Each Breakthrough diabetes team is required to track the core national measures with diabetes mellitus: results from the HOPE study and MICRO-HOPE substudy. …

Breakthrough Measures of Diabetes Population HDC 2006
Each Breakthrough diabetes team is required to track the core national measures measures 1 through 6 along with the count of patients with DM tracked by the clinical information system Patients with DM is defined as patients with the diagnosis of diabetes, Type 1 and Type 2 ICD-9 code of 25000-25099 ICD-9 codes are not always accurate, however; and organizations are reminded that clinical judgment should subsequently take precedence when selecting patients to include in a specific diagnostic category For clinic systems with an integrated dental clinic, measure 13 is also required Teams are welcome to track any of the additional measures 7-16 as useful to their work

REQUIRED MEASURES Measure
1 Average HbA1c

Definition

Data Gathering Plan
On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had an HbA1c in the past 12 months Add all of these patients most recent HbA1c values together and divide by the number of such persons

Goal
70

Average HbA1c value for diabetic patients in the clinical information system

Notes/Comments If many patients in the clinical
information system do not have at least one HbA1c, then this measure may not give a useful estimate of population average Thus, we require teams to report the number of patients for whom an HbA1c within the past 12 months has been documented The goal 7 for average HbA1c derives from current ADA guidelines for individual patients Reference 8 Reference 8

2 Patients with 2 HbA1cs in last year at least 3 months apart

The number of diabetic patients in the clinical information system who have had two HbA1cs at least 91 days apart in the last 12 months, divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage

On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had two HbA1cs within the last 12 months at least 91 days apart At the same time, count the number of patients in the clinical information system

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3 Documentation of selfmanagement goal setting

The number of diabetic patients in the clinical information system with documented
self-management goals in the last 12 months divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage

On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have documented self-management goals set with a clinician in the past 12 months At the same count the number of patients in the clinical information system

References 11-16

You must choose one of the Cardiac Risk Reduction measures statins, ACE/ARBs or Aspirin/Antithrombotics to report monthly
4 Cardiac Risk Reduction Option 1: Statins The number of diabetic patients in the clinical information system 40 years and older who have a current prescription for statins divided by the number of diabetic patients 40 years and older in the clinical information system Multiply by 100 to get percentage The number of diabetic patients in the clinical information system 55 years and older who have a current prescription for ACE inhibitors or ARB medication divided by the number of diabetic patients 55 years and older in the clinical information system Multiply by 100 to get percentage On the last workday of each
month, search the clinical information system for all patients 40 years and older with a diagnosis of DM who have a current prescription for statins At the same time count the number of patients with a diagnosis of DM 40 years and older in the clinical information system On the last workday of each month, search the clinical information system for all patients 55 and older with a diagnosis of DM who have a current prescription for ACE inhibitors or ARB medication At the same time count the number of patients with a diagnosis of DM 55 years and older in the clinical information system 60 The statin recommendation is based on the Heart Protection Study References 2 and 21

4 Cardiac Risk Reduction Option 2: ACE inhibitors or ARB medication

We believe usual practice ought to be a test of an ACE and if ACE is not tolerated, then try an ARB In some cases, ARB will be first choice but because of cost of medication, ACEs ought to be a common starting point ACEI/ARB option is based primarily on the HOPE trial Reference 1

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4 Cardiac Risk Reduction Option 3: Aspirin or
other antithrombotic Agent

The number of DM patients 40 years and older and in the clinical information system who have a current prescription for aspirin or other antithrombotic agent divided by the total number of diabetic patients 40 years and older in the clinical information system Multiply by 100 to get percentage

5 Patients with BP 130/80

The number of diabetic patients in the clinical information system with blood pressure reading less than 130/80 at last reading within the past 12 months, divided by the diabetic patients in the clinical information system with a documented blood pressure in the last 12 months Multiply by 100 to get percentage

