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## Complete Summary

#### TITLE

Diagnosis and management of type 2 diabetes mellitus: percentage of
adult patients who have had a screen for A1C, LDL less than 100 mm/dL,
blood pressure less than 130/80, who are current documented non-smokers
and take daily aspirin.

#### SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
management of type 2 diabetes mellitus in adults. Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2008 Mar. 89 p. \[126
references\]

### 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

Process

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the percentage of adult patients who have
had a screen for A1C, low-density lipoprotein (LDL) less than 100 mm/dL,
blood pressure less than 130/80 mm Hg, who are current documented
non-smokers and take daily aspirin.

#### RATIONALE

The priority aims addressed by this measure are:

Percentage of adult patients, ages 18 to 75 with type 2 diabetes
mellitus, who achieve established control around comprehensive measures.

#### PRIMARY CLINICAL COMPONENT

Type 2 diabetes mellitus; hemoglobin A1C; low-density lipoprotein (LDL)
cholesterol; blood pressure; tobacco use; aspirin; clopidogrel;
ticlopidine

#### DENOMINATOR DESCRIPTION

Adult patients with type 2 diabetes mellitus. Two options for defining
the denominator are listed in the related \"Denominator
Inclusions/Exclusions\" field of the Complete Summary.

#### NUMERATOR DESCRIPTION

Adult patients with type 2 diabetes mellitus who meet ALL of the
following criteria: screen for A1C and low-density lipoprotein (LDL),
LDL less than 100 mg/dL, blood pressure less than 130/80 mm Hg, who
don\'t use tobacco and are regularly using aspirin, clopidogrel, or
ticlopidine.

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

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

#### NATIONAL GUIDELINE CLEARINGHOUSE LINK

-   [Diagnosis and management of type 2 diabetes mellitus in
    adults.](http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12693)

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Unspecified

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement

### Application of Measure in its Current Use

#### CARE SETTING

Physician Group Practices/Clinics

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Group Clinical Practices

#### TARGET POPULATION AGE

Age greater than or equal to 18

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Unspecified

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

See the \"Burden of Illness\" field.

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Unspecified

#### BURDEN OF ILLNESS

-   Diabetic inpatients suffer increased morbidity, mortality, length of
    stay, and other related hospital costs compared to non-hyperglycemic
    inpatients. These negative outcomes are observed more frequently in
    hospitalized patients with newly discovered hyperglycemia.
    Hyperglycemia is an independent marker of inpatient mortality in
    patients with undiagnosed diabetes.

-   Hyperglycemia has been associated with increased infection rates and
    poorer short-term and long-term outcomes in critically ill patients
    in the Intensive Care Unit (ICU), post-myocardial infarction (MI),
    and postsurgical settings.

-   Patients with type 2 diabetes are at a significantly high risk for
    development of heart disease.

-   Cardiovascular disease is the primary cause of morbidity and
    mortality in people with type 2 diabetes. The risk of coronary
    artery disease is approximately doubled in men and quadrupled in
    women with diabetes.

-   Seventy to seventy-five percent of adult patients with diabetes die
    of macrovascular disease\--specifically coronary, carotid and/or
    peripheral vascular disease.

-   Dyslipidemia is a known risk factor for macrovascular disease.

-   Small density low-density lipoprotein (LDL) cholesterol (more
    atherogenic) particles are increased in type 2 diabetes, and LDL
    cholesterol itself may differ in people with diabetes compared with
    people without diabetes. Patients with diabetes develop more
    atherosclerosis than patients without diabetes with the same
    quantitative lipoprotein profiles.

-   High triglycerides and low high-density lipoprotein (HDL)
    cholesterol levels are independent risk factors for cardiovascular
    disease in the patient with diabetes.

-   Uncontrolled hypertension is a major cardiovascular risk factor that
    also accelerates the progression of diabetic nephropathy.

-   There is a substantial increase in the prevalence of depression
    among people with diabetes as compared to the general adult
    population. The prevalence of depression is two times as likely in
    people with diabetes and without complications, and depressive
    symptoms may be found in up to 50% of those who have diabetes with
    complications. Depression impacts the ability of a person with
    diabetes to achieve blood glucose control, which in turn impacts the
    rate of development of diabetes complications.

-   In type 2 diabetes, albuminuria may be present at the time of
    diagnosis in about 10% of patients, and another 10% later develop
    it.

