Article Challenges Process for Disseminating Diabetes Performance Measures
The modern era in diabetes performance measurement began in 1997 when the Diabetes Quality Improvement Project – the first national disease-specific measure – set recommended thresholds for intermediate outcomes (i.e., A1c, blood pressure, and LDL-C) that are risk factors for diabetes morbidity. Since then, pressure to develop more stringent measures for “optimal” control of these risk factors in patients with diabetes accelerated, despite the absence of new evidence from 1998 to 2008. Even as ongoing major trials were attempting to determine the optimal thresholds for these risk factors, some organizations developed and implemented new measures of “optimal” control and some have proposed even more stringent composite measures that incorporate each of the “optimal” measures to assess physician performance. Results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. The authors suggest that examination of another industry may provide some answers as to how diabetes performance measures got ahead of the evidence.
Until recently, Toyota held an unchallenged reputation in quality for its automotive products – and the means by which that quality was achieved. The Toyota culture empowered workers to stop the assembly line by pulling the ‘andon cord’ when they identified a problem to prevent its propagation down the line. Some have argued that as Toyota grew the culture changed, and quality issues were not looked at to the same degree; thus, early warnings either were not heeded or not disclosed. The authors suggest that the same kind of thing has happened to the quality system for diabetes care. Instead of trying to develop better measures using risk adjustment, stratification, linked or continuous measures as recommended by many experts, the goal became rapid introduction of readily auditable measures of “optimal” care, with meeting the measures as the goal. Leadership did not allow the andon cord to be pulled.
In order to restore accountability, the authors make several recommendations, including designating independent centers under AHRQ (Agency for Healthcare Research and Quality) to evaluate the strength of evidence and methodology for any proposed measures, and public televising of any meeting at which the evidence and discussion occur. They also suggest that only when those who promulgate measures are held personally responsible for their decisions should they hold physicians on the front-line of patient care personally responsible for their implementation.
Pogach L and Aron D. Sudden acceleration of diabetes quality measures: Time to pull the andon cord? JAMA February 16, 2011;305(7):709-710.
Drs. Pogach and Aron are part of VA/HSR&D’s Diabetes Mellitus Quality Enhancement Research Initiative (DM-QUERI).