Variation in Diabetes Care Quality Among Medicare Advantage Plans: Understanding the Role of Case Mix

1University of Minnesota, Minneapolis, MN.
American Journal of Medical Quality (Impact Factor: 1.25). 12/2011; 27(5):377-82. DOI: 10.1177/1062860611428529
Source: PubMed


This study investigates whether variation in Medicare Advantage plan performance on comprehensive diabetes care is explained by the case mix of plans. Using data on 513 Medicare Advantage plan-year observations for 2007 and 2008, the authors estimate multivariate regressions for 3 diabetes care quality measures: (1) hemoglobin screening, (2) low-density lipoprotein screening, and (3) retinal eye exam. Plan case mix is measured with the percentage of a plan's enrollees who have type 1 diabetes with and without comorbidities and the percentage of a plan's enrollees who have type 2 diabetes with and without comorbidities. Plans with a higher percentage of enrollees with type 1 diabetes with comorbidity and plans with a higher percentage of enrollees with type 2 diabetes without comorbidity have lower performance, on average. Finding evidence of a relationship between case mix and Healthcare Effectiveness Data and Information Set performance reinforces the argument for developing standardized risk adjustment or stratification methods in public reporting and pay-for-performance efforts.

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    ABSTRACT: BACKGROUND:: Performance measures are used for assessing quality of care. Higher performance shown by these measures is expected to reflect better care, but little is known whether they predict better patient outcomes. OBJECTIVE:: To assess the predictive value of performance measures of glucose management on glycemic control, and evaluate the impact of patient characteristics on this association. RESEARCH DESIGN:: Cohort study (2007-2009). SUBJECTS:: A total of 15,454 type 2 diabetes patients (mean age, 66.5 y; 48% male) from the GIANTT cohort. MEASURES:: We included performance measures assessing frequency of HbA1c monitoring, glucose-lowering treatment status, and treatment intensification. Associations between performance and glycemic control were tested using multivariate linear regression adjusted for confounding, reporting estimated differences in HbA1c with 95% confidence intervals (CI). Impact of patient characteristics was examined through interactions. RESULTS:: Annual HbA1c monitoring was associated with better glycemic control when compared with no such monitoring (HbA1c -0.29%; 95% CI -0.37, -0.22). This association lost significance in patients with lower baseline HbA1c, older age, and without macrovascular comorbidity. Treatment status was associated with better glycemic control only in patients with elevated baseline HbA1c. Treatment intensification after elevated HbA1c levels was associated with better glycemic control compared with no intensification (HbA1c -0.21; 95% CI -0.26, -0.16). CONCLUSIONS:: Performance measures of annual HbA1c monitoring and of treatment intensification did predict better patient outcomes, whereas the measure of treatment status did not. Predictive value of annual monitoring and of treatment status varied across patient characteristics, and it should be used with caution when patient characteristics cannot be taken into account.
    Medical care 12/2012; 51(2). DOI:10.1097/MLR.0b013e318277eaf5 · 3.23 Impact Factor
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    ABSTRACT: OBJECTIVE: To assess whether quality indicators for treatment of cardiovascular and renal risk factors are associated with short-term outcomes in patients with diabetes. DESIGN: A prospective cohort study using linear regression adjusting for confounders. SETTING: The GIANTT database (Groningen Initiative to Analyse Type 2 Diabetes Treatment) containing data from primary care medical records from The Netherlands. PARTICIPANTS: 15 453 patients with type 2 diabetes mellitus diagnosed before 1 January 2008. Mean age 66.5 years, 47.5% men. EXPOSURE: Quality indicators assessing current treatment (CT) status or treatment intensification (TI) for patients with diabetes with elevated cardiovascular or renal risk factors. MAIN OUTCOME MEASURES: Low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and albumin:creatinine ratio (ACR) before and after assessment of treatment quality. RESULTS: Use of lipid-lowering drugs was associated with better LDL-C levels (-0.41 mmol/litre; 95% CI -0.48 to -0.34). Use of blood pressure-lowering drugs and use of renin-angiotensin system inhibitors in patients with elevated risk factor levels was not associated with better SBP and ACR outcomes, respectively. TI was also associated with better LDL-C (-0.82 mmol/litre; CI -0.93 to -0.71) in patients with elevated LDL-C levels, and with better SBP (-1.26 mm Hg; CI -2.28 to -0.24) in patients with two elevated SBP levels. Intensification of albuminuria-lowering treatment showed a tendency towards better ACR (-2.47 mmol/mg; CI -5.32 to 0.39) in patients with elevated ACR levels. CONCLUSIONS: Quality indicators of TI were predictive of better short-term cardiovascular and renal outcomes, whereas indicators assessing CT status showed association only with better LDL-C outcome.
    BMJ quality & safety 02/2013; 22(4). DOI:10.1136/bmjqs-2012-001203 · 3.99 Impact Factor