Fighting the Flu and Pneumonia

Influenza poses significant risks for the elderly. Yet only 60% of elderly whites were immunized in 1995, and rates were even lower for minority groups–50% for Hispanics and 40 percent for blacks. QIOs have been working on a range of projects to increase flu and pneumonia immunization, as well improve hospital treatment for pneumonia. Some examples:

• The West Virginia Medical Institute, the West Virginia QIO, successfully organized a statewide collaborative to improve inpatient influenza and pneumococcal vaccination rates. In 1999, West Virginia's hospitals rarely gave influenza or pneumonia vaccine and almost never screened inpatients for the vaccine. WVMI partnered with the majority of hospitals in West Virginia, the state hospital association and the state health department. Within one year, screening rates increased by 25-30% statewide for both vaccines, and hospital influenza vaccine use increased by 25%. For this effort, WVMI, along with the West Virginia Hospital Association, received the Jansen Pharmaceutical National Patient Safety Award in 2001.

• Lumetra, the California QIO, launched a campaign to develop long-term effective solutions to low pneumococcal immunization rates. Through a three-year campaign that targeted multiple ethnic groups and providers, California pneumococcal immunization rates increased 9.1%. Consequently, 152,784 more eligible Medicare beneficiaries in California were vaccinated against pneumococcal disease than at the commencement of the campaign.

• Texas Medical Foundation’s 1998 immunization project targeted more than 560,000 Medicare beneficiaries in 44 Texas counties, with a goal of increasing flu and pneumonia vaccination (PPV) rates. TMF developed new partnerships with groups like the Texas Department of Health, area agencies on aging, hospital systems, and city/county health departments. All 44 counties experienced an increase in PPV claims, with some reporting double-digit increases.

• Carolinas Center for Medical Excellence, the North Carolina QIO, sponsors the Senior Vaccination Season Coalition, a collaborative effort of organizations working to increase influenza and pneumococcal immunizations. The coalition’s efforts have included partnering with local health departments statewide, offering North Carolina physicians immunization office toolkits to implement reminder systems in their offices, postage-paid reminder postcards to mail to their patients, and providing clinic location information to toll-free telephone numbers operated by the American Lung Association of North Carolina and the CDC’s Immunization Hotline to inform the public of available immunization clinics. Outpatient immunization rates showed significant improvement during the last three years thanks to the program. From 1998-2001, the influenza immunization rate increased 8.5%, from 63.9% to 72.4%; the pneumococcal immunization rate rose 11.0%, from 58.5% to 69.5%.

• Qualidigm, the Connecticut QIO, worked with providers to develop and distribute a clinical pathway for Medicare patients with community-acquired pneumonia. The project resulted in significant increases in the proportion of patients receiving antibiotics within eight hours, in use of blood cultures prior to antibiotics, and in oxygen assessment within 24 hours. In addition, in-hospital mortality, 30-day mortality and length of stay decreased.

• IPRO, the New York QIO, developed a comprehensive contact management system to assist in physician office quality improvement activities. The system contained over 5,000 high-volume Medicare physicians and tracked information such as performance on quality indicators, intervention materials ordered and received, and the physician offices’ progress towards implementation of quality improvement tools such as chart stickers and pre-printed orders. These activities, along with key partnerships and coalitions, assisted New York state in improving performance over the SOW6 on flu immunization rates from 64% to 70%, and on pneumococcal immunization rates from 50% to 64%.

• Quality Improvement Professional Research Organization, the Puerto Rico QIO, focused on delivering antibiotics to dual-eligible Medicare patients hospitalized for pneumonia within eight hours. A preliminary data analysis revealed that a disparity existed between dual-eligible and non dual-eligible patients. Interventions to reduce the disparity included face-to-face meetings, mailings of materials, and motivating hospitals to develop quality teams that studied the root causes of the disparity. Changes in protocols, development of new procedures and processes, and assignment of new responsibilities to emergency room physicians increased compliance for antibiotic administration within eight hours from 16.2% to 88.3%.

• FMQAI, the Florida QIO, took the lead role in establishing a collaborative of 29 Florida managed care organizations to work on flu immunization. FMQAI also launched a multilingual, multimedia effort to educate Medicare beneficiaries about the benefits of flu vaccines. The two efforts resulted in significant increases in influenza immunization rates.

• Since 1997, Quality Partners of Rhode Island, the Rhode Island QIO, has led the Ocean State Adult Immunization Coalition (OSAIC), which coordinates public education campaigns about influenza and pneumococcal targeting adults age 50 and older. The coalition also distributes a tool kit of current information about the vaccine, proper storage, and billing and reimbursement to physicians. For the past two years, free billing and reimbursement training workshops have been offered to physician offices and agencies. 67% of adults age 65 and older in Rhode Island reported receiving the pneumococcal vaccine in 2001, representing a 10.1% increase from 1999.

