Authors from the National Quality Forum discuss development of the next generation of diabetes measures, including those that reflect "the voice of the patient."
Diabetes is the 7th leading cause of death in the United States and afflicts more than 29 mil­lion Americans, often causing major complications, such as heart disease, retinopathy, and chronic kidney dis­ease.1 Existing quality measures have provided an important foundation to help improve diabetes care. Specifically, healthcare performance measures are important tools used to quantify the quality, cost, and efficiency of care pro­vided to patients. Healthcare providers use measurement results to gauge the quality of care that is being provided, determine where improvement efforts are most needed, and monitor whether or not improvement activities are hav­ing the desired effects. The primary goal of healthcare performance mea­surement is to improve the quality of healthcare received by patients and their families, and ultimately, to im­prove health.
To help drive broader health im­provements for people living with dia­betes or prediabetes, the healthcare community needs to address the lack of measures in numerous important areas, such as measures to better as­sess patients’ health outcomes, mea­sures targeted to those with metabolic syndrome, and measures that use various types of clinical and patient-reported information.
NQF MEASURE ENDORSEMENT
The mission of the National Quality Forum (NQF), a nonprofit, nonpartisan, membership-based organization, is to lead national collaboration to improve health and healthcare quality through measurement. One way that NQF fulfills this mission is to endorse performance measures. Measures en­dorsed by NQF undergo a stringent evaluation by multistake­holder committees comprised of clinicians and other experts from hospitals and other healthcare providers, employers, health plans, public agencies, community coalitions, and patients—many of whom use measures on a daily basis to ensure better care. NQF-endorsed measures undergo routine reevaluation to ensure that they are still the best available measures and reflect current scientific knowledge. Because NQF’s endorsement process is rigorous, fully transparent, and powered by multistakeholder consensus, performance measures endorsed by NQF are considered to be those most likely to facilitate achievement of high quality and efficient healthcare for patients and their families.
NQF’S PORTFOLIO OF DIABETES MEASURES
Currently, NQF has a portfolio of 35 endorsed diabetes mea­sures. Many of these measures are among NQF’s longest standing measures, several of which have been endorsed since 2002. Many measures in the portfolio are currently used in various public and/or private accountability and quality improvement programs, including public reporting and pay-for-performance programs administered by CMS.
In an effort to illuminate a path forward for diabetes qual­ity measurement, in 2008, a panel of diabetes and measure­ment experts, convened by NQF, developed a measurement framework for diabetes2 (see FIGURE). This framework reflects the full spectrum of the disease by incorporating 4 trajectories specific to diabetes type and related outcomes and comor­bidities. Key measurement opportunities, portrayed in the framework, include prevention through behavioral and life­style interventions, as well as glycemic, lipid, and blood pres­sure management (phase 1); ongoing management that also incorporates the prevention, screening, diagnosis, and early treatment of complications (phase 2); and management and treatment of complications (phase 3). This framework can be used both to map and assess existing performance measures for diabetes as well as to highlight gaps in measurement. NQF’s Endocrine Standing Committee, which is responsible for evaluating many of the measures in the diabetes portfo­lio, reevaluated this framework in 2014 but made no changes.
NQF’s portfolio of diabetes measures includes at least a few measures for each of the 3 phases in the measurement framework. These include measures focusing on:
• Weight and body mass index (BMI)
• Eye care
• Foot care
• Blood glucose control
• Angiotensin-converting enzyme inhibitor/angiotensin re­ceptor blocker (commonly known as ACEI/ARB) therapy and blood pressure control
• Screening for kidney disease
• Medication adherence
• Hospital admissions for complications
• Rate of lower-extremity amputations
• Per capita resource use for health plans
NQF’s portfolio of diabetes measures now addresses, at least to some extent, several of the issues and gaps in mea­surement identified by the expert panel convened in 2008, including expanding measurement to include hospitals and other care settings and providers, measuring resource use, and updating measures, as needed, when clinical evidence changes. Specifically, many of the measures in the current portfolio assess performance for individual clinicians or groups of clinicians, as well as for health plans, a few as­sess hospital performance, one assesses performance of home health agencies, and a few reflect population health. Two-thirds of the measures assess various processes of care (eg, foot exams, eye care), while the remaining measures as­sess intermediate clinical outcome measures (eg, good and poor glucose control, blood pressure control, and inpatient days with hyperglycemia or hypoglycemia), population-level health outcomes (eg, amputation rate), and resource use.
