Arizona Health Care Cost Containment System
Arizona Long Term Care System (ALTCS) Performance Measure

PERFORMANCE MEASURES FOR DIABETES CARE
Measurement Period: October 1, 2005, through September 30, 2006
Prepared by the Division of Health Care Management
November 2007
Anthony D. Rodgers
Director, AHCCCS

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)
PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period October 1, 2005, through September 30, 2006

INTRODUCTION

1

SIGNIFICANCE OF THE MEASURES

2

STUDY METHODS
Population ..................................................................................................................
Measurement Period ..................................................................................................
Sample Frame ............................................................................................................
Data Sources ..............................................................................................................
Data Collection ..........................................................................................................
Data Quality and Reliability ......................................................................................
Study Indicators .........................................................................................................
Performance Measure Goals ......................................................................................
National Benchmarks .................................................................................................

3
3
3
4
4
4
4
5
5

RESULTS
Included Cases ...........................................................................................................
Hb A1c Testing ..........................................................................................................
Lipid Profiles .............................................................................................................
Eye Examinations ......................................................................................................
Results by Race/Ethnicity ..........................................................................................

5
5
6
6
6

DISCUSSION
Overall Results ...........................................................................................................
Contractor Performance .............................................................................................
Quality Improvement Efforts .....................................................................................
Conclusion .................................................................................................................

7
7
7
7

REFERENCES

8

TABLES AND FIGURES
APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS

10
i -vii

Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care System (ALTCS)

PERFORMANCE MEASURES FOR DIABETES CARE
For the Measurement Period October 1, 2005, through September 30, 2006

INTRODUCTION
boomers” who are aging and living longer
than people in previous generations. A
sedentary lifestyle and a dramatic rise of
obesity in the U.S. population also are
increasing the incidence of diabetes.8

More than 20 million Americans age 20
years and older, or 9.6 percent of all people
in this age group, have diabetes, according
to an estimate by the federal Centers for
Disease Control and Prevention (CDC).
About 1.5 million new cases of diabetes
were diagnosed among people 20 years
and older in 2005.1

Nearly 20 percent of all
people 60 and older have
diabetes.

Diabetes had been diagnosed in an
estimated 244,000 Arizona adults as of
2002, the most recent year for which statespecific data are available.2

Centers for Disease Control and Prevention

Diabetes was the sixth leading cause of
death in the United States in 2002, causing
or contributing to at least 224,000 deaths. 3

About one out of every 10 health care
dollars in the United States is spent on
diabetes and its complications. Total U.S.
expenditures related to diabetes were
approximately $132 billion in 2002 – $92
billion in direct medical costs and another
$40 billion in indirect costs because of
missed work days or other losses in
productivity.9 At least 4 million
hospitalizations and more than 26 million
outpatient visits annually in the U.S. are
associated with diabetes.10,11

In the United States, Hispanics, Blacks,
American Indians and Alaska Natives are
approximately twice as likely to have
diabetes than non-Hispanic Whites. The
prevalence of diabetes also is higher
among older Americans – about 20 percent
of all people 60 and older have diabetes –
as well as among people with low
socioeconomic status and those covered by
Medicaid. 1,4,5

Diabetes is the leading cause of end-stage
kidney disease and new cases of blindness
among adults. It also is responsible for
more than 60 percent of nontraumatic
lower-limb
amputations.
Other
complications include heart disease, stroke,
and nervous system disorders.3

The number of people in the United States
with diagnosed diabetes has more than
doubled in the last 15 years.6 The
prevalence of diabetes in Arizona also has
increased during that time.7 Contributing to
this increase is the large number of “baby

1

The purpose of this study is to monitor
performance of managed care plans
contracted with the Arizona Long Term
Care System (ALTCS) for diabetes-related
measures. Results of the measurement are
used to determine whether these managed
care plans (known as Contractors), are
meeting Performance Standards specified
in their contracts.

• 2 in 3 people with diabetes die
of heart disease or stroke
• Diabetes is the #1 cause of
adult blindness
• Diabetes is the #1 cause of
kidney failure
• Diabetes causes more than 60%
of nontraumatic lower-limb
amputations

These measures evaluate the percent of
ALTCS elderly and physically disabled
(E/PD) members with diabetes who
receive certain clinical services to detect
and prevent or reduce complications. This
report summarizes current results of these
Performance Measures.

Diabetes: The Numbers. National Diabetes
Education Program, January 2007

SIGNIFICANCE OF THE MEASURES
As with many diseases, other conditions
(known as comorbid conditions) may be
present. For example, the increased
prevalence of lipid abnormalities found
with type 2 diabetes contributes to higher
rates of cardiovascular disease among
diabetics.12

With diabetes, sustained high blood sugars
result in damage to the very fine blood
vessels of the eyes, peripheral nerves and
kidneys,
known
as
microvascular
complications. One of these complications
is retinopathy (damage to the retina of the
eye), which causes 12,000 to 24,000 new
cases of blindness each year. In addition,
up to 70 percent of people with diabetes
have mild to severe forms of nervous
system damage, including impaired
sensation or pain in the feet or hands,
slowed digestion of food, carpal tunnel
syndrome and other nerve problems.3
Diabetes also is the leading cause of end
stage renal (kidney) disease, or ESRD.

Patients with diabetes also have worse
outcomes with acute illness. A recent study
found that diabetics who are hospitalized
for trauma have longer stays in the
intensive care unit and more complications
than people who do not have diabetes.13
Despite its potentially deadly effects,
diabetes can be controlled. Many
complications of the disease can be
prevented or reduced with early detection,
improved care and better education of
patients in self-management techniques.6,12

Diabetes is responsible for macrovascular
complications as well. These include
coronary and peripheral artery disease,
which may lead to heart attack or stroke,
and amputations.