• Mountain-Pacific Quality Health Foundation, the Hawaii QIO, worked with more than 10 organizations in the local health care community to improve immunization rates for the pneumococcal vaccine. After two years of work—including a television ad campaign; legislative activities to improve immunization access; a direct mail campaign to pharmacies and physicians throughout the state; bus posters; presentations to native Hawaiian organizations and parish nurses, and other public awareness activities, data showed 74.9% pneumococcal immunizations coverage for Hawaii. This coverage rate represents a 40% relative improvement from 1999-2001—twice the national rate of relative improvement.

• The Colorado Foundation for Medical Care, the Colorado QIO, has used several strategies to keep Colorado strong in providing influenza/pneumcoccal immunizations. Colorado vaccination rates are among the highest in the nation, with some 78% of seniors age 65 and older being vaccinated for influenza while 69% received the vaccination for pneumococcal disease during the 2000-2001 influenza season. One component of Colorado's immunization strategy includes a collaboration between community vaccination providers and managed care companies that serve Medicare beneficiaries. The collaboration, facilitated by the Colorado QIO, allowed Medicare managed care beneficiaries to receive no-cost influenza vaccinations at grocery stores and other convenient settings.

• The Carolinas Center for Medical Excellence, the South Carolina QIO, has worked with health departments, hospitals, and federally qualified health centers to coordinate a mailing to South Carolina’s 611,000 Medicare beneficiaries about the availability and locations of flu shots. The mailer has helped steadily increase immunization rates in the state. CMR also works with the state health department to sponsor an annual media campaign promoting immunizations through an award winning television commercial called Flu Shots Aren’t Just for Kids.

• Louisiana Health Care Review's, the Louisiana QIO, pneumonia media campaign, has dramatically increased the number of pneumonia shots given at community clinics. LHCR recorded an average 60% increase in pneumonia shots given at community clinics in 2001.

• The Kansas Foundation for Medical Care, the Kansas QIO, representing a largely rural state, recognized the importance of assisting small rural hospitals address quality improvement issues. In collaboration with the Kansas Hospital Association and the state rural health agency, KFMC launched a project to improve influenza and pneumococcal immunizations in patients discharged from Critical Access Hospitals. The team recruited 17 rural Critical Access Hospitals to participate in this effort. After implementation of a "rapid cycle" quality improvement program, assessment of influenza immunizations improved from 17% to 62% and assessment of pneumococcal immunizations improved from 36% to 51%. This project demonstrated the feasibility of working with small rural hospitals to make measurable improvements in quality.

• QSource, the Tennessee QIO, successfully organized a statewide collaborative with the state health department and other community partners to improve influenza and pneumococcal vaccination rates. QSource sponsored Medicare vaccination reimbursement workshops, launched media campaigns, and distributed community education and provider education immunization toolkits. QSource distributed more than 110 immunization resource binders to hospitals and clinics to help improve internal processes and implement new protocols. Efforts also included the development of an interactive Web site that provides information, resources and locations for immunization events. These initiatives and rapid cycle improvement projects helped increase outpatient flu immunization rates by 9% and pneumonia immunization rates by 14%.

• Ohio KePRO, the Ohio QIO, partnered with a regional medical association, local health departments and hospital wellness programs to provide a regional "Vote and Vaccinate" program for senior citizens on Election Day in 2000, 2001, and 2002. Due to influenza vaccine supply delays in 2000, influenza vaccinations were provided in 2001 and 2002. Pneumococcal vaccinations were provided all three years. Each year the number of immunizations administered has increased. In 2002, the state had a significant increase in the numbers of vaccinations provided. Senior citizen voters are becoming acclimated to having the nurses at polling sites and those voters have offered positive feedback about receiving their vaccinations in a "one stop," easy access situation.

• Primaris, the Missouri QIO, reports that three out of every four Medicare beneficiaries were vaccinated against influenza in 2001, a nearly 10% increase over two years. Multiple interventions caused this increase, including the efforts of the Show-Me State Adult Immunization Coalition. This strategic coalition of Primaris, private corporations, community organizations, and government agencies partnered with 27 local health departments to notify 40,000 beneficiaries in 32 Missouri counties with the lowest pneumococcal and influenza immunization rates about the need for immunizations and how to obtain them.

• The New Mexico Medical Review Association, the New Mexico QIO, developed a project aimed at the disparities in influenza and pneumococcal immunization status between Hispanic and non-Hispanic populations in the state. NMMRA conducted extensive research to identify the causes that underlie disparities in immunization status. Using this information, NMMRA developed culturally appropriate interventions targeting Hispanic Medicare beneficiaries, and lay health workers, or promotoras, disseminated the information. In addition, NMMRA developed a multimedia advertising campaign and practitioner materials in English and Spanish to reach this audience. Through the effort, the influenza vaccination rate increased from 23.6% during the 2000–2001 flu season to 41.6% during the 2001–2002 flu season. Of those who received the influenza immunization, the percent of Hispanics also increased from 57.9% during the 2000–2001 flu season to 65.7% during the 2001–2002 flu season.

