The American Journal of Managed Care May 2005
A Statewide Collaboration to Monitor Diabetes Quality Improvement Among Wisconsin Health Plans
Objective: The Wisconsin Collaborative Diabetes Quality Improvement Project was initiated in 1999 by the Wisconsin Department of Health and Family Services, Diabetes Prevention and Control Program to monitor quality of diabetes care among the state's health plans.
Study Design: Prospective observational.
Methods: Annual invitations were mailed to all Wisconsin managed care plans to participate in the project. Collaborators submitted Comprehensive Diabetes Care Health Plan Employer Data and Information Set (HEDIS) measures, as well as other selected HEDIS measures. Data were summarized and reported anonymously back to the collaborators at quarterly forums and in annual reports.
Results: Five of the 6 Comprehensive Diabetes Care HEDIS measures have improved significantly in Wisconsin since 1999. Despite this improvement, measure variation across health plans remains high. Collaborators have continued to share resources and best practices at quarterly forums and through statewide initiatives.
Conclusions: This project is an example of an ongoing statewide collaborative quality improvement effort among otherwise competing health plans. Collaboration at regular forums, sharing of HEDIS data to assess quality of diabetes care in health plans, and sharing of resources and best practices may have contributed to improvements in the quality of diabetes care in Wisconsin.
(Am J Manag Care. 2005;11:332-336)
Research has demonstrated that improving the
clinical care of diabetes mellitus reduces overall
costs, reduces secondary health issues, and
improves the quality and length of life of individuals
with diabetes.1,2 The Wisconsin Collaborative Diabetes
Quality Improvement Project was initiated in 1999 by
the Wisconsin Department of Health and Family
Services, Diabetes Prevention and Control Program as a
collaborative effort to build on this research locally. A
quality collaborative is a relatively new form of intervention,
the goal of which is to create a rapid healthcare
change by incorporating multiple organizations into the
endeavor.3 This project includes staff from health plan
quality improvement departments, the state health
department, and a university partner. The collaborative
project was established as a forum to share resources,
population-based strategies, and best practices, in order
to improve the quality of diabetes care.
An important part of the project is the annual collection
and reporting of the Health Plan Employer Data
and Information Set (HEDIS) Comprehensive Diabetes
Care measures. The collaborators chose the HEDIS
measures to evaluate quality for several reasons. First,
these data must be collected to obtain accreditation
from the National Committee for Quality Assurance
(NCQA). Because many of the health plans were
already collecting these data, the burden of data collection
was not increased, encouraging initial participation.
Furthermore, the data are collected annually
and offer standardized and consistent measurement at
the population level.
A central objective of the project is the discussion
and sharing of ideas among health plan collaborators.
All collaborators are invited to regular quarterly forums.
Forum discussion topics have included rotation of diabetes
measures, stratification of hemoglobin A1c (HbA1c)
and low-density lipoprotein (LDL) data, diabetes registries,
and efforts to improve eye examination rates.
Time during each forum is reserved for collaborators to
share their ongoing projects and initiatives to improve
the quality of diabetes care in their organization.
Diabetes Prevention and Control Program staff is in frequent
contact with the collaborators, providing technical
assistance and updated information.
Through this project, the collaborators are able to
monitor progress in the quality of diabetes care in
health plans across the state of Wisconsin. Health
plans gain knowledge about best practices, strategies,
and resources in addition to unique feedback on their
relative performance over time on HEDIS measures.
Each year, from 1999 through 2002, all Wisconsin
health maintenance organizations (HMOs) and several
other health systems, including an intertribal healthcare
system, were invited to participate in the
Wisconsin Collaborative Diabetes Quality Improvement
Project. A small stipend was provided in the first year
only to health plans that volunteered to participate. A
total of 22 plans participated in 1 or more years; 15 plans
participated for all 4 years and were included in this
analysis. These 15 plans were similar to the other plans
in Wisconsin regarding size and location in the state.
The HEDIS Comprehensive Diabetes Care measures
were first piloted in 1998. The baseline was established
the following year, and the Comprehensive Diabetes Care
measures have been repeated yearly since then. Years referenced
in this report reflect the year that care was provided
(eg, when 1999 is mentioned, we are referring to
1999 as the year that care was provided, which is a HEDIS
2000 measure). HEDIS Comprehensive Diabetes Care
measures are limited to individuals with diabetes aged 18
to 75 years. The eligible population was defined as any
individual with a diabetes diagnosis meeting the continuous
enrollment definition in a managed care organization
or healthcare delivery system. Individuals with diabetes
were identified using criteria defined by the NCQA.4
The 6 HEDIS Comprehensive Diabetes Care measures
are LDL cholesterol (LDL-C) screening, LDL-C
controlled (LDL <130 mg/dL), nephropathy monitoring,
HbA1c poorly controlled (>9.5%), HbA1c testing, and eye
examination. Higher percentages are desired for all
measures, except for HbA1c poorly controlled. Decreasing
percentages in the HbA1c poorly controlled
measure demonstrates improvement in control of HbA1c.
