Quality Metrics and Goal Setting

Transcription

1 Quality Metrics and Goal Setting Pavan Chava DO Ochsner Department of Endocrinology Director for Diabetes Management for Ochsner Health System 9/17/2016

2 Disclosures Sanofi- Research and travel grant

3 Goals Review ADA guideline goals Review 2016 HEDIS Metrics Compare ADA goals to HEDIS Tips to improve quality metrics

4 HEDIS Healthcare Effectiveness Data and Information Set (HEDIS) Used by roughly 90% of health care plans Purpose: compare quality (performance) Standard way to report performance of health plans nationally and to be used as report card by purchasers and consumers

5 HEDIS Effectiveness of Care Measures- one of several sections within HEDIS Preventative Health and Chronic Care measures Other Quality Measures- PQRS, Commercial insurance measures (Ex: Quality Blue- BCBS)

6 Key Terms Process Measure- Ex: ordering A1c, doing foot exam, eye exam Outcome Measure- Ex: Getting A1c to goal or BP under control Claims Data- data captured via claim put into insurance Encounter data- Diagnosis placed during a visit Bundles Metrics- Must meet all components in the bundle to be compliant (Not currently in HEDIS)

7 Key Terms Administrative data- data from claims or EMR data submitted to health plan Hybrid Data- administrative data and medical record data Random sample of member records

8 Identify Patients with Diabetes

9 Eligible Population Age during the measurement year Age matters for cheese, wine, and quality metrics

10 Patient Identification Claims OR Pharmacy data Claims with diagnosis of diabetes 2 outpatient visits 2 ED visit 2 Nonacute Inpatient Encounter/Obs 1 Acute Inpatient Visit Different Dates

11 Pharmacy Data Description Prescription Alpha-glucosidase Acarbose Miglitol inhibitors Amylin analogs Pramlinitide Antidiabetic combinations Alogliptinmetformin Glyburidemetformin Metforminsitagliptin Alogliptinpioglitazone Linagliptinmetformin Sitagliptinsimvastatin Canagliflozinmetformin Metforminpioglitazone Glimepiridepioglitazone Metforminrepaglinide Glimepiriderosiglitazone Metforminrosiglitazone Glipizidemetformin Metforminsaxagliptin Insulin Insulin aspart Insulin isophane human Insulin aspartinsulin Insulin isophane-insulin regular aspart Insulin lispro protamine Insulin lispro-insulin lispro protamine Insulin detemir Insulin regular human Insulin glargine Insulin glulisine Meglitinides Nateglinide Repaglinide Glucagon-like peptide- Exenatide Liraglutide Albiglutide 1 (GLP1) agonists Sodium glucose Canagliflozin Dapagliflozin Empagliflozin cotransporter 2 (SGLT2) inhibitor Sulfonylureas Chlorpropamide Glipizide Tolazamide Glimepiride Glyburide Tolbutamide Thiazolidinediones Pioglitazone Rosiglitazone Dipeptidyl peptidase-4 Alogliptin Saxagliptin (DDP-4) inhibitors Linagliptin Sitaglipin

12 A1c Metrics

13 HEDIS- Annual A1c Testing An A1c test to be done in the measurement year Identified by claim or encounter or lab data If point of care A1c testing done may not be captured unless submitted as a claim or automated data. If using hybrid data- documentation must include date and result

14 A1c Poor Control % of patients with A1c > 9% Counted in the numerator if: A1c > 9% Did not have test done Value is missing Not counted in numerator: A1c 9% CPT II Recent A1c < 7% CPT II Recent A1c 7-9%

15 A1c Control % of patients with A1c < 8% Some plans use < 9% Not compliant if A1c 8% OR Missing result Test not done

16 A1c < 7% in Selected Population Exclusion Age > 65 CABG during measurement year or year prior Percutaneous Intervention during measurement year or year prior Ischemic vascular disease diagnosis Thoracic Aortic Aneurysm CHF Prior MI ESRD CKD 4 Dementia Blindness Amputation

17 ADA- A1c Testing A1c testing at least twice a year for patients achieving treatment goals (E) Perform Quarterly if therapy changed or not at goal (E) Can use POC testing for assessing level of care (E) Should not use for diagnosis