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Stroke Prevention/Treatment

From 1996-1999, QIOs in 22 states developed projects focused on increasing warfarin use in patients with atrial fibrillation who demonstrated appropriate clinical indications. A number of these projects also looked at whether patients discharged on warfarin received proper education about their condition and medication. Some of the projects also evaluated the percent of atrial fibrillation patients taking warfarin who maintain an international normalized ratio (INR) between 2.0 and 3.0, which indicates that their warfarin therapy is being properly managed.

All of the projects attempting to increase the percentage of appropriate patients receiving warfarin reported a positive impact, with a median increase of 23%. All projects that sought to boost the percentage of patients discharged on warfarin who received appropriate education were successful, with a median gain of 120%. Finally, all of the projects seeking to improve the percentage taking warfarin that maintain an INR between 2.0 and 3.0 also showed gains, with a median increase of 20%. Some examples:

• Lumetra estimates that its success in increasing use of warfarin—from 48% to 52% of eligible patients—translated into the prevention of an estimated 70 strokes and savings of roughly $2.6 million a year in medical costs alone in California.

• Louisiana Health Care Review, Inc. worked with 17 local organizations to improve care for patients suffering from stroke or stroke-like symptoms who present to acute care facilities. The project resulted in a significant reduction in the use of fast-acting nifedipine, from 32% of patients to 4%. The study also showed a moderate increase in the percent of patients treated with three or more blood pressure measurements and in the percent receiving a CT or MRI scan within two hours.

• Healthcare Quality Strategies, Inc., the New Jersey QIO, in conjunction with 29 New Jersey hospitals, increased the number of Medicare patients with atrial fibrillation discharged on warfarin from 58% to 69%. This project, which combined process changes and a new Fast Track methodology, produced positive benefits for more than 14,000 of New Jersey’s older adults with atrial fibrillation. The Fast Track methodology combines monthly visits with continuous interim data feedback.

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Secondary Prevention of Heart Attack/Heart Disease

QIO’s have led the way in devising effective programs to improve performance measures for the prevention of secondary heart attacks. QIO-provider projects to improve care for heart attack patients save thousands of lives a year. Some examples:

• Four QIOs (Alabama, Connecticut, Iowa, and Wisconsin) worked jointly on the Cooperative Cardiovascular Project (CCP), which laid the groundwork for the first national provider-based project to prevent secondary heart attacks in the elderly. By providing baseline data and requesting improvement plans, QIOs and collaborating hospitals were able to stimulate significant improvements in all areas of care. Highlights included an increase in in-hospital use of aspirin for appropriate patients from 84% to 90% and the prescription of beta-blockers at discharge from 47% to 68%. These improvements were associated with a 10% reduction in 30-day and one-year mortality rates in these states. At follow-up, performance on all quality indicators except reperfusion experienced a greater degree of improvement in the pilot states than in the rest of the nation. At one year after heart attack, mortality rates for pilot states dropped to nearly one percentage point below the rest of the nation.

• The Oklahoma Foundation for Medical Quality, the Oklahoma QIO, worked with VHA Oklahoma/Arkansas Inc. and its 22 member hospitals as a part of the CCP/AMI Project. The initiative resulted in significant improvements in door-to-drug time for aspirin (from 240 to 5 minutes), beta- blockers (from 24.5 to 4.9 hours), and thrombolysis (144 to 37 minutes). Rates of smoking cessation counseling and beta-blockers prescribed at discharge both increased from 33% to 100% of eligible patients, while aspirin prescribed at discharge increased from 77% to 100% of eligible patients.

• MassPRO, the Massachusetts QIO, has teamed with the American Heart Association to create a national initiative, Get With The Guidelines, to improve the care of patients hospitalized with cardiovascular disease. In the pilot phase, MassPRO partnered with 12 Massachusetts groups including the New England Affiliate of the American Heart Association and the Massachusetts Chapter of the American College of Cardiology. Over a 12-month period, treatment rates rose from 48% to 87% for smoking cessation counseling, 54% to 79% for lipid lowering therapy, 59% to 79% for LDL measurement, 60% to 68% for blood pressure control, and exercise counseling rates or referral to cardiac rehabilitation rates rose from 34% to 73%. This project continues in Massachusetts and has become a national initiative of the American Heart Association, which is partnering with QIOs in a number of states. The pilot data will appear in the Archives of Internal Medicine in 2003.

