Developing a Quality Measure for Clinical Inertia in Diabetes Care

Authors

  • Dan R. Berlowitz,

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    • Address correspondence to Dan R. Berlowitz, M.D., M.P.H., CHQOER, ENRM VA Hospital, 200 Springs Road, Bedford, MA 01730. Dan R. Berlowitz, Director, Mark Glickman, Ph.D., and Ashley T. Wong, M.A., are with the Center for Health Quality, Outcomes & Economic Research, Edith Nourse Rogers VA Hospital, Bedford MA. Drs. Berlowitz and Glickman are also with the Department of Health Services, Boston University School of Public Health, Boston. Arlene S. Ash, Ph.D., is with the Health Care Research Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston. Robert H. Friedman, M.D., is with the Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston. Leonard M. Pogach, M.D., M.B.A., is with the VA New Jersey Health Care System for Health Care; Center for Healthcare Knowledge Management, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, East Orange, NJ. Audrey L. Nelson, Ph.D., R.N., F.A.A.N., Associate Chief of Nursing Service, is with the James A. Haley Hospital, Tampa, FL. Dr. Nelson is Director, Patient Safety Center of Inquiry, and Director, HSR&D REAP on Patient Safety Outcomes, and also a Co-Director, AHRQ Patient Safety Research Center on Safe Patient Transitions, VA Patient Safety Center of Inquiry, Tampa, FL.

  • Arlene S. Ash,

  • Mark Glickman,

  • Robert H. Friedman,

  • Leonard M. Pogach,

  • Audrey L. Nelson,

  • Ashley T. Wong


Abstract

Objective. To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.

Data Sources. Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.

Study Design. Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.

Principal Findings. Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p<.001).

Conclusions. Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.

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