implementation of care and preventive services for people with diabetes. Refer to diabetes educator, preferably a certified. diabetes educator (CDE) …
Wisconsin Essential Diabetes Mellitus Care Guidelines, 2004
one page
The recommendations in these Essential Diabetes Mellitus Care Guidelines are intended to serve as a guide for clinicians and others involved in the implementation of care and preventive services for people with diabetes They are not intended to replace or preclude clinical judgement Abnormal physical or lab findings should result in follow-up/intervention For particular details and references for each specific area, please refer to the supporting documents and implementation tools in the full-text guideline available via the Internet at http://dhfswisconsingov/health/diabetes/DBMCGuidelnshtm or telephone: 608 261-6871
Perform diabetes-focused visit Review management plan, assess problems and goals Assess physical activity Assess nutrition/weight/BMI/growth Refer to diabetes educator, preferably a certified diabetes educator CDE; curriculum to include the ten key areas of the national standards for diabetes self-management education Refer to registered dietician, preferably a CDE; to include areas defined by the American Dietetic Associations Nutrition Practice Guidelines Check A1c Goal: 70 or 1 above
lab norms Review goals, meds, side effects, and frequency of hypoglycemia Assess self-blood glucose monitoring schedule Check lipid profile Adult goals: Total Cholesterol 200 mg/dL Triglycerides 150 mg/dL HDL 40 mg/dL men HDL 50 mg/dL women Non-HDL Cholesterol 130 mg/dL LDL 100 mg/dL optimal goal LDL 70 mg/dL for high risk Blood pressure Adult goal: 130/80 mmHg Pediatric goal: below 90 of ideal for age Assess smoking status Start aspirin prophylaxis unless contraindicated Check albumin/creatinine ratio using a random urine sample, also called urine microalbumin/creatinine ratio Check serum creatinine Perform routine urinalysis Perform dilated eye exam by an ophthalmologist or optometrist Inspect feet, with shoes and socks off Perform comprehensive lower extremity exam Perform oral health screening Advise dental exam by general dentist or periodontal specialist Assess emotional health; screen for depression Assess sexual health concerns Provide influenza vaccine Provide pneumococcal vaccine Provide preconception counseling/assessment Assess contraception/discuss family planning Screen for gestational diabetes
: Every 3 months : Every 3 6 months consider
more often if A1c 70 and/or complications exist Each focused visit; revise as needed Each focused visit Each focused visit
At diagnosis, then every 6 12 months, or more as needed : At diagnosis; then, if age 18, every 3 6 months; if age 18, every 6 12 months : At diagnosis; then every 6 12 months or more as needed : Every 3 months : Every 3 6 months Each focused visit Each focused visit, 2 4 times/day, or as recommended : If 2 years, after diagnosis and once glycemic control is established Repeat annually if abnormal Follow National Cholesterol Education Program NCEP III guidelines : Annually If abnormal, follow NCEP III guidelines
Each focused visit
Each visit; if smoker, counsel to stop; refer to cessation Age 40 with diabetes; Age 40, individualize based on risk
: Begin with puberty or after 5 years duration, then annually : At diagnosis, then annually At diagnosis, then annually At diagnosis, then as indicated : If age 10, within 3 5 years of onset, then annually : At diagnosis, then annually; two exceptions exist see Section 7 Each focused visit; stress need for daily self-exam Annually, with monofilament At diagnosis, then each focused visit At diagnosis, then
every 6 months if dentate and every 12 months if edentate Each focused visit Each focused visit Annually, if age 6 months Once; then per Advisory Committee on Immunization Practices 3 4 months prior to conception At diagnosis and each focused visit At 24 28 weeks gestation or sooner if high risk consider referring to provider experienced in care of diabetic women during pregnancy Test all people age 45; if normal and person has no risk factors, retest in 3 years
Perform fasting plasma glucose test or oral glucose tolerance test
Diabetes Advisory Group, 2004
M
Working with health systems
Mission
The Wisconsin Diabetes Advisory Group, convened by the Department of Health and Family Services, Diabetes Prevention and Control Program, provides the foundation for active partnerships across the state Members include over 90 diverse partners, including health care and professional organizations, minority groups, business coalitions, insurance and managed care organizations, voluntary and community-based organizations, academic centers, industry and public health representatives and consumers The Wisconsin Collaborative Diabetes Quality Improvement Project is a joint partnership