18 ADA- A1c Goals A1c goal for most patients is < 7% (A) Can set goal at < 6.5% if can be achieved easily (C) No hypoglycemia risk No CVD A1c goal < 8% may be appropriate for some patients (B) Advanced complications Limited life expectancy High risk for hypoglycemia

19 ADA- A1c Goals DCCT showed that intensive control (A1c < 7%) decreased rates of microvascular disease ACCORD trial- looked at Intensive therapy (A1c < 6%) vs standard therapy (7-7.9%) and cardiovascular event rates At year 1- A1c of 6.4% and 7.5% achieved 257 (I) vs 203 (S) patient died. Reduction in microvascular complications but absolute risk reduction smaller. Microalbuminuria, neuropathy The Action to Control Cardiovascular Risk in Diabetes Study Group N Engl J Med 2008; 358: June 12, 2008

20 ADA- A1c Goals UKPDS 10 year F/U DM 2 newly diagnosed Between group diff in A1c was lost after year 1 Cardiovascular benefit seen 10 years post Tx MI Rate- 15% reduction if Insulin or SU used MI rate- 33% reduction with metformin Legacy effect Rury et al. N Engl J Med 2008; 359:

21 American Diabetes Association- Standards of Medical Care in Diabetes-2016

22 HEDIS- Eye Exam Retinal or dilated exam by either optometrist or ophthalmologist in measurement year A Negative (Neg for Retinopathy) in the year prior- CPT II code Can use a retinal eye camera Hybrid Data- a note in the chart that ophthalmoscopic exam done by eye care professional Chart or photograph of retinal abnormalities

23 HEDIS- Eye Exam Hybrid Data- a note in the chart that ophthalmoscopic exam done by eye care professional Chart or photograph of retinal abnormalities Blindness is not an exclusion Unable to distinguish legally blind vs completely blind

24 ADA- Screening For Retinopathy Adults with Type 1 should have dilated eye exam within 5 years of diagnosis (B) Patients with Type 2 should have dilated eye exam at diagnosis (B) If no evidence of retinopathy after 1 or more exams, then an exam every 2 years can be considered (B) Retinal photography can serve as a screening tool, but not a substitute for comprehensive eye exam which should be performed initial and as rec by opt/ophth (E)

25 HEDIS- Medical Attention for Nephropathy Nephropathy screening or monitoring test yearly Urine for albumin/creatinine ratio. 24-hour urine for albumin or protein. Timed urine for albumin or protein. Spot urine for albumin or protein. 24-hour urine for total protein. Random urine for protein/creatinine ratio

26 Medical Attention for Nephropathy On an ACE/ARB Evidence of Stage 4 CKD Evidence of ESRD Evidence of Kidney Transplant Visit with nephrologist No restriction on diagnosis code Atleast 1 ACE/ARB dispensed

27 STEP 1: Is there documentation of ESRD, chronic or acute renal failure, renal insufficiency, diabetic nephropathy, dialysis or renal transplant? YES STOP! Member is compliant NO STEP 2: Was a urine test for albumin or protein performed during the measurement year? YES STOP! Member is compliant NO STEP 3: Review for evidence of ACE inhibitor/arb therapy. Is there evidence of therapy in the measurement year? YES STOP! Member is compliant NO STOP! Member is not compliant HEDIS NCQA

28 ADA- Screening for Kidney Disease Nephropathy changed to Diabetic Kidney Disease (DKD) Assess urinary albumin yearly in DM 1 duration 5 years and all DM 2 (B) Continued monitoring of alb/cr in patients with albuminuria on ACE or ARB is reasonable to assess response to Tx (E)

29 ADA- Management of Diabetic Kidney Disease ACE or ARB is NOT recommended for primary prevention of DKD in patients with normal BP, normal urine alb/cr ratio and normal GFR (B) 2-3 specimens over 3-6 month period should be abnormal before diagnosing albuminuria. Causes of false positive: Exercise within 24 hours Infection/Fever CHF Marked hyperglycemia Menstruation Marked HTN

30 HEDIS- BP Control BP < 140/90 (cannot be =) Most recent BP reading Outpatient visit Nonacute inpatient encounter No measurement is considered uncontrolled Must have both systolic and diastolic If multiple readings on the same day the lowest will be used

