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Aligning to Improve Outcomes: The Alliance to Reduce Disparities in DiabetesA presentation from a symposium at the Centers for Disease Control and Prevention’s (CDC) Division of Diabetes Translation's (DDT) 34th annual Diabetes Translation Conference on April 11-14, 2011 in Minneapolis, Minnesota.
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www.alliancefordiabetes.org
Diabetes Equity ProjectDallas, Texas
CDC 2011 Diabetes Translation ConferenceMinneapolis, MNApril, 2011
Diabetes Equity Project (DEP)
• Primary Goals
– To support physician volunteerism in Dallas County by providing a standardized approach to diabetes self-management training & advocacy for diabetic patients receiving care in volunteer charity clinics
– To expand the role of Community Health Workers to a chronic disease management support/adjunctive function
http://www.youtube.com/watch?v=jYr2IkB0UZc
This project was supported by a grant from The Merck Company Foundation through its Alliance to Reduce Disparities in Diabetes program.
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Diabetes Equity Project (DEP):Interventional Strategy
• Intervention Program– Patient Relationship Expansion
• Community Diabetes Education Program (CoDE™)• One-on-One format - Up to 7 patient contacts per year
– Culturally competent relationship-based program delivery• Treatment adherence & disease control
troubleshooting– Knowledge Transfer Expansion
• ADA Standards of Care & AADE’s 7 Self-Care Behavior Education
– System Expansion• Disease registry management – Targeted patient recall
(VIPs)• Regular physician reporting – Fax, Scanned, HIE
DEP Early Results:Race & Ethnicity Demographics - 2010
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9.6%
53.9%
14.2%
0.6%16.4%
0.4% White
White/Hispanic
Non-White Hispanic
Black/Hispanic
African American
Other
N = 475 (10/1/09 – 9/30/10)
68.7% Hispanic
DEP Early Results:Preferred Primary Language - 2010
5
N = 514 (10/1/09 – 9/30/10)
DEP Early Results: Educational Level Achieved - 2010
6N = 161 (10/1/09 – 9/30/10)
• DEP Data from DiaWeb and includes patients enrolled through 2/24/11 and patient visits up through 3/11/10.• Minnesota Community Measurement and Minnesota Department of Health. 55.0% (A1c < 7) 2009 data - Includes patients from 1/1/2008 through 12/31/2009 with
two or more visits coded with a diabetes ICD-9 code, and has been seen within 7/1/2008 through 12/31/2009 once regardless of any diagnosis code . Measured annually. http://www.health.state.mn.us/diabetes/pdf/FactSheet2010.pdf.
• HealthTexas Provider Network Decision Support EHR Audit Report Dashboard. Percentage of Patients with A1c Control. Includes patients with two or more patient visits at least 7 days apart. December 2010 Audit
DEP Early Results:Diabetes Control – Dec.09 – Mar.11
Diabetes Equity ProjectPercent of Patients with A1c<7
Includes Patients with 2 or More Visits Through 3/11/2011N=710
30.8%
46.9%51.4%
55.0%
0%
10%
20%
30%
40%
50%
60%
DEPInitial A1c
DEPMost Recent A1c
HTPN Minnesota
% P
ts.
wit
h A
1c<
7
DEP Early Results:Glucose Control - Dec.09 – Nov.10
Baseline 3 Months 6 Months 9 Months 12 Months6
6.5
7
7.5
8
8.5
98.7
7.1 7.1 7.17.4
Mean A1c
8* For patients with at least two A1c measurements. Change from baseline is statistically significant (p-value <.001) at 3, 6, 9, and 12 months.
