Diabetes Measures in EHRs Linked to Improved Care

Omar A. Contreras, MPH Diabetes Prevention and Control Program Arizona Department of Health Services June 27, 2014

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What does What does medicine do? public health do?

Saves lives one at a time Saves lives millions at a time

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Essential Services of Public Health

     Monitor health status Diagnose and investigate Inform, educate, and empower Mobilize community partnerships Develop policies and plans      Enforce laws and regulations Link people to needed services/assure care Assure a competent workforce Evaluate health services Research Source of Ten Essential Public Health Services: Core Public Health Functions Steering Committee, 1994

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Framework for Improving the Performance of Public Health Health Department + PH System + Community Partners + Workforce Builds Operational Capacity

(Infrastructure)

Impacts Every Community Program and Public Health Activity

(Chronic Disease, Inf. Disease, EH)

Which leads to Better Health Outcomes Reduced Disparities Better Preparedness

Investments here Pay big dividends here Source: D. Lenaway. Centers for Disease Control and Prevention, Office of Chief of Public Health Practice. 2009 (unpublished)

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Governmental Public Health State and Local Health Departments

Retain the primary responsibility for health under the US Constitution State and the District of Columbia Health Departments Tribal Health Departments Local Health Departments * Number based on 2010 National Profile of Local Health Departments (NACCHO, 2011) ** Numbers cited from ASTHO, Profile of State Public Health, Volume Two, 2011

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Territorial Health Departments

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State and the District of Columbia Health Departments Federally Qualified Health Centers Tribal Health Departments

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Territorial Health Departments Local Health Departments

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• • • • • •

Outline

Arizona Department of Health Services/Arizona Diabetes Program – Diabetes in Arizona – – Epidemiology and Surveillance Trends and Cost Analyses The Arizona Diabetes Coalition Diabetes measures and systems change Public Health in Action Grant EHR and non-physician team base approach to diabetes care Summary

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Arizona Department of Health Services Hierarchy

Arizona Department of Health Services Agency Director Division of Public Health Prevention Services Assistant Director Bureau of Tobacco and Chronic Diseases Office of Chronic Disease Programs Diabetes Heart Disease and Stroke Bureau Chief Healthy Aging CPR CHW Arizona Diabetes Coalition and Leadership Council

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Arizona Diabetes Program

• • • •

What we do and what we provide?

Ongoing technical assistance to internal and external partners Information and guidance on funding resources Develop diabetes specific strategies and public health interventions at a systematic, policy, and environmental levels Supports and oversees the activities Arizona Diabetes Coalition and Leadership Council

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Diabetes in Arizona

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Leading causes of death in the United States for 2011

Source: National Center for Health Statistics, www.cdc.gov/nchs .

Leading Death

1. Heart disease 2. Cancers 3. Chronic lung diseases 4. Strokes 5. Accidents 6. Alzheimer’s disease 7. Diabetes mellitus 8. Pneumonia and influenza 9. Kidney diseases 10. Suicides

Death rate per 100,000

191.4

184.6

46.0

41.4

39.4

27.2

23.5

17.2

14.7

12.3

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Diabetes in Arizona

• • • • 1/9 Arizonans have diabetes 1/3 of those who have diabetes in Arizona are unaware that they have it Diabetes is the leading cause of new cases of blindness and kidney failure Known risk factors – Obesity – Physical inactivity or increase in sedentary lifestyle – Built environment

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County* Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Pima Pinal Santa Cruz Yavapai Yuma

How do rate by county?

Diabetes

8.0% 15.7% 13.3% 15.6% 17.0% 15.9% 16.0% 10.0% 14.6% 12.1% 12.2% 14.4% 10.3% 10.6% 11.8%

Arizona

10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6% 10.6%

Hypertension**

17.5% 44.4% 17.2% 28.8% 27.5% 27.0% 34.8% 26.5% 38.2% 34.8% 25.6% 35.7% 34.5% 38.5% 40.8% *Source: Arizona Behavioral Risk Factor Surveillance System, (AZ-BRFSS, 2013) ** 2011 Numbers shown as 2012 data not available

Arizona

28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1% 28.1%

Obesity

25.1% 27.4% 22.3% 25.1% 34.5% 34.3% 32.0% 26.0% 29.4% 31.1% 23.5% 25.7% 33.7% 33.8% 28.6%

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Arizona

26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0% 26.0%

Source: AZ Health Matters (2012), AZ BRFSS

Arizona Adults with Diabetes by Race/Ethnicity, 2012

16,0%

14,7%

14,0%

12,5%

12,0%

10,6% 9,9%

10,0%

9,4%

8,0% 6,0% 4,0% 2,0% 0,0% Black Hispanic Other White Overall

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Arizona Age-adjusted Death Rate due to Diabetes, by Gender (2012)

35

29,2

30 25 20 15 10 5 0

18,6 23,5

Female Male Overall

Source: AZ Health Matters (2012), AZ BRFSS azdhs.gov

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Arizona Age-adjusted Death Rate due to Diabetes, by Race/Ethnicity (2012)

90 80 70

80,2

60 50 40 30

27,6 49,4

20 10

Source: AZ Health Matters (2012), AZ BRFSS

0 American Indian/Alaska Native Asian/Pacific Islander Black/African American

40,8 18,3 23,5

Hispanic/Latino White, Non-Hispanic Overall

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Estimated costs

Estimated Costs of Diabetes, 2007

Total $174 billion $116 billion Direct medical costs Indirect medical costs $58 billion

Estimated Costs of Diabetes, 2012

Total $245 billion $176 billion Direct medical costs Indirect medical costs $69 billion Source: http://www.diabetes.org/advocate/resources/cost-of-diabetes.html

, retrieved 11/25/2013

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Estimated costs AZ, cont.

