Diabetes and Hypertension

Transcription

1 State of Tennessee Department of Finance and Administration STATE HEALTHCARE REPORT CARD VERSION 1.1 Diabetes and Hypertension March th Avenue North, Suite 777 Nashville, TN Phone Fax Lenox Park Boulevard, Suite 309 Memphis, TN Phone Fax

2 Acknowledgements Pooling statewide healthcare data across public and private providers was no easy task. This report was developed through the cooperation and participation of the major health plans in Tennessee, specifically: Aetna, BlueCross BlueShield of Tennessee, Cigna, Humana, Medicare, Medicaid 1 and UnitedHealthcare. The culmination of their effort is represented in this State Healthcare Report Card, Version 1.1, which would not have been possible without their participation. The inspiration to develop this report arose from priorities identified during the Quality 1.0 DesignShop, underwritten by the Agency for Health Care Research and Quality (AHRQ) and hosted by the Vanderbilt Center for Better Health. Group facilitators included Matt Andrews, Doug Cantrell, Tom Lloyd, Katherine Stubbs and Steve Weissenburger. The diverse group at the workshop was composed of the following participants and organizations: Bill Anderson, HealthSpring Craig Becker, THA Nancy Blair, FedEx Rachel Block, State of NY Susan Christensen, Baker Donelson Brooks Daverman, State of TN Linda Davis, State of MN Vicki Estrin, Vanderbilt Regional Informatics Dawn FitzGerald, QSource Gaye Fortner, Knoxville Business Coalition Phyllis Franklin, TMA Mark Frisse, Vanderbilt Regional Informatics David Goetz, State of TN Charles Handorf, TMA Melissa Hargiss, State of TN William Hauser, Aetna Robin Hemphill, Health Care Solutions Group Ron Hill, Vanderbilt Rodney Holmes, Vanderbilt Regional Informatics Janice Huckaby, UHC Jeanne James, State of TN Jim Jirjis, Vanderbilt Janet King, Vanderbilt Regional Informatics Larry Kloess, HCA TriStar Richard Lachiver, Humana Laurie Lee, State of TN David Moroney, BlueCross Rob McLaughlin, Cigna Ginny Meadows, SharedHealth Michael Minch, TMA Gregg Mitchell, Tennessee Academy of Family Physicians Shawn Morris, HealthSpring Michael Morse, North Highland Sharon Mullins, Vanderbilt Jeff Ockerman, State of TN Emily Passino, State of TN Rebecca Reynolds, UT Memphis Will Rice, Vanderbilt Regional Informatics Bill Rudman, UT Memphis Dick Salmon, Cigna David Sensibaugh, Eastman Chemical Hardy Sorkin, HealthSpring Jack Starmer, Vanderbilt Bill Stead, Vanderbilt Regional Informatics Sarah Stewart, Vanderbilt Regional Informatics Bruce Taffel, SharedHealth Cristie Travis, Memphis Business Group on Health Mary Van Cleave, THA Ruth Wescott, HCA Patrick Willard, AARP 1 The Medicaid program in Tennessee is TennCare. Department of Finance and Administration Page 2 QSource-TN

3 Introduction Many institutions produce statewide statistics across a wide spectrum of healthcare measures. In these reports, Tennesseans consistently rank poorly on virtually every indicator when compared nationally. These measures include incidence and prevalence of disease as well as measures of quality of care. Rather than trying to replicate these results or provide an overarching statement on the quality of healthcare in Tennessee, this State Healthcare Report Card, Version 1.1 is meant to simply document and track two significant diseases affecting Tennesseans diabetes and hypertension. According to the most recent Behavioral Risk Factor Surveillance System Report (BRFSS) 1, Tennessee s rate of diabetes is the highest of all the states in the nation. More than half a million of the state s men, women and children age 18 and older are living with diabetes. Representing 11.9 percent of the population, that makes diabetes more prevalent here than nationally, and well above the Health People 2010 Objective for diabetes of 2.5 percent. In addition to being one of the most disabling conditions, diabetes is one of the most expensive. One in five U.S. healthcare dollars an estimated $174 billion 2 was spent treating patients with diabetes in For every dollar that employers pay, 75 cents is dedicated to caring for employees with one or more chronic health conditions, diabetes among them. The result? Tennessee is spending more but without the better health to show for it. 3 If you add high blood pressure and high cholesterol to the mix, the consequences are worse. In 2007, more than one third of Tennesseans were affected by these conditions, which increase the risk and severity of both diabetes and heart disease. 4 A Statewide Response This report card is designed to investigate what can be learned about diabetes and hypertension, as well as the care received by people with these diseases. The report takes a focused approach to show what questions can be answered using the existing data and those questions that cannot. The results should foster conversation around healthcare and assist the state in setting priorities for future healthcare reports. They will also serve as a tool for policymakers in defining future legislative goals As of fiscal year 2003, Tennessee spent 4 % of the gross state product on health expenditures, compared to 3% nationally; Department of Finance and Administration Page 3 QSource-TN

