A recent report from The Netherlands analyzed the relationship between quality of care in diabetes and long-term cardiovascular outcomes. The authors had access to a large database of 10,058 patients with type 2 diabetes. They looked at a number of predictors including whether the patients were treated for high blood glucose, high cholesterol, high blood pressure and albuminuria (a marker of incipient kidney damage in diabetes). Over 3 years, treatment of high lipids and albuminuria were each associated with about a 25% reduction in cardiovascular events and all-cause mortality (HR = 0.77, 0.67–0.88; HR = 0.75, 0.59–0.94). Glucose lowering treatment status was associated with a similar effect, but only in patients with an elevated HbA1c level at baseline (HR = 0.72, 0.56–0.93). (Oddly, treatment of hypertension was not associated with better outcomes.)
This report is important for several reasons. First, it serves to validate that we are probably measuring the right things when we do quality improvement based on the Medicare 5-star program or other quality measurement initiatives based on the HEDIS criteria.
Second, it points out how soon we get the payoff. The effect of high quality management is apparent within 3 years, probably sooner. (Unfortunately, the report does not provide information on exactly when the effects were seen, only that they occurred over the course of the 3-year study.) You don't need to wait 20 years to see the benefits in terms of mortality, morbidity and costs.
Third, this study emphasizes the big opportunity represented by untreated albuminura. Primary care in the US is generally fair to good at tracking A1C and cholesterol in diabetes patients, but our track record with monitoring and managing albuminuria is much worse. So, a big take-home message for me is to work hard on urine monitoring.
Sidorenkov G, Voorham J, de Zeeuw D, Haaijer-Ruskamp FM, Denig P (2013) Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes? PLoS ONE 8(10): e78821. doi:10.1371/journal.pone.0078821