New Approaches Focusing on Dynamic Variables Related to Changes in. New Approaches Focusing on Dynamic

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1 New Approaches Focusing on Dynamic New Approaches Focusing on Dynamic Variables Related to Changes in Variables Related to Changes in Member s Health Status: Member s Health Status: Diabetic HbA1c Predictive Model Brenton B. Fargnoli Blue Cross & Blue Shield of Rhode Island

2 Outline Outline Background Predictive Rules Validity Applications 2

3 Background Background 3

4 The Diabetic Epidemic The Diabetic Epidemic Prevalent 23.6 million people (7.8% of population) Expensive Medical Expenditures: $116 Billion National Diabetes Statistics, 2007 American Diabetes Association,

5 Lab Data Gap Lab Data Gap Clinical and Economic Effectiveness: HbA1c<7%: (6, 4.5) HbA1c>9%: (6, 4.5) Annual HbA1c Screening: (1,1) Thus, it is the lab values, not the presence of screenings which are significant. de Brantes et al., Am J Managed Care,

6 Variables Variables Associated Associated with with HbA1c HbA1c Level Level Association Age Drug Adherence Drug Therapy Co-Morbidities Physician Visits Ethnicity No Association Gender Income A1c screenings Shectman et al., Diabetes Care,

7 Predictive Rules Predictive Rules 7

8 HbA1c s Continuous Risk HbA1c s Continuous Risk Gradient Gradient 1% HbA1c Reduction Associated with Decreases: 43% Amputations 36% Nephropathy, Neuropathy, Retinopathy 30% Depression 24% ESRD 14.5% Cataracts 14% MI 12.5% Stroke IMPACT Product 8

9 Applied HbA1c-Comorbidity Applied HbA1c-Comorbidity Relationship Relationship Retinopathy Example: Retinopathy Example: A1C %: Retinopathy Prevalence: (1-Prevalence) P (0 Co-Morbidities) P(Only Retinopathy) P(Ret&Neur Only) P(Ret + 1) P(R, Neur, Dep Only) Performed for 156 combinations of 9 Co-Morbidities 9

10 Predicted Predicted A1c A1c from from # # of of Co-Morbidities Co-Morbidities Predicted A1c P(0) P(1 Only) P(2 Only) P(3 Only)

11 Polynomial Extrapolation Polynomial Extrapolation 11

12 Drug Intensity-Disease Intensity Drug Intensity-Disease Intensity Relationship Relationship High Intensity (+0.75) Type II Insulin use 3 oral anti-diabetics Low Intensity (-0.75): No pharmaceuticals needed Adapted and Modified from Shectman et al., Diabetes Care,

13 Drug Adherence Drug Adherence Reflects: Self-Management Drug Effectiveness Calculated with Avg. Days Supply Method (% Adherence 82%) x (-1.5) Adapted and Modified from Shectman et al., Diabetes Care,

14 Rules Summary Rules Summary Co-Morbidities: 0: : : : : : : : : : No PCP nor Eye Appts for full year: (+0.75) Pharmacy Insulin: (+0.75) 3 oral anti-diabetics: (+0.75) None (-0.75) (% Adherent 82%) x (-1.5) Predicted HbA1c=(Co-Morbidity Index + Pharmacy Index)/2 Note: All adjustments are from

15 Validity Validity 15

16 Paired T-Test Paired T-Test All Inclusive All Inclusive Excluding Physician Visit Outliers Excluding Physician Visit Outliers Predicted Actual Actual Predicted Mean Variance Observations Pearson Correlation Hypothesized Mean Difference 0 df 99 t Stat P(T<=t) two-tail t Critical two-tail Mean Variance Observations Pearson Correlation Hypothesized Mean Difference 0 df 84 t Stat P(T<=t) two-tail t Critical two-tail Predictions compared with BCBSRI HEDIS Data 16

17 Predictive Power Predictive Power Method 1 Method 2 Deviation from Mean Avg. Absolute Deviation Deviation Confidence 77% 80% 17

18 Limitations Limitations Variance Patients skipping full year of appointments Variables limited to data fields within pharmacy and insurance claims 18

19 Applications Applications 19

20 Disease Management Disease Management Patient-Level Identify Actionable Members Measure Intervention Effectiveness 20

21 Marketing Marketing Population-Level Track and report group s year over year changes in predicted mean HbA1c 21

22 References References NIH. National Diabetes Statistics American Diabetes Association. Direct and Indirect Costs of Diabetes in the United States. de Brantes F, Wickland P, Williams J:The Value of Ambulatory Care Measures: A Review of Clinical and Financial Impact from an Employer/Payer Perspective. Am J of Managed Care 14: , 2008 IMPACT Product: Meta-analysis of case-controlled, longitudinal studies Schectman J, Nadkarni M, Voss J: The Association Between Diabetes Metabolic Control and Drug Adherence in an Indigent Population. Diabetes Care 25: ,

23 Questions Questions 23