Community Health Checkup June 2008

Transcription

1 A project of Better Health Greater Cleveland, the Robert Wood Johnson Foundation s Aligning Forces for Quality initiative and other funders. Community Health Checkup June 2008 Diabetes Care and Outcomes in Greater Cleveland

2 To the Community: In July, 2006, the Robert Wood Johnson Foundation announced a bold initiative, called Aligning Forces for Quality, to create regional partnerships across the United States to improve the health of their citizens with chronic conditions. These partnerships were intended to align the often different interests of those who get care, those who give care, and those who pay for care. During the waning summer months, Greater Cleveland assembled a most remarkable partnership of primary care physicians, public health agencies, patient advocates, employers and health plans. We were delighted to be among an elite group of 14 communities supported by the Foundation, and our work began in early During the past 18 months, our partners, who represent the spectrum of primary care delivery in the region, have worked side-by-side to devise strategies we hoped would bring meaningful change in the health of our patients. We began with a blank canvas and bold direction from the Robert Wood Johnson Foundation: Publicly report the quality of outpatient care for chronic disease; find ways to get patients more involved in their own care; and, help doctors and patients achieve measurable improvement in their health care and their health. Tackling each of these goals in turn, or just within our own organizations, or just for one lifelong medical condition, would have been challenge enough. Better Health Greater Cleveland is taking them on in synchrony, across the diverse landscape of our medical community. Many of you probably are unfamiliar with Better Health Greater Cleveland, the organization that stands behind these efforts. We are certain, however, that you know the collaborators that comprise it. We are among the names you trust to provide your and your family s health care. We provide your health benefits and oversee public health in our region. We know that no one can bring better health alone. The partners of Better Health Greater Cleveland are pleased and proud to publish this first Community Health Checkup, a determined first step toward improving health and health care in Northeast Ohio. The Checkup describes how well our practice partners and their patients with diabetes did in 2007 in obtaining recommended care and achieving desired outcomes. The prevalence of diabetes has reached epidemic proportions in Greater Cleveland and nationwide. Poorly controlled diabetes exacts a cruel toll, causing kidney failure, blindness, leg amputations and heart disease. It disproportionately affects minorities and Better Health Greater Cleveland Community Health Checkup Report June 2008 Page ii

3 the poor, both in prevalence and complication rates. More than 100,000 people in Cuyahoga County have been diagnosed with diabetes, and perhaps another 30,000 have it but don t yet know they do. A healthier Cleveland will be a Greater Cleveland, with better quality of life, fewer missed work days, and fewer unnecessary hospitalizations for avoidable complications of common chronic conditions. We are just getting started on this ambitious journey, and we believe our region already can claim some benefit. First, because patients, nurses, doctors, insurance companies, hospitals and employers are talking to each other and seeking solutions for all our patients. Second, because this Checkup, and the ones that will follow, identify pathways for improvement. Already, we ve learned that we are doing well by national standards, but that we also all have room to improve. We plan to grow, by targeting additional medical conditions, by expanding to include aspects of hospital care, and by adding new partners. We hope you ll be one of them. Because everyone has a part to play. Randall D. Cebul, M.D., Program Director Better Health Greater Cleveland June, 2008 Better Health Greater Cleveland Community Health Checkup Report June 2008 Page iii

4 BETTER HEALTH GREATER CLEVELAND COMMUNITY HEALTH CHECKUP REPORT - JUNE 2008 TABLE OF CONTENTS LETTER TO THE COMMUNITY TABLE OF CONTENTS LIST OF TABLES AND FIGURES EXECUTIVE SUMMARY PART ONE. UNDERSTANDING GREATER CLEVELAND S COMMUNITY HEALTH CHECKUP ii iv v 1 4 A. What is Better Health Greater Cleveland and Who are Our Partners? B. What and Who does the Community Health Checkup Include? C. Will There Be Future Reports? What Else Will Be Included? D. Better Health s Diabetes Measures and Standards 1. Our Measures Nationally Endorsed, Locally Vetted a. Process of Care Measures (4) b. Outcome Measures (5) 2. Our Standards and How We Selected Them a. Principles and Individual Standards b. Summary Standards: Principles and Targets 3. How We Obtain Our Measures: Advantages and Limitations a. Advantages of our records-based approach b. Limitations of our records-based approach PART TWO. BETTER HEALTH S DIABETES CHECKUP REGIONAL RESULTS 17 A. Overview B. Overall Achievement on Summary Standards and Individual Standards C. Overall Achievement by Insurance Categories, 2007 D. Overall Achievement by Race/Ethnicity, 2007 E. Achievement by Estimated Household Income, 2007 F. Achievement by Estimated Educational Attainment, 2007 G. Opportunities to Improve H. Comparison to National Achievement on Comprehensive Diabetes Measures of the National Committee for Quality Assurance [NCQA] Better Health Greater Cleveland Community Health Checkup Report June 2008 Page iv

5 PART THREE. TABLE OF CONTENTS (CONTINUED) BETTER HEALTH S DIABETES CHECKUP REGIONAL RESULTS 31 A. Overview B. Patient Characteristics of Our Partner Practices C. Results Across Our EMR-Based Partner Practices 1. Overview 2. Results by Practice: Summary Outcome and Process Standards 3. Practice-Level Summary Standards by Insurance Type D. Results Across Our Federally Qualified Health Center Partners E. Individual Standards by Practice LIST OF TABLES AND FIGURES Tables 1. Diabetes Process and Outcome Measures and Standards. 2. NCQA / HEDIS Comprehensive Diabetes Care Measures: Better Health s Region- Wide Achievement Compared to Health Plans Nationwide. 3a. Insurance Types in 30 EMR Practices. 3b. Race/Ethnicity in 30 EMR Practices. 3c. Census-Based Income and Educational Attainment Estimates in EMR Practices. 3d. Insurance Types in Federally Qualified Health Centers. 3e. Race/Ethnicity in Federally Qualified Health Centers. 3f. Income and Education Estimates in Federally Qualified Health Centers. 4a. Summary and Individual Outcomes at Federally Qualified Health Centers. 4b. Summary and Individual Processes at Federally Qualified Health Centers. 5a. Summary and Individual Outcome Achievement in 30 EMR Practices. 5b. Summary and Individual Process Achievement in 30 EMR Practices. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page v

6 Figures 1. Achievement on Summary Outcome Standard and its Five Component Standards. 2. Achievement on Summary Process Standard and its Four Component Standards. 3. Regional Achievement by Insurance Type on Better Health s Summary Standards. 4. Regional Achievement by Race on Summary Standards. 5. Regional Achievement by Income on Summary Standards. 6. Regional Achievement by Educational Attainment on Summary Standards. 7. Summary Standards Achievement Within Our Partner Practices. 8. Regional Achievement Compared with Nationwide Health Plan Data: Hemoglobin A1c Testing Performed. 9. Region and Nation: Good (A1c < 7) and Poor (A1c > 9) Hemoglobin A1c Control. 10. Region and Nation: Eye Examination Performed and Kidney Management. 11. Region and Nation: LDL Cholesterol Screening and Good LDL Cholesterol Control (LDL < 100). 12. Region and Nation: Very Good (BP < 130/80) and Good (BP < 140/90) Blood Pressure Control. 13a. Alphabetical Listing of 30 EMR Practices: Achievement on Summary Standards. 13b. Rank by Outcomes: Achievement on Summary Standards. 13c. Rank by Processes: Achievement on Summary Standards. 14a. Medicare Patients: Summary Standards: Alphabetical Listing. 14b. Medicare Patients: Rank by Outcomes. 14c. Medicare Patients: Rank by Processes. 15a. Commercially Insured Patients: Alphabetical Listing. 15b. Commercially Insured Patients: Rank by Outcomes. 15c. Commercially Insured Patients: Rank by Processes. 16a. Medicaid Patients: Alphabetical Listing. 16b. Medicaid Patients: Rank by Outcomes. 16c. Medicaid Patients: Rank by Processes. 17a. Uninsured Patients: Alphabetical Listing. 17b. Uninsured Patients: Rank by Outcomes. 17c. Uninsured Patients: Rank by Processes. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page vi