2

macrovascular complications affecting the
heart, brain and legs, especially in people
who have a history of cardiovascular
problems.13,14 Control of cholesterol and
lipids
can
reduce
cardiovascular
complications by 20 to 50 percent.3

Glucose
Control
––
Control
of
hyperglycemia (increased blood sugar) is
critical to reducing both the incidence and
progression of complications associated
with diabetes. Physicians utilize a
glycosylated hemoglobin, or Hb A1c, test
to monitor patients’ blood glucose levels.
This test indicates a person’s average
glucose level over a two- to three-month
period by measuring the amount of glucose
that has bonded with hemoglobin in the
body’s red blood cells.

A fasting lipid profile is performed to
measure total cholesterol (TC), highdensity
lipoproteins
(HDL)
and
triglycerides. These results are used to
calculate
and
manage
low-density
lipoprotein (LDL) levels.

Studies in the United States and abroad
have shown that improved glycemic
control greatly benefits people with
diabetes. In general, for every percentage
point decrease in Hb A1c levels, the risk of
developing microvascular complications is
reduced by 35 to 40 percent. 3,14,15

Eye Care — It is estimated that regular eye
exams and timely treatment, including
laser
therapy,
could
reduce
the
development of severe vision loss by up to
60 percent.3 People with diabetes should
have
comprehensive
dilated
eye
examinations by ophthalmologists or
optometrists, in order to detect and treat
retinopathy and prevent vision loss.

Lipid Management –– Managing lipid
levels has been shown to reduce

STUDY METHODS
AHCCCS used Health Plan Employer Data
and Information Set (HEDIS) 2006
specifications
from
the
National
Committee for Quality Assurance (NCQA)
for
this
measurement.
HEDIS
methodology includes six indicators of
comprehensive diabetes care. AHCCCS
has identified three of these indicators for
performance measurement: Hb A1c testing,
lipid screening, and retinal (eye) exams.

Measurement Period
The measurement period for this study was
the AHCCCS contract year from October
1, 2005, through September 30, 2006. For
two of the indicators, services that were
provided in the year prior to the
measurement period were counted toward
the numerator.
Sample Frame
The sample frame consisted of E/PD
members who were:
• ages 18 through 75 years as of
September 30, 2006,
• continuously enrolled with one ALTCS
Contractor during the measurement period
with no more than a one-month gap in
enrollment, and

Population
• The population included in this
measurement consisted of elderly or
physically disabled (E/PD) members
enrolled with ALTCS managed care plans
who had a diagnosis of type 1 or type 2
diabetes in the measurement period or the
year prior to the measurement period.

3

•

enrolled with that
September 30, 2006.

Contractor

Contractors collected data for additional
services provided to their members,
including services that were paid for by
Medicare,
from
medical
records.
Contractors also were allowed to use data
from their claims system if they paid a
qualified claim that was not captured in
PMMIS. This information was entered into
the electronic tool by Contractor staff,
according to detailed instructions from
AHCCCS.

on

Members were identified as having type 1
or type 2 diabetes by either pharmacy or
encounter data (records of claims paid by
Contractors for covered services). For
example, a member was identified as
having diabetes if he or she had one faceto-face encounter with a diagnosis of
diabetes in an acute inpatient or emergency
room setting during the measurement
period or the previous year.

Data Quality and Reliability
AHCCCS conducts validation studies to
evaluate the completeness of encounter
data, compared with the corresponding
medical records. The two most recent
annual studies of encounters submitted by
ALTCS E/PD Contractors show encounteromission rates of less than 5 percent for
each year.

Data Sources
Recipient, claim/encounter, and other data
were initially collected and stored in the
AHCCCS Prepaid Medical Management
Information System (PMMIS). These data
were then loaded into the AHCCCS
Decision Support System (ADDS), which
used HEDIS programming to select sample
members and collect some data. Medical
record data collected by Contractors were
used to supplement encounter data.

In order to document the reliability of data
collected outside of the AHCCCS
encounter system for this study,
Contractors were required to submit hard
copies of the appropriate sections of
medical records or documentation of a paid
claim with their electronic data tools.

Data Collection
As many as 80 percent of ALTCS elderly
and physically disabled members also are
covered by Medicare. Medicare is the
primary payer for these “dually enrolled”
members. Medicare providers may bill
AHCCCS health plans for copayments for
their members. However, if they do not bill
for copayments for these services,
AHCCCS will not have data in PMMIS on
the services being measured in this study.

Study Indicators
Three indicators that are part of the HEDIS
measure of Comprehensive Diabetes Care
were measured, as documented through
either administrative data or medical
record review.

AHCCCS initially collected data on
diabetes services from its encounter
subsystem. When encounters for specific
services within the measurement period or
in the previous year were not found in
encounter data, AHCCCS provided
demographic data for those sample
members to the appropriate Contractors,
using a standardized electronic data
collection tool.

Hb A1c testing — This indicator measured
the percent of members who had one or
more Hb A1c tests during the measurement
period.
Lipid (LDL-C) profile — This indicator
measured the percent of members who had
one or more fasting lipid profiles during
the measurement period or the prior year.

4

These performance standards are designed
to provide milestones for Contractors to
meet in achieving the AHCCCS longrange goals for these measures, known as
benchmarks. The AHCCCS-established
benchmarks are: Hb A1c testing, 88
percent; lipid screening, 85 percent; and
retinal exams, 64 percent.

Retinal examinations — This indicator
measured an eye screening for diabetic
retinal disease, including a retinal or
dilated eye exam by an eye care
professional
(optometrist
or
ophthalmologist) within the measurement
period or a negative retinal exam (no
evidence of retinopathy) by an eye-care
professional in the year prior to the
measurement year.

