Hidden complexities in assessment of glycemic outcomes: are quality rankings aligned with treatment?
Hidden complexities in assessment of glycemic outcomes: are quality rankings aligned with treatment?
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DOI：
10.2337/dc09-1665
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发表时间：
2010-10
期刊：
影响因子：
16.2
通讯作者：
Aron DC
中科院分区：
文献类型：
--
作者：
Pogach LM;Rajan M;Maney M;Tseng CL;Aron DC
使用阈值和连续测量，基于血糖治疗方案的复杂性，评估实现<7% A1 C水平的设施排名。我们对2003-2004年退伍军人健康管理局医疗中心的行政数据进行了回顾性分析。使用国家质量保证委员会（NCQA）测量规范确定合格患者。复合血糖方案（CGR）定义为接受胰岛素或三种口服药物。根据z分数分布和统计学显著性（P < 0.05），使用五个有序类别对设施进行排名。使用NCQA定义的排名与接受CGR的子集进行比较，CGR使用<7%阈值和连续测量，对7.9和<7.0%之间的值给予比例积分。使用斯皮尔曼相关系数评估等级相关性。从127家机构（范围480- 5，411，平均1，601）共确定了203，302例患者（平均年龄55.2岁）; 26.7%（17.9-35.2%）接受CGR，包括22.0%接受胰岛素治疗。平均A1 C和达到A1 C <7%的百分比总体为7.48和48%，使用阈值测量的接受CGR的患者为8.32和24.8%;使用连续测量的比例分别为60.1和37.2%。总体和CGR子集之间的等级相关性为0.61; 24个排名最高或最低的设施中有8个变为非显著性状态;另外5个站点改变了排名。设施排名在实现NCQA <7%的措施，如指定的显着不同的排名使用CGR子集。公开报告或支付的衡量应按CGR对排名进行分层。持续的措施可以更好地将激励措施与治疗强度结合起来。
To evaluate facility rankings in achieving <7% A1C levels based on the complexity of glycemic treatment regimens using threshold and continuous measures. We conducted a retrospective administrative data analysis of Veterans Health Administration Medical Centers in 2003–2004. Eligible patients were identified using National Committee for Quality Assurance (NCQA) measure specifications. A complex glycemic regimen (CGR) was defined as receipt of insulin or three oral agents. Facilities were ranked using five ordinal categories based up both z score distribution and statistical significance (P < 0.05). Rankings using the NCQA definition were compared with a subset receiving CGRs using both a <7% threshold and a continuous measure awarding proportional credit for values between 7.9 and <7.0%. Ranking correlation was assessed using the Spearman correlation coefficient. A total of 203,302 patients (mean age 55.2 years) were identified from 127 facilities (range 480–5,411, mean 1,601); 26.7% (17.9–35.2%) were receiving CGRs, including 22.0% receiving insulin. Mean A1C and percent achieving A1C <7% were 7.48 and 48% overall and 8.32 and 24.8% for those receiving CGRs using the threshold measure; proportion achieved was 60.1 and 37.2%, respectively, using the continuous measure. Rank correlation between the overall and CGR subset was 0.61; 8 of 24 of the highest or lowest ranked facilities changed to nonsignificance status; an additional five sites changed rankings. Facility rankings in achieving the NCQA <7% measure as specified differ markedly from rankings using the CGR subset. Measurement for public reporting or payment should stratify rankings by CGR. A continuous measure may better align incentives with treatment intensity.