Diabetes
Comprehensive Diabetes Care
Diabetes is the fifth leading cause of death in the United States. According to the American Diabetes Association “there are 23.6 million children and adults in the United States, or 7.8% of the population, who have diabetes. While an estimated 17.9 million have been diagnosed with diabetes, unfortunately, 5.7 million people (or nearly one quarter) are unaware that they have the disease.” The total prevalence of diabetes increased 13.5% from 2005-2007. Diabetes also contributes to higher rates of morbidity – people with diabetes are at higher risk for heart disease, blindness, kidney failure, extremity amputations and other chronic conditions.
The ADA estimates the total annual economic cost of diabetes in 2007 to be $174 billion. Medical expenditures totaled $116 billion and were comprised of $27 billion for diabetes care, $58 billion for chronic diabetes-related complications, and $31 billion for excess general medical costs. The HEDIS Comprehensive Diabetes Care measures include the following.
Hemoglobin A1c test & levels
High levels of sugar in the blood are one common finding in patients with diabetes. Frequent testing for hemoglobin A1c (HbA1c), measures a patient’s average blood sugar level.
People with poorly controlled diabetes as shown by high blood sugar levels are more likely to develop high blood pressure, high cholesterol and fat levels, heart disease, eye and nerve problems, and kidney problems.
Although HbA1c test results mean different things for different patients depending upon their overall health status and age, most physicians believe, based on current medical evidence, that levels above 9.0 mean poor overall diabetes control.
Two measures are reported:
- HbA1c test measures the percentage of patients ages 18-75 with diabetes who received at least one screening test for HbA1c during the measurement year. A higher screening rate can suggest that a health plan works with its provider network to promote more frequent and appropriate blood tests for patients.
- HbA1c level <= 9.0% measures the percentage of patients with HbA1c results less than or equal to 9.0. NCQA defines HbA1c poor control as a level greater the 9.0%, CCHRI reverses this rate in the results.
Retinal exam
Diabetes is the leading cause of new cases of blindness in people 20-74. Every year 12,000-24,000 people lose their sight because of diabetes. Experts recommend that people with diabetes have an examination of their retina every year because diabetes-related eye disease can be present even if a person has no problem seeing. When doctors find eye disease in diabetic patients early, they can start treatment in time to save vision for most people. In people with type 1 diabetes, therapy that keeps blood sugar levels as close to normal as possible reduces damage to the eyes by 76% (New England Journal of Medicine, September 30, 1993). Experts believe that these results can also be applied to those with type 2 diabetes.
The HEDIS Comprehensive Diabetes Care measure reports how many people with diabetes had an examination by an eye care professional during the measurement year. For some patients, depending upon their overall health status and how well their diabetes is controlled, an eye exam performed during the prior year was also counted in the results for this measure. A higher rate could mean the health plan works harder to promote regular exams or makes exams easier to obtain. More exams mean earlier medical treatment and less blindness in the diabetic population.
Cholesterol Management
Heart disease strikes people with diabetes twice as often as people without diabetes and is one of the most common medical complications. Higher levels of cholesterol and fat in the blood greatly contribute to the increased incidence of coronary artery disease and heart disease. It is very important that LDL cholesterol levels be measured at least yearly in patients with diabetes. Efforts should be made, depending upon the patient, to maintain LDL cholesterol at levels lower than 100 mg/dL. The HEDIS Comprehensive Diabetes Care measure calculates the percentage of patients with diabetes who received an LDL cholesterol screening during the measurement year or prior year and the percentage of those who had cholesterol levels below 100 mg/dL. A higher screening rate of LDL cholesterol could indicate that a health plan is working hard to promote regular medical exams for patients with diabetes.
Nephropathy Monitoring
Diabetes is the leading cause of end-stage renal disease accounting for 44% of new cases. People with diabetes are much more likely than the general population to develop acute and chronic kidney problems, such as renal insufficiency, end-stage renal disease and diabetic nephropathy. These serious complications can require long-term kidney dialysis or kidney transplant. Importantly, early detection of kidney disorders can lead to earlier treatment, and slow or prevent further deterioration of the kidneys and help avoid dialysis or transplant.
One of the first signs of kidney problems is protein in the urine. It is therefore very important that patients with diabetes have a test at least once a year that measures micro albuminuria. The HEDIS Comprehensive Diabetes Care measure reports the percentage of health plan members with diabetes ages 18-75, who received a screening for micro albuminuria during the measurement year.
Blood Pressure Control <130/80 and <140/90
According to the American Diabetes Association “more than 65% of people with diabetes die from heart disease or stroke. With diabetes, heart attacks occur earlier in life and often result in death.” Much of the burden of illness and cost of diabetes treatment is attributed to potentially preventable long-term complications including heart disease, blindness, kidney disease and stroke. Appropriate and timely screening and treatment can significantly reduce the disease burden.
Studies have shown that up to 60% of adults with diabetes have high blood pressure. Individuals with both diabetes and hypertension have approximately twice the risk of cardiovascular disease as non-diabetic people with hypertension. In the United Kingdom Prospective Diabetes Study (UKPDS), each 10-mmHg decrease in mean systolic blood pressure was associated with a reduction in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial infarction, and 13% for micro vascular complications
There are two different measures of blood pressure control based on different thresholds. The most stringent is the percent of members achieving a blood pressure under 130/80. The second measure establishes a threshold of 140/90. Caution should be used in evaluating the results for the 130/80 measure as there is less evidence to support more stringent control and it may not be appropriate for all specified individuals due to issues such as complications, lack of office visits, etc.
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