Can collaborative learning and performance monitoring improve diabetes care in Medicare managed care plans?

Process and outcomes of care improved among Medicare patients with diabetes after six Arizona Medicare managed care plans collaborated for performance monitoring and implementing plan-specific interventions.

Why is this important?

Care for diabetes requires regular follow-up, education, and monitoring. Since the average physician participates with multiple health plans and patients often move from plan to plan, improvements in diabetes management may be facilitated by collaborative effort between quality improvement organizations, health plans, and physicians.

Interventions

Six Medicare managed care plans in Arizona collaborated with the state's Medicare Quality Improvement Organization (QIO), formerly called a peer review organization (PRO), to adopt a common set of diabetes quality measures. The QIO provided comparative feedback on health plan performance at the beginning of the project and one year later. Each health plan designed its own intervention, which may have included one or more of the following components:

• case management;
• physician-developed tracking forms;
• medical record reminder systems;
• data feedback for individual physicians; and
• patient education.

Findings

The quality of diabetes care among Medicare patients improved after one year.

• A greater proportion of patients received all needed services including diabetes monitoring, education, and follow-up treatment (34 percent before vs. 55 percent after the intervention).
• The proportion of patients with their blood sugar under control (glycosylated hemoglobin A1c below 8 percent) rose from 40 percent of patients prior to 62 percent after the intervention (Marshall et al. 2000).

Implications

This experience demonstrates the feasibility of collaboration among competing health care organizations to improve the management of diabetes care by primary care physicians.

Systematic reviews of quality improvement studies have found that multifaceted approaches can improve clinician compliance with guidelines and patient outcomes of care (Renders et al. 2001; Shojania et al. 2004). Common elements include:

• Educating patients and health professionals to improve adherence;
• Tracking patients and sending reminders for follow-up care and missed appointments;
• Prompting physicians to deliver recommended services;
• Providing physicians with feedback on their performance; and
• Involving nurses and multidisciplinary teams in patient education and care.

Improvement Ideas and Resources

Additional resources are available from the Medicare Quality Improvement Community.

Measure:

This was a before-and-after intervention trial among Medicare patients with type 2 diabetes continuously enrolled for at least one year in one of six Arizona managed care plans that together enrolled 40 percent of all Medicare beneficiaries in the state. Random samples of medical records (380 at baseline in 1995 and 767 at post-intervention remeasurement in 1996) were reviewed to determine the proportion of 14 quality indicator services that were provided to patients when needed during a one-year period. Diabetes monitoring indicators included quarterly blood pressure measurement, biannual foot exam, biannual glycosylated hemoglobin test, annual eye exam, annual lipid profile, and annual dipstick for urine protein. Diabetes education measures included diet, exercise, medication, and glucose self-monitoring. Follow-up measured whether an ACE inhibitor was prescribed if the patient had hypertension or proteinuria, treatment was provided for hyperlipidemia, and patients with abnormal eye exams were referred to an ophthalmologist (Marshall et al. 2000).

Limitations:

Lack of a control group means that the results cannot be definitively attributed to the intervention, nor is it possible to attribute the results to a specific change in process at the health plan or provider level. Though improvements were substantial, the quality of care and outcomes achieved are still far short of ideal performance.

Source:

The study used medical records and was conducted by researchers at Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, in collaboration with the Medicare managed care plans (Marshall et al. 2000).

References:

* Indicates source of data used in the chart(s).* Marshall, C. L., M. Bluestein, E. Briere et al. 2000. Improving Outpatient Diabetes Management Through a Collaboration of Six Competing, Capitated Medicare Managed Care Plans. American Journal of Medical Quality 15 (2): 65–71.

Renders, C. M., G. D. Valk, S. Griffin et al. 2001. Interventions to Improve the Management of Diabetes Mellitus in Primary Care, Outpatient and Community Settings. Cochrane Database of Systematic Reviews (1): CD001481.

Shojania, K. G., M. D. Ranji, L. K. Shaw et al. 2004. Diabetes Mellitus Care. Vol. 2 of Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies; Technical Review 9. Rockville, Md.: Agency for Healthcare Research and Quality.