The Aims and Measures section is intended to provide guideline users with a menu of measures for multiple purposes, which may include the following:
• population health improvement measures,
• qualityimprovementmeasuresfordeliverysystems,
• measuresfromregulatoryorganizationssuchasJointCommission,
• measuresthatarecurrentlyrequiredforpublicreporting,
• measuresthatarepartofCenterforMedicareServicesPhysicianQualityReporting initiative,
• othermeasuresfromlocalandnationalorganizationsaimedatmeasuringpopulation health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing thegapbetweencurrentclinicalpracticeandtherecommendationssetforthintheguideline.
Thesubdivisionsofthissectionare:
• AimsandMeasures
• ImplementationToolsandResources
Copyright © 2014 by Institute for Clinical Systems Improvement
Quality Improvement Support:
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults
1
Institute for Clinical Systems Improvement
www.icsi.org2
Aims and MeasuresNote: a multifactorial intervention targeting hyperglycemia and cardiovascular risk factors in individuals withdiabetes ismost effective. Both individualmeasures of diabetes care, aswell as comprehensivemeasuresofperformanceonbroadersetsofmeasures,arerecommended.Arandomizedcontrolledtrialhas shown a 50% reduction in major cardiovascular events through a multifactorial intervention targeting hyperglycemia,hypertension,dyslipidemia,microalbuminuria,aspirinandACEinhibitoruseinindividualswithmicroalbuminuria(Gaede, 2003).
GoalsforA1c,low-densitylipoproteinandotherdiabetesmeasuresshouldbepersonalized,andlowergoalsforA1candlow-densitylipoproteinthanthoseincludedhereinthepriorityaimsandmeasuresmaybeclini-callyjustifiedinsomeadultswithT2DM.However,effortstoachieveA1cbelow7%mayincreaseriskofmortality,weightgain,hypoglycemiaandotheradverseeffectsinmanypatientswithT2DM.Therefore,the aims and measures listed here are selected carefully in the interests of patient safety.
Outcome Measures
1. Diabetes Optimal Care:Increasethepercentageofpatientsages18-75yearswithT2DMmellituswhoare optimally managed (individual components and composite measure):
Measures for accomplishing this aim:
PercentageofpatientswithT2DMmellitusages18-75yearsoldwhoachieveanyorallofthefollowing:
a. PercentageofpatientswithHbA1c<8%.
b. Percentageofpatientswithbloodpressuremostrecentmeasurementlessthan140/90mmHg.
c. Percentageofpatientswhoaretobaccofree.
d. PercentageofpatientswithestablishedASCVDanddocumenteddailyaspirinuse(unlesscontra-indicated).
e. Percentageofpatients ages40-75yearswithT2DMwithuntreatedLDL>70mg/dLwhoareprescribedstatintherapy.
f. Percentageofpatientswithalloftheabove.
2. ManagementofT2DMinhigh-riskpatients(Trialmeasure):Decreasethepercentageofadultpatientsages18-75withT2DMmellituswithpoorlycontrolledglucoseandcardiovascularriskfactors(individual components and composite measure):
Measures for accomplishing this aim:
a. PercentageofpatientswithT2DMmellituswithHbAlc>9%.
b. PercentageofpatientswithT2DMmellituswithASCVDandnotonstatin.
c. PercentageofpatientswithT2DMandestablishedASCVDwhodonothavedocumentationofdailyaspirinuse(excludepatientsforwhomaspiriniscontraindicated).
d. PercentageofpatientswithT2DMmellituswithbloodpressuremeasurementgreaterthan160/100mmHg.
e. Percentageofpatientswhoarecurrentsmoker.
f. Percentageofpatientswithanyoftheabove(a-e).
Noteabouttrialmeasure:Thismeasureisintendedforinternalqualityimprovementusetomeasureprevalenceofpatientswithtype2diabeteswhoseglucoseandcardiovascularfactorsarepoorlycontrolled.
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org3
3. Lifestylemodificationandnutritiontherapy–increasethepercentageofpatientsages18-75yearsnewlydiagnosedwithT2DMwhoareadvisedaboutlifestylemodificationandnutritiontherapy.
Measure for accomplishing this aim:
a. Percentageofnewlydiagnosedpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapy within one year of diagnosis.
4. MedicationManagement– increase thepercentageofpatientswithT2DMwhoareonappropriatemedication management.
Measures for accomplishing this aim:
a. Percentageofpatientsages40-75yearswithuntreatedLDL>70mg/dLwhoareprescribedstatintherapy.
b. PercentageofpatientswithestablishedASCVDwithdocumentedaspirinuse(unlesscontraindi-cated).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org4
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Measurement Specifications
Measurement #1 a, b, c, d, e, f: Diabetes Optimal Care
Measurement DescriptionPercentageofpatientswithT2DMages18-75yearsoldwhoachieveanyorallofthefollowing:
a. PercentageofpatientswithHgbA1c<8%.
b.Percentageofpatientswithbloodpressuremostrecentmeasurementlessthan140/90mmHg.
c. Percentageofpatientswhoaretobaccofree.
d. PercentageofpatientswithestablishedASCVDwithdocumenteddailyaspirinuse(unlesscontra-indicated)
e. Percentage of patients ages 40-75years andT2DMwith untreatedLDL>70mg/dLwho areprescribedstatintherapy.
f. Percentageofpatientswithalloftheabove.
