May 2002, (Vol. 3, No. 3)
The Wisconsin Collaborative Diabetes Quality Improvement Project: A Collaborative Success
By: Kristine Dawson, MS, Robert Stone-Newsom, Ph.D., & Faye Gohre, RN, BSN

Diabetes is  a serious, common, costly, yet controllable chronic disease that affects approximately 330,000 people in Wisconsin. Much of the health and economic burden of diabetes can be averted through known prevention measures.

The Wisconsin Diabetes Control Program (DCP), established by a CDC grant in 1994, is charged with conducting surveillance and evaluation of the burden of diabetes, designing community interventions and health communications, and working with health systems to improve diabetes care. The DCP provides statewide coordination of diabetes activities through its Diabetes Advisory Group, comprised of over 50 diverse government, non-profit and for profit partners, including state HMOs.

In 1998, the Diabetes Advisory Group partners developed and endorsed the Essential Diabetes Mellitus Care Guidelines, a model (revised in 2001) with the potential to help improve diabetes care throughout Wisconsin (1). The DCP solicited the active participation of state HMOs in the guideline development, critique, and approval process. The DCP also initiated and maintains a communication system that allows regular sharing of new information with the HMOs.

In 1999, the DCP partnered with the University of Wisconsin-Madison to develop a quality improvement project that collects comparative population data to assess the status of diabetes care in Wisconsin, while evaluating implementation of the Guidelines within Wisconsin's HMOs. A workgroup, the Wisconsin Collaborative Diabetes Improvement Project, was convened that included MetaStar, the Division of Health Care Financing, the majority of Wisconsin HMOs, and three other health systems. To obtain valuable information while minimizing the data collection burden, the workgroup selected existing HEDIS® (Health Plan Employer Data and Information Set) methodology and diabetes care measures (2,3).

The Wisconsin Collaborative Diabetes Quality Improvement Project's continuing goal is to improve, through collaboration and sharing, the level of preventive diabetes care measures received statewide. In the first year of the project (4), 1999 HEDISâ (1998 data) measures were collected in a pilot project from a number of state HMOs, a tribal council, a health provider, and an insurance corporation to assess the feasibility of this collaborative project. The second year, collecting data for care delivered in 1999 (2000 HEDISâ), represents baseline comprehensive project data (5). In the third year, collecting data for care delivered in 2000 (2001 HEDIS®), direct comparison of data collected in years two and three could be made to assess the success of ongoing quality improvement initiatives. Significantly, these data efforts have not only been used for comparisons between systems, but have also served as the basis for sharing improvements in care and data systems among health plans, and for the development of statewide collaborative quality improvement projects.

Methods

The project collects data from licensed Wisconsin HMOs (18 of 24 in year one, 18 of 22 in year two, and 17 of 20 in year 3) and, additionally, from select health system members. Because patients in the latter health care organizations could be included in one or more HMOs, aggregate calculations include only data from HMOs. Of the greater than 1.5 million individuals enrolled in HMOs in Wisconsin, 98% were represented by year 3 of this project (6). This representation rate has increased with each year of the project: 68% in the first year, 84% in the second year, to this year's rate of 98% (4,5).

Participants reported data pertaining to HEDISâ definitions for Comprehensive Diabetes Care measures for each year of the project. These measures are limited to individuals with diabetes 18-75 years of age, and include: eye exam; LDL-C screening performed; LDL-C controlled (<130 mg/dL); hemoglobin A1c (the HbA1c test measures the amount of sugar that is attached to the hemoglobin in red blood cells, with results given as a percentage); HbA1c poorly controlled (>9.5%); and nephropathy monitoring (2,3).

Results

An overall comparison of the Comprehensive Diabetes Care summary measures for plans participating in both 2000 (1999 data, n=18) and 2001 (2000 data, n=17) is presented in Figure 1. As mandatory reporting of Comprehensive Diabetes Care measures began with 2000 HEDISâ (1999 data), aggregate data is now comparable across all participating plans. Improvement was seen across all measures. Percent receiving eye exam improved by 11% overall (62% to 69%), LDL-C screening improved by 8% (72% to 78%), LDL-C control (<130mg/dL) by 13% (45% to 51%), one/more HbA1c by 1% (86% to 87%), poorly controlled HbA1c (>9.5%) remained the same (28% to 28%) and nephropathy monitoring improved by 11% (47% to 52%).

