Guidelines and Performance Measures for Diabetes

Diabetes mellitus has become a majorpublic health problem in the UnitedStates and around the world. A result ofgenetic predisposition combined withdetrimental changes in lifestyle, type 2diabetes is reaching epidemic proportions.The costs are very high, both interms of financial burden and qualityof life.

A wide variety of healthcare organizationshave developed diabetes guidelines toimprove the quality of care for patients.Increasingly, there is agreement and collaborationon such guidelines, leading tothe next step in quality management,performance measures. There is a growingtrend to find ways to provide incentivesfor improved diabetes care. Initiativessuch as the National Committee forQuality Assurance's physician recognitionprogram, the Bridges to ExcellenceDiabetes Care Link program, the NationalDiabetes Quality Improvement Alliance,and the American Medical AssociationPhysician Consortium for PerformanceImprovement are all helping to establishan incentive for improved diabetes care.

(Am J Manag Care. 2007;13:S41-S46)

Guidelines for diabetes provide recommendations for controlof glycemia as well as blood pressure (BP) and lipidlevels. They are based on evolving evidence and, accordingly,are subject to frequent revision. Guideline goals areto improve quality of care; decrease morbidity, mortality, and costs byreducing complications; improve the quality of life for people with diabetes;and reduce the disease burden on society.

Several disease-specific and specialty-specific professional organizationshave developed diabetes practice guidelines, including theAmerican Diabetes Association (ADA), American Association ofClinical Endocrinologists (AACE)/American College of Endocrinologists(ACE), and the American College of Physicians. Statehealth organizations and large provider organizations or insurers mayalso establish guidelines for treatment. Performance measures based ondiabetes guidelines have been developed by national organizationsconcerned with quality of care, such as the National Committee forQuality Assurance (NCQA) and the Joint Commission on Accreditationof Healthcare Organizations, in an attempt to assess and recognizethe quality of diabetes care being delivered.

Recommendations for Managing Diabetes

A number of recommendations and guidelines for managingpatients with diabetes exist. The focus of recommendations variesdepending on the group issuing them. For example, the NationalCholesterol Education Program provides guidelines for lipid control inpatients with diabetes, which it includes under the category of coronaryheart disease risk equivalent,¹ but does not address other areas ofdiabetes management. The most comprehensive guidelines are thosepublished by the ADA² and AACE/ACE.

Some of the key recommendations for diabetes management aresummarized in Table 1.^1-6 Glycemic, BP, and lipid control are the majorareas of concern for most organizations because of their impact onchronic complications. In general, treatment goals are similar amongall organizations.

Other evaluations recommended for patientswith diabetes include an annual foot examinationand annual tests for diabetic kidney disease (serumcreatinine, blood urea nitrogen, microalbuminuria),retinopathy, and neuropathy. Adult patients shouldreceive at least 1 lifetime pneumococcal vaccineand annual influenza vaccinations. Aspirin therapyshould be used for primary prevention in adults atincreased risk for cardiovascular disease (CVD) andfor secondary prevention in those with a history ofCVD. Smoking cessation counseling and preconceptioncare should be provided as needed.²

Diabetes-related Measurements andPerformance Improvement Initiatives

The NCQA provides an overall assessment ofthe performance of our healthcare system. Its Stateof Health Care Quality 2005 results reported thatfor the sixth straight year, healthcare quality for the65 million Americans enrolled in accountablehealth plans improved substantially acrossalmost all clinical indicators, including poor A1Ccontrol (Figure 1).⁷ On average, healthcare improvedamong all health plans, regardless of payer(ie, private employer, Medicare, or state Medicaidagency), that actively measure and report qualityresults.

