Quality Improvement Support: Diagnosis and …...Numerator and Denominator Definitions Numerator: Number of patients with blood pressure measurement greater than 160/100 mmHg. Denominator:

The Aims and Measures section is intended to provide guideline users with a menu of measures for multiple purposes, which may include the following:

• population health improvement measures,

• qualityimprovementmeasuresfordeliverysystems,

• measuresfromregulatoryorganizationssuchasJointCommission,

• measuresthatarecurrentlyrequiredforpublicreporting,

• measuresthatarepartofCenterforMedicareServicesPhysicianQualityReporting initiative,

• othermeasuresfromlocalandnationalorganizationsaimedatmeasuringpopulation health and improvement of care delivery.

This section provides resources, strategies and measurement for use in closing thegapbetweencurrentclinicalpracticeandtherecommendationssetforthintheguideline.

Thesubdivisionsofthissectionare:

• AimsandMeasures

• ImplementationToolsandResources

Copyright © 2014 by Institute for Clinical Systems Improvement

Quality Improvement Support:

Diagnosis and Management of Type 2 Diabetes Mellitus in Adults

1

Institute for Clinical Systems Improvement

www.icsi.org2

Aims and MeasuresNote: a multifactorial intervention targeting hyperglycemia and cardiovascular risk factors in individuals withdiabetes ismost effective. Both individualmeasures of diabetes care, aswell as comprehensivemeasuresofperformanceonbroadersetsofmeasures,arerecommended.Arandomizedcontrolledtrialhas shown a 50% reduction in major cardiovascular events through a multifactorial intervention targeting hyperglycemia,hypertension,dyslipidemia,microalbuminuria,aspirinandACEinhibitoruseinindividualswithmicroalbuminuria(Gaede, 2003).

GoalsforA1c,low-densitylipoproteinandotherdiabetesmeasuresshouldbepersonalized,andlowergoalsforA1candlow-densitylipoproteinthanthoseincludedhereinthepriorityaimsandmeasuresmaybeclini-callyjustifiedinsomeadultswithT2DM.However,effortstoachieveA1cbelow7%mayincreaseriskofmortality,weightgain,hypoglycemiaandotheradverseeffectsinmanypatientswithT2DM.Therefore,the aims and measures listed here are selected carefully in the interests of patient safety.

Outcome Measures

1. Diabetes Optimal Care:Increasethepercentageofpatientsages18-75yearswithT2DMmellituswhoare optimally managed (individual components and composite measure):

Measures for accomplishing this aim:

PercentageofpatientswithT2DMmellitusages18-75yearsoldwhoachieveanyorallofthefollowing:

a. PercentageofpatientswithHbA1c<8%.

b. Percentageofpatientswithbloodpressuremostrecentmeasurementlessthan140/90mmHg.

c. Percentageofpatientswhoaretobaccofree.

d. PercentageofpatientswithestablishedASCVDanddocumenteddailyaspirinuse(unlesscontra-indicated).

e. Percentageofpatients ages40-75yearswithT2DMwithuntreatedLDL>70mg/dLwhoareprescribedstatintherapy.

f. Percentageofpatientswithalloftheabove.

2. ManagementofT2DMinhigh-riskpatients(Trialmeasure):Decreasethepercentageofadultpatientsages18-75withT2DMmellituswithpoorlycontrolledglucoseandcardiovascularriskfactors(individual components and composite measure):


a. PercentageofpatientswithT2DMmellituswithHbAlc>9%.

b. PercentageofpatientswithT2DMmellituswithASCVDandnotonstatin.

c. PercentageofpatientswithT2DMandestablishedASCVDwhodonothavedocumentationofdailyaspirinuse(excludepatientsforwhomaspiriniscontraindicated).

d. PercentageofpatientswithT2DMmellituswithbloodpressuremeasurementgreaterthan160/100mmHg.

e. Percentageofpatientswhoarecurrentsmoker.

f. Percentageofpatientswithanyoftheabove(a-e).

