HLTH 6510 Week 7 Diabetes Quality Measures Paper Example

What Diabetes Quality Measures Count and What They Were Never Built to Capture

Student Name

Walden University

HLTH 6510: Essentials of the U.S. Healthcare Delivery System and Population Health

Instructor Name

Month Day, Year

What Diabetes Quality Measures Count and What They Were Never Built to Capture

Measures Actually in Use

Care for adults with diabetes is among the most heavily measured areas of U.S. health care. Health plans report on it through HEDIS, the measure set maintained by the National Committee for Quality Assurance, and the same or similar measures appear in Medicare Advantage star ratings, Medicaid managed care contracts and the quality bonus arrangements of the community health center and physician groups in the course's composite region. This paper examines three measures commonly used in that family: blood sugar control, eye examination and statin therapy. It classifies them, works through their specifications and explains what part of care they were never built to capture.

Classifying the Measures

Donabedian (1988) proposed judging quality by three kinds of evidence: the setting and resources care is delivered with, the actions taken for the patient and what happens to the patient's health afterward. The blood sugar control measure, which credits a plan for each adult with diabetes whose latest A1c falls under a set target, is an intermediate outcome: a laboratory value associated with long-term complications but not itself a complication. The eye examination measure, the share who had a retinal exam, is a process measure. The statin therapy measure, the share of eligible patients who received and stayed on a statin, is a process measure tied to a treatment proven to reduce cardiovascular events.

Working Through the Specifications

The specifications matter more than the measure names. For blood sugar control, the denominator is plan members aged 18 to 75 identified as having diabetes through claims or pharmacy data in the measurement year or the year before. People enrolled in hospice or palliative programs drop out of the count, as are many older members with advanced illness and frailty. The numerator counts members whose most recent A1c in the year is below 8%. A member with no A1c on record counts as not controlled. The eye examination measure has a similar denominator and counts members with a retinal exam in the year, or a negative exam in the prior year. The statin measure narrows its denominator to members of certain ages without contraindications, and it also credits staying on the drug, not only starting it.

Three consequences follow. First, the denominator comes from plan enrollment, so uninsured patients and those who changed plans during the year are invisible to the plan's measure. Second, the most recent A1c determines the result, so a patient with poor control most of the year and one good value in December counts as controlled. Third, exclusions remove some of the patients for whom tight control is least appropriate, which is sensible, but the rules for who is excluded are administrative and may not match clinical judgment.

What the Measures Were Never Built to Capture

Harm from overtreatment. A measure that rewards A1c below a target says nothing about low blood sugar caused by treatment. Clinicians and researchers warned that rapidly tightening diabetes targets in quality programs could push some patients, especially older adults with other illnesses, toward dangerous hypoglycemia (Pogach & Aron, 2011). The measure counts the value, not the cost of reaching it.

What patients experience. None of the three measures captures whether patients understand their treatment, can afford their medications, feel better or can manage daily life with diabetes.

Continuity and transitions. The measures look at whether something happened in a year, not whether the same clinician followed the patient, whether a hospital discharge led to timely follow-up or whether the specialist's recommendations reached the primary care team. The transitions identified in week four as the region's weakest points do not appear.

The uninsured and churning. Because denominators come from enrollment, a plan can score well while patients who lost coverage midyear go unmeasured.

What the Measures Do Well

The measures earn their place. Blood sugar control, eye examinations and statin therapy each track care linked to real reductions in complications, and public reporting on them has pushed plans and practices to build registries, send reminders and follow up with patients who miss visits. Their specifications are public, so a clinic can check its own performance against the same rules a plan uses. And because they are standardized, a health center in the rural county can compare itself with health centers elsewhere. Any critique of what the measures omit has to start by granting that what they include matters.

The trouble begins when a measure becomes the whole picture, especially when payment is attached to it. A score built from three numbers cannot describe the care of a person whose diabetes interacts with depression, distance from specialists and a high-deductible plan, which is the typical patient in the composite county.

How the Region Uses the Measures

In the composite region, two Medicaid managed care plans pay the community health center a bonus based partly on blood sugar control. The health center has responded sensibly, with outreach to bring patients in for A1c tests before year end. That improves the score and probably improves care. But it also concentrates effort on what is counted. Staff time spent on December testing drives is time not spent on the transition problems that do not appear in any measure. The incentive is not wrong, but it is partial, and a health center has to decide deliberately how much of its limited staff time the measured work should take.

What to Do With Measures That Omit Things

The answer is not to abandon these measures; they track care that matters and have improved it. It is to read them alongside information they omit: the clinic's own counts of patients with low blood sugar events, a few patient-reported questions at visits and a measure of follow-up within a week after hospital discharge. The aim of improving care, health and cost together (Berwick et al., 2008) is not served by a scorecard that sees only what its specifications define. The measures should stay; the scorecard should grow.

References

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. https://doi.org/10.1377/hlthaff.27.3.759

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Pogach, L., & Aron, D. C. (2011). Sudden acceleration of diabetes quality measures. JAMA, 305(7), 709-710. https://doi.org/10.1001/jama.2011.153