National Benchmarks
NCQA reports national Mediacid averages
for these measures, based on data
submitted by Medicaid managed care
plans. The HEDIS 2005 national means
(averages) reported for Medicaid plans
were used to establish the current
AHCCCS minimum standards in 2006.
HEDIS rates for the 90th percentile of
plans were used to set the benchmarks.

Performance Measure Goals
AHCCCS has established the following
Contractor performance standards for these
measures. If ALTCS Contractors have
achieved
the
AHCCCS
minimum
performance standard (MPS) for any
measure, they should strive to meet the
AHCCCS goal.
Measure

MPS

Goal

Hb A1c testing

75 %

77%

Lipid screening

76%

78%

Retinal exams

45%

47%

The 2005 mean for annual Hb A1c testing
among Medicaid plans was 76.2 percent.
The mean for lipid screening was 80.5
percent. The mean for retinal exams was
48.6 percent.

RESULTS
with diabetes who were enrolled with six
long-term care Contractors during the
measurement period.

Results for each measure were analyzed
overall, by individual Contractor and by
race/ethnicity. This report indicates
whether changes in rates overall or by
Contractor are statistically significant,
when compared with rates for the previous
measurement period. Changes from the
previous measurement are described as
increases or decreases only when analysis
using the Pearson chi-square test yields a
statistically significant value (p<.05); that
is, the probability of obtaining such a
difference by chance only is relatively low.

Hb A1c Testing
The overall rate of members who received
an Hb A1c test during the measurement
period increased to 79.7 percent, from 74.8
percent in the previous period (p=.007).
Rates by Contractor ranged from 73.9
percent to 82.4 percent (Table 1). One
Contractor
showed
a
statistically
significant increase and one showed a
statistically significant decrease in its rate
for this measure.

Included Cases
This measurement included 1,088 ALTCS
elderly and physically disabled members

5

toward this numerator a negative retinal
exam in the previous year. In the current
measurement, Contractors were allowed to
submit data meeting this criterion.

Five Contractors exceeded both the
AHCCCS minimum performance standard
and goal for this measure, while only three
achieved this level of performance in the
previous measurement (Figure 1). One
Contractor, Pima Health Systems, was 1.1
percentage points below the MPS.

All Contractors still achieved both the
minimum performance standard and goal
for this measure, while two surpassed the
benchmark (Figure 3).

Lipid (LDL-C) Profiles
The overall rate of members who had an
LDL-C test or fasting lipid profile during
the measurement period or the preceding
year was 80.9 percent, an increase over the
previous rate of 73.6 percent (p<.001).

ALTCS Diabetes Care Rates,
CYE 2006 vs. CYE 2005
100
80

Rates by Contractor ranged from 77.3
percent to 91.0 percent (Table 2). Two
Contractors demonstrated statistically
significant increases.

60
40
20

All Contractors exceeded the MPS and five
exceeded the goal for this measure. One
Contractor, Pinal/Gila County Long Term
Care, also exceeded the AHCCCS
benchmark (Figure 2). In the previous
measurement, three Contractors exceeded
the MPS and goal for this measure.

0
Hb A1c

Lipid

CYE 2006

Eye

CYE 2005

Results by Race/Ethnicity
For all measures, there were no significant
differences in rates for members who
identified themselves as Hispanic, Native
American or Black, compared with nonHispanic White members. Relative rates
were as follows (results for Native
Americans should be interpreted with
caution, since there were only 20 members
in this category):

Eye Examinations
The overall rate of members who had a
dilated eye (retinal) examination was 60.4
percent, a decline from 66.6 percent in the
previous measurement (p<.003).
Rates by Contractor ranged from 52.3
percent to 77.0 percent (Table 3). One
Contractor, Evercare Select, experienced a
relative decrease of 23.5 percent in its rate
for eye exams.
The decline in this Contractor’s rate and
overall may be due to changes in
Contractor data collection processes to
conform to current HEDIS methodology.
The criteria for measuring eye exams
under HEDIS 2006 methodology allows
managed care organizations to count

6

Hb A1c

Lipid

Retinal

White

80.4%

79.5%

60.0%

Hispanic

77.5%

83.3%

64.9%

Native American

85.0%

85.0%

60.0%

Black

76.5%

76.5%

57.6%

Other/Unknown

86.4%

84.0%

46.9%

DISCUSSION
assisted living facilities and attendant care
providers.

Overall Results
AHCCCS overall rates improved in two of
the three measures, Hb A1c testing and
lipid profiles, and exceed the comparable
HEDIS averages for Medicaid health plans
nationwide. While the rate for retinal
exams declined somewhat, the AHCCCS
rate is well above the national Medicaid
mean of 48.6 percent and also exceeds the
HEDIS commercial mean of 54.8 percent.

In order to assist ALTCS Contractors with
further improving their rates for these
measures, AHCCCS has provided health
plans with educational materials and
opportunities, as well as information on
successful strategies for increasing the use
of preventive-care services, such as Hb A1c
testing, lipid profiles and eye exams.

Contractor Performance
Contractors met the AHCCCS minimum
performance standards for all measures,
with the exception of Pima Health System,
which was below the MPS for one
measure.

Successful strategies used in other
programs include: automated reminders by
telephone, advising patients that they are
due for tests; frequent nurse follow-up by
phone, especially as part of a case
management or disease management
program;
group
visits
with
multidisciplinary provider teams, including
a physician, pharmacist, diabetes educator,
nutritionist,
and/or
mental
health
professional as part of the care team;
culturally relevant patient information
materials and other interventions, such as
food preparation classes that incorporate
traditional foods, in diabetes education;
and social support groups, which allow
patients to share experiences, and give
health care professionals opportunities to
further encourage the lifestyle changes
often necessary to control diabetes.16-21
Because depression and other mental
health issues often coexist with diabetes,
Contractors also should ensure that
members receive behavioral health
services as needed to support their abilities
to manage their self-care.

