PMC Measure Review Diabetes v8FINAL Website

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Performance Measurement
Management of Diabetes: Review of the Performance Measures by the Performance
Measurement Committee of the American College of Physicians
Writing Committee
Amir Qaseem, MD, David Baker, MD, Mary Ann Forciea, MD, Eve Kerr, MD, Kesavan Kutty, MD,
Sarah West, MSN, RN
ACP Performance Measurement Committee Members*
David W. Baker, MD, MPH (Chair); J. Thomas Cross, MD, MPH; Andrew Dunn, MD, MPH; Mary
Ann Forciea, MD; Robert A. Gluckman, MD; Robert H. Hopkins, MD; Eve Kerr, MD; Kesavan
Kutty, MD; Ana Maria López, MD, MPH; Catherine MacLean, MD, PhD; Stephen D. Persell, MD,
MPH; Terrence Shaneyfelt, MD
Corresponding author:
A. Qaseem
190 N. Independence Mall West
Philadelphia, PA 19106
Email aqaseem@acponline.org
* Individuals who served on the Performance Measurement Committee from initiation of the
project until its approval

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Introduction
Diabetes is major medical and public health issue in the United States. Some 29.1 million
American adults (9.3% of the population) are diabetic (1). In 2012, diabetes accounted for an
estimated $176 billion in direct medical costs and an additional $69 billion in lost wages,
disability, premature death, and other indirect costs (2).
Evidence shows that there is a quality gap between clinical guidelines and practice. One survey
of practicing internists found that patients’ HbA1c levels were at goal only 65% of the time and
adequate control of hypertension among diabetic patients was achieved only 37% of the time
(3). Performance measure reporting from the National Committee for Quality Assurance’s
(NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) also shows room for
improvement (4). In 2013, rates of adequate HbA1c control (<8%) reported in HEDIS ranged
from 72% to 87% (5).
The ACP Performance Measurement Committee (PMC) reviewed performance measures
related to the management of diabetes to assess whether the measures are evidence-based,
methodologically sound, and clinically meaningful.
Methods
We performed a search to identify relevant performance measures from the National Quality
Forum (NQF), the American Medical Association-Physician Consortium for Performance
Improvement (AMA-PCPI), and National Quality Measures Clearinghouse (NQMC) websites.
The inclusion criteria were performance measures currently used in the Centers for Medicare
and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) or currently used in
the CMS Electronic Record Incentive program. The PMC identified and reviewed 8 performance
measures.
Conclusion

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Recommendation
ACP Supports NQF 0055: “Comprehensive Diabetes Care: Eye Exam (Retinal) Performed.”
Rationale
The current evidence supports the benefit of regularly performed vision examinations in
reducing vision complications in diabetic adults (6-7). Although we support this measure, we
suggest that the specifications include all patients over the age of 18 years, as long as for older
patients the level of risk for retinopathy is specified. The current American Geriatrics Society
guidelines support biennial screening for all adults, including over 75 years of age who are at
risk for retinopathy (8). Patients with late onset diabetes who maintain good control are
extremely unlikely to get retinopathy in their lifetimes. The frequency of vision exam should be
based on clinical risk. Additionally, there is potential for overuse if a physician cannot obtain
confirmation of a previous eye exam during the calendar year.
Measure Specifications
NQF 0055: Comprehensive Diabetes Care: Eye Exam (Retinal) Performed
Status: NQF Endorsed, Updated September 2, 2014 (2015 PQRS Measure #117)
Measure
Steward:
National Committee for Quality Assurance
Description: The percentage of patients 18-75 years of age with diabetes (type 1 and
type 2) who had an eye exam (retinal) performed.
Numerator
Statement:
Patients who received an eye screening for diabetic retinal disease. This
includes people with diabetes who had the following:
- A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) in the measurement year
OR
- A negative retinal exam or dilated eye exam (negative for retinopathy) by
an eye care professional in the year prior to the measurement year.
For exams performed in the year prior to the measurement year, a result
must be available.
Denominator
Statement:
Patients 18-75 years of age by the end of the measurement year who had a
diagnosis of diabetes (type 1 or type 2) during the measurement year or
the year prior to the measurement year.
Exclusions
(optional):
Exclude patients who did not have a diagnosis of diabetes, in any setting,
during the measurement year or the year prior to the measurement year.
AND
Exclude patients who meet either of the following criteria:
-A diagnosis of polycystic ovaries, in any setting, any time in the patient’s
history through December 31 of the measurement year.
-A diagnosis of gestational or steroid-induced diabetes, in any setting,
during the measurement year or the year prior to the measurement year
Type of
Measure:
Process