7 EXECUTIVE SUMMARY Better Health Greater Cleveland is an unparalleled alliance of regional stakeholders that is committed to improving the health and quality of care for Greater Cleveland s residents with common chronic medical conditions. The alliance synchronizes three vital initiatives: 1) measuring and publicly reporting physician group practice achievement using nationally endorsed indicators of high quality care; 2) consumer education that builds community understanding of health care quality and spurs patient activation in their care; and 3) coordinated region-wide provider education in quality improvement. This Community Health Checkup Report represents our first public report to the Northeast Ohio community. Diabetes First. This first Checkup highlights the 2007 results of the care and patient outcomes for our region s adult patients with diabetes. We elected to focus first on diabetes because of its epidemic nature in Greater Cleveland and nationwide, and because it is the most common preventable cause of kidney failure, blindness, leg amputations, and vascular disease. There are over 100,000 persons in Cuyahoga County with diagnosed diabetes, and another 30,000 with diabetes who have not been diagnosed. The Centers for Disease Control estimates that 90% of their complications could be eliminated with proper management. Partner Practices in This First Report. In the Community Health Checkup, 40 group practices in 6 organizations contributed detailed information about their care and outcomes for almost 25,000 patients with diabetes during We report separately for 30 practices in health care organizations having electronic medical records (Cleveland Clinic, Kaiser Permanente, and The MetroHealth System) and for the practices of our three Federally Qualified Health Centers (Care Alliance, Neighborhood Family Practice, and Northeast Ohio Neighborhood Health Services [NEON]). Three additional partner health care organizations and their practices will contribute their results on diabetes for our second Report, expected in the fall of Region-wide Results Against National Benchmarks. For reference against national benchmarks, we compared our region-wide results to the nine (9) standards for Comprehensive Diabetes Care of the National Committee for Quality Assurance (NCQA). Our region-wide results were better than the NCQA national averages for all 9 standards and across patients insured by Medicare, Commercial insurers, and Medicaid. Remarkably, uninsured patients in our partner practices also fared well against insured patients in the NCQA 2007 report (there being no comparable report to benchmark achievement on uninsured patients). Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 1

8 Our Standards. Although we are pleased to be able to report our results against national benchmarks, the alliance used additional nationally endorsed measures and produced nine (9) locally vetted standards of care. We created two challenging Summary Standards and related targets for achievement at the region-wide, practice, and patient levels. Our Summary Process Standard incorporates four (4) individual standards and includes actions that the physician should take to properly measure, monitor, or manage diabetes or prevent its complications. Practices and the region are reported on the percentage of patients who meet all 4 standards. Our Summary Outcome Standard includes five (5) individual standards that include the results of blood tests, physical examination findings, and behavior-related measures that predict risk for diabetic complications. Because outcomes require the engagement of the patient in addition to good decisions by the physician, we report practices and the region on the percentage of patients who meet four or five of the 5 standards. Reports by Race, Insurance Type, and Other Factors. Because we believe that the resources available to patients are important determinants of health outcomes, our partner practices have committed to report results by their patients primary insurance (Medicare, Commercial, Medicaid, or uninsured). All practice organizations also have provided information on their patients self-reported race and de-identified U.S. Census estimates of their patients household incomes and educational attainment. In the Checkup, we report practice-level results overall and by insurance category. At the region-wide level, we also report results according to race (white, African-American, and Hispanic), income, and maximum educational attainment. Data aggregation and analyses are conducted by partners at the Center for Health Care Research and Policy at MetroHealth Medical Center. Region-wide Results on Our Standards. Region-wide results on our Summary Standards produced a consistent picture, overall and by subgroups classified by insurance, race, and estimated household income and educational attainment. Overall, 38% of our patients achieved good results on our Summary Outcome Standard, and 46% achieved good results on our Summary Process Standard. In general, patients with fewer resources faired more poorly on our Summary Outcome Standard than did those with greater resources, while patients with fewer resources had similar achievement levels on our Summary Process Standard. Summary Outcomes were better for: Medicare and Commercially insured patients than for Medicaid and uninsured patients; for white patients as compared to African-American and Hispanic patients; for patients with higher household incomes as compared to those with lower incomes; and for those with higher education levels as compared to those with lower education levels. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 2

9 In contrast, Summary Processes were generally similar across different patient subgroups. Indeed, uninsured and Medicaid patients of partner practices exceeded the region-wide average, as did African-American and Hispanic patients. Process achievement was virtually the same across patients grouped by estimated household income or educational attainment. Practice-Level Reports: Opportunities for Improvement. At a clinical practice level across the region, there was considerable variation in these results, offering individual practices and the broader community many opportunities for improvement. Top-ranked practices for Outcomes had achievement levels that were 70% higher than the lowest ranked practices; top-ranked practices for Processes had achievement levels that were 100% higher than lowest ranked practices. No practice performed equally well on both Summary Standards, suggesting different targets and strategies for improvement across different practices. Comments: This first Better Health Greater Cleveland Community Checkup Report provides a snapshot of diabetes care and outcomes in the region. Our camera has a large lens, but not large enough: it reflects care for one in four persons with known diabetes in Cuyahoga County; partner physicians represent fewer than half of the county s primary care doctors. We look forward to growing the partnership and broadening our scope. Like a snapshot, it also reflects simply a point in time and not a moving picture. In future reports, we will be able to measure improvements over time, and not just achievement against a fixed set of standards. Our region-wide results, and our practice-level reports, provide benchmarks for future comparison. Finally, we believe that these results challenge all community stakeholders in better health, including not only physicians and their practices, but regional employers, health plans, public health organizations, and, most importantly, our patients. Everyone has something to learn from this Checkup and to contribute to the dramatic changes that we hope it will help motivate. We want our patients to demand good care, to ask good questions, and to recognize that their active engagement is vital to their health. We want public health officials and policymakers to advocate for patient-centered resources that otherwise limit what the patient and her doctor can achieve. We want our practices to identify and share best practices, to design approaches to delivering care that make the right decisions the easiest ones to make, and to develop systems that help their patients help themselves with the tough problems, such as exercising, eating properly, avoiding cigarettes, and often taking many medicines and testing themselves on challenging schedules. Finally, we want our region s employers and health plans to align with our patients and providers, to realize that better health is lower cost health care, and that preventing and effectively managing chronic conditions is an investment in their bottom lines as well as the health of the community. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 3

10 PART ONE UNDERSTANDING GREATER CLEVELAND S COMMUNITY HEALTH CHECKUP A. WHAT IS BETTER HEALTH GREATER CLEVELAND AND WHO ARE OUR PARTNERS? Better Health Greater Cleveland is an unparalleled alliance of regional stakeholders that is committed to improving the health and quality of care for Greater Cleveland s residents with common chronic medical conditions. The alliance synchronizes three vital initiatives: 1) measuring and publicly reporting physician group practice achievement using nationally endorsed indicators of high quality care; 2) consumer education that builds community understanding of health-care quality and spurs patient activation in their care; and 3) coordinated region-wide provider education in quality improvement. This Community Health Checkup represents our first public report to Northeast Ohio. Better Health Greater Cleveland leverages regional cooperation and the electronic medical records capabilities of the region s health systems to report on outpatient care across all payer sources and socioeconomic groups for several important conditions, including diabetes, hypertension, coronary artery disease and heart failure. This first Community Health Checkup highlights care and outcomes for adult patients with diabetes. Future reports also will include selected aspects of our region s hospitals care and outcomes. The Better Health alliance is one of 14 selected by the Robert Wood Johnson Foundation to participate in its national initiative, Aligning Forces for Quality The Regional Market Project. Its objective is to improve the health of people with chronic conditions by aligning multiple stakeholders and resources that influence health care quality in regions throughout the United States. Better Health Greater Cleveland Participants range from public health agencies to the regional business community. Founding partners of Better Health include The MetroHealth System, which serves as Robert Wood Johnson Foundation grantee, The Center for Community Solutions, and Health Action Council. Committed partners are listed below, categorized as Primary Care Practices, Public Health Organizations and Consumers, and Employers and Health Plans. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 4

