Diabetes HbA1c {Poor Control}

Measure Description

Name	Description	Numerator	Denominator	Source	Reference
Diabetes HbA1c	Percentage of patients aged 18 through 75 years with type 1 or type 2 diabetes mellitus who had a most recent hemoglobin A1c (HbA1c) greater than 9 percent	Number of patients from the denominator whose most recent hemoglobin A1c level during the measurement year is greater than 9 percent	Number of patients aged 18 through 75 years of age with a diagnosis of type 1 or type 2 diabetes mellitus during the measurement year	NCQA / NQF/ PQRI/ PCPI 2009	National Committee for Quality Assurance

Part 1: Introduction

Part 2: Characteristics for Success: Diabetes HbA1c

Part 3: Implementation of Clinical Quality Measure: Diabetes HbA1c

Part 4: Improvement Strategies: Diabetes HbA1c

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information

Part 1: Introduction 

Diabetes is a chronic disease that is characterized by a broad range of metabolic abnormalities. Continued medical management and patient self-management are required to prevent acute complications and minimize the risk of complications that develop over time. Although diabetes medical management continues to improve, significant challenges remain. Consider the following:

• Diabetes is a leading cause of disability and death in the United States, affecting an estimated 17 million people – about 6.2 percent of the population. Approximately one-third are unaware of their disease. ⁽¹⁾
• Each year, nearly one million American adults are diagnosed with diabetes.
• Total cost of diabetes in the United States is estimated at more than $98 billion annually. ⁽²⁾
• HbA1c measures blood glucose control in type 1 and type 2 diabetics. For every 1 percent reduction in results of HbA1c blood tests, the risk of developing eye, kidney, and nerve disease is reduced by 40 percent while the risk of heart attack is reduced by 14 percent.^{(3, 4)}
• Diabetes disproportionately affects racial and ethnic minorities. African Americans, Hispanics, Native Americans, and Asian/Pacific Islanders are more likely to be diagnosed with diabetes. Rates of diabetic-related kidney failure are 2.6 times higher among African Americans. Death rates are also higher among African American, Hispanic, and Native American diabetics.⁽⁵⁾

Although the challenge is daunting, it is clear that experts do know what good diabetes care looks like and are continually increasing public knowledge about good diabetes care. The scientific literature, centers of excellence in diabetes care, and the experience of health care organizations are consistent in pointing to common themes in excellent diabetes care.

It is well accepted that measuring performance allows an organization to document how well care is currently provided and lay the foundation for improvement. 

The HRSA Diabetes HbA1c measure is designed to measure the percentage of patients aged 18 through 75 years with type 1 or type 2 diabetes mellitus that had a most recent hemoglobin A1c (HbA1c) greater than 9 percent. Identifying HbA1c values greater than 9 percent among adult patients aged 18 to75 years allow an organization the opportunity to focus on those patients who are in poor control and at highest risk. Consider the characteristics of a good performance measure and the IOM framework, Envisioning the National Healthcare Quality Report :

• Relevance: Does the performance measure relate to a frequently-occurring condition or have a great impact on patients at an organization’s facility?
• Measurability: Can the performance measure realistically and efficiently be quantified given the facility’s finite resources?
• Accuracy: Is the performance measure based on accepted guidelines or developed through formal group decision-making methods?
• Feasibility: Can the performance rate associated with the performance measure realistically be improved given the limitations of the clinical services and patient population?

To ensure that a performance measure has these characteristics, it is often based on, or aligned with, current evidence-based guidelines and proven measures.

The Diabetes HbA1c measure aligns with measures endorsed by the National Committee for Quality Assurance (NCQA) and similar performance metrics used by HRSA grantees and programs. The measure also aligns with those adapted by the Office of Regional Operations (ORO) and is similar to the one used by the Bureau of Primary Health Care (BPHC) in the clinical portion of its Uniform Data Systems (UDS) process. Similar measures also exist in the national measure set for Healthy People 2010.

Diabetes HbA1c

Name	Description	Numerator	Denominator	Source	Reference
Diabetes HbA1c	Percentage of patients aged 18 through 75 years with type 1 or type 2 diabetes mellitus who had a most recent hemoglobin A1c (HbA1c) greater than 9 percent	Number of patients from the denominator whose most recent hemoglobin A1c level during the measurement year is greater than 9 percent	Number of patients aged 18 through 75 years of age with a diagnosis of type 1 or type 2 diabetes mellitus during the measurement year	NCQA / NQF/ PQRI/ PCPI 2009	National Committee for Quality Assurance

As with all performance measures, there are essential inclusions, exclusions, and clarifications that are required to ensure that an organization collects and reports data in the same way. This allows an organization using the measure to compare itself with others. Detailed specifications for the measure, with descriptions of inclusion and exclusion criteria, are found in the section, Part 3: Data Infrastructure: Diabetes HbA1c.

Improvement Experience: Diabetes HbA1c

As mentioned above, the Diabetes HbA1c measure was chosen to align with existing measures. The data demonstrating the experience with these measures is discussed briefly in this section.

The importance of glycemic control as part of the comprehensive management of diabetes is well documented, and HbA1c testing is a well-established strategy to monitor glycemic control in patients with diabetes. Unfortunately, NCQA data from 2007(6) reveals that between 13 and 22 percent of patients with diabetes do not get regular HbA1c testing. When tested, significant numbers of patients are in poor control with HbA1c values of 9 percent or greater: 29.6 percent of commercial populations, 27.3 percent for Medicare, and 48.7 percent of Medicaid populations. Systematic approaches are necessary to achieve improvements in the quality of care delivery and health care outcomes for patients.

Putting systems in place to track HbA1c testing frequency and HbA1c values enables an organization to better understand how effectively it is able to care for its patients with diabetes. Identifying adult patients aged 18 through 75 years with HbA1c values greater than 9 percent provides an opportunity for an organization to focus attention and services on those patients who are in poor control and at highest risk. These same tracking systems can facilitate appropriate management and follow-up for patients providing critical steps to help them attain and maintain their established glycemic goals.

Trends in NCQA data revealed organizations that implement best practices to ensure effective, high quality care can result in improved glycemic control for populations of patients. HbA1c testing in commercially insured populations in New Hampshire exceeded 92 percent and testing for Medicaid populations in Minnesota was 88 percent in 2007. ⁽⁶⁾ Diabetes patients who maintain near-normal HbA1c values can gain an average extra five years of life, eight years of sight, and six years free from kidney disease. ⁽²⁾