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Level of
Analysis:
Clinician: Group/Practice, Clinician: Individual, Health Plan, Integrated
Delivery System
Care Setting: Ambulatory Care: Clinician Office/Clinic
Data Source: Administrative claims, Electronic Clinical Data: Pharmacy, Paper Medical
Records
Recommendation
ACP does not support NQF 0056: “Diabetes: Foot Exam.”
Rationale
Although we recognize the value of foot exams in diabetic patients, particularly visual
inspection and sensory exam, there is no good evidence that patient outcomes are affected by
regularly performed pulse exams, especially for asymptomatic patients. Therefore, we do not
support this measure because it calls for all three elements in the foot exam. There is no
evidence evaluating the benefit of pulse exam on patient outcomes (e.g., downstream
ulceration) and the routine screening in asymptomatic patients could lead to overuse of Arterial
Brachial Index (ABI) and procedures for peripheral arterial disease that may not be beneficial.
Instead, there should be a focus on addressing vascular risk in all patients with an emphasis on
statin treatment, blood pressure control and smoking cessation.
NQF 0056: Diabetes: Foot Exam
Measure
Steward:
type 2) who received a foot exam (visual inspection with either a sensory
exam with mono filament and a pulse exam) during the measurement year
Numerator
Statement:
Patients who received a foot exam (visual inspection and sensory exam with
monofilament and a pulse exam) during the measurement year
Denominator
Statement:
diagnosis of diabetes (type 1 or type 2) during the measurement year or the
year prior to the measurement year
Exclusions: A diagnosis of gestational or steroid-induced diabetes
Type of
Measure:
Process
Level of Analysis: Clinician: Group/Practice, Clinician: Individual
Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data:
Pharmacy, Paper Medical Records

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Recommendation
ACP supports NQF 0059 with modifications: “Comprehensive Diabetes Care: Hemoglobin A1c
(HbA1c) Poor Control (>9%).”
Rationale
Although ACP supports this measure with modifications, the specifications should include all
patients over the age of 18 years. The current American Geriatrics Society guideline
recommends avoidance of poor glycemic control for adults beyond 75 years of age (8),
particularly if poor control can lead to symptoms. However, regardless of expansion in age, the
specifications of the current measures should exclude patients with dementia and patients with
life limiting diagnoses (receiving hospice and palliative care) where the intervention has the
potential to cause more harms than benefits.
NQF 0059: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Measure
Steward:
type 2) whose most recent HbA1c level during the measurement year was
greater than 9.0% (poor control) or was missing a result, or if an HbA1c test
was not done during the measurement year
Numerator
Statement:
Patients whose most recent HbA1c level is greater than 9.0% or is missing a
result, or if an HbA1c test was not done during the measurement year. The
outcome is an out of range result of an HbA1c test, indicating poor control
of diabetes. Poor control puts the individual at risk for complications
including renal failure, blindness, and neurologic damage. There is no need
for risk adjustment of this intermediate outcome measure.
Denominator
Statement:
the year prior to the measurement year
Exclusions
(Optional):
Exclude patients who did not have a diagnosis of diabetes, in any setting,
AND
Exclude patients who meet either of the following criteria:
-A diagnosis of polycystic ovaries, in any setting, during the measurement
year or the year prior to the measurement year.
Type of
Measure:
Outcome
Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Health Plan, Integrated
Delivery System, Population: National, Population: Regional, Population:

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State
Data Source: Administrative claims, Electronic Clinical Data: Pharmacy, Electronic Clinical
Data: Laboratory, Paper Medical Records
Recommendation
ACP supports NQF 0062: “Comprehensive Diabetes Care: Medical Attention for Nephropathy.”
Rationale
ACP supports this measure. We suggest however, that when this measure is revised, the
specifications of the current measure exclude patients with dementia and patients with life
limiting diagnoses (receiving hospice and palliative care) where the intervention has the
potential to cause more harms than benefits.
NQF 0062: Comprehensive Diabetes Care: Medical Attention for Nephropathy
Measure
Steward:
type 2) who received a nephropathy screening test or had evidence of
nephropathy during the measurement year
Numerator
Statement:
Patients who received a nephropathy screening test or had evidence of
nephropathy during the measurement year
Denominator
Statement:
Exclusions: None
Type of
Measure:
Process
Delivery System
Data Source: Administrative claims, Electronic Clinical Data: Laboratory, Pharmacy,
Paper Medical Records

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Recommendation
ACP does not support NQF 0416: “Diabetic Foot & Ankle Care, Ulcer Prevention – Evaluation of
Footwear.”
Rationale
Although we recognize the value of proper footwear in diabetic patients, there is no current
evidence showing that evaluation of proper footwear in primary care leads to improvement in
outcomes. This may be an appropriate measure for podiatrists although, supporting
documentation provided with the measure demonstrates there is already a 93% provider
(podiatrist) compliance rate with measure interventions (9).
NQF 0416: Diabetic Foot & Ankle Care, Ulcer Prevention – Evaluation of Footwear
Status: NQF Endorsed , Updated December 30, 2014 (2015 PQRS Measure #127)
Measure
Steward:
American Podiatric Medical Association
Description: Percentage of patients aged 18 years and older with a diagnosis of diabetes
mellitus who were evaluated for proper footwear and sizing.
Numerator
Statement:
Patients who were evaluated for proper footwear and sizing at least once
within 12 months
Definition: Evaluation for proper footwear includes a foot examination
documenting the vascular, neurological, dermatological and
structural/biomechanical findings. The foot should be measured using a
standard measuring device and counseling on appropriate footwear should
be based on risk categorization.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
G8410: Footwear evaluation performed and documented
OR
Footwear Evaluation Not Performed
OR
G8415: Footwear Evaluation was not performed
Denominator
Statement:
All patients aged 18 years and older with a diagnosis of diabetes mellitus
Exclusions: Footwear evaluation not performed for documented reasons. For example
bilateral amputee.
Type of
Measure:
Process
Level of Analysis: Clinician: Individual
Data Source: Administrative claims, Electronic Clinical Data: Electronic Health Record,
Paper Medical Records

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Recommendation
ACP does not support NQF 0417: “Diabetic Foot & Ankle Care, Peripheral Neuropathy –
Neurological Evaluation.”
Rationale
In 2010, the Centers for Disease Control and Prevention (CDC) reported a moderate
performance gap with the foot exam in adults with diabetes [75% of all adults between ages
65-74, 73% of adults between ages 45-64, and 71.5% of adults over age 75 (10)]. Although we
recognize the value of foot exams in diabetic patients, there is no evidence to suggest that
regular, comprehensive full lower extremity neurological examination in the primary care
setting benefits asymptomatic patients. However, foot exams with a mono filament should be
performed.
NQF 0417: Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation
Status: NQF Endorsed, Updated December 30, 2014 (2015 PQRS Measure #126)
Measure
Steward:
American Podiatric Medical Association
Description: Percentage of patients, 18 years or older, with a diagnosis of diabetes
mellitus who had a neurological examination of their lower extremities
within 12 months.
Numerator
Statement:
Patients who had a lower extremity neurological exam performed at least
once within 12 months
Definition:
Lower Extremity Neurological Exam-Consists of a documented evaluation
of motor and sensory abilities and should include: 10-g monofilament plus
testing any one of the following: vibration using 128-Hz tuning fork,
pinprick sensation, ankle reflexes, or vibration perception threshold),
however the clinician should perform all necessary tests to make the
proper evaluation.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
G8410: Footwear evaluation performed and documented
OR
Footwear Evaluation Not Performed
OR
G8415: Footwear Evaluation was not performed
Denominator
Statement:
All patients aged18 years and older with a diagnosis of diabetes mellitus
Exclusions: Clinician documented that patient was not an eligible candidate for lower
extremity neurological exam measure, for example patient bilateral
amputee, patient has condition that would not allow them to accurately
respond to a neurological exam (dementia, Alzheimer’s, etc.), patient has
previously documented diabetic peripheral neuropathy with loss of

