New collaborative tool helps case managers track diabetes patients
AMA, JCAHO, and NCQA combine forces
For the first time, organizations representing physicians, health plans, and hospitals have collaborated in the development of a common set of evidence-based measures for evaluating performance in health care. Experts say case managers can use these new protocols as a measuring stick for diabetes patients.
The American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations, and the National Committee for Quality Assurance (NCQA) have jointly established broadly applicable measures for the management of adult diabetes. The new tool, called the Coordinated Performance Measurement for the Management of Adult Diabetes, lays the groundwork for testing a single-source approach to measuring performance of care provided to diabetes patients in multiple settings. Development of the document was led by a diabetes expert panel composed of clinical leaders and advisors in diabetes care.
Panel member Tim Kresowik, MD, principal clinical coordinator at the Iowa Foundation for Medical Care in Des Moines, says the central aim is standardization of various types of measures. "Unless measures are standardized to the point where people are using the same definitions, exclusions, and patient inclusion criteria, it is very difficult to compare what may seem on the surface to be the same measure," he explains.
According to Kresowik, the measures essentially are designed as a series of performance measures collected at the physician level, which can act as a measure of the quality of the care patients receive for diabetes. For example, one primary measure would gauge whether recommended diagnostic testing was performed adequately.
Case managers with a certain number of patients they are monitoring can use this tool as a "measuring stick," says Kresowik. While the measures are targets at the physician office level, the measures also are applicable to ambulatory clinics associated with hospitals, he says. In fact, Kresowik says, staff at the nurse level with a set of patients whose care they are helping to manage can apply these measures. "If you are talking about diabetes case management, I think it would be very appropriate," he says. What is required in those cases is an adequate comparison of performance, whether it is a comparison to non-case management or among case managers, he adds.
Kresowik points out that most existing measures have been hospital-based measures. "Most of the types of performance that are being looked at are inpatient." Two additional measuring sets, one dealing with the care of ambulatory patients with coronary artery disease, also are under development, he adds.
Judy Homa-Lowry, president of Homa-Lowry Healthcare Consulting in Canton, MI, says that how useful these new measures are for hospitals will turn on the model the hospital is using. But many hospital-owned physician offices are beginning to do more care management in the office, she notes. "That can be helpful, especially if a hospital is having problems with direct admissions from physician offices."
Typically, she says, attempts are made to address that problem by placing a nurse in the admitting department or performing care management in the emergency room. It requires a fair amount of education, she says. But increasingly, hospitals are designing education programs for their outpatient departments in an effort to keep staff trained and monitored to reduce inpatient stays.
According to Homa-Lowry, Joint Commission performance measures in other areas also are beginning to take on a broader scope than those currently measured for ORYX. "Even if it is directed at inpatient issues, they also want to see how the hospital-owned outpatient facilities would be part of the process," she explains. For example, if a hospital selected measures for cardiac care and had a cardiac clinic, it would want the cardiac clinic to have access to the data in order to determine what changes could be made in the outpatient program that might limit inpatient and reduce readmissions, she says. "It is really becoming a continuum of care issue."
According to Kresowik, collaboration among the various groups was critical in the development of these measures. "People have talked for a long time about trying to come together and develop some standardization," he says. These measures also are very close to measures established by the Health Care Financing Administration (HCFA). Ideally, HCFA, the Joint Commission, and NCQA eventually will adopt the same measures, he adds.
Some previous attempts to establish measures in the treatment of diabetes have resulted in "arbitrary thresholds," argues Kresowik. "It is a real challenge when you are trying to ascribe that to the performance of the physician, because much of the patients’ diabetes control relates to the patients’ compliance with their therapy. If you have very highly motivated patients who follow instructions, take their medication, and follow their diet, they will have a good result," he explains.
In other cases, the physician may do everything correctly but the patient is not as compliant and may wind up with a less favorable result. However, those more closely resemble "intermediate outcomes measures" as opposed to "process measures," such as ordering a certain diagnostic test, which the physician has far more control over, Kresowik says. "When you measure intermediate outcomes, you have to take into account the role of the patient more heavily," says Kresowik. In those cases, these measures display results in a fashion that lets hospitals compare the distribution of patient results to other hospitals without arbitrary thresholds about what constitutes a "good" or "bad" result.
The new measures are designed to be available for physicians to measure themselves against others with the involvement of the Joint Commission and NCQA to increase accountability, Kresowik says. "You want to be able to measure at a physician level because that is ultimately where the organization is going to succeed or fail." When some of the measures are reduced to the physician level, it may be difficult to make adequate comparisons, he warns. "When you start talking about a handful of patients, it is difficult to make comparisons. "Nevertheless, ultimately that is the level that is aggregated up to the organization level," he adds.
[For more information, contact: Tim Kresowik, MD, Principal Clinical Coordinator, Iowa Foundation for Medical Care, Des Moines. Telephone: (515) 223-2900. Judy Homa-Lowry, President, Homa-Lowry Healthcare Consulting, Canton, MI. Telephone: (734) 459-9333.]
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