-   Up to 21% of patients with type 2 diabetes mellitus are found to
    have retinopathy at the time of diagnosis of diabetes mellitus.
    Prevalence of retinopathy is related to the duration of diabetes
    mellitus. After 20 years of diabetes mellitus, more than 60% of
    patients with type 2 diabetes mellitus have some degree of
    retinopathy. Diabetic retinopathy is estimated to be the most
    frequent cause of new cases of blindness among adults ages 20 to 74
    years.

-   Patients with type 2 diabetes have twice the average risk of
    suffering a stroke.

-   Peripheral arterial disease is commonly associated with diabetes. As
    many as 36 percent of patients with diabetes have lower-extremity
    peripheral arterial disease based on lower-extremity blood pressure
    readings. Peripheral vascular disease in combination with peripheral
    neuropathy places patients with diabetes at increased risk for
    nontraumatic amputations of the lower extremity.

#### EVIDENCE FOR BURDEN OF ILLNESS

American Diabetes Association. Standards of medical care in
diabetes\--2007. Diabetes Care2007 Jan;30(Suppl 1):S4-41. \[234
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17192377)

Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of
comorbid depression in adults with diabetes: a meta-analysis. Diabetes
Care2001 Jun;24(6):1069-78.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11375373)

Consensus development conference on the diagnosis of coronary heart
disease in people with diabetes: 10-11 February 1998, Miami, Florida.
American Diabetes Association. Diabetes Care1998 Sep;21(9):1551-9. \[20
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9727908)

de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association
of depression and diabetes complications: a meta-analysis. Psychosom
Med2001 Jul-Aug;63(4):619-30.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11485116)

Fong DS, Aiello L, Gardner TW, King GL, Blankenship G, Cavallerano JD,
Ferris FL 3rd, Klein R. Retinopathy in diabetes. Diabetes Care2004
Jan;27(Suppl 1):S84-7. \[10 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14693935)

Garg A. Lipid-lowering therapy and macrovascular disease in diabetes
mellitus. Diabetes1992 Oct;41 Suppl 2:111-5. \[35 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1526329)

Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from
coronary heart disease in subjects with type 2 diabetes and in
nondiabetic subjects with and without prior myocardial infarction. N
Engl J Med1998 Jul 23;339(4):229-34.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9673301)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
management of type 2 diabetes mellitus in adults. Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2008 Mar. 89 p. \[126
references\]

Lustman PJ, Gavard JA. Psychosocial aspects of diabetes in adult
populations. In: National Diabetes Data Group. Diabetes in America. 2nd
ed. Bethesda (MD): National Institutes of Health, National Institute of
Diabetes and Digestive and Kidney Diseases; 1995. p. 507-18.

Morrish NJ, Stevens LK, Fuller JH, Jarrett RJ, Keen H. Risk factors for
macrovascular disease in diabetes mellitus: the London follow-up to the
WHO Multinational Study of Vascular Disease in Diabetics.
Diabetologia1991 Aug;34(8):590-4.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1936663)

Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE.
Hyperglycemia: an independent marker of in-hospital mortality in
patients with undiagnosed diabetes. J Clin Endocrinol Metab2002
Mar;87(3):978-82.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11889147)

van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz
M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin
therapy in the critically ill patients. N Engl J Med2001 Nov
8;345(19):1359-67.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11794168)

#### UTILIZATION

Unspecified

#### COSTS

Unspecified

### 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

Adult patients with diabetes mellitus. Two options for defining the
denominator are listed in the \"Denominator Inclusions/Exclusions\"
field.

It is understood that many medical groups will not have electronic
access to an integrated database containing both visit data and lab
data. In this case, manual identification of at least 20 adult patients
meeting the denominator definition will be necessary and the numerator
data collected from the medical record.

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Adult patients with type 2 diabetes mellitus. Two options for defining
the denominator are listed below:

[Definition 1]{.underline}

-   Patients 18 years or older with a primary, secondary, or tertiary
    diagnosis of diabetes (International Classification of Diseases,
    Ninth Revision \[ICD-9\] code 250.xx). Established patients with
    diabetes should be included. This requires both a visit in the
    target month AND a diabetic visit in a window of 12 to 24 months
    before the target month. Both types 1 and 2 are included.