11 Committed Partners Better Health Greater Cleveland As of June 2008 Primary care practices (54 sites, 520 physicians) o Cleveland Clinic, Main Campus and Regional Medical Practices o University Hospitals Family Practice o Case Western Reserve University Practice-Based Research Network o Kaiser Permanente-Ohio o Louis Stokes VA Medical Center o MetroHealth System, Main Campus and Center for Community Health o Northeast Ohio Neighborhood Health Services, Inc. (NEON) o Care Alliance o Neighborhood Family Practice o Huron Hospital Public Health Organizations and Consumers o Cleveland Department of Health o Cuyahoga County Department of Health o Ohio Department of Health o NetWellness.org o Ohio Department of Job and Family Services o OneCommunity Employers and Health Plans o Health Action Council (HAC) o HAC Health Plan Advisory Committee o Health Plans Kaiser Permanente of Ohio Medical Mutual of Ohio United HealthCare of Ohio Anthem Cigna Aetna o Ohio Medicaid Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 5

12 B. WHAT AND WHO DOES THE COMMUNITY HEALTH CHECKUP INCLUDE? This first Community Health Checkup includes region-wide and clinical practice-level information about how Greater Cleveland s participating primary care practices are doing in the care and outcomes of their adult patients with diabetes. Collectively, data were submitted, analyzed, and reviewed by 6 health care organizations which care for approximately 25,000 patients with diabetes. Three of the organizations, representing 30 group practices throughout the Greater Cleveland area (Cleveland Clinic, MetroHealth, and Kaiser Permanente), obtained data from their electronic medical records (EMRs) and related registries; the other three are Federally Qualified Health Centers (Neighborhood Family Practice, Northeast Ohio Neighborhood Health Services, Inc. [NEON], and Care Alliance), which used their diabetes patient registries to identify random samples of 50 patients for detailed review of their paper-based medical records. All practices used agreed-upon definitions for diabetes and the patients with diabetes who were eligible to be reviewed and reported. Patients included in the reports were between 18 and 75 years of age and were seen in the practice by a primary care physician at least twice in calendar year Specific measures and our standards for achievement are described in detail in section D. For the Community Health Checkup to accurately describe care across all types of patients in the region, we also obtained information from participating practices that enables us to describe our results categorized according to patients insurance status, race, estimated household income, and estimated maximum educational attainment. To categorize by insurance, we identified each patient s primary insurer as Medicare, a Commercial insurer, Medicaid, or that he/she had no insurance (was classified by the practice as self-pay or uninsured). Race was categorized as white, African American, Hispanic, or Other by patient self-report to their practice. Household income and educational attainment were estimated by obtaining census data from the vicinity around the patient s home. Unique strengths and special limitations of our approaches for measurement are described in more detail in section D. 3. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 6

13 C. WILL THERE BE FUTURE REPORTS? WHAT ELSE WILL BE INCLUDED? We expect to publish reports twice yearly, with our second report coming in fall Our reports will continue to highlight care and outcomes for the region s patients with chronic conditions, disparities in our measures by insurance and other social indicators, and improvement. Because this is our first Community Health Checkup, future reports will allow us to highlight improvements in our measures by comparison with this first report, and not simply achievement by comparison to nationally endorsed and locally vetted measures. In addition, as more practices are able to measure and report their care, we expect our reports to describe a larger part of the region s residents. Finally, we will begin to measure and report selected aspects of our region s hospitals achievement in the care and outcomes of patients with chronic health conditions, including patients experiences with their preparation for returning to the community following hospital discharge. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 7

14 D. BETTER HEALTH S DIABETES MEASURES AND STANDARDS 1) Our Measures Nationally Endorsed, Locally Vetted This first report includes nine nationally endorsed clinical measures for people with diabetes. We distinguish measures, such as tests to be monitored, from standards, which are the desired frequency or target results of those tests. The nine clinical measures include many of the most important and evidence-based indicators of care processes and outcomes in diabetes, as endorsed by the National Quality Forum 1 (NQF) the American Diabetes Association 2 (ADA), the National Committee on Quality Assurance 3 (NCQA), and the Veterans Affairs Administration-Department of Defense 4 (VHA-DOD). To select our measures, our Clinical Advisory Committee received and approved recommendations of its Diabetes Subcommittee, which reviewed the research literature and the recommendations of these and other national organizations. a. Process of Care Measures (4). Our four process of care measures include actions that the physician should take to properly measure, monitor, or manage diabetes or prevent its complications. These include: 1) Testing for blood sugar control using the hemoglobin A1c blood test; 2) Testing the urine for kidney problems (measuring the urine microalbumin level) or treating with ACE inhibitor or ARB drugs to prevent progression of kidney problems; 3) Referring the patient to an ophthalmologist or optometrist for an eye examination to detect early and treatable diabetic eye disease, with a kept appointment by the patient; and 4) Providing a pneumonia ( pneumococcal ) vaccination to avoid preventable lung infections to which patients with diabetes are especially susceptible. Standards for these four process measures are reported individually and as a summary (or composite ) process score within each practice and for the region as a whole. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 8

15 b. Outcome Measures (5). Our five outcome measures include the results of blood tests, physical examination findings, and behavior associated with the occurrence of diabetic complications. These measures are sometimes called intermediate outcomes or risk factors, since they are not medical outcomes per se such as diabetes-related blindness, kidney failure, or leg amputation but their results predict these outcomes, with better results lowering the risk, and poorer results raising the risk. For simplicity s sake, we will refer to these measures as outcomes. Good results on these outcome measures require active patient involvement in her own self-care in addition to good treatment by the doctor. Our five outcome measures include: 1) Good results of tests for blood sugar control, measured by the Hemoglobin A1c (or more simply, A1c ) value; 2) Good results on blood tests for bad (LDL) cholesterol or treatment with cholesterol-lowering statin medications; 3) Good blood pressure levels; 4) Good weight control, measured by the body mass index ; and 5) Avoidance of cigarette smoking. As with our process of care measures, standards for these five outcome measures also are reported individually and as a summary score within each practice and across the region. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 9

16 2. Our Standards and How We Selected Them a. Principles and Individual Standards. For each process and outcome measure, our Diabetes Subcommittee reviewed relevant standards of the NQF, NCQA, VHA-DOD, ADA, the American Medical Association (AMA), and the Agency for Health Care Research and Quality (AHRQ). For several of the measures, different organizations have established different standards (target values) above (or below) which a practice could be recognized for desirable (or undesirable) achievement. In these cases, three principles guided the subcommittee s deliberations about which target value or standard to choose: 1) Favorable framing. We first sought to define each standard in a favorable frame, such that higher levels of reported achievement are associated with a higher proportion of a practice s patients meeting the standard. This principle guided decisions, for example, to reject a commonly used standard for hemoglobin A1c levels the percentage of a practice s patients in poor glycemic control, where lower numbers are better in favor of a standard that reports the percentage of patients in a given practice who have good glycemic control. We also report the percentage of documented non-smokers instead of the percentage of smokers for the same reason. 2) Relevant to populations. Second, we sought to define standards that would apply to most all diabetic patients in a population, without need for numerous patient exclusions or extensive statistical risk-adjustments. This principle guided our choice of relatively conservative target values for Hemoglobin A1c and blood pressure because of concerns that seeking more aggressive targets on older patients, or those with multiple co-morbid illnesses regardless of age, might lead to more risk than benefit. At least for A1c, data supporting this concern were recently published by the National Institutes of Health 5 as they stopped the aggressive treatment arm in a large clinical trial (called ACCORD ) due to safety concerns. 3) Use of all available evidence: a cost-effective approach. Two of our measures and related standards reflect hybrid approaches that allow for desirable results either if a test result is better than a specified target value or if recommended treatment has been prescribed for the underlying medical pathology. We developed two hybrid standards: one for management of bad cholesterol giving credit for meeting low LDL cholesterol targets or treating with LDL-lowering statin drugs and another for managing potential kidney problems giving credit for regular monitoring of urine protein levels or treating with certain classes of blood pressure drugs called ACE inhibitors and ARBs. Both of these hybrid standards are based on Grade A evidence as evaluated by the American Diabetes Association 2 and simultaneously minimize unnecessary repeated testing if proper treatment has been prescribed. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 10

