and health outcomes. More research is needed to better understand the relationship between guideline adherence and health outcomes, specifically for guidelines that are based on limited scientific evidence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0669-z) contains supplementary material, which is available to authorized users.

Inequitable access to health services for older adults with diabetes: potential solutions on a state level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.

Improving outcomes for diabetic patients undergoing revascularization for critical limb ischemia: does the quality of outpatient diabetic care matter?

BACKGROUND

Diabetic patients who undergo lower extremity surgical revascularization for critical limb ischemia (CLI) are at high risk for amputation or death, even when their inpatient procedures are successful. We hypothesized that postoperative outcomes might be improved in regions where diabetics with CLI receive more frequent high-quality outpatient care.

METHODS

A retrospective cohort study was performed among 172,134 patients with CLI (52% male, 15% black, mean age 76 years) who underwent open and endovascular lower extremity revascularization procedures using Medicare claims (2004-2007), which included 84,653 (49%) beneficiaries who were diabetic. Regional utilization of annual serum cholesterol and hemoglobin A1c testing were used to assess the quality of outpatient diabetic care. We examined relationships between frequency of diabetic testing with amputation-free survival (AFS), major adverse limb events (MALE), and rates of readmission across all US hospital referral regions.

RESULTS

There was significant regional variation in annual serum cholesterol and hemoglobin A1c testing across the United States (87% highest quartile vs. 59% lowest quartile, P < 0.01). Compared with the lowest quartile of diabetic testing, diabetic patients undergoing lower extremity revascularization in regions with the highest quartile of diabetic testing had significantly improved AFS (hazards ratio [HR]: 0.94, 95% confidence interval [CI]: 0.90-0.97; P < 0.01) and MALE (HR: 0.92, 95% CI: 0.89-0.96; P < 0.01) persisting up to 2 years after lower extremity revascularization, even after adjusting for procedure type, gender, age, race, and comorbidities. Moreover, the risk of 30-day readmission was significantly reduced in regions with the highest versus lowest quartile of diabetic testing (odds ratio: 0.91, 95% CI: 0.85-0.97; P < 0.01). Nondiabetic patients with CLI, in comparison, did not benefit to the same extent from undergoing revascularization in regions with high-quality outpatient diabetic care.

CONCLUSIONS

Diabetic patients undergoing lower extremity revascularization in regions with higher utilization of diabetic care quality measures have significantly better long-term limb salvage and readmission outcomes. Our study underscores the importance of providing optimal outpatient care to diabetics following vascular surgery and outlines a potential strategy for quality improvement in these high-risk patients.

Promoting integrated approaches to reducing health inequities among low-income workers: applying a social ecological framework

BACKGROUND

Nearly one of every three workers in the United States is low-income. Low-income populations have a lower life expectancy and greater rates of chronic diseases compared to those with higher incomes. Low- income workers face hazards in their workplaces as well as in their communities. Developing integrated public health programs that address these combined health hazards, especially the interaction of occupational and non-occupational risk factors, can promote greater health equity.

METHODS

We apply a social-ecological perspective in considering ways to improve the health of the low-income working population through integrated health protection and health promotion programs initiated in four different settings: the worksite, state and local health departments, community health centers, and community-based organizations.

RESULTS

Examples of successful approaches to developing integrated programs are presented in each of these settings. These examples illustrate several complementary venues for public health programs that consider the complex interplay between work-related and non work-related factors, that integrate health protection with health promotion and that are delivered at multiple levels to improve health for low-income workers.

CONCLUSIONS

Whether at the workplace or in the community, employers, workers, labor and community advocates, in partnership with public health practitioners, can deliver comprehensive and integrated health protection and health promotion programs. Recommendations for improved research, training, and coordination among health departments, health practitioners, worksites and community organizations are proposed.

Mental comorbidity and quality of diabetes care under Medicaid: a 50-state analysis

BACKGROUND

Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees.

METHODS

For all 657,628 fee-for-service Medicaid enrollees with diabetes during 2003 to 2004, the study compared Healthcare Effectiveness Data and Information Set (HEDIS) diabetes performance measures (hemoglobin A1C, eye examinations, low density lipoproteins screening, and treatment for nephropathy) and admissions for ambulatory care-sensitive conditions (ACSCs) between persons with and without mental comorbidity. Nested hierarchical models included individual, county, and state-level measures.

RESULTS

A total of 17.8% of the diabetic sample had a comorbid mental condition. In adjusted models, presence of a mental condition was associated with a 0.83 (0.82-0.85) odds of obtaining 2 or more HEDIS indicators, and a 1.32 (1.29-1.34) increase in odds of one or more ACSC hospitalization. Among those with diabetes and mental comorbidities, living in a county with a shortage of primary care physicians was associated with reduced performance on HEDIS measures; living in a state with higher Medicaid reimbursement fees and department of mental health expenses per client were associated both with higher quality on HEDIS measures and lower (better) rates of ACSC hospitalizations.

