Objectives: To evaluate facility rankings in achieving <7% A1c levels based upon the complexity of glycemic treatment regimens (CGR) using threshold and continuous measures.

Research Design and Methods: Retrospective administrative data analysis of Veterans Health Administration Medical Centers in 2003-2004. Eligible patients were identified using National Committee for Quality Assurance (NCQA) measure specifications. CGR was defined as receipt of insulin or three oral agents. Facilities were ranked using 5 ordinal categories based upon both Z score distribution and statistical significance (P<0.05). Rankings using the NCQA definition were compared to a subset receiving CGR using both a <7% threshold and a continuous measure awarding proportional credit for values between 7.9% and <7.0%. Ranking correlation was assessed using the Spearman correlation coefficient.

Results: 203,302 patients (mean age 55.2 years) were identified from 127 facilities (range 480-5411, mean 1601); 26.7%(17.9%-35.2%) were on CGR, including 22.0% receiving insulin. Mean A1c and percent achieving <7% were 7.48% and 48% overall and 8.32% and 24.8% for those on CGR using the threshold measure; proportion achieved was 60.1% and 37.2%, respectively, using the continuous measure. Rank correlation between the overall and CGR subset was 0.61; 8 of 24 of the highest or lowest ranked facilities changed to non-significance status; an additional 5 sites changed rankings.

Conclusions: Facility rankings in achieving the NCQA <7% measure as specified differ markedly from rankings using the CGR subset. Measurement for public reporting or payment should stratify rankings by CGR. A continuous measure may better align incentives with treatment intensity.