17 Based on these principles and the recommendations of national quality organizations, our four process standards and our five outcome standards are summarized in Table 1. Table 1. Diabetes Process and Outcome Measures and Standards Measure Standard/Target Hemoglobin A1c Test Performed Kidney Management Process of Care Standards At least once during 2007 Urine tested for microalbumin during 2007 or treatment with ACE inhibitor or ARB during 2007 Eye Examination Visit to Ophthalmologist or Optometrist during 2007 Pneumonia Vaccination Documented at any time Outcome Standards Hemoglobin A1c Value < 8%, most recent value in 2007 Blood Pressure < 140/80, most recent value in 2007 LDL Cholesterol Management LDL Cholesterol <100 mg/dl, most recent value in 2007, or on Statin during 2007 Body Mass Index <30, most recent value in 2007 Smoking Status Non-smoker, most recent documentation Hemoglobin A1c Test Performed Control of blood sugar (Glycemic control) is fundamental to the management of diabetes. The Hemoglobin A1c is reflects average blood glucose levels over several months. According to the American Diabetes Association, A1c testing should be performed routinely in all patients with diabetes, at initial assessment and then as part of continuing care. Testing is most helpful when obtained repeatedly (e.g., every three months in those patients in whom treatment is changing or target levels have not been achieved). However, the frequency of A1c testing depends on the clinical situation of the individual patient and the judgment of the clinician. A single level in a year s time is a relatively low threshold. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 11

18 Kidney Management Diabetic kidney disease (nephropathy) occurs in 20 40% of patients with diabetes and is the single leading cause of end-stage renal disease (ESRD) that requires dialysis. Low levels of protein (albumin) in the urine (microalbuminuria) is a marker for development of nephropathy in type 2 diabetes. Most importantly, there are interventions that reduce the risk and slow the progression of renal disease. In addition to good control of blood sugar and blood pressure, there is substantial evidence for the benefit of treatment with Angiotensin Converting Enzyme Inhibitors (ACE-Is) or Angiotensin Receptor Blockers (ARBs). Eye Examination Diabetic eye disease (retinopathy) is a highly specific complication of diabetes and is the most frequent cause of new cases of blindness among adults aged years. Most importantly, laser photocoagulation surgery is very effective in preventing visual loss due to diabetic retinopathy. Therefore, early identification is beneficial. In addition, glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes. Patients with diabetes should have annual dilated and comprehensive eye examination by an ophthalmologist or optometrist. Pneumonia Vaccination Influenza and pneumonia are common, preventable infectious diseases associated with high mortality and morbidity in the elderly and in people with chronic diseases. Patients with diabetes are at higher risk. Therefore, it is recommended that at least one lifetime pneumococcal vaccine be provided for adults with diabetes. Hemoglobin A1c Value There is considerable disagreement among organizations, governmental agencies, and professional societies about the most appropriate target level for A1c that should be used for public reporting and for quality improvement. The American Diabetes Association recommends <7%, but their guidelines state: Less stringent goals (than <7%) are appropriate for individuals >65, those with co-morbid conditions, and those with side effects. These guidelines are similar to those of the Veterans Healthcare Administration and Department of Defense and the American Geriatric Society. We have chosen a level that is the simplest to apply across large populations with varying risks of adverse events from aggressive control. We recognize that the target for an individual patient may differ and depends upon clinical circumstances, physician judgment, and patient preferences. Blood Pressure and Cholesterol Management Cardiovascular disease is the major cause of illness and death for individuals with diabetes. Hypertension and dyslipidemia (hypercholesterolemia) commonly co-exist with diabetes and are risk factors for cardiovascular disease. Diabetes itself is a risk factor. There is a great deal of evidence to support the benefits of controlling cardiovascular risk factors in preventing or slowing cardiovascular disease in people with diabetes. Work continues on the most appropriate target levels for blood pressure and LDL-cholesterol. Blood Pressure Randomized clinical trials have demonstrated the benefit (reduction of coronary heart disease [CHD] events, stroke, and nephropathy) of lowering blood Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 12

19 pressure to <140 mmhg systolic and <80 mmhg diastolic in individuals with diabetes. Lower thresholds have been recommended by some. The ongoing Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is designed to determine whether lowering systolic blood pressure to <120 mmhg provides greater cardiovascular protection than a systolic blood pressure level of <140 mmhg in patients with type 2 diabetes. LDL Cholesterol Management For most patients with diabetes, the first priority of dyslipidemia therapy is to lower LDL cholesterol to a target goal of <100 mg/dl. Multiple clinical trials have demonstrated significant effects of pharmacologic (primarily statin) therapy on cardiovascular outcomes in subjects with coronary disease and for primary prevention. Body Mass Index Maintaining or achieving an ideal body weight is an integral component of diabetes prevention, management, and self-management education. Thus, weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes. A BMI below 18.5 is considered underweight, 18.5 to 24.9 is normal, 25 to 29.9 is overweight, and 30 or above is considered obese. Our target BMI of less than 30 is consistent with the recommendations of the American Diabetes Association. Smoking Status Cigarette smoking contributes to one of every five deaths in the U.S. and is the most important modifiable cause of premature death. Studies of individuals with diabetes have consistently found a heightened risk of cardiovascular disease and premature death among smokers. Smoking is also related to the premature development of microvascular complications of diabetes. b. Summary Standards: Principles and Targets As mentioned above, we constructed two Summary Standards to reflect overall good results: one for our outcome standards, and a second for our process standards. Thus, all practices, and the region overall, are rated on these two Summary Standards, reflecting achievement on the 5 outcome standards and the 4 process standards, respectively. We created our Summary Standards for three main reasons: 1) To Simplify Understanding of Overall Performance. First, we want to make it simpler to understand overall performance despite the fact that several components are being measured and reported. Measuring and understanding quality is complicated for all of us! 2) To Clearly Distinguish Standards that Depend on Different Factors. Second, we want to distinguish overall Outcomes achievement from overall Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 13

20 Process achievement because success on these different measures is likely to depend on different factors. Process measures mostly depend on what doctors and their practices do. Outcome measures also depend very much on patient selfcare, as well as other forces, such as the patient s available resources including money for medicines and test strips for monitoring diabetes, insurance coverage, places to exercise, the patient s ability to read and understand instructions, etc. 3) To Provide Focus for Improvement. Third, we want to help our practices and other stakeholders to focus on the big picture in their efforts to improve, and not just individual standards. As our results in this report show, everyone has room to improve. Where do we start? Our summary standards can provide some guidance over and above their individual components. The Summary Standards reflect how each patient of each doctor in each practice is doing on our outcomes and process standards. At the practice or region level, we ask: Summary Outcome Standard: How many of our 5 individual standards does each patient meet? We measure our achievement by determining the percentage of patients in each practice who meet at least 4 of the 5 standards listed in Table 1. Summary Process Standard: How many of our 4 individual standards does each patient meet? We measure our achievement by determining the percentage of patients in each practice who meet ALL 4 standards listed in Table 1. We were more strict on our achievement target for our Summary Process Standard requiring all 4 standards to be met because this standard depends more on the doctor and is more until his/her control. We were more lenient in our achievement target for our Summary Outcome Standard requiring that either 4 or 5 of the 5 standards be met - because this standard depends on the patient and the patient s resources almost as much as the doctor and the practice. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 14

21 3. How we obtain our Measures: Advantages and Limitations All of the measures we report are obtained from the medical records of our partner practices and systems, not from insurance claims. This approach has remarkable advantages but it also has some limitations that we discuss below. Among participating practices with electronic medical records (EMRs), we obtain these measures on virtually all diabetic patients between the ages of 18 and 75 who visited the same doctors office at least twice during calendar year We exclude only patients whose diagnosis is diabetes of pregnancy. For partner practices that do not have EMRs, the same measures were collected using a standard protocol from a random sample of 50 charts of diabetes patients. Both kinds of practices, those with and without EMRs, provide information about their patients neighborhoods, including average household income and maximum educational attainment, using information from the year 2000 U.S. census. No identifiers for patients or their doctors are shared with anyone outside of the clinical practice or health care organization. The Community Health Checkup is based on care provided to about 25,000 adult patients with diabetes in the region. a. Advantages of our records-based approach As mentioned above, our medical records-based approach has remarkable advantages but also some limitations as compared to using insurance claims. Advantages of our EMR-centered approach include our ability to: 1) measure our achievement on all of our patients, regardless of how they are insured, whether they have health insurance at all, or whether they change their insurance status; 2) accurately link doctors and their patients, facilitating appropriate attribution of care to specific doctors and their group practices; 3) obtain actual test results, and not simply whether the test was performed, allowing us flexibility in the standards (target values) we choose to establish, and to adopt different standards over time or for different interested users of our information; 4) obtain records of doctors prescriptions of medications, enabling us to report their intentions regarding treatments; and 5) report all information in a timely way (not requiring the practice s submission and adjudication of insurance claims), enabling us to provide useful feedback for quality improvement to practices and practice leaders, and to patients. It is noteworthy that this first Community Health Checkup Report, prepared during the second quarter of 2008, covers the entire calendar year In contrast, the most current claims-based data for national comparison purposes (see Part Two, Section H) pertain to actions and outcomes made a year earlier, in This unfortunate delay reflects the realities of insurance claims submission, processing, adjudication, analysis, and reporting. And, in the best of circumstances, this occurs without the benefit of knowing how we re doing with uninsured patients, or those who have switched insurers. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 15

