1103 — Assessing Appropriateness of Lipid Management among Patients with Diabetes
Beard AJ, Klamerus ML, and Hofer TP, Center for Clinical Management Research, Ann Arbor VA HSR&D; Lucatorto M, VA Office of Analytics and Business Intelligence; Downs JR, VERDICT, South Texas Veterans Healthcare System; Holleman R, Hogan MM, and Kerr EA, Center for Clinical Management Research, Ann Arbor VA HSR&D;
Treatment that is both safe and efficacious is a hallmark of patient-centered care. Current lipid performance measures that emphasize treating to a target low density lipoprotein (LDL) can motivate overtreatment, leading to adverse events. In collaboration with VA clinical and operations experts, we have developed a tightly-linked clinical action measure, designed to encourage appropriate clinical action while minimizing overtreatment. We applied this measure to examine what proportion of VA diabetic patients are receiving appropriate care for dyslipidemia and the degree of potential overtreatment with high dose statins.
We used 2009-2010 data from the national corporate data warehouse to determine the proportion of diabetic Veterans, 50-75 years old, passing the clinical action measure for dyslipidemia, defined as: having an index LDL <100 mg/dL; or being on at least a moderate dose statin at the time of the index LDL; or having appropriate clinical action within 90 days following the index LDL; or for those with no index LDL, being prescribed a moderate dose statin. Veterans 18 years and older with diabetes were considered to have potential overtreatment if they had no diagnosis of Ischemic Heart Disease (IHD) and were prescribed a high dose statin. Variability across facilities was assessed using multilevel logistic models.
There were 877,398 patients from 881 facilities in the full diabetes cohort; 601,908 were 50-75 years old and thus eligible for the clinical action measure. 492,944 (81.9%) passed the clinical action measure: 64.1% with an index LDL <100 mg/dL; 6.6% with an index LDL >=100 mg/dL and on a moderate dose statin; 6.3% with an index LDL >=100 mg/dL and appropriate clinical action; and 4.9% with no index LDL but prescribed a moderate dose statin. Facility pass rates varied substantially from 33% to 94% (p <.001). 123,343 patients without IHD were on high dose statins and thus potentially overtreated – representing 14.1% of all diabetic Veterans. Rates of potential overtreatment by facility varied substantially, ranging from 6% to 25% (p <0.001). Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (p <.001).
Over 80% of diabetic Veterans are receiving appropriate dyslipidemia management, as indicated by the linked clinical action measure, but substantial variation exists across facilities. 14% of diabetic Veterans may be experiencing overtreatment, and rates of potential overtreatment vary widely across facilities.
Most patients achieve near maximal benefit in cardiovascular risk reduction from moderate dose statins, however, a large proportion of diabetic Veterans without IHD are on high-dose statins – placing them at increased risk of adverse events, as recently highlighted by the FDA’s black box warning regarding Simvastatin 80 mg. The clinical action measure motivates appropriate treatment, and decreases potential overtreatment, by rewarding care processes beyond achievement of a target LDL value. VHA plans to implement this measure in FY2012.