- Open Access
Defining and measuring population health quality of outpatient diabetes care in Israel: lessons from the quality indicators in community health program
© The Author(s). 2018
- Received: 24 March 2018
- Accepted: 19 April 2018
- Published: 3 May 2018
The original article was published in Israel Journal of Health Policy Research 2018 7:10
In Israel, as in other Organization for Economic Co-operation and Development countries, performance measurement is a key public health strategy in monitoring and improving population health outcomes. The Israeli Quality Indicators in Community Healthcare (QICH) program has utilized electronic health records to monitor ambulatory care for the entire Israeli population since 2002. In 2006 the measures were updated to include laboratory values. They have been subsequently revised by stratifying by age, duration, adding medications, and changing frequency of testing for certain process measures. However, the QICH glycemic control measures do not address co-morbid conditions either thru exclusion criteria or higher target ranges. They also do not address potential over treatment in patients with complex medication conditions.
In the United States there have also been changes in nationally endorsed diabetes specific performance measures since 2007. However, there have also been public disagreements among United States professional societies, government agencies, and performance measurement organizations as to whether the current glycemic dichotomous (“all or none”) threshold measures, without exclusion criteria, are consistent with the most recent evidence. Specifically, most guidelines now recommend individualized target goals based upon co-morbid conditions, risk of harms from medications, and patient preferences.
Concerns have been raised that the current glycemic performance measures have resulted in inappropriate care, such as medication over-treatment, and serious harms, such as hypoglycemia, especially in older adults. There currently are no national surveillance systems or measures that monitor these untoward outcomes.
We recommend several actions that QICH could consider to advance diabetes specific performance measurement science and population health: Convene an international conference; implement technical modifications of current measures and surveillance systems; and, most importantly, acknowledge patient autonomy by developing measures that document individualization of target values using shared decision making.
- Diabetes measures
- Population health
- Complex conditions
- Unintended harms
Since 2002, the Israel Quality Indicators in Community Healthcare (QICH) program has monitored ambulatory care for the Israeli population using electronic health care records. Indicators were created with the consensus of health plans and the Israeli medical association. Diabetes was one of the initial conditions and was expanded in 2006 to include intermediate outcome data  similar to the National Committee for Quality Assurance (NCQA) measures approved for implementation in 2007 . The QICH denominator differed by including only those patients receiving oral agents or insulin.
Calderon-Margalit et al.  report improved trends in adherence to process outcomes and intermediate outcomes from 2002 to 2010. Since all patients received medications, the improvement is not likely to be attributable to increased prevalence of new-onset diabetes. However, without stratification trends in the < 65 and 65–74-year age groups could not be assessed.
Additionally, there was a positive association of the composite quality indicator score with rates of end-stage complications and mortality from 2006 to 2012, accounting for a lag period. These findings are similar to United States [US] trends . However, unmeasured factors, such as decreased smoking rates or improved care delivery, could be more important than intermediate outcome measures, especially given the short lag time.
QICH continued to utilize the NCQA measures [< 130/80 mm/Hg, < 7% A1c] through 2010 for all patients 18–74 years, although HEDIS revised them in 2008 after early termination of the ACCORD Study. However, after 2012, QICH significantly revised the measures (Ronit Calderon, personal communication). The changes included identification of patients by laboratory value; changing the target values of A1c to < 8% for older patients and those with duration of diabetes greater than 10 years; assessment of patients with nephropathy receiving ACEI/ARB therapy; and changing the frequency of eye examinations from annually to every other year.
Balancing benefits and harms of treatment for individuals while monitoring population health will require a major shift in our approach to diabetes performance measurement. It will be necessary, for some measures, to involve patients and clinicians in setting personalized goals rather than being dictated by “meeting a measure”. Treatment decisions require knowledge-guided by professionalism and patient consent, guided by ethics . “The physician should not treat the disease but the patient who is suffering from it (Rambam).”
LP and DA contributed equally to the commentary. Both authors read and approved the final manuscript.
Drs. Aron and Pogach have published extensively on the topic of diabetes guidelines, medication safety, and diabetes performance measures. The opinions expressed are solely those of the authors, and do not represent any institution or agency.
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