31 ADA BP Recommendations Systolic Target <140 mmhg (A) Lower systolic target < 130 mmhg for certain individuals (C) Younger patients Albuminuria HTN + 1 addition ASCVD risk factor if can be achieved without any burden Diastolic Target < 90 mmhg (A) Lower Diastolic target < 80 mmhg for certain individuals (B) Same criteria as lower systolic target

32 ADA BP Recommendations < 130/70 mmhg not recommended for older adults (C) Intensive BP targets not assoc w/ decrease in mortality, or MI Small decrease in absolute risk of stroke 1% Increased risk serious adverse events- hypotension, arrhythmia, hyperkalemia ACCORD- no benefit with aggressive BP lowering- avg BP in Tx group 119/64 ADVANCE- Showed improvement but Tx group avg BP was 136/73 McBrien et al. Arch Int Med Sep 24; 172 (17):

33 Statin Therapy % of patients dispensed any strength statin Also report % patients with 80% adherence rate Metric for LDL goal retired in 2015 Goal- Assess use of statin therapy for Primary Prevention Exclusion- patients with cardiovascular disease Pregnancy IVF ESRD Cirrhosis Myalgia, myopathy, myositis, rhabdo

34 ADA Recommendations on Lipid Management Obtain lipid profile at initiation of station therapy and "periodically" thereafter to monitor response and adherence (E) Diabetes + ASCVD- High Intensity statin < 40 yo with additional ASCVD risk factors- consider mod-high intensity statin (C) Age without additional ASCVD risk factorsconsider mod intensity statin (A)

35 ADA Recommendations on Lipid Management Age with ASCVD risk factors- high intensity statin (B) Age > 75 without ASCVD risk factors- consider mod intensity statin (B) Age > 75 with ASCVD risk factors- consider mod or high intensity statin (B)

36 American Diabetes Association- Standards of Medical Care in Diabetes-2016

37 IMPROVE-IT Trial Double Blind, Randomized trial- 7 years 18,000 patients hospitalized for ACS and had LDL mg/dl on therapy or mg/dl not on therapy Simvastatin 40 mg and Zetia vs Simvastatin 40 mg vs Placebo Primary Endpoint- Composite: CV death, Non fatal MI, unstable angina, Revascularization, non fatal stroke Primary endpoint 32.7% (Sim/Zetia) vs 34.7% (Sim) LDL difference 16.7 mg/dl 27% with DM Absolute risk reduction 5% (RR 14%) in combo vs Sim. Zetia + Mod Statin- consider in pt w/ ACS with LDL 50 mg/dl or who cannot tolerate high dose statin (A) Cannon et al. NEJM. June (25)

38 ADA- Older Adults (Age 65)

39 Older Adults Insulin secretagogues should be used with caution due to hypoglycemia risk Glyburide contraindicated Hospice patients may require an approach emphasizing comfort and symptom relief Keep BG < 200 mg/dl Prevent Hypoglycemia

40 Tips to Improve Metrics Accurate Coding Inaccurate diagnosis can lead to patient incorrectly placed into a registry Using Diabetes code to order screening A1c Missing a code can make a patient noncompliant with a metric when they should be excluded (Ex: Gestational Diabetes, PCOS) Using CPT II codes- tracking codes to help with data collection Entering information that are important for metrics in a discreet data field

41 Tips to Improve Metrics Addressing Health Care gaps regardless of reason for visit Due to time constraints can consider focusing on process goals Updating health maintenance with outside medical records Making team members aware of quality metricscan improve workflow and tee up closing gaps Utilization of Health Maintenance screens or flowsheets

42 Tips to Improve Metrics Work with referring providers on sharing of data as well as appropriate documentation Use staff to scrub schedule to look for gaps that can be closed- order labs prior Utilization of registries and written order guidelines to close process gaps Efficient utilization of limited resources Decrease duplication of services Engage patients by letting them know gaps

43 Tips to Improve Metrics Accurately measure blood pressure Avoid use of automatic cuff Repeat at end of visit Instruct patients to take their medications before appointments Use a team approach to care Timely completion of notes If you are shooting for 100% you may be over treating

44 Questions? Resources American Diabetes Association- Standards of Medical Care in Diabetes-2016 HEDIS NCQA