Performance has improved considerably over theperiod of time the NCQA has been measuring commonlyaccepted cardiovascular measures. A newanalysis in 2005 showed that those improvementshave saved the lives of 40 000 to 67 000 Americansand prevented many more critical events such assecond heart attacks (Table 2).⁷

Historically, only health maintenance organizationsand point-of-service plans have participatedin accountability activities.⁷ In 2005, for the firsttime, 41 preferred provider organizations (PPOs),covering 27 million Americans, collected somequality data that were reported to the NCQA.⁷Recently, the NCQA has drafted new Health PlanEmployer Data Information Set (HEDIS) measuresfor PPOs in an attempt to expand reporting ofhealthcare outcomes. The NCQA seeks to providePPO performance information to public and privatepurchasers, as well as regulators, who haveexpressed an interest in reviewing such data.Furthermore, several large purchasers have startedto require HEDIS reporting by PPOs. The NCQAplans to begin such reporting in 2007.^7,8

Performance benchmarks developed by differentorganizations can provide important insights intothe quality of care both within individual healthcarepractices and across broader entities, such as insuranceplans or states. With the proliferation of healthmonitoring and accreditation firms, health plansmay be held accountable for their performance inmanaging diabetes, and employers may, in turn, useperformance data to make better-informed decisionswhen purchasing health insurance products.

Diabetes Physician Recognition Program.

In1997, the NCQA and the ADA developed andlaunched the Diabetes Physician RecognitionProgram (DPRP) to help identify physicians providingquality diabetes care. Recognition is contingenton a physician or medical group demonstrating provisionof care consistent with performance measuresbased on practice guidelines for managing diabetes(Table 3).^9,10

The DPRP-recognized physicians and groups arepublicized through health plan provider directoriesand on the NCQA's Web site.¹⁰ Recognized physicians and groups also receive visibility through ADA'sWeb site and the 1-800-DIABETES national callcenter. In 2000, the Web site had more than 1 millionvisitors per month, and the call center had more than500 calls per month seeking referral to a physician.¹⁰

As shown in Figure 2, the DPRP may havealready had a positive effect on patient care.¹¹Among DPRP applicants, the average percentage ofdiabetes patients who had glycosylated hemoglobinlevels of <7% increased from 25% to 46% from 1997to 2003. During the same time period, the percentageof patients with diabetes from DPRP applicantswhose low-density lipoprotein cholesterol met theperformance measure increased from 17% to 45%,and the percentage of patients monitored for kidneydisease increased from 60% to 85%.¹⁰

The Bridges to Excellence Initiative.

Bridges toExcellence is a multistate, multiemployer coalitiondeveloped by employers, physicians, healthcareservice researchers, and other industry experts toidentify and reward quality across the healthcaresystem. Diabetes and BP control are a significantpart of the pay-for-performance quality measurements,because this effort is built around theNCQA's recognition programs.¹²

Diabetes Care Link

Diabetes Care Link

The specific initiative that is part of the Bridgesto Excellence program is called .Physicians who demonstrate they are top performersin diabetes care can earn up to $80 per year for eachperson with diabetes covered by a participatingemployer. To participate, physicians must demonstratethat their performance with diabetes managementis consistent with the standards set by theNCQA/ADA's DPRP. The programoffers employers savings of about $350 perpatient per year. More information can be found athttp://www.bridgestoexcellence.org.^9,12,13

In addition to the National Business Coalitionon Health,¹¹ Bridges to Excellence participantsinclude:

• Employers
• Health plans
• NCQA
• Medstat
• WebMD Health

National Diabetes Quality Improvement Alliance.

The National Diabetes Quality ImprovementAlliance involves 13 national organizations, includingthe ADA, the American Medical Association(AMA), the NCQA, and the National Institute ofDiabetes and Digestive and Kidney Diseases,which have joined together with the common goalof improving diabetes care. The mission of thisalliance is to identify, develop, and promote theuse of a national performance measurement setfor diabetes.¹³

The benchmarks recommended by the Allianceare shown in Table 4.¹⁴ They include measures forquality improvement, which allow healthcare practitionersand health plans to monitor their own performance,and measures for public reporting toprovide information to patients making healthcaredecisions.