On the last workday of each month, search the clinical information system for all patients 40 years and older with a diagnosis of DM and who have a current prescription for aspirin or other antithrombotic agent At the same time count the total number of patients 40 years and older with a diagnosis of DM and years old in the clinical information system On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM with a BP 130/80 in the last 12 months At the same time count the
total number of patients with a diagnosis of DM who have a documented blood pressure in the clinical information system in the last 12 months

Reference 8, 29 Suitable agents include Warfarin/Coumadin, Plavix clopidogrel, Ticlid ticlopidine, low molecular weight heparin, and any newer agents that may become available that are shown to be equivalent or superior to the existing medications

The 130/80 cut-off changed from earlier years UKPDS References 3 4 and HOT Trial Reference 5 justify lower the better and ADA clinical guidelines were changed several years ago to reflect this See also current guidelines References 6,7,8 Teams should strive to document blood pressure for at least 90 of their clinical information system patients Cut-off of 100 aligns with ADA guidelines since 2000 References 7, 8; National Cholesterol Education Program NCEP Adult Treatment Panel III guidelines from 2001 Reference 9 and update, Reference 23

6 Patients with LDL 100

The number of diabetic patients in the clinical information system whose most recent fasting LDL was less than 100 in the last 12 months, divided by the number of patients with a fasting LDL in the past 12 months Multiply by
100 to get percentage

On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM whose most recent fasting LDL was less than 100 in the last 12 months At the same time, count the number of patients with a diagnosis of DM who have had a fasting LDL in the last 12 months

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For clinic systems with an integrated dental clinic, the following measure is also required: 13 Dental exam in The number of patients in the On the last workday of each month, past year clinical information system who search the clinical information obtained a dental exam in last 12 system for all patients with a months, divided by the total diagnosis of DM who have had a number of diabetic patients in the documented dental exam in the last clinical information system Multiply 12 months At the same time count by 100 to get percentage the total number of patients with a diagnosis of DM in the clinical information system

Effective treatment of periodontal infection and reduction of periodontal inflammation is associated with a reduction in
glucose blood levels Early detection during regular dental examinations is very important Reference 20

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ADDITIONAL RECOMMENDED MEASURES: Your team may choose to track and report on any of these additional measures These measures can be used to enhance care and increase the ability to achieve the required measures above Measure Definition Data Gathering Plan Goal Notes/Comments 7 Patients who are The number of patients in the On the last workday of each month, 12 Healthy People 2010 current smokers registry who are current smokers search the registry for all patients Clinical Practice Guideline for documented within the last 12 with DM who are current smokers treating tobacco use and months, divided by the total documented within the last 12 dependence number of DM patients in the months At the same time count the Ref 14 Note: PECS versions 2x registry with smoking status total number of patients with DM in reported current smokers on documented within the last 12 the registry with smoking status registry summary reports but in fact months Multiply by 100 to get
documented within the last 12 based calculations on tobacco use percentage months PECS version 3 will align calculation with the label on the registry summary report 8 Dilated eye exam in past year The number of patients in the clinical information system who have had a dilated eye exam in the last 12 months, divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had a dilated eye exam in the last 12 months At the same time count the total number of patients with a diagnosis of DM in the clinical information system On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had a documented comprehensive annual foot exam in the last 12 months At the same time count the total number of patients with a diagnosis of DM in the clinical information system 70 Reference 8

9 Comprehensive foot exam in the past year

The number of patients in the clinical information system who have had an annual comprehensive foot exam documented in the last
12 months, divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage

An annual comprehensive foot exam has been part of ADA guidelines for some time LEAP exam is one type This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity Reference 8

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10 Microalbuminuria screening in past year

The number of patients in the clinical information system 12 years and older but less than 70 years of age who are not already on ACEI or ARB and have had a microalbuminuria screening test in the last 12 months, divided by the total number of diabetic patients in the clinical information system 12 years and older but less than 70 years of age who are not already on ACEI or ARB Multiply by 100 to get percentage

