Zhang Q, Safford M, Ottenweller J, Hawley G, Repke D, Burgess J F, Dhar S, Cheng H, Naito H, Pogach L M
Veterans Affairs Medical Center, East Orange, New Jersey 07018, USA.
Diabetes Care. 2000 Jul;23(7):919-27. doi: 10.2337/diacare.23.7.919.
To develop a risk adjustment method for HbA1c, based solely on administrative data and to determine the extent to which risk-adjusted HbA1c changes the identification of high- or low-performing medical facilities.
Through use of pharmacy records, 204,472 diabetic patients were identified for federal fiscal year 1996 (FY96). Complete information (HbA1c levels, demographic data, inpatient records, outpatient pharmacy utilization records) was available on 38,173 predominantly male patients from 48 Veterans Health Administration (VHA) medical facilities. Hierarchical mixed-effects models were used to estimate risk-adjusted unique facility-level HbA1c.
Predicted HbA1c demonstrated expected patterns for major factors known to influence glycemic control. Poorer glycemic control was seen in minorities and patients with greater disease severity, longer duration of disease (using treatment type or presence of amputation as surrogates), and more extensive comorbidity (measured by an adapted Charlson index). Better glycemic control was seen in Caucasians, older diabetic patients, and patients with higher outpatient utilization. The number of performance outliers was reduced as a result of risk adjustment. For mean HbA1c levels, 7 facilities that were initially identified as statistically significant outliers were no longer outliers after risk adjustment. For high-risk HbA1c (>9.5%) rates, 12 facilities that were initially identified as statistically significant outliers were no longer outliers after risk adjustment.
Risk adjustment using only administrative data resulted in substantial changes in identification of high or low performers compared with non-risk-adjusted HbA1c. Although our findings are exploratory, risk adjustment using administrative data may be a necessary and achievable step in quality assessment of diabetes care measured by rates of high-risk HbA1c (>9.5%).
开发一种仅基于管理数据的糖化血红蛋白（HbA1c）风险调整方法，并确定风险调整后的HbA1c在多大程度上改变了对医疗绩效高或低的医疗机构的识别。
通过药房记录，确定了1996财年（FY96）的204472名糖尿病患者。来自48个退伍军人健康管理局（VHA）医疗机构的38173名主要为男性的患者拥有完整信息（HbA1c水平、人口统计学数据、住院记录、门诊药房使用记录）。使用分层混合效应模型来估计风险调整后的各医疗机构独特的HbA1c水平。
预测的HbA1c显示出已知影响血糖控制的主要因素的预期模式。在少数族裔、疾病严重程度更高、病程更长（以治疗类型或截肢情况作为替代指标）以及合并症更广泛（通过改良的查尔森指数衡量）的患者中，血糖控制较差。在白种人、老年糖尿病患者以及门诊利用率较高的患者中，血糖控制较好。风险调整后，绩效异常值的数量减少。对于平均HbA1c水平，最初被确定为具有统计学意义的异常值的7个医疗机构在风险调整后不再是异常值。对于高危HbA1c（>9.5%）率，最初被确定为具有统计学意义的异常值的12个医疗机构在风险调整后不再是异常值。
与未进行风险调整的HbA1c相比，仅使用管理数据进行风险调整导致对绩效高或低的医疗机构的识别有显著变化。尽管我们的发现具有探索性，但使用管理数据进行风险调整可能是通过高危HbA1c（>9.5%）率衡量糖尿病护理质量评估中必要且可实现的一步。