The portfolio also includes one all-or-none composite measure that assesses the percentage of patients who have their glucose and blood pressure under control, are taking statins, are non-smokers, and take aspirin or anti-platelet medications if they have ischemic vascular disease. Min­nesota Community Measurement (MNCM), the developer of this measure, considers this a patient-centric approach to measurement because individuals with diabetes are more likely to avoid or postpone long-term complications of the disease if they can simultaneously reach target blood glucose and blood pressure, take other appropriate medications, and not smoke. MNCM has recently updated this measure to re­flect the new cholesterol management guidelines released by the American College of Cardiology and the American Heart Association.3
Importantly, 2 of the newest measures in the portfolio, de­veloped under contract to CMS, are some of the first de novo “eMeasures” endorsed by NQF. These measures, which as­sess the number of inpatient hospital days during which the patient is either hyper- or hypoglycemic, are calculated di­rectly from hospital electronic health records (EHRs). Finally, several of the measures in the portfolio, that were developed by the National Committee for Quality Assurance, are spe­cific to patients who, in addition to diabetes, also have seri­ous mental illness—a high-risk subgroup that is of particular interest within the Medicaid and dual-eligible populations.
WE NEED MORE AND BETTER MEASURES
Clearly, however, many of the issues noted in the measure­ment framework (eg, need for consideration of access, psy­chosocial needs, and therapy risk) are not addressed by the measures currently included in NQF’s diabetes portfo­lio. Moreover, the portfolio does not yet include measures based on patient-reported outcomes (eg, patient/family engagement, shared decision-making, etc). Also, although noted as a priority for future measure development by the 2008 expert panel, no new measures of primary prevention of type 2 diabetes have been added to the portfolio.
During its most recent deliberations, the Endocrine Stand­ing Committee identified numerous areas where additional measure development is needed. Some of the most impor­tant gaps identified by the Committee include measures for prediabetes or metabolic syndrome and measures of the oc­currence and severity of hypoglycemia, particularly among the elderly and in the ambulatory setting. The Committee also noted the need for measures that assess change in in­termediate clinical outcomes (eg, glycated hemoglobin or A1C levels) over time and/or across settings of care. Yet, de­velopment of such measures likely will be challenging and, potentially, controversial. For example, decisions regarding threshold levels (eg, what constitutes good control of blood glucose levels) are complicated when there is also a need to provide individualized care, allow for patient involvement and choice in decision making, and address the issue of dia­betes in the likely context of multiple chronic conditions. Likewise, there are methodological challenges in the devel­opment of longitudinal measures—measures that assess care across time—that must be addressed, such as how to attribute outcomes of care to specific providers, which time points should be used in measurement, small sample sizes due to attrition in patient panels over time, etc.
1. CDC. National Diabetes Statistics Report: Estimates of diabetes and its burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014.
2. National Quality Forum. Towards a comprehensive diabetes measure set: value-based episodes of care. Work summary presented at NQF: September 23, 2008; Washington, DC.
3. Stone NJ, Robinson JG, Lichenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline. J Am Coll Cardiol 2014;63(25 PtB):2889-2934. doi:10.10161/jack.2013.11.002
In diabetes, there is a strong measurement base on which to build the next generation of measures. We anticipate that diabetes measures will increasingly reflect the voice of the patient and the vital role of self-management. Fur­ther, as the electronic infrastructure improves, critical data accessible in EHRs and patient devices will be leveraged in measurement. As these gaps are filled, measurement will continue to drive improvement in the lives of people living with diabetes.