Three
Contractors
currently
have
Corrective Action Plans (CAPs) in place to
improve results for these measures.
AHCCCS has increased performance
standards for these measures for the
measurement period ending Sept. 30, 2008,
so Contractors must continue successful
interventions to ensure they meet
contractual requirements.
Quality Improvement Efforts
AHCCCS Contractors have utilized a
variety of strategies to improve care of
their diabetic members. These include
intensive member education, monitoring
and
follow
up
through
disease
management programs; developing and
distributing practice guidelines to primary
care physicians (PCPs), and advising PCPs
of diabetic members who are due for
specific services. One high-performing
Contractor, Pinal/Gila County Long Term
Care, has incorporated requirements to
ensure that members make regular visits to
their physicians and have diabetes tests
performed into its contracts with home and
community-based service providers, such

Conclusion
Diabetes can be devastating and costly.
However, clinical services that help
monitor and control glucose and lipid
levels, or detect retinal damage early, can
help reduce the burden of disease.

7

http://www.cdc.gov/nccdphp/aag/pdf/aag_ddt2
004.pdf. Accessed September 22, 2006.
7
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Behavioral
Risk Factor Surveillance System Prevalence
Data..
Available
at:
http://apps.nccd.cdc.gov/brfss/display_c.asp?yr
_c=2004&yr=2005&cat=DB&state=AZ&bkey
=20050405&qkey=1363&qtype=C&grp=0&S
UBMIT2=Compare. Accessed September 15,
2004, and September 22, 2006.
8
National
Diabetes
Information
Clearinghouse. Diabetes overview. National
Institute of Diabetes and Digestive and Kidney
Diseases.
Available
at:
http://diabetes.niddk.nih.gov/dm/pubs/overvie
w/index.htm#who. Accessed August 30, 2005.
9
American Diabetes Association. Economic
costs of diabetes in the US in 2002. Diabetes
Care.
2003;26:917-932.
Available
at:
http://www.care.diabetesjournals.org/cgi/conte
nt/full/26/3/917. Accessed March 19, 2003.
10
Centers for Disease Control and Prevention.
Indicators for chronic disease surveillance.
MMWR. 2004; 53(RR-11):100. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtm
l/rr5311a1.htm Accessed September 22, 2006.
11
Beers MH, Berkow R, eds. The Merck
Manual of Diagnosis and Therapy. 17th ed.
Whitehouse Station, NJ: Merck Research
Laboratories; 1999.
12
American Diabetes Association. Standards
of medical care in diabetes − 2006. Diabetes
Care. 2006; 29:S4-S42. Available at:
http://care.diabetesjournals.org/cgi/content/full
/29/suppl_1/s4. Accessed July 27, 2006.
13
Barclay L. Trauma patients with diabetes
mellitus have increased hospital morbidity.
Medscape Medical News. July 18, 2007.
Available
at:
http://www.medscape.com/viewarticle/559964.
Accessed July 25, 2007.
14
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Preventing
diabetes and its complications. Available at:
http://www.cdc.gov/nccdphp/publications/facts
heets/Prevention/diabetes.htm.
Accessed
September 22, 2006.

Contractors must maintain an active focus
on member and provider outreach related
to diabetes care, in order to continue
improvements in these performance
measures.

REFERENCES
1
American Diabetes Association. Total
prevalence of diabetes and pre-diabetes.
Available at:
http://www.diabetes.org/diabetesstatistics/prevalence.jsp. Accessed July 27,
2006.
2
Centers for Disease Control and Prevention.
Diabetes surveillance system: State-specific
estimates of diagnosed diabetes among adults.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at:
http://www.cdc.gov/diabetes/statistics/prev/stat
e/table15.htm. Accessed September 15, 2004.
3
Centers for Disease Control and Prevention.
National diabetes fact sheet 2005. Atlanta, GA.
U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention.
2005.
Available
at:
http://www.cdc.gov/diabetes/pubs/factsheet.ht
m. Accessed July 27, 2006.
4
National Center for Health Statistics. Health,
United States, 2004. Table 8: Age-adjusted
percentages (with standard errors) of selected
diseases and conditions among persons 18
years of age and over, by selected
characteristics: United States, 2003. Centers
for Disease Control and Prevention.
Hyattsville, Maryland: 2004. Available at:
http://www.cdc.gov/nchs/hus.htm. Accessed
September 20, 2005.
5
National Diabetes Education Program.
Diabetes: The Numbers. U.S. Department of
Health and Human Services. January 2007.
6
Centers for Disease Control and Prevention.
Diabetes: disabling, deadly, and on the rise.
Centers for Disease Control and Prevention,
National Center for Chronic Disease
Prevention and Health Promotion. Available
at:

8

15

For questions or comments about this report,
please contact:
Rochelle Tigner,
Quality Improvement Manager
Clinical Quality Management
602-417-4683
or
Rochelle.Tigner@azahcccs.gov

