SC PA Data Review Robert A. Gabbay, MD, PhD Professor of Medicine, Penn State College of Medicine
Dec 30, 2015
SC PA Data ReviewRobert A. Gabbay, MD, PhDProfessor of Medicine, Penn State College of Medicine
PCMH-A(Patient-Centered Medical Home Assessment)
• Survey designed to help systems and provide practices move toward the PCMH model• Utilized to help teams identify areas for
improvement• A sense of how PCMH like you are
1 2 3 4 5 6 7 8 9 100
2
4
6
8
10
12
PCMH-A Average Change
Start End
Practice
Asse
smen
t Sca
le (1
-12)
PCMH-A Assessment
• On average, practices reported an average increase of +2.3/12 points (20%)• The top 3 most improved categories:• Empanelment (+3.3 points)• Quality Improvement Strategy (+3.0 points)• Patient Centered Interactions (+2.6 points)
(All on a scale from 1-12)
HEDIS Goals• HEDIS & Quality Measurement Goals• 90th Percentile of the HEDIS New England or Mid-Atlantic
Benchmarks (whichever was higher)• Standardized set of performance measures
• HEDIS goals used for PA SPREAD:• % DM pts A1C >9 – 13.63%• % DM pts A1C <8 – 74.70%• % DM pts BP <140/90 – 76.33%• %DM pts LDL <100 – 58.15%• %DM pts tobacco query – 90%• % DM pts nephrology screening – 92.46%• % DM pts eye exam – 90%• % DM pts foot exam – 90%• %DM pts with self-management goals – 90%• % DM pts with tobacco cessation interventions – 90%
*All criteria for goals based on a 12 month period EXCEPT tobacco query & tobacco cessation intervention which are based on a 24 month period
Steady Denominators = Good!
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0
200
400
600
800
1000
1200
Count of DM Patients Ages 18-75SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Excellent Job! Now Part of Planned Care at Every Visit
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients Tobacco QuerySouthCentral Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Mean Change in Abs %: Increased +12.0% (statistically significant)
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Nephropathy Screening/TreatmentSouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
*The mean change in percentage points increased +8.1%, making it statistically significant
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Dilated Eye Exam Results DocumentedSouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Mean Change in Abs %: Increased +8.1% (statistically significant)
*The mean change in percentage points increased +19.5%, making it statistically significant
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Foot ExamSouthCentral Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Mean Change in Abs %: Increased +19.5% (statistically significant)
You Are Likely Doing This – How Do We Track It?
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Self-Management GoalsSouthCentral Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Improving As Processes of Care Get Implemented
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
5%
10%
15%
20%
25%
30%
% DM Patients with A1C>9SouthCentral Hamilton
Oyster Point
GIM GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Practices Close To The HEDIS 90% Goal
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with A1C<8SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Many Practices Close To The HEDIS 90% Goal
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with BP <140/90SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Some Practices at HEDIS 90% Goal, Others – More Work To Do
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with LDL <100SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Great Work… But More To Do!
• All of this was accomplished WITHOUT extra money• Planned care at every visit• Reaching out to high risk• Self-management support• Working as a team• MEETING AS A TEAM
Why We Have Done This• Each A1C point drop:• Eye disease risk reduced by 76%• Kidney disease risk is reduced by 50%• Nerve disease risk is reduced by 60%• Any cardiovascular disease event risk is reduced by 42%• Stroke by 57%
• Better screening nephropathy, feet and eyes reduces ESRD, amputations, and blindness.
In your population of over 11,000 diabetes patients – this is huge!