Comprehensive Diabetes Care: Hemoglobin A1c (HgbA1c)

ACP does not support QPP measure 001: “Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9%).” Measure developers cite a significant performance gap based on data from the 2013 HEDIS reporting year and a large proportion of patients with HbA1c >9% indicates poor quality care. However, there is insufficient evidence to describe an appropriate definition of poor HbA1c control. Furthermore, this measure encourages clinicians to measure A1c in patients with diabetes at least annually while evidence suggests that patients who are well controlled should be re-evaluated every 6 months. The fact that this measure errs on the side of annual evaluation is a conservative treatment approach. Moreover, the measure specifications include several flaws. First, specifications should include appropriate exclusion criteria for patients where the potential harms outweigh the benefits of treating to a target HbA1c (e.g., patients with dementia, patients receiving end of life care, and patients aged > 80 years). Second, developers should consider revising the specifications to include some element of risk-adjustment for socioeconomic status and other unmodifiable risk factors to avoid potentially penalizing clinicians who disproportionately treat a large percentage of patients who cannot easily achieve HbA1c measurements below 9% (e.g., hospice/palliative care clinicians, clinicians who specialize in dementia care). Finally, this measure intends to assess quality performance at the health plan level and implementation at the individual clinician level could unfairly penalize certain clinicians who disproportionately treat a large percentage patients who cannot easily achieve HbA1c measurements <9%.