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Jeph Herrin, PhD 1,2 Phil Aponte, MD 3 Briget da Graca, JD, MS 3 Greg Stanek, MS 3 Terianne Cowling, BA 3 Cliff Fullerton, MD, MSc 4 Priscilla Hollander,

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Presentation on theme: "Jeph Herrin, PhD 1,2 Phil Aponte, MD 3 Briget da Graca, JD, MS 3 Greg Stanek, MS 3 Terianne Cowling, BA 3 Cliff Fullerton, MD, MSc 4 Priscilla Hollander,"— Presentation transcript:

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2 Jeph Herrin, PhD 1,2 Phil Aponte, MD 3 Briget da Graca, JD, MS 3 Greg Stanek, MS 3 Terianne Cowling, BA 3 Cliff Fullerton, MD, MSc 4 Priscilla Hollander, MD, PhD 3 David J Ballard, MD, MSPH, PhD 3 1. Department of Medicine, Yale University, New Haven CT 2. Health Research and Educational Trust, Chicago IL 3. Institute for Health Care Research and Improvement, Baylor Health Care System, Dallas, TX 4. HealthTexas Provider Network, Baylor Health Care System, Dallas, TX AHRQ grant: R21 HS20696-02

3 Electronic Health Records (EHRs) may :  Improve communication between patient and physician  Provide clinical decision support  Provide registry-type functionality for tracking care  Facilitate physician performance measurement Some or all of these may lead to improved care of patients with chronic conditions. Bodenheimer, T. 2003. “Interventions to Improve Chronic Illness Care: Evaluating Their Effectiveness.” Disease Management 6 (2): 63–71.

4 Evidence is limited:  Evaluations of tailored EHRs  Evaluations of commercial EHRs on a small scale And conflicting  No impact on chronic care  Some impact on chronic care No large studies of commercially available EHRs…

5 …until recently †.  We looked at14,501 diabetes patients at 34 practices  Our outcome was “Optimal Care” (HbA1c≤8 percent; LDL cholesterol < 100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and documented aspirin use in patients 40 years of age)  We found a difference of 9.2% (95% CI: 6.1, 12.3) in the final year between patients exposed to the HER (higher rate of optimal care) and those not exposed to it.  Also improved processes of care (eye exams, foot exams, labs) † Herrin, J., Nicewander D, Fullerton C, Aponte P, Stanek G, Cowling T, Collinsworth A, Fleming NS, Ballard DJ. "The effectiveness of implementing an electronic health record on diabetes care and outcomes." 2012. Health Serv Res 47(4): 1522-1540.

6 Hypothesis: The effect of the EHR on the care and outcomes of diabetes patients was due in part or in entirety to the incorporation of a “Diabetes Management Form” (DMF), a component of the EHR designed to manage the care of diabetes patients.

7 HealthTexas Provider Network (HTPN)  Is the ambulatory care network affiliated with the Baylor Health Care System, a not-for-profit integrated healthcare delivery system serving patients throughout North Texas.  Comprises >100 practices, with 450 physicians, and has >1 million patient encounters annually. The current study incorporates all practices which include physicians specializing in Internal Medicine (IM) or Family Medicine (FM), with EHR implemented prior to Jan 1 2006.

8 HTPN Service Areas in Texas Setting

9 What made this study possible is the contemporaneous collection of data on diabetes patients.  In 2007 HTPN established and began populating a retrospective diabetes prevalence cohort database using the AMA Physician Consortium Adult Diabetes Performance Measure set.  Each cohort was defined by the claims-based algorithm used by the Centers for Medicare and Medicaid Service (CMS)  All patients with ≥2 ambulatory care visits ≥7 days apart with a diabetes-related billing code (CMS National Measurement Specifications Diabetes Quality of Care Measures [2002]: ICD-9-CM Diagnosis Codes 250.xx) during the preceding 12 months were identified from administrative data.

10 All patients who :  Were 40 years or older  Had at least 2 diabetes related visits in 2007  Had no DMF “exposure” in 2007 or prior  Had at least 2 diabetes related visits in 2009 Know: age, sex, insulin usage, number of visits

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12 Key element – last dialogue box

13 Primary Outcome: Optimal Care Bundle  HbA1c≤8 percent  LDL cholesterol < 100 mg/dl  blood pressure < 130/80 mmHg  not smoking; and  documented aspirin use All criteria met = optimal care (yes/no)

14 Secondary Clinical:  HbA1c≤8 percent  LDL < 100 mg/dl  BP < 130/80 mmHg  not smoking  documented aspirin use  Triglycerides < 150  Total cholesterol < 100 Process:  HbA1c checked  Lipids checked  Microalbumin checked  Eye exam done  Foot exam done  Flu vaccine  Smoking status assessed  Smoking cessation

15 Design Considerations:  Not all patients have measurements in both 2007 and 2009  DMF exposure in 2009 might effect outcomes in 2009

