Physicians help achieve quality diabetes care
Physician-level quality measurement stressed
A program cosponsored by the Washington, DC-based National Committee for Quality Assurance (NCQA) and the American Diabetes Association (ADA) in Alexandria, VA, has placed a strong emphasis on physician-level quality measurement and reporting for diabetes treatment. The initiative, called the Diabetes Physician Recognition Program (DPRP), recognizes physicians who deliver superior diabetes care and appears to have had an impact on improving quality of care.
The program was initiated in 1997, and through the end of 2001, more than 1,500 physicians have achieved recognition, impacting care to an estimated 500,000 patients with diabetes. Aggregate performance results indicate that DPRP-recognized physicians provide quality care and have improved care delivery between 1997 and 2001:
The average rate of diabetes patients who had Hemoglobin A1c (HbA1c) levels of less than 8% increased from 50% to 70%, an indication that more adults with diabetes are maintaining proper HbA1c control. HbA1c is a measure of average blood sugar over the previous three months.
The rate of diabetes patients who had properly controlled low-density lipoprotein (LDL) cholesterol gained 35 percentage points (37% to 72%).
The rate of diabetes patients monitored for kidney disease rose from 60% to 84%.
"We felt it would be useful to create a program whereby providers who provide what we think is superior care get recognition," explains Nathaniel Clark, MD, MS, RD, vice president for clinical affairs for the ADA. "They are listed on our web site and receive a certificate to hang on their wall. When anybody contacts us and asks for advice on who to see, these physicians would be preferentially recognized and referred."
Initially, clinical practice guidelines were developed based on available clinical evidence. "In the past two or three years, that process has become much more rigorous, so that now when we make recommendations, we specify what level of evidence exists," Clark explains. The guidelines are updated every year.
Another significant change occurred with the establishment of the Diabetes Quality Improvement Project (DQIP), which began as a coalition of the ADA; NCQA; the Centers for Medicare & Medicaid Services; the American College of Family Physicians; the American College of Physicians, American Society of Internal Medicine; Foundation for Accountability; and the Veterans Health Administration, but which now represents more than 30 national organizations. The DQIP has its own set of measures; the DPRP’s are consistent with those measures but go beyond DQIP by applying performance criteria to each measure. (See chart, below.)
There is a fine distinction between measures and guidelines, Clark explains. "The purpose of a measure is to determine for a population what percentage are, in theory, doing well or are not doing well," he notes. "A guideline is a statement of what the ideal is."
For example, says Clark, the measure that is used in this country for hemoglobin A1c is how much of the population is above 9.5% and how much below. "The guideline is that a patient’s hemoglobin A1c should be less than 7%."
The reason this distinction is so important, he notes, is that if you chose that same 7% as a measure, most of the population would not meet the measure. "It’s too strict," Clark explains. "Most people think the average A1c is about 8.5%, or perhaps as high as 9%." Today, DPRP looks at what percentage of patients are above 9.5%, and what percentage are below 8%.
While the numbers achieved by recognized physicians are impressive, was their performance spurred by the incentive of increased referrals, or did those physicians who already were providing superior care submit their data to the program in order to receive the incentives?
"There’s no question that those who choose to participate are highly likely to be giving a higher level of care," Clark concedes. "However, we’ve also seen there are people who decide to apply, start collecting data, and realize they have problems, which causes them to make changes — for example, increase the frequency with which they check patients’ feet, or the number of patients they treat for elevated cholesterol levels. It’s really a matter of providing an incentive for people who care for patients with diabetes to do a better job; we hope it will help ensure a higher level of care."
Clark admits that there currently are not a lot of incentives being offered. "One of the more hopeful developments was the recent announcement by GE that they have agreed to offer a higher level of reimbursement to providers who are recognized by the DPRP," he notes.
"Ideally, you shouldn’t have to reward doctors to ensure superior care, but in this competitive environment where doctors are being pushed to see more and more patients, you need to have incentives to try to induce physicians to give better care," he continues. "I hope that the G.E. initiative will spread, and more and more health plans will do things for doctors who provide superior care. For example, they might decide to pay to help your office put in a computerized data system, which would be incredibly helpful. Or they might pay you more money for each diabetes patient you see. We need to create a business case for why quality needs to change; without that, you’re really appealing to the martyrs."
|
NCQA/ADA Diabetes Physician Recognition Program |
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| Measures for Adult Patients | |||
| Required Measures | Goal | Points | Frequency |
| HbA1c* (most recent result) | 93% | NA | Once per year |
Proportion w/ HbA1c • 8% |
55% | 5 | |
Proportion w/ HbA1c >9.5%* • |
21% | 10 | |
Eye exam* |
61% | 10 | Annual** |
|
Foot exam |
80% | 10 | Annual |
|
Blood pressure frequency (most recent result) |
97% | 10 | Once per year |
|
Proportion <140/90 mm Hg |
65% | 5 | |
|
Nephropathy assessment* |
73% | 10 | Annual** |
|
Lipid profile* |
85% | 5 | Annual** |
|
Proportion with LDL <130 mg/dl* |
63% | 5 | |
|
Total Points |
70 | ||
|
Points to Achieve Recognition 52 |
52 | ||
|
Optical Patient Survey Measures |
Goal | Points | Response |
|
Tobacco status & counseling^^ |
76% | 10 | Yes |
|
Self-management education |
90% | 10 | Annual |
|
Medical nutrition therapy |
90% | 10 | Annual |
|
Self-monitoring of blood glucose: |
|||
|
— noninsulin-treated patients |
50% | 1 | Yes |
|
— insulin-treated patients |
90% | 4 | Yes |
|
Patient satisfaction with: |
|||
|
— diabetes care overall |
58% | 1 | |
|
— diabetes questions answered |
56% | 1 | Excellent, Very |
|
— access during emergencies |
46% | 1 | Good, or Good |
— explanation of lab results |
50% | 1 | (on a scale of |
— courtesy/personal manner of provider |
77% | 1 | Excellent to Poor) |
|
Total Points (including Required Measures) |
110 | ||
|
Points to Achieve Recognition |
82 | ||
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Notes: * Consistent with DQIP and HEDIS measures. ** Measure may be performed in the past two years, based on patient- specific criteria. ^^ For calculation of results for this measure, the denominator for patients receiving a referral for tobacco cessation will be the number of patients from the applicant’s sample who report in the patient survey that they use tobacco. |
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Source: National Committee for Quality Assurance, Washington, DC; American Diabetes Association, Alexandria, VA. |
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Need More Information?
For more information, contact:
- Nathaniel Clark, MD, MS, RD, Vice President for Clinical Affairs, American Diabetes Association, 1701 N. Beauregard St., Alexandria, VA 22311. Telephone: (703) 299-5533. Web site:
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