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A Statewide Collaboration to Monitor Diabetes Quality Improvement Among Wisconsin Health Plans
Effie E. Siomos, BA; Robert Stone Newsom, PhD; Jenny Camponeschi, MS; and Patrick L. Remington, MD, MPH

A Statewide Collaboration to Monitor Diabetes Quality Improvement Among Wisconsin Health Plans

Effie E. Siomos, BA; Robert Stone Newsom, PhD; Jenny Camponeschi, MS; and Patrick L. Remington, MD, MPH

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 recommendations.

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 physician.

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%.


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