Study Examines Threshold for Glycemic Control among Veterans with Diabetes
In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Using VA data, investigators identified 203,302 Veterans with diabetes who received VA care in FY03 or FY04 from 127 facilities. Of the entire cohort, 26.7% (54,351) of the Veterans were on CGR.
Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. While it is possible that the observed difference in rankings between the NCQA measure overall and those receiving CGR may reflect differences in the quality of care provided to Veterans with more complex healthcare issues, it could also reflect patient characteristics among facilities. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
Pogach L, Rajan M, Maney M, Tseng C-L, and Aron D. Hidden complexities in assessment of glycemic outcomes: Are quality rankings aligned with treatment? Diabetes Care October 2010;33(10):2133-39. E-pub July 9, 2010.
This study was funded by HSR&D (IIR 06-091) and through VA/HSR&D’s Diabetes Mellitus Quality Enhancement Research Initiative (DM-QUERI). Drs. Pogach and Aron are the Clinical Coordinators for DM-QUERI.
