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    Original Investigation
    Health Policy
    August 14, 2019

    Association Between Clinical Practice Group Adherence to Quality Measures and Adverse Outcomes Among Adult Patients With Diabetes

    Author Affiliations
    • 1The Dartmouth Institute, Dartmouth Medical School, Lebanon, New Hampshire
    • 2Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
    • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 4Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 5Division of General Medicine, Beth Israel Deaconess Hospital, Boston, Massachusetts
    JAMA Netw Open. 2019;2(8):e199139. doi:10.1001/jamanetworkopen.2019.9139
    Key Points español 中文 (chinese)

    Question  What are the correlations between types of quality measures in treatment of diabetes, and how might these correlations be associated with quality-based reimbursement for chronic diseases?

    Findings  In this cross-sectional study of 652 258 adults with diabetes from 2010 to 2014 at the clinical practice group level, correlations among quality measures were weak, and process and disease control performance were not strongly associated with hospitalization rates. Process and disease control performance at the clinical practice group level explained 3.9% of the variation in hospitalization rates at the individual level.

    Meaning  These findings raise concern about the use of utilization-based outcomes (hospitalizations) as a measure of quality in chronic diseases.


    Importance  Clinical practice group performance on quality measures associated with chronic disease management has become central to reimbursement. Therefore, it is important to determine whether commonly used process and disease control measures for chronic conditions correlate with utilization-based outcomes, as they do in acute disease.

    Objective  To examine the associations among clinical practice group performance on diabetes quality measures, including process measures, disease control measures, and utilization-based outcomes.

    Design, Setting, and Participants  This retrospective, cross-sectional analysis examined commercial claims data from a national health insurance plan. A cohort of eligible beneficiaries with diabetes aged 18 to 65 years who were enrolled for at least 12 months from January 1, 2010, through December 31, 2014, was defined. Eligible beneficiaries were attributed to a clinical practice group based on the plurality of their primary care or endocrinology office visits. Data were analyzed from October 1, 2018, through April 30, 2019.

    Main Outcomes and Measures  For each clinical practice group, performance on current diabetes quality measures included 3 process measures (2 testing measures [hemoglobin A1c {HbA1c} and low-density lipoprotein {LDL} testing] and 1 drug use measure [statin use]) and 2 disease control measures (HbA1c <8% and LDL level <100 mg/dL). The rates of utilization-based outcomes, including hospitalization for diabetes and major adverse cardiovascular events (MACEs), were also measured.

    Results  In this cohort of 652 258 beneficiaries with diabetes from 886 clinical practice groups, 42.9% were aged 51 to 60 years, and 52.6% were men. Beneficiaries lived in areas that were predominantly white (68.1%). At the clinical practice group level, except for high correlation between the 2 testing measures, correlations among different quality measures were weak (r range, 0.010-0.244). Rate of HbA1c of less than 8% had the strongest correlation with hospitalization for MACE (r = −0.046; P = .03) and diabetes (r = −0.109; P < .001). Rates of HbA1c control at the clinical practice group level were not significantly associated with likelihood of hospitalization at the individual level. Performance on the process and disease control measures together explained 3.9% of the variation in the likelihood of hospitalization for a MACE or diabetes at the individual level.

    Conclusions and Relevance  In this study, performance on utilization-based measures—intended to reflect the quality of chronic disease management—was only weakly associated with direct measures of chronic disease management, namely, disease control measures. This correlation should be considered when determining the degree of financial emphasis to place on hospitalization rates as a measure of quality in treatment of chronic diseases.