• The Alabama Quality Assurance Foundation, the Alabama QIO, worked with 20 hospitals and cardiovascular surgery teams to significantly improve the care of patients undergoing coronary artery bypass grafting (CABG) surgery. Key results include: the percent of patients who had breathing tubes removed after surgery within six hours increased from 9% to 41.2%; the use of internal mammary artery grafts increased from 73% to 84%, and aspirin use at discharge increased from 88% to 92%. These improvements were associated with a statistically significant reduction in risk-adjusted mortality.

• Primaris worked with five hospital emergency departments to improve the treatment of patients with heart attacks following an error that resulted in a patient’s death. The Missouri QIO established a collaborative that required participants to administer aspirin within 20 minutes of a patient’s arrival. Following meetings and conference calls, timely aspirin administration occurred 92% of the time, compared to 14% prior to the collaborative, and the average amount of time it took for emergency room staff to administer the medication dropped from 33 minutes to 14 minutes. Also, Primaris worked with 113 of 114 acute care hospitals in Missouri to improve smoking cessation counseling rates in patients diagnosed with MI. This care indicator rose 16% during the last three years, wtih more than half of the hospitalized Medicare patients diagnosed with MI receiving counseling.

• The Georgia Medical Care Foundation, the Georgia QIO, manages a series of multi-faceted, statewide clinical quality improvement initiatives in which approximately 67% of Georgia’s acute care providers are now participating. One of these initiatives focused on providing technical, consultative, and educational support to hospitals to improve systems of care heart attack patients. Since 1998, GMCF has seen an overall improvement of 16% in the key indicators related to AMI. To respond to requests by small and/or rural hospitals that triage and transfer heart attack patients from the emergency department, GMCF also developed an abbreviated software application. Twelve smaller hospitals are using this tool, along with other GMCF consultative services, to improve care to AMI patients.

• The MPRO, the Michigan QIO, collaborated with the American College of Cardiology, and 31 hospitals, in three ACC AMI Guidelines Applied in Practice (GAP) projects. The projects showed that the use of a standardized order form resulted in significantly higher rates for early aspirin and LDL cholesterol measurements, and the use of an AMI standard discharge form demonstrated significant improvement in aspirin, beta-blocker, smoking cessation counseling, dietary counseling and cholesterol lowering treatment at discharge. The results of the AMI GAP projects demonstrate that adherence to guideline-based therapy is enhanced when there are AMI-specific standard orders and discharge tools, focused implementation strategies, quality improvement support, and high expectations of the hospital team.

• QSource worked closely with the American Heart Association to promote the "Get with the Guidelines" national initiative to hospitals in our state. QSource helped 18 Tennessee hospitals gain national recognition for their efforts and worked with other collaborators to improve care and outcomes for heart attack patients. These improvement efforts were associated with a 7% absolute improvement in early administration of beta-blockers, and a 9% absolute improvement in beta-blocker at discharge.

• The Kansas Foundation for Medical Care conducted extensive efforts statewide to improve utilization of beta-blockers after a heart attack. These efforts included multiple visits with individual hospitals, sharing of quality improvement success stories, educational programs, and a series of "rapid cycle" quality improvement programs to improve heart attack care. Statewide, over the past three years, Kansas has experienced a 20% increase in use of beta-blockers after a heart attack. In the most recent rapid-cycle quality improvement effort, 15 hospitals working on heart attack care reported that 90% of eligible heart attack patients were discharged on beta-blockers.

• IPRO used an intense, multi-faceted intervention approach to improve quality of care for Medicare beneficiaries with Congestive Heart Failure. Along with standard educational approaches, IPRO worked with more than 50 hospitals to provide on-site audit and feedback services. The on-site audits focused not only on the quality indicators, but also on putting processes and systems in place that could help providers improve their performance. In addition, IPRO created a web site that allowed providers direct access to reports, educational materials, best practices information, and even free online CME credits. These activities helped New York state improve performance on CHF indicators by 6% over the SOW6.

• The Carolinas Center for Medical Excellence’s collaborative approach, or Fast Track Feedback, encouraged South Carolina hospitals to adopt a Plan, Do, Study, Act methodology for monitoring and evaluating patient care. Nearly all of South Carolina’s acute care hospitals participated in this effort, which was applied to examining care processes for elderly patients with heart failure and AMI, and to exploring ways to improve processes to achieve better outcomes. As a result of CMR’s efforts, all of South Carolina’s acute care hospitals worked on heart failure, which resulted in overall improvement in all quality indicators. Nearly all of the participating hospitals worked on AMI and also showed great improvement in all indicators.

