Diabetes Monitoring for People with Diabetes and Schizophrenia

ACP does not support NQF measure #1934: “Diabetes Monitoring for People with Diabetes and Schizophrenia.” This measure targets a vulnerable population and data exist to support the benefit of screening for diabetes in patients who are diagnosed with schizophrenia AND obesity and who are also prescribed antipsychotic pharmacotherapy on improvements in clinical outcomes. However, the measure is significantly flawed. Developers should consider separating the numerator into two discrete measures: testing for HbA1c and testing for LDL. Also, the specifications should include exclusion criteria for patients who are currently prescribed statin therapy and patient refusal. Furthermore, the one-year time-frame for LDL assessment is not based on clinical evidence and therefore, implementation may promote overuse of direct LDL testing in patients without calculable LDL due to hypertriglyceridemia or in patients who are not fasting. Additionally developers cite clinical guideline recommendations based on expert from the American Heart Association/American College of Cardiology (AHA/ACC) to form the basis of the measure. AHA/ACC recommend monitoring adherence to drug therapy every 3-12 months. Furthermore, the denominator specifications should include an evidence-based age range. The United States Preventive Services Task Force (USPSTF) recommends LDL testing in men aged 35 years and older and men aged 20-35 years if they are at increased risk for coronary heart disease. The USPSTF recommends screening women aged 45 years and older if they are at increased risk of coronary heart disease and women aged 20- 45 yeas if they are at risk for coronary heart disease. Additionally, guideline recommendations on LDL testing in patients who are prescribed statin therapy disagree. LDL testing is not indicated if the patient is currently receiving statin therapy. Some guidelines argue that clinicians need not measure LDL in patients with type II diabetes; rather, they should prescribe statins regardless of LDL results. This controversy in measurement versus treatment makes this a relatively unfair measure. It is burdensome for clinicians to re-check LDL in patients who already receive statin therapy unless the clinician is assessing for adherence to therapy. Of note, the measure is not feasible for implementation at the individual clinician level. While health plans can easily obtain detailed clinical management data from various information systems (e.g., claims, EHRs, pharmacy), clinicians are not privy to the same information. This measure is appropriately specified to assess performance of health plans covering a significant proportion of patients who are diagnosed with mental illness.