22 b. Limitations of our records-based approach In general, the limitations of the EMR-based approach, or to any practice-based approach in most organizations, relate to under-reporting performance on our achievement standards. These limitations theoretically can be quite important, and they can vary from standard to standard, and from one health care organization to another. Because many patients are free to obtain their care in different places, an approach that relies on practice-centered reporting relies on two factors: 1) whether the patient received a relevant service outside the home practice; or 2) if he/she did, whether the relevant outside service is documented in the medical record of the practice. Often, in our highly fragmented health system, even if a relevant test or treatment was received by the patient outside of his/her practice, details of the service are not communicated to the home practice or health care organization. For our diabetes measures and standards, this is likely to be an especially important problem in documenting eye examinations, because eye exams frequently are performed at free-standing eye clinics, leading to an underestimate of practice achievement for this standard. In addition, until our practices have complete information on medication prescriptions that are filled by patients, we are unable to report filled prescriptions, instead being limited to documented doctors prescriptions for medications. Exceptions to this under-reporting limitation occur in true systems of care, such as health maintenance organizations, where bills are generated for services obtained outside of the home practice, and documentation of these services is simpler. In Greater Cleveland, Kaiser Permanente is an example of a system in which reporting should be more complete. At the other extreme are small practices that are not connected to larger organizations with sophisticated information systems or patient registries. In these types of practices, more of the relevant services are likely to be obtained outside of the home practice, creating challenges to comprehensively collecting information that is important for clinical performance measurement and reporting. Nonetheless, as documented by our region s relatively resource-poor Federally Qualified Health Centers, committed smaller practices can collect and document relevant information in relatively inexpensive patient registries. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 16

23 PART TWO BETTER HEALTH GREATER CLEVELAND S DIABETES CHECKUP REGIONAL RESULTS FOR 2007 A. OVERVIEW The following sections summarize how Greater Cleveland s adult patients with diabetes are doing in relation to nationally endorsed clinical measures of care processes and outcomes. We highlight achievement on our locally vetted Summary Outcome Standard and our Summary Process Standard, described in Part One, Section D. 2. b. Greater detail is provided on our individual practices achievement in Part Three. We first report region-wide results on the summary standards and by individual component standards: overall, and then by patients categorized by their insurance status (Medicare, Commercial, Medicaid, or Uninsured), race (White, African-American, or Hispanic), and estimated household income (low, middle, high) and educational attainment (low, middle, high). Next, we report our region s results by comparison to national achievement on standards of the National Committee on Quality Assurance 3, reported for health plans nationwide in late The regional results reported here describe 30 practices of three large health care organizations that use electronic medical records (EMRs), including The MetroHealth System, Cleveland Clinic and Kaiser Permanente. In Part Three, we also report on the region s three Federally Qualified Health Centers (Care Alliance, Neighborhood Family Practice and Northeast Ohio Neighborhood Health Services [NEON].) This Report represents a snapshot of diabetes care and outcomes in Greater Cleveland during It covers results pertaining to about 25,000 patients cared for by over 500 primary care doctors (mostly, specialists in General Internal Medicine or Family Practice) in six health care organizations. As such, it represents a remarkable collaborative of health care providers who are committed to improving the health of their patients almost 40% of the primary care doctors in Cuyahoga County. At the same time, this is an incomplete picture, as we know there are over 100,000 adults with known diabetes in the county 6 and probably another 30,000 who have diabetes but do not know it. As a snapshot, this Report represents merely a single point in time. Future Reports will include more practices, patients, and measures of improvement as well as achievement on our standards. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 17

24 B. OVERALL ACHIEVEMENT ON SUMMARY STANDARDS AND INDIVIDUAL STANDARDS Figures 1 and 2 highlight the region s overall achievement on our Summary Outcome Standard, its 5 component standards, and our Summary Process Standard and its 4 component standards. Included are 23,461 patients of the 30 partner practices at Cleveland Clinic, Kaiser Permanente, and The MetroHealth System. Figure 1. Region-wide Achievement on Better Health s Summary Outcome Standard and its Five Component Standards As described previously, achievement on our Summary Outcome Standard reflects the percentage of our patients with diabetes who meet 4 or more of our 5 Outcome Standards. Overall, 38% of our patients met this target in 2007, with 62% meeting 3 or fewer standards. Achievement on individual standards varied. Collectively, 83% had target LDL cholesterol levels (less than 100) and/or were prescribed a statin medication; 83% were documented non-smokers; 68% had target Hemoglobin A1c levels (less than 8); 49% had target blood pressure levels (lower than 140/80), and only 31% met target levels for weight control (Body Mass Index below 30). Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 18

25 Figure 2. Region-wide Achievement on Better Health s Summary Process Standard and its Four Component Standards Overall achievement on our Summary Process Standard and its component standards was somewhat better. Collectively, 46% of our patients met all 4 Process Standard targets in 2007, with 54% meeting 3 or fewer standards. By individual standard, 93% had one or more A1c test obtained, 88% had a urine test for kidney problems or were on medications to delay kidney failure, 75% had a documented Pneumococcal vaccination, and 65% had a documented eye examination during As mentioned previously, it is likely that the rate of eye examinations was probably higher than we report here due to undocumented examinations outside of our partner practices (especially at MetroHealth and Cleveland Clinic), but the magnitude of this under-reporting is not known. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 19

26 C. OVERALL ACHIEVEMENT BY INSURANCE, 2007 Figure 3 highlights the region s overall achievement on our Summary Outcome Standard and our Summary Process Standard, stratified by insurance category. Included are 23,461 patients of the 30 partner practices at Cleveland Clinic, Kaiser Permanente, and The MetroHealth System. Collectively, 8754 (37%) of the patients had Medicare as their primary insurer, 11,941 (51%) had a commercial insurer, 1317 (6%) were insured by Medicaid, and 1449 (6%) were uninsured. The horizontal lines in the Figure represent the 38% region-wide overall achievement on the Summary Outcome Standard (at left) and the 46% region-wide overall achievement on the Summary Process Standard (at right). Overall achievement on our Summary Outcome Standard varied considerably across patients in the different insurance categories, while achievement on our Summary Process Standard was much more similar across insurance categories. Medicare patients fared best on both standards, with about half meeting each of the summary standards. Uninsured patients and those insured by Medicaid were much less likely to achieve our Summary Outcome Standard, while these same patients had average or above average achievement on our Summary Process Standard. Figure 3. Region-wide Achievement on Better Health s Summary Standards, by Insurance Category Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 20

27 D. OVERALL ACHIEVEMENT BY RACE/ETHNICITY, 2007 Figure 4 highlights the region s overall achievement on our Summary Outcome Standard and our Summary Process Standard, stratified by race/ethnicity category. This report describes patients in three categories related to race and ethnicity. While there were a small number of patients reported in other categories, they were too varied and too few in number (449) to provide meaningful comparisons. In addition, race-related data were not reported by Kaiser Permanente. Thus Figure 4 describes 15,180 adults with diabetes across 20 practices at Cleveland Clinic and The MetroHealth System. Collectively, 9341 (62%) are white, 5144 (34%) are African-American, and 695 (5%) are Hispanic. Again, the horizontal lines represent the 38% region-wide overall achievement on the Summary Outcome Standard (at left) and the 46% region-wide overall achievement on the Summary Process Standard (at right). Figure 4. Region-wide Achievement on Better Health s Summary Standards, by Race Category Overall achievement on our Summary Outcome Standard varied a modest amount across patients by race, with African-American patients faring less well (31%) than Hispanic (38%) or white (40%) patients. Similar to our results by insurance, there was little variation across race categories in achievement on our Summary Process Standard, although both African-American and Hispanic patients had somewhat higher levels of achievement than did our region s white patients. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 21

