Diabetes Data Dilemmas: Diabetes Prevention and Control

Kansas Diabetes Quality of Care Project

Seventh Annual Disease Management ColloquiumPhiladelphia, PA

May 8, 2007Marti Macchi, MEd, Director, Special Studies

Kansas Department of Health and EnvironmentJoe Brisson, Vice President Client Services

Browsersoft

Outline

Project RationaleStatewide ProjectProject ComponentsFirst Year OutcomesData Translated Into PracticeFuture DirectionOpen HRE™ Project

Project RationaleData – Decision Support

Burden of Diabetes in Kansas

2005 – 7.0% Adult Kansans diagnosed with diabetes

7th Leading cause of death (683 Kansans died of diabetes in 2004)

Estimated direct and indirect costs of diabetes were nearly $1.3 billion a year

2004 Kansas Behavioral Risk Factor Surveillance System, KDHE.Center for Health & Environmental Statistics,Office of Vital Statistics KDHE, 2004Lewin Group, Inc., American Diabetes Association,, 2002

Average Yearly Health Care CostUnited States 2002

$13,243

$2,560$0

$2,000$4,000$6,000$8,000

$10,000$12,000$14,000

Person With DiabetesPerson Without Diabetes

Source: Hogan P etal. Economic Cost of Diabetes in the U.S.in 2002. American Diabetes Association. Diabetes Care. 26: 917-932, 2003.

Costs Associated with Poorly Controlled Versus Well

Controlled Diabetes

$49,673$11,62910%$45,557$10,4249%$42,467$9,5558%$40,230$8,9547% (goal)$38,726$8,5766% (normal)

Adult with Diabetes, Hypertension & Heart

Disease

Adult with Diabetes

A1cLevel

Average Medical Care Over 3 Year PeriodSource: Gilmer, Todd P, et al. Diabetes Care 1997; Vol. 20, No. 12.

Kansas Diabetes Prevention & Control Program Objectives

60.7% to 63.5%Recommended annual influenza immunization

49.3% to 51.6%Recommended annual pneumococcal immunization

67.5% to 83.0%Dilated eye exam

60.8% to 83.0%Annual foot exam 69.1 % to 83.0 %HbA1c test

By 2008, increase the rate of:

Statewide Project

RawlinsCheyenne Decatur Norton Phillips Smith JewellRepublic

Washington Marshall NemahaBrown Doniphan

Sherman Thomas Sheridan Graham Rooks Osborne Mitchell

Cloud

Ottawa

Clay

Morton

Wallace Logan Gove Trego Ellis Russell

Lincoln

Ellsworth

Saline

Greeley Wichita Scott Lane NessRush

BartonRice

McPher-son

Hamilton Kearney Finney

Stanton Grant Haskell

Stevens Seward

Gray

Meade Clark

Ford

Hodgeman

Comanche

Kiowa

Edwards

Pawnee

Stafford

Pratt

Reno

Kingman

HarperBarber

Harvey

Sumner

Sedgwick

Cowley

Butler

ChautauquaMont-gomery Labette Cherokee

ElkWilson Neosho

Greenwood

Crawford

Bourbon

Linn

Allen

Miami

Anderson

Franklin

Wood-son

LyonCoffey

Osage

Marion

Chase

Dickinson

Morris

Geary

Waubaunsee

Pottawatomie

RileyJackson

Shawnee

Atchison

Leavenworth

Douglas Johnson

Jefferson

Stafford

Reno

Kansas Diabetes Quality of Care Project Sites

Project Organization Demographics

68 funded organizations90 sites statewide350 participating health professionals50% of Kansas’ counties representedDiverse organizations participatingOver 4,000 patients with Diabetes

Types of participating organizations:Local Health DepartmentsCommunity Health ClinicsSafety Net ClinicsAmerican Indian Health ClinicHome Health AgenciesHospital Affiliated PracticesPrivate PracticesFarmworker ProgramPromotora Program

Project Organization Demographics – cont’d

Project Components

First Year-----ProcessChronic Care Model TrainingChronic Disease Electronic Management System (CDEMS) TrainingData Entry and AnalysisQuarterly ReportsOffice Protocol Development EncouragedDiabetes Teams EncouragedRegular Team Meetings EncouragedMonthly Conference CallsSite Visits

Project Components

Second Year-----OutcomesAdvanced CDEMS TrainingAdvanced Data AnalysisDiabetes Teams EstablishedRegular Team Meetings DocumentedOffice Protocols ImplementedMonthly Conference CallsImproved Quality of Care Measures

The Chronic Care Model

Chronic Care Model Components

Health Care Organization Delivery System DesignDecision SupportSelf-Management SupportCommunity ResourcesClinical Information System

CDEMSHow does it work?

