The Dartmouth Institute, Dartmouth Medical School, Lebanon, New Hampshire.
Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
JAMA Netw Open. 2019 Aug 2;2(8):e199139. doi: 10.1001/jamanetworkopen.2019.9139.
Clinical practice group performance on quality measures associated with chronic disease management has become central to reimbursement. Therefore, it is important to determine whether commonly used process and disease control measures for chronic conditions correlate with utilization-based outcomes, as they do in acute disease.
To examine the associations among clinical practice group performance on diabetes quality measures, including process measures, disease control measures, and utilization-based outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective, cross-sectional analysis examined commercial claims data from a national health insurance plan. A cohort of eligible beneficiaries with diabetes aged 18 to 65 years who were enrolled for at least 12 months from January 1, 2010, through December 31, 2014, was defined. Eligible beneficiaries were attributed to a clinical practice group based on the plurality of their primary care or endocrinology office visits. Data were analyzed from October 1, 2018, through April 30, 2019.
For each clinical practice group, performance on current diabetes quality measures included 3 process measures (2 testing measures [hemoglobin A1c {HbA1c} and low-density lipoprotein {LDL} testing] and 1 drug use measure [statin use]) and 2 disease control measures (HbA1c <8% and LDL level <100 mg/dL). The rates of utilization-based outcomes, including hospitalization for diabetes and major adverse cardiovascular events (MACEs), were also measured.
In this cohort of 652 258 beneficiaries with diabetes from 886 clinical practice groups, 42.9% were aged 51 to 60 years, and 52.6% were men. Beneficiaries lived in areas that were predominantly white (68.1%). At the clinical practice group level, except for high correlation between the 2 testing measures, correlations among different quality measures were weak (r range, 0.010-0.244). Rate of HbA1c of less than 8% had the strongest correlation with hospitalization for MACE (r = -0.046; P = .03) and diabetes (r = -0.109; P < .001). Rates of HbA1c control at the clinical practice group level were not significantly associated with likelihood of hospitalization at the individual level. Performance on the process and disease control measures together explained 3.9% of the variation in the likelihood of hospitalization for a MACE or diabetes at the individual level.
In this study, performance on utilization-based measures-intended to reflect the quality of chronic disease management-was only weakly associated with direct measures of chronic disease management, namely, disease control measures. This correlation should be considered when determining the degree of financial emphasis to place on hospitalization rates as a measure of quality in treatment of chronic diseases.
临床实践团体在与慢性病管理相关的质量指标上的表现已成为报销的核心。因此，重要的是要确定常用的慢性病过程和疾病控制措施是否与基于利用的结果相关，就像在急性疾病中那样。
检查糖尿病质量指标（包括过程指标、疾病控制指标和基于利用的结果）方面的临床实践团体表现之间的关联。
设计、设置和参与者：这项回顾性、横断面分析检查了来自国家健康保险计划的商业索赔数据。定义了一个合格的糖尿病受益人群体，年龄在 18 至 65 岁之间，从 2010 年 1 月 1 日至 2014 年 12 月 31 日至少有 12 个月的参保记录。根据他们主要的医疗或内分泌科就诊次数，将合格的受益人群体分配到一个临床实践团体。数据于 2018 年 10 月 1 日至 2019 年 4 月 30 日进行分析。
对于每个临床实践团体，当前糖尿病质量指标的表现包括 3 项过程指标（2 项检测指标[糖化血红蛋白（HbA1c）和低密度脂蛋白（LDL）检测]和 1 项药物使用指标[他汀类药物使用]）和 2 项疾病控制指标（HbA1c <8%和 LDL 水平<100mg/dL）。还测量了基于利用的结果的发生率，包括糖尿病住院和主要不良心血管事件（MACEs）。
在这个来自 886 个临床实践团体的 652258 名糖尿病受益人群体中，42.9%的人年龄在 51 至 60 岁之间，52.6%是男性。受益人群居住的地区以白人为主（68.1%）。在临床实践团体层面，除了两项检测指标之间的高度相关性外，不同质量指标之间的相关性较弱（r 范围为 0.010-0.244）。HbA1c 低于 8%的比例与 MACE（r=-0.046；P=0.03）和糖尿病（r=-0.109；P<0.001）的住院率相关性最强。临床实践团体层面的 HbA1c 控制率与个体层面的住院可能性没有显著关联。过程和疾病控制措施的表现共同解释了个体层面 MACE 或糖尿病住院可能性变化的 3.9%。
在这项研究中，基于利用的措施的表现——旨在反映慢性病管理的质量——仅与慢性病管理的直接指标（即疾病控制指标）呈弱相关。在确定将住院率作为慢性病治疗质量衡量标准的财务重点程度时，应考虑到这一点。
