PMC Measure Review Diabetes v8FINAL Website

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Performance Measurement

Management of Diabetes: Review of the Performance Measures by the Performance Measurement Committee of the American College of Physicians

Writing Committee

Amir Qaseem, MD, David Baker, MD, Mary Ann Forciea, MD, Eve Kerr, MD, Kesavan Kutty, MD,

Sarah West, MSN, RN

ACP Performance Measurement Committee Members*

David W. Baker, MD, MPH (Chair); J. Thomas Cross, MD, MPH; Andrew Dunn, MD, MPH; Mary

Ann Forciea, MD; Robert A. Gluckman, MD; Robert H. Hopkins, MD; Eve Kerr, MD; Kesavan Kutty, MD; Ana Maria López, MD, MPH; Catherine MacLean, MD, PhD; Stephen D. Persell, MD,

MPH; Terrence Shaneyfelt, MD Corresponding author: A. Qaseem 190 N. Independence Mall West Philadelphia, PA 19106 Email [email protected] * Individuals who served on the Performance Measurement Committee from initiation of the project until its approval

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Introduction Diabetes is major medical and public health issue in the United States. Some 29.1 million American adults (9.3% of the population) are diabetic (1). In 2012, diabetes accounted for an estimated $176 billion in direct medical costs and an additional $69 billion in lost wages, disability, premature death, and other indirect costs (2). Evidence shows that there is a quality gap between clinical guidelines and practice. One survey of practicing internists found that patients’ HbA1c levels were at goal only 65% of the time and adequate control of hypertension among diabetic patients was achieved only 37% of the time (3). Performance measure reporting from the National Committee for Quality Assurance’s (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) also shows room for improvement (4). In 2013, rates of adequate HbA1c control (<8%) reported in HEDIS ranged from 72% to 87% (5). The ACP Performance Measurement Committee (PMC) reviewed performance measures related to the management of diabetes to assess whether the measures are evidence-based, methodologically sound, and clinically meaningful. Methods We performed a search to identify relevant performance measures from the National Quality Forum (NQF), the American Medical Association-Physician Consortium for Performance Improvement (AMA-PCPI), and National Quality Measures Clearinghouse (NQMC) websites. The inclusion criteria were performance measures currently used in the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) or currently used in the CMS Electronic Record Incentive program. The PMC identified and reviewed 8 performance measures. Conclusion

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Recommendation ACP Supports NQF 0055: “Comprehensive Diabetes Care: Eye Exam (Retinal) Performed.” Rationale The current evidence supports the benefit of regularly performed vision examinations in reducing vision complications in diabetic adults (6-7). Although we support this measure, we suggest that the specifications include all patients over the age of 18 years, as long as for older patients the level of risk for retinopathy is specified. The current American Geriatrics Society guidelines support biennial screening for all adults, including over 75 years of age who are at risk for retinopathy (8). Patients with late onset diabetes who maintain good control are extremely unlikely to get retinopathy in their lifetimes. The frequency of vision exam should be based on clinical risk. Additionally, there is potential for overuse if a physician cannot obtain confirmation of a previous eye exam during the calendar year. Measure Specifications NQF 0055: Comprehensive Diabetes Care: Eye Exam (Retinal) Performed Status: NQF Endorsed, Updated September 2, 2014 (2015 PQRS Measure #117) Measure Steward:

National Committee for Quality Assurance

Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.

Numerator Statement:

Patients who received an eye screening for diabetic retinal disease. This includes people with diabetes who had the following: - A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year OR - A negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. For exams performed in the year prior to the measurement year, a result must be available.

Denominator Statement:

Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.

Exclusions (optional):

Exclude patients who did not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year. AND Exclude patients who meet either of the following criteria: -A diagnosis of polycystic ovaries, in any setting, any time in the patient’s history through December 31 of the measurement year. -A diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year

Type of Measure:

Process

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Level of Analysis:

Clinician: Group/Practice, Clinician: Individual, Health Plan, Integrated Delivery System

Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data: Pharmacy, Paper Medical

