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Quality measures are a tool to drive healthcare toward value-based care, and in diabetes care these measures can improve diabetes management and prevent downstream conditions, such as cardiovascular disease. However, there are multiple hurdles that healthcare organizations face when implementing quality measures for diabetes care, explained Sean M. Oser, M.D., M.P.H., associate professor in the Department of Family Medicine at the University of Colorado School of Medicine, in a 

There are many differences between recommendations for quality measures and reimbursement policies for covered services from different insurers. Although Oser suggested that these all need to be streamlined, in the interim, health systems and provider organizations should have a quality improvement program or team to help understand these requirements. The team can translate the requirements down to the practice level from the health plan or health system and gather data from the electronic health record (EHR) to turn it into an actionable report.

The ability to generate reports allows providers and health systems to track measurement and performance over time to see what progress, if any, is being made. He recommends ensuring there is transparency with stakeholders so they can also follow the progress or see where improvements are lagging. “There is a ton of data that we have available now to try to improve our performance on quality measures and to target where they are not being met,” Oser said.

Advanced EHRs have the capability to generate reports and identify care gaps in real time, too. Previously, when using paper records or older EHRs, Oser would have to search through them to find the latest laboratory results to see the patient’s hemoglobin A1C level or the date of their most recent eye exam. Now, when that data is entered into the EHR, care gaps are highlighted as soon as the patient’s chart is opened during the visit.

Communication is another important aspect of filling those gaps. Patients or providers might get letters from health plans indicating that a patient who has diabetes might not be taking their statin based on claims information, but Oser doesn’t view that communication as very actionable at the practice level. What has been more successful is using care managers or nurses at the health plan to reach out to patients directly to be their personal care manager. “Actual face-to-face — or at least person to person on a telephone — communication can be a whole lot more effective than some of those letters that are received,” he said.

Another area where data has evolved for the benefit of patients with diabetes is with continuous glucose monitoring (CGM), Oser noted. “We’ve relied for a very long time on hemoglobin A1C checks, and they remain extremely useful, but they’re not always right,” he said.

CGM measures glucose levels as frequently as every minute for up to 15 minutes depending on the system, and this data provides an average glucose level. Oser noted there is a small difference between average glucose and hemoglobin A1C. In the latter, the percent of the portion of the hemoglobin molecule that has glucose attached is being measured. While this is associated with average glucose levels, “it’s not a direct correlation,” he explained.

“CGM gives us the actual average glucose, which is what we’re really looking for in the first place,” Oser said. There are many reasons why a hemoglobin A1C level may be inaccurate, such as during pregnancy, in patients with chronic kidney disease, or in patients with variants of their hemoglobin, such as in sickle cell disease.

The National Committee for Quality Assurance recently changed the name of a measure from being based on hemoglobin A1C levels to glycemic management, which allows for a measure directly derived from CGM. Higher levels are associated with diabetic retinopathy, diabetic nephropathy, chronic kidney disease and more.

Traditionally, the thought is “the lower the A1C [level], the better,” Oser said. “But as we bring glucose levels down, it stands to reason that occasionally glucose levels will drop too low, and that can be very dangerous in the short term.”

Low levels are associated with seizures and severe hypoglycemia, but CGM devices can predict low glucose before it happens and sound an alert on the device to give the patient a chance to prevent hypoglycemia. “Since an alarming amount of hypoglycemia develops without any symptoms, CGM can be a real life-changer here,” Oser said.

However, CGMs also have a tremendous amount of raw data. The hope is that in the future, more EHR systems will be able to manage that raw data and produce insights the way CGM systems currently do. Reports from this data can also show how much time is spent within certain ranges and how much time is spent above or below the target range. The CGM data also show how much variability there is in glucose data.

A patient with a hemoglobin A1C level of 6.7% may have a lot of really high and really low glucose readings that averaged out to look like they are meeting the glycemic target. However, the CGM will provide the extra information that shows the patient is “experiencing pretty dangerous swings in glucose,” he said.

“It’s really revolutionized the way I care for people with diabetes when I feel CGM is appropriate, which is not in every case, but I’ll use it often and get a lot more information,” Oser said.

Oser says he follows up with the data from the CGM by engaging patients about their own care. One way he does this is by focusing on the things going well. If the CGM report has multiple measures and one met its target, he starts with that. For example, if someone’s average glucose level is always high, but they have no low glucose levels, Oser will explain how that is a positive. “I try really hard to avoid using language that is judging or leading,” he said. “Focusing on CGM, I’ve found, always gives me something to start with and always something to align with a patient to be able to let them know that this takes work."

