Focus on Diabetes

A Word About Quality of Care in Diabetes

Over the course of the last 10 years, the American Diabetes Association (ADA) has actively participated in defining what constitutes quality care in diabetes and specifying how to measure the extent to which those goals are met. This journey began with the annual publication of the ADA Standards of Care, which has evolved from general clinical practice recommendations to a definition of what constitutes quality care in diabetes through specific goals for blood glucose, blood pressure, lipids, and other clinical parameters. The Standards are important because they represent consensus in regard to quality diabetes care.

The next phase of the journey established diabetes quality of care measures. This began with the Diabetes Quality Improvement Project, which was a collaborative effort among the ADA, NCQA, and the Foundation for Accountability (FACCT), Health Care Finance Administration (HCFA, now CMS). This select group developed measures that became the basis for the Health Plan Employer Data and Information Set (HEDIS) Comprehensive Diabetes Care measure. More recently, many other organizations involved in diabetes care have joined the effort to improve diabetes care by participating in the National Diabetes Quality Improvement Alliance. This group, which makes recommendations to the National Quality Forum, continues to define and redefine measures for diabetes care. Agreed-upon diabetes care measures have supported numerous quality improvement projects, pay-for-performance initiatives (e.g., the ADA- and NCQA-sponsored Diabetes Physician Recognition Program), and more.

Although we have come a long way in defining and measuring the quality of diabetes care, there is still plenty of room for improvement. The HEDIS data tell us that diabetes care is improving over time, but that too many Americans are simply not getting the care they need to reach the targets defined in the ADA Standards of Care. To reach those targets, we have major challenges: first, to continue and accelerate reorganizing health care according to a chronic care model to provide the diabetes care needed; and second, to provide incentives to reward both health care practitioners who provide high-quality services and patients who adhere to their treatment regimens. Unfortunately, the current health care system compensates health care practitioners based on processes completed rather than whether their patients are achieving their diabetes goals.

As pay-for-performance programs begin to move the focus from units of work completed to results achieved, many physicians are concerned about their ability to meet quality-of-care goals. I would encourage them to see pay-for-performance as recognition for quality care delivered. It is important to recognize, however, that it is a significant paradigm shift from the traditional per-unit payment system to which they are accustomed, which may cause concern. To provide high-quality diabetes care, practitioners also need information systems that help them track patient progress toward goals, as well as tools to help meet those goals. However, the current system does not compensate practitioners who invest in those systems and tools.

Therefore, we need to do a better job of enabling and accelerating the use of technology so health care practitioners can help their patients achieve treatment targets. If we are to improve the current system, we must change the quality of the health care practitioner-patient interaction. Information systems are an important enabler to helping health care practitioners reach all the patients in their practice—especially those who don’t visit the doctor regularly.

While our health care system excels at providing care according to the acute care model, we remain challenged by chronic and preventive care. We need to address this challenge head-on because we now know that we can prevent or delay diabetes through lifestyle changes in diet and exercise. There are many ways we can lead this transition, including providing reimbursement for preventive care, influencing our society to better facilitate a healthy lifestyle, and developing better systems to help people make long-term lifestyle changes.

Since diabetes is a highly complicated chronic disease, we must remain focused on piloting and sharing proven quality improvement strategies that work. Health plans and employers play an essential role in promoting improved care for their members and employees with diabetes, and in supporting primary and secondary prevention efforts. Obesity is a major health risk factor, not just for diabetes, but for many diseases. Helping patients reach and maintain a healthy weight is a challenge that, when conquered, decreases the risk of contracting many chronic diseases and can improve a person’s quality of life. Quality diabetes care requires that the health care practitioner and patient work collaboratively to reach treatment goals and manage risk factors to avoid or delay long-term complications. This edition of Quality Profiles provides a timely tool to help health care organizations respond effectively to the challenge of improving diabetes care across the continuum of primary, secondary, and tertiary prevention.