Osterweil N. Tight glucose control may
provide long-term benefits in diabetics.
Medscape Medical News, 2004. Available at:
http://www.medscape.com/viewarticle/480466.
Accessed June 16, 2004.
16
Karter AJ, Ferrara A, Darbibiab JA,
Ackerson LM, Selby JV. Self-monitoring of
blood glucose: language and financial barriers
in a managed care population with diabetes.
Diabetes
Care.
2000;
23(4):477-483.
Available at:
http://care.diabetesjournals.org/cgi/content/abs
tract/23/4..
17
Piette JD, Weinberger M, Kraemer FB,
McPhee SJ. Impact of automated calls with
nurse follow-up on diabetes treatment
outcomes in a department of veterans affairs
health care system. Diabetes Care. 2001;
24(2):202-208.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/full/24/2. Accessed September 22, 2006.
18
Brown SA, Garcia AA, Kouzekanani K,
Hanis CA. Culturally competent diabetes selfmanagement
education
for
Mexican
Americans. Diabetes Care. 2002; 25(2):259268. Available at:
http://care.diabetesjournals.org/cgi/content/full
/25/2 Accessed September 22, 2006..
19
Gilliland SS, Azen SP, Perez GE, Carter JS.
Strong in body and spirit: Lifestyle
intervention for Native American adults with
diabetes in New Mexico. Diabetes Care. 2002;
25(1):78-83. Available at:
http://care.diabetesjournals.org/cgi/content/abs
tract/full/25/1 Accessed September 22, 2006..
20
Sadur CN, Moline N, Costa M, et al.
Diabetes management in a health maintenance
organization: efficacy of care management
using cluster visits. Diabetes Care. 1999;
22(12):2011-2017.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/22/12. Accessed September 22, 2006.
21
Glazier R, Bajcar J, Kennie N, Willson K. A
systematic review of interventions to improve
diabetes care in socially disadvantaged
populations.
Diabetes
Care.
1999;
22(12):2011-2017.
Available
at:
http://care.diabetesjournals.org/cgi/content/abs
tract/29/7. Accessed September 22, 2006.

9

TABLE 1
AHCCCS Clinical Quality Performance Measures for Diabetes
Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES
Measurement Period: October 1, 2005, through September 30, 2006

Contractor
Evercare Select *
Mercy Care LTC *
Pinal/Gila County LTC *
Cochise Health Systems *
Yavapai County LTC *
Pima Health System LTC
TOTAL

Included
Cases

Total Receiving
HbA1c Test

Percent Receiving
HbA1c Test

255

210

82.4%

215

149

69.3%

325

267

82.2%

271

209

77.1%

100

80

80.0%

112

101

90.2%

94

75

79.8%

97

77

79.4%

88

68

77.3%

93

63

67.7%

226

167

73.9%

231

163

70.6%

1088

867

79.7%

1019

762

74.8%

Relative Percent
Change

Notes:
Results of the previous measurement period (Oct. 1, 2004, through Sept. 30, 2005), are shown in shaded rows

* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).

10

Significance
Level

18.8%

p=.001

6.5%

p=.127

-11.3%

p=.036

0.5%

p=.945

14.1%

p=.152

4.7%

p=.427

6.6%

p=.007

Figure 1
Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES
100%
90.2%
82.4%

80%

82.2%

79.8% 79.4%

80.0%

79.7%

77.3%

77.1%

74.8%

73.9%
70.6%

69.3%

67.7%

60%

40%

20%

0%
Cochise Health Evercare Select * Mercy Care LTC
Systems *
*

Pima Health
System LTC

Current Measurement

11

Pinal/Gila County Yavapai County
LTC *
LTC *

Previous Measurement

TOTAL

TABLE 2
AHCCCS Clinical Quality Performance Measures for Diabetes
LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES
Measurement Period: October 1, 2005, through September 30, 2006

Contractor
Pinal/Gila County LTC *
Cochise Health Systems *
Mercy Care LTC *
Pima Health System LTC *
Evercare Select *
Yavapai County LTC *
TOTAL

Total Receiving
Included Cases Fasting Lipid Profile

Percent Receiving Relative Percent
Fasting Lipid Profile
Change

100

91

91.0%

112

101

90.2%

94

77

81.9%

97

76

78.4%

325

262

80.6%

271

213

78.6%

226

181

80.1%

231

174

75.3%

255

201

78.8%

215

143

66.5%

88

68

77.3%

93

43

46.2%

1088

880

80.9%

1019

750

73.6%

Notes:
Results of the previous measurement period (Oct. 1, 2004, through Sept. 30, 2005), are shown in shaded rows

* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).

12

Significance
Level

0.9%

p=.838

4.5%

p=.537

2.6%

p=.542

6.3%

p=.221

18.5%

p=.003

67.1%

p<.001

9.9%

p<.001

Figure 2
LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES
1
91.0% 90.2%
81.9%

0.8

78.8%

78.4%

80.6%
77.3%

80.9%

80.1%

78.6%

75.3%

73.6%

66.5%

0.6

46.2%

0.4

0.2

0
Evercare Select *

Cochise Health
Systems *

Yavapai County
LTC *

Mercy Care LTC *

Current Measurement

13

Pinal/Gila County
LTC *

Previous Measurement

Pima Health
System LTC *

TOTAL

TABLE 3
AHCCCS Clinical Quality Performance Measures for Diabetes
RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES
Measurement Period: October 1, 2005, through September 30, 2006

Contractor
Pinal/Gila County LTC *
Evercare Select *
Pima Health System LTC *
Yavapai County LTC *
Cochise Health Systems *
Mercy Care LTC *
TOTAL

Percent
Total Receiving Receiving Retinal
Retinal Exam
Exam

Included
Cases
100

77

77.0%

112

95

84.8%

255

167

65.5%

215

184

85.6%

226

141

62.4%

231

143

61.9%

88

50

56.8%

93

51

54.8%

94

52

55.3%

97

66

68.0%

325

170

52.3%

271

140

51.7%

1088

657

60.4%

1019

679

66.6%

Relative
Percent
Change
-9.2%

p=.146

-23.5%

p<.001

0.8%

p=.915

3.6%

p=.789

-18.7%

p=.070

1.3%

p=.875

-9.4%

p=.003

Notes:
Results of the previous measurement period (Oct. 1, 2004, through Sept. 30, 2005), are shown in shaded rows

* Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS).