There are also quality measures related to diabetes self-management, education and support (DSMES), which engage patients. Diabetes relies heavily on patient self-management, which involves taking all of the medications as prescribed, because patients often have multiple prescriptions; being mindful of what, when and how they eat; and paying attention to movement and exercise. “Often, people with diabetes are on blood pressure medications that can be impacted by diet as well as by activity,” Oser said. “So, everything is really interrelated. There’s a large burden of self-management. So DSMES programs can really help patients directly in those ways.”

Oser also discussed how quality measures can be adapted to address social determinants of health, comorbidities, socioeconomic challenges, or cultural, racial and ethnic differences. Data show African American and Hispanic patients are likely to have higher hemoglobin A1C levels than White patients despite having the same average glucose level. "There is an important cultural, ethnic, racial difference there where CGM, for example, which is measuring the glucose levels and can calculate the actual average glucose level, can get rid of that disparity,” he said.

Since getting to the physician’s office can be a challenge for some people who can’t take time off work or travel the distance, the CGM can eliminate some of those barriers by sending the data to the office. However, there are access challenges with CGM,even though coverage for CGM has been increasing and its cost has been coming down. Oser recommends having a CGM that the practice owns and can provide to the patient for episodic use. “There are [Current Procedural Terminology] codes, billing codes, for the activities around that [so] it’s an office-based charge instead of the patient having to pay a copay for supplies and for continuous use,” Oser said. “It’s also a really useful way for practices to become more engaged with and eventually more comfortable with CGM.”

Sean M. Oser, M.D., M.P.H., an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine, discussed diabetes management and quality measures in a Managed Healthcare Executive K-Cast video series.

Diabetes Quality Measures Have Challenges But Also Successes

Why consumer price transparency for medication is so important

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Women living in rural areas experience higher rates of menopausal symptoms — such as mood changes, sleep issues sand musculoskeletal pain — compared to women in urban and suburban communities.

A new, first-of-its-kind study published in 

 found that these symptoms occur particularly during the late menopause transition and post-menopause.

Women living in rural communities tend to face more health issues than those in urban communities, such as higher rates of anxiety, depression, obesity and heart disease.

However, there is limited research on how women in rural, suburban and urban communities experience menopause differently, according to study authors.

Menopause — a natural but sometimes burdensome stage in a woman’s life — can greatly affect her health and well-being. Many women (80%) experience symptoms such as hot flashes and night sweats, which can lead to poor sleep, memory issues and depression.

Menopause Challenges Across Rural, Suburban and Urban Communities

Rural women may have a more difficult time during menopause as they are more likely to deal with challenges including higher stress, financial problems, smoking and lower levels of education.

Common menopause symptoms such as trouble sleeping, mood swings, memory issues and discomfort in the urinary area are well-known, but little is known about how often or how severely rural women experience them.

Researchers of the study compared how menopause affects rural women differently from those in suburban and urban communities, focusing on symptoms, treatments and attitudes toward menopause care, using data from a 2019 online survey by HealthyWomen and WebMD.

From September to October 2019, the survey gathered responses from 3,197 U.S. women aged 18 and older. Researchers focused on women aged 45 and older in the late menopause transition or postmenopause.

Data was divided by rural, suburban and urban residence, and age-weighted proportions of symptoms and treatments were analyzed using chi-square tests to identify differences between groups.

Out of 1,531 women, 45% were in the late menopause transition (average age 50) and 55% in postmenopause (average age 65). Rural women in late menopause transition reported higher rates of muscle aches (65%) and panic attacks (30%) compared with urban and suburban women.

In postmenopause, rural women experienced more mood swings (23%), urinary incontinence (23%) and vaginal dryness (37%) than those in urban and suburban communitues.

Hot flashes were common with 71% in late menopause transition and 20% in postmenopause, but only 11% of women used menopause hormone therapy, regardless of where they lived.

Access to menopause resources did vary by location.

Additionally, researchers found that rural, urban and suburban women use different ways to find health information.

To raise awareness about the risks and benefits of therapies such as menopause hormone therapy (MHT), it’s suggested that organizations should modify communication methods to fit the target audience.

Researchers found that rural women in the late menopause transition relied more on healthcare providers for information, while urban women used social media more often. Postmenopausal rural women were also less likely to engage with blogs or message boards compared to urban women.

