Association Between Clinical Practice Group Adherence to Quality Measures and Adverse Outcomes Among Adult Patients With Diabetes

J Michael Mcwilliams,Christina A Nguyen,Lauren G Gilstrap,Bruce E Landon,Mary Beth Landrum,Sartaj Alam,Barbara Bai,Michael E Chernew

doi:10.1001/jamanetworkopen.2019.9139

Abstract

Clinical practice group performance on quality measures associated with chronic disease management has become central to reimbursement. Therefore, it is important to determine whether commonly used process and disease control measures for chronic conditions correlate with utilization-based outcomes, as they do in acute disease. To examine the associations among clinical practice group performance on diabetes quality measures, including process measures, disease control measures, and utilization-based outcomes. This retrospective, cross-sectional analysis examined commercial claims data from a national health insurance plan. A cohort of eligible beneficiaries with diabetes aged 18 to 65 years who were enrolled for at least 12 months from January 1, 2010, through December 31, 2014, was defined. Eligible beneficiaries were attributed to a clinical practice group based on the plurality of their primary care or endocrinology office visits. Data were analyzed from October 1, 2018, through April 30, 2019. For each clinical practice group, performance on current diabetes quality measures included 3 process measures (2 testing measures [hemoglobin A1c {HbA1c} and low-density lipoprotein {LDL} testing] and 1 drug use measure [statin use]) and 2 disease control measures (HbA1c <8% and LDL level <100 mg/dL). The rates of utilization-based outcomes, including hospitalization for diabetes and major adverse cardiovascular events (MACEs), were also measured. In this cohort of 652 258 beneficiaries with diabetes from 886 clinical practice groups, 42.9% were aged 51 to 60 years, and 52.6% were men. Beneficiaries lived in areas that were predominantly white (68.1%). At the clinical practice group level, except for high correlation between the 2 testing measures, correlations among different quality measures were weak (r range, 0.010-0.244). Rate of HbA1c of less than 8% had the strongest correlation with hospitalization for MACE (r = -0.046; P = .03) and diabetes (r = -0.109; P < .001). Rates of HbA1c control at the clinical practice group level were not significantly associated with likelihood of hospitalization at the individual level. Performance on the process and disease control measures together explained 3.9% of the variation in the likelihood of hospitalization for a MACE or diabetes at the individual level. In this study, performance on utilization-based measures-intended to reflect the quality of chronic disease management-was only weakly associated with direct measures of chronic disease management, namely, disease control measures. This correlation should be considered when determining the degree of financial emphasis to place on hospitalization rates as a measure of quality in treatment of chronic diseases.

Highlights

Since the early 2000s, performance on quality measures has become central to the reimbursement of medical providers, most commonly within clinical practice groups and hospitals
Rate of hemoglobin A1c (HbA1c) of less than 8% had the strongest correlation with hospitalization for major adverse cardiovascular event (MACE) (r = −0.046; P = .03) and diabetes (r = −0.109; P < .001)
Hemoglobin A1c of less than 8% had the strongest correlation with hospitalization for MACEs (r = −0.046; P = .03), whereas low-density lipoprotein (LDL) testing had the weakest correlation (r = −0.013; P > .05)

Summary

Introduction

Since the early 2000s, performance on quality measures has become central to the reimbursement of medical providers (defined as any health care professionals who directly care for patients and bill Medicare under their own license), most commonly within clinical practice groups and hospitals. Payment models have gravitated away from traditional process and disease control measures and toward utilization-based outcomes, such as hospitalizations, to define and measure quality This change is demonstrated most clearly by the evolution of the accountable care organization quality benchmark measures.[3,4] the Medicare Payment Advisory Commission recently recommended a focus on hospitalization rates as a population-based quality measure in alternative payment models[5] and in their proposed replacement of the Merit-Based Incentive Payment System, largely to ease the burden of quality reporting.[6]

Methods

Results

Discussion

Conclusion