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## Complete Summary

#### TITLE

Adult diabetes: percentage of patients with most recent blood pressure
less than 140/90 mm Hg.

#### SOURCE(S)

National Diabetes Quality Improvement Alliance performance measurement
set for adult diabetes. Chicago (IL): National Diabetes Quality
Improvement Alliance; 2003 May 1. 11 p.

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure assesses the percentage of adult diabetes patients aged
18-75 years with most recent blood pressure less than 140/90 mm Hg

This measure is used for the purpose of public reporting. The measure is
currently in use for public reporting through the National Committee on
Quality Assurance (NCQA) HEDIS® Program.

#### RATIONALE

Intensive control of blood pressure in patients with diabetes reduces
diabetes complications, diabetes-related deaths, strokes, heart failure,
and microvascular complications.

American Association of Clinical Endocrinologists/American College of
Endocrinology (AACE/ACE) recommends that a blood pressure determination
during the initial evaluation, including orthostatic evaluation, be
included in the initial and every interim physical examination.

American Diabetes Association (ADA) recommends a blood pressure
determination during the initial evaluation (with orthostatic
measurements when indicated) and comparison to age-related norms. The
routine follow-up examinations should include blood pressure
measurement.

The Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC VI) recommends that to detect
evidence of autonomic dysfunction and orthostatic hypertension, blood
pressure should be measured in the supine, sitting, and standing
positions in all patients with diabetes mellitus; automated ambulatory
blood pressure monitoring may be especially helpful.

The National Kidney Foundation (NKF) recommends that all individuals
should be evaluated during health encounters to determine whether they
are at increased risk of having or of developing chronic kidney disease.
This evaluation of risk factors should include blood pressure
measurement.

Clearly, the clinical recommendations and treatment goals for persons
with diabetes define as the target blood pressure less than 130/85 mm
Hg.

The Alliance public reporting measure remains at less than 140/90 for
two reasons:

1.  Many valid reasons may exist why an individual patient does not
    achieve a target blood pressure less than 130/85 mm Hg. Therefore,
    it is not appropriate to hold a large group (e.g., a health plan)
    accountable for a population reaching a blood pressure less than
    130/85 mm Hg.

2.  For population-based measurement, it is desirable to have a
    distribution of results so that populations can be distinguished.
    Based on National Committee for Quality Assurance (NCQA) Health Plan
    Employer Data and Information Set (HEDIS®) 2001 data for the
    treatment of hypertension, at least 55% of commercial health plans
    currently do not meet a population level of less than 140/90.
    Therefore, room for improvement remains at this level.

#### PRIMARY CLINICAL COMPONENT

Diabetes mellitus; hypertension; blood pressure management

#### DENOMINATOR DESCRIPTION

All patients diagnosed with diabetes aged 18-75 years

#### NUMERATOR DESCRIPTION

The number of patients from the denominator with most recent blood
pressure less than 140/90 mm Hg

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Variation in quality for the performance measured

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

American Association of Clinical Endocrinologists, American College of
Endocrinology. Medical guidelines for the management of diabetes
mellitus: the AACE system of intensive diabetes self-management\--2002
update. Endocr Pract2002 Jan-Feb;8(Suppl 1):40-82. \[96 references\]

K/DOQI clinical practice guidelines for chronic kidney disease:
evaluation, classification, and stratification. Kidney Disease Outcome
Quality Initiative. Am J Kidney Dis2002 Feb;39(2 Suppl 2):S1-246.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11904577)

Standards of medical care for patients with diabetes mellitus. Diabetes
Care2002 Jan;25(Suppl 1):S33-49. \[91 references\]

UK Prospective Diabetes Study Group. Tight blood pressure control and
risk of macrovascular and microvascular complications in type 2
diabetes: UKPDS 38 \[published erratum appears in BMJ 1999 Jan
2;318(7175):29\]. BMJ1998 Sep 12;317(7160):703-13.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9732337)

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement\
National reporting

### Application of Measure in its Current Use

#### CARE SETTING

Ambulatory Care\
Community Health Care\
Managed Care Plans\
Physician Group Practices/Clinics\
Rural Health Care

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Physician Assistants\
Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Individual Clinicians

#### TARGET POPULATION AGE

Age 18-75 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

-   Total: 18.2 million people - 6.3% of the population - have diabetes

-   Diagnosed: 13 million people

-   Undiagnosed: 5.2 million people

-   New cases diagnosed per year: 1.3 million

-   About one third of these individuals do not know that they have the
    disease.

