Crossing the Quality Assessment Chasm: Aligning Measured and True Quality of Care

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DESCRIPTION (Provided by the Applicant): Diabetes control within an ambulatory setting has many long-term benefits, including the minimization of morbidity and mortality often associated with the disease. Several studies have established and validated the importance of an aggressive approach to treatment for patients with type I and Type II diabetes. These studies measured improvement in diabetes control by comparing the year-to-year average of HBA1c values in an intensively treated group with the values among a traditionally treated group. Quality of care was assessed using a comparison of cross sectional averages of HBA1c in the two populations over time. In research settings it was fitting to use this cross sectional approach to quality improvement. However, most patient care settings are not as well monitored or controlled as these research studies. As a result, the translation of these measures of quality into actual practice is not simple. Using a cross sectional approach to quality assessment in what is, inherently, a longitudinal disease in a heterogeneous population is flawed. The purpose of this study is to identify and quantify the impact on quality assessment of real-world circumstances where the current cross sectional measures of quality do not reflect the true quality of care being rendered. It will leverage more detailed and discrete data available from electronic medical records in order to develop measures that account for heterogeneity among different diabetic patient panels, credit improvement in the control of diabetes among individuals in a given population over time, recognize provider effort in medical management, and incorporate management of diabetes co-morbidities such as high blood pressure and hyperlipidemia. The result of the analysis will help to create a new set of quality measures that is more consistent with actual clinical care. The aims of the study are as follows: 1. Evaluate structural and clinical issues that may affect the validity of comparisons among providers made using quality measures for diabetes. Among the issues to be explored are a) the manner in which diabetes is defined; b) the way patients are linked to providers, and c) the concordance between use of diabetes medications and achieving thresholds for quality of care. 2. Develop a new quality measure for diabetes that accounts for patient heterogeneity in terms of baseline HBA1c and expected trajectory of improvement in diabetes control based on clinical parameters and other data available through the EHR 3. Explore the DCCT and patient data for year to year individual variability in diabetes control to assess the impact of variability in an individual's diabetes control over time on microvascular outcomes. 4. Disseminate findings through public policy communications through the Leonard Davis Institute and work with practitioners and additional institutions to assess their quality of care under the old and proposed new quality of care measures.