• Stratis Health worked with the state rural health agency to develop and offer a collaborative project for Minnesota's first 10 Critical Access Hospitals, focusing on heart failure and atrial fibrillation. The project used four in-person learning workshops over 10 months starting in December 2001, with support, contact, and action between each workshop. In heart failure, 50% of the hospitals showed improvement in the availability of LVF data, and 75% demonstrated improvement in patient education. In atrial fibrillation, 50% showed improvement in some or all of the areas. Based on the success of this project, Stratis Health is launching a second Critical Access Hospital collaborative, for up to 30 hospitals, in March 2003.

• The Colorado Foundation for Medical Care's Inpatient Team established an outreach program consisting of semi-annual regional hospital meetings for hospitals to present ongoing quality improvement projects to one another. In addition, CFMC presents clinical informational updates and data feedback. CFMC also produced a resource notebook containing examples of pathways and standing orders, which are successfully being used in Colorado hospitals. A large number of Colorado hospitals have chosen acute myocardial infarction and heart failure core measures and frequently request information on these topics. Through CFMC facilitation of these regional meeting, hospitals took necessary steps in systems change for both AMI and HF care in Colorado. Over the last three years Colorado hospitals have accomplished an overall relative improvement of 15%.

• The Delmarva Foundation for Medical Care, Maryland and District of Columbia QIO, helped seven (15%) of Maryland’s acute care hospitals raise their performance rates to 90% or better on at least 6 of 13 quality indicators during 2001 and 2002. These hospitals received Delmarva’s Campaign for Medicare Excellence Award for improving the timing of medications for people suffering from heart attacks, and for ensuring that correct medications were prescribed for patients treated for various heart conditions. The hospitals achieved their performance gains through a combination of enhanced communication, increased accountability, ongoing data collection, data analysis and feedback. Hospitals chosen for the award also maintained their rate of excellence for a minimum of six months. The award program successfully stimulated interest in working with the Delmarva to improve clinical performance.

• Information and Quality Healthcare, the Mississippi QIO, worked with 70 hospitals to promote system changes to standardize processes for AMI care. Physician education and components of the project were extended to the outpatient setting and clinics by the hospitals. Collaborators, also including associations, agencies and coalitions, worked to reduce cardiovascular disease occurrence in the state. IQH's Tobacco Quitline Mississippi, a smoking cessation counseling service, provided vital support for the AMI project by highlighting the importance of smoking cessation counseling in the state.

• MetaStar, the Wisconsin QIO, joined with five Wisconsin business coalitions to successfully reduce unnecessary use of bilateral heart catheterizations. Encouraged by the success of this project, MetaStar has joined with one of the coalitions and the Wisconsin Diabetes Control Program in a program to encourage more appropriate use of preventive, screening, and clinical services for patients with diabetes.

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Improving Care for Diabetes

Promoting more effective treatment for diabetes often involves developing programs to educate providers and patients. Some examples:

• The South Dakota Foundation for Medical Care, the South Dakota QIO, worked in collaboration with physicians, residents, the University of South Dakota School of Medicine and the Indian Health Service to educate providers about the benefits of annual screening for microalbuminuria and the use of ACE inhibitors to delay development and/or progression of diabetic kidney disease. Among the 179 physicians and 40 clinics that participated, the percentage of patients tested increased more than five-fold, from 9% to 50%.

• Health Services Advisory Group, Inc., the Arizona QIO, worked with six Medicare managed care organizations to improve outpatient diabetes management by providing comparative feedback of baseline data. The results: mean glucose levels fell from 8.9 to 7.9; the proportion of patients with glucose levels below 8.0 rose from 40% to 61.6%; the proportion of indicated services provided to patients rose from 35% to 55%; the mean number of physician office visits fell 13% while the number of services provided per visit doubled.

• QSource worked with the state diabetes education program, physician offices, and community partners to increase the awareness of diabetes preventative care services for the Medicare population. QSource conducted regional educational workshops, targeted state medical associations, developed consumer awareness campaigns, distributed 60+ community-based toolkits and participated in statewide forum for diabetes care sponsored by the governor's office. These efforts resulted in an absolute improvement of 12% for A1C testing, and a 23% absolute improvement in lipid profile rates.

• Qualis Health, the QIO for Washington, Alaska and Idaho, worked with the Washington State Department of Health, the Group Health Cooperative of Puget Sound and more than 30 clinics across the state to implement the Washington State Diabetes Collaborative. Participating clinics chose different process and outcomes measures to focus on, and shared their successes in regular "learning sessions." Measurable improvements have been noted in the rate of foot exams, blood sugar testing, and in levels of LDL cholesterol in patients with diabetes.

