title: Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment.
abstract: BACKGROUND
  Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high-dose 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.
  
  
  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 moderate-dose 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.
authors.affiliation: Center for Clinical Management Research, Department of Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
authors.forename: Ashley J
authors.initials: AJ
authors.lastname: Beard
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Hofer
authors.forename: John R
authors.initials: JR
authors.lastname: Downs
authors.forename: Michelle
authors.initials: M
authors.lastname: Lucatorto
authors.forename: Mandi L
authors.initials: ML
authors.lastname: Klamerus
authors.forename: Rob
authors.initials: R
authors.lastname: Holleman
authors.forename: Eve A
authors.initials: EA
authors.lastname: Kerr
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000097:blood*; D019468:Disease Management; D004305:Dose-Response Relationship, Drug; D050171:Dyslipidemias / Q000097:blood / Q000188:drug therapy*; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008077:Lipoproteins, LDL / Q000097:blood*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D008077:Lipoproteins, LDL