Mitigating case mix factors by choice of glycemic control performance measure threshold

Abstract

Objective: Performance measures are tools for assessing quality of care, but may also be influenced by patient factors. We investigated how currently endorsed performance measures for glycemic control in diabetes may be influenced by case mix composition. We assessed differences in HbA1c performance measure threshold attainment by case mix factors for HbA1c >9% and examined how lowering the threshold to HbA1c >8% or >7% changed these differences.

Research Design and Methods: Using data from the 1999-2002 National Health and Nutrition Examination Survey for 843 adults self-reporting diabetes, we computed the mean difference in HbA1c threshold attainment of >9%, >8%, and >7% by various case mix factors. The mean difference is the average percentage point difference in threshold attainment for population groups compared to the overall population.

Results: Diabetes medication was the only factor for which the difference in threshold attainment increased at lower thresholds, with mean differences of 5.7 percentage points at HbA1c >9% (reference), 10.1 at HbA1c >8% (p<0.05), and 14.1 at HbA1c >7% (p<0.001).

Conclusions: As 87% of U.S. adults have HbA1c <9%, a performance measure threshold of >9% will not drive major improvements in glycemic control. Lower thresholds do not exacerbate differences in threshold attainment for most factors. Reporting by diabetes medication use may compensate for heterogeneous case mix when using a performance measure threshold of HbA1c > 8% or lower.