Applying diabetes-related prevention quality indicators to a national cohort of veterans with diabetes

OBJECTIVE - The Prevention Quality Indicators (PQIs) are measures of hospitalizations that reflect quality of ambulatory care. We applied the PQIs of metabolic decompensation to Veterans Health Administration (VHA) utilizers with diabetes. We identified patient-level characteristics associated with hospitalization for metabolic decompensation, developed a risk-adjustment model for the measures, and compared regional network performance using these PQIs. RESEARCH DESIGN AND METHODS - This was a retrospective cohort study of 406,575 veterans with diabetes who used the VHA between 1997 and 1999. The outcomes were the PQIs of uncontrolled diabetes, short-term complications, or a combined measure. Patient-level variables were identified from administrative databases. Variation in performance of the networks was compared between full risk adjustment and age and sex adjustment only. RESULTS - In fiscal year 1999, there were 1,719 VHA discharges (4.2 per 1,000 cohort members) for uncontrolled and short-term complications of diabetes. A logistic regression model including age, sex, marital status, Charlson Comorbidity Index, mental health condition, insulin use, and oral antiglycemic medication use was developed for risk adjustment of the combined PQI. Full risk adjustment changed performance ranks of the networks using the combined PQI outcome relative to age and sex adjustment only. Ten networks remained in the same quartile of performance, five moved one quartile, and seven moved two or more quartiles. CONCLUSIONS - The PQIs of uncontrolled and short-term complications of diabetes are uncommon outcomes among veterans with diabetes and should be used only as a combined Outcome. More complete risk adjustment should be used when comparing systems of care using the combined measure.