Patient Data Entered

% of Patients ReceivingVaccinations and Foot ExamsNeeds Improvement

Hard copy insertedinto patient’s chart

Dr. updatespatient’s chart

First Year Outcomes

42%60%42%Holding routine diabetes team meetings

46%66%45%Quantifiable goals for quality of care provided to Patients

% change4th quarter 1st quarter Outcomes

Health Care Organization

Organizations Checking Yes on the Quarterly Office Self-Assessment Form

50%54%36%Non-physician staff empowered to order overdue labs

-60%60%All patients scheduled for follow-up

8%39%36%Non-physician staff allowed to do foot exam

18%57%48%Non-physician staff empowered to administer flu and pneumonia vaccinations

76%69%39%Routinely ask patients to remove socks and shoes before exam

% change4th quarter 1st quarter Outcomes

Delivery System Design

First Year Outcomes Cont’d….

Organizations Checking Yes on the Quarterly Office Self-Assessment Form

50%54%36%CDEMS used to make decisions about needed care for patients

% change4th quarter 1st quarter Outcomes

Decision Support

First Year Outcomes Cont’d….

200%54%18%Patients routinely know their targets for blood pressure, finger stick blood sugar, and HbA1

64%69%42%Provide resources for patients to allow them to be full partners in their care

% change4th quarter 1st quarter Outcomes

Self-management Support

Organizations Checking Yes on the Quarterly Office Self-Assessment Form

66%75%45%Use CDEMS to record patients with eye exams, foot exams, HbA1c, flu and pneumonia vaccinations

55%42%27%Use CDEMS as a reminder system to prompt when a patient is due for labs or visit

% change4th quarter 1st quarter Outcomes

Clinical Information Systems

First Year Outcomes Cont’d….

30%51%39%Develop partnerships in the community for referral

% change4th quarter 1st quarter Outcomes

Community Resources

Organizations Checking Yes on the Quarterly Office Self-Assessment Form

01 to 2

3 to 56+

14.0

42.6

32.9

10.4

0

10

20

30

40

50

Pat

ian

t P

erce

nta

ge

Number of Visits

Percentage of Patients by Number of Visits

Patient Office Visits

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

0-1415-29

30-5960+

0.4 2.6

43.9

49.9

05

101520253035404550

Pat

ient

Per

cent

age

Age Group

Percentage of Patients by Age Group

Age Demographics

1st Year Results 2005-2006 - CDEMS Data ,Office of Health Promotion (KDHE)

White AfricanAmerican

AmericanIndian

Asian Hispanic Unspecified

73.9

4.70.4 0.3

11.2 8.8

0

10

20

30

40

50

60

70

80

Pat

ien

t P

erce

nta

ge

Percentage of Patients by Ethnicity

Ethnicity

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

Percentage of Patients by Insurance Type

6.7

28.9

15.8

25.8

7.7

05

101520253035

Medicaid Medicare Commercial Other None

Type of Insurance

Pat

ient

Per

cent

age

Insurance

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

<=24 Normal 25-29

Overweight >=30 Obese

-

7.415.9

42.2

010203040506070

Pat

ient

Per

cent

age

Body Mass Index Range

Percentage of Patients by Body Mass Index

Body Mass Index

Body Mass Index is defined as weight in kilograms divided by height in meters squared (kg/m2)

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

Comorbidity/Complication Profile of Patients

56.5Hypertension

3.5Retinopathy

3.9Peripheral Vascular Disease

3.7Cerebrovascular Disease (stroke)

4.6Nephropathy

9.6Neuropathy

12.5Heart Disease/Coronary Artery Disease

56.3Hyperlipidemia

Percentage (%)Comorbidity/Complication

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

Specialty Care Received

DM Edu.Nutrition Edu.

