Arizona Health Care Cost Containment System Arizona Long Term Care System (ALTCS) Performance Measure PERFORMANCE MEASURES FOR DIABETES CARE Measurement Period: October 1, 2006, through September 30, 2007 Prepared by the Division of Health Care Management November 2008 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, 2006, through September 30, 2007 INTRODUCTION 1 SIGNIFICANCE OF THE MEASURES 2 STUDY METHODS Population .................................................................................................................. Measurement Period .................................................................................................. Sample Frame ............................................................................................................ Data Sources .............................................................................................................. Data Collection .......................................................................................................... Data Quality and Reliability ...................................................................................... Study Indicators ......................................................................................................... Deviations from Previous Methodology .................................................................... Performance Measure Goals....................................................................................... National Benchmarks ................................................................................................. 4 4 4 4 4 4 4 5 5 5 RESULTS Included Cases ........................................................................................................... Hb A1c Testing .......................................................................................................... Lipid Profiles ............................................................................................................. Eye Examinations ...................................................................................................... Results by Race/Ethnicity .......................................................................................... Results by County Type ............................................................................................. 6 6 6 6 7 7 DISCUSSION Overall Results ........................................................................................................... Contractor Performance ............................................................................................. Quality Improvement Efforts ..................................................................................... Conclusion ................................................................................................................. 8 8 8 9 REFERENCES 9 TABLES AND FIGURES 11 APPENDIX: METHODOLOGY AND TECHNICAL SPECIFICATIONS ii 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, 2006, through September 30, 2007 INTRODUCTION Diabetes is a serious health problem that is growing rapidly in the United States. More than 23 million Americans age 20 years and older, or 10.7 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 1.6 million new cases of diabetes were diagnosed among U.S. adults in 2007, and another 5 to 6 million people have diabetes that has not been diagnosed.1 The number of people in the United States with diagnosed diabetes has nearly tripled in the last 25 years. From 1980 through 2005, the number of Americans with diabetes increased from 5.6 million to 15.8 million.3 The prevalence of diabetes in Arizona also increased during that time.4 A sedentary lifestyle and a dramatic rise of obesity in the U.S. population are contributing to the increase in this costly and potentially deadly disease. Surveys conducted in recent years have found that about 60 percent of American adults are either overweight or obese.5,6 Another study found that nearly half of obese persons have type 2 diabetes.7 In Arizona, an estimated 375,000 adults had diabetes in 2006, and another 125,000 were living with undiagnosed diabetes. Diabetesrelated hospitalizations in Arizona nonfederal facilities accounted for more than $3.5 billion in 2006, with an average length of stay of 5 days.2 Nearly 20 percent of all people 60 and older have diabetes. Number of Persons (in millions) with Diagnosed Diabetes, U.S., 1980–2005 Centers for Disease Control and Prevention Hispanics, Blacks, American Indians and Alaska Natives are approximately twice as likely to have diabetes than non-Hispanic Whites in the U.S. 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. 