28 E. ACHIEVEMENT BY ESTIMATED HOUSEHOLD INCOME, 2007 Figure 5 highlights the region s overall achievement on our Summary Outcome and Summary Process Standards, stratified by estimated household income category. Each practice organization provided estimates of each patient s household income using information from the 2000 U.S. Census. Patients are divided into three categories in relation to household incomes of all Cuyahoga County residents, with approximately onethird categorized into low (less than $35,000), middle (between $35,000 and $48,000), and high (more than $48,000) income categories. As above, horizontal lines represent the 38% region-wide overall achievement on the Summary Outcome Standard (left) and the 46% region-wide overall achievement on the Summary Process Standard (right). Figure 5. Region-wide Achievement on Better Health s Summary Standards, by Income Category Results by income were similar to those described for insurance categories (Figure 3). Overall achievement on our Summary Outcome Standard varied considerably, ranging from 43% in the highest income category to 32% in the lowest income category. As with our results by insurance, however, there was only modest variation across income categories in the achievement of our Summary Process Standard. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 22

29 F. ACHIEVEMENT BY ESTIMATED EDUCATIONAL ATTAINMENT, 2007 Figure 6 highlights the region s overall achievement on our Summary Outcome and Summary Process Standards, stratified by estimated patient educational attainment. As with our income estimates, each practice organization used the 2000 Census to provide estimates of each patient s educational attainment. Patients are divided into three categories in relation to the percentage of high school graduates in Cuyahoga County in the 2000 census; high education reflects neighborhood with graduation rates above 90%; low education reflects neighborhood with graduation rates below 80%; and middle reflects neighborhoods with graduation rates between 80% and 90%. Again, horizontal lines represent the 38% region-wide achievement on the Summary Outcome Standard (left) and the 46% region-wide achievement on the Summary Process Standard (right). Figure 6. Region-wide Achievement on Better Health s Summary Standards, by Educational Attainment Category Results by estimated educational attainment were quite similar to those across income categories. Overall achievement on our Summary Outcome Standard varied from 43% in the highest education level to 33% in the lowest education level. As with our results by insurance and income, however, there was very little variation across educational categories in the achievement of our Summary Process Standard, with achievement levels ranging from 46% (high education) to 48% (low education). Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 23

30 G. OPPORTUNITIES TO IMPROVE Figure 7 summarizes the individual performance of our 30 partner practices that use electronic medical records (EMRs) to measure, report, and improve achievement on their patients with diabetes. Information to link practices with their achievement level is found in Part Three. Collectively, these 30 practices care for 23,461 patients with diabetes. The top panel describes each practice s score on Better Health s Summary Outcome Standard; the bottom panel describes each practice s score on Better Health s Summary Process Standard. The plots describe the percentage of each practice s adults with diabetes who meet the Summary Outcome Standard (top) or Summary Process Standard (bottom). The overall region-wide percentages for each Summary Standard are identified in the middle of each chart (38% for Outcomes; 46% for Processes.) Several points about Figure 7 are notable. All identify opportunities to improve our achievement. 1. Wide variation across practices. On our Summary Outcome Standard, patients in the top 10% of our practices achieve 45% of our standards, while patients in the lowest 10% of our practices achieve 26% of our standards, a 70% difference between the achievement of the highest and lowest ranked practices. On our Summary Process Standard, patients in the top 10% of our practices achieve 55% of our standards, while patients in the lowest 10% of our practices achieve 27% of our standards, a two-fold difference between the achievement of the highest and lowest ranked practices. 2. No practice achieves 100% on either Summary Standard. We have set high bars for achievement on both of our Summary Standards, but we are striving to attain perfection, or close to perfection! Even the highest ranked practices still have a long way to go. 3. No practice does equally well on both Summary Standards. The figures highlight two practices (identified as A and B) and their comparative rankings on our Summary Outcome Standard and our Summary Process Standard. Practice A, highest ranked on the Summary Outcome Standard, has room to improve on its Summary Process Standard. Practice B, highest ranked on our Summary Process Standard, has room to improve on its Summary Outcome Standard. 4. Improvement targets and strategies will vary across sites. Practice leaders representing all partner practices have been provided with details about their achievement on our two standards, on each of our 9 component standards, and how they are doing with subgroups of patients by insurance and Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 24

31 other measures. Each practice is motivated to improve, but the target strategies for improvement will vary somewhat across sites. As an example, practices with better Process achievement than Outcome achievement may want to target ways in which to better engage their patients, whether by improving their programs for smoking cessation or weight management, or by testing new approaches to activating their patients in better self-care. Figure 7. Percentage of Patients in Each of Our 30 Electronic Medical Recordsbased Practices achieving our Summary Outcome Standard (top panel) and Summary Process Standard (bottom panel), with two highlighted practices Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 25

32 H. COMPARISON TO NATIONAL ACHIEVEMENT ON COMPREHENSIVE DIABETES MEASURES OF THE NATIONAL COMMITTEE ON QUALITY ASSURANCE (NCQA)*, 2007 Table 2 and Figures 8-12 compare Greater Cleveland s region-wide results on NCQA s Comprehensive Diabetes Measures with the achievement of health plans reporting their results to NCQA in Most health plans nationwide voluntarily report their information to NCQA to create a Healthcare Effectiveness Data and Information Set (HEDIS), a tool used to measure achievement on important dimensions of care and service. Better Health Greater Cleveland is fortunate to have health plan partners who are members and active participants in our Leadership Team and Clinical Advisory Committee. With their encouragement, we have defined our data collection and reporting capabilities to be able to report our results in a way that is consistent with alternative approaches and standards. The table and figures that follow compare our practice partners results with health plans nationwide, using their 2006 data as reported by NCQA in The 9 standards in NCQA s Comprehensive Diabetes Measures include some that are included in Better Health s standards, such as the performance of an eye examination (Figure 10, left panel) and obtaining at least one Hemoglobin A1c in the one-year measurement period (Figure 8), but they also include standards that are slightly different from those we have chosen (such as the negatively framed poor glycemic control standard, discussed in Part One, Section D.2. and shown in Figure 9, right panel). Included in the Better Health Greater Cleveland reports for these figures are 23,461 patients of the 30 partner practices at Cleveland Clinic, Kaiser Permanente, and The MetroHealth System, stratified by insurance, as reported above and in the NCQA s State of Health Care Quality report (available at see pp ). In addition, we provide information in Table 2 and Figures 8-12 to enable comparison of Better Health s results among the uninsured with health plan data across insurance categories. There are several common findings across these comparisons: First, as displayed best in Table 2, among health plans reporting to NCQA, there are consistent and fairly substantial differences in achievement across insurance categories, with Medicare plans reporting the highest levels and Medicaid plans performing much less well. Second, Greater Cleveland s achievement is better than the national health plan average across all standards and all insurance types. Third, for several standards (for example, see Figures 8 and 9,) Greater Cleveland s Medicaid achievement is substantially higher than the national average for patients in Medicaid health plans. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 26

33 Fourth, there are no NCQA data pertaining to the uninsured. In the U.S., there are more than 47 million uninsured. They are largely invisible in performance reporting. Finally, Greater Cleveland s uninsured diabetic patients compare quite favorably to the national average of performance for insured groups. Table 2. NCQA / HEDIS Comprehensive Diabetes Care Measures. Better Health s Region-Wide Achievement Compared to Health Plans Nationwide. Measure Group Medicare Commercial Medicaid Uninsured Overall Hb A1c testing performed Region** National Mean Good Hb A1c Control (<7) Region National Mean Poor Hb A1c Control (>9) Region National Mean Eye Exam performed Region National Mean Monitoring Nephropathy* Region National Mean LDL Screening Region National Mean Good LDL Control (<100) Blood Pressure Control (<130/80) Blood Pressure Control (<140/90) Region National Mean Region National Mean Region National Mean Regional Patients, # (%) (37) (51) (6) (6) * Monitoring Nephropathy / Kidney Management (urine microalbumin screen or ACE inhibitor or ARB prescription) ** Regional achievement describes the 30 EMR practices (Cleveland Clinic, Kaiser Permanente and MetroHealth.) Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 27