On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM between 12 years and older but less than 70 years of age who are not on ACEI or ARB and who have had a microalbuminuria
screening test in the last 12 months At the same time count the total number of patients with a diagnosis of DM in the clinical information system who are 12 years and older but less than 70 years of age and who are not on ACEI or ARB On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who obtained an Influenza vaccination in last 12 months At the same time count the total number of patients with a diagnosis of DM in the clinical information system On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had one pneumococcal vaccination at any time in the past At the same time count the total number of patients with a diagnosis of DM in the clinical information system

Reference 8 Screening may be accomplished by several different tests Albumin/creatinine ratio test is the preferred test This is the test item specifically measured in the PECS summary report for this measure Reference 10 discusses microalbuminuria screening for adults and children with diabetes

11 Influenza vaccination

The number of patients in the clinical information system who
obtained an Influenza vaccination in last 12 months, divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage

Reference 8

12 One pneumococcal vaccine

The number of patients in the clinical information system who have had one pneumococcal vaccination at any time, divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage

Reference 8

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13 Dental exam in past year

The number of patients in the clinical information system who obtained a dental exam in last 12 months, divided by the total number of diabetic patients in the clinical information system Multiply by 100 to get percentage

14 Depression Screening 12 months

The of patients with a documented screening for depression in the past 12 months divided by the of patients in the clinical information system Multiply by 100 to get percent

On the last workday of each month, search the clinical information system for all patients with a diagnosis of DM who have had a documented dental exam in
the last 12 months At the same time count the total number of patients with a diagnosis of DM in the clinical information system On the last day workday of each month from the clinical information system: count the of patients with a documented screening for depression in the past 12 months; count the total of patients in the clinical information system

Note: Clinic systems with an integrated dental clinic MUST choose this measure AND one other measure Reference 20

15 Exercise

The number of DM patients whose last documented exercise rate within the last 12 months was 3Xweek @ least 20 minutes, divided by the total number of DM patients Multiply by 100 to get a percentage

On the last workday of each month, search the clinical information system for all DM patients whose last documented exercise rate within the last 12 months was 3Xweek @ least 20 minutes At the same time count the total number of DM patients

Depression is probably the most common mental disorder in primary care practice Because depressed patients in primary care settings commonly present with somatic symptoms rather than complaints of depressed mood, clinicians must be proficient in the assessment
and management of depression The skillful differential diagnosis of depressive symptoms is essential because major depression commonly presents as an associated problem in patients with other physical illnesses References 17-19 ADA Guidelines, Ref 8 Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease, ref 24; Behavioral counseling in primary care promote physical activity, Ref 25

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16 Weight Reduction

The number of DM patients with a BMI 25 at any time in the last 12 months who have lost 10 pounds by comparing their maximum recorded weight in the 12 months period to their latest recorded weight, divided by the total number of DM patients who have or had a BMI 25 at any time in the last 12 months Multiply by 100 to get a percentage

On the last workday of each month, search the clinical information system for all DM patients with a BMI 25 at any time in the last 12 months who have lost 10 pounds by comparing their maximum recorded weight in the 12 months period to their latest recorded weight At the same time count
the total number of DM patients who have or had a BMI 25 at any time in the last 12 months

ADA Guidelines, Ref 8; Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults Ref 26-28