1,3,4 Source: Centers for Disease Control and Prevention 1 Care System (ALTCS) for diabetes-related measures. The 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. Total U.S. expenditures related to diabetes are approximately $174 billion a year ― a 32 percent increase since 2002 ― according to a study commissioned by the American Diabetes Association. That includes $116 billion in direct medical costs and another $58 billion in indirect costs because of missed work days or other losses in At least 4 million productivity.8 hospitalizations annually in the U.S. are associated with diabetes.9 Results of the measurement are used to determine whether these managed care plans (known as Contractors), are meeting Performance Standards specified in their contracts. This report summarizes these results and compares Contractors’ rates to performance standards and national means for managed care plans. The purpose of this study is to monitor performance of managed care plans contracted with the Arizona Long Term SIGNIFICANCE OF THE MEASURES With diabetes, sustained high blood sugars result in damage to very small blood vessels throughout the body. One of these “microvascular” complications is retinopathy (damage to the retina of the eye), which causes 12,000 to 24,000 new cases of blindness each year. Diabetes also is the leading cause of end stage renal (kidney) disease, or ESRD, and is responsible for more than half of nontraumatic lower-limb amputations.1 As with many diseases, other conditions (known as comorbid conditions) may be present. The increased prevalence of hyperlipidemia (high cholesterol levels) found with type 2 diabetes contributes to higher rates of cardiovascular disease among diabetics. • 2 in 3 people with diabetes die of heart disease or stroke • Diabetes is the #1 cause of adult blindness Diabetes also results in “macrovascular” complications, including coronary and peripheral artery disease. In fact, heart disease and stroke account for about 65 percent of deaths among people with diabetes.10 • Diabetes is the #1 cause of kidney failure Diabetes: The Numbers National Diabetes Education Program In addition, up to 70 percent of people with diabetes have mild to severe forms of neuropathy (nerve damage), including impaired sensation or pain in the feet or hands, carpal tunnel syndrome and motor deficits. Patients with diabetes also have worse outcomes with acute illness. For example, diabetics who are hospitalized for trauma have longer stays in the intensive care unit and more complications than people who do not have diabetes.11 2 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.1,12 Lipid Management –– Managing lipid levels has been shown to reduce 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), high-density lipoproteins (HDL) and triglycerides. These results are used to calculate and manage low-density lipoprotein (LDL) levels. 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. 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 Ten-year post-trial monitoring from one of these studies, the landmark United Kingdom Prospective Diabetes Study (UKPDS), indicates that a strategy of early and intensive glucose lowering has lasting, significant effects – not only on major diabetes end points, such eye and kidney disease – but also on the risk of heart attack and other causes of mortality.15 However, data compiled by the Arizona Department of Health Services (ADHS) indicate that many diabetic patients in the state are not getting the tests they need. In its 2007 annual report of diabetes indicators, ADHS reported that only 70 percent of Arizonans with diabetes received an Hb A1c test during the preceding year, 41 percent had a lipid screening performed and 47.6 percent had a dilated retinal exam.2 STUDY METHODS The Arizona Health Care Cost Containment System (AHCCCS) used Healthcare Effectiveness Data and Information Set (HEDIS) 2007 specifications for this measurement. Developed and maintained by the National Committee for Quality Assurance (NCQA), HEDIS is a widely adopted and reliable methodology that allows for comparisons with Medicaid health plan averages. national AHCCCS has selected three of the HEDIS indicators of comprehensive diabetes care for measurement of Contractor performance: Hb A1c testing, lipid screening, and retinal (eye) exams. 3 sample members were selected and initial service data were collected. Population The population included elderly and physically disabled (E/PD) members enrolled with ALTCS managed care plans who had diagnoses of type 1 or type 2 diabetes in the measurement period or the year prior to the measurement period. 