N=351 N=233 N=131 N=73 N=43
DEP Early Results:Disparity Reduction – Dec.09 – Nov.10
DEP helps avoid disparities in diabetes care:
• No differences in “improvement” of Diabetes Control between:– “Minorities and Non-Minorities”– Males and Females– Persons of different age groups– Location where DEP operated
* P-Value < 0.0001
Non-Minority = White & Non-Hispanics; Minority = Non-White & Hispanics
DEP Early Results:Patient Attrition Rate - Sept.09 – Nov.10
• Attrition Rate = 18.5% (123 patients)– No Show – 40.7%– Ineligible – 24.4%– Patient Relocated – 17.9%– Scheduling Conflicts – 5.7%– Patients opted out – 4.1%– Lack of Transportation – 2.4%– Mortality – 2.4%– Other – 2.4%
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*Note: For patients that left the program, the average of the most recent A1c measure was 8.5. Specifically, for those patients who had 2 or more visits, the average of the most recent A1c measure was 8.1.
• DEP Data from DiaWeb and includes patients enrolled and patient visits through 12/31/2010. • Minnesota Community Measurement and Minnesota Department of Health. Includes patients from 1/1/2008 through 12/31/2009 with two or more visits coded with
a diabetes ICD-9 code, and has been seen within 7/1/2008 through 12/31/2009 once regardless of any diagnosis code . Measured annually. http://www.health.state.mn.us/diabetes/pdf/FactSheet2010.pdf.
• HealthTexas Provider Network Decision Support EHR Audit Report Dashboard. Includes patients with two or more patient visits at least 7 days apart. December 2010 Audit
Diabetes Equity ProjectPercent of Patients with BP<130/80
Includes Patients with 2 or More Visits Through 12/31/2010N=578
56.0%50.7%
41.7%
0%
10%
20%
30%
40%
50%
60%
DEP HTPN Minnesota
% P
ts. W
ith B
P<1
30/8
0DEP Early Results:Blood Pressure Control - 2010
DEP Early Results:Improving Service Quality – Top Box Scores
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N 121 82 133 108 62 65 221 151 165 154 194 216 224 165
4 question survey administered to all patients after each visit.1. Were you treated with respect today?2. During today’s visit, did you increase your understanding of diabetes care for yourself?3. Do you feel that you could call the DHP to ask questions about the care of your diabetes?4. How likely would you be to recommend this program to one of your friends or family who has
diabetes?• Comments for staff improvement?
Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10 Oct-1090%
92%
94%
96%
98%
100%
Total
To
p B
ox
%
Diabetes Equity Project (DEP):Next Steps - #1
• Reduce % of DEP enrollees with A1c > 9%– Utilize diabetes registry to identify patients
with Hgb-A1c > 9%– Leverage patient relationship to identify
“new levers” influencing adherence & compliance
– Link patients with clinic-based Advanced Nurse Practitioners increasing RX management efficiency
• “Case management” approach utilizing Diabetes Health Promoters (pilot 2 sites in 2011)
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.
DEP Early Results:Reduced Patients in “Poor Control”
• DEP Data from DiaWeb and includes patients enrolled through 2/24/11 and patient visits up through 3/11/10.
Diabetes Equity ProjectPercent of Patients with A1c>=9
Includes Patients with 2 or More Visits Through 3/11/2011N=710
38.3%
21.3%
0%
10%
20%
30%
40%
50%
Initial A1c Most Recent A1c
% P
ts. w
ith A
1c>=
9
Diabetes Equity Project (DEP):Next Steps - #2
• Results suggest promise for applying DEP to privately insured patient population – Introduced to Baylor’s private physician
practices (HealthTexas – 450+ physicians)– HTPN Disease Management Committee
approved interventional pilot project• Pilot with Hispanic ethnicity• Work-flow changes referring Hispanic patients to
Diabetes Health Promoters (~246 patients) • Track changes in disease control between
Hispanic & Non-Hispanic patients (A1c<7%)
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Jim Walton, DO, MBAVice President & Chief Health Equity Officer
Baylor Health Care System
or
Chris Snead, RN, BSNHealth Equity Manager Office of Health Equity
Diabetes Equity Project (DEP):For additional details, please contact