Measure of the Month: Low Back Pain

This week, the KHC launched a project dedicated to healthcare affordability, in partnership with NRHI. The movement, called Affordable Care Together, is focused on health, price, and waste — the three drivers of affordable healthcare.

The KHC has long been a trusted partner in reporting healthcare quality performance data. But you can’t address quality without also looking at value. For the Measure of the Month in September, we are highlighting a measure of healthcare waste – Use of Imaging Studies for Low Back Pain.

Low back pain is among the most common causes of disability and lost productivity in the United States, and more than 80% of the population will experience low back pain in their lifetime. However, low back pain is usually not caused by something very serious. A very common cause of low back pain is strain of the muscles and ligaments. This type of low back pain is very common and usually gets better within a few days to a few weeks. Most people with low back pain don’t need to have imaging tests or visit a specialist, nor do they usually need surgery.

What is recommended care for Low Back Pain?

People 18-50 with low back pain should not receive an imaging study (an X-ray, CT scan, or MRI) within the first 28 days unless a “red flag,” which refers to a serious symptom or physical exam finding, is detected by their doctor. Here are some reasons why doctors are discouraged from recommending an imaging test too early in the process of your evaluation.

Imaging tests have some risks. X-rays and CT scans expose your body to radiation. Over time, repeated exposure to radiation may increase your chance of getting cancer. Having an X-ray series of your lower back gives you about as much radiation exposure as 65 chest X-rays. Having a CT scan of your lower back gives you about as much radiation exposure as 165 chest X-rays. Since MRIs use magnets rather than X-rays, there is no risk from radiation. However, having metal objects or implants in your body (such as pacemakers, artificial joints, screws, stents, plates or staples) can be a serious risk and interfere with the test.

For most cases of low back pain, an imaging test doesn’t give doctors much information that’s useful for diagnosis or treatment, because strain on muscles and ligaments do not show up on these tests.

Medical research shows people with low back pain who get imaging tests do not recover any better or faster than those who do not receive them.

Having an imaging test can lead to more care than you need — and expose you to more risks. Many things that show up on imaging tests are not serious and may not be the cause of your pain. However, once these things have been seen on a scan, there is a tendency to want to do something about it. Often, this results in more tests or procedures that can be harmful, such as back surgery.

How do we compare nationally?

The KHC has tracked the Use of Imaging Studies for Low Back Pain since 2007. Kentuckiana and Kentucky has not seen much improvement in appropriate testing for low back pain, and our region continues to lag behind nationally in its performance on this measure. In 2016, 55% percent of patients in the Kentuckiana region received appropriate testing, and just 51% percent of patients throughout the Commonwealth received appropriate testing, compared to national rates of 71% to 74%.

This data perhaps illuminates a gap in care for Kentucky and Southern Indiana patients that can be explored as part of Affordable Care Together.

Measure of the Month: HPV Immunization

Beginning in 2017, immunization against human papilloma virus (HPV), a sexually transmitted virus that causes cervical cancer, was added to the Immunizations for Adolescents HEDIS measure that is tracked in KHC’s annual Consolidated Measurement Reports. Earlier this month, the American Cancer Society (ACS) launched a campaign to increase the HPV vaccination rate for 13-year-olds to 80% by 2026, making this a good time to highlight HPV vaccination in our Measure of the Month series.

ABOUT THE MEASURE

Immunizations for Adolescents includes three types of vaccines:

  1. Meningococcal meningitis
  2. Tetanus, diptheria, acellular pertussis (TDAP/TD)
  3. Human papilloma virus (HPV)

Traditionally, just meningococcal and TDAP/TD were included in the combination for immunization, but beginning last year, a second combination was created that added HPV. Health plans began monitoring the vaccination rates for performance in 2016.

According to measure specifications, children should complete the HPV vaccine series by their 13th birthday. According to the ACS, the vaccine is most effective when given at ages 11 or 12 but can be administered to individuals up to age 26.

