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.