References 1 Heart Outcomes Prevention Evaluation Study Investigators: Effect of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results from the HOPE study and MICRO-HOPE substudy Lancet 355: 253-259, 2000 2 Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial Lancet 360: 7-22, 2002 3 UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in Type 2 diabetes: UKPDS 38 British Medical Journal BMJ 317: 703-713, 1998 4 Adler, et al Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes UKPDS 36: prospective observational study BMJ 321: 412-419, 2000 5 Hansson et al: Effects of intensive blood pressure lowering and low-dose aspirin on patients with hypertension:
principal results of the Hypertension Optimal Treatment HOT randomized trial Lancet 351: 1755-1762, 1998 6 Treatment of Hypertension in Adults with Diabetes Technical review Treatment of Hypertension in Adults with Diabetes Position statement Diabetes Care 25:134-147, 2002 and Diabetes Care 26, Supplement 1:80-83, 2003 7 ADA Clinical Practice Recommendations 2003 Standards of Medical Care for Patients with Diabetes Mellitus Diabetes Care, 26:S33-50, 2003 8 ADA Clinical Practice Recommendations 2004 Standards of Medical Care for Patients with Diabetes Mellitus Diabetes Care, 27:S1S137, 2004 9 Executive Summary of the Third Report of the National Cholesterol Education Program NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults Adult Treatment Panel III JAMA, 285: 2486-2497, 2001 10 K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification Kidney Disease Outcome Quality Initiative Am J Kidney Dis 2002 Feb;392 Suppl 1:S1-246

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11 Olivarius N, Beck-Nielsen H, Andreasen A, Horder
M, and Pedersen P Randomised controlled trial of structured personal care of type 2 diabetes mellitus BMJ 2001, 3237319: 970-5 http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedlist_uids11679387doptAbstract 12 Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice Diabetes Care 2001 Aug;248:1365-70 http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedlist_uids11473071doptAbstract 13 Norris SL, Engelgau MM, Narayan KM Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials Diabetes Care 2001 Mar;243:561-87 Review http://wwwncbinlmnihgov/entrez/queryfcgi?cmdRetrievedbPubMedlist_uids11289485doptAbstract 14 Maly RM, Leake B, Frank JC, DiMatteo MR, Reuben DB Implementation of consultative geriatric recommendations: the role of patientprimary care concordance Jrnl Amer Ger Soc 2002;50:1372-1380 15 Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA The relative importance of physician communication, participatory decisionmaking and patient understanding in diabetes self-management J
Gen Inter Med 2002;17:243-252 16 Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial Medical Care 371:5-14, 1999 17 Rush AJ, Golden WE, Hall GW et al Depression in Primary Care: Clinical Practice Guideline Agency for Health Care Policy and Research AHCPR Publication No 93-0550 US Department of Health and Human Services, Rockville, MD 1993 18 Cohen-Cole SA, Kaufman KG: Major depression in physical illness: Diagnosis, prevalence, and antidepressant treatment A ten-year review: 1982-1992 Depression 1993; 1:181-204 19 Coyne J,Schwenk TL, Fechner-Bates S: Non-detection of depression by primary care physicians reconsidered Gen Hosp Psychiatry 1995; 17:3-12 20 Grossi, Skrepcinski, DeCaro, et al, Treatment of Periodontal Disease in Diabetics Reduces Glycated Hemoglobin;, J Periodontology, August 1997, Volume 68, Number 8, pages 713-719 21 Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study CARDS: multicentre randomised
placebo-controlled trial, Lancet 364: 68596, 2004 22 A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report JAMA 2000;283:3244-3254 23 Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines, Circulation 2004;110:227-239, http://wwwnhlbinihgov/guidelines/cholesterol/atp3upd04pdf 24 Thompson PD, et al Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: A statement from the Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism Circulation 2003;107:3109-3116 25 US Preventive Services Task Force Behavioral counseling in primary care to promote physical activity: recommendation and rationale Ann Intern Med 2002;137:205-207 26 Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults Arch Intern Med 1998;158:1855-1867 27 Yanovski SZ, et al Obesity N Engl J Med 2002;346:591-602 28 Cummings S, et al Position of the American Dietetic Association: weight management J Am Dietetic Assoc 2002;102:1145-1155

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29 ADA Clinical Practice Recommendations 2004, Diabetes Care 27:S72-S73, 2004

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Source:srph.tamhsc.edu