1051 — An Out of Range (OOR) Glycemic Population Health Safety Measure
Pogach LM, VA New Jersey Research Office; Maney M, VA New Jersey Health Care System; Soroka O, VA New Jersey Health Care System; Tseng C, VA New Jersey Health Care System; Aron DC, Louis Stokes Cleveland VA Medical Center;
VA,AGS and ADA recommend target A1c of 7.5%-8.0% or higher in persons with decreased life expectancy or at risk for serious hypoglycemia. Therefore, DHHS has recommended that the < 8% A1c NCQA measure be revisited. Our objective was to evaluate an OOR measure that assessed both over- treatment (OT) (A1c < 7%) and under- treatment (UT) (A1c > 9%) among high risk, largely elderly patients.
This was a cross-sectional study of Veterans receiving insulin(I) or sulfonylurea(SU)in FY12 who were at high risk for hypoglycemia (being 75 years or older, or with a serum creatinine = > 2.0 mg/dL, or having a diagnosis of cognitive impairment or dementia). The national average and facility specific performance for OOR, OT and UT were determined using the last A1c in 2013.
We identified 435,078 patients on I/SU, of whom 133,302 (30.6%) met the inclusion criteria at 130 facilities (average number of patients: 1,017; range 126 - 3,587). The mean age was 75.5 years. The A1c was OOR in 45.2% of patients: OT in 31% of patients (6 % with A1c < 6.0%; 16% with < 6.5%), UT in 14.2% (4.7% with A1c > 9.0-9.5%; 9.5% with > 9.5%). Only 27.6% were in the guideline recommended range (A1c 7.5-8.4%). The OOR measure ranged from 37.6% in the best performing decile (of the 130 facilities) to 53.5% in the worst performing decile. The ranges for OT and UT alone in best and worst performing deciles were 23.4%-41.2% and 9.7%-20.4%, respectively. Facility rankings for OT or UT were poorly correlated (Spearman's rho = -0.44).
Nearly half of our study population of elderly or ill patients, most of whom would not be included in current HEDIS measures, were OT or UT, and therefore at risk for short term harms. About one in four were in the recommended range. There was significant facility level variation, and even the best performers had more than a third of high risk patients with OOR A1c.
We propose that a single measure can be used to simultaneously address multiple ranges of glycemic control in a vulnerable population to monitor patient safety.