#### EVIDENCE FOR INCIDENCE/PREVALENCE

American Diabetes Association. Diabetes statistics. \[internet\].
Alexandria (VA): American Diabetes Association; \[accessed 2004 Jun
11\]. \[2 p\].

National diabetes fact sheet: national estimates on diabetes.
\[internet\]. Atlanta (GA): Centers for Disease Control and Prevention
(CDC), National Center for Chronic Disease Prevention and Health
Promotion; 2003\[updated 2003 Dec 04\]; \[accessed 2004 Feb 01\]. \[8
p\].

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

-   Diabetes is the leading cause of end-stage renal disease, accounting
    for 43% of new cases. Adults with diabetes account for more than 60%
    of nontraumatic lower limb amputations and are also twice as likely
    to have heart disease than people without diabetes.

-   Diabetes is the sixth leading cause of death listed on U.S. death
    certificates in 2000. This is based on the 69,301 death certificates
    in which diabetes was listed as the underlying cause of death.
    Altogether, diabetes contributed to 213,062 deaths.

-   Complications from diabetes include hearth disease, stroke,
    hypertension, retinopathy, end-stage renal disease, peripheral
    neuropathy, non-traumatic lower limb amputations, periodontal
    disease, pregnancy complications affecting mother and fetus,
    ketoacidosis, and coma.

-   Intensive control of blood pressure in patients with diabetes
    reduces diabetes complications, diabetes-related deaths, strokes,
    heart failure, and microvascular complications.

#### EVIDENCE FOR BURDEN OF ILLNESS

American Association of Clinical Endocrinologists, American College of
Endocrinology. Medical guidelines for the management of diabetes
mellitus: the AACE system of intensive diabetes self-management\--2002
update. Endocr Pract2002 Jan-Feb;8(Suppl 1):40-82. \[96 references\]

American Diabetes Association. Diabetes statistics. \[internet\].
Alexandria (VA): American Diabetes Association; \[accessed 2004 Jun
11\]. \[2 p\].

Diabetes Control and Complications Trial Research Group. The absence of
a glycemic threshold for the development of long-term complications: the
perspective of the Diabetes Control and Complications Trial.
Diabetes1996 Oct;45(10):1289-98.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8826962)

Diabetes Control and Complications Trial Research Group. The effect of
intensive treatment of diabetes on the development and progression of
long-term complications in insulin-dependent diabetes mellitus. N Engl J
Med1993 Sep 30;329(14):977-86.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8366922)

National diabetes fact sheet: national estimates on diabetes.
\[internet\]. Atlanta (GA): Centers for Disease Control and Prevention
(CDC), National Center for Chronic Disease Prevention and Health
Promotion; 2003\[updated 2003 Dec 04\]; \[accessed 2004 Feb 01\]. \[8
p\].

Standards of medical care for patients with diabetes mellitus. Diabetes
Care2002 Jan;25(Suppl 1):S33-49. \[91 references\]

UK Prospective Diabetes Study Group. Tight blood pressure control and
risk of macrovascular and microvascular complications in type 2
diabetes: UKPDS 38 \[published erratum appears in BMJ 1999 Jan
2;318(7175):29\]. BMJ1998 Sep 12;317(7160):703-13.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9732337)

#### UTILIZATION

Unspecified

#### COSTS

-   2002 cost of diabetes in the United States: \$132 billion

-   Direct medical costs: \$92 billion

-   Indirect costs: \$40 billion (disability, work loss, premature
    mortality)

#### EVIDENCE FOR COSTS

American Diabetes Association. Diabetes statistics. \[internet\].
Alexandria (VA): American Diabetes Association; \[accessed 2004 Jun
11\]. \[2 p\].