The KHC community reports with 2016 data has not yet been released, but the community averages for HPV vaccination have been calculated and will be included on that report when it is released. In Kentuckiana, the HPV vaccination rate in 2016 was 16.7%. In Kentucky, the rate was 14.1%. National rates of vaccination range from 13.9% for PPO plans to 22.7% for Medicaid (see chart below).

WHY IT’S IMPORTANT

According to CDC data, Kentucky has the highest rate of HPV-related cancers in the country.

Kentucky historically has lagged in HPV vaccination rates compared national rates. And that lack of vaccination has translated into poorer outcomes. Although best known for causing cervical cancer, HPV can cause a variety of cancers, including oral cancer, vaginal cancer, and penile cancer. According to the CDC, Kentucky has the highest rate of HPV-related cancers in the country (see graph on the right).

But if vaccinated appropriately, individuals are protected from HPV. ACS has identified five strategies to drive its “Mission: HPV Cancer Free” campaign:

  1. Strengthen provider recommendations
  2. Activate partners and stakeholders
  3. Know the data and track progress
  4. Implement evidence-based interventions and systems changes
  5. Increase parental knowledge

According to a survey of parents and providers, parents rate the HPV vaccine as more important than clinicians think they do, on a scale of 0 (not important) to 10 (extremely important).

One of the interesting things the ACS has highlighted in its campaign materials is that strong provider recommendation is key to vaccination, but parents cite lack of provider recommendation as one of the reasons that they don’t initiate HPV vaccination. According to data, parents value the HPV vaccination as highly as they do other adolescent vaccinations, but providers’ estimation of how highly parents value the vaccine is much lower (see graph BELOW/RIGHT/LEFT). The perceived and real concerns of parents influence how clinicians recommend and administer the HPV vaccine.

RESOURCES

For more information on the Immunizations for Adolescents measure, including HPV, visit the National Committee for Quality Assurance website here.

Additionally, find more resources about HPV vaccination from ACS website. Specifically, for Kentucky providers, a recording of a webinar that outlines strategies can be found here.

Measure of the Month: Colorectal Cancer Screening

Colorectal cancer (CRC) is the third leading cause of cancer death in the United States, but 60% of these deaths could be avoided if everyone 50 years or older had regular screening tests. In Kentucky, less than half of individuals over the age of 50 are getting screened with only slightly better scores in Kentuckiana with 56% getting the right screening. That translates into higher-than-national-average incidence and mortality rates in the Commonwealth. Kentucky leads the nation in CRC prevalence and is fourth in the nation for CRC deaths, according to the Centers for Disease Control (CDC) data.

About 44 percent of people in Kentuckiana were not properly screened for colorectal cancer in 2015.

Since 2007, the KHC has measured appropriate colorectal cancer screening in Kentuckiana and Kentucky. While we’ve seen gains in screening (from 42% to 56% in Kentuckiana between 2007 and 2015), we still lag behind national levels, and it continues to be an area of focus throughout the Commonwealth.

There are a few ways that an individual can get screened for colorectal cancer. The traditional way is through a colonoscopy, which is done every 10 years, starting at age 50. But there are other – less intensive – methods that can also qualify as appropriate screening, depending on various factors. A flexible sigmoidoscopy, where a narrow tube with a camera is used to look inside the rectum and lower colon, can be done up to four years prior to the measurement year to satisfy screening requirements. Alternatively, a fecal occult blood test (FOBT) test, a test on a stool sample, qualifies if done during the measurement year.

Of course, the appropriate screening method will vary depending on various risk factors, including family history, previous diagnoses, and history of pre-cancerous polyps. It is important to speak to your physician about which method is best for you.

As a partner on the Kentucky Department for Public Health’s Organized Approaches to Increase CRC grant, the KHC distributes annual individual provider and group practice reports throughout the Commonwealth of Kentucky on CRC screening rates. We are also working with our network of local employers to provide resources for improving CRC screening rates. A KHC Colorectal Cancer Screening Resource for Employers webpage on the KHC website provides businesses with tools to improve their CRC screening rates.

