MEMORANDUM TO Daniel Johnson, UHF FROM Peter Shin, Brad

Document Sample
MEMORANDUM TO Daniel Johnson, UHF FROM Peter Shin, Brad Powered By Docstoc
					                                                                                    SCHOOL OF PUBLIC HEALTH
                                                                                         & HEALTH SERVICES

                                                                               DEPARTMENT OF HEALTH POLICY




MEMORANDUM


TO:            Daniel Johnson, UHF

FROM:          Peter Shin, Brad Finnegan, and Sara Rosenbaum, GWU

RE:            UHF Centers of Excellence: Quality of Care and Patient Satisfaction – December
               2008 Update

DATE:          March 20, 2009



This memo summarizes the most recent results from the ongoing UHF health center grantee
reporting project, which began as a pilot in December 2005. Consistent with previous updates,
the four grantees selected by UHF as centers of excellence continue to report strong performance
on measures of clinical quality and patient satisfaction relative to prior reporting periods and to
available national Medicaid average rates. In keeping with the attempts to improve quality
among health centers, the grantees agreed to adding higher standards for the diabetes measures.
In addition to the higher standards for diabetes measures, the grantees are reporting the raw
diabetes data, which allows us to further analyze the clinical measures and provide statistical
analysis over time. Beginning with the June 2008 reporting cycle, grantees reported percent of
diabetes patients with blood pressure <130/80 mm Hg, percent of patients with most recent LDL-
C <100 mg/dL, and percent of patients with most recent HbA1c level ≤ 7.0%. In the most recent
reporting cycle, the grantees agreed to add a moderate HbA1c control of between 7.0% and
9.0%.

The memo presents figures showing the semi-annual trends for the core clinical care measures of
cervical cancer screening, comprehensive diabetes care, asthma pharmacologic therapy, tobacco
use screening and cessation counseling, and prenatal HIV screening, as well as selected patient
satisfaction data. Where possible, the national benchmarks are also included for comparison.

In addition to the quality and access data, the some of the grantees provided some insight into
where the UHF investments were being made. Not surprisingly, their reports indicate much (40-
50%) of the UHF funding are used for hiring and supporting medical and specialty care staff,
with other outlays for enabling and administrative services as well as training and technical
equipment.

The memo describes the progress to date and ends with next steps.



        2021 K STREET, NW, SUITE 800 WASHINGTON, DC 20006 202-296-6922 FAX 202-296-0025
UHF Progress Report                         2
March 20, 2009




Improved Access to Care

Between 2006 and 2008, health centers have seen significant increases in patients (Table 1). For
example, Miami increased from 6,825 patients to 7161, and New York reported an increase of
8,946 to 9,094. DC also reported significant gains over the past 3 years, increasing the number
of patients from 6,522 to 8,590. The largest percentage is Excelth, which saw a 170% increase
in the number of patients, growing from 958 to 2,580 patients over the same time period.

                       1. Patient Access to UHF Centers of Excellence


                                   Patient growth (2006-08)       % Increase
                Miami, FL                6,825 - 7,161                5%
                New York, NY             8,946 - 9,094                2%
                New Orleans, LA           958 - 2,580                169%
                Washington, DC           6,522 - 8590                32%



Continuing Quality Improvement Trends

As of December 2008, all grantees had performed at equal or better levels than in many of the
clinical national Medicaid benchmarks. Some of fluctuations over the course of this 3 year
project may be due to modifications in the understanding and the definition of the measures,
changes in personnel abstracting and compiling the data, as well as fluctuations in the number of
charts reviewed due to practical and administrative constraints. In terms of patient satisfaction,
the grantees report moderate levels of satisfaction across most measures, but there is still room
for improvement in all measures. The following section describes their performance in clinical
quality and reporting to date.


Clinical Care

Cervical Cancer Screening

Figure 1 shows three grantees were continuing to exceed the national average for cervical cancer
screening. The final grantee matched the national average (65%) for the percent of women who
had at least one PAP tests in the previous two years. Collectively, the centers provided a PAP
test for about 77 percent of women. Between the pilot of December 2005 and the last reporting
period of December 2008, New York and DC have both witnessed improvements (84% vs. 93%,
72% vs. 78%, respectively). Miami reported a drop of three percent over the past three years.
New Orleans has had a cumulative increase since joining the project (47% vs. 65% between June
2007 and June 2008).
UHF Progress Report                                                3
March 20, 2009




                                 1.Cervical Cancer Screening:
                            Percent of women who had ≥ 1 PAP test
                             Miami           New York              D.C.         New Orleans               National



