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DTEC™
IMPROVING THE QUALITY OF
CARE THROUGH CLAIMS DATA
ANALYSIS
Benjamin Eng, MD, MA
AHQA 2005 Fall Meeting
Quality Measurement and Improvement in the New Medicare Prescription Drug Benefit
November 17, 2005
Washington, D.C.
© Pfizer Inc. All rights reserved
AGENDA
Introduction
What is DTEC™?
DTEC™ Reports
Examples from test sites
Potential Part D implications and applications
© Pfizer Inc. All rights reserved
CHALLENGES FACING HEALTHCARE TODAY
Many Organizations Face Challenges in Identifying Gaps in the Quality of
Care for Patient Populations
Many Organizations Face Challenges in Identifying Gaps in the Quality of
Care for Patient Populations
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DTEC Supports the Quality Improvement Process
Assess Baseline Performance
Assess Baseline Performance
Identify Barriers for Intervention
Identify Barriers for Intervention
Target Individuals for Intervention
Target Individuals for Intervention
Design and Implement Intervention
Design and Implement Intervention
Reassess Performance Periodically
Reassess Performance Periodically
™
© Pfizer Inc. All rights reserved
DTEC Supports the Quality Improvement Process
Assess Baseline Performance
Assess Baseline Performance
Identify Barriers for Intervention
Identify Barriers for Intervention
Target Individuals for Intervention
Target Individuals for Intervention
Design and Implement Intervention
Design and Implement Intervention
Reassess Performance Periodically
Reassess Performance Periodically
™
© Pfizer Inc. All rights reserved
WHAT IS DTEC™?
DTEC is a service offered by Pfizer that:
•Uses the customer’s claims data to identify their member populations with targeted diseases
–First module covers CV diseases (hyperlipidemia, hypertension, diabetes, ischemic heart disease, congestive heart failure)
•Produces aggregate and member-specific reports
•Provides analysis of the aggregate reports
DTEC is HIPAA-compliant because no member-specific data leaves the customer or is viewed by Pfizer
© Pfizer Inc. All rights reserved
DTEC™ BENEFITS
DTEC
• Lowers the barriers to improving the quality of care members receive
• Leverages existing data resources to develop reports that facilitate use of appropriate interventions for targeted groups of members
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DATA FIELDS UTILIZED BY DTEC™ SOFTWARE
Member ID PCP ID Member Gender Year of Birth Effective Date Termination Date
Member ID Claim Number Claim Line Number From Service Date To Service Date Procedure Code Principal Diagnosis Additional Diagnoses (4) Place of Service
NDC Number Member ID Prescription ID Date Filled Days Supplied Quantity
Member ID Claim Number Claim Line Number From Date To Date Principal Diagnosis Additional Diagnoses (4)
Place of Service
Professional Services InformationProfessional Services Information Drug Utilization InformationDrug Utilization Information
Facility Services InformationFacility Services InformationEnrollment InformationEnrollment Information
Analyzed Over Time Analyzed
Over Time
EMERGENCY
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DTEC™ SUMMARY DATABASE
Summary Dataset
Claims and Enrollment Data Data for Population
(4 files)
Claims and Enrollment Data Data for Population
(4 files)
Demographics
Patterns
Care Improvement
DT
EC
So
ftw
are
Continuous EnrollmentContinuous Enrollment
Disease IdentificationDisease Identification
DemographicsCo-morbidities Complications
Utilization
DemographicsCo-morbidities Complications
Utilization
Quality GapsQuality Gaps
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DTEC™ PATIENT IDENTIFICATION
Levels of confidence for identifying members with each targeted disease
• Lenient, Normal and Strict
Stratifications of disease severity
•Usual, Moderate and High
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CONFIDENCE LEVELS FOR DISEASE IDENTIFICATION ARE INCLUSIVE
LenientLenient NormalNormal StrictStrict
(LENIENT INCLUDES MEMBERS CATEGORIZED AS NORMAL AND STRICT)
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EXAMPLE: DTEC™ CRITERIA FOR IDENTIFYING MEMBERS WITH HYPERLIPIDEMIA
Hospitalization with Diagnosis or
Diagnosis on Professional Claimswith Different Dates of Service or
Rx for Lipid Lowering Agent or
Diagnosis on Professional Claimsand Rx for Lipid Lowering Agent
1
4
4
3/1
1
3
2
1/1
1
1
1
NA
Criteria StrictNormalLenient
Minimum Number of Claims Needed
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PERCENT OF MEMBERS IN COMMERCIAL HEALTH PLAN POPULATION IDENTIFIED BY DTEC™ AS HAVING CV DISEASE
Data on file for 100,000 member commercial health plan Note: The Lenient category includes members classified as Normal and Strict
Lenient Normal Strict
DM
5%
Hyperlipid
14%
HTN
16%
IHD
4%
Any CVDs
25%
© Pfizer Inc. All rights reserved
DTEC™ SOFTWARE PROCESS
Care Improvement Reports
Care Improvement Reports
DTEC Phase 2Query DatabaseDTEC Phase 2
Query Database
Summary Access Database(in DTEC)
Summary Access Database(in DTEC)
DTEC Phase 1Data Audit and Summary
DTEC Phase 1Data Audit and Summary
Raw Claims Data(4 Files)
Raw Claims Data(4 Files)
Demographic Reports
Demographic Reports
Utilization Reports
Utilization Reports
PatientDrill Down
PatientDrill Down
Clinical ReportsClinical Reports
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1 Care Imp. Report1 Care Imp. Report 1 Care Imp. Report1 Care Imp. Report 1 Care Imp. Report1 Care Imp. Report1 Care Imp. Report1 Care Imp. Report
HypertensionHypertension HyperlipidemiaHyperlipidemia Ischemic Heart Disease