34 Figure 8. Regional Achievement Compared with Nationwide Health Plan Data: Hemoglobin A1c Testing Performed Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 28

35 Figure 9. Regional Achievement Compared with Nationwide Health Plan Data: Good Hemoglobin A1c Control (A1c < 7) (Left Panel) and Poor Hemoglobin A1c Control (A1c > 9) (Right Panel) Figure 10. Regional Achievement Compared with Nationwide Health Plan Data: Eye Examination Performed (Left Panel) and Monitoring Nephropathy / Kidney Management* (Right Panel) *Urine microalbumin obtained or ACE inhibitor or ARB prescription Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 29

36 Figure 11. Regional Achievement Compared with Nationwide Health Plan Data: LDL Cholesterol Screening (Left Panel) and Good LDL Cholesterol Control (LDL < 100) (Right Panel) Figure 12. Regional Achievement Compared with Nationwide Health Plan Data: Very Good Blood Pressure Control (BP < 130/80) (Left Panel) and Good Blood Pressure Control (BP < 140/90) (Right Panel) Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 30

37 PART THREE BETTER HEALTH GREATER CLEVELAND S DIABETES CHECKUP PRACTICE REPORTS FOR 2007 A. OVERVIEW In this part of the Community Health Checkup Report, we describe our partner practices, including selected characteristics of our patients with diabetes. Practice locations and selected patient services of each practice are available on our web site in the About The Practices section: Detailed comparative data on the achievement of our partner practices on our Summary Outcome Standard and our Summary Process Standard also are reported. We report separately for 30 practices of the three large health care organizations that use electronic medical records (EMRs), including Cleveland Clinic, Kaiser Permanente, and The MetroHealth System and for our region s three Federally Qualified Health Centers (Care Alliance, Neighborhood Family Practice and Northeast Ohio Health Services, Inc.). Across the 30 EMR-based practices, overall results on our two Summary Standards are highlighted as well as results by patients categorized by insurance type (Medicare, Commercial, Medicaid, and uninsured). In contrast to our regional reports, in which we summarize all eligible patients of all practices, achievement of individual practices are reported only if they care for at least 50 patients in a given insurance category. Top achieving practices are those in approximately the top decile (top 10%) of relevant practices. For our FQHC partners, we summarize achievement at the organizational level. B. PATIENT CHARACTERISTICS OF OUR PARTNER PRACTICES Tables 3a through 3f describe selected characteristics of patients with diabetes cared for in our partner practices. Tables 3a-3c. Collectively, the 30 EMR-based practices (Cleveland Clinic, Kaiser Permanente, and MetroHealth) report their care for 23,461 adult patients with diabetes seen in their practices at least twice during calendar year Individual practices vary considerably in their number of diabetic patients, with nine practices reporting care for more than 1,000 patients (one practice reported over 2,000) and three practices reporting care for fewer than 200. There also is considerable diversity by insurance category (Table 3a), race (Table 3b) (note: race data are not available for Kaiser Permanente practices), and estimated neighborhood income and educational attainment (Table 3c). Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 31

38 As shown in Table 3a, 37% of our partners diabetic patients are insured by Medicare (range across practices, 22-48%), 51% by commercial health plans (range across practices, 15-73%), 6% by Medicaid (range across practices, 0-28%), and 6% are uninsured (range, 0-38%). In the two systems that report patient race in Table 3b, patients reported as Hispanic reflect 4% of our overall sample (range, 0-60%), although Hispanic patients represent more than 10% of only three of the 30 practices. African- American patients reflect 33% of our sample (range, 2-96%). Table 3c summarizes household incomes and high school graduation rates of our patients, using census-based estimates provided by each system. Across the 30 practices, estimated median income of our patients households in the year 2000 was $39,500, with a range from $22,000 to $67,800. We estimate that almost 4 in 5 of our patients graduated high school, with a range across practices from 63% to 90%. Tables 3d-3f. Tables 3d 3f provide the same information for samples of 50 patients from each of our three partner Federally Qualified Health Centers Care Alliance, Neighborhood Family Practice, and Northeast Ohio Health Services, Inc. (NEON). While the FQHCs are quite diverse in the proportion of patients insured by Commercial insurers (range, 2-40%), Medicaid (range, 6-34%) or who are uninsured (range, 20-78%) (Table 3d), ranges were much smaller by estimated household income ($22,500-$28,400) and educational attainment (range of estimated high school graduation rates, 68%-72%) (Table 3f). Reflecting their different catchment areas in Greater Cleveland, two of the three FQHCs serve predominantly African-American patients, while almost half of the patients self-report as Hispanic in the third system (Table 3e). Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 32

39 Table 3a. Insurance of Patients at Our Partner Practices Electronic Medical Records Systems Qualifying % % % % Diabetics Medicare Commercial Medicaid Uninsured THE REGION: All 30 EMR-Based Practices Avon Medical Facility KP* Beachwood Family Health Center CC Bedford Medical Center KP Broadway Health Center MH Brooklyn Medical Group MH Buckeye Health Center MH Chagrin Falls Family Health Center CC Chapel Hill Medical Center KP Cleveland Clinic Main Campus CC Cleveland Heights Medical Center KP Fairlawn Medical Center KP Independence Family Health Center CC J. Glen Smith Health Center MH Lakewood Family Health Center CC Lakewood Medical Center KP Lee Harvard Health Center MH MHMC Faculty/Residents Practice MH MHMC Family Practice MH MHMC Internal Medicine MH Parma Medical Center KP Solon Family Health Center CC Strongsville Family Health Center CC Strongsville Medical Center KP Strongsville Medical Group MH Thomas F. McCafferty Health Center MH Twinsburg Medical Center KP West Park Medical Group MH Westlake Family Health Center CC Willoughby Hills Family Health Center CC Willoughby Medical Center KP THE REGION: All 30 EMR-Based Practices *CC = Cleveland Clinic, KP = Kaiser Permanente, MH = MetroHealth System Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 33

40 Table 3b. Race/Ethnicity of Patients at Our Partner Practices % Qualifying % % Electronic Medical Records Systems African Diabetics White* Hispanic American THE REGION: All 30 EMR-Based Practices Avon Medical Facility KP 173 Beachwood Family Health Center CC Bedford Medical Center KP 1154 Broadway Health Center MH Brooklyn Medical Group MH Buckeye Health Center MH Chagrin Falls Family Health Center CC Chapel Hill Medical Center KP 441 Cleveland Clinic Main Campus CC Cleveland Heights Medical Center KP 2051 Fairlawn Medical Center KP 283 Independence Family Health Center CC J. Glen Smith Health Center MH Lakewood Family Health Center CC Lakewood Medical Center KP 271 Lee Harvard Health Center MH MHMC Faculty/Residents Practice MH MHMC Family Practice MH MHMC Internal Medicine MH Parma Medical Center KP 1646 Solon Family Health Center CC Strongsville Family Health Center CC Strongsville Medical Center KP 592 Strongsville Medical Group MH Thomas F. McCafferty Health Center MH Twinsburg Medical Center KP 148 West Park Medical Group MH Westlake Family Health Center CC Willoughby Hills Family Health Center CC Willoughby Medical Center KP 842 THE REGION: All 30 EMR-Based Practices % Other Race *Practices in the KP (Kaiser Permanente) system did not report race/ethnicity. Regional percentages are calculated from CC (Cleveland Clinic) and MH (MetroHealth) system practices only. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 34