Measure of the Month: Statin Therapy

February is American Heart Month, a time when individuals are reminded to focus on their heart health. February 2 was National Wear Red Day, when you probably saw many people wearing red to raise awareness about cardiovascular disease (CVD), the leading cause of death in the United States.

The Kentuckiana Health Collaborative added two measures to 2017 reporting to reflect the importance of caring for the heart – Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes. These measures replaced Persistence of Beta-Blocker Treatment after a Heart Attack, which KHC Measurement Strategy Team members decided to discontinue because of low volume of data.

Statin Therapy for Patients with Cardiovascular Disease. This measures the proportion of patients with a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD) who were given a statin medication to lower LDL cholesterol. There are two rates reported for this measure – whether the individual was dispensed a high- or moderate-intensity statin medication, and whether the individual remained on that statin medication for at least 80 percent of the treatment period. Men at least 21 years old with ASCVD and women at least 40 years old with ASCVD are encouraged to take a statin medication.

Statin Therapy for Patients with Diabetes. This measure looks at statin medication for patients with diabetes that do not have cardiovascular disease. Individuals with diabetes are at a higher risk for developing cardiovascular disease, thought to be due in part to elevations in unhealthy cholesterol levels. The main difference between this measure and the measure above is the intensity of the statin dispensed. While the CVD measure looks for high- or moderate-intensity statin medication, diabetes patients can be dispensed a statin of any intensity and still meet the criteria for the measure.

For more information on Statin Therapy for CVD or Statin Therapy for Diabetes, along with information about hundreds of other measures, you can go to the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse website.

Measure of the Month: Substance Use Treatment

This year, the KHC added a few new measures to our annual quality reports. One of the most heavily discussed was the Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET). IET is used to identify the percentage of people with a new diagnosis of alcohol or other drug dependence who initiate treatment and ultimately follow up with two more related services after the initial treatment.

The IET measure was identified as a candidate for inclusion after KHC developed a focus on behavioral health issues, including being involved in opioid dependence projects and the integration of mental and physical health. Behavioral healthcare quality measurement isn’t as established as some others, like preventive or pediatric care, which limits the options for what the KHC could select.

More specifically, IET measures the percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two age range rates are reported.

  1. Percentage of patients who initiated treatment within 14 days of the diagnosis.
  2. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.

The diagnosis of individuals with dependence disorders is a first step in the process of care, but too often, that diagnosis does not lead to some sort of treatment. This measure looks at the treatment piece of that process.

Nationally, the rate of those who initiated treatment within 14 days of diagnosis (either through inpatient admission, outpatient visit, intensive outpatient encounter, or partial hospitalization) is 34-41 percent. For follow-up with additional services in the two weeks following the initial treatment, the national rate is 11-13 percent for commercially-insured individuals and about 3.5 percent for individuals with Medicaid. When KHC’s next quality reports come out in the near future, we can compare Kentuckiana and statewide rates to national ones.

For more information on the IET measure, you can go to the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse website here.

Measure of the Month: Acute Adult Bronchitis

It seems like everyone has been sick in the last couple of weeks, either with common colds, sinus infections, the flu, or bronchitis. But for those of us who have had bronchitis recently, do you know what the proper course of medical treatment is?

Antibiotics are rarely needed to treat bronchitis, since acute bronchitis is almost always caused by a virus and chronic bronchitis requires other therapies. However, a large percentage, 79 percent, of persons in Kentuckiana with bronchitis received unnecessary antibiotics in 2015. Only 21 percent of adults in the Kentuckiana area with bronchitis were not given an antibiotic.

The KHC tracks prescriptions of antibiotics for acute bronchitis because taking antibiotics when they are not needed can be harmful. Each time someone takes an antibiotic, the bacteria that normally live in your body (on the skin, in the intestine, in the mouth and nose, etc.) are more likely to become resistant to antibiotics. Common antibiotics then cannot kill infections caused by these resistant germs.

