1 TennCare Diabetes Program Evaluation Presentation to AcademyHealth Kenton Johnston, MPH, MS, MA June 4, 2007 An Individually-Matched Control Group Evaluation.

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TennCare Diabetes Program Evaluation

Presentation to AcademyHealthPresentation to AcademyHealth

Kenton Johnston, MPH, MS, MA

June 4, 2007

An Individually-Matched Control Group Evaluation of a Disease Management Program to Improve Quality and Control Costs in a Diabetic Medicaid Population

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Overview

Research Objective:

Evaluate diabetes disease management program for state Medicaid (TennCare) population

Outcomes of interest: diabetic quality of care and medical cost savings (Inpatient & Prof/Outpatient)

Outline:

Program Description

Study Design

Findings

Limitations, Conclusions, Implications

TennCare Diabetes Program EvaluationTennCare Diabetes Program Evaluation

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Program Description

Outcome of diabetes treatment highly dependent on self-care

Non-adherence to recommended regimens an obstacle to improved health status

Medicaid population tends to exhibit higher utilization & costs, as well as poorer health outcomes

CareSmart Diabetes Disease Management (DM) Program – developed internally by BCBST for TennCare population

For Type 1 and Type 2 diabetics

Program: behavior change & health education, self-management, personalized telephone coaching, compliance with ADA clinical practice guidelines, and PCP support

Member consent obtained for enrollment in program


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Study Design – Individual Matching With Propensity Model

Methodological “toolbox” for DM program evaluation Randomized controlled trials Population based pre-post methodology Predictive modeling Control group matching (individual, group)

Problem: finding a good control group not easy

Solution: Individually-matched controls using propensity scores (matched pairs cohort study)

Propensity score is continuous number that represents individual probability of being in study group

Propensity score reduces entire set of covariates to one score for easy individual matching

This approach allows for smaller “n”


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Study Design – Population & Methods

Study and control group member criteria Continuously enrolled in TennCare 24-months of 2004-05 Diagnosed with Type 1 or 2 diabetes in 2004 or earlier Not dually eligible – Medicaid only

126 study members enrolled in CareSmart Diabetes Program for at least 6 months in 2005 were individually matched to 126 diabetic controls not enrolled in program in 2004 or 2005

Propensity model covariates: demographics, diseases & comorbidities, quality of care, medical utilization, costs

Baseline Period: Jan - Dec 2004 for matching control & study

Intervention Period: Jan - Dec 2005


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Study Design – Dependent Variables


Diabetic quality of care operationally defined according to recommended preventive services outlined by ADA

Screening for kidney disease First annual HbA1c screening Second annual HbA1c screening Retinopathy screening LDL cholesterol screening

Medical services utilization and cost Reported as totals (not specific only to diabetes) Inpatient admissions, inpatient days, inpatient $$$ ER encounters, office visit encounters, Prof/Outpatient $$$ Total $$$ RX utilization & cost data unavailable

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Findings – Baseline Results


N = 126 Matched PairsIntervention Group

Control Group p-value

DemographicsAge, MEAN 49.2 50.6 0.648Gender, % MALE 21.4% 25.4% 0.458MorbidityOrthopedic Conditions & Disorders, % 88.9% 86.5% 0.744Coronary Artery Disease, % 24.6% 21.4% 0.550Congestive Heart Failure, % 14.3% 17.5% 0.491Hypertension, % 72.2% 72.2% 1.000Renal Failure, % 3.2% 3.2% 1.000Medical Services UtilizationInpatient Admissions, per person 0.66 0.63 0.563Inpatient Days, per person 2.54 1.99 0.579ER Encounters, per person 3.26 2.98 0.915Office Visit Encounters, per person 16.0 15.8 0.447Medical Services Allowed CostsInpatient, per person 2,630.17$ 2,405.41$ 0.358Professional/Outpatient, per person 5,962.77$ 5,760.52$ 0.314Total, per person 8,592.94$ 8,165.92$ 0.289Diabetic Quality of Care MeasuresScreening for Kidney Disease, % 18.3% 16.7% 0.741One HbA1c Screening, % 52.4% 50.0% 0.706Two HbA1c Screening, % 32.5% 32.5% 1.000Retinopathy Screening, % 46.8% 40.5% 0.311LDL Screening, % 43.7% 43.7% 1.000Overall Diabetic Quality Score, MEAN 1.94 1.83 0.492