Records Recommendation ACP does not support NQF 0056: “Diabetes: Foot Exam.” Rationale Although we recognize the value of foot exams in diabetic patients, particularly visual inspection and sensory exam, there is no good evidence that patient outcomes are affected by regularly performed pulse exams, especially for asymptomatic patients. Therefore, we do not support this measure because it calls for all three elements in the foot exam. There is no evidence evaluating the benefit of pulse exam on patient outcomes (e.g., downstream ulceration) and the routine screening in asymptomatic patients could lead to overuse of Arterial Brachial Index (ABI) and procedures for peripheral arterial disease that may not be beneficial. Instead, there should be a focus on addressing vascular risk in all patients with an emphasis on statin treatment, blood pressure control and smoking cessation. Measure Specifications NQF 0056: Diabetes: Foot Exam Status: NQF Endorsed, Updated September 02, 2014 (2015 PQRS Measure #163) Measure Steward:


Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection with either a sensory exam with mono filament and a pulse exam) during the measurement year


Patients who received a foot exam (visual inspection and sensory exam with monofilament and a pulse exam) during the measurement year


Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year

Exclusions: A diagnosis of gestational or steroid-induced diabetes Type of Measure:

Process

Level of Analysis: Clinician: Group/Practice, Clinician: Individual Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data:

Pharmacy, Paper Medical Records

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Recommendation ACP supports NQF 0059 with modifications: “Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9%).” Rationale Although ACP supports this measure with modifications, the specifications should include all patients over the age of 18 years. The current American Geriatrics Society guideline recommends avoidance of poor glycemic control for adults beyond 75 years of age (8), particularly if poor control can lead to symptoms. However, regardless of expansion in age, the specifications of the current measures should exclude patients with dementia and patients with life limiting diagnoses (receiving hospice and palliative care) where the intervention has the potential to cause more harms than benefits. Measure Specifications NQF 0059: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9%) Status: NQF Endorsed, Updated September 02, 2014 (2015 PQRS Measure #1) Measure Steward:


Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year


Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year. The outcome is an out of range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment of this intermediate outcome measure.



Exclusions (Optional):

Exclude patients who did not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year. AND Exclude patients who meet either of the following criteria: -A diagnosis of polycystic ovaries, in any setting, during the measurement year or the year prior to the measurement year. -A diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.

Type of Measure:

Outcome

Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Health Plan, Integrated Delivery System, Population: National, Population: Regional, Population:

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State Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data: Pharmacy, Electronic Clinical

Data: Laboratory, Paper Medical Records Recommendation ACP supports NQF 0062: “Comprehensive Diabetes Care: Medical Attention for Nephropathy.” Rationale ACP supports this measure. We suggest however, that when this measure is revised, the specifications of the current measure exclude patients with dementia and patients with life limiting diagnoses (receiving hospice and palliative care) where the intervention has the potential to cause more harms than benefits. Measure Specifications NQF 0062: Comprehensive Diabetes Care: Medical Attention for Nephropathy Status: NQF Endorsed, Updated September 02, 2014 (2015 PQRS Measure #119) Measure Steward:


Description: The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a nephropathy screening test or had evidence of nephropathy during the measurement year


Patients who received a nephropathy screening test or had evidence of nephropathy during the measurement year



Exclusions: None Type of Measure:

Process

Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Health Plan, Integrated Delivery System

Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data: Laboratory, Pharmacy,

Paper Medical Records

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Recommendation ACP does not support NQF 0416: “Diabetic Foot & Ankle Care, Ulcer Prevention – Evaluation of Footwear.” Rationale Although we recognize the value of proper footwear in diabetic patients, there is no current evidence showing that evaluation of proper footwear in primary care leads to improvement in outcomes. This may be an appropriate measure for podiatrists although, supporting documentation provided with the measure demonstrates there is already a 93% provider (podiatrist) compliance rate with measure interventions (9). Measure Specifications NQF 0416: Diabetic Foot & Ankle Care, Ulcer Prevention – Evaluation of Footwear Status: NQF Endorsed , Updated December 30, 2014 (2015 PQRS Measure #127) Measure Steward:

American Podiatric Medical Association

Description: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.


Patients who were evaluated for proper footwear and sizing at least once within 12 months Definition: Evaluation for proper footwear includes a foot examination documenting the vascular, neurological, dermatological and structural/biomechanical findings. The foot should be measured using a standard measuring device and counseling on appropriate footwear should be based on risk categorization. Numerator Quality-Data Coding Options for Reporting Satisfactorily: G8410: Footwear evaluation performed and documented OR Footwear Evaluation Not Performed OR G8415: Footwear Evaluation was not performed


All patients aged 18 years and older with a diagnosis of diabetes mellitus

Exclusions: Footwear evaluation not performed for documented reasons. For example bilateral amputee.