When bronchitis is caused by a virus or irritation in the air (like cigarette smoke), antibiotic treatment will not help it get better. Since acute bronchitis almost always gets better on its own, it is better to wait and take antibiotics only when they are needed.

To see more information on Kentucky performance in this and other measures, click here.

Measure of the Month: Diabetes

November 14 was World Diabetes Day, so November’s “Measure of the Month” selection is our series of diabetes management measures. One out of ten Kentuckiana residents has Type 2 Diabetes, so it’s an important series of measures in our reporting.

At the KHC, we measure in many different ways the care that patients with diabetes receive, including receiving recommended screening for A1c (average level of blood sugar over the past two to three months), nephropathy, and retinopathy. Diabetes is the number one cause of blindness in Kentucky, and just 49 percent of individuals with diabetes in Kentuckiana receive the recommended retinal eye exam for detecting and monitoring retinopathy.

Looking at the “benchmark” providers in the area (the top performing docs who make up the care for 10 percent of the population for each measure), A1c screening and nephropathy screening rates are 100 percent, compared to region’s total rate of 93 percent and 90 percent for A1c and nephropathy screenings, respectively. Eye exam rates for the benchmark providers are 74 percent.

Diabetes Composite Scores by Kentuckiana County

In Kentuckiana, less than half (44 percent) of patients with diabetes receive all of the above recommended screenings. This is up from 37 percent in 2010, but there is still a long way to go to make sure that all Kentuckiana residents with diabetes get the care that they need. The proportion of patients who receive all recommended screenings varies greatly between the seven counties in Indiana and Kentucky that make up the Kentuckiana region. Rates range from 40% in Oldham County, Kentucky, to 64% in Floyd County, Indiana.

In Kentucky, the focus of the 2017 World Diabetes Day was to engage people with undiagnosed diabetes in schools, congregations, and workplaces by raising awareness, testing, and shepherding them into a local diabetes prevention program.  The National Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program which has been demonstrated to delay or prevent the development of type 2 diabetes among people at high risk. To support this effort, the KHC added information and a link to a user-friendly pre-diabetes screening tool to our public reporting website, www.GoHealthShare.com. Knowing your risk is the first step to proactively treating or preventing diabetes. By answering a handful of simple questions, users can easily determine their risk of developing pre-diabetes.

The Louisville Department of Public Health and Wellness has lead the world diabetes efforts and has distributed a tool kit with a paper screening. The Kentuckiana Regional Planning & Development Agency (KIPDA) Diabetes taskforce aims to support this initiative by hosting an ambitious screening campaign, over the course of the next two months, with the goal of screening 10,000 local residents for diabetes risk. The Louisville Health Advisory Board, a coalition of organizations within the community that works for better health outcomes, plans to do that through various marketing strategies that will raise awareness and result in use of the prediabetes screening tool.

Diabetes Scores – Kentuckiana, Kentucky, and National Averages

Measure of the Month: Breast Cancer Screening

It’s that time of year again, when we see more pink than usual – everywhere from consumer products like cereal boxes to athletes’ gloves and shoes on the football field. October is breast cancer awareness month, a month where special attention is given to breast cancer research and early screening efforts. The pink we see this month is the official color to signal breast cancer awareness. Approximately one in eight women will develop breast cancer in their lifetime, according to the American Cancer Society. Breast cancer is the second most common newly diagnosed cancer and second leading cause of cancer death among women in the US.

There is a special emphasis on appropriate screening and early detection of breast cancer, because when breast cancer is detected early, there are more treatment choices and better chances for survival. The five-year survival rate for women who are diagnosed at Stage 0 or Stage I cancer is nearly 100 percent, while women who aren’t diagnosed until Stage IV only have about 22 percent five-year survival rate.

The most common way to screen for breast cancer is to get a mammogram, an x-ray picture of the inside of the breast. Mammograms are important because they can find about 80 percent of all breast cancers. The KHC has measured proper screening for breast cancer at a community level since 2006. In that time, the Kentuckiana rate of screening has increased slightly from 78 percent to 80 percent.