16 Naïve Design: Use all available data No DMF DMF Followup 2007 2009 2008 Followup Baseline

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18 All PatientsNever ExposedSome Form Use n(%) P-value N3577 (100.0)1371 (100.0)2206 (100.0) Age Category 0.045 41-50679 (19.0)256 (18.7)423 (19.2) 51-601326 (37.1)476 (34.7)850 (38.5) 61-701300 (36.3)521 (38.0)779 (35.3) 71+272 ( 7.6)118 ( 8.6)154 ( 7.0) Sex 0.185 Male1776 (49.7)700 (51.1)1076 (48.8) Female1801 (50.3)671 (48.9)1130 (51.2) Insulin use 0.836 No2936 (82.1)1123 (81.9)1813 (82.2) Yes641 (17.9)248 (18.1)393 (17.8) Visits in 2007 0.837 192 ( 2.6)34 ( 2.5)58 ( 2.6) 2748 (20.9)302 (22.0)446 (20.2) 3874 (24.4)332 (24.2)542 (24.6) 4712 (19.9)268 (19.5)444 (20.1) 5436 (12.2)160 (11.7)276 (12.5) 6-10636 (17.8)248 (18.1)388 (17.6) 11+79 ( 2.2)27 ( 2.0)52 ( 2.4) HbA1c<=8 0.356 No379 (10.6)137 (10.0)242 (11.0) Yes3198 (89.4)1234 (90.0)1964 (89.0) Perfect Care 0.086 No2562 (71.6)993 (72.4)1569 (71.1) Yes325 ( 9.1)110 ( 8.0)215 ( 9.7) Missing690 (19.3)268 (19.5)422 (19.1)

19 Naïve Results: Unadjusted No Form Use Form Use BaselineFollowupChangeBaselineFollowupChange n/N (%) (% pts)n/N (%) (% pts)P-value* Optimal Care Met110/1103 (10.0)242/1215 (19.9)9.9215/1784 (12.1)468/2017 (23.2)11.2<0.001 Outcomes A1c<81066/1317 (80.9)1081/1347 (80.3)-0.71711/2133 (80.2)1676/2173 (77.1)-3.10.041 LDL good795/1183 (67.2)868/1226 (70.8)3.61329/1906 (69.7)1445/2033 (71.1)1.40.020 BP good455/1361 (33.4)574/1371 (41.9)8.4807/2201 (36.7)1074/2205 (48.7)12<0.001 TRI good667/1232 (54.1)758/1271 (59.6)5.51047/2003 (52.3)1158/2113 (54.8)2.50.024 Cholesterol good1003/1233 (81.3)1058/1271 (83.2)1.91622/2007 (80.8)1780/2113 (84.2)3.40.018 Smoking status170/1284 (13.2)174/1360 (12.8)-0.4270/2099 (12.9)247/2196 (11.2)-1.60.070 Process Aspirin Prescribed740/1371 (54.0)1086/1371 (79.2)25.21252/2206 (56.8)1898/2206 (86.0)29.3<0.001 A1c checked1317/1371 (96.1)1347/1371 (98.2)2.22133/2206 (96.7)2173/2206 (98.5)1.8<0.001 Lipids checked1232/1371 (89.9)1271/1371 (92.7)2.82002/2206 (90.8)2112/2206 (95.7)5<0.001 Microalbumin778/1356 (57.4)879/1360 (64.6)7.31186/2172 (54.6)1643/2192 (75.0)20.4<0.001 Eye Exam351/1371 (25.6)538/1371 (39.2)13.6494/2206 (22.4)1005/2206 (45.6)23.2<0.001 Foot Exam98/1371 ( 7.1)623/1371 (45.4)38.3228/2206 (10.3)1619/2206 (73.4)63.1<0.001 Flu vaccine732/1371 (53.4)801/1371 (58.4)51124/2206 (51.0)1217/2206 (55.2)4.2<0.001 Smoking Assessed1284/1371 (93.7)1360/1371 (99.2)5.52099/2206 (95.1)2196/2206 (99.5)4.4<0.001 Smoking Cessation126/170 (74.1)143/174 (82.2)8.1185/270 (68.5)215/247 (87.0)18.50.002

20 Naïve Results: Adjusted No FormForm UseDifferenceP-value absolute change (%) Optimal Care Met5.926.380.46<0.001 Outcomes A1c<80.150.240.090.519 LDL good1.750.71-1.04<0.001 BP good5.646.520.88<0.001 TRI good2.231.86-0.370.007 Cholesterol good1.591.41-0.17<0.001 Smoking0.00 0.032 Process Aspirin Prescribed16.0216.060.04<0.001 A1c checked0.010.00 <0.001 Lipids checked2.482.09-0.39<0.001 Microalbumin7.639.932.30<0.001 Eye Exam8.6313.164.53<0.001 Foot Exam24.8130.105.29<0.001 Flu vaccine3.051.63-1.42<0.001 Smoking Assessed2.152.850.69<0.001 Smoking Cessation7.199.572.37<0.001

21 Improved Design: Only Patients with both 2007 & 2009 measurements! No DMF DMF Followup 2007 2009 2008 Followup Baseline