• Primaris enrolled select physician offices in the state’s first Diabetes Collaborative, using a model specifying essential elements of diabetes care. As a result, patients of these practices meeting the national goal of two hemoglobin A1c tests per year rose 397%; and by September 2002, 520 patients were enrolled in active care registries. These clinics are now applying clinical lessons learned to other chronic diseases. Using statewide and regional partnerships, Primaris also reached almost 10,000 Missouri physicians with guidelines and systems change tools. Compared to two years earlier, 12,612 more Medicare beneficiaries with diabetes received a biennial lipid profile, 9,474 received an annual A1c, and 6,423 a biennial eye exam statewide.

• Health Care Excel, the Indiana QIO, conducted a project with selected Indiana nursing homes to determine how to improve care for people with diabetes. Data were obtained at three intervals to assess the level of care among beneficiaries with diabetes in nursing homes by measuring the number of beneficiaries who received hemoglobin A1C (HbA1c) testing. Interventions for the project were developed by an interdisciplinary Medicare QIO diabetes workgroup and included continuous quality improvement education, diabetes education, and development of policies and procedures for diabetes care in nursing homes. The data revealed an increase in administering the HbA1c test 56.7% to 86.6%. Rates were sustained at 81.2%. In addition to a higher rate of HbA1c testing in the intervention group, the data displayed an unexpected trend in positive outcomes, demonstrated by lower levels of HbA1c test results.

• North Dakota Health Care Review, Inc., the North Dakota QIO, collaborated with clinics that provide care to more than 60% of the state’s diabetic population. Five years of implementing system improvements such as a diabetes care flow sheet have led to statistically significant increases in the project’s five quality indicators: semi-annual office visits, annual hemoglobin A1c rates, eye exams, urinalysis, and measurement of microalbumins. The QIO also has developed a system widely used by providers in the state that facilitates tracking of the health status of diabetics and includes a patient reminder system for routine diabetes standards of care such as HbA1c, dilated eye exams, and lipid testing.

• Acumentra Health, the Oregon QIO, worked with five Medicare managed care organizations to improve screening rates and outcomes for patients with diabetes. The result: significant increases over a three-year period in dilated eye exams (16%), glucose testing (14%), patients with improved glucose control (13%), and patients with tight blood pressure control (5%).

• Quality Partners of Rhode Island developed a task force to increase the number of dually enrolled beneficiaries with diabetes who have a biennial lipid test. The task force designed interventions for both providers and dually enrolled beneficiaries. Physician-targeted interventions included audit and feedback, site visits, and clinical information to address the knowledge deficit regarding the critical link between diabetes and cardiovascular disease. Dually enrolled beneficiaries received a direct mailing with messages to talk to their doctor about having a lipid test. In addition, the task force coordinated a statewide diabetes campaign targeting the dually enrolled beneficiary audience as well as the general population. These interventions helped increase the statewide rate of lipid testing from 46.8% to 73.6%. Also, the disparity in lipid testing between dually enrolled and non-dually enrolled beneficiaries fell from 10.7% to 3.4%, representing a gap reduction of 7.3%.

• Virginia Health Quality Center, the Virginia QIO, used a variety of interventions to boost eye exams among Medicare beneficiaries with diabetes, such as direct mailings and follow-up reminders to beneficiaries, and mailings to physicians, media campaigns, and collaborations with community organizations. The results showed an increase in eye exams for the intervention group, while no such change occurred in the control group. The greatest increases in eye exams directly correlated with the timing of interventions.

• The Kansas Foundation for Medical Care, the Kansas QIO, conducted a program to improve office management of diabetes services. In visits with 319 physician offices, KFMC discovered that only 29% were utilizing standardized systems to assure that patients were receiving HbA1c tests, lipid profile measurements, and routine eye exams. KFMC combined this program with a continuing education program for nurses, and 117 offices took advantage of the educational opportunity. In response to these efforts, 54 offices adopted flow sheets to improve care for their patients with diabetes.

• Carolinas Center for Medical Excellence implemented a three-pronged approach to improve care for Medicare beneficiaries with diabetes: physician-, patient-, and community-level interventions. Physician-level interventions included interactive teleconferences with national- and state-recognized experts, targeted medical and professional association media activities, statewide partnerships, and multiple direct mailings of clinical tools and performance rates. Multiple direct mailings for patient education and awareness were among the patient-level interventions. The community-level activities consisted of health-related news articles and editorials in major and local newspapers across the state. The result: absolute improvements of 21.1% in lipid profiles (from 53.4% to 74.5%); 11.1% improvement in A1C testing (from 69.8% to 80.9%), and 2.3% improvement for dilated eye exams (from 69.6% to 71.9%).

• New Mexico Medical Review Association played an integral role in a joint initiative of the American Association of Health Plans and the American Diabetes Association involving over 200 health plans in Albuquerque, NM. As the first of three sites to pilot a community partnership to address diabetes concerns, this effort involved participating plans jointly creating and endorsing guidelines based on ADA recommendations for distribution to providers throughout the state.

