Evaluation of glycemic over and under-treatment indicators for high-risk Veterans

高危退伍军人血糖治疗过度和治疗不足指标的评估

• 批准号: 9108718
• 负责人: Leonard Marshall Pogach
• 金额: --
• 依托单位: VA NEW JERSEY HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-11-01 至 2015-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9108718
• 关键词: 5 year old; Academic Detailing; Address; Adverse effects; Advocate; Age; Age-Years; American; Awareness; Caring; Categories; Characteristics; Chronic; Chronic Kidney Failure; Clinical; Clinical Pharmacists; Code; Collaborations; Community Healthcare; Complex; Data; Dementia; Development; Diabetes Mellitus; Diagnosis; Evaluation; Exclusion Criteria; Formularies; Funding; Future; Glomerular Filtration Rate; Goals; Guidelines; Health; Health Services Accessibility; Hypoglycemia; Impaired cognition; Individual; Insulin; Life Expectancy; Linear Models; Measures; Medical; Mental Health; Methodology; Methods; Microvascular Dysfunction; National Committee for Quality Assurance; Non-Insulin-Dependent Diabetes Mellitus; Oral; Organization administrative structures; Outcome; Output; Patient Care; Patient Preferences; Patients; Performance; Persons; Pharmaceutical Preparations; Population; Population Surveillance; Populations at Risk; Predisposition; Prevalence; Primary Health Care; Provider; Psyche structure; Publishing; Recommendation; Regimen; Reporting; Rewards; Risk; Risk Factors; Secondary Prevention; Sensitivity and Specificity; Services; Site; Specialist; Stratification; Sulfonylurea Compounds; System; Time; Training; Variant; Veterans; Vietnam; Work; basal insulin; base; cohort; diabetes management; direct patient care; glycemic control; health administration; high risk; improved; inclusion criteria; medical specialties; meetings; operation; outreach; patient safety; pharmacy benefit; population health; programs; shared decision making; skills; tertiary prevention

Background: One in four veterans have diabetes, of whom 40% are 60-69 years of age (the Vietnam era cohort); and about 25% are over 70 years of age. Serious co-morbid conditions are common (31%) even in younger (<65 years) veterans. About one in five veterans >65 years have cognitive impairment or dementia, and about 30% have an estimated Glomerular Filtration Rate of <60 ml/min/1.73m2. About 30% of veterans receive insulin, and the use of basal insulin has increased by 41% since 2008. Recent American Diabetes Association Guidelines agree with VHA-DoD Diabetes Guidelines that target values should be individualized based upon factors such as life expectancy, comorbid conditions, patient preferences, and risk for serious hypoglycemia. However, the current National Committee for Quality Assurance (NCQA) <7% A1c measure for persons less than 65 years of age neither stratifies by insulin nor excludes serious non-diabetes related or mental co-morbid conditions. The NCQA <8% A1c measure applicable to persons 65 to 74 years of age has no exclusion criteria. There is also no recommendation to assess glycemic management in individuals with diabetes >75 years of age. Due to these concerns, VHA only tracks A1c >9% (poor control).This gap led the DM-QUERI R&M Committee to recommend development of clinical indicators for potential over- and under treatment of glycemic control as a key strategic goal. Based upon our published work (continuous measures, glycemic regimen complexity and co-morbid conditions), we will work in partnership with VACO partners to refine and evaluate such indicators. Objectives: The long term objective of this proposal is to improve the appropriateness of glycemic management. Our specific aims are: (1) To develop technical specifications for clinical indicators of under- and overtreatment. a) To evaluate the impact of different inclusion and exclusion criteria on measure performance characteristics (e.g., sensitivity and specificity). b) To work with our VACO Program Office partners to finalize measure specification. (2) To assess variation at various VA organizational levels (CBOCs, facilities, and VISNS). 3) To work with our VACO Program Office partners to utilize clinical indicators for over- and undertreatment to inform quality improvement, surveillance and direct patient care. Methods: We will use Corporate Data Warehouse. All Veterans will be attributed to a facility or CBOC based upon primary care assignment; for unassigned Veterans, we will use the site where the majority of diabetes care was provided. The last A1c value within the time period of evaluation will be used as the primary analysis, and the first A1c as an alternative. Veterans will be eligible for the potential overtreatment measure if they are receiving sulfonylurea or insulin therapy and also meet inclusion criteria of age or significant co-morbid conditions. We will use three different thresholds reflecting increasingly tight glycemic control: <7%, <6.5%, and <6%. Veterans will be eligible for the under treatment measures if they are receiving a complex glycemic regimen (insulin or two or more oral agents) and do not have decreased life expectancy or serious comorbid illness. We will define undertreatment (which may vary by cohort) using a partial credit approach: A1c values >8.5% receive no credits (coded 1), full credit for <7.0% (or 7.5%) (coded 0), and partial credit for A1c values between 8.5% to 7.0% (or 7.5%) using our previously developed methodology of linear interpolation. Differences among facilities or CBOCs will be determined by assigning facilities within 5 ordinal categories based upon both Z score distribution (<=10% [5 Stars or best]; 10-33% [4 Stars]; 34-66% [3 Stars]; 67-90% [2 Stars], and >90% [1 Star] and statistical significance (P<0.05) for all categories (except the middle category (3 stars)) following NCQA criteria. Multi-level hierarchical linear modeling will estimate the amount of variation across different organizational units, as well as assess characteristics of Veterans who are at greatest risk.