4 Introduction The stateʹs ultimate interest is to improve healthcare affordability and quality using informed strategies rather than one size fits allʺ solutions. Key players will share information, then use it in ways best suited to their customers. This report is a first step toward identifying what can be accomplished through more sophisticated and comprehensive measurement of healthcare quality in Tennessee. This State Healthcare Report Card, Version 1.1 aggregates performance data from nearly all of the state s healthcare payers commercial, Medicare and Medicaid in one place. Using data reported on a statewide and county by county basis, it illustrates the prevalence of diabetes, high blood pressure and high cholesterol across the Volunteer State and the consequences when these conditions are not managed effectively. Background The need for this report card was identified as part of the Quality 1.0 DesignShop a workgroup of 40 providers, health plans, employers and academicians that gathered to explore common ground in the measuring, reporting and use of healthcare quality data. Hosted by the Vanderbilt Center for Better Health, the workgroup convened October 21 22, 2008, and identified three primary objectives: 1. Target conditions that are important to the healthcare system (purchasers, providers, employers, etc.). 2. Use data and indicators for these conditions that are feasible, reliable and can be collected consistently across health plans. 3. Focus on county level information as a first step toward identifying public health interventions. This report card demonstrates what can be accomplished with healthcare quality measurement that is more sophisticated and comprehensive. As a result, stakeholders of all types can advance the conversation concerning these largely preventable conditions. The ultimate goal is to help state healthcare stewards refine their prevention and treatment efforts, to aid policymakers in defining legislative goals and, above all, to improve the health of all Tennesseans. Department of Finance and Administration Page 4 QSource-TN

5 Methodology This State Healthcare Report Card, Version 1.1 includes diabetes, hypertension and cholesterol management data derived from two sets of measures: HEDIS (Healthcare Effectiveness Data and Information Set) and PQI (Prevention Quality Indicators). HEDIS Measures HEDIS measures were developed by the National Committee on Quality Assurance (NCQA). For this report, six health plans submitted county level and/or statewide health plan HEDIS data for the period January 1 December 31, They were: Cigna BlueCross BlueShield of Tennessee Humana Medicare Medicaid UnitedHealthcare Two categories of HEDIS measures are included in this report: screening measures (e.g., how many diabetics have had their blood sugar levels tested) and condition control measures (e.g., are blood sugar levels adequately controlled). Both types of measures can be calculated administratively using claims, encounter and/or laboratory data. Measures can also be calculated via a hybrid method, for which medical record data are added to ensure more accurate reporting. The screening measures in this State Healthcare Report Card, Version 1.1 were calculated using administrative data and reported at the county level. A statewide average was also calculated. To meet county level requirements, the participating health plans retraced their measure denominator files back to the original enrollee demographic files to identify the enrollee s county of residence. One health plan that attempted to perform this look back (Aetna) was unable to provide data at the county level but intends to do so for the next measurement year. All in all, the combined data for the diabetes screening measures includes nearly 220,000 patients with diabetes, and roughly 29,000 patients with hypertension. Condition control measures are limited to state level statistics in this report because the data on these measures have two major flaws for county level reporting. First, condition control measures rely heavily on the supplementation of medical record data, but NCQA requires Commercial PPO health plans to report all HEDIS measures utilizing the administrative method only, without chart supplementation. As a result, HEDIS observed rates for PPO plans are nearly always lower than the real rate of patients whose conditions are controlled; combining PPO and HMO data can skew the results. Second, hybrid measures are calculated using sample data. These data are drawn to represent the plan s entire eligible population (i.e., plan members Department of Finance and Administration Page 5 QSource-TN