Participating organizations provided data for their
commercial populations only. Medicare and Medicaid
beneficiaries were not included, to facilitate comparison
over time, among plans (eg, some plans do not insure
Medicare patients), and with national data. Participants
reported their data collection methods (administrative
or hybrid), eligible populations, sample sizes, and the
percentage of patients in the sample size meeting the
requirements for each HEDIS measure.
To maintain confidentiality among health plans, collaborators
were each assigned a unique, confidential code
number. They could then see their relative ranking within
the group, but would not know which code numbers
corresponded to specific plans, other than their own.
Each health plan reported a percentage for each
measure. For each year, the mean of these reported percentages
was calculated to determine the aggregate
average percentage for all 15 health plans that participated
during all 4 years of the project. Data published in
the NCQA publication The State of Health Care Quality
2003: Industry Trends and Analysis,5 were derived
from similar methods, including calculations of the
mean rather than the median. This method permits
comparison of Wisconsin data with national and regional
data. Because patients from the intertribal health system
may have been included in one or more HMOs,
aggregate calculations included only HMO data.
Trends over time and variation between plans were
examined. Each plan's 4-year average percentage was
calculated for each of the 6 measures. The range and
mean for each measure illustrates which diabetes care
measures were consistent or varied between plans. The
intertribal health system was included in these calculations.
Trends over time, from 1999 through 2002, were
calculated for Wisconsin and the United States. To
account for ceiling effects, percent improvement was
calculated as a decrease in failure rate.6 This calculation
represents the reduction in the proportion not having
the indicator (eg, an increase from 80% to 90% represents
a 50% reduction in the proportion without the
indicator). The Wilcoxon signed rank test was used to
compare 1999 averages to 2002 averages for Wisconsin;
a comparison of means with equal variance was used to
compare US averages from 1999 through 2002.
Representatives of the health plans met quarterly to
share and discuss findings from the HEDIS data and to
share resources, best practices, strategies, and barriers
encountered in their organizations. The quarterly forums
generally included brainstorming, as well as discussion
about data collection issues, data analysis, and results
relating to the project. The forums were generally well
attended, with much of the group representing quality
improvement managers; total attendance, including individuals
participating by teleconference, was generally
numbered in the 20s. Two separate educational sessions
provided an opportunity for collaborators to learn more
about HEDIS and allowed them to ask specific questions.
Ongoing communication through several methods
was essential to the success of this collaboration.7-12
Collaborator e-mail discussions and updates occurred
monthly; presentations at local and national conferences
were also frequent. Participation in the project, defined
as the submission of HEDIS data for that year, was evaluated
yearly. Despite the high turnover rate in quality
improvement managers, most (15 of 22) health plans
continued to submit their HEDIS Comprehensive
Diabetes Care measures annually for the 4 years of this
report, as well as attend and participate in forums.
Collaborators also strived to improve the quality of
diabetes care through statewide collaborative quality
improvement initiatives. In 2001, the collaborators
developed the Diabetes Eye Care Initiative. Collaborators
raised concerns that the dilated eye examination is
the only diabetes measure performed outside the primary
care office system. This factor may decrease
patient adherence and adds a barrier in communicating
results from the eye care specialist to the primary care
physician. A lack of communication provides challenges
in collecting accurate data. The objectives of this initiative
included increasing the percentage of individuals
with diabetes receiving eye examinations as well as
improving communication and reporting of results and
Using joint letterhead to show a united message, the
Diabetes Eye Care Initiative targeted all primary care
physicians and eye care specialists in the state.
Physicians were encouraged to use an "Eye Exam
Communication Form," which was created to report
results from the eye care specialist to the primary care
The second initiative was the Cardiovascular Risk
Reduction Initiative, the goal of which was to prevent
cardiovascular events in persons at risk or with established
cardiovascular disease. Materials included 1-page
guidelines for healthcare providers and patient wallet
cards to assist individuals in tracking their own lipid
and blood pressure results.
Of the 20 HMOs in Wisconsin, 15 HMOs submitted
consecutive yearly data from 1999 through 2002 for
the HEDIS Comprehensive Diabetes Care measures. Improvements
were noted for all 6 HEDIS Comprehensive
Diabetes Care measures during the 4-year period,
although most measures varied widely across HMOs.
Figure 1 illustrates the overall improvement across
Comprehensive Diabetes Care measures. From 1999
through 2002, percentages of patients with LDL-C
screening, LDL-C controlled, and nephropathy monitoring
improved consistently across all years. Poorly controlled
HbA1c showed improvement, decreasing from 30%
in 1999 to 21% in 2002. Hemoglobin A1c testing
improved after the first year, but leveled off at about 90%
by 2002. Similarly, eye examination rates improved after
the first year, but leveled off at about 67%.