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protective sensation.
Type of
Measure:
Process
Level of Analysis: Clinician: Individual
Electronic Health Record, Paper Medical Records
Recommendation
ACP does not support NQF 0575: “Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c)
Control (<8.0%).”
Rationale
The current evidence shows that although lower blood glucose levels improves patient
outcomes, the harms of hypoglycemia are also important and should be considered (7, 11). In
addition, independent patient variables (such as diet, ability to pay for medications, medication
compliance, and patient preference) make it difficult for physicians to have complete control
over HbA1c levels (11). Additionally, for this measure, the denominator exclusions are
imprecise and could promote over treatment, particularly for those at high risk of hypoglycemia
(patients with dementia and chronic kidney disease, among others). Denominator exclusions
should specifically include: 1) patients with dementia, 2) patients with chronic kidney disease
and 3) patients with limited life expectancy where the interventions have the potential to cause
more harms than benefit.
NQF 0575: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Control (<8.0%)
Status: NQF Endorsed, Updated September 02, 2014 (Not a PQRS Measure)
Measure
Steward:
Description: The percentage of members 18 - 75 years of age with diabetes (type 1 and
type 2) whose most recent HbA1c level is <8.0% during the measurement
year
Numerator
Statement:
Patients whose most recent HbA1c level is less than 8.0% during the
measurement year. The outcome is a result of an HbA1c test, indicating
desirable control of diabetes. Poor control puts the individual at risk for
complications including renal failure, blindness, and neurologic damage.
There is no need for risk adjustment for this intermediate outcome.
Denominator
Statement:
Exclusions
(Optional):
Exclusions:
-Exclude patients who did not have a diagnosis of diabetes, in any setting,

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AND
-Exclude patients who meet either of the following criteria:
-A diagnosis of polycystic ovaries, in any setting, any time in the patient’s
history through December 31 of the measurement year.
during the measurement year or prior to the measurement year.
Type of
Measure:
Outcome
Delivery System
Laboratory, Electronic Clinical Data: Pharmacy, Paper Medical Records
Recommendation
ACP is awaiting this measure to complete the NQF review and endorsement process
Rationale
NQF 0729: Optimal Diabetes Care (Composite Measure)
Status: NQF Endorsed
Measure
Steward:
MN Community Measurement
Description: The percentage of adult diabetes patients who have optimally managed
modifiable risk factors (A1c, LDL, blood pressure, tobacco non-use and daily
aspirin usage for patients with diagnosis of ischemic vascular disease) with
the intent of preventing or reducing future complications associated with
poorly managed diabetes
Patients ages 18 - 75 with a diagnosis of diabetes, who meet all the
numerator targets of this composite measure: A1c < 8.0, LDL < 100, Blood
Pressure < 140/90, Tobacco non-user and for patients with diagnosis of
ischemic vascular disease, daily aspirin use unless contraindicated
Please note that while the all-or-none composite measure is considered to
be the gold standard, reflecting best patient outcomes, the individual
components may be measured as well. This is particularly helpful in quality
improvement efforts to better understand where opportunities exist in
moving the patients toward achieving all of the desired outcomes. Please
refer to the additional numerator logic provided for each component.
Numerator
Statement:
Patients ages 18 to 75 with diabetes who meet all of the following targets