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). When specific services within the measurement period 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 provided by AHCCCS, Contractors collected additional data from medical records and claims systems. Additional service information was entered on the electronic tool by Contractor staff, according to detailed instructions from AHCCCS. For example, a member was identified for the study if he or she had a face-to-face encounter with a medical provider and the associated claim included a diagnosis of diabetes. A member also may be identified as diabetic when dispensed insulin or other certain types of drugs used to treat diabetes. 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 encounter-omission rates of less than 5 percent for each year. Measurement Period The measurement period for this study was the AHCCCS contract year from October 1, 2006, through September 30, 2007. 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 complete encounter data. Thus, additional data is collected by Contractors from medical records. In order to document the reliability of data collected outside of the AHCCCS encounter system, Contractors were required to submit hard copies of the appropriate sections of medical records or documentation from their claims systems. Sample Frame The sample frame consisted of E/PD members who were: • ages 18 through 75 years as of September 30, 2007, • continuously enrolled with one ALTCS Contractor for at least 11 member months during the measurement period, and • enrolled with that Contractor on September 30, 2007. Data Sources The primary data sources were recipient, claim/encounter, and medical record data. Data Collection Recipient and encounter data are stored in the AHCCCS Prepaid Medical Management Information System (PMMIS). These data were loaded into the AHCCCS Decision Support System (ADDS), from which Study Indicators • Hb A1c testing — This indicator measured the percent of members who had one or more Hb A1c tests during the measurement year. 4 AHCCCS also has established Goals that Contractors should strive to meet if they are already meeting minimum standards, as well as Benchmarks, or long-range goals based on national HEDIS benchmarks. Lipid (LDL-C) profile — This indicator measured the percent of members who had one or more fasting lipid profiles during the measurement year. • Retinal examinations — This indicator measured an eye screening for diabetic retinal disease with a retinal or dilated eye exam by an eye-care professional (optometrist or ophthalmologist) within the measurement year. A negative retinal exam (no evidence of retinopathy) by an eye-care professional in the year prior to the measurement year also counts toward the numerator for this measure. • AHCCCS Performance Standards Measure MPS Goal Benchmark Hb A1c testing 77% 78% 89% Lipid screening 81% 82% 91% Retinal exams 67% 68% 68% It should be noted that the current Minimum Performance Standard for lipid screening is based on a two-year measurement period and was established in contract prior to the change in methodology to a one-year measurement period. AHCCCS has revised the MPS for future measurements, based on the change in methodology. Deviations from Previous Methodology AHCCCS previously measured lipid screening within a two-year period, according to HEDIS specifications. NCQA has revised the HEDIS specifications to measure lipid screening within a one-year period and AHCCCS has implemented the change in methodology with the current measurement. National Benchmarks NCQA reports national means (averages) for these measures, based on data submitted by managed care plans. The HEDIS 2006 national means for Medicaid plans were used to establish the current AHCCCS minimum standards in 2007. HEDIS rates for the 90th percentile of plans were used to set the benchmarks. All Performance Standards increased from the previous year. This change brings the HEDIS measure in line with “Standards of Medical Care in Diabetes,” published by the American Diabetes Association (ADA). For several years, the ADA standards have included the recommendation that adults with diabetes be tested for lipid levels at least annually or more often if needed to achieve goals for lipid management. However, the change limits comparability of the current rate for lipid screening with results for previous years. The comparable national means, as reported by NCQA, are: HEDIS National Means Measure Performance Measure Goals AHCCCS has established a Minimum Performance Standard (MPS) for each measure, which ALTCS Contractors must meet. If they do not meet the MPS for any measure, they must implement a Corrective Action Plan to bring the rate up to the contractual standard and may face a financial sanction if they fail to show improvement. Medicaid Commercial Hb A1c testing 78.0% 87.5% Lipid screening 71.1% 83.4% Retinal exams 51.4% 54.7% The national means are based on the same methodology employed by AHCCCS for this measurement and are useful for comparisons with AHCCCS results. 