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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
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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
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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
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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”
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!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
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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.
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Provider Expectations
• Establish new expectations for Medicaid expansion
• Expectations track NCQA Physician Practice Connections
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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
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Questions?