National diabetes fact sheet: national estimates on diabetes.
\[internet\]. Atlanta (GA): Centers for Disease Control and Prevention
(CDC), National Center for Chronic Disease Prevention and Health
Promotion; 2003\[updated 2003 Dec 04\]; \[accessed 2004 Feb 01\]. \[8
p\].

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All patients diagnosed with diabetes aged 18-75 years

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All patients diagnosed with diabetes aged 18-75 years

**Exclusions**\
None

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition

#### DENOMINATOR TIME WINDOW

Time window follows index event

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
The number of patients from the denominator with most recent blood
pressure less than 140/90 mm Hg

**Exclusions**\
None

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Encounter or point in time

#### DATA SOURCE

Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Individual Case

#### OUTCOME TYPE

Clinical Outcome

#### PRE-EXISTING INSTRUMENT USED

None

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a higher score

#### ALLOWANCE FOR PATIENT FACTORS

Unspecified

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

Unspecified

### Identifying Information

#### ORIGINAL TITLE

Percentage of patients with most recent blood pressure less than 140/90
mm Hg.

#### MEASURE COLLECTION

[National Diabetes Quality Improvement Alliance Performance
Measures](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1344&doc=4064)

#### MEASURE SET NAME

[National Diabetes Quality Improvement Alliance Performance Measurement
Set for Adult
Diabetes](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=1344&doc=4065)

#### DEVELOPER

National Diabetes Quality Improvement Alliance

#### FUNDING SOURCE(S)

Unspecified

#### COMPOSITION OF THE GROUP THAT DEVELOPED THE MEASURE

National Committee for Quality Assurance\'s (NCQA\'s) Measurement
Advisory Panels (MAPs) are composed of clinical and research experts
with an understanding of quality performance measurement in the
particular clinical content areas.

#### FINANCIAL DISCLOSURES/OTHER POTENTIAL CONFLICTS OF INTEREST

In order to fulfill National Committee for Quality Assurance\'s
(NCQA\'s) mission and vision of improving health care quality through
measurement, transparency and accountability, all participants in
NCQA\'s expert panels are required to disclose potential conflicts of
interest prior to their participation. The goal of this Conflict Policy
is to ensure that decisions which impact development of NCQA\'s products
and services are made as objectively as possible, without improper bias
or influence.

#### INCLUDED IN

Ambulatory Care Quality Alliance

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2003 May

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

National Diabetes Quality Improvement Alliance performance measurement
set for adult diabetes. Chicago (IL): National Diabetes Quality
Improvement Alliance; 2003 May 1. 11 p.

#### MEASURE AVAILABILITY

The individual measure, \"Percentage of Patients with Most Recent Blood
Pressure Less Than 140/90 mm Hg,\" is published in the \"National
Diabetes Quality Improvement Alliance Performance Measurement Set for
Adult Diabetes.\" This document is available in Portable Document Format
(PDF) from the [National Diabetes Quality Improvement Alliance Web
site](http://www.nationaldiabetesalliance.org/Final_03_Measures.pdf).

#### NQMC STATUS

This NQMC summary was completed by ECRI on December 9, 2003. The
information was verified by the measure developer on August 19, 2004.

#### COPYRIGHT STATEMENT

No copyright restrictions apply, however, the following disclaimer
pertains:

This document was developed and approved by the National Diabetes
Quality Improvement Alliance. No other version of this document is
approved by, or may be presented as the work product of, the National
Diabetes Quality Improvement Alliance. For more information about the
National Diabetes Quality Improvement Alliance, visit the Alliance home
page at
[www.nationaldiabetesalliance.org](http://www.nationaldiabetesalliance.org/).

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/10/2008