5 RESULTS LDL-C test or fasting lipid profile during the measurement year was 72.0 percent (Table 2A). Because HEDIS specifications have been revised to measure this screening during a one-year period, the rate cannot be directly compared with the previous AHCCCS rate, which measured lipid screenings in a two-year period. However, data for the two previous measurements also are presented in this report (Table 2B). Results for each measure were analyzed overall, by individual Contractor, by members’ race/ethnicity and by rural vs. urban areas. Changes in Contractor and overall rates from the previous measurement period are described as increases or decreases 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. Contractor rates in current measurement ranged from 47.8 percent to 82.8 percent. While the AHCCCS MPS is based on screening in a two-year period, one Contractor did exceed this standard, as well as the AHCCCS Goal. In addition, this and another Contractor exceeded the HEDIS Medicaid mean of 71.1 percent for lipid screening in a one-year period. Included Cases This measurement included 1,233 ALTCS elderly and physically disabled members who were identified as having diabetes and were enrolled with eight long-term care Contractors during the measurement period. Hb A1c Testing The overall rate of Hb A1c testing during the measurement year was 80.1 percent, compared with the previous rate of 79.7 percent (Table 1). The change is not statistically significant (p=.791). Eye Examinations The overall rate of members who had a dilated eye (retinal) examination in the measurement year or a negative exam in the previous year was 57.1 percent, compared with 60.4 percent in the previous measurement (Table 3). The change is not statistically significant (p=.108). Rates by Contractor ranged from 54.7 percent to 87.3 percent. One Contractor showed a statistically significant increase and one showed a statistically significant decrease in its rate. This is the first time a rate has been measured for two new Contractors. Rates by Contractor ranged from 26.1 percent to 76.2 percent. Two Contractors showed statistically significant increases and two showed statistically significant decreases in their rates for this measure. This is the first time a rate has been measured for two new Contractors. Four Contractors exceeded the AHCCCS Minimum Performance Standard (MPS) for this measure (Figure 1). In addition, three Contractors exceeded the Goal of 78 percent, which also is the current HEDIS Medicaid mean. Two Contractors exceeded the AHCCCS MPS and one exceeded the Goal and Benchmark for this measure (Figure 2). In addition, four Contractors had rates that surpassed the most recent HEDIS means for both Medicaid and commercial health plans. Lipid (LDL-C) Profiles The overall rate of members who had an 6 Results by County Type There were significant differences in rates between members residing in rural and urban counties for two of the measures. Members living in urban counties were more likely to have an Hb A1c test during the year, at 83.6 percent, than those in rural counties, at 73.0 percent (p< .001). Members in urban counties also were more likely to have a lipid screening during the year, at 76.0 percent, compared with those living in rural counties, at 63.8 percent (p< .001). 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: Rates by Race/Ethnicity, CYE 2007 Hb A1c Lipid Retinal White 80.2% 72.3% 54.8% Hispanic 81.0% 71.5% 61.3% 77.1% 70.0% 57.1% Native American 75.0% 70.0% 45.0% Other/Unknown 79.4% 73.5% 57.4% 1 Black 2 There was no significant difference in rates between members residing in rural and urban counties for the measure of retinal exams (p= .364). There were no significant differences in rates by race/ethnicity 1 Non-Hispanic Whites are used as the reference group, for analyzing whether disparities in use of services exist based on race/ethnicity. 2 Results for Native Americans should be interpreted with caution, since there were only 20 members in this category. 7 DISCUSSION Overall Results AHCCCS overall rates remained stable for two of the three measures, Hb A1c testing and retinal exams. This is the first year that AHCCCS has measured lipid screening in a one-year period. AHCCCS overall rates for all three measures exceeded the national averages for Medicaid managed care plans Compared with the most recent HEDIS national means, AHCCCS overall rates for all three measures exceeded the averages for Medicaid managed care plans. The AHCCCS overall rate for retinal exams also exceeded the most recent HEDIS commercial mean. variety of strategies to improve care of diabetic members. These include intensive member education, monitoring of members’ test status and follow up by case managers and nurses; distributing to primary care physicians (PCPs) practice guidelines and other tools, such as a diabetic flow sheet to help