Noteabouttrialmeasure:Thismeasureisintendedforinternalqualityimprovementusetomeasureprevalenceofpatientswithtype2diabeteswhoseglucoseandcardiovascularfactorsarepoorlycontrolled.

Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Sixteenth Edition/July 2014


www.icsi.org3

3. Lifestylemodificationandnutritiontherapy–increasethepercentageofpatientsages18-75yearsnewlydiagnosedwithT2DMwhoareadvisedaboutlifestylemodificationandnutritiontherapy.

Measure for accomplishing this aim:

a. Percentageofnewlydiagnosedpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapy within one year of diagnosis.

4. MedicationManagement– increase thepercentageofpatientswithT2DMwhoareonappropriatemedication management.


a. Percentageofpatientsages40-75yearswithuntreatedLDL>70mg/dLwhoareprescribedstatintherapy.

b. PercentageofpatientswithestablishedASCVDwithdocumentedaspirinuse(unlesscontraindi-cated).

Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014


www.icsi.org4


Measurement Specifications

Measurement #1 a, b, c, d, e, f: Diabetes Optimal Care

Measurement DescriptionPercentageofpatientswithT2DMages18-75yearsoldwhoachieveanyorallofthefollowing:

a. PercentageofpatientswithHgbA1c<8%.

b.Percentageofpatientswithbloodpressuremostrecentmeasurementlessthan140/90mmHg.

c. Percentageofpatientswhoaretobaccofree.

d. PercentageofpatientswithestablishedASCVDwithdocumenteddailyaspirinuse(unlesscontra-indicated)

e. Percentage of patients ages 40-75years andT2DMwith untreatedLDL>70mg/dLwho areprescribedstatintherapy.

f. Percentageofpatientswithalloftheabove.

Population DefinitionPatientsages18-75yearsoldwithT2DM.

Data of Interest# of patients who achieve any or all of the following control criteria

#ofpatientsages18-75yearsoldwithT2DM

Numerator and Denominator DefinitionsNumerator: a.NumberofpatientswithHgbA1c<8%.

b. Numberpatientswithmostrecentbloodpressuremeasurementlessthan140/90mmHg.

c. Numberofpatientswhoaretobaccofree.

d. NumberofpatientswithestablishedASCVDwithdocumenteddailyaspirinuse(unlesscontraindicated).

e. Numberofpatientsages40-75yearswithtype2diabetesanduntreatedLDL>70mg/dLwhoareprescribedstatintherapy.

f. Numberofpatientswithalloftheabove.

Denominator: a.Numberofpatientsages18-75yearsoldwhohaveT2DM.

b. Numberofpatientsages18-75yearsoldwhohaveT2DM.

c. Numberofpatientsages18-75yearsoldwhohaveT2DM.

d. Numberofpatientsages18-75yearsoldwhohaveT2DMandestablishedASCVD.

e. Number of patients ages 40-75 years old who have T2DM and untreated LDL >70mg/dL.

f. Numberofpatientsages18-75yearsoldwhohaveT2DM.


www.icsi.org5

Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.

NotesThisisanoutcomemeasure,andimprovementisnotedasanincreaseintherate.Thismeasureshouldbecalculatedasbothanindividualcomponentsmetandacomposite(allcomponentsmetatthesametime)measure.

GoalsforA1c,low-densitylipoproteinandotherdiabetesmeasuresshouldbepersonalized,andlowergoalsforA1candlow-densitylipoproteinthanthoseincludedhereinthepriorityaimsandmeasuresmaybeclini-callyjustifiedinsomeadultswithT2DM.However,effortstoachieveA1cbelow7%mayincreaseriskofmortality,weightgain,hypoglycemiaandotheradverseeffectsinmanypatientswithT2DM.Therefore,the aims and measures listed here are selected carefully in the interests of patient safety.



www.icsi.org6

Measurement #2aManagementofT2DMinhigh-riskpatients(TrialMeasure)

Measurement DescriptionPercentageofpatientswithT2DMwithHbAlc>9%.


