Improving Health Care, Improving Lives: 2007 AHRQ Annual Conference

Systems-Level Approaches to Reducing Racial, Ethnic and Income

Disparities in Healthcare Quality

Frederick P. Cerise, M.D., M.P.H Vice President Health Affairs and Medical Education

Louisiana State University System

September 28, 2007

Percent of Medicaid Eligibles and Louisiana Population, by Race

Medicaid Eligibles

63

3732

54

59

0

10

20

30

40

50

60

70Louisiana Population

African-American

African-American

White WhiteOther Other

SOURCE: DHH data as of 8/31/2007; LA population est. 2005.

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Graph shows only CC PCPs with 10+ patients

overall level = 65%, red = stat sig diff > .05 from overall levelsymbol size proportional to # of patients, range 10 to 335

HbA1c Test in Past Year, HEDIS , Adjusteddenominator: HEDIS diabetes

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Graph shows only CC PCPs with 10+ patients

overall level = 68%, red = stat sig diff > .05 from overall levelsymbol size proportional to # of patients, range 10 to 335

LDL Test in Past 2 Years, HEDIS , Adjusteddenominator: HEDIS diabetes

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Graph shows only CC PCPs with 10+ patients

overall level = 30%, red = stat sig diff > .05 from overall levelsymbol size proportional to # of patients, range 10 to 335

Eye Exam in Past 2 Years, HEDIS , Adjusteddenominator: HEDIS diabetes

Two Approaches

• Systems-level intervention targeted to providers with lower performance on selected measures

• Establish expectations of all providers to be eligible to participate in Medicaid

Targeted Intervention

• 75 “bottom left” provider

– Control: providers were mailed baseline indicator levels

– Education only: providers were mailed baseline levels and nurse educators visited providers

– Education + Reminder System: providers were mailed baseline levels, nurse educators visited providers, and providers had access to the reminder system

• All analyses are “intention to treat”

!Reminder

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baseline followupTIME PERIOD

CONTROL EDUCATIONEDUC+SYS

Baseline & Follow-up Values for HbA1c testsby treatment group

CONTROL over time, p = 0.000EDUCATION over time, p = 0.000EDUC+SYS over time, p = 0.000

EDUC vs CONT, p = 0.652EDUC+SYS vs CONT, p = 0.041EDUC vs EDUC+SYS, p = 0.017

These p-values are from tests comparing baseline to follow-up

changes between pairs of groups

These p-values are from tests comparing baseline to follow-up

levels within each group

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baseline followupTIME PERIOD

CONTROL EDUCATIONEDUC+SYS

Baseline & Follow-up Values for Diabetic LDL testsby treatment group

CONTROL over time, p = 0.005EDUCATION over time, p = 0.006EDUC+SYS over time, p = 0.000

EDUC vs CONT, p = 0.806EDUC+SYS vs CONT, p = 0.341EDUC vs EDUC+SYS, p = 0.224

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baseline followupTIME PERIOD

CONTROL EDUCATIONEDUC+SYS

Baseline & Follow-up Values for Diabetic Eye Examsby treatment group

CONTROL over time, p = 0.000EDUCATION over time, p = 0.000EDUC+SYS over time, p = 0.000

EDUC vs CONT, p = 0.161EDUC+SYS vs CONT, p = 0.199EDUC vs EDUC+SYS, p = 0.027

Conclusion

• African Americans and low income patients are disproportionately represented among Medicaid recipients.

• There is great variation in performance among practices caring for Medicaid recipients.

• Practices with more patients tend to have higher compliance with standards.

• Systems level interventions can improve outcomes for Whites and African Americans.

• Despite improvements, some disparities remain.

Provider Expectations

• Establish new expectations for Medicaid expansion

• Expectations track NCQA Physician Practice Connections

Medicaid Expansion

• Expectations for primary care providers– Access and communications– Patient tracking and registry– Care management – Patient self management support– Electronic prescribing– Test tracking– Referral tracking– Performance reporting and improvement– Interoperability

Questions?