Parameter

All Payers MEDICAID MEDICARE Private Insurers

Treated Population

416,200 81,800 168,100 236,500

Cost per Person

$5,420 $3,750 $3,580 $2,580

Total Costs (2010) Adjusted to 2013

$2,258,000,000 $2,412,300,000 $307,000,000 $602,000,000 $610,000,000 $327,980,000 $643,140,000 $651,680,000 2011 Arizona Hospital Discharge Data indicated a total of 7,065 discharges related to diabetes and chronic conditions.

Arizona Diabetes Cost Data (2010) – CDC Chronic Disease Cost Calculator

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$167,815,464 azdhs.gov

Arizona Diabetes Coalition

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Vision

A state without diabetes

Mission

To reduce the health, social, and economic burden of diabetes in Arizona

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How are the Coalition and Council structured?

Arizona Diabetes Program and ADHS Electronic Health Records Arizona Diabetes Leadership Council Chair: Sandra Leal Arizona Diabetes Coalition Chair: Sandra Leal Pre-Diabetes Tribal Advocacy DSMT/E

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SALUD (Supporting Action for Latinos Against Diabetes)

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Arizona Diabetes Leadership Council • • • • • • • Reorganized Fall 2006 >18-21 member leadership council – Representation from academia, health plans, government, private companies, non-profit organizations, etc.

Meet 6 times a year as a council and quarterly with the coalition Each Coalition workgroup chair is represented in the Leadership Council.

Ex-Officio members Well established by-laws: www.azdiabetes.gov

Constant communication between leadership body and ADHS Diabetes Program

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Diabetes Measures and Systems Change

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Health Care Flowchart

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Pillars of Health Care Reform Cost Access Coverage Quality

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Quality and access to Care

There are thousands of new doctors and nurses in communities around the country and millions more patients getting care.

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Improving Quality

• • • • Increase the utilization of EHR in multiple healthcare systems Encourage completion of NQF standard measures for diabetes and hypertension Require reporting and accountability for health plans  Coordinate care and medical home models  Improve patient safety, reduce medical errors, promote health and wellness Capacity development for FQHCs and other health systems

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Measure

0055 0056 0059 0061 0062 0064 0575 0018

National Quality Forum (NQF) Measures (Diabetes)

Recommended Measure Title

Eye Exam (no evidence of retinopathy) Foot Exam HbA1c Poor Control (HbA1c >9%) Blood Pressure Management Urine Screening LDL Management and Control HbA1c Control (<8%) Controlling High Blood Pressure

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Role of EHR systems in FQHCs

• • • • Advocate for your patients Referral mechanism for DSME and prevention programs Provision of preventative care for chronic care patients EHRs can help avoid re-admission rates and improve and adherence to self-management

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Public Health in Actions Grant

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• • • •

What is the Public Health in Actions Grant?

5 year collaborative grant Focuses on policy, system, and environmental change 32 states funded – Basic and Enhanced components Year 1 has been completed

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Implementation of EHR system change and performance measures

Proportion of health care systems reporting on NQF measures 18 and 59 Proportion of health care systems with EHRs appropriate for treating patients with high blood pressure and diabetes Increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level

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System level changes and non-physician team based care in Federally Qualified Health Centers

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Summary

• • • • Diabetes remains a prevalent disease in Arizona, specifically in rural areas Diabetes NQF measures offers the ability to detect care when the recommended care was given or when recommended care was not received.

Non-physician staff will continue to be on high demand and integration into a team base approach to diabetes health should be warranted Health systems changes via the utilization of electronic health records show positive trends in the improvement of diabetes care

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Looking into the future

• • • Establish a data sharing agreement between ADHS and FQHCs and/or the Alliance for Community Health Centers Ability to generate standardize reports on patients with diabetes and hypertension Reducing the gaps and inconsistencies resulting in lack of data within the EHR

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Our ever changing public health system Police

FQHCS

MCDPH Churches Home Health Doctors Drug Treatment EMS Fire ADHS Laboratory Facilities Parks Schools Hospitals Philanthropist Corrections Elected Officials Nursing Homes Mass Transit Civic Groups Environmental Health Tribal Health Employers Mental Health Economic Development Urban Planners

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Questions?

Contact Information Omar A. Contreras, MPH Diabetes Prevention and Control Program Manager Arizona Department of Health Services [email protected]

(602) 542-2758

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