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Less than 10% of diabetes initiatives include hypoglycemia performance measure

Despite a universal inclusion of hypoglycemia in diabetes clinical practice guidelines, the condition is rarely included as a performance measure of patient care, according to findings published in JAMA Internal Medicine.

"Health care organizations use publicly reported performance measures for quality measurement and improvement and pay-for-performance initiatives," Rene Rodriguez-Gutierrez, MD, MSc, from the Mayo Clinic, and colleagues wrote for the Hypoglycemia as a Quality Measure in Diabetes Study Group. "These measures should ideally promote high-quality care that is evidence based and congruent with clinical practice guidelines. However, they should also reward patient-centered care that yields optimal outcomes with the lowest risk of harm."

The researchers identified 18 diabetes practice guidelines and 23 performance measures initiatives published between January 2010 and March 2016 by entities including the American Diabetes Association, the International Diabetes Federation, the American College of Endocrinology and the American Association of Clinical Endocrinology.

Rodriguez-Gutierrez and colleagues reported that all of the practice guidelines recommended that physicians evaluate for and treat hypoglycemia. In contrast, just two organizations — the National Institute of Health Excellence and the National Information Diabetes Service in the United Kingdom — included corresponding performance measures. These measures only addressed severe hypoglycemia, not mild. The other 21 performance measures failed to address the prevention, ascertainment or treatment of hypoglycemia.

The researchers also found that 80% to 90% of the performance measure initiatives incorporated other measures, which included BP control, smoking cessation, aspirin use, hemoglobin A1c measurement and target level, nephropathy, LDL cholesterol target level, retinopathy and neuropathy screening.

They called for the prevention of hypoglycemia to be a focus of diabetes care, noting the significant morbidity, mortality and quality of life implications.

"Efforts are under way to develop reliable, measurable, actionable, and meaningful hypoglycemia measures," Rodriguez-Gutierrez and colleagues concluded. "These measures may include documentation of hypoglycemic events at each visit, hypoglycemia awareness and management education programs, prescription and patient use of diabetes medical alerts, or prescriptions of glucagon and/or glucose tablets. Engagement of patients to identify and address precipitating causes of hypoglycemia, including treatment regimen change, can also be recorded. When carefully constructed and implemented, a hypoglycemia-focused performance measure would serve as a counterbalance for the current measures. It would be a paradigm shift in the care for patients with diabetes because it would facilitate a holistic approach that prioritizes not only efficacy but also safety and patient-centeredness of diabetes care. – by Chelsea Frajerman Pardes

Disclosure: One author reported receiving support from the Centers for Medicare & Medicaid Services to develop and maintain publicly reported quality measures. No other authors reported any relevant financial disclosures.