Impact of Clinic Systems and
Improvement Strategies On Costs of Care
for Adults with Diabetes
Todd P Gilmer PhD
Patrick J O’Connor MD MPH
William A Rush PhD
A Lauren Crain PhD
Robin R Whitebird PhD
Anne M Hanson BA
Leif I Solberg MD
University of California, San Diego
HealthPartners Research Foundation
Clinic Characteristics Related to
Efficiency in the Production of Health
• Output = Health
• Measured by clinical outcomes important in diabetes:
– Glycemic control, BP control, lipid control
• PJ O’Connor presenting tomorrow @ 9
• Inputs measured by costs for services = this paper
• Next step:
– Use clinical outcomes as inputs into a health utility
model to calculate QALYs
• Regression methods to identify clinic characteristics
related to efficiency
Quest for Health
Goal = to identify provider & system characteristics associated
with care and outcomes for patients with DM & CHD
• Multi - level survey of patients, providers, clinic
managers and medical directors, medical group
administrators and medical group medical directors
• Medical record review
• Merged to 3 years of health care encounters/claims
Clinic Systems and
Improvement Strategies
Care Management Strategies
Patient Education
Registries
Information Support
Overall QI Efforts
Specific QI Strategies
Cost Estimation
• 43% Capitated, 29% FFS, 28% Cap/FFS
• Encounter + claims data
• RVUs for outpatient services
• DRGs for hospitalization
• National payment rates
• Simulated outlier payment
• Drugs priced at 68% of AWP
• GLM: f(gam) l(log) robust cluster(clinic)
• Standard errors by Delta method
Study Subjects:
1624 Adults with Diabetes
Demographics:
Female %, No.
Age Mean, SD
47.3
62.7
770
12.9
A1c Mean, SD
Duration DM Mean, SD
7.5
12.0
1.5
12.7
Chronic diease %, No.:
CHD
HT
Lipids
Depression
24.8
65.6
62.4
24.9
404
1068
1016
405
Socioeconomic %, No.:
Low income
Low education
19.4
7.0
316
113
Care Management Strategies
Non-urgent appointments available the same day
Clinic coordinates care between providers
Clinic requires patients to have "their own" clinician
Clinicians to meet to discuss patient care problems
Clinic has medical information available when it is needed
Follow-up phone calls are made to patients after office visits
Patients are reminded when they need additional care
-3488
-322
1409
-3962
705
-242
1296
0.159
0.855
0.339
0.002
0.707
0.877
0.406
Care Management Strategies - Theories
• Improves communication across physicians
• Expands an individual physician's repertoire of effective
clinical management strategies
• Anticipating and sometimes avoiding hospitalization when
a moderately ill patient encounters a series of providers in
a single episode of illness
• Forum for physician-nurse communication that may benefit
care
Registries
Clinic registry exists
Registry identifies the regular physician
Registry includes dates of laboratory tests
Registry includes test results
Registry indicates when services are due
Registry prioritizes patients on clinical status
Registry are updated regularly
Registry indicates patients' levels of cardiovascular risk
-1533
-887
-1104
48
-1545
-1727
-76
-2916
0.320
0.561
0.446
0.971
0.247
0.193
0.956
0.019
Information Support
Databases used to identify patients
Database used to systematically monitor labs
EMR - provider entry of data
122
2439
809
0.932
0.038
0.481
Specific QI strategies
Diabetes
Quality of care
RX utilization
Resource use
1891
1429
-2883
0.178
0.293
0.017
Heart disease
Quality of care
RX utilization
Resource use
-660
3059
-3228
0.659
0.029
0.014
Depression
Quality of care
RX utilization
Resource use
-391
2962
-3037
0.863
0.038
0.144
“Clinical Economics”
• Estimates of cost impacts associated with the use of
specific office systems and improvement strategies in
medical group practices
• Physician meetings, “smart registries,” resource and
pharmacy-based strategies
• Mechanisms by which these office systems and QI
strategies affect costs of care and the relationship of costs
to clinical outcomes of patients deserve further investigation