(Editor’s Note:  The Second section of information requested from SETMA by the RWJF concerned clinical performance measures both as to process, was a standard-of-care task performed, and to outcomes, did a standard-of-care task reflect that the patient was being treated well.)

SETMA does extensive clinical performance measures, all of which are found on our website at the following link:  Public Reporting   I will only illustrate three here:

1. Diabetes
2. Hypertension
3. Lipids

The following is the front page of SETMA’s Diabetes Disease Management tool:

The Diabetes Disease Management tool is interactive with all of the patient’s record.  The following is a link to the full Diabetes Management Tool tutorial:  Diabetes Tutorial

From the work documented in the Diabetes Disease Management Tool, the following analytics can be done.

Through this longitudinal display, in 2009, we discovered that our patients who were well controlled all year were often losing their control of diabetes in October, November and December.  We then did further audits to see if they were being seen less often and being tested less often and they were.  In 2010, in September, we sent letters to all 7,000+ patients with diabetes alerting to this fact.  We indicated we wanted them to enjoy holiday celebrations but to maintain their exercise and dietary discretion.  We had them sign a contract to be seen twice in those three months and to be tested twice.  In 2011, our audit showed that this phenomenon had disappeared. 

The above compares the standard deviation of our controlled patients with diabetes (gold) and that of the uncontrolled.  We established our goal to be .7 for our diabetes populations.  We discovered that our controlled patients were seen 1.2 times more often.  This is statistically significant and we saw an opportunity to improve the control of all of our patients by making sure that all patients with diabetes had 4-5 visits a year.

No leverage points for improvement were found in the data above. (the controlled are gold and are patients with diabetes treated to goal and the selected are the uncontrolled patients in purple)

From the above, we found that our HMO capitated patients who have a zero office co-pay are treated more effectively than Fee-for-Service Medicare allowing the inference that the cost of care for the FFS Medicare patients is a barrier to the effectiveness of care in that when that barrier is removed in a similar population that the care improves.  We were able to see that for diabetes we had eliminated ethnic disparities of care.

From the above profile, we were able to see that our older patients have better control of diabetes than our younger patients. Concerned that this might reflect co-morbidities rather than excellence of care, we tested the patients for malnutrition (pre-albumin), weight loss and  appetite and found that they were not malnourished but were responding well to increased attention.

The following is the diabetes quality measurement set of PCPI.  The elements are collected automatically without the provider doing anything, but at the point of service, once the provider completes the audit of patent’s care can be reviewed by the provider.

The following is the PCPI diabetes audit for 2011.  Once again, 2009, 2010, 2011 and the first quarter of 2012 are on our website.

There are currently twelve different published audit sets for diabetes.  We track all of those.  The following is the audit set with measures, discriminators and the aggregate score for the NCQA Diabetes Recognition program. That program changed this in February of 2012 and SETMA is updating our audit to reflect the new standards.  All of SETMA providers and clinics have NCQA Diabetes Recognition.