Data of Interest#ofpatientswithHbA1c>9%


Numerator and Denominator DefinitionsNumerator: NumberofpatientswithHbA1c>9%.

Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.


NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).



www.icsi.org7

Measurement #2b

Measurement DescriptionPercentageofpatientswithT2DMwithASCVDandnotonastatin.


Data of Interest#ofpatientswithASCVDandnotonastatin


Numerator and Denominator DefinitionsNumerator: NumberofpatientswithASCVDandnotonastatin.






www.icsi.org8

Measurement #2c

Measurement DescriptionPercentageofpatientswithT2DMandestablishedASCVDwhodonothavedocumentationofdailyaspirinuse(excludepatientsforwhomaspiriniscontraindicated).


Data of Interest#ofpatientswithestablishedASCVDandnodocumentationofdailyaspirinuse(unlesscontraindicated)


Numerator and Denominator DefinitionsNumerator: NumberofpatientswithestablishedASCVDwhodonothavedocumentationofdailyaspirin

use(excludepatientsforwhomaspiriniscontraindicated).






www.icsi.org9

Measurement #2d

Measurement DescriptionPercentageofpatientswithT2DMwithbloodpressuregreaterthan160/100mm/Hg.


Data of Interest#ofpatientswithBP>160/100mmHg


Numerator and Denominator DefinitionsNumerator: Numberofpatientswithbloodpressuremeasurementgreaterthan160/100mmHg.






www.icsi.org10

Measurement #2e

Measurement DescriptionPercentageofpatientswhocurrentlysmoke.


Data of Interest# of patients who currently smoke


Numerator and Denominator DefinitionsNumerator: Numberofpatientswhocurrentlysmoke.






www.icsi.org11

Measurement #2f

Measurement DescriptionPercentageofpatientswithT2DMwithanyofthefollowing(2a-2e)(compositemeasure).


Data of Interest#ofpatientswithanyofthefollowing(2a-2e)


Numerator and Denominator DefinitionsNumerator: Numberofpatientswithanyofthefollowing(2a-2e).






www.icsi.org12

Measurement #3a

Measurement DescriptionPercentageofnewlydiagnosedpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapywithin one year of diagnosis.


Data of Interest#ofpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapywithinoneyearof

diagnosis


Numerator and Denominator DefinitionsNumerator: Numberofpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapywithin

one year of diagnosis.



NotesThis is a process measure, and improvement is noted as an increase in the rate.



www.icsi.org13

Measurement #4a

Measurement DescriptionPercentageofpatientsages40-75yearswithuntreatedLDL>70mg/dLwhoareprescribedstatintherapy.

Population DefinitionPatientsages40-75yearsoldwithT2DManduntreatedLDL>70mg/dL.

Data of Interest#ofpatientswhoareprescribedstatintherapy

#ofpatientsages40-75yearsoldwithT2DManduntreatedLDL>70mg/dL

Numerator and Denominator DefinitionsNumerator: Numberofpatientswhoareprescribedstatintherapy.

Denominator: Numberofpatientsages40-75yearsoldwhohaveT2DManduntreatedLDL>70mg/dL.





www.icsi.org14

Measurement #4b

Measurement DescriptionPercentageofpatientswithestablishedASCVDwithdocumentedaspirinuse(unlesscontraindicated).


Data of Interest#ofpatientswithestablishedASCVDwithdocumentedaspirinuse(unlesscontraindicated)


Numerator and Denominator DefinitionsNumerator: Number of patients with establishedASCVDwith documented aspirin use (unless

contraindicated).





Documents

Quality Improvement Support: Diagnosis and …...Numerator and Denominator Definitions Numerator: Number of patients with blood pressure measurement greater than 160/100 mmHg. Denominator: