ACP Review Questions Validity of Diabetes Quality Measures

In a recent evaluation, the American College of Physicians (ACP) has raised significant concerns regarding the quality measures associated with diabetes care, concluding that the majority of these measures lack scientific backing and have not been adequately tested for efficacy. This comprehensive review, published in the Annals of Internal Medicine, highlights the pressing need for improved evidence and more rigorous testing to enhance the quality of diabetes management practices across the United States.

The ACP Performance Measurement Committee, comprised of leading experts in the field, scrutinized 14 existing diabetes care measures used by internists, group practices, and health plans. Notably, they found that only five of these measures could be endorsed based on their evaluation criteria. "A lot of these measures were created with good intentions to measure quality of care," stated Dr. Rebecca Andrews, MD, chair of the ACP Board of Regents and member of the review committee. "However, without a solid evidence base, they become burdensome to physicians and do not achieve their intended goals."

The evaluation employed a rigorous rating scale, assessing measures for importance, appropriate use, clinical evidence base, specifications, and feasibility, thereby creating a robust framework for analysis. Despite the existence of numerous measures, Dr. Andrews emphasized that "fourteen measures for one chronic condition is too much," advocating for a more streamlined focus on impactful performance measures.

Historically, the debate surrounding the effectiveness of quality measurement in healthcare has persisted for decades, with a considerable body of literature questioning their meaningfulness. A pivotal study published in The New England Journal of Medicine in 2018 indicated that only 37% of internal medicine measures were deemed valid. This long-standing skepticism is mirrored in the ACP's latest findings, particularly concerning diabetes-related measures that have tended to prioritize compliance over genuine care improvement.

Dr. Patrick J. O’Connor, MD, MA, MPH, a senior research investigator at HealthPartners Institute, expressed his concerns regarding existing metrics that focus on checking boxes rather than addressing the root causes of complications associated with diabetes. For instance, the yearly eye exam measure, although still widely used, fails to tackle the underlying issues of glucose and blood pressure control that are crucial for preventing complications like retinopathy. "If we aim to prevent eye disease in diabetics, we must focus on managing blood sugar and blood pressure rather than just performing annual eye exams," O’Connor stated.

The ACP committee supported some diabetes measures at the health plan level, including the diabetes eye exam measure MIPS #117, but withheld support at the individual physician level due to concerns over its uncertain validity. Furthermore, the committee expressed doubts about the effectiveness of other measures, such as those assessing kidney health and foot examinations, which lacked strong evidence backing their use. The panel highlighted the need for a more comprehensive approach to diabetes management that encompasses blood pressure and cholesterol control alongside smoking cessation efforts.

The ACP's findings serve not only as a critique but also as a call to action for healthcare organizations to refine and improve their quality measures. "When we publish these reviews, our goal is to provide constructive feedback on each measure's strengths and weaknesses, guiding organizations in their efforts to create more effective performance measures," Dr. Andrews remarked.

In light of these discussions, the ACP committee has proposed a new measure aimed at aligning diabetes care with contemporary standards. This measure would focus on tracking the prescription of sodium-glucose co-transporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) agonists in conjunction with metformin for adults with type 2 diabetes who demonstrate inadequate glycemic control. Initial discussions with the Centers for Medicare & Medicaid Services (CMS) have taken place to consider this measure for inclusion in future quality programs.

The implications of the ACP's review extend beyond simply improving diabetes care; they underscore a broader necessity for healthcare quality measures to be grounded in solid evidence and to prioritize meaningful outcomes over compliance-based metrics. As healthcare continues to evolve, the call for more scientifically sound, patient-centered measures becomes ever more critical, ensuring that the delivery of care not only meets standards but truly enhances patient health and quality of life.

As healthcare professionals and organizations reflect on these findings, the challenge remains to develop a set of quality measures that not only ensure accountability but also foster genuine improvements in patient care. The ACP's proactive stance signals a vital shift towards a more evidence-based approach in diabetes management, with the ultimate goal of improving health outcomes for millions affected by this chronic condition.