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest# of patients who achieve any or all of the following control criteria
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: a.NumberofpatientswithHgbA1c<8%.
b. Numberpatientswithmostrecentbloodpressuremeasurementlessthan140/90mmHg.
c. Numberofpatientswhoaretobaccofree.
d. NumberofpatientswithestablishedASCVDwithdocumenteddailyaspirinuse(unlesscontraindicated).
e. Numberofpatientsages40-75yearswithtype2diabetesanduntreatedLDL>70mg/dLwhoareprescribedstatintherapy.
f. Numberofpatientswithalloftheabove.
Denominator: a.Numberofpatientsages18-75yearsoldwhohaveT2DM.
b. Numberofpatientsages18-75yearsoldwhohaveT2DM.
c. Numberofpatientsages18-75yearsoldwhohaveT2DM.
d. Numberofpatientsages18-75yearsoldwhohaveT2DMandestablishedASCVD.
e. Number of patients ages 40-75 years old who have T2DM and untreated LDL >70mg/dL.
f. Numberofpatientsages18-75yearsoldwhohaveT2DM.
Institute for Clinical Systems Improvement
www.icsi.org5
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThisisanoutcomemeasure,andimprovementisnotedasanincreaseintherate.Thismeasureshouldbecalculatedasbothanindividualcomponentsmetandacomposite(allcomponentsmetatthesametime)measure.
GoalsforA1c,low-densitylipoproteinandotherdiabetesmeasuresshouldbepersonalized,andlowergoalsforA1candlow-densitylipoproteinthanthoseincludedhereinthepriorityaimsandmeasuresmaybeclini-callyjustifiedinsomeadultswithT2DM.However,effortstoachieveA1cbelow7%mayincreaseriskofmortality,weightgain,hypoglycemiaandotheradverseeffectsinmanypatientswithT2DM.Therefore,the aims and measures listed here are selected carefully in the interests of patient safety.
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org6
Measurement #2aManagementofT2DMinhigh-riskpatients(TrialMeasure)
Measurement DescriptionPercentageofpatientswithT2DMwithHbAlc>9%.
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswithHbA1c>9%
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: NumberofpatientswithHbA1c>9%.
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org7
Measurement #2b
Measurement DescriptionPercentageofpatientswithT2DMwithASCVDandnotonastatin.
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswithASCVDandnotonastatin
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: NumberofpatientswithASCVDandnotonastatin.
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org8
Measurement #2c
Measurement DescriptionPercentageofpatientswithT2DMandestablishedASCVDwhodonothavedocumentationofdailyaspirinuse(excludepatientsforwhomaspiriniscontraindicated).
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswithestablishedASCVDandnodocumentationofdailyaspirinuse(unlesscontraindicated)
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: NumberofpatientswithestablishedASCVDwhodonothavedocumentationofdailyaspirin
use(excludepatientsforwhomaspiriniscontraindicated).
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org9
Measurement #2d
Measurement DescriptionPercentageofpatientswithT2DMwithbloodpressuregreaterthan160/100mm/Hg.
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswithBP>160/100mmHg
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: Numberofpatientswithbloodpressuremeasurementgreaterthan160/100mmHg.
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org10
Measurement #2e
Measurement DescriptionPercentageofpatientswhocurrentlysmoke.
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest# of patients who currently smoke
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: Numberofpatientswhocurrentlysmoke.
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org11
Measurement #2f
Measurement DescriptionPercentageofpatientswithT2DMwithanyofthefollowing(2a-2e)(compositemeasure).
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswithanyofthefollowing(2a-2e)
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: Numberofpatientswithanyofthefollowing(2a-2e).
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as a decrease in the rate. The purpose of this measure istodecreasethepercentageofadultpatientsages18-75withT2DMwithpoorlycontrolledglucoseandcardiovascularriskfactors(clinicalstrategiesthat targethigh-riskpopulationsmaybemoreviablewithlimited resources).
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org12
Measurement #3a
Measurement DescriptionPercentageofnewlydiagnosedpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapywithin one year of diagnosis.
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapywithinoneyearof
diagnosis
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: Numberofpatientswhoareadvisedaboutlifestylemodificationandnutritiontherapywithin
one year of diagnosis.
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as an increase in the rate.
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org13
Measurement #4a
Measurement DescriptionPercentageofpatientsages40-75yearswithuntreatedLDL>70mg/dLwhoareprescribedstatintherapy.
Population DefinitionPatientsages40-75yearsoldwithT2DManduntreatedLDL>70mg/dL.
Data of Interest#ofpatientswhoareprescribedstatintherapy
#ofpatientsages40-75yearsoldwithT2DManduntreatedLDL>70mg/dL
Numerator and Denominator DefinitionsNumerator: Numberofpatientswhoareprescribedstatintherapy.
Denominator: Numberofpatientsages40-75yearsoldwhohaveT2DManduntreatedLDL>70mg/dL.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as an increase in the rate.
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014
Institute for Clinical Systems Improvement
www.icsi.org14
Measurement #4b
Measurement DescriptionPercentageofpatientswithestablishedASCVDwithdocumentedaspirinuse(unlesscontraindicated).
Population DefinitionPatientsages18-75yearsoldwithT2DM.
Data of Interest#ofpatientswithestablishedASCVDwithdocumentedaspirinuse(unlesscontraindicated)
#ofpatientsages18-75yearsoldwithT2DM
Numerator and Denominator DefinitionsNumerator: Number of patients with establishedASCVDwith documented aspirin use (unless
contraindicated).
Denominator: Numberofpatientsages18-75yearsoldwhohaveT2DM.
Method/Source of Data CollectionDatashouldbecollectedfromEMRforallpatientvisitsinthepast12months.
NotesThis is a process measure, and improvement is noted as an increase in the rate.
Diagnosis and Management of Type 2 Diabetes Mellitus in Adults Aims and Measures Sixteenth Edition/July 2014