6 Methodology with the particular condition being measured) and thus cannot reliably be used to report results at the county level. To address these two problems with condition control measures the lack of hybrid data from PPOs and the fact that sample data cannot be reliably subdivided into county level data and in order to present the most accurate representation for these measures, only statewide level Commercial HMO and Medicaid hybrid data are included in the current analysis. For each condition control measure, performance was calculated as an average of the health plans results. A county level performance rate and statewide weighted average were calculated for each of the HEDIS screening measures detailed in Table 1, while the average health plan performance was calculated for each of the condition control measures. Appendix A describes the source data behind each HEDIS measure. Table 1. Selected HEDIS 2008 Performance Measures Numerator Description Measure Screening Measures (Administrative) HbA1c testing Comprehensive An HbA1c test was performed during the measurement year. Diabetes Care LDL C screening Comprehensive An LDL C test was performed during the measurement year. Diabetes Care LDL C screening * An LDL C test was performed during the measurement year. Cholesterol Management for People with Cardiovascular Conditions Condition Control Measures (Hybrid) HbA1c poor control (>9.0%) The enrollee is numerator compliant if the most recent HbA1c level is >9.0% or is missing a result or if an HbA1c test was not done during the measurement year. The enrollee is not numerator compliant if the result for the most recent HbA1c test during the measurement year is <= 9.0%. For this measure, a lower rate indicates better performance. Comprehensive Diabetes Care LDL C control (<100 mg/dl) Blood pressure control (<130/80 mm Hg) The enrollee is numerator compliant if the most recent LDL C level is < 100 mg/dl. If the result for the most recent LDL C test during the measurement year is >= 100 mg/dl or is missing, or if an LDL C test was not done during the measurement year, the enrollee is not numerator compliant The enrollee is numerator compliant if the most recent BP level taken during the measurement year is <130/80 mm Hg. If the result for the most recent BP reading during the measurement year is >= 130/80 mm Hg or is missing, or was not done during the measurement year, the enrollee is not numerator compliant. Comprehensive Diabetes Care Comprehensive Diabetes Care Department of Finance and Administration Page 6 QSource-TN

7 Methodology Table 1. Selected HEDIS 2008 Performance Measures Numerator Description Measure Screening Measures (Administrative) Blood pressure control (<140/90 mm Hg) The enrollee is numerator compliant if the most recent BP level taken during the measurement year is <140/90 mm Hg. If the result for the most recent BP reading during the measurement year is >= 140/90 mm Hg or is missing, or was not done during the measurement year, the enrollee is not numerator compliant. Comprehensive Diabetes Care Blood pressure control (<140/90 mm Hg) LDL C control (<100 mg/dl) * Medicare data were unavailable. Reported separately as Commercial HMO and Medicaid data. Prevention Quality Indicators The percentage of enrollees years of age who had a diagnosis of hypertension and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year. If the result for the most recent BP reading during the measurement year is >= 140/90 mm Hg or is missing, or was not done during the measurement year, the enrollee is not numerator compliant. The enrollee is numerator compliant if the most recent LDL C level is < 100 mg/dl. If the result for the most recent LDL C test during the measurement year is >= 100 mg/dl or is missing, or if an LDL C test was not done during the measurement year, the enrollee is not numerator compliant. Controlling High Blood Pressure Cholesterol Management for People with Cardiovascular Conditions The Agency for Health Care Research and Quality (AHRQ) has developed PQI measures to address preventable hospitalizations. PQI data for the measures summarized in Table 2 were derived from hospital discharges for the most recent year available (calendar year 2006). Even though these indicators are based on hospital inpatient data, they provide insight into the quality of the healthcare system outside the hospital setting. For example, patients with diabetes may be hospitalized for diabetic complications if their conditions are not adequately monitored or if they do not receive the patient education needed for appropriate self management. Although other factors outside the direct control of the healthcare system such as poor environmental conditions or lack of patient adherence to treatment recommendations can result in hospitalization, the PQIs provide a good starting point for assessing quality of outpatient health services in the community. A lower rate on these measures indicates fewer admissions and thus better ambulatory care health system performance. Measure PQI 1 and PQI 14 Table 2. Selected AHRQ Preventive Quality Indicator (PQI) Measures Description Admissions Due To Diabetes Complications Patients with diabetes who were hospitalized for a short term complication of their disease and/or for uncontrolled diabetes Department of Finance and Administration Page 7 QSource-TN

