Q&A with Ben Shirley on PQA's New Diabetes Measures

PQA endorsed two new diabetes-focused health plan performance measures in December 2020. More than 34 million Americans have diabetes, according to the Centers for Disease Control and Prevention. These measures will help evaluate the quality of care for a disease that annually costs America $327 billion.

Ben Shirley, PQA's associate director of performance measurement, provides insights in this Q&A blog on the measures, the quality gaps they address, and PQA's work to develop pharmacy performance measures for diabetes.

One of the measures evaluates the Use of Medications to Prevent Major Cardiovascular Events in Persons with Diabetes (CVDM). Why are people with diabetes at increased risk for cardiovascular disease and what does this measure aim to accomplish?

Adults with diabetes are as much as four times as likely to die from heart disease than adults without diabetes, with almost 70% of people 65 or older with diabetes dying from some form of heart disease, according to the American Heart Association. Although diabetes is treatable, patients with diabetes may have comorbidities such as hypertension, high cholesterol, and other conditions that significantly increase their risk for cardiovascular disease.

For these reasons, lowering the risk for cardiovascular events is a key goal in treating and managing diabetes. Evidence shows that medications such as specific glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter-2s (SGLT-2) are effective in reducing risk of cardiovascular events in persons with type 2 diabetes. Clinical guidelines strongly recommend their use in patients with type 2 diabetes. This measure is a tool intended to compare health plans’ performance with respect to how effective they are at ensuring that patients who meet the measure criteria receive these recommended treatments.

The second measure endorsed is Persistence to Basal Insulin (PST-INS). What is the difference between persistence and adherence?

Persistence captures whether or not a patient remained on a therapy (i.e., did not discontinue). This is similar but conceptually distinct from adherence under the proportion of days covered (PDC) methodology, which captures the percentage of days that a patient had medication on hand.

Many claims-based adherence studies have excluded patients treated with insulin, as there are feasibility challenges with prescription claims data being used to accurately determine days' supply of injectables.  This measure fills a critical measurement and care gap because our PQA-endorsed PDC diabetes measure does not include individuals using insulin.

What is the clinical gap that this measure addresses?

Approximately 7.4 million Americans with diabetes use one or more formulations of insulin, according to the American Diabetes Association. Despite the prevalence of insulin and its important role in treating diabetes, there is a significant gap in quality measurement related to insulin. Measuring adherence for insulin is challenging due to difficulty in accurately estimating days’ supply associated with injectable medications. PQA’s Persistence to Basal Insulin measure adopts an empirically-derived persistence methodology to overcome these difficulties and provides an evidence-based, valid, and reliable quality measure focused on patients receiving basal insulin.

An estimated 34.2 million Americans have diabetes (more than 10% of the population). What other diabetes-related measures does PQA have and how do they work together to improve care?

PQA recognizes the importance of diabetes treatment in the healthcare system and is proud to steward several quality measures that work in harmony to promote high-quality diabetes care through both adherence and appropriate medication use. Beyond the new CVDM measure, the Proportion of Days’ Covered: Diabetes All Class (PDC-DR) and Statin Use in Persons with Diabetes (SUPD) measures also play an important role in key measurement programs.

The PDC-DR measure captures the percentage of individuals 18 years and older who meet the 80% PDC threshold for diabetes medications during the measurement year. Adherence to diabetes medications can lower blood sugar and decrease complications such as visual loss and renal failure, and the American Diabetes Association Standards of Medical Care in Diabetes specifically charge providers with identifying and addressing barriers to adherence.

The SUPD measure captures individuals ages 40 to 75 years with diabetes who receive a statin medication. The American Diabetes Association and the American College of Cardiology / American Heart Society recommend statin use in persons with diabetes as a first-line lipid-lowering agent for prevention of cardiovascular disease. By ensuring that patients receive guideline concordant care, the SUPD measure incentivizes the closure of treatment gaps, leading to improved patient outcomes.

PQA is developing a set of pharmacy performance measures.  Three measure concepts in development now are related to diabetes: hemoglobin A1c reporting and blood pressure reporting and a proportion of days covered (PDC) composite measure for renin angiotensin system antagonists, statins, and diabetes medications. What is the role of pharmacists in diabetes care and how will these measures help pharmacists demonstrate their contributions to patient care?

Pharmacists are uniquely positioned to contribute to diabetes care given their frequent touchpoints with patients. While a person with diabetes may only visit a prescriber’s office a few times a year, they tend to visit their pharmacy more often. This provides opportunities for education, follow-up, and interventions to improve adherence and other medication-related behaviors.

The hemoglobin A1c and blood pressure reporting measure concepts are being developed as a first step in a multi-part development pathway. Reporting measures encourage the development of data infrastructure to create a landscape where pharmacies are able to effectively share A1c and blood pressure information with payers and other stakeholders in our healthcare system. These measure concepts then become the foundation upon which PQA may develop outcome measures that capture the percentage of patients at goal or those improving over time. This allows pharmacies to demonstrate their value in managing and improving patient care.

The PDC Composite (Pharmacy) measure will allow individual pharmacies to be measured on the medication adherence of their patients, providing opportunities for pharmacies with strong outreach and intervention programs to demonstrate their patients’ improved adherence scores. The combination of multiple therapies to provide one measure score is designed to increase the measure denominator and allow for a reliable quality measure, thereby providing accurate comparisons between pharmacies’ performance.

Although the blood pressure reporting and PDC composite measure concepts are not specific only to individuals with diabetes, the measure still captures areas of quality that are important to patients with diabetes and will help to advance quality of care for these patients.

Are there gaps in diabetes care that could be addressed by additional PQA measures?

Although the new CVDM measure helps address cardiovascular risk in persons with diabetes, this remains a key priority area for future measure development. For example, there is considerable interest from stakeholders for measure development related to obesity and weight loss to reduce cardiovascular risk. 

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