Baseline Matching Results - Time Period of Jan - Dec, 2004

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Findings – Intervention Quality Results


Statistically significant positive difference on 4 of 5 measures & on overall score

Improvement in both study & control groups from 2004

Propensity matched control group enables us to rule out secular trend as sole cause



Diabetic Quality of Care MeasuresScreening for Kidney Disease, % 38.9% 22.2% 0.004 *One HbA1c Screening, % 94.4% 84.1% 0.008 *Two HbA1c Screening, % 71.4% 56.3% 0.013 *Retinopathy Screening, % 54.8% 32.5% 0.001 *LDL Screening, % 87.3% 81.0% 0.169Overall Diabetic Quality Score, MEAN 3.47 2.76 0.001 *

Study Period Results - Time Period of Jan - Dec, 2005

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Findings – Intervention Utilization Results


Statistically significant difference on office visits – study members had higher utilization

Office visit finding not surprising given this is the setting for quality measures

Inpatient admissions & days lower for study members – not statistically significant

ER encounters higher for study members – not statistically significant



Medical Services UtilizationInpatient Admissions, per person 0.44 0.57 0.215Inpatient Days, per person 1.99 2.97 0.179ER Encounters, per person 3.09 2.42 0.416Office Visit Encounters, per person 15.9 12.9 0.010 *


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Findings – Intervention Cost Results


None of the cost findings were statistically significant

Inpatient & total costs trending in downward direction for study group

Prof/Outpatient costs higher for study group

Financial analysis—using control group to calculate expected costs—shows program savings impact for study group



Medical Services Allowed CostsInpatient, per person 1,894$ 2,806$ 0.243Professional/Outpatient, per person 5,771$ 5,397$ 0.099Total, per person 7,665$ 8,203$ 0.345

Financial AnalysisBase Year 2004 Total $, MEAN per person 8,593$ 8,166$ 0.289Study Year 2005 Total $, MEAN per person 7,665$ 8,203$ 0.345Control Group Total $ Inflation Percentage 0.5% n/aStudy Group Expected Year 2005 $, per person 8,632$ n/a n/aStudy Group Actual Year 2005 $, per person 7,665$ n/a n/a

Study Group Year 2005 Total $ Savings, per person 967$ n/a n/a


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Limitations


Unable to analyze RX data

Psychological or sociological variables not included/available for propensity model potential source of confounding

“Non-Participation Bias” Study members agreed to participate in the program Controls either could not be contacted by telephone or

refused to participate

We did not control for practice patterns of member providers (data not available for all members)

Lab values unavailable on > 50% of study and control population so we were not able to control for these

Available HbA1c and LDL values showed HbA1c close to stat sig (.09) difference in baseline period

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Conclusions & Implications


Conclusions: Improvement in quality in study group was not due solely to general

secular trend towards quality, but was also positively impacted by the diabetes program intervention itself

Mixed findings for utilization & cost, but may be showing trend in right direction

Implications: DM programs can be successful in improving quality of care in

chronically diseased state Medicaid populations

A matched-pairs cohort study using propensity scores is a valuable tool for evaluating program outcomes in small to medium sized populations

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Thank You

Presentation to AcademyHealthPresentation to AcademyHealth

Kenton Johnston, MPH, MS, MA

June 4, 2007

E-mail: [email protected]


1 TennCare Diabetes Program Evaluation Presentation to AcademyHealth Kenton Johnston, MPH, MS, MA June 4, 2007 An Individually-Matched Control Group Evaluation.

Documents

caresmart diabetes program

study group slide

program controls

diabetics program

study control groups

study group propensity

control population

diabetes inpatient admissions