8 Methodology Measure PQI 3 PQI 16 PDI 15 PQI 7 Table 2. Selected AHRQ Preventive Quality Indicator (PQI) Measures Description Patients with diabetes who were hospitalized for a long term complication of their disease Rate of lower extremity amputations among patients with diabetes Pediatric patients who were hospitalized due to diabetes complications Admissions Due To Hypertension Patients who were hospitalized due to uncontrolled hypertension Summary While all of the measures in this report are considered to be well established and are widely used, utilizing them in this fashion to get a snapshot of healthcare in Tennessee illustrates the difficulty of obtaining complete, accurate, timely data especially for those measures that rely largely on medical records. Nevertheless, drawing data from a broad assortment of health plans, including commercial and publicly funded, does allow for a more sophisticated understanding of the opportunities for advancing the health of all Tennesseans. Department of Finance and Administration Page 8 QSource-TN

9 Results To put the following results into context, Figure 1 presents regional and metropolitan rates of adult respondents who answered Yes when asked if they were ever told by a doctor they had diabetes, excluding gestational diabetes. Appendix B displays the specific results for each region. Areas estimated to have the greatest percentage of adults with diabetes include the East and Northeast regions of Upper East Tennessee, as well as a swath of South Central counties, where as many as out of every 100 adults are projected to be diabetic. Even in the better counties and regions, nine out of 100 adults are estimated to have diabetes, compared with a national average of 8 out of 100 adults. Figure 1. Ever Been Told by a Doctor That You Have Diabetes, 2007 Source: Tennessee Behavioral Risk Factor Surveillance Survey (BRFSS), 2007, TN Dept. of Health. Statewide county level maps are color coded to reflect stratified performance levels. These maps are displayed for all HEDIS screening (administrative) and AHRQ prevention quality indicator measures. Specific county level HEDIS rates for the screening measures can be found in Appendix C, and specific county level rates for the PQI measures for both calendar year 2005 and 2006 are shown in Appendix D. For the condition control (hybrid) measures, Table 6 presents the average health plan performance at the statewide level. References to West, Middle and East Tennessee reflect the state s Grand Regions. Screening Measures The following three administrative measures address the prevalence of blood sugar screening for diabetics and of LDL C ( bad ) cholesterol screening for both diabetics and those with cardiovascular conditions. The county level screening ranges for the measures are: HbA1c Testing Rates Among Patients with Diabetes % LDL C Screening Rates Among Patients with Diabetes % LDL C Screening Rates Among Patients with Cardiovascular % Conditions Department of Finance and Administration Page 9 QSource-TN

10 Results Each of these ranges was divided into five equal groups, or quintiles, and color coded to indicate a ranking from lowest performance (dark blue) to top performance (palest blue). HbA1c Testing Rates Among Patients with Diabetes As demonstrated in Table 3, the calculated multi payer statewide average for HbA1c testing was 5.35 percent higher than the Medicaid HMO national average but lower than the national average for both Commercial and Medicare HMOs. Table 3. HEDIS 2008 TN vs. HEDIS 2008 National Average for HbA1c Testing Rates Among Patients with Diabetes Tennessee Average Commercial HMO Medicare HMO Medicaid HMO 82.75% 88.10% 88.10% 77.40% Figure 2. HbA1c Testing Rates Among Patients with Diabetes HbA1c Testing Rate The statewide average for blood sugar (HbA1c) testing rate was percent with an overall range of percent. The greatest concentration of top performing counties ( percent) occurred in the eastern portion of Middle Tennessee (six counties) and into neighboring Sequatchie and Cumberland counties in East Tennessee. In the East Grand Region, a second cluster in the north included Blount, Campbell, Hancock, Jefferson, Sevier and Union counties. The largest grouping of low performing counties ( percent) could be found in West Tennessee, particularly the southern half of the region. LDL C Screening Rates Among Patients with Diabetes The calculated multi payer statewide average for LDL C screening rates among diabetics was 6.22 percent higher than the Medicaid HMO national average but lower than the national average for both Commercial and Medicare HMOs. Table 4. HEDIS 2008 TN vs. HEDIS 2008 National Average for LDL-C Screening Rates Among Patients with Diabetes Tennessee Average Commercial HMO Medicare HMO Medicaid HMO 77.12% 83.90% 85.70% 70.90% Department of Finance and Administration Page 10 QSource-TN