背景：每四名退伍军人中就有一人患有糖尿病，其中40%的人年龄在60-69岁(越南时代 约25%的人年龄在70岁以上。严重的合并症很常见(31%)，即使在 年轻的(65岁)退伍军人。大约五分之一的65岁退伍军人患有认知障碍或痴呆症， 约30%的患者估计肾小球滤过率为60毫升/分钟/1.73平方米。约30%的退伍军人 接受胰岛素治疗后，基础胰岛素的使用量自2008年以来增加了41%。新近的美国糖尿病 协会指南与VHA-DoD糖尿病指南一致，即目标值应个性化 基于预期寿命、合并症、患者喜好和严重疾病风险等因素 低血糖症。然而，目前的国家质量保证委员会(NCQA)和lt；7%的A1C措施 65岁以下的人既不按胰岛素分层，也不排除严重的非糖尿病相关或 精神疾病。适用于65至74岁人群的NCQA&lt；8%A1C措施具有 没有排除标准。也没有建议评估患有糖尿病的患者的血糖管理。 糖尿病患者，75岁。由于这些担忧，VHA只跟踪了A1c&>9%(控制不善)。这一差距导致了 DM-QUERI R&M委员会建议制定潜在的过度和不足的临床指标 将血糖控制作为一项关键战略目标进行治疗。基于我们已发表的工作(连续测量， 降血糖方案的复杂性和并存情况)，我们将与VACO合作伙伴合作 细化和评估这些指标。 目标：这项建议的长期目标是提高血糖的适宜性 管理层。我们的具体目标是：(1)制定以下临床指标的技术规范 过度治疗。A)评价不同的纳入和排除标准对衡量标准的影响 特征(例如，敏感性和特异性)。B)与我们的VACO计划办公室合作伙伴一起敲定 测量规格。(2)评估退伍军人管理局不同组织级别(CBOC、设施和 VISNS)。3)与我们的VACO计划办公室合作伙伴合作，利用临床指标 治疗不足，为质量改进、监测和指导病人护理提供信息。 方法：我们将使用企业数据仓库。所有退伍军人都将归因于设施或CBOC 在初级保健分配时；对于未分配的退伍军人，我们将使用糖尿病患者最多的地点 提供了护理。将使用评估时间段内的最后A1c值作为主要分析， 以及第一辆A1C作为替代方案。退伍军人如果符合以下条件，将有资格获得潜在的过度治疗措施 接受磺脲或胰岛素治疗，并符合年龄或重大合并症的纳入标准 条件。我们将使用三个不同的阈值来反映日益严格的血糖控制：&lt；7%，&lt；6.5%， -lt；6%。如果退伍军人正在接受复合血糖治疗，他们将有资格享受正在接受治疗的措施 治疗方案(胰岛素或两种或两种以上口服药物)，不会降低预期寿命或严重并存 生病了。我们将使用部分信用方法来定义低待遇(可能因队列而异)：A1C值 &gt；8.5%没有积分(编码为1)，完全积分为&lt；7.0%(或7.5%)(编码为0)，部分积分为A1c值 使用我们以前开发的线性内插方法，在8.5%到7.0%(或7.5%)之间。 设施点或CBOC之间的差异将通过分配5个有序类别内的设施点来确定 基于Z分数分布(&lt；=10%[5星或最佳]；10-33%[4星]；34-66%[3星]；67-90%[2 星]，和&gt；90%[1星]和统计意义(P&lt；0.05)对于所有类别(除中间类别(3 STARS))遵循NCQA标准。多层分层线性建模将估计变化量 在不同的组织单位，以及评估处于最大风险的退伍军人的特征。