Diabetes Spectrum
Volume 13 Number , 2000, Page 5
Nutrition FYI

The Diabetes Quality Improvement Project

Sue McLaughlin, BS, RD, CDE, LMNT, LD

The Diabetes Quality Improvement Project (DQIP) is a coalition of public and private entities formed in July 1997. The steering committee, composed of representatives from four organizations, met with the overall goal of establishing a set of diabetes-specific performance and outcome measures that would allow for fair comparisons of health care plans, stimulate quality improvement, be based on scientific evidence, and yet be user-friendly to payers and consumers.

Steering committee members included the American Diabetes Association (ADA), the Foundation for Accountability (FACCT), the Health Care Financing Administration (HCFA), and the National Committee for Quality Assurance (NCQA). The original steering committee was subsequently expanded to include the American Academy of Family Physicians, the American College of Physicians, and the Veterans Administration. All organizations were represented by experts in their respective fields: generalist physicians; specialists in diabetes care and education; experts in health services research, epidemiology and statistics, and health plan administration; and others. DQIP is funded by the HCFA portion of the Balanced Budget Act of 1997.1

The need for a set of standard diabetes care measurements was based on numerous studies and reports in recent years that have indicated that diabetes care throughout the United States is suboptimal. This recognition has resulted in the development of internal accountability measures or "report card" systems by managed care organizations, hospitals, and government agencies with the intent of analyzing diabetes care in their own institutions. Except for HCFA's requirement for managed care plans to submit limited performance measurement data, these measurement systems have been voluntary and administered by nonprofit organizations dedicated to improving the health care provided to Americans (e.g., the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]).

Scope of Work
Member representatives assigned to the DQIP reviewed the following data as a basis for determining the diabetes-specific performance and outcome measures:

  • The ADA Standards of Medical Care for Patients with Diabetes Mellitus
  • FACCT diabetes measures
  • ADA Provider Recognition Program
  • NCQA's Robert Wood Johnson Chronic Care Initiative
  • Veterans' Affairs diabetes performance measures
  • HCFA diabetes work
  • NCQA's Health Plan Employer Data and Information Set (HEDIS) experience and "Desired Attributes of Measures"

The committee then developed a suggested list of measurement areas that it felt should be pursued. The final version of the DQIP Measure Set differs slightly from that initially suggested because several measures were moved from one area to another. The ADA conducted a patient survey in early 1999 because the committee believes that patient-reported measures of quality of care are critical to a comprehensive evaluation of diabetes care. The survey format was such that 10 questions were posed for each accountability measure to help evaluate its appropriateness.

Following a thorough analysis and discussion, the committee formally adopted the original list of seven accountability measures: percentage of patients receiving >1 HbA1c test/year; percentage with the highest risk glucose level; percentage assessed for nephropathy; percentage receiving a lipid profile once in 2 years; percentage with a low-density lipoprotein cholesterol of <130 mg/dl; percentage with blood pressure of <140/90 mm Hg; and percentage receiving a periodic dilated eye exam, as well as two new measures: those receiving an annual foot examination and those receiving counseling on smoking cessation. In addition, the committee approved three quality improvement measures: self-management education, medical nutrition therapy, and interpersonal care (patient satisfaction).

While all committee members agreed to the adoption of the above, NCQA voiced concern about expanding the number of measurements because of the challenges involved in keeping pace with recording volumes of measurement data in a timely manner. A synopsis of the final version of the DQIP Measure Set follows (see Tables 1, 2, and 3). The measures included in Tables 1 and 2 are usually collected via patient chart or lab audit, while measures in Table 3 are obtained via patient reporting.

Table 1. DQIP Accountability Measure Set: Synopsis

   1. Percentage of patients receiving >1 glycohemoglobin (HbA1c test/year
   2. Percentage of patients with the highest risk glucose level (i.e., HbA1c >9.5%)
   3. Percentage of patients assessed for nephropathy
   4. Percentage of patients receiving a lipid profile once in 2 years
   5. Percentage of patients with a low-density lipoprotein cholesterol level <130 mg/dl
   6. Percentage of patients with blood pressure of <140/90 mm Hg
   7. Percentage of patients receiving a periodic dilated eye exam

Table 2. DQIP Quality Improvement Measure Set: Synopsis

   1. Hemoglobin A1c levels of all patients reported in five categories (i.e.,
      <7.5%, 7.51-8.50%, >9.50%, not measured)
   2. Distribution of low density lipoprotein cholesterol values
   3. Distribution of blood pressure values
   4. Proportion of patients receiving a well-documented foot exam, including a
      risk assessment

A great deal of discussion revolved around the establishment of these measures and the level of care that would be acceptable. The committee recognized that providing optimal care for patients often requires more intensive management than indicated by these measures.