11 Results Figure 3. LDL C Screening Rates Among Patients with Diabetes LDL C Screening Rate Top performance for cholesterol (LDL C) screening of diabetics was again concentrated in eastern Middle Tennessee and neighboring counties in East Tennessee. Largely the same counties were top performers ( percent screening rate) as for HbA1c testing rates among patients with diabetes. The number of top and low performing counties was near equal in West Tennessee. Poor performance ( percent) was distributed more evenly throughout Middle Tennessee, but included the cluster of Clay, Jackson, Pickett and Smith counties toward the region s northeast corner. In East Tennessee, nearly 15 percent of its 34 counties also demonstrated poor performance. The overall testing range was percent. The statewide weighted average for cholesterol screening was percent. LDL C Screening Rates Among Patients with Cardiovascular Conditions The calculated multi payer statewide average for LDL C testing among cardiac patients was 0.96% percent higher than the Medicaid national average but lower than both the national average for Commercial and Medicare HMOs. Table 5. HEDIS 2008 TN vs. HEDIS 2008 National Average for LDL-C Screening Rates Among Patients with Cardiovascular Conditions Tennessee Average Commercial HMO Medicare HMO Medicaid HMO 77.26% 88.20% 87.90% 76.30% Department of Finance and Administration Page 11 QSource-TN

12 Results Figure 4. LDL C Screening Rates Among Patients with Cardiovascular Conditions LDL C Screening Rate West Tennessee had its best performance in this measure, with five counties (Benton, Carroll, Crockett, Lauderdale and McNairy) achieving the highest LDL C screening rates ( percent). Compared to diabetics, low LDL C screening rates among cardiovascular patients ( ) shifted to the eastern counties of West Tennessee and into Middle Tennessee, where poor performance was also clustered in five counties in the northeast corner (Clay, DeKalb, Jackson, Pickett and Putnam). Top performance in Middle Tennessee was distributed throughout the region but largely to the south and north, where Macon, Sumner and Trousdale counties formed the only high rate cluster. In East Tennessee, that cluster included Blount, Cocke and Sevier counties, and nearby Union demonstrating the highest rates. The second best tier ( ) included seven counties running diagonally west east across the region with a scoring range of percent). The statewide weighted average was percent. Condition Control Measures For hybrid condition control measures, the average of health plan performance was calculated utilizing the available data from Commercial HMO and Medicaid HMO HEDIS 2008 results, as reported in Table 6. Table 6. HEDIS 2008 TN Health Plan Average vs. HEDIS 2008 National Averages for Commercial HMO and Medicaid HMO Measure HbA1c Poor Control (>9.0%) Among Patients with Diabetes* LDL C control (<100 mg/dl) Among Patients with Diabetes Blood pressure control (<130/80 mm Hg) Among Patients with Diabetes HEDIS 2008 Commercial HMO TN HEDIS 2008 National Commercial HMO HEDIS 2008 Medicaid HMO TN HEDIS 2008 National Medicaid HMO 27.17% 29.40% 49.71% 47.70% 40.36% 43.80% 24.47% 31.40% 35.31% 32.10% 28.43% 29.60% Department of Finance and Administration Page 12 QSource-TN

13 Results Table 6. HEDIS 2008 TN Health Plan Average vs. HEDIS 2008 National Averages for Commercial HMO and Medicaid HMO Measure Blood pressure control (<140/90 mm Hg) Among Patients with Diabetes Blood pressure control (<140/90 mm Hg) Among Patients with Hypertension LDL C control (<100 mg/dl) Among Patients with Cardiovascular Conditions HEDIS 2008 HEDIS 2008 HEDIS 2008 HEDIS 2008 National National Commercial Medicaid Commercial Medicaid HMO TN HMO TN HMO HMO 59.03% 63.90% 53.42% 55.50% 60.64% 62.20% 50.12% 53.40% 52.43% 58.70% 29.91% 38.30% *For this measure, a lower rate indicates better blood sugar control and thus better performance. Tennessee s Commercial HMO plans compared unfavorably with those nationally, performing better than the HEDIS 2008 National Commercial HMOs for only two of the six measures: HbA1c poor control (>9.0%) among patients with diabetes, and blood pressure control (<130/80 mm Hg) among patients with diabetes. Tennessee s Medicaid plans fared worse when compared to the HEDIS 2008 National Medicaid HMOs, demonstrating poorer performance for every measure. The largest gaps in performance occurred when measuring LDL C control (<100 mg/dl) among patients with diabetes and among those with cardiovascular disease. For diabetic patients, there was a gap of 6.93 percentage points between the Tennessee Medicaid HMO and the National Medicaid HMOs. For cardiovascular patients there was a gap of 8.39 percentage points between the two. Prevention Quality Indicators The diabetes and hypertension PQI measures in this section identify hospital admissions that, potentially, could have been avoided if there had been early intervention in an outpatient setting. Again, these measures are designed to provide insight into the quality of the healthcare system outside the hospital setting. They show risk adjusted hospital admissions per 100,000 county residents during calendar year The ranges for each measure are as follows: Diabetes Short Term Complications Admission per 100,000 Rate (PQI 1) and/or Uncontrolled Diabetes Admission Rate (PQI 14) Diabetes Long Term Complications Admission per 100,000 Rate (PQI 3) Lower Extremity Amputation Rate Among per 100,000 Diabetics (PQI 16) Pediatric Diabetes Short Term Complications per 100,000 (PDI 15) Hypertension (PQI 7) per 100,000 Department of Finance and Administration Page 13 QSource-TN