[Definition 2]{.underline}

-   Patients ages 18 to 75 continuously enrolled for the last 12 months
    AND

    a.  Two or more ambulatory visits or one acute inpatient or
        emergency room visit with a primary or secondary diagnosis of
        diabetes in the last 12 months: 250.xx, 362.0x (diabetic
        retinopathy), 366.41 (diabetic cataract), 357.2x (polyneuropathy
        in diabetes)

    b.  One or more prescriptions for insulin in the last 12 months
        (coding is available on disk from either Institute for Clinical
        Systems Improvement \[ICSI\] or from the National Committee for
        Quality Assurance \[NCQA\] Web site \[NCQA.org\]). (See
        Annotation #17, \"Prescribing Insulin Therapy\" in the original
        measure documentation.)

    c.  One or more prescriptions for oral agents in the last 12 months
        (coding is available on disk from either ICSI or from the
        NCQA.org Web site). (See Annotation #19, \"Prescribing
        Non-Insulin Agents\" in the original measure documentation.)

**Exclusions**\
Unspecified

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

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

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Encounter\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window precedes index event

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Adult patients with type 2 diabetes mellitus from the denominator who
meet ALL of the following criteria: screen for A1C and low-density
lipoprotein (LDL), LDL less than 100 mg/dL, blood pressure less than
130/80 mm Hg, who don\'t use tobacco and are regularly using aspirin,
clopidogrel, or ticlopidine.

**Exclusions**\
Unspecified

#### 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

Episode of care

#### DATA SOURCE

Administrative data\
Laboratory data\
Medical record

#### LEVEL OF DETERMINATION OF QUALITY

Not Individual Case

#### OUTCOME TYPE

Clinical Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### 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

Adult patients who have had a screen for A1c value (under review), LDL
less than 100 mm/dL, blood pressure less than 130/80, who are current
documented non-smokers and take daily aspirin.

#### MEASURE COLLECTION

[Diagnosis and Management of Type 2 Diabetes Mellitus in Adults
Measures](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=26&doc=12949)

#### DEVELOPER

Institute for Clinical Systems Improvement

#### ADAPTATION

Measure was not adapted from another source.

#### RELEASE DATE

2003 Nov

#### REVISION DATE

2008 Mar

#### MEASURE STATUS

This is the current release of the measure.

This measure updates a previous version: Institute for Clinical Systems
Improvement (ICSI). Management of type 2 diabetes mellitus. Bloomington
(MN): Institute for Clinical Systems Improvement (ICSI); 2006 Nov. 82 p.

#### SOURCE(S)

Institute for Clinical Systems Improvement (ICSI). Diagnosis and
management of type 2 diabetes mellitus in adults. Bloomington (MN):
Institute for Clinical Systems Improvement (ICSI); 2008 Mar. 89 p. \[126
references\]

#### MEASURE AVAILABILITY

The individual measure, \"Adult Patients Who Have Had a Screen for A1c
Value (Under Review), LDL Less Than 100 mm/dL, Blood Pressure Less Than
130/80, Who Are Current Documented Non-Smokers and Take Daily Aspirin.\"
is published in \"Health Care Guideline: Diagnosis and Management of
Type 2 Diabetes Mellitus in Adults.\" This document is available from
the [Institute for Clinical Systems Improvement (ICSI) Web
site](http://www.icsi.org/guidelines_and_more/guidelines__order_sets___protocols/).

For more information, contact ICSI at, 8009 34th Avenue South, Suite
1200, Bloomington, MN 55425; phone: 952-814-7060; fax: 952-858-9675; Web
site: [www.icsi.org](http://www.icsi.org/); e-mail:
<icsi.info@icsi.org>.

#### NQMC STATUS

This NQMC summary was completed by ECRI on July 6, 2004. This NQMC
summary was updated by ECRI Institute on January 31, 2005, December 30,
2005, February 1, 2007 and again on August 1, 2008.

#### COPYRIGHT STATEMENT

This NQMC summary (abstracted Institute for Clinical Systems Improvement
\[ICSI\] Measure) is based on the original measure, which is subject to
the measure developer\'s copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be
downloaded by any individual or organization. If the abstracted ICSI
Measures are downloaded by an individual, the individual may not
distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization,
copies may be distributed to the organization\'s employees but may not
be distributed outside of the organization without the prior written
consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved
by the Institute for Clinical Systems Improvement, Inc. The Institute
for Clinical Systems Improvement, Inc. assumes no liability for any
adaptations or revisions or modifications made to the abstracts of the
ICSI Measures.

### Disclaimer

#### NQMC DISCLAIMER

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008