Smoke cessationSelf Mgt. Goal

Set

28.5

22.8

7.1

16.9

05

101520253035

Pat

ien

t P

erce

nta

ge

Specialty Care

Percentage of Patients Who Received Specialty Care

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

Preventive Care Practices

A1c Test Flu Vac PneumoVac

FootCheck

RetinalExam

SelfMoniter

BG

75.9

24.1

10.5

51.1

25.721.6

0

10

20

30

40

50

60

70

80Pa

tient

Per

cent

age

Percentage of Patients by Preventive Care Practices

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

HbA1c Levels

<7.0 7.0 - 7.9 8.0 - 8.9 9.0 - 9.910 +

38.7

16.3

7.04.3 7.5

0102030405060

Pat

ient

Per

cent

age

HbA1c Level (%)

Percentage of Patients by HbA1c Level

1st Year Results 2005-2006 - CDEMS Data, Office of Health Promotion (KDHE)

Data Translated Into Practice- at the clinic level

New office protocols in all organizationsDiabetes patient newslettersPatient certificates for improved A1cPre-visit patient self-assessment programsCDEMS data used to guide team decisions Improved communication among providersSeparate diabetes clinic days establishedPatients made full partners in care

Data Translated Into Practice- at the community level

Pre-Diabetes Screening ProgramsCommunity health fairsChurches Cattle and hog processing plants

New Community PartnershipsYMCAPodiatristsOptometristsDentists

Community Diabetes Education ProgramsTargeting seniorsTargeting overweight/obese

Project Direction

Continue to add organizationsProvide technical assistance to practices to further improvements in diabetes indicatorsCollaborate with other chronic disease programs (Hypertension quality of care project)Explore collecting primary prevention dataExplore interfacing CDEMS with EHROpenHRE™ expansion (Pilot to additional clinics)

OpenHRE™ Pilot Project

Process ProblemMethod of data collection was not efficient (manual spreadsheets)Accuracy of information obtained was affected due to inconsistent data collection and submissionTimeliness to aggregate dataReporting – limited to MS Excel

About OpenHRE™

OpenHRE Community - is a consortium of communities and organizations working together to achieve secure and sustainable Health Record Exchanges.

OpenHRE™ - toolkit consists of three configurable services that connect existing data sources for Health Information Exchange. The OpenHRE™ toolkit is available for download as free, open source software.

OpenHRE™ Pilot Project

Pilot DeploymentCollect data from 5 rural sites representing 13 clinics (1,408 patients)Remove directly identifiable patient dataCreate web-based Diabetes Summary ReportImplement OLAP Reporting

Kansas Department of Health and EnvironmentCDEMS - PilotBrowsersoft/OpenHRE

Kansas Department of Health and EnvironmentCDEMS - PilotBrowsersoft/OpenHRE

Plainville

Colby

Ellworth

Salina

Hiawatha

ReportingDatabase

KDHE Server running the OpenHRE application.

JPivot BrowserOLAP Application

Tomcat

Mondrian

Diabetes SummaryReport

CDEMSAdapter

Replicated site databases

Diabetes Summary ReportParameters Screen

Diabetes Summary ReportReport Output

OLAP Reporting ToolParameters Screen

OLAP Reporting ToolSample Output

OLAP Reporting ToolSample Graph Output

Problems AddressedProcess Problems

Method of data collection was not efficient (manual spreadsheets)Eliminated manual entry for participating clinics

Accuracy of information obtained was affected due to inconsistent data collection and submission

Automated collection occurs monthly or more frequently if desired

Timeliness to aggregate dataNightly updates as new data arrives

Reporting – limited to MS ExcelParameter driven Diabetes Summary ReportOLAP tool for Data Analysis

Open source software provides a cost effective deploymentReusabilitySustainable

Contact Information

Marti Macchi, MEdDirector of Special Studies

Kansas Department of Health and Environment

MMacchi@kdhe.state.ks.us

Joe BrissonBrowsersoft, Inc.Vice President of Client Services joeb@browsersoft.com