14 Results A lower rate on these measures indicates fewer admissions and thus better performance of preventive care in the ambulatory healthcare system. The indicators do not measure hospitals quality of care. The counties with the best performance (fewer admissions) are represented in palest blue while those with the worst performance (more admissions) appear in dark blue. Figure 5. Diabetes Short Term Complications (PQI 1) and/or Uncontrolled Diabetes (PQI 14) Risk Adjusted Rate per 100,000 Population When diabetes is uncontrolled, excess glucose (hyperglycemia) or insulin (hypoglycemia) can result in hospitalization due to potentially life threatening complications. These include a buildup of fatty acids in the blood (diabetic ketoacidosis), an increased concentration of bodily fluids (hyperosmolarity) and even coma. As such, AHRQ recommends that admissions measures for short term complications and uncontrolled diabetes be used in conjunction. 5 Adult diabetics in West Tennessee were the most deeply affected, with eight of the region s 21 counties (more than 38 percent) demonstrating the highest admission rates ( per 100,000 population). Only Henderson, McNairy and Weakley counties had the lowest rates ( per 100,000). The lowest performance in Middle Tennessee was clustered in Jackson, Overton and Putnam counties, with Coffee and Robertson bringing the regional total to five. Six of East Tennessee s 34 counties performed in the bottom tier and were located largely to the east. Middle Tennessee demonstrated the best performance. Thirty percent of its counties (12 of 40) had the lowest admission rates; these counties were scattered throughout the region. 5 When combined, these create a Healthy People 2010 indicator, which is tied to a national goal to reduce the hospitalization rate for uncontrolled diabetes in persons years of age from 7.2 per 10,000 population to 5.4 per 10,000 population; (p. 39). Department of Finance and Administration Page 14 QSource-TN

15 Results Figure 6. Diabetes Long Term Complications (PQI 3) Risk Adjusted Rate per 100,000 Population Long term complications of diabetes include renal, eye, neurological and circulatory disorders, which are experienced at some time by most diabetics. Preventable admissions due to long term complications ranged from per 100,000. In West Tennessee, poor performance dominated the region, with only Chester and Benton counties demonstrating performance in the top two tiers. In Middle Tennessee, there was a cluster of low performance in Coffee, DeKalb and Warren counties. Otherwise, overall performance was strong, particularly in the western half of the region. One quarter of East Tennessee s 34 counties had the lowest admission rates ( ), while Claiborne, Marion and Meigs counties had the highest admission rates ( ). Figure 7. Lower Extremity Amputation Rate Among Diabetics (PQI 16) Risk Adjusted Rate per 100,000 Population Rates of lower leg amputations among diabetic patients ranged from per 100,000 population. High amputation rates could be found in nine of West Tennessee s 21 counties. This included Shelby, which had the poorest performance among the state s metropolitan counties, the others being Davidson, Hamilton and Knox. Best and worst performance was scattered throughout Middle and East Tennessee with no real clusters in either category. In both regions, five counties had the highest amputation rates while eight had the lowest. Department of Finance and Administration Page 15 QSource-TN

16 Results Figure 8. Pediatric Diabetes Short Term Complications (PDI 15) Risk Adjusted Rate per 100,000 Population Results for admissions due to pediatric diabetes complications were mixed. There were 20 counties that had at least 10 pediatric diabetic cases with no admissions (represented in palest blue). As to high rates of admission ( per 100,000 population), these persisted in West Tennessee particularly along the southern border counties of Hardeman, Hardin and McNairy counties as well as Decatur and Madison to their immediate north. In Middle Tennessee, higher admission rates were clustered in Coffee, Giles, Lewis, Marshall and Rutherford counties. Five strong performers from tier two ( ) could be found near the region s western border. A cluster to the west also occurred in East Tennessee and included four counties: Bledsoe, Marion, Rhea and Sequatchie. Scott and Hancock to the north rounded out the region s tier two performers. Campbell, Claiborne, Greene and Johnson counties also to the north demonstrated the highest rates of admissions among children. Figure 9. Hypertension Admissions Rate (PQI 7) Risk Adjusted Rate per 100,000 Population Hypertension is a chronic condition that is usually controllable in an outpatient setting with appropriate use of drug therapy. High admission rates for hypertension ( per 100,000 population) were scattered throughout West Tennessee. Only Benton and Chester Department of Finance and Administration Page 16 QSource-TN

