Quality of Care of Medicare Patients With Diabetes in a Metropolitan Fee-for-Service Primary Care Integrated Delivery System

Abstract

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

The Effectiveness of Implementing an Electronic Health Record on Diabetes Care and Outcomes

“…Previous research conducted within the HTPN primary care practices found that Medicare claims data indicated substantially more patients received an annual eye test than was documented in HTPN medical records (Hollander et al. ), suggesting at least some of the 13.5 percentage point difference between the EHR and non‐EHR practices seen here was due to improved documentation. Anecdotally, “foot examination” is another measure that was inconsistently documented in paper charts and it is likely that the substantial improvement seen in both the overall foot examination measure and its components with EHR exposure partly resulted from improved documentation influenced by the structure provided within the EHR.…”

The Impact of Primary Care: A Focused Review

“…These include the Health Tracking Physician Survey [37], the International Health Policy Survey [38], and the Ambulatory Care Experiences Survey [39]. Other studies have used claims data [40, 41] and medical record review [40, 42–44] to assess the quality, performance, and cost-effectiveness of primary care in various settings.…”

“…For example, a survey fielded in five countries determined that the USA performed well in delivering preventive care according to clinical guidelines [38], hypothesizing that this result might be due to third party insurers' increasing emphasis on quality measurement using tools such as the National Committee for Quality Assurance's (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS). In addition to HEDIS, other indicators, such as the Diabetes Quality Improvement Project [40], have been developed to support measurement of the quality of care provided in a primary care setting for a particular condition. Many measures of performance and quality in the healthcare setting are disease-specific.…”

Evaluation of Quality Improvement Performance in the Community Diabetes Education (CoDE) Program for Uninsured Mexican Americans

“…34,35 In 2005, a study of diabetes quality improvement for Medicare patients performed in a group of private practices within this system revealed that 16% had received foot examinations, 19% had blood pressure <130/80 mm Hg, 38% were screened for diabetic nephropathy, and 49% had received dilated retinal examinations. 36 However, an RCT performed in 2006 in the same system in fee-for-service primary care clinics that utilized highly trained diabetes nurses to manage Medicare patients with diabetes did not demonstrate any improvement in overall diabetes care or costs associated with diabetes care. 37,38 In comparison, the present study's RCT demonstrated superior performance regarding quality measures utilizing a low-cost community health worker as the diabetes educator during the same 2-year period.…”