• Stratis Health joined forces with eye health organizations in Minnesota on a consumer campaign to mail reminders and promote the importance of annual eye exams for persons with diabetes. In addition, Stratis Health offered clinics an Eye Exam Reporting Form, a tool to help facilitate the reporting of eye exam results from the eye care provider to the primary care provider. During the SOW6, Minnesota’s biennial eye exam rate went from 75.0% to 79.0%.

• Information and Quality Healthcare successfully recruited 193 providers in Mississippi to collaborate in its diabetes project. Providers were encouraged to implement permanent systems changes to better manage patients. Diabetes awareness messages were distributed to beneficiaries through education programs and health fairs during the initiative. In addition, physician-provider champions educated colleagues, stressing the need for emphasis on the quality indicators, a strategy that resulted in increased diabetes indicator rates.

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Guarding Against Breast Cancer

QIOs around the nation are involved in dozens of cooperative, community based-efforts to increase mammography rates:

• The Arkansas Foundation for Medical Care, the Arkansas QIO, has held a series of health fairs in counties with the lowest rates of mammography among African American women. The health fairs are held in partnership with the Witness Project, a church-based education program that aims to enhance awareness and knowledge of breast and cervical cancer, and increase screening and early detection behaviors among low-income, rural, African-American women. The project supports the efforts of a team of African American breast and cervical cancer survivors who "witness" their friends and neighbors in small group sessions, ranging in size from 2-25 women. Women who participated in the baseline Witness program demonstrated significant increases in mammography compared to a control group. Results show that among those who received the intervention, women who normally did not get mammograms, an average of 23.6% sought and received a mammogram in the 6-month period following the intervention.

• Quality Insights of Delaware, the Delaware QIO, has worked to educate opinion leaders and raise awareness about mammography among African-American women. Through a local coalition, called Mature African Americans for Mammography (MAAM) the QIO invites community members to educational meetings and asks them to share information with family, friends, and others. The MAAM Coalition has reached as many as 3,000 women resulting in nearly 350 new mammography screenings. In addition, the program helped increase the number of mammograms received by African American senior women from 40% in 1998 to 45% in 2000.

• The Mountain-Pacific Quality Health Foundation, the QIO for Montana, Wyoming and Hawaii, made great strides in raising mammography rates by using a variety of interventions and establishing partnerships with breast cancer awareness groups. Creating partnerships has resulted in higher breast cancer awareness and has increased Montana’s rates of mammography screening by six percentage points from 1997-1998 to 1999-2000. A similar effort in Wyoming resulted in a 6.5 percentage point increase over the same time period.

• The New Mexico Medical Review Association developed the Beads Project as a patient-friendly intervention for use as a teaching tool during patient visits. The tool consists of a set of beads that depict the average size of breast lumps discovered through a combination of various early detection methods (breast self-exam, clinical breast exam and mammography) as compared to the size of breast lump found when none of the early detection methods is employed. A bilingual (English and Spanish) poster that illustrates various breast-lump sizes accompanies the bead set and hangs in patient exam rooms. This intervention combines the powerful images of the breast beads with the opportunity for patient-physician discussion and physician referral. In one Beads Project site, documented mammograms increased from 40%-67% during the interventions period.

• Health Care Excel, the Kentucky QIO, developed statewide strategies in conjunction with the Kentucky Breast Cancer Task Force and Kentucky Breast Cancer Coalition to help improve mammography rates in the state. From the baseline period of 1997-1998 to the remeasurement period of October 1999-September 2001, rates for non-HMO female Medicare beneficiaries with biennial mammography services increased statewide, from 52.8% to 58.6%.

• Lumetra developed materials about mammography that speak to Asian Pacific Islander women who suffer high rates of breast cancer. Lumetra and its partner organizations developed multi-lingual, culturally appropriate patient materials, translated into Chinese, Tagalog, and Vietnamese because one-third of the population is not proficient in English. As a result of this project, the National Cancer Institute and the Centers for Medicare and Medicaid Services have implemented a nationwide rollout of the Lumetra breast cancer materials for the Asian Pacific Islander (API) community. Lumetra also has worked with Medicare+Choice organizations throughout the state to address breast cancer screening. Lumetra developed an extensive Breast Cancer Screening Toolkit and distributed it to all M+C organizations. Information and helpful hints were included in the Toolkit to assist in customizing an outreach program to specific populations.

• Primaris joined with the American Cancer Society and the Breast and Cervical Cancer Control Program, to develop a 2002 Mother’s Day Campaign to raise awareness about the value of mammography screening. Sixty-four mammography centers statewide implemented the campaign. With corporate partners, Primaris also mailed mammography reminder notices to 4,000 Medicare women who had not received a mammogram, advising them of the availability of the van in their neighborhood. In addition, almost 200 clinics and physician offices now use Primaris’s mammography recall system. Statewide, 2,588 more women aged 50-69 received a mammogram than two years previously.