14

Significance
Level

Figure 3
RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES
100.0%

85.6%

84.8%

80.0%

77.0%

68.0%

66.6%

65.5%
62.4% 61.9%

60.0%

60.4%
56.8%

55.3%

54.8%

52.3% 51.7%

40.0%

20.0%

0.0%
Cochise Health
Systems *

Evercare Select * Mercy Care LTC *

Pima Health
System LTC *

Current Measurement

15

Pinal/Gila County
LTC *

Previous Measurement

Yavapai County
LTC *

TOTAL

METHODOLOGY
Arizona Health Care Cost Containment System (AHCCCS)
Arizona Long Term Care system (ALTCS)
DIABETES PERFORMANCE MEASURES
Measurement Period: October 1, 2005, through September 30, 2006

Background
The federal Centers for Disease Control and Prevention (CDC) estimates that more than 20
million Americans age 20 years and older, or 9.6 percent of all people in this age group, have
diabetes. About 1.5 million new cases of diabetes were diagnosed among people 20 years and
older in 2005.1
An estimated 244,000 Arizona adults had a diagnosis of diabetes in 2002, the most recent year
for which state-specific data are available.2
Diabetes was the sixth leading cause of death in the United States in 2002, causing or
contributing to at least 224,000 deaths. 3
In the United States, Hispanics, Blacks, American Indians and Alaska Natives are two to three
times more likely to have diabetes than non-Hispanic Whites. The prevalence of diabetes also
is higher among older Americans – nearly 20 percent of all people 60 and older have diabetes
– as well as among people with low socioeconomic status and those covered by Medicaid. 1,4
The number of people in the United States with diagnosed diabetes has more than doubled in
the last 15 years.5 The prevalence of diabetes in Arizona also has increased during that time.6
Contributing to this increase is the large number of “baby boomers” who are aging and living
longer than people in previous generations. A sedentary lifestyle and a dramatic rise of
obesity in the U.S. population also are increasing the incidence of diabetes.7
About one out of every 10 health care dollars in the United States is spent on diabetes and its
complications. Total U.S. expenditures related to diabetes were approximately $132 billion in
2002 – $92 billion in direct medical costs and another $40 billion in indirect costs because of
missed work days or other losses in productivity.8 At least 4 million hospitalizations and more
than 26 million outpatient visits annually in the U.S. are associated with diabetes.9
Diabetes is the leading cause of end-stage kidney disease and new cases of blindness among
adults. It also is responsible for more than 60 percent of nontraumatic lower-limb
amputations. Other complications include heart disease, stroke, and nervous system
disorders.3
Purpose
The purpose of this study is to monitor performance of health plans contracted with the
Arizona Long Term Care System (ALTCS) for diabetes-related measures. These measures
evaluate the percent of ALTCS members with diabetes who receive certain clinical services to
detect and prevent or reduce complications. This report summarizes current results of these
Performance Measures.

i

Measurement Period
October 1, 2005, through September 30, 2006
Study Questions
1. What is the number and percent, overall, and by Contractor, of members enrolled
with (ALTCS) Contractors who met the sample frame criteria and who had one or
more HbA1c blood tests during the measurement period?
2. What is the number and percent, overall, and by Contractor, of members enrolled
with ALTCS Contractors who met the sample frame criteria and who had at one or
more fasting lipid profiles (cholesterol, high density lipoprotein or HDL and low
density lipoprotein or LDL) during the measurement period or the preceding year?
3. What is the number and percent, overall, and by Contractor, of members enrolled
with ALTCS Contractors who meet the sample frame criteria and had a retinal
exam during the measurement period or the preceding year?
Population
This study includes AHCCCS members diagnosed with diabetes, as defined by HEDIS®
2006. Members may be identified as diabetic during the measurement year or the twelve
months prior to the measurement period.
Population Exclusions
The following members are excluded from this study:
•
Members less than 18 years of age.
•
Members greater than 75 years of age.
•
Members not enrolled the last day of the study period
•
Members with a gap in coverage greater than one month
•
Members with steroid induced diabetes and gestational diabetes
•
Members with a diagnosis of polycystic ovaries who do not have two face-to-face
encounters with the diagnosis of diabetes in any setting during the measurement year
or prior year
•
Tribal and Fee for Service members will be excluded due to the inability to
accurately collect complete data on these populations. Often these members seek
medical care outside of the AHCCCS system; therefore, data would not be available
from AHCCCS administrative data.
Population Stratification
The population will be stratified by:
•
Program type (ALTCS*)
•
Contractor
* E/PD and VD populations for each Contractor are combined before stratifying

Sample Frame
The sample frame consists of members 18 through 75 years of age as of September 30, 2006,
who were continuously enrolled during the measurement period, with no more than one gap in
enrollment of up to 31 days, and diagnosed with type 1 or type 2 diabetes.