Other organizations that promote performanceimprovement in diabetes care include the AMAPhysician Consortium for Performance Improvement,which publishes, along with a data collectionflow sheet, performance measures that are a subsetof those defined by the National Diabetes QualityImprovement Alliance.¹⁵

Although all of these quality initiatives arehelping to establish an incentive for improved diabetescare, the morbidity and mortality from thedisease and the cost of care remain challenging.Because diabetes may lead to long-term complications,investment in measures to achieve betterglycemic control is necessary. Achieving guidelinegoals and performance measures requires an organizedsystem of diabetes care ideally delivered by amultidisciplinary diabetes care team that providesdiabetes education, medical nutrition therapy, andappropriately prescribed physical activity and cliniciancare that will usually involve the use ofantihyperglycemic medications. With advances inmedical research and a better understanding ofthe pathophysiology of diabetes, new and noveltherapies can contribute to this treat-to-targetapproach.

Address correspondence to: Andrew J. Ahmann, MD, MS, Oregon Health & Science University,3181 SW Sam Jackson Park Road, Portland, OR 97239-3098. E-mail: ahmanna@ohsu.edu.

Circulation.

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3. American College of Endocrinology consensus statementon guidelines for glycemic control. 2002;8(suppl 1):5-11.

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4. Snow V, Aronson MD, Hornbake ER, Mottur-Pilson C,Weiss KB; Clinical Efficacy Assessment Subcommittee ofthe American College of Physicians. Lipid control in themanagement of type 2 diabetes mellitus: a clinicalpractice guideline from the American College ofPhysicians. 2004;140:644-649.

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5. Brown AF, Mangione CM, Saliba D, Sarkisian CA;California Healthcare Foundation/American GeriatricsSociety Panel on Improving Care for Elders with Diabetes.Guidelines for improving the care of the older personwith diabetes mellitus. 2003;51(suppl):S265-S280.

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6. Chobanian AV, Bakris GL, Black HR, et al; NationalHeart, Lung, and Blood Institute Joint National Committeeon Prevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure; National High Blood PressureEducation Program Coordinating Committee.TheSeventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment ofHigh Blood Pressure. The JNC 7 report. 2003;289:2560-2572.

7. National Committee for Quality Assurance. 2005 Stateof Health Care Quality. Industry trends and analysis.Washington, DC: National Committee for QualityAssurance; 2005. Available at: http://web.ncqa.org.Accessed June 21, 2006.

8. National Committee for Quality Assurance. Publiccomment for the development of PPO HEDIS technicalspecifications. June 14, 2006. Washington, DC: NationalCommittee for Quality Assurance; 2006. Available at:http://web.ncqa.org. Accessed June 21, 2006.

9. National Committee for Quality Assurance. 2004 Stateof health care quality: industry trends and analysis.Available at: http://web.ncqa.org. Accessed June 21,2006.

10. National Committee for Quality Assurance, AmericanDiabetes Association. Diabetes Physician RecognitionProgram (DPRP). Available at: www.ncqa.org/dprp.Accessed July 31, 2006.

11. National Committee for Quality Assurance Web site.Available at: http//www.ncqa.org. Accessed November30, 2006.

12. Bridges to Excellence. Rewarding quality across thehealthcare system. 2006. Available at: http://www.bridgestoexcellence.org. Accessed November 30, 2006.

13. National Diabetes Quality Improvement Alliance.Available at: www.nationaldiabetesalliance.org.Accessed November 30, 2006.

14. National Diabetes Quality Improvement Alliance.Performance measurement set for adult diabetes.Approved January 21, 2005. Available at: http://www.nationaldiabetesalliance.org/measures.html. AccessedNovember 30, 2006.

15. Physician Consortium for Performance Improvement.Clinical performance measures: adult diabetes. Toolsdeveloped by physicians for physicians. Available at:http://www.ama-assn.org/ama1/pub/upload/mm/370/diabetesset.pdf. Accessed November 30, 2006.

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