Clinical Geriatrics

This article is the second in a continuing series on diabetes in the elderly. The first article in the series, “Pathophysiology of Diabetes in the Elderly,” was published in the April issue of the Journal. The remaining articles in the series will discuss such topics as the role of exercise and dietary supplements in the management of diabetes, treatment of diabetes with oral and parenteral agents, as well as microvascular and macrovascular complications of diabetes.

Introduction to Quality Improvement Efforts
Diabetes mellitus is a prevalent, chronic disease in older adults, often accompanied by cardiovascular comorbid conditions that lead to functional impairments and disabilities.¹ Twelve million adults age 60 years and older were estimated to have diabetes in 2007.² American adults with diagnosed diabetes is expected to increase by 165% by 2050, with the largest percent increase among those age 75 years or older.³

Despite the prevalence of diabetes and the availability of effective treatment, many adults of all ages with diabetes do not receive all of the care shown or considered to be associated with improved outcomes, defined as decreased cardiovascular and microvascular complications.^4,5 Efforts to improve the quality of diabetes care have been ongoing for the past decade, and different quality performance measures have been investigated and promulgated. Establishing quality-of-care guidelines and measures for older adults with diabetes has the added difficulty that high-quality diabetes studies frequently do not include substantial numbers of older adults. Thus, evidence supporting the appropriateness of commonly used quality measures for the older adult population is often lacking. While specific treatment targets for older adults remain debatable, diabetes is a severe disease, and physicians must prioritize its treatment. Available quality measures can help physicians keep track of the multiple components of care associated with high-quality diabetes management.

Development of Diabetes Quality Performance Measures
In response to the need to improve the quality of diabetes care, the Diabetes Quality Improvement Project (DQIP) was formed, with support from more than 25 key organizations, including the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA),⁶ the American Diabetes Association (ADA), and the Veterans Health Administration (VHA) in the U.S. Department of Veterans Affairs. In 1997, the DQIP developed a set of quality performance measures for diabetes care so that quality of care could be assessed in a standardized manner.⁷ Variations of these performance measures have been adapted and incorporated into the Healthcare Effectiveness Data and Information Set (HEDIS), the ADA Diabetes Physician Recognition Program, the American Medical Association (AMA) Diabetes Mellitus Measures Group, and the VHA performance monitoring program, among others.

The DQIP partners continued their work through the National Diabetes Quality Improvement Alliance (NDQIA). The NDQIA integrated diabetes measures provided by the AMA-Physician Consortium for Performance Improvement (AMA-PCPI),⁸ and these measures have been endorsed by the National Quality Forum (NQF),⁹ which continues to promote the use of a set of updated standardized measures to assess the quality of diabetes care.

Structure of Quality Performance Measures
Quality performance measures include both: (1) process measures; and (2) outcome measures. Process measures typically reflect guidelines of care for patients with diabetes, such as the frequency with which a provider measures a patient’s blood pressure (BP), glycated hemoglobin (HbA1c), or lipid levels. Ideally, improvement in each process measure leads to improvement in associated outcome measures.