ii

•

Prior Period Coverage (PPC) will be considered a break in enrollment.
•
A change of county service area with the same Contractor, without a gap in
enrollment, will not be considered a break in enrollment.
Sample Selection
The sample frame will be identified through enrollment, claims and encounter records using
the stated criteria. A statistical software program will be used to select a representative,
random sample, using a 95-percent confidence level and a confidence interval of +/-5 percent.
Based on prior studies, an over sampling rate of 10 percent will be utilized.
Identification of Members with Diabetes
Members with diabetes will be identified, according to HEDIS 2006 specifications, by
pharmacy data (National Drug Code or NDC list) or by specific diagnosis codes. To be
included in the measurement, members must have had two face-to-face encounters with
different dates of service in an ambulatory or non-acute inpatient setting, or one face-to-face
encounter in an acute inpatient or emergency room setting during the measurement year, or
the year prior to the measurement year, with a diagnosis of diabetes as specified above.
Indicators
HbA1c testing
This indicator measures whether selected members received one or more HbA1c tests during
the measurement period, identified through either administrative data or medical record
review, according to HEDIS 2006 specifications. A member is considered to have had an
HbA1c test if:
•
a claim or encounter, using codes listed in the following table, or an automated laboratory
record with a service date during the measurement period was found for the member
Codes to Identify HbA1c Tests
CPT Code
LOINC
83036
4548-4, 4549-2, 17855-8, 17856-6

or
•

there was documentation in the member’s medical record (at a minimum, a note or lab
result record) indicating the date an HbA1c test was performed. The following notations count
toward this indicator:
o glycated hemoglobin
o glycosylated hemoglobin
o A1c
o HbA1c
o Hemoglobin A1c
o HgbA1c
Fasting Lipid Profile
This indicator measures whether selected members received one or more LDL-C tests during
the measurement period or year prior to measurement period, identified through either
administrative data or medical record review, according to HEDIS 2006 specifications. A
member is considered to have had an LDL-C test if:

iii

•

a claim or encounter, using codes listed in the following table, or an automated laboratory
record with a service date during the measurement period that was found for the member,
Codes to Identify LDL-C Screening
CPT Code
LOINC
80061, 83715, 83716, 83721
2089-1, 12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 24331-1

or
•

there was documentation in the member’s medical record (at a minimum, a note or lab
result record) indicating the date a fasting lipid profile was performed and the result.
Retinal Exam
This indicator measures an eye screening for diabetic retinal disease, documented through
either administrative data or medical record review. It includes a retinal or dilated eye exam
by an eye care professional (optometrist or ophthalmologist) within the measurement period
or a negative retinal exam (no evidence of retinopathy) by an eye-care professional in the year
prior to the measurement year. At a minimum, documentation in the medical record must
include:
•
a note or letter from an ophthalmologist, optometrist or other health-care professional
summarizing the date on which the procedure was performed and the results of a retinal
evaluation performed by an eye-care professional
or
•
a chart or photograph of retinal abnormalities. If fundus photography was used in the
exam, there must be documentation in the medical record indicating the date on which the
procedure was performed and evidence that an eye-care professional reviewed the results.
Alternatively, results may be read by a qualified reading center that operates under the
direction of a medical director who is a retinal specialist
or
•
a note, which may be prepared by a primary care provider, indicating the date on which
the procedure was performed, and that an ophthalmoscopic exam was completed by an eyecare professional, with results of the exam.
Denominator
1. The number of members who met the sample frame criteria
Numerators
1. The number of ALTCS EP/D members who had one or more Hb A1c tests during the
measurement period
2. The number of ALTCS EP/D members who had one or more fasting lipid profiles during
the measurement period or the preceding year
3. The number of ALTCS EP/D members who had a retinal exam during the measurement
period or a negative retinal exam in the preceding year
Confidentiality Plan
AHCCCS continues to work in collaboration with Contractors to maintain compliance with
the Health Insurance Portability and Accountability Act (HIPAA) requirements. The Data
Analysis and Research (DA&R) Unit maintains the following security and confidentiality
protocols:

iv

•

To prevent unauthorized access, the sample member file is maintained on a secure,
password-protected computer, by the DA&R project lead.
•
Only AHCCCS employees who analyze data for this project will have access to study
data.
•
Requested data are used only for the purpose of performing health care operations,
oversight of the health care system, or research.
•
Only the minimum amount of necessary information to complete the project is sent to and
returned from Contractors.
•
Sample files given to Contractors are tracked to ensure that all records are returned.
•
Member names are never identified or used in reporting.
•
Upon completion, all study information is removed from the computer and placed on a
compact disk, and stored in a secure location.
Data Sources
•
Recipient demographic information, as well as encounters and pharmacy data (Form C),
will be used by AHCCCS to identify the population.
•
Encounters will be used by AHCCCS to identify services. Contractors will use
administrative (claims) or laboratory data to collect additional service information. When
these data are not available, data will be collected from members’ medical records.
Data Collection Process
•
The population file will be obtained from the AHCCCS Decision Support system
(ADDS). The sample population will be selected by the Data Analysis & Research DA&R)
unit of the Division of Health Care Management from this file.
•
Applicable services from administrative (encounter) data will paired with members
selected for the study.
•
After initial data collection by AHCCCS, electronic data files will be sent to Contractors.
These files will contain only the Contractors’ sample members.
•
Contractors will collect additional service data and enter it on the electronic file.
•
The electronic data file will then be returned to AHCCCS.
•
AHCCCS will require Contractors to submit laboratory records, medical records,
electronic data directly transmitted by laboratories, or claims data to verify services that were
provided.
Quality Assurance Process
•
Contractors will be instructed in use of the data collection methods, sample file layout and
timelines for data collection.
•
Contractors will receive written instructions for data collection, in addition to AHCCCS
resource and contact information for assistance.
•
AHCCCS will verify that all records have been returned. The distribution to Contractors
and return of sample files will be monitored by the DA&R Unit.
Data Validation
•
To verify that an HbA1c test, fasting lipid profile or retinal examination was performed,
Contractors must submit any one of the following for each member identified as receiving
indicator services: laboratory records, medical records, electronic data directly transmitted by
laboratories, or claims data