Members include the DPCP, the University of Wisconsin Population Health Institute, MetaStar Wisconsins Quality Improvement Organization, the Department of Health and Family Services Division of Health Care Financing Medicaid Program, health maintenance organizations HMOs, and other health systems The Wisconsin Collaborative Diabetes Quality Improvement Project was established as a forum to: Evaluate implementation of the Essential Diabetes Mellitus Care Guidelines Share resources, population-based strategies and best practices Improve diabetes care through collaborative quality improvement initiatives
The Wisconsin Department of Health and Family Services, Diabetes Prevention and Control Program DPCP is dedicated to improving the health of people at risk for or with diabetes Forming and maintaining strong, active partnerships are key to achieving this mission The DPCP uses a statewide approach to improve the health of people at risk for or with diabetes by:
Designing populationbased community interventions and health communications Outreach to high risk populations Conducting surveillance and evaluation of the burden of diabetes Coordinating of efforts through the
Wisconsin Diabetes Advisory Group
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Collaboration is Key
The Centers for Disease Control and Prevention CDC awards a Core Capacity Cooperative Agreement to establish the Diabetes Control Program DCP in the Wisconsin Department of Health and Family Services, Division of Public Health
Advisory partners endorse and publish the Guidelines; partners begin statewide implementation efforts; some HMOs customize Guideline materials
1994
1995
1996
1997
1998
1999
The Department of Health and Family Services, Diabetes Control Program establishes Diabetes Advisory Group with 35 diverse partners, including several health maintenance organizations
Diabetes Advisory Group develops Essential Diabetes Mellitus Care Guidelines to help improve diabetes care in Wisconsin
70 of Wisconsins HMOs adopt the Guidelines; the one page Guidelines and the statewide approach appeal to the HMOs
Partners convene HMO quality improvement workgroup; HMOs and health systems agree to participate in a joint project to evaluate implementation of the Guidelines; use voluntary HEDIS Comprehensive Diabetes Care measures
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Being a part of the HMO Diabetes Collaborative is a great experience We all work
together sharing ideas, approaches, outcomes and barriers to tackle the tough health issues that face people with diabetes Two of my favorite aspects of the work we do in the Collaborative are in-depth problem solving and assisting with the development of resource materials for patients and health care providers I believe our efforts promote best practice in diabetes care across all regions of Wisconsin
Quality Coordinator, Blue Cross Blue Shield of Wisconsin
Project Year 2: partners develop collaborative diabetes quality improvement eye initiative; project expands to include collection of selected HEDIS cardiovascular care measures
Project Year 3: HMOs continue to make improvements in diabetes measures; baseline established for selected cardiovascular measures; diabetes eye exam initiative evaluation begins; collaborators assess potential cardiovascular initiative
Project Year 6: collaborators expanded diabetes eye exam initiative to include survey of all participating health systems to identify processes and initiatives that may improve diabetes care
Project Year 7: diabetes care measures continue to show improvement; project expands to include the Wisconsin Arthritis,
Asthma, and Comprehensive Cancer Control Programs
2000
2001
2002
2003
2004
2005
2006
HEDIS diabetes measures become mandatory for NCQA accredited HMOs; partners publish Project Year 1 findings
Project Year 4: HMOs continue to improve diabetes measures and selected cardiovascular measures; diabetes eye exam initiative continues
Project Year 5: diabetes care measures continue to show improvement; cardiovascular risk reduction initiative introduced
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D
Obese Overweight includes obese High Blood Pressure High Cholesterol Lack of Physical Activity Current Smoker 0
Diabetes Facts and Figures