                                                                   98
                                                                    90                 92
                                                                                      90              90         93
                                    89
                   84                               84                                              85
                 76 72           77               76 72                 76                             78            78
                                      70                                           70                           73
                           64               64              64               65             66
                                                                                           66              67         65
                                                                                                                       65
                                                                                                          61
                                                                          47




                   Decem           June-06          Decem           June-07          Decem           June-08     Decem
                   ber-05                           ber-06                           ber-07                      ber-08

            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios




Comprehensive Diabetes Care

Figures 2-10 feature the grantees’ results for the five measures of quality of care for patients with
diabetes. As previously stated, the grantees decided to increase the quality standard applied to
the measures, for three of the diabetes measures – more rigorous thresholds were used and are
within the standard range as defined by the measure in question.

Figure 2 shows three of the four grantees exceeded the national average for the percent diabetes
patients with blood pressure below the critical mark of 140/90 mm Hg. There is considerable
fluctuation in the longitudinal results, likely due to changes in the methodology and definition of
the measure. Miami had a slight increase in the percent of patients with blood pressure below
140/90 mm Hg over the past three years. New York reported the same percent of patients with
blood pressure below 140/90 mm Hg with 68 percent. D.C., however, reported a decline in the
percent below the critical blood pressure mark from 68% to 53%. New Orleans has had an
increase (51% vs. 61%) since reporting in June ‘07, although we cannot say whether any of these
changes are statistically significant.
UHF Progress Report                                                4
March 20, 2009




                                    2. Diabetes Chart Reviews:
                               Percent of patients with blood pressure
                                          < 140/90 mm Hg

                              Miami           New York              D.C.         New Orleans                   National


                                      96              96           100
                                     95
                                                     88                             90
                                                   81                    83              83
                                                                                                          78
                    68
                  65 68                                                68
                                                                                       62 59  63
                                                                                                           67
                                                                                                             61
                                                                                                                 6668
                                                                                                                      61
                                                                                           57                 60
                                  54                                        51                                      53 56




                    Decem           June-06          Decem           June-07          Decem           June-08         Decem
                    ber-05                           ber-06                           ber-07                          ber-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios




In addition to the blood pressure measure used from the beginning of this project, a second
quality standard (more rigorous than 140/90 threshold) was added by consensus in June 2008.
Figure 3 shows that two of the health centers (New York and New Orleans) exceeded the
national average for the percent of patients with diabetes with blood pressure under 130/80 mm
Hg. New York reported the largest increase in the number of diabetes patients with normal
blood pressure (38% to 50%).

                                    3. Diabetes Chart Reviews:
                               Percent of patients with blood pressure
                                          < 130/80 mm Hg

                              Miami           New York              D.C.         New Orleans                   National

                                                                                                          50
                                                                  46
                           38          39                                                                            37
                      35                                    33                35
                                             30                                     31                                    30
                                                                                                   29           29
                                                                         26




                                 NR

                           December-07                               June-08                              December-08
            NR = DC did not report raw data to calculate this measure
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios
UHF Progress Report                                                5
March 20, 2009



Figure 4 shows all four health centers exceed the national average for the percent of patients with
diabetes receiving at least one LDL-C test. In addition, New York improved the percentage of
patients receiving the test compared to December 2005 and New Orleans improved compared to
its earliest reporting cycle in June 2007 (80% vs. 88%, and 89% vs. 98% respectively).


                            4. Diabetes Chart Reviews:
                Percent of patients with diabetes with ≥ 1 LDL-C test
                            Miami           New York             D.C.         New Orleans                National




                                 97              97                          96     97 99         98
                      92                                          93 94
                                                                   90 89
                                                                           94 94
                 88                                                           86       89
                                                                                      87       88
                   80                                82                 81       81          83 84
                           78        78
                                    75 78           76 78                                 73       71




                 Decem ber-05        June-06      Decem ber-06       June-07      De cem ber-07        June-08   De cem ber-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios
UHF Progress Report                                                6
March 20, 2009



Figure 5 highlights the percent of diabetic patients with their cholesterol level under control
(below 130 mg/dL). Over the three year period, New York, Miami and D.C. all saw a decrease
in the percentage of their patients with their cholesterol level under control, using the national
benchmark of below 130 md/dL (80% vs. 76%, 97% vs. 79%, and 87% vs. 76% respectively).
New Orleans reported an increase in the percentage of patients with their cholesterol level under
the 130 mg/dL critical mark compared to their initial reporting in 2007 (64% vs. 85%). All four
health centers performed well above the national mean of 51 percent.


