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Disparity in LDL-C Testing of Dually Enrolled Patients with Diabetes Patient and Practitioner Factors Ruth Medak, MD Senior Clinical Coordinator OMPRO AHQA Technical Conference Analytic Methodologies Track 11:10 am, February 1, 2002 Project Goal

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Disparity in LDL-C Testing of Dually Enrolled Patients with DiabetesPatient and Practitioner Factors

Ruth Medak, MD

Senior Clinical Coordinator

OMPRO

AHQA Technical Conference

Analytic Methodologies Track

11:10 am, February 1, 2002

project goal
Project Goal
  • Investigate causes of performance disparities in diabetes indicator tests between
    • Dually enrolled:Oregon patients on Medicare FFS + Medicaid
    • Non-dually enrolled:Oregon patients on Medicare FFS
  • Design and implement interventions based on factors
performance disparity in diabetes indicator tests for oregon medicare ffs patients
Performance Disparity in Diabetes Indicator Tests for Oregon Medicare FFS Patients
  • Significant disparity in LDL-C testing (12.2%) between dually enrolled and non-dually enrolled Oregon Medicare FFS patients with diabetes
  • No significant disparity in HbA1c testing
  • Significant disparity in dilated eye exams (7.5% —below CMS threshold)

Data source: 1997–1998 Oregon Medicare FFS diabetes claims

project design
Project Design

Interviews + baseline medical record abstraction

Hypothesis development

Intervention development

Intervention implementation

Remeasurement(medical record abstraction and claims)

semistructured interviews and medical records abstraction
Semistructured Interviewsand Medical Records Abstraction

Sampling criteria: physicians with >5 DE and >10 NDE patients

Sample: 40 physicians

Recruited: 18 physicians

Interviewed: 16 physicians

Records abstracted: 244 patients of 15 physicians* 5 diabetes specialists

6 general internists

4 family physicians

*1 physician withdrew following the interview

semistructured interviews
Semistructured Interviews

Fifteen physicians and staff

  • use of lipid testing guidelines
  • lipid testing practices
  • barriers to testing
  • characteristics of dually enrolled and non-dually enrolled patients with diabetes
  • use of diabetes management systems
baseline measurement retrospective medical record abstraction
Baseline Measurement: Retrospective Medical Record Abstraction

66 DE records and 178 NDE records abstracted

  • test dates and results
  • blood pressure
  • hyperlipidemia treatment
  • use of systems
  • patient comorbidities
  • patient behavior (missed appointments,treatment refusal, etc.)
analytic methods
Analytic Methods
  • Combination of qualitative and quantitative methods
    • Results from semi-structured interviews analyzed using Nud*Ist qualitative software
    • Results from medical record data abstraction analyzed using MS Access and SPSS
      • Statistical analysis: Chi-square test was used to check for statistically significant differences between variables at the α=0.05 level of significance
results practitioner interviews
Results: Practitioner Interviews

LDL-C testing goals • compatible with CMS quality

indicators and ADA guidelines

Reasons not to test • advanced terminal illness

• normal LDL-C without medications

• patient indifference to treatment

Patient indifference • perceived as common among to treatment Medicaid patients

• most physicians not discouraged by initial patient indifference regarding glycemic and lipid treatment

results practitioner interviews continued
Results: Practitioner Interviews (continued)

Delegation • no standing order protocol for LDL-C testing

• most reported referring patients to nurse educator or CDE for education

Systems approach • 7 of 15 reported use of flow sheet

• 10 of 15 reported obtaining lab prior to visit more often than not

• 10 of 15 reported using flow sheet or obtaining lab prior to visit

results performance in ldl c and hba1c testing for de and nde patients of interviewed physicians
Results: Performance in LDL-C and HbA1c Testing for DE and NDE Patients of Interviewed Physicians
  • Significant disparity (23.4%) in LDL-C testing between dually enrolled and non-dually enrolled patients with diabetes
  • No significant disparity in HbA1c testing

Data source: March 1, 1999–February 28, 2001 medical record abstraction

results factors associated with dually enrolled patients
Results: Factors Associated with Dually Enrolled Patients

Medicare patients with Medicaid coverage:

  • More likely than patients without Medicaid coverage to have
    • mobility limitation
    • nephropathy
    • insulin therapy
    • psychiatric disorder
results patient factors associated with ldl c testing
Results: Patient Factors Associated with LDL-C Testing

For the aggregate sample:

  • Less likely to receive testing
    • mobility limitation
    • nephropathy

Although some patient factors were significantly more common among DE patients, no significant association was found with LDL-C testing disparity between DE and NDE

results use of a system flow sheet or planned visit
Results: Use of a System (Flow Sheet or Planned Visit)

Diabetes specialists were significantly more likely to use systems

Use of a diabetes management system was not significantly more likely to be found in the charts of non-dually enrolled patients

Aggregate

Data source: March 1, 1999–February 28, 2001 medical record abstraction

results ldl c tests among patients whose charts show use of a system by patient coverage
Results: LDL-C Tests Among Patients Whose Charts Show Use of a System, by Patient Coverage
  • Use of a diabetes management system was significantly associated with LDL-C testing
    • aggregate
    • non-dually enrolled patients

Data source: March 1, 1999–February 28, 2001 medical record abstraction

results ldl c tests among patients whose charts show use of a system by provider type
Results: LDL-C Tests Among Patients Whose Charts Show Use of a System, by Provider Type

No significant performance difference between specialists and nonspecialists

Data source: March 1, 1999-February 28, 2001 medical record abstraction

conclusions from interviews and chart abstraction
Conclusions from Interviews and Chart Abstraction

The interviews and abstracted chart data did not explain the disparity in LDL-C testing between dually enrolled and non-dually enrolled patients with diabetes.

conclusions from interviews and chart abstraction continued
Conclusions from Interviews and Chart Abstraction(continued)

Factors associated with receivinga biennial LDL-C test:

  • documented diagnosis of hyperlipidemia
  • treatment by a diabetes specialist
  • use of a diabetes management system

Factors associated with not receivinga biennial LDL-C test:

  • mobility limitations
  • nephropathy
hypothesis for intervention
Hypothesis for Intervention

Implementation of a patient management system will lead to increased LDL-C testing of both dually enrolled and non-dually enrolled patients with diabetes

  • Implementation may not reduce LDL-C testing disparity between dually enrolled and non-dually enrolled patients with diabetes
intervention tools
Intervention: Tools
  • Data support for systems change
  • Practitioner-specific performance data (automatically generated)
  • Flow sheet
  • Electronic registry
  • Planned visit concept paper
  • Systems change concept paper
intervention participants and methods
Intervention: Participants and Methods

Participants

  • Project participants
  • Additional target practitioners treating 25% of Oregon Medicare FFS dually enrolled patients

Methods

  • Detailing visits to project participants
  • Detailing visits to 1/3 to 1/2 of target practitioners
  • Mail packets to remaining target practitioners
remeasurement
Remeasurement

Interim measurements

Medical record abstractions*

  • laboratory tests and results
  • blood pressure
  • use of systems

Final measurement

Medicare FFS claims data CY 2001–2002

*5–6 months after interviews and 5–6 months after intervention