FIGURE 1: Percent of Wisconsin Adults with Risk Factors Related to Diabetes 2003-2004
20 53 59 No Diabetes Diabetes 86
22 66 31 58 18 32 22
16
10
20
30
40
50
60
70
80
90
100
Source: Wisconsin Behavioral Risk Factor Survey, 2003-2004 Overweight is defined as Body Mass Index BMI 250 kg/m2, Obesity is defined as BMI 300 kg/m2 Data are from 2003
Participating in the HMO Collaborative is the key to developing a common definition and to understanding key priorities This forum for managed care organizations and other agencies throughout the State of Wisconsin reflects the
commitment of all the various stakeholders Above all we have a common goal to improve the health care processes and outcomes for people with diabetes
Healthcare Quality Nurse, Unity Health Insurance
Serious: People with diabetes are at increased risk of numerous complications, including blindness, kidney disease, foot and leg amputations, and heart disease Many adverse outcomes can be prevented by an aggressive program of early detection and appropriate treatment Common: Diabetes affects an estimated 329,000 adults and 4,000 children in Wisconsin African American, American Indian, and older populations often have the highest rates of diabetes Costly: The cost of diabetes in Wisconsin is staggering In 2002, estimated direct costs for diabetes were 317 billion and
estimated indirect costs were 135 billion, totaling 452 billion Source: Wisconsin Diabetes Surveillance Report, 2005 Controllable: The Diabetes Prevention Program DPP study results August 2001 found that participants randomly assigned to intensive lifestyle intervention 30 minutes of physical activity a day and diet improvement reduced their risk of developing type 2 diabetes by 58 This is significant news and offers
encouragement that reduction in risk factors with modest lifestyle changes may be the best way to prevent or delay type 2 diabetes
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C
Collaboration is Key
What is the Project?
The Wisconsin Collaborative Diabetes Quality Improvement Project
Goal: to improve the quality of diabetes care in Wisconsins HMOs
Three Project Components
Evaluate implementation of the Essential Diabetes Mellitus Care Guidelines
Collaborators selected the Health Plan Employer Data and Information Set HEDIS Comprehensive Diabetes Care measures, developed by the National Committee for Quality Assurance NCQA Data offers uni 
que opportunity to use the measures to assess Guideline implementation in Wisconsin NCQA uses HEDIS to accredit HMOs The use of HEDIS criteria provides standardized data collection at the population level to assess quality of care The Department of Health and Family Services, Diabetes Prevention and Control Program contracts with the University of Wisconsin Population Health Institute for confidential analysis and reporting of HMO HEDIS data In 2003 the HMO collaborators represented over 99 percent of the over one million nonMedicaid and non-Medicare individuals currently enrolled
in HMOs in Wisconsin, compared to 98 percent in 2001, 84 percent in 2000, and 68 percent in 1999 The Project expanded to collect select cardiovascular measures in 2000, select cancer screening measures in 2001, and select asthma care measures in 2004
1
2
1 2 2 2
Wisconsin Out-of-state
1
1 Numbers
1
16
in stars indicate number of collaborators in that area
12 3 1
1
FIGURE 2: Locations of Project Collaborators, Including those Located Outside Wisconsin - 2005
Share resources, populationbased strategies and best practices
The Department of Health and Family Services, Diabetes Prevention and Control Program maintains a system for ongoing communication with the HMOs Partners convene a quarterly forum for HMO quality managers Collaborators discuss issues and strategies eg, registry development, data collection issues, provider profiles, quality improvement activities
Improve diabetes care through collaborative quality improvement initiatives
Collaborators developed their first statewide quality improvement initiative in 2001 The goals of the Diabetes Eye Care Initiative are to increase exams and improve reporting of results and recommendations Collaborators use joint
letterhead to provide united message
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Collaboration is Key
Results
LDL-C screening improved by 31 since 1999 70 to 92 LDL-C controlled 130 mg/dL improved by 59 since 1999 44 to 70 Nephropathy monitoring improved by 36 since 1999 45 to 61 Poorly controlled HbA1c 90 improved by 28 since 1999 a decrease from 29 to 21 demonstrates improvement One/more HbA1c tests improved by 10 since 1999 84 to 92 Eye exams rates improved by 2 since 1999 63 to 64