Type of Measure:

Process

Level of Analysis: Clinician: Individual Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data: Electronic Health Record,

Paper Medical Records

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Recommendation ACP does not support NQF 0417: “Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation.” Rationale In 2010, the Centers for Disease Control and Prevention (CDC) reported a moderate performance gap with the foot exam in adults with diabetes [75% of all adults between ages 65-74, 73% of adults between ages 45-64, and 71.5% of adults over age 75 (10)]. Although we recognize the value of foot exams in diabetic patients, there is no evidence to suggest that regular, comprehensive full lower extremity neurological examination in the primary care setting benefits asymptomatic patients. However, foot exams with a mono filament should be performed. Measure Specifications NQF 0417: Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation Status: NQF Endorsed, Updated December 30, 2014 (2015 PQRS Measure #126) Measure Steward:

American Podiatric Medical Association

Description: Percentage of patients, 18 years or older, with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.


Patients who had a lower extremity neurological exam performed at least once within 12 months Definition: Lower Extremity Neurological Exam-Consists of a documented evaluation of motor and sensory abilities and should include: 10-g monofilament plus testing any one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold), however the clinician should perform all necessary tests to make the proper evaluation. Numerator Quality-Data Coding Options for Reporting Satisfactorily: G8410: Footwear evaluation performed and documented OR Footwear Evaluation Not Performed OR G8415: Footwear Evaluation was not performed


All patients aged18 years and older with a diagnosis of diabetes mellitus

Exclusions: Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure, for example patient bilateral amputee, patient has condition that would not allow them to accurately respond to a neurological exam (dementia, Alzheimer’s, etc.), patient has previously documented diabetic peripheral neuropathy with loss of

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protective sensation. Type of Measure:

Process

Level of Analysis: Clinician: Individual Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data:

Electronic Health Record, Paper Medical Records Recommendation ACP does not support NQF 0575: “Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%).” Rationale The current evidence shows that although lower blood glucose levels improves patient outcomes, the harms of hypoglycemia are also important and should be considered (7, 11). In addition, independent patient variables (such as diet, ability to pay for medications, medication compliance, and patient preference) make it difficult for physicians to have complete control over HbA1c levels (11). Additionally, for this measure, the denominator exclusions are imprecise and could promote over treatment, particularly for those at high risk of hypoglycemia (patients with dementia and chronic kidney disease, among others). Denominator exclusions should specifically include: 1) patients with dementia, 2) patients with chronic kidney disease and 3) patients with limited life expectancy where the interventions have the potential to cause more harms than benefit. Measure Specifications NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%) Status: NQF Endorsed, Updated September 02, 2014 (Not a PQRS Measure) Measure Steward:


Description: The percentage of members 18 - 75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year


Patients whose most recent HbA1c level is less than 8.0% during the measurement year. The outcome is a result of an HbA1c test, indicating desirable control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome.



Exclusions (Optional):

Exclusions: -Exclude patients who did not have a diagnosis of diabetes, in any setting, during the measurement year or the year prior to the measurement year.

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AND -Exclude patients who meet either of the following criteria: -A diagnosis of polycystic ovaries, in any setting, any time in the patient’s history through December 31 of the measurement year. -A diagnosis of gestational or steroid-induced diabetes, in any setting, during the measurement year or prior to the measurement year.

Type of Measure:

Outcome

Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Health Plan, Integrated Delivery System

Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data:

Laboratory, Electronic Clinical Data: Pharmacy, Paper Medical Records Recommendation ACP is awaiting this measure to complete the NQF review and endorsement process Rationale Measure Specifications NQF 0729: Optimal Diabetes Care (Composite Measure) Status: NQF Endorsed Measure Steward:

MN Community Measurement

Description: The percentage of adult diabetes patients who have optimally managed modifiable risk factors (A1c, LDL, blood pressure, tobacco non-use and daily aspirin usage for patients with diagnosis of ischemic vascular disease) with the intent of preventing or reducing future complications associated with poorly managed diabetes Patients ages 18 - 75 with a diagnosis of diabetes, who meet all the numerator targets of this composite measure: A1c < 8.0, LDL < 100, Blood Pressure < 140/90, Tobacco non-user and for patients with diagnosis of ischemic vascular disease, daily aspirin use unless contraindicated Please note that while the all-or-none composite measure is considered to be the gold standard, reflecting best patient outcomes, the individual components may be measured as well. This is particularly helpful in quality improvement efforts to better understand where opportunities exist in moving the patients toward achieving all of the desired outcomes. Please refer to the additional numerator logic provided for each component.