Table 3. DQIP Patient-Reported Measure Set: Synopsis

   Quality Improvement Set
   1. Self-management education
   2. Medical nutrition therapy
   3. Patient satisfaction (e.g., access to care, patient involvement in care
   decision, provider communication skills)

   Accountability Set
   1. Annual foot exam
   2. Smoking cessation counseling

The DQIP committee noted that care should be taken not to confuse measures with standards of care. The standards for diabetes care seek to provide health care professionals who treat diabetes with a means to set treatment goals, assess the quality of diabetes treatment provided, identify areas in which more attention is needed, and define timely and necessary referral patterns to appropriate specialists. They also are meant to help people with diabetes assess the quality of the medical care they receive, develop expectations for their role in their medical treatment, and compare their treatment outcomes to standard goals.2

In comparison, the measures are an indicator or tool used to assess the level of care provided within a system of care to populations of patients with diabetes. Measures do not reflect either the minimal or maximal level of care that should be provided to individual patients with diabetes. For example, if one reviews the ADA position statement "Tests of Glycemia in Diabetes," it may be noted that expert opinion recommends glycohemoglobin testing at least 2 times per year for those meeting treatment goals and more frequently (4 times per year) for those in whom therapy has changed or who are not meeting glycemic goals.3 Yet the DQIP Accountability Set measurement indicates that health care plans will have met the goal if one HbA1c is drawn per year.

The decision to use the measurements shown here was made for several reasons, including 1) many individuals with diabetes in this country do not receive HbA1c testing even once annually, thus requesting that the test be drawn 24 times annually appears very unlikely; 2) stratifying the population with diabetes on this and other variables is currently not possible; and finally, 3) there are no evidence-based data to indicate the correct number of HbA1c values that should be collected annually for type 1 or type 2 diabetes. For this and other measures, DQIP recommended that plans and providers be accountable for at least the level of testing or variables as indicated.

Some of the measures have exclusions based on age or co-morbidity or based on results from a previous exam. Most measures apply to people with diabetes between 10 and 75 years of age, regardless of type of diabetes.

The Accountability Set includes measures that are recommended for plan-to-plan or provider-to-provider comparisons and are included in the HEDIS Reporting Set as voluntary in 1999 and mandatory in 2000. Each of the components in this list has undergone multiple studies in a variety of practice settings.

The Quality Improvement Set of measures has yet to be validated for comparing across plans and settings. However, some health care plans may choose to use it for internal quality improvement. The committee plans to field test these in DQIP's second phase and consider them for future versions of the HEDIS Reporting Set.

The Patient-Reported Measures reflect expert consensus and some data recognizing that diabetes is a disease for which 95% of the care lies with the patient. Therefore, the quality and level of education and care provided is critical to patients' ability to care well for their diabetes.

Implications for Diabetes Educators and Clinicians
Quality improvement--or quality assurance, continuous quality improvement, or whatever new buzzword takes hold--is here to stay. If you are involved with an ADA Recognized Program for Diabetes Self-Management Training, the ADA/NCQA Provider Recognition Program, or another program that provides diabetes care and you are providing quality care, you are already doing some type of evaluation and analysis of the quality of your program.

As managed care assumes a greater presence throughout the country, providers will be required to demonstrate that they are providing quality care to the members of the health care plans with which they are associated. There is evidence that if providers collect data on what they do, participate in reviewing the data from their patient populations, and are held accountable for the care given, ultimately care will improve. The measurements recommended by DQIP are a step toward assuring that, at a minimum, a basic level of diabetes care will be provided to an increasing number of health care plan members with diabetes.

Of particular interest to diabetes educators are the Patient-Reported Measures (Table 3). Self-management education and medical nutrition therapy are included here. The research-based Nutrition Practice Guidelines for Type 1 and 2 Diabetes demonstrate the value and positive outcomes that may be achieved with practice guideline care.4-6 Implementation of these guidelines in your practice setting with appropriate outcomes tracking systems will help to document the critical need for quality nutrition care provided by registered dietitians and other qualified nutrition professionals in any health care plan that truly provides quality care to its members.

DQIP Future Plans
As of this writing, the DQIP committee has completed the first phase of its work: defining an initial comprehensive diabetes measurement set. Future committee activities (DQIP 2.0) will include monitoring the adoption of the DQIP measures by health care organizations, evaluating the need for revision of current measures or addition of new ones, and expanding the DQIP partnership network. To access more detailed information and further updates, visit ADA's Web site at www.diabetes.org/dqip.asp.