HEDIS Comprehensive Diabetes Care Measures
for care provided in 1999-2004
Diabetes measures have improved since the Project data collection began in 1999, as shown below The figure and calculations reflect data submitted by all HMOs
The HbA1c poorly controlled measure changed from 95 to 90 in 2003
FIGURE 3: Percent of Patients Receiving HEDIS Comprehensive Diabetes Care Measures for care provided in 1999-2004
LDL-C Screening
LDL-C Controlled
Nephropathy Monitoring HbA1c Poorly Controlled low percent desired One/more HbA1c
Eye Exam
Percent
For all HMOs that submitted data in each year Similar trends exist for the 13 continously participating HMOs The HbA1c poorly controlled measure changed from 95 to 90 in 2003
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Selected
HEDIS Cardiovascular-related Care Measures
for care provided in 2000-2004
Results below show there is improvement in all of the cardiovascular-related measures since 2000 The figure and calculations reflect data submitted by all participating HMOs that submitted data with a denominator greater than or equal to 30 Beta-blocker treatment after heart attack improved by 8 since 2000 90 to 97 Cholesterol screening after acute CV event improved by 5 since 2000 80 to 84 Cholesterol controlled 130 mg/dL after acute CV event improved by 10 since 2000 67 to 74 High blood pressure control improved by 28 since 2000 54 to 69
FIGURE 4: Percent of Patients Receiving Selected HEDIS Cardiovascular-related Care Measures for care provided in 2000-2004
Beta Blocker Treatment
Cholesterol Screening
Cholesterol Controlled 130 mg/dL
Blood Pressure Controlled Percent
For all HMOs that submitted data with a denominator 30
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C
Measure DIabEtES
Eye exam
Collaboration is Key
How do we compare?
System with Highest Percentage System with Lowest Percentage Wisconsin Average of Systems Regional Average National Average
Comparison of Regional, National, and Project Populations Receiving Selected HEDIS
Measures for care provided in 2004
LDL-C screening LDL-C control 130 mg/dL LDL-C control 100 mg/dL Nephropathy monitored Poorly controlled HbA1c 90 One/More HbA1c
97 82 81 79 38 97 88 78 100 90 80 95
84 57 33 47 12 83 43 63 95 58 38 77
92 70 47 61 21 92 64 69 97 74 57 84
90 64 41 48 29 87 50 67 96 67 50 81
91 65 40 52 31 87 51 67 96 68 51 82
CarDIovaSCular
Control high blood pressure Beta-blocker treatment after heart attack Cholesterol management after acute CV event LDL-C control 130 mg/dL Cholesterol management after acute CV event LDL-C control 100 mg/dL Cholesterol management after acute CV event LDL-C screening
Two new measures were added for care provided in 2004 Regional data was provided by a collaborative partner Source: The State of Health Care Quality 2005: Industry Trends and Analysis, National Committee for Quality Assurance Lower percentage desired Data includes all systems that submitted data with a denominator greater then or equal to 30 All measures were performed on enrollees ages 18-75 years old except the following: beta-blocker treatment after CV event 35 yrs control high blood pressure 46-85 yrs
Project Advantages
Diabetes and cardiovascular
care measures continue to improve collectively in Wisconsin Collaborators are using data reports to discuss barriers, problem-solve, and identify potential quality improvement initiatives People with diabetes and cardiovascular disease in Wisconsin benefit from the improvements in care HMOs receive local benchmarking data, reports to share with managers and community stakeholders, and a forum to address mutual concerns and best practices Communication and sharing forums help: Distribute new research and resources Promote dynamic brainstorming and planning Coordinate sharing of quality improvement strategies Diabetes registries continue to be utilized by some HMOs Wisconsins diverse HMOs continue their willingness to collaborate with each other, community partners, and the state health department on quality improvement projects
Collaborators remain motivated and committed to The Diabetes Prevention and Control Program the projects success receives valuable data for surveillance and evaluation, as well as vital support toward their Ongoing collaboration is vital to continue mission to improve the health of people at risk for these statewide improvements -8or with
diabetes
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Collaboration is Key
Results
Variation in HEDIS Comprehensive Diabetes Care Measures by Health Systems for care provided in 1999 and 2004
