Self-reported performance improvement strategies of highly successful Veterans Health Administration facilities.

The Veterans Health Administration (VHA) has achieved considerable success in improving health care through the use of clinical performance measures. This report examines the self-reported strategies used by the most successful facilities in the VHA system. For fiscal year 2002, facilities that scored the highest on any of 24 clinical performance measures were queried as to which strategies they used to achieve their level of performance. The most commonly cited strategies across all performance categories were organizational change (55.6%), clinical reminders (41.4%), audit and feedback to providers (39.6%), and staff education (32.5%). Certain strategies were more likely to be cited for 1 or more specific performance categories (eg, clinical reminders for immunization [61.1%], screening [60.6%]). These findings suggest that successful facilities are generally using evidence-based strategies to achieve high clinical performance. However, some evidence-based implementation strategies were rarely cited (eg, use of clinical champions).

Trends in care practices and outcomes among Medicare beneficiaries with diabetes.

BACKGROUND: While diabetes is a major issue for the aging U.S. population, few studies have described the recent trends in both preventive care practices and complications among the Medicare population with diabetes. Using the Medicare Quality Monitoring System (MQMS), this 2004 study describes these trends from 1992 to 2001 and how these rates vary across demographic subgroups. METHODS: Outcomes include age- and gender-adjusted rates of 15 indicators associated with diabetes care from 1992 to 2001, the absolute change in rates from 1992 to 2001, and 2001 rates by demographic subgroups. The data were cross-sectional samples of Medicare beneficiaries with diabetes from 1992 to 2001 from the Medicare 5% Standard Analytic Files. RESULTS: Use of preventive care practices rose from 1992 to 2001: 45 percentage points for HbA1c tests, 51 for lipid tests, 8 for eye exams, and 38 for self-monitoring of glucose levels (all p<0.05). Rates for short-term and some long-term complications of diabetes (e.g., lower-extremity amputations and cardiovascular conditions) fell from 1992 to 2001 (p<0.05). However, rates of other long-term complications such as nephropathy, blindness, and retinopathy rose during the period (p<0.05). Nonwhites and beneficiaries aged <65 and >85 exhibited consistently higher complication rates and lower use of preventive services. CONCLUSIONS: The Medicare program has seen some significant improvement in preventive care practices and significant declines in lower-limb amputations and cardiovascular conditions. However, rates for other long-term complications have increased, with evidence of subgroup disparities. The MQMS results provide an early warning for policymakers to focus on the diabetes care provided to some vulnerable subgroups.

Variation in diabetes care among states: do patient characteristics matter?

OBJECTIVE: To examine state variability in diabetes care for Medicare beneficiaries and the impact of certain beneficiary characteristics on those variations. RESEARCH DESIGN AND METHODS: Medicare beneficiaries with diabetes, aged 18-75 years, were identified from 1997 to 1999 claims data. Claims data were used to construct rates for three quality of care measures (HbA(1c) tests, eye examinations, and lipid profiles). Person-level variables (e.g., age, sex, race, and socioeconomic status) were used to adjust state rates using logistic regression. RESULTS: A third of 2 million beneficiaries with diabetes aged 18-75 years did not have annual HbA(1c) tests, biennial eye examinations, or biennial lipid profiles. There was wide variability in the measures among states (e.g., receipt of HbA(1c) tests ranged from 52 to 83%). Adjustment using person-level variables reduced the variance in HbA(1c) tests, eye examinations, and lipid profiles by 30, 23, and 27%, respectively, but considerable variability remained. The impact of the adjustment variables was also inconsistent across measures. CONCLUSIONS: Opportunities remain for improvement in diabetes care. Large variations in care among states were reduced significantly by adjustment for characteristics of state residents. However, much variability remained unexplained. Variability of measures within states and variable impact of the adjustment variables argues against systems effects operating with uniformity on the three measures. These findings suggest that a single approach to quality improvement is unlikely to be effective. Further understanding variability will be important to improving quality.