Ischemic Heart Disease
DiabetesDiabetes
6 Reports6 Reports 6 Reports6 Reports 6 Reports6 Reports 6 Reports6 Reports
Summary ReportSummary Report
DTEC ReportsDTEC Reports
DTEC™ REPORTS
CHF Added
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DTEC™ AGGREGATE DISEASE POPULATION REPORTS Disease prevalence by level of confidence
Demographics by disease severity
Comorbidities and complications (2 reports)
Hospitalizations, ER visits and medical services received
Medications / medication compliance (2 reports)
Care Improvement reports
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CARE IMPROVEMENT REPORTS
Aggregate reports show the percentage of the disease population meeting the care improvement algorithm criteria
Member specific targeting reports “drill down” and produce lists of individual members for possible intervention
DTEC uses specific predefined criteria, called care improvement algorithms, that identify populations with opportunities to improve the quality of care
© Pfizer Inc. All rights reserved
Sample Claims Based Quality Inferences
No renal function testing
No lipid profile
No cholesterol test after hospitalization
Thiazide or loop diuretic, no potassium check
ACE or ARB treatment
No follow up visit within 45 days of discharge
No HbA1c test
No lipid profile
No renal function testing
No urine protein test
No eye examination
No follow up visit within 45 days of hospitalization
Fewer than 2 visits during reporting period
Heart FailureHeart Failure DiabetesDiabetes
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Intervention Decision Making Belongs in the Hands of the Clinician
1 Patient CI Report1 Patient CI Report
1 Care Imp. Report1 Care Imp. Report
1 Patient CI Report1 Patient CI Report
Patient Detail ReportPatient Detail Report
1 Patient CI Report1 Patient CI Report
1 Care Imp. Report1 Care Imp. Report
1 Patient CI Report1 Patient CI Report
1 Care Imp. Report1 Care Imp. Report1 Care Imp. Report1 Care Imp. Report
HypertensionHypertension HyperlipidemiaHyperlipidemia Ischemic Heart Disease
Ischemic Heart Disease
DiabetesDiabetes
6 Reports6 Reports 6 Reports6 Reports 6 Reports6 Reports 6 Reports6 Reports
Summary ReportSummary Report
DTEC ReportsDTEC Reports
CI – Care Improvement
CHF Added
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EXAMPLES OF DTEC DATA SUMMARIES FROM THE TEST SITES
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5%
10%
16% 16%
3%4%
35%
15%
DM Hyperlipid HTN IHD
MCO Benchmark (NHANES III)
PREVALENCE OF CARDIOVASCULAR DISEASES COMPARED TO BENCHMARK DATAPercent of Members with CVD
Data on file for 200,000 member combined commercial and Medicare health plans
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CLASSIFICATION OF MEMBERS WITH DIABETES BY SEVERITY (N=5,629)
43%43%
13%13%
44%44%Usual Moderate
Severe
Data on file for 200,000 member combined commercial and Medicare health plans
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DIABETES COMORBIDITIES
11%
3%4%
11%
36%
51%
22%
Hyperlipidemia
Hypertension
Ischemic HD
CHF
Cerebrovascular Dis
Obesity
Acute MI
Percent of Members with Diabetes
Data on file for 200,000 member combined commercial and Medicare health plans
© Pfizer Inc. All rights reserved
COMPLICATIONS IN MEMBERS WITH DIABETES
10%
3%
15%
7%
1%
8%
1%
Hypoglycemia Kidney Failure
Skin Ulcer
UTI Visual Loss
Other Eye
Peripheral Neuropathy
Percent of Members
Data on file for 200,000 member combined commercial and Medicare health plans
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CARE IMPROVEMENT OPPORTUNITIES IN MEMBERS WITH DIABETES
23%
9%
13%
28%
12%
41%
29%
No HbA1c No Eye Exam
No Lipid Profile
w/HTN, No ACEI
or B
w/Chol, No Statin
No Hosp F/U <2 Visits/Year
Percent of Members
Data on file for 200,000 member combined commercial and Medicare health plans
© Pfizer Inc. All rights reserved
EXPERIENCE WITH DTEC™ SERVICE Implemented with nearly 20 health plans
• Includes 2 Medicare Advantage plans
Purpose of DTEC implementation has included•To measure baseline CV assessment data
•To determine whether to start a CV quality initiative
•To identify patients for a case management quality improvement program
•To identify patients for a pilot Diabetes intervention program
•To identify patients for a patient CV education program
•To document quality trends over multiple years
•To identify a population of high risk patients to conduct an adherence study on
© Pfizer Inc. All rights reserved
Unique Features of DTEC’s Design
Data audit and integration is automated after data input files are properly formatted
Summary dataset is retained while individual claims are processed and discarded
Pre-defined reports are based on the summary dataset, transferring analysis to the desktop
Population level reporting is linked to member level drill down reports for targeting interventions
Clinician level review of drill down patient lists is supported to verify quality improvement insights
© Pfizer Inc. All rights reserved
Possible Implications for QIOs and Medicare Part D Quality Claims data can provide insight into the quality of
care for beneficiaries
The resource burden to integrate and analyze A, B, D and administrative claims data can be dramatically lowered leveraging this type of technology
Similar tools can place analytic power and targeting capabilities in the hands of Quality Improvement Organizations to work with Medicare providers
Data analytics can only support clinical decision making. Clinical decision making belongs in the hands of the clinician.
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