Tools for Improving the Quality of Care in Your Clinical Practice

  1. Obtain a copy and familiarize yourself and your colleagues with the ADA Clinical Practice Recommendations.2 Current position statements, including "Standards of Medical Care for Patients with Diabetes Mellitus," are included there, as well as a list ing of current technical reviews, consensus statements, and The National Standards for Diabetes Self-Management Education Programs and the American Diabetes Association Review Criteria. Work with colleagues to implement the standards in your practice setting to promote accountability and to improve the quality of care provided to patients. Follow through by measuring and documenting outcomes. Share this data with your organization's administration and others in the health care industry by submitting it for publication.
  2. Obtain a copy of the Nutrition Practice Guidelines (available for purchase; see information below), implement them in your practice setting, and document and report outcomes. Outcomes should be shared with your colleagues, your employer, and administrators of health care plans to demonstrate cost-effectiveness and the impact of quality care on the lives of those with diabetes.
  3. Stay current. For an update on the latest information on DQIP, check the following online addresses: http://www.ncqa.org/hedis/dqip/htm or http://www.diabetes.org/dqip.asp.

Glossary of Related Terms and Definitions

Foundation for Accountability (FACCT): An organization whose mission is to understand consumer needs for information regarding health care quality and to provide vehicles for consumers to become active partners in evaluation, influencing, and improving the health care system.

Health Plan Employer Data and Information Set (HEDIS): A set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. It is sponsored, supported, and maintained by the National Committee for Quality Assurance (NCQA), a nonprofit organization committed to evaluating and publicly reporting on the quality of managed care plans.
     HEDIS, in combination with information from NCQA'a accreditation program (a rigorous and expert evaluation of how managed care plans are organized and how they operate), provides the most complete view of health plan quality available to guide choice among competing health plans. HEDIS 3.0 provides purchasers and consumers with an unprecedented ability both to evaluate the quality of different health plans along a variety of important dimensions and to make their plan decisions based on demonstrated value rather than solely on cost.7

National Committee for Quality Assurance (NCQA): An independent organization that provides information allowing purchasers and consumers of managed health care to distinguish among health plans based on quality of care.

Nutrition Practice Guidelines: Systematically developed statements to assist nutrition practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.8 They are based on the best available research and professional judgment; are comprehensive, specific, and manageable; and have been thoroughly researched and validated through field-testing by a reasonable pool of practitioners.9 They may also be used by other health care providers, institutions, nutrition care units, diabetes care programs, policy makers, and others.
     Nutrition practice guidelines for type 1 and type 2 diabetes have been published, and those written for gestational diabetes are currently undergoing field-testing. To order a copy of Nutrition Practice Guidelines for Type 1 and Type 2 Diabetes, call the American Dietetic Association at 1-800-877-1600 or order electronically at http://www.eatright.org.

Provider Recognition Program: The American Diabetes Association (ADA) Provider Recognition Program, co-sponsored by NCQA, is a voluntary program in which a physician or a group of associated physicians who provide to people with diabetes can apply for recognition. Physicians can achieve recognition by submitting data that demonstrate the provision of quality diabetes care. The program assess 11 measures that were carefully defined and tested for their relationship to improved care for people with diabetes.
     To request a brochure, order application material,s, or learn more, physicians should call ADA at 1-800-676-4065, ext. 2202, or e-mail to prp@diabetes.org.

l ADA Diabetes Quality Improvement Project (DQIP): http://www.diabetes.org/dqip.asp

2 American Diabetes Association: Clinical Practice Recommendations 1999. Diabetes Care 22 (Suppl. 1):S1-114, 1999.

3 American Diabetes Association: Position statement: Tests of glycemia in diabetes. Diabetes Care 22 (Suppl. 1):S77-79, 1999.

4 Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz M: Practice guidelines for medical nutrition therapy provided by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc 95:999-1006, 1995.

5 Franz M, Monk A, Barry B, McClain K, Weaver T, Cooper N, Upham P, Bergenstal R, Mazze R: Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. J Am Diet Assoc 95:1009-17, 1995.

6 Kulkarni K, Castle G, Gregory R, Holmes A, Leontos C, Powers M, Snetselaar L, Splett P, Wylie-Rosett J, the Diabetes Care and Education Dietetic Practice Group: Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. J Am Diet Assoc 98:62-70, 1998.

7 HEDIS 3.0 Executive Summary: http://www.ncqa.org/hedis/30exsum.htm.

8 Field M, Lohr K (Eds): Guidelines for Clinical Practice: From Development to Use. Institute of Medicine. Washington, D.C., National Academy Press, 1992.

9 American Dietetic Association, Quality Assurance Committee: Learning the language of quality care. J Am Diet Assoc 93:531, 1993.

Sue McLaughlin, BS, RD, CDE, LMNT, LD, is owner of On-Site Health and Wellness, providing medical nutrition therapy and diabetes self-management training in Omaha, Neb.

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Copyright 2000 American Diabetes Association

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