v

•

This documentation must contain confirmation of an examination being performed and the
date of service.
•
A double-blind validation may be performed by AHCCCS, matching the Contractorsupplied documentation with data on the Contractor’s electronic file.
Limitations
•
A large portion of the ALTCS population also is covered by Medicare and seeks services
outside the AHCCCS provider system. Because Medicare is the primary payer for Medicare
beneficiaries, AHCCCS does not have the ability to collect information on services provided
to members outside the AHCCCS system. Thus, some members with diabetes may not be
identified for inclusion in this study.
Deviations from Previous Methodology
Codes to identify diabetic members were updated in HEDIS® 2006, including:
•
Removing Glucophage/metformin from the table of prescriptions that identify diabetics
using pharmacy data. Diabetic members on these medications are identified through diagnosis
coding only.
•
Removing glychohemoglobin from the HbA1c screening indicator description.
•
Deleting CPT codes 99288 from the table that identifies acute inpatient/emergency
department visits.
•
Adding UB-92 revenue code 19X to the outpatient/non-acute codes.
•
Adding CPT codes 99203 and 99213 to the table that identifies eye exams.
•
Adding ICD-9CM code 251.8 to the table that identifies steroid-induced diabetes.
In previous studies, AHCCCS had measured whether a retinal exam was provided in the
measurement year or the prior year, regardless of the result. This deviation from HEDIS has
been eliminated.
Analysis Plan
•
The denominator will be divided by the numerator to determine the percentage of
compliance with each indicator. The rates will be analyzed and reported overall, by ALTCS
Contractor and by race/ethnicity.
•
Variability of distribution will be calculated by range and standard deviation. Any
Contractor with results more than two standard deviations from the mean will be identified,
and the reason ascertained if possible. To avoid skewed and misleading conclusions, any
such Contractor may be excluded from selected charts and graphs. Clear documentation in
the report will caveat any Contractor exclusions and the reasons for exclusion.
Comparative Analysis
•
Prior studies will be compared to the current results.
•
The results of this study will be compared to national HEDIS means and percentiles for
Medicaid health plans as reported by the National Committee for Quality Assurance (NCQA),
and to the AHCCCS Minimum Performance Standard and Goal.
•
Individual Contractors will be compared to each other and to the statewide average.
Report Format
•
The report will include the methodology used, narrative summary of analysis findings,
limitations and recommendations

vi

•

Findings will be displayed in appropriate charts, tables and/or graphs, with results reported
by individual Contractor, program type, and statewide aggregate.
•
The comprehensive findings will be presented in a manner that will allow for easy
interpretation of the data by evaluators at the federal, state, and Contractor levels.
•
Results will be reported on the AHCCCS website and will be sent to the Centers for
Medicare and Medicaid Services (CMS).
Definitions
Statistically Significant: A finding is described as statistically significant, when it can be
demonstrated that the probability of obtaining such a difference by chance only is relatively
low. It is customary to describe one's finding as statistically significant, when the obtained
result is among those that (theoretically) would occur no more than 5 out of 100 times, p<=
.05, or occur no more than 1 out of 100 times, p<=. 01, when the only factors operating are
the chance variations that occur whenever random samples are drawn. It is important to note
that a finding may be statistically significant but may not be clinically or financially
significant.
The statistically significant value is calculated using the Pearson chi-square test.
parameters used are:
Degree of Freedom =1
Statistical Significance Level p<= .05

The

References
1

American Diabetes Association. Total prevalence of diabetes and pre-diabetes. Available at:
http://www.diabetes.org/diabetes-statistics/prevalence.jsp. Accessed July 27, 2006.
2
Centers for Disease Control and Prevention. Diabetes surveillance system: State-specific estimates of
diagnosed diabetes among adults. Centers for Disease Control and Prevention, National Center for Chronic
Disease
Prevention
and
Health
Promotion.
Available
at:
http://www.cdc.gov/diabetes/statistics/prev/state/table15.htm. Accessed September 15, 2004.
3
Centers for Disease Control and Prevention. National diabetes fact sheet 2005. Atlanta, GA. U.S. Department
of Health and Human Services, Centers for Disease Control and Prevention. 2005. Available at:
http://www.cdc.gov/diabetes/pubs/factsheet.htm. Accessed July 27, 2006.
4
National Center for Health Statistics. Health, United States, 2004. Table 8: Age-adjusted percentages (with
standard errors) of selected diseases and conditions among persons 18 years of age and over, by selected
characteristics: United states, 2003. Centers for Disease Control and Prevention. Hyattsville, Maryland: 2004.
Available at: http://www.cdc.gov/nchs/hus.htm. Accessed September 20, 2005.
5
Centers for Disease Control and Prevention. Diabetes: disabling, deadly, and on the rise. Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Available at:
http://www.cdc.gov/nccdphp/aag/pdf/aag_ddt2004.pdf. Accessed September 22, 2006.
6
Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion. Behavioral Risk Factor Surveillance System Prevalence Data.. Available at:
http://apps.nccd.cdc.gov/brfss/display_c.asp?yr_c=2004&yr=2005&cat=DB&state=AZ&bkey=20050405&qkey
=1363&qtype=C&grp=0&SUBMIT2=Compare. Accessed September 15, 2004, and September 22, 2006.
7
National Diabetes Information Clearinghouse. Diabetes overview. National Institute of Diabetes and Digestive
and Kidney Diseases. Available at: http://diabetes.niddk.nih.gov/dm/pubs/overview/index.htm#who. Accessed
August 30, 2005.
8
American Diabetes Association. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003;26:917932. Available at: http://www.care.diabetesjournals.org/cgi/content/full/26/3/917. Accessed March 19, 2003.
9
Centers for Disease Control and Prevention. Indicators for chronic disease surveillance. MMWR. 2004; 53(RR11):100. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5311a1.htm Accessed September 22,
2006.

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