Blood glucose (or sugar) may be vital to brain and muscle function, but it’s possible to have too much of a good thing. Diabetes, a condition characterized by too much sugar in the blood, is associated with a range of health complications. By helping our patients with Type 2 diabetes, we can prevent many poor health outcomes associated with the condition—and the resulting billions in avoidable health care spending.
What is our approach to managing quality for such large populations of patients?
Partners eCare, our electronic health record, allows us to collect health information and develop standardized lists, known as “registries”, to track lab results, blood pressure readings, and other relevant clinical information –all in a single location for an entire population of patients. Our population health coordinators work with our clinical team to review the data from these patient registries regularly, so they can reach out to patients who would benefit from updated lab testing, blood pressure monitoring, procedures, or medication therapy.
What are we measuring and why?
Diabetes and its complications can be well controlled through the close management of blood sugar, blood pressure, and cholesterol. By controlling these, we can help to ensure high quality care and prevention of such preventable complications as kidney disease, vision loss, and heart disease.
How does this measure differ from traditional metrics that rely on claims (billing) data?
We use our electronic health record (EHR) data to identify patients with diabetes, using information entered by clinicians into the general patient problem list and notes from individual office encounters. For glucose monitoring, the EHR requires a more recent (prior 6 months) measurement of HbA1c level. For blood pressure, it captures additional details regarding the results of blood pressure readings over time and across different settings (including home blood pressure readings). For lipids, the EHR accounts for whether patients are treated with the appropriate dose of statin medications. This approach more accurately identifies individuals with this condition, enabling clinicians to make better clinical decisions about patient care.
Glycemic Control
When blood sugar is not well controlled, diabetes can trigger harmful effects on blood vessels and nerves, ultimately leading to complications including kidney disease and vision loss. To track our effectiveness in managing patients’ blood glucose, we monitor prevalence of patients with diabetes whose blood sugar is under control based on Hemoglobin A1c (HbA1c) level. By using eCare instead of claims data, we have improved the “good blood sugar control” measure as follows: 1) we require the HbA1c to be measured in the last 6 months as opposed to the 12 month timeframe seen in traditional measures, 2) we include all adults over 18 years old (not excluding the elderly over 75 years old), and 3) we allow physicians to document HbA1c results from outside of our system.
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| Total Eligible Patients |
| Year |
BWPO |
CRMA |
MGPO |
NWPHO |
NSHS |
PHS |
| 2018/19 |
13,009 |
6,444 |
16,279 |
6,512 |
9,566 |
51,810 |
| 2019/20 |
12,672 |
6,232 |
16,597 |
6,553 |
10,550 |
52,604 |
Measure Details
Data Periods: April 2018 - March 2019 and April 2019 - March 2020
Partners HealthCare Data Source: Electronic Health Record (EHR) System
Denominator: Adult patients (age≥18 years) with diabetes defined as 1) a diagnosis present on the electronic problem list, or 2) a clinician-entered diagnosis during an office visit in the most recent 12 months, or 3) presence of a billing diagnosis (claims data) in the last 12 months, or 4) the patient has been flagged by the physician as having a diagnosis of diabetes using the EHR registry tool.
Numerator: The number of adult patients with diabetes with a HbA1c level less than or equal to 9% measured in the last 6 months.
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Blood Pressure Control
Patients with diabetes are at high risk for cardiovascular disease, making the control of their high blood pressure even more important. We track the percentage of our eligible patients diagnosed with diabetes whose most recent blood pressure reading, within the past six months, shows it is well controlled. By using eCare instead of claims data, we have improved the good blood pressure control measure as follows: we account for patient age (where risk/benefit assessments of aggressive blood pressure control are needed); we include all adults over 18 years old (not excluding the elderly over 75 years old); and we account for whether the patient is already on maximum medication therapy.
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| Total Eligible Patients |
| Year |
BWPO |
CRMA |
MGPO |
NWPHO |
NSHS |
PHS |
| 2018/19 |
13,009 |
6,444 |
16,279 |
6,512 |
9,566 |
51,810 |
| 2019/20 |
12,757 |
6,232 |
16,626 |
6,558 |
10,561 |
52,734 |
Measure Details
Data Periods: April 2018 - March 2019 and April 2019 - March 2020
Partners HealthCare Data Source: Electronic Health Record (EHR) System
Denominator: Adult patients (age≥18 years) with diabetes defined as 1) a diagnosis present on the electronic problem list, 2) a clinician-entered diagnosis during an office visit in the most recent 12 months, 3) presence of a billing diagnosis (claims data) in the last 12 months, or 4) flagged by the physician as having a diagnosis of diabetes using the EHR registry tool.
Numerator: The number of adult patients with diabetes and a recorded blood pressure reading in the most recent six months and either 1) the most recent blood pressure reading meets the blood pressure goal, or 2) the average of the most recent 3 blood pressure readings within the last 18 months meets the blood pressure goals as defined below:
- Age < 60 years, blood pressure ≤ 140/90 mmHg
- Age ≥ 60 years, diastolic blood pressure < 70 mmHg
- Prescribed three or more antihypertensive medications from three different drug classes (regardless of blood pressure readings)
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Lipid Control
Like high blood pressure, high lipid, or cholesterol, levels in the blood can lead to cardiovascular disease. Therefore, controlling high lipid levels can save lives by preventing these cardiovascular complications. That is why we track patients with diabetes who have their lipids under control, as measured by their LDL cholesterol level or the use of appropriate lipid-lowering medications such as statins. We have improved our definition of lipid control by 1) including all adults 18 years and older with diabetes (not excluding the elderly over 75 years old), 2) allowing physicians to document lipid results from outside of our system, and 3) accounting for whether a patient is already being treated with maximal medication therapy.
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| Total Eligible Patients |
| Year |
BWPO |
CRMA |
MGPO |
NWPHO |
NSHS |
PHS |
| 2018/19 |
13,009 |
6,444 |
16,279 |
6,512 |
9,566 |
51,810 |
| 2019/20 |
9,581 |
4,346 |
12,175 |
4,759 |
7,416 |
38,277 |
Data Periods: April 2018 - March 2019 and April 2019 - March 2020
Partners HealthCare Data Source: Electronic Health Record (EHR) System
Denominator: Adult patients (age≥18 years) with diabetes defined as 1) a diagnosis present on the electronic problem list, 2) a clinician-entered diagnosis during an office visit in the most recent 12 months, 3) presence of a billing diagnosis (claims data) in the last 12 months, or 4) flagged by the physician as having a diagnosis of diabetes using the EHR registry tool.
Numerator: The number of patients with 1) a LDL cholesterol level less than 100 mg/dL measured in the last 12 months or 2) a prescription for a moderate or high dose of a statin medication.
Learn more.
Measure Details
Permanent exclusions allow our clinicians to identify patients for whom we are not actively managing diabetes. We remove these patients from the denominator. This includes patients who are deceased, no longer receiving care from our primary care physician, or those incorrectly diagnosed with diabetes.
Permanent exceptions allow our clinicians to identify patients correctly diagnosed with diabetes but for whom strict glycemic, blood pressure, or lipid control is no longer clinically appropriate. We count these patients as contributing positively to the numerator. This includes patients with a terminal illness or advanced dementia.
Temporary exceptions allow our clinicians to identify patients correctly diagnosed with diabetes, but for whom strict glycemic, blood pressure, or lipid control may be temporarily not clinically appropriate. We count these patients as contributing positively to the numerator for 12 months following this designation. This includes patients who have a competing comorbidity, are compliant with maximum tolerated therapy, are intolerant to medical therapy or have a contraindication, are declining medication, or are not able to afford medication.