                             5. Diabetes Chart Reviews:
               Percent of patients with most recent LDL-C <130 mg/dL
                             Miami           New York              D.C.         New Orleans               National




                 97
                    87                                                                                   86          85
                   80                             81 84
                                                    78
                                                                                   84
                                                                                                                79 76
                                     74                            75 72
                                                                    74                              77            76
                                                                                      72 70            73
                                    69                                                                67
                                                                       64              62
                           50 48            50              50               51              51            51         51




                   Decem           June-06          Decem           June-07          Decem           June-08     Decem
                   ber-05                           ber-06                           ber-07                      ber-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios



In the past year, the grantees decided to also show their performance for a lower cut-off point of
less than 100 mg/dL and had agreed to report actual values for cholesterol levels in a
standardized collection instrument developed by GW and approved by the group. Figure 6
illustrates all four centers exceeded the national average of 31 percent. Additionally, three of the
four health centers reported an increase in the percentage of patients with cholesterol levels
below 100 mg/dL level. Collectively more than 54 percent of the grantees diabetic patients had
cholesterol levels below 100 mg/dL.
UHF Progress Report                                                7
March 20, 2009




                             6. Diabetes Chart Reviews:
               Percent of patients with most recent LDL-C <100 mg/dL
                             Miami           New York              D.C.         New Orleans               National


                                                   63
                                                                                                           60
                                                                                  55       53
                        50                                                                          49
                                 42
                                          39
                                                            31                                                  31




                                       June-08                                               December-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios



Figure 7 shows collectively more than 92 percent of diabetes patients at the four grantees
received an HbA1c test in the past year. In addition, all four centers far exceeded the national
benchmark of 77 percent.


                            7. Diabetes Chart Reviews:
                Percent of patients with diabetes with ≥ 1 HbA1c test
                             Miami           New York              D.C.         New Orleans               National



                100              99               9797             96 95            100
                                                                                   96 98             97    96 97
                  9292                                              93 92             92        95 95
                                   89                88                                           87     89 87
                                    83
                                                                             76              78       79       77
                           75               75              75




                   Decem           June-06          Decem           June-07          Decem           June-08    Decem
                   ber-05                           ber-06                           ber-07                     ber-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios



Figure 8 also illustrates another key aspect of the quality of diabetes care patients at health
centers receive. All grantees had a far lower percentage of patients with poor diabetes control
than the national average of 48 percent. Three of the health centers had 25 percent or fewer of
their patients with poor diabetes control. All three centers participating from the beginning of
UHF Progress Report                                                8
March 20, 2009



the study either stayed stable (D.C. at about 25%) or experienced increases in their percentages
between December 2005 and June 2008 (16% vs. 24% for New York and 24% vs. 29% for
Miami), though all three fluctuated over the two year period. New Orleans witnessed an increase
since their reporting began in June 2007 (19% vs. 27%).



                             8. Diabetes Chart Reviews:
              Percent of patients with most recent HbA1c level > 9.0%
                             Miami           New York              D.C.         New Orleans                National



                           50               50              50                49        48 49                             48
                                                                                                               47

                                                                                                          39
                                      35               36
                                                                         32
                                                                                                                    29
                      26                                               27                  26       26                   27
                 24                               25                               24                                  25
                                                                                                                      24
                                                                                                           23
                                    21              21             21     19         19
                   16            15                                                                   15




                   Decem           June-06          Decem           June-07          Decem           June-08         Decem
                   ber-05                           ber-06                           ber-07                          ber-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios



Similar to the LDL-C measure, the grantees agreed to provide raw data for the HbA1c level of
their patients. This allowed GW to analyze the data further to determine the percentage of
diabetes patients with good HbA1c control (less than or equal to 7.0%) and the percentage of
diabetes patients with moderate HbA1c control (between 7.0% and 9.0%). Figure 9 shows the
percentage of patients with moderate control. When examined in comparison with Figures 8 and
10, all four grantees have larger percentages of patients with good control of HbA1c levels than
either moderate control or poor control.
UHF Progress Report                                                9
March 20, 2009




                               9. Diabetes Chart Reviews:
                     Percent of patients with most recent HbA1c level
                                 between 7.0% and 9.0%
                                    Miami               New York                 D.C.             New Orleans


                               45        45

                                                             38                                           37
                                                   33                                                           34
                                                                                      30        29




                                           June-08                                            December-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios



Figure 10 illustrates that all centers are exceeding the national average of 32 percent at year’s
end. New York performed well above the national average with 47 percent of patients with good
control by end of the 2008.


