Performance Measure for Lipid Management in Veterans with Diabetes Encourages Treatment with Moderate Dose Statins
BACKGROUND:
Extensive research has demonstrated that statins reduce the risk of macrovascular complications in patients with diabetes. However, recent analyses of cardiovascular prevention studies, as well as the recognition that high dose statins have significant toxicities, raise concerns about the appropriateness of focusing on LDL targets rather than appropriate treatment. If the ultimate goal of performance measures is to improve the quality of patient care, then quality measures for dyslipidemia should focus on motivating evidence-based strategies for reducing cardiovascular risk. Therefore, clinical action performance measures are increasingly being recommended to help make performance measurement more clinically meaningful. In this retrospective cohort study, investigators developed a clinical action performance measure for lipid management in Veterans with diabetes that is designed to encourage appropriate treatment with moderate dose statins, while minimizing overtreatment. They then examined performance on this measure among Veterans (n=964,818) who received primary care at nearly 900 VA facilities from 7/10 to 6/1, and had been diagnosed with diabetes in the 24 months prior to the measurement period. They assessed what proportion received appropriate lipid management according to this new clinical action measure vs. the treat-to-target measure of LDL < 100mg/dl that was then in place. Possible overtreatment also was examined by assessing the proportion of Veterans without ischemic heart disease (IHD) who were on a high dose statin.
FINDINGS:
- Of the 668,209 Veterans aged 50-75 years in this study, 85% passed the clinical action measure (compared to 67% using the existing metric of LDL < 100): 67% with LDL < 100; 13% with LDL >=100 and on either a moderate dose statin (8%) or with appropriate clinical action (6%); and 4% with no index LDL on at least a moderate dose statin.
- Approximately 15% of the study cohort did not meet the clinical action measure: 8% had an LDL >100 and were not on any statin; 6% had no LDL measurement and were not on a statin; and 1% were only on a low dose statin.
- Veterans who did not meet the clinical action measure had fewer primary care visits, on average, during the measurement period than Veterans who did meet the measure (4.7 visits vs. 6.3 visits).
- Of the entire cohort aged >=18 years, 14% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL < 100) had higher rates of potential overtreament.
LIMITATIONS:
- This study was unable to account for medications prescribed outside VA. Investigators also could not assess patient contraindications to statins (e.g., prior adverse events) or determine whether patients who were potentially overtreated suffered any harms from high dose statins.
IMPLICATIONS:
- Findings suggest that continued use of threshold measures for lipid management may promote overtreatment. A modified version of the clinical action performance measure is being implemented in the VA healthcare system.
Beard A, Hofer T, Downs J, Lucatorto M, Klamerus M, Holleman R, and Kerr E. Assessing Appropriateness of Lipid Management among Patients with Diabetes: Moving from Target to Treatment. Circulation: Cardiovascular Quality and Outcomes December 11, 2012;e-pub ahead of print.