17 Results demonstrated top performance there. The largest cluster of high admission rates began with Overton and Fentress counties in Middle Tennessee and continued along East Tennessee s northern border, affecting Campbell, Claiborne, Hancock and Scott counties as well as Morgan to its immediate south. In Middle Tennessee, five counties with low admission rates ( per 100,000) surrounded poor performing Fentress, Overton and White counties. Top performance in the East Region centered in its eastern half with Carter, Green, Jefferson and Sevier, along with Roane and Sequatchie to the west. Department of Finance and Administration Page 17 QSource-TN

18 Future Efforts The incidence of preventable and chronic disease is consistently high for Tennessee s adults and children. This reality necessitates new and continued efforts to expand and refine state data collection and the interventions upon which they are based. By collecting comprehensive statewide data on the prevalence, diagnosis and treatment of these chronic conditions, Tennessee hopes to improve the quality and availability of healthcare to its citizens. Over time, the State Healthcare Report Card series will be enhanced to include more performance data, more health plans and additional HEDIS measures pertinent to other health conditions. As the breadth, depth and analysis of this data improves, so will its usefulness to providers, health plans, purchasers and consumers. The data will also aid the development of a more comprehensive state health plan that involves new stakeholders both within state government and from other sectors. While collaborating collectively, these stakeholders will act independently, using the data available to develop tailored strategies and, ultimately, improve the quality and affordability of healthcare in Tennessee. In the immediate future, the state will seek feedback from people with different perspectives to improve the data collection and reporting processes. The state will encourage these same stakeholders to turn these findings into action for their respective target populations. Working together, this first step will become a pathway to more affordable, efficient and transparent healthcare that improves the lives of all Tennesseans. Department of Finance and Administration Page 18 QSource-TN

19 Appendix A Summary of HEDIS 2008 Measure Data Sources By Health Plan Eligible Population Screening Measures Condition Control Measures Diabetics Cardiovascular Hypertension Plan /Product Table 3 HbA1c Testing Table 4 Diabetes LDL-C Screening Table 5 Cardiovasc ular LDL-C Screening Table 6 Various: Diabetes and Cardiovascular 95,298 Medicare 5,681 2,448 14,861 United Healthcare / Medicare HMO 25,785 4,277 29,960 Medicaid 15,859 3,705 30,791 UnitedHealthcare / HMO 20,655 4,247 39,037 Cigna / HMO 7,182 1,405 Cigna / PPO 52,830 15,381 BlueCross BlueShield of Tennessee / PPO 2, Humana / PPO 13,130 3,377 28,494 UnitedHealthcare / PPO Department of Finance and Administration Page 19 QSource-TN

20 Appendix B Tennessee Behavioral Risk Factor Surveillance Survey (BRFSS) State and Regions 2007 State and Regional Weighted Data Have you ever been told by a doctor that you have diabetes, not including gestational diabetes? Total Respondents Diabetes * Weighted Risk Population at Risk TENNESSEE 5, ,003 Northeast ,325 East ,007 Southeast ,981 Upper Cumberland ,765 Mid-Cumberland ,728 South Central ,013 Northwest ,880 Southwest ,273 Shelby ,264 Davidson ,792 Knox ,488 Hamilton ,627 Madison ,650 Sullivan ,710 *Number of respondents who answered YES, not including gestational diabetes. Weighted risk is the estimated percentage of the adult population that has diabetes based on the survey. Population at risk is the estimated population with diabetes based on the survey. Note: The sum of regional estimates in this column will not add up to the statewide total due to incomplete coverage of all demographic groups in every region. Department of Finance and Administration Page 20 QSource-TN