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from the most recent visit during the measurement year:
A1c less than 8.0, LDL less than 100, Blood Pressure less than 140/90,
Tobacco non-user and Daily aspirin for patients with diagnosis of ischemic
vascular disease use unless contraindicated
Denominator
Statement:
Patients ages 18 to 75 with diabetes who have at least two visits for this
diagnosis in the last two years (established patient) with at least one visit in
the last 12 months
Exclusions: Valid exclusions include patients who only had one visit to the clinic with
diabetes codes during the last two years, patients who were pregnant, died
or were in hospice or a permanent resident of a nursing home during the
measurement year.
Type of
Measure:
Composite
Level of Analysis: Clinician: Group/Practice, Integrated Delivery System
Data Source: Electronic Clinical Data, Electronic Clinical Data: Electronic Health Record,
Electronic Clinical Data: Registry, Paper Medical Records
Gaps in Performance Measurement — Opportunities to Promote High-Value Care
PMC believes that there is a need for performance measures that focus on individualized care
of patients with diabetes.

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References
1. US Department of Health and Human Services. Centers for Disease Control and
Prevention. National Diabetes Statistics Report, 2014.
http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf.
Accessed July 17, 2014.
2. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2012.
Diabetes Care. 2013; 36(4):1033-1046.
3. Lynn L, Hess BJ, Weng W, et al. Gaps in quality of diabetes care in internal medicine
residency Clinics suggest the need for better ambulatory care training. Health Affairs.
2012; 31(1):150-158.
4. National Center for Quality Assurance. Comprehensive diabetes care.
http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2014Tableof
Contents/DiabetesCare.aspx. Accessed January 26, 2015)
5. National Committee for Quality Assurance. Performance measure specifications for
National Quality Forum-Endorsed Performance Measure 0575 (Comprehensive Diabetes
Care: Hemoglobin A1c (HbA1c) Control (<8.0%)). National Quality Forum Web Site
http://www.qualityforum.org/Qps/QpsTool.aspx. Accessed July 17, 2014.
6. American Diabetes Association. Microvascular complications and foot Care. Diabetes
Care: The Journal of Clinical and Applied Research and Education. 2015; 38(1): 58-66.
7. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical
Endocrinologists. Medical guidelines for clinical practice for developing a diabetes
mellitus comprehensive care plan. Endocrine Practice. 2011; 17(2): 1-53.
8. American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes
Mellitus. Guidelines Abstracted from the American Geriatrics Society Guidelines for
Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. 2013; 61:2020-
2026.
9. American Podiatric Medical Association. Diabetic foot & ankle care: ulcer prevention-
evaluation of footwear, peripheral neuropathy-neurological evaluation. 2012 Measure
Testing Project.
10. Centers for Disease Control and Prevention (CDC). CDC’s Diabetes Program-Data and
Trends-Prevalence of Diabetes-Percent of Foot Exam in the Last Year for Adults Aged
=18 Years, by Age. 2012. Retrieved from:
http://www.cdc.gov/diabetes/statistics/preventive/tNewFtChkAgeTot.htm.

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11. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care.
2013; 36: 11-66.
Financial Statement: Financial support for the Performance Measurement Committee comes
exclusively from the ACP operating budget.
Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members
were declared, discussed, and resolved. A record of conflicts of interest is kept for each PMC
meeting and conference call and can be viewed at:
http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.h
tm
APPROVED BY THE ACP BOARD OF REGENTS ON:
April 27, 2015
Members of the PMC:
Individuals who served on the Performance Measurement Committee from initiation of the
project until its approval:
David W. Baker, MD, MPH
J. Thomas Cross, Jr., MD, MPH
Andrew Dunn, MD, MPH
Mary Ann Forciea, MD
Robert A. Gluckman, MD
Robert H. Hopkins, MD
Kesavan Kutty, MD
Eve Askanas Kerr, MD, MPH
Ana María López, MD, MPH
Catherine MacLean, MD, PhD
Stephen D. Persell, MD, MPH
Terrence Shaneyfelt, MD, MPH
Requests and inquiries: Amir Qaseem, MD, PhD, MHA, FACP, American College of Physicians,
190. N Independence Mall West, Philadelphia, PA 19106: email, aqaseem@acponline.org

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