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Results
from Indiana Medicare QIO Diabetes Project in Nursing Facilities
The
Indiana Medicare QIO recently conducted a local project with selected Indiana
nursing facilities to determine how to improve care for people with diabetes in
an alternative health care setting. The interventions were formulated by the Medicare
QIO interdisciplinary diabetes workgroup and through exploratory work with nursing
facilities and partners. Numerous, unique challenges were considered when interventions
were designed and the project implemented. The interventions were divided into
three main categories including continuous quality improvement (CQI) education,
diabetes education, and development of policies and procedures for diabetes care
in nursing facilities. Baseline, interim, and final remeasurement data were obtained
to assess the level of care among beneficiaries with diabetes residing in nursing
facilities by measuring the number of beneficiaries who received hemoglobin A1c
(HbA1c) testing. While improvement in the indicator rate was demonstrated by the
data, results also revealed a positive trend in HbA1c levels.
The
immediate objective of this project, to increase the number of Medicare beneficiaries
with diabetes, residing in Medicare-certified nursing facilities, receiving HbA1c
testing, was supported by statistically significant data from baseline to final
remeasurement. Data also supported the hypothesis that quality improvement activities
with an intervention group of nursing facilities compared with a control group
would result in a higher rate of HbA1c testing in the intervention group.
The
results reveal the intervention group, Group A, demonstrated continuous improvement
in the HbA1c testing rate for the duration of the study. When comparing baseline
and final data, Group A demonstrated a statistically significant improvement from
56.7% in May 2001, to 86.6% in February 2002. The comparison group, Group B, improved,
though not significantly, from 33.6% in May 2001, to 45.0% in February 2002. An
incidental finding-although the difference was significant only at interim measurement--in
outcome results showed that Group A nursing facilities had a greater percentage
of residents whose HbA1c level was below 7.0 compared to Group B at every measurement
period. Additionally, the data reveal that 26% of the residents in Group A had
HbA1c testing done quarterly compared to only 4% for Group B (p<.001).
Throughout
the project, Group B continued to show a slight improvement in the rate of HbA1c
testing. The exact reason is not known, but it is speculated that the Hawthorne
effect may have contributed to this increase, as well as the fact that some of
the same physicians practice in Group A and B nursing facilities. The change in
a physician's practice of ordering a HbA1c in Group A nursing facilities may carry
over to Group B nursing facilities. Other secular changes may have contributed
to this increase as the Medicare QIO completed other statewide diabetes quality
improvement projects during this same time period.
This
project provided resources to nursing facilities that previously were not available.
This local project, which addresses critical care issues that impact the management
and care of individuals with diabetes, will assist in the development of future
activities to improve care that all beneficiaries receive in nursing facilities.
The Medicare QIO anticipates the resources, partnerships, and efforts invested
in this project will have positive and sustained effects that will assist in conducting
future projects.
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