Breast cancer screening rates vary widely throughout the state. Green indicates Area Development Districts (ADDs) that have rates above the state average. Red ADDs scored below the state average.

Statewide, the average screening rate for breast cancer is 75 percent, slightly above national averages. This translates into a near-average rate of breast cancer mortality – Kentucky ranked 27th in breast cancer mortality in 2014, the last year that data was available. The rates among Kentucky’s Area Development Districts (ADDs) vary widely, however, illustrating the disparities between care in the Commonwealth. Rates range from lows of 61 percent in the eastern part of the state to highs of 81 percent in the western part of the state.

During this month of increased breast awareness, take a moment to evaluate whether you are due for screening. Women ages 50 to 74 should have a mammogram at least every two years.

Measure of the Month: Antidepressant Medication Management

Percentage of patients with a diagnosis of major depression remained on an antidepressant medication for at least 84 days (12 weeks).

This year, the KHC added a new measure to its public reporting website – Antidepressant Medication Management. It is actually made up of two measures that both indicate how well patients stick with depression medication after a new episode of major depression.

This measure is important because depression can be successfully treated by working with a primary care provider and/or a behavioral health provider, and in instances when medication is deemed as appropriate, it is important to for patients to adhere to medication treatment plans. In fact, primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, according to researchers. Often, medication is combined with other treatments, such as talk therapy. Specialized care by a psychiatrist or other mental health professional

Percentage of patients with a diagnosis of major depression who remained on an antidepressant for at least 180 days (6 months).

may be recommended for moderate to severe cases.

There are two rates for this measure: the acute phase, during which remission is induced (staying on the medication at least 84 days), and a continuation phase, during which remission is preserved (staying on the medication at least 180 days).

Nationally, there is a gap between performance in this measure between commercial and Medicaid patients. In Kentucky and Kentuckiana, rates tend to sit between these two national rates. We lag behind national commercial values but are better than national Medicaid measures.

KHC has made mental health the primary focus of its 2018 annual conference and will continue to identify and adopt measures that can drive improved care for patients’ mental health.

Measure of the Month: Immunizations

School has started for most Kentuckiana students, so what better way to kick off our new “Measure of the Month” series than by focusing on an integral part of school preparation: childhood and adolescent immunizations.

“While vaccines are often thought of as something for babies and young children, preteens and teens also need vaccines to stay healthy throughout the school year,” the Centers for Disease Control website advises. “Vaccination protects preteens and teens against serious and potentially life-threatening diseases, including meningitis and cancers caused by HPV infections.”

Two of the healthcare provider quality measures we track through our yearly reporting at the KHC are childhood immunizations and adolescent immunizations. By their second birthday, children should receive 10 vaccinations, and by their thirteenth birthday, they should receive another three vaccinations.

Vaccinations include:

Children:

  • DTap
  • Influenza
  • Polio
  • MMR
  • HiB (H Influenza Type B)
  • Hepatitis B
  • Chicken Pox
  • PCV (Pneumococcal conjugate)
  • Hepatitis A
  • Rotavirus

Adolescents:

  • Meningitis
  • Tdap
  • HPV

The Kentuckiana rate of adolescent immunizations is above national averages.

In Kentuckiana, the adolescent immunization rate of 75% percent for all recommended vaccinations is above the national rates of 65% for PPO plans, 74% for HMO plans and 73% Medicaid rate. This year will be the first year that immunization against HPV, a sexually transmitted virus that causes cervical cancer, is included in the adolescent immunization measure. Kentucky has the 11th highest cervical cancer rate in the country, and according the CDC, they are 33rd in the country for vaccination rate (ages 13-17). There has been an increased emphasis on vaccinating boys against HPV in recent years to help control the spread of HPV.

Over the last four years, when KHC began measuring adolescent immunizations, the rate of total vaccinations has risen slightly from 73% to 75%. It will be interesting to see how the addition of the HPV vaccine affects the rates both locally and nationally.

To see Kentuckiana and Kentucky KHC reports (including specific immunization rates), visit our community measurement page.