track tests that must be performed periodically, and advising PCPs of diabetic members who are due or overdue for specific services. Contractor Performance One Contractor, Mercy Care Long Term Care Plan, met the AHCCCS Minimum Performance Standards for all measures. Based on the previous year’s results, another Contractor, Pima Health System, implemented a Corrective Action Plan (CAP) in 2007 to improve its rates for Hb A1c testing. This Contractor’s interventions were successful, with its rate for this measure increasing from 73.9 percent in the previous period to 82.5 percent in the current measurement. The interventions that involve PCPs may be especially effective, since research shows that, among people with diabetes, physicians are the primary source of information about their disease and best positioned to influence compliance with self-management and receipt of 7 recommended services. Contractors should continue to reinforce with providers the current clinical standards of care ― including lipid screening at least annually ― for members with diabetes. As previously noted, AHCCCS increased performance standards for these measures for the current measurement period. for the next measurement period, ending Sept. 30, 2008, the AHCCCS MPS for Hb A1c testing was increased slightly to encourage continued improvement so that Contractors perform at levels above the HEDIS national Medicaid mean. In order to assist ALTCS Contractors with 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. Quality Improvement Efforts AHCCCS Contractors have utilized a 8 Contractors must maintain an active focus on member and provider outreach related to diabetes care, in order to continue improvements in these performance measures. Successful strategies used in other programs include: automated reminders by telephone to advise 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 that include a physician, pharmacist, diabetes educator, nutritionist, and/or mental health professional; and culturally relevant patient information materials and other interventions, such as food preparation classes that incorporate traditional foods, in diabetes education.16-20 REFERENCES 1 Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008. Available at: http://www.diabetes.org/diabetes-statistics.jsp. Accessed July 27, 2008. 2 Arizona Diabetes Coalition, Surveillance Committee. Arizona Diabetes Indicators Annual Report 2007. Arizona Department of Health Services, Diabetes Prevention and Control Program. December 2007. 3 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. 4 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/ta ble15.htm. Accessed September 15, 2006. 5 Davis SN, Perkins JM. Role of the endocannabinoid system is management of patients with type 2 diabetes mellitus and cardiovascular risk factors. Medscape 2008. Available at: http://www.medscape.com/viewarticle/5722252. Accessed Apr. 23, 2008. 6 Vega CP. Stress and obesity: Partners in disease. Medscape 2007. Available at: http://www.medscape.com/viewprogram/7780. Accessed Sept. 25, 2007. 7 Public knowledge, perceptions and behavior regarding diabetes and diabetes prevention: A societal barometer. Princeton, NJ: Gallup Inc., 2008. Available at: http://www.ncdp.com/downloads/FINAL%20PRIN TED%20REPORT%20WITH%20COVER.pdf. Accessed July 7, 2008. A systematic review of 17 studies of interventions to improve diabetes care among “socially disadvantaged” populations (e.g., low-income, minority populations and those with or low educational attainment) found that the most effective interventions were: • those that were tailred to the members’ culture, • the use of community educators or lay people to support patient self-management • use of treatment algorithms (such as diabetic flow sheets), and • frequent contacts with patients over a longer duration (more than 10 times over a period of six months or more).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. 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. 9 8 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/abstract /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):259-268. 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/abstract /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/abstract /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):20112017. Available at: http://care.diabetesjournals.org/cgi/content/abstract /29/7. Accessed September 22, 2006. Devastating toll of diabetes reaches $174 billion [press release]. Alexandria, VA: American Diabetes Association; January 23, 2008. Available at: http://www.diabetes.org/for-media/prdevastating-toll-of-diabetes-reaches-174-billion012308.jsp .Accessed February 7, 2008. 9 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/mmwrhtml/rr5 311a1.htm Accessed September 22, 2006. 