                           10. Diabetes Chart Reviews:
             Percent of patients with most recent HbA1c level < 7.0%
                             Miami            New York             D.C.         New Orleans               National


                                                                                           47

                                 40                39                             40
                                                                                                     38    37
                                                            31                                                   32
                        29                28




                                       June-08                                               December-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios
UHF Progress Report                                                10
March 20, 2009



Asthma

The asthma measure was separated into three components; the number of eligible patients with
assessment and severity test of their asthma, of those assessed, the number who were diagnosed
as persistent and if found to be persistent, put on appropriate pharmacologic therapy. The first
aspect measures the percentage of patients with asthma who were given an assessment and
severity test. Figure 11 illustrates that none of the grantees surpassed the national average of
asthma patients with assessment and severity test at 87 percent. Longitudinally, the four centers
have fluctuated greatly, but comparisons between reporting at the beginning of the project and
now all decreased for each center. A portion of this fluctuation can likely be attributed to the
small number of Asthma patients seen by a couple of the health centers. In addition, the
understanding of the measure changed over time and grantees settled on a measure that captures
the number of eligible patients assessed, then tested for the severity of their asthma, and if found
to be persistent, put on appropriate pharmacologic therapy. Previously, the measure examined
the percent of patients diagnosed with mild, moderate, or severe persistent asthma who were prescribed
either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative
treatment.


                             11. Asthma Chart Reviews:
                Percent of patients with assessment and severity test

                            Miami          New York             D.C.        New Orleans                National *
                                                                      100          100
                                     100             100
                                                    97              100        100100100           100
                    96                                                                               94
                 9292               91
                                                 85                         86               87             88        87
                                                                                                                  81 81
                                                                                                                   77
                                                                                                           71
                           64              64              64 65


                                 39                                                                              36

                                                                                                  17



                   Decem          June-06          Decem           June-07          Decem         June-08         Decem
                   ber-05                          ber-06                           ber-07                        ber-08
             Note: National benchmark is for ages 5-56, CHC percentages are for ages 5-40.
             Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios



The final portion of the Asthma measure (as shown in Figure 12) is of those patients who were
diagnosed with persistent asthma, the percentage that were prescribed either the preferred long-
term control medication (inhaled corticosteroid) or an acceptable alternative treatment during the
measurement period.
UHF Progress Report                                                 11
March 20, 2009




                                  12. Asthma Chart Reviews:
                          Percent of patients with persistent diagnosis
                             in appropriate pharmacologic therapy

                               Miami                New York                   D.C.              New Orleans
                          100                   100       100                                  100        100



                                     97.5



                                                                                     95



                                                                                                                    NR


                                       June-08                                                December-08
             Note: New Orleans did not report this portion of the Asthma measure. National benchmark is not available for this measure.
             Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios




Tobacco and Smoking

Figures 13 and 14 show the percent of adult patients who were queried about tobacco use and
smokers who were advised to quit. Although there are currently no national benchmarks with
which to compare the grantee results for asking about tobacco use, most patients (>89%) were
queried about smoking.

The national average of smokers who were advised to quit is 76 percent, while the grantees
advised between 67 and 100 percent of their own smoker patients to quit. Between 89 and 100
percent of the patients were asked about their tobacco use, and between 2005 and 2008, New
York saw a slight decline in the percentages of patients queried about their status as a smoker
(92% vs. 89%) – however, this may largely be due to changes in methodology. Miami reported
the same percentage in 2005 as 2008, and DC and New Orleans both saw increases from their
initial reporting (72% vs. 96% and 65 vs. 92%, respectively).
UHF Progress Report                                               12
March 20, 2009




                               13. Tobacco Chart Reviews:
                       Percent of patients queried about tobacco use
                                Miami               New York                   D.C.               New Orleans



                 100             100               98                                                           100
                                        93                         96 97            93 95           95 93            96
                   92                                    90                                           92           89 92
                                                       84              85             85                 85
                       72                                                                    69
                                     63                                     65




                December-05         June-06      December-06         June-07      December-07         June-08   December-08




                           14. Tobacco Chart Reviews:
               Percent of patients who were advised to quit smoking
                             Miami           New York              D.C.         New Orleans               National



                 98                                                                                             100
                                                                                   86
                                                  78                                                  79           8181
                                                                                                       77             76
                                 71 69                  69         72 70
                                                                                      68 68                68     67
                                   63                               64                 6363               64
                                                    58                                              59
                    52
                   48