Discussion

The State of Managed Care Quality, compiled by NCQA and based upon quality measure information submitted by hundreds of managed care organizations nationwide, reports national data for all HEDIS® health measures (7). This data, when compared with our study's data (Table 1), clearly indicates our commercial HMO study population achieved marks above the national averages for all Comprehensive Diabetes Care measures in both 2000 and 2001 (1999 and 2000 data).

Table 1: Comparison of National and Study Populations Receiving Comprehensive Diabetes Care Measures

  Wisconsin Average

(HMO Participants)
National Average


  1999 Data (n=18)> 2000 Data 1999 Data 2000 Data
Eye exam 62% 69% 45% 48%
LDL-C screening performed 72% 78% 69% 77%
LDL- C controlled (<130 mg/dL) 45% 51% 37% 44%
One/more HbA1c 86% 87% 75% 78%
Poorly Controlled HbAlc (>9.5%)* 28% 28% 45% 43%
Nephropathy Monitored 47% 52% 36% 41%

*Low percent is desired

Some data collection limitations should be noted. First, since HMO membership represents 30% of the state population, the results do not present a statewide picture of diabetes care for all individuals, especially those with diabetes who are uninsured or insured through other means. Also, data in this study were collected separately by each participant and are subject to the variability inherent in each organization's ability to abstract data. While true, a positive outcome of this limitation is that the majority of reporting organizations have streamlined their processes by implementing or updating diabetes registries and making improvements in medical documentation. Further, the design of this study and the use of HEDISâ definitions for data abstraction were specifically implemented to limit the affects of this variability.

Ongoing Improvements

In the spring of 2001, members of the workgroup joined efforts to develop a statewide quality improvement project to increase diabetic eye exams and enhance communication between eye care specialists and primary care providers. Collaborators developed a reporting tool, as well as special appeal letters intended to provide a unified message through use of joint letterhead including the name of each partner organization. Project letters and materials were sent to over 4000 primary care providers and eye care specialists across the state. Collaborators agreed to promote the intervention and report related activities for evaluation purposes.

Conclusions

The Wisconsin Collaborative Diabetes Quality Improvement project demonstrates that diabetes related clinical testing is improving, and that the state's diverse HMOs are willing to collaborate with multiple partners and the state health department on diabetes quality improvement projects. This project strongly illustrates that an ongoing communication forum is essential for distribution of new research and resources; to promote dynamic brainstorming and planning; to coordinate the sharing of quality improvement strategies; and to respond to HMO requests. None of these successful results would have been achieved without a high level of commitment to the collaborative effort. Collaboration is key to the continued successes of this project.
Diabetes comparison


References

  1. The Wisconsin Diabetes Advisory Group. Essential Diabetes Mellitus Care Guidelines. Wisconsin Department of Health and Family Services, Division of Public Health, Bureau of Chronic Disease Prevention & Health Promotion. 1998.
  2. National Committee for Quality Assurance: An Overview. Available online:http://www.ncqa.org
  3. National Committee for Quality Assurance. HEDIS® 2000 Vol.2 and HEDIS® 1999 Technical Update.
  4. Quenan L, Remington P, Gohre F, and Zapp P. The Wisconsin Collaborative Diabetes Quality Improvement Project. Wisconsin Medical Journal. 2000; May-June.
  5. Dawson K, Stone-Newsom R, Gohre F, Remington P. The Wisconsin Collaborative Quality Improvement Project Year 2. Technical Report: Wisconsin Public Health and Health Policy Institute, June 2001.
  6. Office of the Commissioner of Insurance State of Wisconsin. HMO Information. Available online: http://oci.wi.gov/
  7. The State of Managed Care Quality Reports. Available online: http://www.ncqa.org