• The Colorado Foundation for Medical Care found that in some areas in Colorado the mammography rate for Latinas can be as much as 26% lower than the state rate. To decrease this disparity, CFMC partners with Colorado's Catholic churches to deliver culturally-sensitive messages on mammography. Over 85% of Catholic churches are participating in this collaboration by displaying bilingual educational materials and publishing messages in church bulletins. Priests actively support the project by making announcements from the pulpit. Promotoras (health educators) from a health care clinic that provides free care to persons without insurance, have contracted with CFMC to provide education on the importance of mammograms in Denver neighborhoods surrounding four predominantly Latino churches.

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Preventing Errors and Injuries

• The Alabama Quality Assurance Foundation has partnered with 14 nursing homes to implement a Falls Prevention Project in their facilities. The goal of the program is to reduce the prevalence of falls and increase the use of quality improvement tools and techniques. Data from the Minimum Data Set (MDS) and the MDS Quality Indicators are used to analyze results from this project. The success of this project is based on the working relationship between skilled nursing facilities in Alabama, the Alabama Nursing Home Association, the Alabama Department of Public Health and AQAF. The first group of skilled nursing facilities that have participated in this project has realized a decrease in the number of falls.

• Primaris reported a 33% reduction in self-reported nursing facility falls in twelve select skilled nursing facilities. Primaris selected the facilities in eleven Missouri counties for its falls and injury reduction program, which included risk assessment (both of resident and of environment), care planning, and exercise. Participants felt that the benefit from reduction of repeat falls was significant.

• HealthInsight, the Utah QIO, launched a project designed to help hospitals make systems changes to reduce medication errors. As a result, Utah hospitals achieved a 25% reduction in the number of medication errors that occurred during the four major phases of the patient medication process. Hospitals also increased by 30% the number of errors caught during the medication-ordering phase and therefore prevented these errors from impacting patient care.

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Facilitation of Preventive Health Services

• Qualis Health developed software to track delivery of preventive health services for older adults and to remind physicians and patients when services are due. The software is provided to primary care providers free of charge by Qualis Health, which also offers implementation assistance and ongoing technical support. Idaho sites using the software have shown substantial improvements in care for diabetes patients, as well as increased use of other preventive services, such as immunizations. To date, 22 clinics using the software have increased 81% of their quality measures in a range from 2%-30%. The software was developed in consultation with the Idaho Department of Health and Welfare, which has financed a Web site to promote the computer-based tracking and reminder system.

• The MPRO developed a successful incentive program that uses public recognition to encourage physicians’ offices to participate in quality improvement projects. The program launched the "Governor's Award of Excellence for Improving Preventive Care in the Ambulatory Care Setting", endorsed by Michigan’s governor. The award recognizes primary care physicians’ offices that are actively participating in activities to improve the quality of care for adults in the areas of breast cancer screening, diabetes, and influenza and pneumococcal immunizations. Physicians’ offices submit an application for nomination and quarterly documentation to meet award criteria. Sixty-six offices received the award in 2001. More than 100 physicians' offices will receive the 2002 award.

• Louisiana Health Care Review created a simple and effective process for physician offices and their staff to assess and track delivery of preventive services. Called OPRA—OutPatient Rapid Assessment process—this intervention uses the latest technology to machine read patient-completed health assessments and then track those patients through their doctor visits. OPRA is working to increase delivery of six Medicare priority services, including mammography, immunizations, eye exams and the like. For example, OPRA has led to increases in pneumonia vaccines by up to 40% over the previous year’s rate. Seven other QIOs across the nation have now adopted OPRA for their own use and several other QIOs are evaluating it for their state.

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Improving Home-Health Care Services

CMS requires Home Health Agencies to develop and maintain programs that promote continuous quality improvement in caring for their patients. An integral part of this approach is the requirement that HHAs use a standard core assessment data set, OASIS, when evaluating patients. HHAs will be required to develop an Outcome-Based Quality Improvement program based on OASIS data analysis. Because no mechanism existed previously to provide support to the HHAs in developing and managing QI programs, CMS initiated a pilot project using the QIO program to facilitate implementing this system in HHAs.

• The Delmarva Foundation for Medical Care has led a five-state (Maryland, Michigan, New York, Rhode Island and Virginia) pilot project to explore using the QIO program to help HHAs implement and maintain the OBQI system. Over 400 HHAs participated in the pilot (68% recruitment rate). The participating HHAs identified two outcomes to target for improvement. For the entire pilot, there was a 6.7% improvement in the risk-adjusted outcomes from year one to year two. Individual states ranged in improvement from 10.2% to 2.8%. The OBQI system is being implemented nationally through the QIOs.