                   Decem           June-06          Decem           June-07          Decem           June-08     Decem
                   ber-05                           ber-06                           ber-07                      ber-08
            Source: National Data obtained from Medicaid HEDIS 2008 Audit Means, Percentiles and Ratios
UHF Progress Report                                                 13
March 20, 2009



Prenatal care HIV screening

Figure 15 shows a continued high percentage of women being screened for HIV during early
prenatal care visits. Compared to initial reporting when the program began in December 2005,
all three original grantees have reported increases (Miami: 72% vs. 97%; New York 96% vs.
99%; D.C. 92% vs. 99%). New Orleans recently began providing prenatal care at the grantee
site for the first time since Hurricane Katrina, and as a result there is not any information on the
prenatal measure.

                         15. Prenatal Care HIV Screening:
               Percent of patients who were screening for HIV during
                       the first or second prenatal care visit
                                    Miami                New York                    D.C.              New Orleans

                                                          100
                                                        100                 9898         9998                              979999
                       9692            9497            96                                                   9698
                                     87                                                                   89

                    72




                                                                       nr          n/a         n/a                 n/a              n/a

                   December-          June-06        December-           June-07         December-         June-08        December-
                      05                                06                                  07                               08

            Note: Miami did not report this measure in June 2007 and reported 2nd test between 28-36 weeks instead (see slide 14); NO did not
            offer prenatal care following Hurricane Katrina, and has just begun offering those services; DC did not report this measure in
            December 2007



Due to the grantees high performance in this measure in 2006 and the lack of national
benchmarks, the grantees agreed to amend the measure and additionally report on the percentage
of prenatal patients who were screened again for HIV in their 28-32 weeks of gestation, in
compliance with recommended practice standards. Miami was able to begin this measurement
earlier than the other centers and therefore there is a comparison for the Miami grantee only. For
this clinical measurement Miami increased the percentage of patients who were screened again
for HIV in the 28-32 weeks of gestation from 57 percent to 83 percent. New York and D.C.
began reporting this measure this reporting cycle so there is no comparison available, but 96
percent and 55 percent (respectively) of patients were screened again for HIV in the 28-32 weeks
of gestation. It is important to note that some states vary in the timing of the second prenatal
test, (e.g., 28-36 weeks or generally third trimester) and we will continue to explore the best
timeframe to measure a second HIV screening.
UHF Progress Report                                                   14
March 20, 2009




                         16. Prenatal Care HIV Screening:
               Percent of patients who were screening for HIV during
                                 the third trimester
                                    Miami                 New York                     D.C.               New Orleans

                                                                                                       96
                                                                                            83


                              57                                                                                   55




                                                                                                                            n/a

                                           June-08                                                    December-08



            Note: NO did not offer prenatal care following Hurricane Katrina, and has just begun offering those services;




Patient Satisfaction

The results of the patient satisfaction survey show that there is room for improvement for all
grantees in the three areas of patient satisfaction compared to national averages. Due to the
pediatric population the New York site targets, national child benchmark data is shown. The
findings suggest that the centers could greatly improve their response time when they receive a
call from a patient, with all centers reporting below the national average. In addition, two
centers are well below the national average in both the provider listens measure and the provider
spends enough time measure. Figure 17 shows the results of three questions for which national
benchmark data are available.
UHF Progress Report                                15
March 20, 2009




                            17. Patient Surveys, December 2008
                                  (“always/almost always”)
                        Miami         New York     D.C.      New Orleans      National (2008)




                                                   82                         82
                                             75                   75
                                      70
                                                                         66
                                                                                             61
                       56                               56
                                                                                   49
                            40
                  32                                                                    33
                                 27                          27




                 Call always answered            Provider listens      Provider spends enough
                        same day                                                 time




Discussion

The evaluation continues to find these health centers to be providers of high quality care. They
continue to apply and adapt standard measures largely defined in terms of health plan
performance to their primary care practices. In addition, the four UHF health center grantees
continue to strive to improve their performance in clinical measures and create more stringent
benchmarks to enhance their quality of care. With the centers providing the raw numerator and
denominator numbers for the diabetes and asthma measure we will be able to estimate statistical
differences over time as well as calculate more restrictive performance measures such as those
used for several of the diabetes care measures. Finally, with the release of the 2008 HRSA UDS
data, which for the first time includes similar quality of care measure for patients with diabetes
(HbA1c <7% and >9%), we hope to be able to compare the performance of these four grantees
with the entire Federal Qualified Health Center population.

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:18
posted:7/29/2009
language:English
pages:15