The mean percent all systems is shown within the high-low range The mean percentage for all of the Comprehensive Diabetes Care measures improved when comparing 1999 to 2004 Variation among the high and low plans decreased for all Comprehensive Diabetes Care measures from 1999 to 2004, except for the eye exam measure The quality of diabetes care in 2004 was most consistent for HbA1c testing and LDL-C screening Wide variations exist in some diabetes care measures in 2004 For example, one system had 88 of its enrollees with diabetes receiving eye exams, while another had 43
Examining variations in each of the Comprehensive Diabetes Care measures helps collaborators learn if quality of care is consistent across all systems, or if significant variation in performance is occurring It also allows collaborators to continue sharing quality initiatives and lessons learned One way to evaluate variation among systems is to assess their average percentages over time The mean and range for each measure were calculated for all plans that
submitted data in 1999 and this information was compared to the range and mean for each measure in 2004 Figure 5 illustrates the range of variation for each Comprehensive Diabetes Care measure in 1999 and 2004, showing the highest and lowest performing plans
FIGURE 5: Range and Mean u for HEDIS Comprehensive Care Measures all plans submitting data in 1999 and 2004
100 80 Percent 60 40 20 0 LDL-C Screening
Low Low High High High High High Low High Low Low Low High Low Low Low Low 1999 2004 Low High Low High High High High
LDL-C Controlled 130
Nephropathy Monitoring
HbA1c Poorly Controlled
One/more HbA1c
Eye Exam
lower percentage desired
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The Wisconsin Collaborative Diabetes Quality Improvement Project highlights an extraordinary level of cooperation among diverse, competitive health maintenance organizations to improve diabetes care in Wisconsin Collaboration is key to this projects successes This collaborative model may serve as the springboard for the expansion to other statewide quality improvement initiatives
We would like to recognize the following organizations for their interest and participation in this project: Advanced Health Care, Atrium Health Plan, Inc,
Blue Cross Blue Shield of Wisconsin, Dean Health Plan, Inc, Great Lakes Inter-Tribal Council, Inc, Group Health Cooperative of Eau Claire, Group Health Cooperative of Southcentral Wisconsin, Gundersen Lutheran Health Plan, Health Tradition Health Plan, Humana Inc, Managed Health Services, Medica Health Plan, Medical Associates, MercyCare Health Plans, Network Health Plan, Physicians Plus Insurance Corporation, Prevea Health Plan, Security Health Plan of Wisconsin, Thedacare, United Healthcare of Wisconsin, Inc, Unity Health Plans Insurance Corporation, and Valley Health Plan The project is also supported by the Wisconsin Department of Health and Family Services, Diabetes Prevention and Control Program and the Diabetes Advisory Group Many individuals made this project possible: Leah Ludlum, RN, BSN, CDE, Jenny Camponeschi, MS, Judy Wing, and Mark Wegner, MD, MPH of the Department of Health and Family Services, Division of Public Health; Kelly Stolzmann, BS, Patrick Remington, MD, MPH, and Robert Stone-Newsom, PhD, from the University of Wisconsin Population Health Institute; MetaStar, Inc; Department of Health and Family Services, Division of Health Care Financing; State of
Wisconsin Employee Trust Funds; Irene Golembiewski, Media Solutions, University of Wisconsin School of Medicine and Public Health; all members of the Wisconsin Collaborative Diabetes Quality Improvement Project including the Wisconsin Arthritis Program, the Wisconsin Asthma Program, the Wisconsin Comprehensive Cancer Control Program, and the Wisconsin Cardiovascular Health Program
The Wisconsin Collaborative Diabetes Quality Improvement Project is an initiative of the Wisconsin Department of Health and Family Services, Division of Public Health, Bureau of Community Health Promotion, Diabetes Prevention and Control Program For questions or to obtain a comprehensive summary concerning this project contact: Wisconsin Department of Health and Family Services Division of Public Health http://dhfswisconsingov/health/diabetes/ This publication was supported in part by Cooperative Agreement Number U32/CCU522717-01 from the Centers for Disease Control and Prevention Its content are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control
Prevention
Source:diabetes-education.com
