# Presentation: 755033

## Improving Health Care, Improving Lives: 2007 AHRQ Annual Conference

**Systems-Level Approaches to Reducing Racial, Ethnic and Income **
**Disparities in Healthcare Quality**
- Frederick P. Cerise, M.D., M.P.H
- Vice President Health Affairs and Medical Education
- Louisiana State University System
- September 28, 2007

## Percent of Medicaid Eligibles and Louisiana Population, by Race

***Medicaid Eligibles***

***Louisiana Population***

- African-
- American

- African-
- American

- White

- White

- Other

- Other

- SOURCE:  DHH data as of 8/31/2007; LA population est. 2005.

**Notes:**
African Americans and low income patients are disproportionately represented in the Medicaid population.

## Slide 3

**Notes:**
2 points:

Larger practices perform better
Greater ability to put medical home systems in place (disease registry, patient tracking, disease management programs, electronic records, decision support, provider feedback, access to drugs, etc)

Compare to smaller practices/cottage industries

2.  Systems interventions can improve care for all

## Slide 4

## Slide 5

## Two Approaches

- Systems-level intervention targeted to providers with lower performance on selected measures
- Establish expectations of all providers to be eligible to participate in Medicaid

## Targeted Intervention

- 75 “bottom left” provider
***Control:*** providers were mailed baseline indicator levels
***Education only***: providers were mailed baseline levels and nurse educators visited providers
***Education + Reminder System:*** providers were mailed baseline levels, nurse educators visited providers, and providers had access to the reminder system
- All analyses are “intention to treat”

**Notes:**
75 lower left hand corner practices selected – evenly divided among 3 groups

COMMENTS ON INTERPRETATION

All results are for CC only, with all people with any third-party insurance dropped
The UNISYS project included only the lowest quartile of PCPs (based on HbA1c testing rates.)
The comparisons of interest are group comparisons on changes in rates from baseline to follow-up; e.g., did the “education only” group change more than the “control group”?
The graphs show raw rates; however, the p-values included on the graphs are for comparisons of adjusted rates.
The baseline data are HEDIS measures calculated as of the 12/31/2005; the follow-up data are HEDIS measures calculated as of 12/31/2006.

COMMENTS, DIABETES MEASURES

The major finding is the upward movement in all the diabetes measures, with the movement quite strong in most of the measures.
This upward movement occurred in all three treatment groups, and it also occurred in the CC population as a whole, not just the UNISYS study PCPs.
In some measures, however, there are groups differences (see graphs), with the “education + reminder system” group generally showing greater improvement.
On the graphs, there are six p-values.
The first three p-values are for changes from baseline to follow-up within each of the three treatment groups
The last three p-values are for the group comparisons

## Slide 8

## CONTROL over time, p = 0.000

**CONTROL over time, p = 0.000**
**EDUCATION over time, p = 0.000**
**EDUC+SYS over time, p = 0.000**
- EDUC vs CONT, p = 0.652
**EDUC+SYS vs CONT, p = 0.041**
**EDUC vs EDUC+SYS, p = 0.017**

- These p-values are from tests comparing baseline to follow-up changes between pairs of groups

- These p-values are from tests comparing baseline to follow-up levels within each group

**Notes:**
Absolute differences:

Baseline
Black 2% worse than whites (significant)

Follow up
Backs 4% worse than whites (significant)

## CONTROL over time, p = 0.005

**CONTROL over time, p = 0.005**
**EDUCATION over time, p = 0.006**
**EDUC+SYS over time, p = 0.000**
- EDUC vs CONT, p = 0.806
- EDUC+SYS vs CONT, p = 0.341
- EDUC vs EDUC+SYS, p = 0.224

**Notes:**
Absolute differences

Baseline
Blacks 4% worse than whites (significant)

Follow up
Blacks 8% worse than whites (significant)

## CONTROL over time, p = 0.000

**CONTROL over time, p = 0.000**
**EDUCATION over time, p = 0.000**
**EDUC+SYS over time, p = 0.000**
- EDUC vs CONT, p = 0.161
- EDUC+SYS vs CONT, p = 0.199
**EDUC vs EDUC+SYS, p = 0.027**

**Notes:**
Absolute differences

Baseline
Blacks 4% better than whites (significant)

Follow up
Blacks 3% better than whites (significant)

## Conclusion

- African Americans and low income patients are disproportionately represented among Medicaid recipients.
- There is great variation in performance among practices caring for Medicaid recipients.
- Practices with more patients tend to have higher compliance with standards.
- Systems level interventions can improve outcomes for Whites and African Americans.
- Despite improvements, some disparities remain.

## Provider Expectations

- Establish new expectations for Medicaid expansion
- Expectations track NCQA Physician Practice Connections

## Medicaid Expansion

- Expectations for primary care providers
- Access and communications
- Patient tracking and registry
- Care management
- Patient self management  support
- Electronic prescribing
- Test tracking
- Referral tracking
- Performance reporting and improvement
- Interoperability

## Questions?