Search

Nurse case management has been shown to improve the quality of diabetes care in closed model health maintenance organizations and Veterans Affairs medical clinics. A randomized controlled trial of a similar intervention within HealthTexas Provider Network, a fee-for-service primary care network in North Texas, demonstrated no benefit in processes of care or clinical outcomes for Medicare diabetes patients. To investigate whether the case management model impacted the cost of diabetes care from the Medicare perspective, we compared the average payments and charges incurred between intervention arms: claims-based audit and feedback; claims- and medical-record-based audit and feedback; and claims- and medical-record-based audit and feedback plus a practice-based diabetes resource nurse. Following adjustment for baseline differences between groups, no significant differences were observed. Thus, within this setting, it appears the nurse case management model produced no improvement in either clinical quality or in costs associated with diabetes from a Medicare perspective.

Diabetes care in the United States is suboptimal. Although closed-panel health maintenance organizations (HMOs) and the Department of Veterans Affairs (VA) report performance superior to national norms, fee-for-service performance is uncertain. To address this issue, 3 outcome and 5 process indicators were measured for 2010 Medicare diabetes patients across 22 sites in a large, fee-for-service primary care group practice. American Diabetes Association standards for glycemic control, low-density lipoprotein cholesterol, and blood pressure were met by 53%, 46%, and 19% of patients, respectively. Diabetes Quality Improvement Project/Alliance poor control markers for the same measures were exceeded by 9%, 20%, and 54% of patients. Chart abstraction demonstrated annual eye examination, foot examination, and nephropathy screening rates of 16%, 49%, and 38%, while Medicare claims showed an annual eye examination rate of 63%. Observed processes and outcomes in this fee-for-service setting were superior to reported national performance and similar to the best performance in staff-model HMOs and the VA.

Background: This paper describes a collaborative Medicare claims data linkage and sharing effort between the Baylor Health Care System (BHCS) and Texas Medical Foundation (TMF, the Texas Quality Improvement Organization) designed to assess the effect of three quality improvement interventions on care delivered to elderly patients with diabetes. The randomized controlled trial is being conducted among a network of primary care physician practices owned by BHCS and focuses on measures of care process and outcome., Methods: Cohort definition and baseline measurement took place between January 1 and December 31, 2000. BHCS administrative data and TMF-supplied Medicare enrollment data were used to define the January 1, 2001 prevalence cohort of Medicare diabetic beneficiaries meeting study inclusion criteria. A total of 22 practices (with 92 physicians and 2,158 patients) were randomized to one of three interventions, each of which involved performance measurement feedback on three claims-based measures of care process. Physician profiles, generated by TMF using Medicare utilization files, were reported to study physicians via academic detailing sessions with a BHCS physician educator., Results: The January 1 - December 31, 2000 baseline Medicare claims for the January 1, 2001 prevalence cohort were provided to HTPN by TMF in October 2001, representing a ten-month lag in the ability of Quality Improvement Organizations to provide Part B data relative to a specific episode of care time frame. Overall baseline rates for the claims-based process measures were: annual HbA1c testing (86.1%), annual eye examination (60.8%), and annual lipid profile (72.5%). As anticipated, medical-record based rates of annual eye examination were significantly underrepresented. Agreement between claims-based and medical record-based measures was very close for annual HbA1c and annual lipid profile., Conclusions: The use of Medicare claims data, through collaboration with a QIO, can help health care providers overcome a significant barrier associated with quality improvement initiatives. Limitations associated with the use of Medicare claims can impact implementation of intervention strategies, but do not prevent them from being a practical tool for improving care.