41 Table 3c. Income and Education Estimates for Our Partner Practices Electronic Medical Records Systems Estimated Estimated Qualifying Median Income Educational Attainment Diabetics (in $) (% HS Grad or More) THE REGION: All 30 EMR-Based Practices , Avon Medical Facility KP* , Beachwood Family Health Center CC , Bedford Medical Center KP , Broadway Health Center MH , Brooklyn Medical Group MH , Buckeye Health Center MH , Chagrin Falls Family Health Center CC , Chapel Hill Medical Center KP , Cleveland Clinic Main Campus CC , Cleveland Heights Medical Center KP , Fairlawn Medical Center KP , Independence Family Health Center CC , J. Glen Smith Health Center MH , Lakewood Family Health Center CC , Lakewood Medical Center KP , Lee Harvard Health Center MH , MHMC Faculty/Residents Practice MH , MHMC Family Practice MH , MHMC Internal Medicine MH , Parma Medical Center KP , Solon Family Health Center CC , Strongsville Family Health Center CC , Strongsville Medical Center KP , Strongsville Medical Group MH , Thomas F. McCafferty Health Center MH , Twinsburg Medical Center KP , West Park Medical Group MH , Westlake Family Health Center CC , Willoughby Hills Family Health Center CC , Willoughby Medical Center KP , THE REGION: All 30 EMR-Based Practices , * CC = Cleveland Clinic, KP = Kaiser Permanente, MH = MetroHealth. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 35

42 Table 3d. Insurance of Sampled Federally Qualified Health Center Patients Electronic Medical Records Systems Sampled % % % % Diabetics Medicare Commercial Medicaid Uninsured All 30 EMR-Based Practices Care Alliance Neighborhood Family Practice Northeast Ohio Health Services, Inc. [NEON] Table 3e. Race/Ethnicity of Sampled Federally Qualified Health Center Patients Electronic Medical Records Systems % % Sampled % % African Other Diabetics White Hispanic American Race All 30 EMR-Based Practices Care Alliance Neighborhood Family Practice Northeast Ohio Health Services, Inc. [NEON] Table 3f. Income and Education Estimates for Sampled Federally Qualified Health Center Patients Electronic Medical Records Systems Estimated Estimated Sampled Median Income Educational Attainment Diabetics (in $) (% HS Grad or More) All 30 EMR-Based Practices 39, Care Alliance 50 22, Neighborhood Family Practice 50 28, Northeast Ohio Health Services, Inc. [NEON] 50 23, Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 36

43 C. RESULTS ACROSS OUR EMR-BASED PARTNER PRACTICES 1. Overview Figures summarize the achievement of our 30 EMR-based partner practices on Better Health s Summary Standards for Outcomes and Processes. Target achievement for the five component standards of our Summary Outcome Standard, and the four component standards of our Summary Process Standard, are described in Table 1 of this Community Health Checkup. They represent nationally endorsed quality measures that we seek to improve, in partnership with our patients and other stakeholders. As described in Part Two, our long-term goal is perfection 100% on both Summary Standards. Our partner practices achieve good results when compared with national benchmarks for diabetes across all nationally reported insurance categories and among our uninsured patients. (Part Two, section H). However, all reporting practices have room to improve on Better Health s more challenging targets (Part Two, section G). The following graphs show our results, first over all insurance categories and then within insurance categories. Each section first sorts our 30 practices alphabetically, and then by rank order for each Summary Standard. Results of practices with fewer than 50 eligible diabetic patients in an insurance category are not reported. Thus, more practices are listed in the overall reports (Figures 13a-c) than for reports within insurance categories. For Medicaid and uninsured patients, for example, only eight and 10 practices qualify for reporting, respectively. Top practices are identified as those whose achievement on a given Summary Standard is high among the reporting practices; that is, they reflect the top level of achievement. These practices will share their approaches and insights with other practices in Better Health s Learning Collaborative, with the expectation that all practices and their patients may learn and improve. We make no effort to report tests of statistical significance or to identify lowest achieving practices. We believe that the practices reporting here have taken a bold step towards perfection and that all practices can improve. 2. Results by Practice: Summary Outcome and Process Standards Figures 13a-c summarize the results for each of 30 partner practices that use EMRs to measure, report and improve achievement on their patients with diabetes. Collectively, these 30 practices report on 23,461 patients. For each practice, the plots describe the percentage of each practice s adults with diabetes who meet Better Health Greater Cleveland s Summary Outcome Standard (left), which is met when a patient achieves at least four of the five standards for good diabetes control; and our Summary Process Standard (right), which is met when a patient has satisfied all four standards of good care processes. The regional average for each Summary Standard is identified at the top and bottom of each chart: 38% for Outcomes; 46% for Processes. Stars indicate practices falling approximately within the top 10% (top decile) of the region s EMR practices on each Summary Standard. Figure 13a reports the practices alphabetically; Figure 13b, in Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 37

44 rank order by achievement on our Summary Outcome Standard; and Figure 13c, in rank order by achievement on our Summary Process Standard. Figure 13a. Percentage of Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Alphabetical Listing, All Insurance Types Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 38

45 Figure 13b. Percentage of Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Outcomes, All Insurance Types Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 39

46 Figure 13c. Percentage of Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Process, All Insurance Types Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 40

47 3. Summary Outcome and Process Standards by Insurance Type The following figures provide information on individual practices achievement within four insurance categories Medicare (Figures 14a-c), Commercial (Figures 15a-c), Medicaid (Figures 16a-c) and Uninsured (Figures 17a-c). The figures summarize the achievement of each of 30 partner practices that use EMRs for measuring, reporting and improving their performance. Collectively, these practices report on 23,461 eligible diabetic patients, although the number of patients within each insurance category is necessarily smaller. Practices with fewer than 50 patients in an insurance category are not reported. For each chart, we describe the percentage of each practice s adults with diabetes who meet Better Health Greater Cleveland s Summary Outcome Standard (left) or Summary Process Standard (right). As above, lists are sorted first alphabetically and then by rank order by Outcomes and Processes, respectively. The regional average within insurance type for each Summary Standard is identified at the top and bottom of each chart. Stars indicate practices falling in the top three (Medicare and Commercial) or top two (Medicaid and Uninsured) of the region s EMR practices on each Summary Standard for that insurance category. Figures 14a 14c describe 27 practices achievement on their 8,754 Medicare patients. Three practices had fewer than the 50 Medicare patients required for reporting. Overall, 47% of our practices Medicare patients met our Summary Outcome Standard and 55% met our Summary Process Standard. Figures 15a 15c describe 27 practices achievement on their 11,941 commercially insured patients. Three practices had fewer than the 50 commercially insured patients required for reporting. Overall, 35% of our practices commercially insured patients met our Summary Outcome Standard and 38% met our Summary Process Standard. Figures 16a 16c describe eight practices achievement on their 1,317 patients insured by Medicaid. Twenty-two practices had fewer than the 50 patients insured by Medicaid required for reporting. Overall, 25% of our practices patients insured by Medicaid met our Summary Outcome Standard, and 49% met our Summary Process Standard. Figures 17a 17c describe 10 practices achievement on their 1,449 patients who were uninsured. Twenty practices had fewer than the 50 uninsured patients required for reporting. Overall, 27% of our practices uninsured patients met our Summary Outcome Standard and 47% met our Summary Process Standard. Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 41

48 Figure 14a. Percentage of Medicare Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Alphabetical Listing, Medicare Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 42

49 Figure 14b. Percentage of Medicare Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Outcomes, Medicare Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 43

50 Figure 14c. Percentage of Medicare Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Processes, Medicare Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 44

51 Figure 15a. Percentage of Commercially Insured Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Alphabetical Listing, Commercially Insured Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 45

52 Figure 15b. Percentage of Commercially Insured Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Outcomes, Commercially Insured Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 46

53 Figure 15c. Percentage of Commercially Insured Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Processes, Commercially Insured Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 47

54 Figure 16a. Percentage of Patients Insured by Medicaid in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Alphabetical Listing, Patients Insured by Medicaid Figure 16b. Percentage of Patients Insured by Medicaid in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Outcomes, Patients Insured by Medicaid Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 48

55 Figure 16c. Percentage of Patients Insured by Medicaid in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Processes, Patients Insured by Medicaid Figure 17a. Percentage of Uninsured Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Alphabetical Listing, Uninsured Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 49

56 Figure 17b. Percentage of Uninsured Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Outcomes, Uninsured Patients Figure 17c. Percentage of Uninsured Patients in Each Practice Achieving Better Health s Summary Outcomes Standard and Summary Process Standard. Rank by Processes, Uninsured Patients Better Health Greater Cleveland Community Health Checkup Report June 2008 Page 50