21 Appendix C County-Level HEDIS 2008 Rates: Screening Measures (State Healthcare Report Card, Version 1.1) Cholesterol Management for Patients with Cardiovascular Comprehensive Diabetes Care Conditions HbA1c Testing LDL-C Screening LDL-C Screening County Name N % N % N % Anderson % % % Bedford % % % Benton % % % Bledsoe % % % Blount % % % Bradley % % % Campbell % % % Cannon % % % Carroll % % % Carter % % % Cheatham % % % Chester % % % Claiborne % % % Clay % % % Cocke % % % Coffee % % % Crockett % % % Cumberland % % % Davidson % % % Decatur % % % DeKalb % % % Dickson % % % Dyer % % % Fayette % % % Fentress % % % Franklin % % % Gibson % % % Giles % % % Grainger % % % Greene % % % Grundy % % % Hamblen % % % Hamilton % % % Hancock % % % Hardeman % % % Hardin % % % Hawkins % % % Haywood % % % Henderson % % % Henry % % % Hickman % % % Houston % % % Department of Finance and Administration Page 21 QSource-TN

22 Appendix C Cholesterol Management for Patients with Cardiovascular Comprehensive Diabetes Care Conditions HbA1c Testing LDL-C Screening LDL-C Screening County Name N % N % N % Humphreys % % % Jackson % % % Jefferson % % % Johnson % % % Knox % % % Lake % % % Lauderdale % % % Lawrence % % % Lewis % % % Lincoln % % % Loudon % % % Macon % % % Madison % % % Marion % % % Marshall % % % Maury % % % McMinn % % % McNairy % % % Meigs % % % Monroe % % % Montgomery % % % Moore % % % Morgan % % % Obion % % % Overton % % % Perry % % % Pickett % % % Polk % % % Putnam % % % Rhea % % % Roane % % % Robertson % % % Rutherford % % % Scott % % % Sequatchie % % % Sevier % % % Shelby % % % Smith % % % Stewart % % % Sullivan % % % Sumner % % % Tipton % % % Trousdale % % % Unicoi % % % Union % % % Van Buren % % % Department of Finance and Administration Page 22 QSource-TN

23 Appendix C Cholesterol Management for Patients with Cardiovascular Comprehensive Diabetes Care Conditions HbA1c Testing LDL-C Screening LDL-C Screening County Name N % N % N % Warren % % % Washington % % % Wayne % % % Weakley % % % White % % % Williamson % % % Wilson % % % STATEWIDE 219, , ,198 Department of Finance and Administration Page 23 QSource-TN

24 Appendix D Preventable Hospitalizations per 100,000 People, by County Diabetes Short-term Complications and/or Uncontrolled Diabetes * Diabetes Pediatric Diabetes Short-term Complications Diabetes Longterm Complications Lower-extremity Amputation Rate among Diabetic Patients Hypertension Hypertension Benchmarks US ** ** ** ** ** South ** ** ** ** ** Tennessee Tennessee County Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay Department of Finance and Administration Page 24 QSource-TN

25 Appendix D Diabetes Short-term Complications and/or Uncontrolled Diabetes * Diabetes Pediatric Diabetes Short-term Complications Diabetes Longterm Complications Lower-extremity Amputation Rate among Diabetic Patients Hypertension Hypertension Tennessee County Cocke Coffee Crockett Cumberland Davidson Decatur De Kalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Department of Finance and Administration Page 25 QSource-TN

26 Appendix D Diabetes Short-term Complications and/or Uncontrolled Diabetes * Diabetes Pediatric Diabetes Short-term Complications Diabetes Longterm Complications Lower-extremity Amputation Rate among Diabetic Patients Hypertension Hypertension Hardeman Tennessee County Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon McMinn Department of Finance and Administration Page 26 QSource-TN

27 Appendix D Diabetes Short-term Complications and/or Uncontrolled Diabetes * Diabetes Pediatric Diabetes Short-term Complications Diabetes Longterm Complications Lower-extremity Amputation Rate among Diabetic Patients Hypertension Hypertension Tennessee County McNairy Macon Madison Marion Marshall Maury Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Department of Finance and Administration Page 27 QSource-TN

28 Appendix D Diabetes Short-term Complications and/or Uncontrolled Diabetes * Diabetes Pediatric Diabetes Short-term Complications Diabetes Longterm Complications Lower-extremity Amputation Rate among Diabetic Patients Hypertension Hypertension Rutherford Tennessee County Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Department of Finance and Administration Page 28 QSource-TN

29 Appendix D Diabetes Short-term Complications and/or Uncontrolled Diabetes * Diabetes Pediatric Diabetes Short-term Complications Diabetes Longterm Complications Lower-extremity Amputation Rate among Diabetic Patients Hypertension Hypertension Williamson Tennessee County Wilson *No information on statistical significance available for this measure. **Not yet available. County rate is statistically better than the overall rate. County rate is statistically worse than the overall rate. Department of Finance and Administration Page 29 QSource-TN