10 American Diabetes Association. Complications of diabetes in the United States. Available at: http://www.diabetes.org/diabetesstatistics/complications.jsp. Accessed July 21, 2008. 11 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. 12 American Diabetes Association. Standards of medical care in diabetes − 2007. Diabetes Care. 2007; 30(S1). Available at: http://care.diabetesjournals.org/cgi/content/full/30/ suppl_1. Accessed April 3, 2007. 13 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/factsheet s/Prevention/diabetes.htm. Accessed September 22, 2006. 14 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. 15 Wood S. Ten years later, UKPDS shows intensive glucose lowering, but not tight BP control, reduces MI, all-Cause mortality. Medscape Medical News. Sept. 11, 2008. Available at: http://www.medscape.com/viewarticle/580370_pri nt?wwparam=1221691717 Accessed Sept. 17, 2008. 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/abstract /23/4. 17 Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Impact of automated calls with nurse follow-up For questions or comments about this report, please contact: Rochelle Tigner Quality Improvement Manager Clinical Quality Management AHCCCS Rochelle.Tigner@azahcccs.gov 10 TABLE 1 AHCCCS Clinical Quality Performance Measures for Diabetes Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES Current Measurement Period: October 1, 2006, through September 30, 2007 Contractor Bridgeway Health Solution Cochise Health Systems Evercare Select * Mercy Care LTC * Pima Health System LTC * Pinal/Gila County LTC Scan Long Term Care Yavapai County LTC * TOTAL Included Cases Total Receiving HbA1c Test Percent Receiving HbA1c Test Relative Percent Change Significance Level 91 70 76.9% N/A N/A N/A N/A N/A 105 77 73.3% -8.1% p=.285 94 75 79.8% 250 218 87.2% 5.9% p=.130 255 210 82.4% 332 290 87.3% 6.3% p=.064 325 267 82.2% 229 189 82.5% 11.6% p=.026 226 167 73.9% 117 64 54.7% -31.6% p<.001 100 80 80.0% 23 13 56.5% N/A N/A N/A N/A N/A 0.8% p=.920 0.6% p=.791 86 67 77.9% 88 68 77.3% 1233 988 80.1% 1088 867 79.7% Notes: * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS). Significance levels in bold face indicate a statistically significant change from the previous measurement. Results of the previous measurement period (Oct. 1, 2005, through Sept. 30, 2006), are shown in shaded rows 11 Figure 1 Hb A1c TESTS - ALTCS E/PD MEMBERS WITH DIABETES Current Measurement Period: October 1, 2006, through September 30, 2007 100% 80% 60% 40% 20% 0% Bridgeway Health Solution Cochise Health Systems Evercare Select * Mercy Care Pima Health Pinal/Gila LTC * System LTC County LTC * Current Measurement 12 Scan Long Term Care Previous Measurement Yavapai County LTC * TOTAL TABLE 2A AHCCCS Clinical Quality Performance Measures for Diabetes ANNUAL LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES Current Measurement Period: October 1, 2006, through September 30, 2007 Included Cases Total Receiving Fasting Lipid Percent Receiving Fasting Lipid Bridgeway Health Solutions 91 64 70.3% Cochise Health Systems 105 71 67.6% Evercare Select 250 202 80.8% Mercy Care LTC * 332 275 82.8% Pima Health System LTC 229 153 66.8% Pinal/Gila County LTC 117 65 55.6% Scan Long Term Care 23 11 47.8% Yavapai County LTC 86 47 54.7% 1233 888 72.0% Contractor TOTAL Notes: * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS). 13 Figure 2 LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES Current Measurement Period: October 1, 2006, through September 30, 2007 100% Minimum Performance Standard 80% 60% 40% 20% 0% Bridgeway Health Solutions Cochise Health Systems Evercare Select Mercy Care Pima Health Pinal/Gila LTC * System LTC County LTC Current Measurement 14 Scan Long Yavapai Term Care County LTC TOTAL TABLE 2B AHCCCS Clinical Quality Performance Measures for Diabetes BIENNIAL LIPID PROFILES - ALTCS E/PD MEMBERS WITH DIABETES Measurement Periods: October 1, 2005, through September 30, 2006 and October 1, 2004, through September 30, 2005 Contractor Cochise Health Systems * Evercare Select * Pima Health System LTC * Pinal/Gila County LTC * Mercy Care LTC * Yavapai County LTC * TOTAL Total Receiving Included Cases Fasting Lipid Profile Percent Receiving Relative Percent Fasting Lipid Profile Change 94 77 81.9% 97 76 78.4% 255 201 78.8% 215 143 66.5% 226 181 80.1% 231 174 75.3% 100 91 91.0% 112 101 90.2% 325 262 80.6% 271 213 78.6% 88 68 77.3% 93 43 46.2% 1088 880 80.9% 1019 750 73.6% Notes: * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS). Significance levels in bold face indicate a statistically significant change from the previous measurement. Results of the previous measurement period (Oct. 1, 2004, through Sept. 30, 2005), are shown in shaded rows 15 Significance Level 4.5% p=.537 18.5% p=.003 6.4% p=.221 0.9% p=.838 2.5% p=.542 67.3% p<.001 9.9% p<.001 TABLE 3 AHCCCS