Diabetes Quality Measures Have Challenges But Also Successes

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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 Managed Healthcare Executive K-Cast video series.

Turning data into action

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.

Continuous glucose monitoring

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.

Self-management

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.”