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23 Primary Analysis All PatientsControlExposed in 2008 n(%) P-value N2087 (100.0)995 (100.0)1092 (100.0) Age Category 0.214 41-50372 (17.8)177 (17.8)195 (17.9) 51-60764 (36.6)344 (34.6)420 (38.5) 61-70791 (37.9)390 (39.2)401 (36.7) 71+160 ( 7.7)84 ( 8.4)76 ( 7.0) Sex 0.135 Male1013 (48.5)500 (50.3)513 (47.0) Female1074 (51.5)495 (49.7)579 (53.0) Insulin use 0.173 No1744 (83.6)843 (84.7)901 (82.5) Yes343 (16.4)152 (15.3)191 (17.5) Visits in 2007 0.881 132 ( 1.5)14 ( 1.4)18 ( 1.6) 2381 (18.3)191 (19.2)190 (17.4) 3538 (25.8)246 (24.7)292 (26.7) 4450 (21.6)211 (21.2)239 (21.9) 5268 (12.8)128 (12.9)140 (12.8) 6-10376 (18.0)184 (18.5)192 (17.6) 11+42 ( 2.0)21 ( 2.1)21 ( 1.9) HbA1c<=8 0.321 No179 ( 8.6)79 ( 7.9)100 ( 9.2) Yes1908 (91.4)916 (92.1)992 (90.8) Perfect Care 0.320 No1828 (87.6)879 (88.3)949 (86.9) Yes259 (12.4)116 (11.7)143 (13.1) Missing0 ( 0.0)

24 Main Results: Unadjusted No Form Use Form Use BaselineFollowupChangeBaselineFollowupChange n/N (%) (% pts)n/N (%) (% pts)P-value* Optimal Care Met116/995 (11.7)241/995 (24.2)12.6143/1092 (13.1)258/1092 (23.6)10.5<0.001 Outcomes A1c<8854/995 (85.8)845/995 (84.9)-0.9906/1092 (83.0)881/1092 (80.7)-2.30.022 LDL good687/995 (69.0)718/995 (72.2)3.1783/1092 (71.7)796/1092 (72.9)1.20.056 BP good353/995 (35.5)486/995 (48.8)13.4387/1092 (35.4)501/1092 (45.9)10.4<0.001 TRI good580/994 (58.4)620/994 (62.4)4628/1091 (57.6)652/1092 (59.7)2.10.243 Cholesterol good835/995 (83.9)860/995 (86.4)2.5934/1092 (85.5)957/1092 (87.6)2.10.025 Smoking status121/995 (12.2)124/995 (12.5)0.3128/1092 (11.7)112/1092 (10.3)-1.50.206 Process Aspirin Prescribed563/995 (56.6)815/995 (81.9)25.3644/1092 (59.0)950/1092 (87.0)28<0.001 A1c checked995/995 (100.0) 01092/1092 (100.0) 0NA Lipids checked994/995 (99.9) 01091/1092 (99.9)1092/1092 (100.0)0.1NA Microalbumin636/995 (63.9)720/995 (72.4)8.4626/1092 (57.3)824/1092 (75.5)18.1<0.001 Eye Exam309/995 (31.1)452/995 (45.4)14.4274/1092 (25.1)538/1092 (49.3)24.2<0.001 Foot Exam87/995 ( 8.7)562/995 (56.5)47.7143/1092 (13.1)788/1092 (72.2)59.1<0.001 Flu vaccine562/995 (56.5)618/995 (62.1)5.6634/1092 (58.1)645/1092 (59.1)10.006 Smoking Assessed995/995 (100.0) 01092/1092 (100.0) 0NA Smoking Cessation92/121 (76.0)111/124 (89.5)13.591/128 (71.1)94/112 (83.9)12.80.091

25 Main Results: Adjusted No FormForm UseDifferenceP-value absolute change (%) Optimal Care Met 7.156.00-1.15<0.001 Outcomes A1c<8 0.57-0.07-0.640.134 LDL good 1.800.68-1.120.027 BP good 7.535.84-1.69<0.001 TRI good 2.271.16-1.110.309 Cholesterol good 1.311.03-0.280.004 Smoking 0.00 0.213 Process Aspirin Prescribed 14.8515.851.00<0.001 A1c checked NA Lipids checked NA Microalbumin 4.969.834.88<0.001 Eye Exam 7.9313.155.22<0.001 Foot Exam 25.6130.274.66<0.001 Flu vaccine 3.210.53-2.680.007 Smoking Assessed NA Smoking Cessation 8.077.16-0.900.057

26 Observational trial Difficult to disentangle exposure and measurement  sicker patients may be more likely to be measured  sicker patients may be more likely to be “exposed” DMF “exposure” includes no measure of fidelity  DMF may merely be opened and closed  DMF may be used incorrectly Incremental effect on top of EHR effect may be difficult to detect

27 While EHR improved care and outcomes of diabetes patients (prior study), evidence here is that the incremental effect of a Diabetes Management Form is negative or mixed. Definitive inferences may require randomized trial

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