Assessing appropriateness of lipid management among patients with diabetes mellitus moving from target to treatment

Ashley J. Beard, Timothy P. Hofer, John R Downs, Michelle Lucatorto, Mandi L. Klamerus, Rob Holleman, Eve A. Kerr

Research output: Contribution to journalArticle

20 Citations (Scopus)

Abstract

Background-Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with highdose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment. Methods and Results-We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients =18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderatedose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is =100 mg/dL. We examined possible overtreatment for patients =18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL =100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort =18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/ dL) had higher rates of potential overtreatment (P<0.001). Conclusions-Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.

Original languageEnglish (US)
Pages (from-to)66-74
Number of pages9
JournalCirculation: Cardiovascular Quality and Outcomes
Volume6
Issue number1
DOIs
StatePublished - Jan 2013
Externally publishedYes

Fingerprint

Hydroxymethylglutaryl-CoA Reductase Inhibitors
LDL Lipoproteins
Diabetes Mellitus
Lipids
Veterans
Therapeutics
Dyslipidemias
Myocardial Ischemia
Primary Health Care
Logistic Models
Costs and Cost Analysis
Medical Overuse

Keywords

  • Cholesterol
  • Diabetes mellitus
  • Lipids
  • Performance measures
  • Quality of care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Assessing appropriateness of lipid management among patients with diabetes mellitus moving from target to treatment. / Beard, Ashley J.; Hofer, Timothy P.; Downs, John R; Lucatorto, Michelle; Klamerus, Mandi L.; Holleman, Rob; Kerr, Eve A.

In: Circulation: Cardiovascular Quality and Outcomes, Vol. 6, No. 1, 01.2013, p. 66-74.

Research output: Contribution to journalArticle

Beard, Ashley J. ; Hofer, Timothy P. ; Downs, John R ; Lucatorto, Michelle ; Klamerus, Mandi L. ; Holleman, Rob ; Kerr, Eve A. / Assessing appropriateness of lipid management among patients with diabetes mellitus moving from target to treatment. In: Circulation: Cardiovascular Quality and Outcomes. 2013 ; Vol. 6, No. 1. pp. 66-74.
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AU - Klamerus, Mandi L.

AU - Holleman, Rob

AU - Kerr, Eve A.

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N2 - Background-Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with highdose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment. Methods and Results-We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients =18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderatedose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is =100 mg/dL. We examined possible overtreatment for patients =18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL =100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort =18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/ dL) had higher rates of potential overtreatment (P<0.001). Conclusions-Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.

AB - Background-Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with highdose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment. Methods and Results-We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients =18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderatedose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is =100 mg/dL. We examined possible overtreatment for patients =18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL =100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort =18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/ dL) had higher rates of potential overtreatment (P<0.001). Conclusions-Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.

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