Clinical Quality Performance Measures for Diabetes RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES Current Measurement Period: October 1, 2006, through September 30, 2007 Contractor Bridgeway Health Solution Cochise Health Systems * Evercare Select Pima Health System LTC Pinal/Gila County LTC Mercy Care LTC * Scan Long Term Care Yavapai County LTC TOTAL Included Cases Percent Total Receiving Receiving Retinal Relative Percent Retinal Exam Exam Change 91 39 42.9% N/A N/A N/A 105 80 76.2% 94 52 55.3% 250 147 58.8% 255 167 65.5% 229 115 50.2% 226 141 62.4% 117 44 37.6% 100 77 77.0% 332 224 67.5% 325 170 52.3% 23 6 26.1% N/A N/A N/A 86 49 57.0% 88 50 56.8% 1233 704 57.1% 1088 657 60.4% N/A N/A 37.7% p=.002 -10.2% p=.121 -19.5% p=.009 -51.2% p<.001 29.0% p<.001 N/A N/A 0.3% p=.983 -5.4% p=.108 Notes: * Denotes the Contractor met or exceeded the AHCCCS Minimum Performance Standard (MPS). Significance levels in bold face indicate a statistically significant change from the previous measurement. Results of the previous measurement period (Oct. 1, 2005, through Sept. 30, 2006), are shown in shaded rows 16 Significance Level Figure 3 RETINAL EXAMS - ALTCS E/PD MEMBERS WITH DIABETES Current Measurement Period: October 1, 2006, through September 30, 2007 100.0% 80.0% Minimum Performance Standard 60.0% 40.0% 20.0% 0.0% Bridgeway Health Solution Cochise Health Systems * Evercare Select Pima Health System LTC Pinal/Gila County LTC Current Measurement 17 Mercy Care LTC * Previous Measurement Scan Long Term Care 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, 2006, through September 30, 2007 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. Measurement Period October 1, 2006, through September 30, 2007 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? 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 a negative exam during the preceding year? Population This study includes AHCCCS members diagnosed with diabetes, as defined by HEDIS® 2007. 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 i 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, 2007, 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. • 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 2007 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 2007 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 ii Codes to Identify HbA1c Tests CPT Code 83036, 83037 CPT Category II 3046F, 3047F 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, identified through either administrative data or medical record review, according to HEDIS 2007 specifications. A member is considered to have had an LDL-C 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 that was found for the member, Codes to Identify LDL-C Screening CPT Code 80061, 83700, 83701, 83704, 83715, 83716, 83721 CPT Category II 3048F, 3049F, 3050F 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 iii 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. • CPT Code CPT Category II HCPCS 67028, 67038-67040, 67101, 67105, 67107, 67108, 67110,67112, 67141, 67145, 67208, 67210, 67218, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, 9920399205, 99213-99215, 99242-99245 2022F, 2024F, 2026F, 3072F S0625, S3000, S0620, S0621 ICD-9-CM Procedure 14.1-14.5, 14.9, 95.02-95.04, 95.11, 95.12, 95.16 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 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: • 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. iv 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 • 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® 2007, including: • Added CPT code 83037 • Added CPT category II codes 3046F and 3047F v • • • • • • • • • • • • Added CPT codes 83700, 83701, and 83704 Added CPT category II codes 3048F, 3049F, and 3050F Added CPT codes 67028 and 67038-67040 Added CPT category II codes 2022F, 2024F, 2026F, and 3072F Added HCPCS codes S0625, S3000, S0620, and S0621 Deleted CPT code 92287 Added CPT codes 99304-99310, 99315, 99316, 99318, 99324-99328, 99334-99337, 99455, 99456 to Table CDC-C. Deleted CPT codes 99271-99275, 99292, 99351-99357 from Table CDC-C. Deleted UB-92 Revenue codes 0115, 0125, 0135, 0145, 0155, 049x, 050x, 053x, 056x. 065x, 076x, 092x, 094x, 096x, 0972-0979, 0984-0986, 0988, 0989 from Table CDC-C. Moved UB-92 Revenue codes 0456 from outpatient/nonacute inpatient description to emergency department description in Table CDC-C. Delete the Outpatient UB-92 revenue codes 052x then add 0520-0523, and 0526-0529. Add the Nonacute Inpatient UB-92 codes 0524 and 0525. In addition, the fasting lipid profile is now required annually instead of biennially. 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 • 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). vi 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. Statistical Significance Level: p <= .05 vii