CONCLUSIONS

Among persons with diabetes treated in the Medicaid system, mental comorbidity is an important risk factor for both underuse and overuse of medical care. Modifiable county and state-level factors may mitigate these quality deficits.

Averting an impending storm: can we reengineer health systems to meet the needs of aging populations?

Arlene Bierman discusses new research findings from a randomized trial evaluating community-based nursing interventions in older adults, and and comments on how we need to to re-engineer health systems to provide greater quality of care.

Review: relation between quality-of-care indicators for diabetes and patient outcomes: a systematic literature review

The authors conducted a systematic literature review to assess whether quality indicators for diabetes care are related to patient outcomes. Twenty-four studies were included that formally tested this relationship. Quality indicators focusing on structure or processes of care were included. Descriptive analyses were conducted on the associations found, differentiating for study quality and level of analysis. Structure indicators were mostly tested in studies with weak designs, showing no associations with surrogate outcomes or mixed results. Process indicators focusing on intensification of drug treatment were significantly associated with better surrogate outcomes in three high-quality studies. Process indicators measuring numbers of tests or visits conducted showed mostly negative results in four high-quality studies on surrogate and hard outcomes. Studies performed on different levels of analysis and studies of lower quality gave similar results. For many widely used quality indicators, there is insufficient evidence that they are predictive of better patient outcomes.

Measuring racial disparities in the quality of ambulatory diabetes care

BACKGROUND

Improving the health of minority patients who have diabetes depends in part on improving quality and reducing disparities in ambulatory care. It has been difficult to measure these components at the level of actionable units.

OBJECTIVE

To measure ambulatory care quality and racial disparities in diabetes care across groups of physicians who care for populations of ambulatory diabetes patients.

RESEARCH DESIGN

Prospective cohort analysis using administrative data.

SUBJECTS

Using fee-for-service Medicare claims data from 2003 to 2005, we link patients to their principal ambulatory care physician. The patients are then linked to the hospital where their physicians work or have their patients admitted, creating physician-hospital networks.

MEASURES

Proportion of recommended diabetes testing received by black and nonblack diabetes patients.

RESULTS

Blacks received 70% of recommended care compared with nonblacks who received 76.9% (P < 0.001). However, for black and nonblack patients, variation in the quality of care exceeds the racial gap in treatment. The network-specific performance rates for blacks and nonblacks were highly correlated (r = 0.67, P < 0.001), but 47% of blacks, versus 31% of nonblacks, received care from the third of networks with lowest quality. Physician-hospital networks with higher overall quality, or patients with higher socioeconomic status, were no less likely to exhibit black-white disparities.

CONCLUSIONS

It is possible to measure, benchmark, and monitor the quality of minority care at the level of networks responsible for ambulatory care. Consequently, it should be easier to provide patients with information on network performance and to design policies that improve the quality of minority-serving providers.

Quality improvement in neurology: AAN Parkinson disease quality measures: report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology

BACKGROUND

Measuring the quality of health care is a fundamental step toward improving health care and is increasingly used in pay-for-performance initiatives and maintenance of certification requirements. Measure development to date has focused on primary care and common conditions such as diabetes; thus, the number of measures that apply to neurologic care is limited. The American Academy of Neurology (AAN) identified the need for neurologists to develop measures of neurologic care and to establish a process to accomplish this.

OBJECTIVE

To adapt and test the feasibility of a process for independent development by the AAN of measures for neurologic conditions for national measurement programs.

METHODS

A process that has been used nationally for measure development was adapted for use by the AAN. Topics for measure development are chosen based upon national priorities, available evidence base from a systematic literature search, gaps in care, and the potential impact for quality improvement. A panel composed of subject matter and measure development methodology experts oversees the development of the measures. Recommendation statements and their corresponding level of evidence are reviewed and considered for development into draft candidate measures. The candidate measures are refined by the expert panel during a 30-day public comment period and by review by the American Medical Association for Current Procedural Terminology (CPT) II codes. All final AAN measures are approved by the AAN Board of Directors.

RESULTS

Parkinson disease (PD) was chosen for measure development. A review of the medical literature identified 258 relevant recommendation statements. A 28-member panel approved 10 quality measures for PD that included full specifications and CPT II codes.

CONCLUSION

The AAN has adapted a measure development process that is suitable for national measurement programs and has demonstrated its capability to independently develop quality measures.