Development and evaluation of a patient-centered quality indicator for the appropriateness of type 2 diabetes management

Abstract

Introduction: Current diabetes quality measures are agnostic to patient clinical complexity and type of treatment required to achieve it. Our objective was to introduce a patient-centered indicator of appropriate diabetes therapy indicator (ADTI), designed for patients with type 2 diabetes, which is based on hemoglobin A1c (HbA1c) but is also contextualized by patient complexity and treatment intensity.

Research design and methods: A draft indicator was iteratively refined by a multidisciplinary Delphi panel using existing quality measures, guidelines, and published literature. ADTI performance was then assessed using OptumLabs Data Warehouse data for 2015. Included adults (n=206 279) with type 2 diabetes were categorized as clinically complex based on comorbidities, then categorized as treated appropriately, overtreated, or undertreated based on a matrix of clinical complexity, HbA1c level, and medications used. Associations between ADTI and emergency department/hospital visits for hypoglycemia and hyperglycemia were assessed by calculating event rates for each treatment intensity subset.

Results: Overall, 7.4% of patients with type 2 diabetes were overtreated and 21.1% were undertreated. Patients with high complexity were more likely to be overtreated (OR 5.60, 95% CI 5.37 to 5.83) and less likely to be undertreated (OR 0.65, 95% CI 0.62 to 0.68) than patients with low complexity. Overtreated patients had higher rates of hypoglycemia than appropriately treated patients (22.0 vs 6.2 per 1000 people/year), whereas undertreated patients had higher rates of hyperglycemia (8.4 vs 1.9 per 1000 people/year).

Conclusions: The ADTI may facilitate timely, patient-centered treatment intensification/deintensification with the goal of achieving safer evidence-based care.

Keywords: diabetes mellitus; health services research; insurance claim review; quality of health care; type 2.

Figure 1

Consensus definition for the appropriate diabetes therapy indicator. (A) Specification of clinical complexity on the basis of patient age during the measurement year and comorbidities ascertained during the year prior to the measurement year. (B) Diabetes treatment regimens that may be suggestive of undertreatment, overtreatment, and appropriate treatment as a function of HbA1c and patient clinical complexity. Medications are classified as increasing the risk of hypoglycemia (sulfonylurea, basal insulin, bolus insulin; ‘hypo-prone’) or not (metformin, sodium-glucose transport protein 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1), dipeptidyl peptidase-4 (DPP4) inhibitors, thiazolidinediones, α-glucosidase inhibitors, meglitinides, amylin analog). Patients treated with multiple daily insulin injections or insulin pump therapy are considered to receive two hypoglycemia-prone medications. CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ED, emergency department; HbA1c, hemoglobin A1c.