Previous studies show that self-confidence, support and knowledge are key factors in helping rural women make informed decisions about MHT.

This study holds many strengths based on the range of findings. One includes using data from a large, diverse U.S. population and comparing rural, suburban and urban women.

However, there are limitations. The study relied on self-reported survey data, it did not track symptom duration and used categories for residence that were defined by the participants themselves.

Recruitment through WebMD provided diversity, but it also created a sample that might not fully represent all women's menopause experiences.

With the low use of menopause hormone therapy, researchers suggest that more education is needed about this treatment. This education should be designed to fit the needs and lifestyles of women in different communities.

A new, first-of-its-kind study found that these symptoms occur particularly during the late menopause transition and post-menopause.

Clinical

Rural Women Experience Worse Menopausal Symptoms and Limited Resources, Study Finds

It was found that those living with posttraumatic stress disorder (PTSD) who took a combination of Rexulti (brexpiprazole) and sertraline had much better improvements in their symptoms than those who took sertraline with a placebo, according to a new study published in 

People with PTSD experience four main symptoms: reliving the trauma, avoiding reminders of it, negative changes in mood or thinking and being easily startled or on edge.

The disorder is common in the U.S. and globally, with the highest risk associated to traumatic events involving violence, such as physical or sexual assaults. PTSD significantly affects people’s lives, leading to social and work challenges, poor quality of life and even suicide.

Currently, the only medications approved by the FDA for PTSD are the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine.

However, these medications don’t work for everyone. For example, in a previous analysis, about 42% of patients didn’t respond to the medications.

They are also less effective for specific symptoms such as reliving the trauma and heightened arousal.

As a result, doctors typically use multiple medications to treat a range of symptoms, highlighting the need for better treatment options

Rexulti is a medication used for other mental health conditions and has shown promise for PTSD. Early studies suggest that combining brexpiprazole with sertraline may effectively and safely reduce PTSD symptoms.

In this parallel-design, double-blind, randomized clinical trial, sponsored by Otsuka Pharmaceutical Development & Commercialization, researchers examined how well the combination of brexpiprazole and sertraline works for treating PTSD in adults compared to sertraline with a placebo. Researchers also reviewed its safety and efficacy.

The study took place at 86 locations in the U.S. from October 2019 to August 2023. Participants first took a placebo for one week, then, for the next 11 weeks, one group took a mix of two medicines: brexpiprazole (2-3 mg daily) and sertraline (150 mg daily). The other group took sertraline (150 mg daily) with a placebo.

To measure improvements, researchers used a tool called CAPS-5, which checks how severe 20 PTSD symptoms are. They also kept track of any side effects during the study.

Out of 1,327 participants screened, 416 joined the study and were split into the two groups. After 10 weeks, more folks in the brexpiprazole sertraline group (64%) finished the study compared to the sertraline and placebo group (56%).

The brexpiprazole + sertraline group showed a much bigger improvement in PTSD symptoms, as measured by CAPS-5 scores, compared to the placebo group.

On average, their scores dropped by 19.2 points, while the placebo group only dropped by 13.6 points, with a statistically significant difference.

Some side effects were reported, including nausea, fatigue and weight gain. These were slightly more common in the brexpiprazole + sertraline group but were generally manageable.

Fewer people in the brexpiprazole and sertraline group (3.9%) stopped the treatment due to side effects compared to the placebo group (10.2%).

This study has many strengths including participants with different types of trauma, making it more relatable of real-life PTSD patients. Most participants hadn’t used PTSD medications before, which helped received clear results.

Additionally, the study also used both doctor and patient reports to measure results.

Though there were limitations, including only monitoring U.S. participants, the study left results potentially only applying to a smaller audience.

The study also excluded people with depression, which is common in PTSD, making the findings less relevant for some patients.

Adding brexpiprazole to ongoing sertraline treatment works was also not tested, and the study didn’t show how long treatment should last. Researchers suggest further investigation is needed to understand long-term effects and safety.

Currently, the only medications approved by the FDA for PTSD are the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine. However, these medications don’t work for everyone.

PTSD Treatment Shows Promise with Brexpiprazole, Sertraline Combination

The patient engagement movement is set to advance significantly in 2025, with patients taking greater ownership of their health. This shift will empower individuals to be actively involved across their entire healthcare journey — from developing innovations, such as drugs and digital health tools, to decisions about the value and access of these interventions.

A prediction for this year from Jason Spangler, M.D., M.P.H., CEO, Center for Innovation & Value Research.

Kim Perry

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