Patients ages 18 to 75 with diabetes who meet all of the following targets

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from the most recent visit during the measurement year:

A1c less than 8.0, LDL less than 100, Blood Pressure less than 140/90, Tobacco non-user and Daily aspirin for patients with diagnosis of ischemic vascular disease use unless contraindicated


Patients ages 18 to 75 with diabetes who have at least two visits for this diagnosis in the last two years (established patient) with at least one visit in the last 12 months

Exclusions: Valid exclusions include patients who only had one visit to the clinic with diabetes codes during the last two years, patients who were pregnant, died or were in hospice or a permanent resident of a nursing home during the measurement year.

Type of Measure:

Composite

Level of Analysis: Clinician: Group/Practice, Integrated Delivery System Care Setting: Ambulatory Care: Clinician Office/Clinic Data Source: Electronic Clinical Data, Electronic Clinical Data: Electronic Health Record,

Electronic Clinical Data: Registry, Paper Medical Records Gaps in Performance Measurement — Opportunities to Promote High-Value Care PMC believes that there is a need for performance measures that focus on individualized care of patients with diabetes.

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References

1. US Department of Health and Human Services. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2014. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Accessed July 17, 2014.

2. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012.

Diabetes Care. 2013; 36(4):1033-1046.

3. Lynn L, Hess BJ, Weng W, et al. Gaps in quality of diabetes care in internal medicine residency Clinics suggest the need for better ambulatory care training. Health Affairs. 2012; 31(1):150-158.

4. National Center for Quality Assurance. Comprehensive diabetes care.

http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2014TableofContents/DiabetesCare.aspx. Accessed January 26, 2015)

5. National Committee for Quality Assurance. Performance measure specifications for National Quality Forum-Endorsed Performance Measure 0575 (Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)). National Quality Forum Web Site http://www.qualityforum.org/Qps/QpsTool.aspx. Accessed July 17, 2014.

6. American Diabetes Association. Microvascular complications and foot Care. Diabetes Care: The Journal of Clinical and Applied Research and Education. 2015; 38(1): 58-66.

7. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists. Medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocrine Practice. 2011; 17(2): 1-53.

8. American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes Mellitus. Guidelines Abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. 2013; 61:2020-2026.

9. American Podiatric Medical Association. Diabetic foot & ankle care: ulcer prevention-evaluation of footwear, peripheral neuropathy-neurological evaluation. 2012 Measure Testing Project.

10. Centers for Disease Control and Prevention (CDC). CDC’s Diabetes Program-Data and Trends-Prevalence of Diabetes-Percent of Foot Exam in the Last Year for Adults Aged =18 Years, by Age. 2012. Retrieved from: http://www.cdc.gov/diabetes/statistics/preventive/tNewFtChkAgeTot.htm.

http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2014TableofContents/DiabetesCare.aspx

http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2014TableofContents/DiabetesCare.aspx

http://www.qualityforum.org/Qps/QpsTool.aspx

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11. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2013; 36: 11-66.

Financial Statement: Financial support for the Performance Measurement Committee comes exclusively from the ACP operating budget. Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of conflicts of interest is kept for each PMC meeting and conference call and can be viewed at: http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.htm APPROVED BY THE ACP BOARD OF REGENTS ON: April 27, 2015 Members of the PMC: Individuals who served on the Performance Measurement Committee from initiation of the project until its approval: David W. Baker, MD, MPH J. Thomas Cross, Jr., MD, MPH Andrew Dunn, MD, MPH Mary Ann Forciea, MD Robert A. Gluckman, MD Robert H. Hopkins, MD Kesavan Kutty, MD Eve Askanas Kerr, MD, MPH Ana María López, MD, MPH Catherine MacLean, MD, PhD Stephen D. Persell, MD, MPH Terrence Shaneyfelt, MD, MPH Requests and inquiries: Amir Qaseem, MD, PhD, MHA, FACP, American College of Physicians, 190. N Independence Mall West, Philadelphia, PA 19106: email, [email protected]

http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.htm

http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.htm

mailto:[email protected]

Documents

PMC Measure Review Diabetes v8FINAL Website