Background

The iDQI is managed by Avalere Health in conjunction with its measure stewards, the Association of Diabetes Care & Education Specialists and Beyond Type 1, with support from Abbott Diabetes Care and Dexcom. The iDQI’s mission is to improve the quality of diabetes care and change standards of care in an era of new and emerging diabetes technology. The iDQI envisions a multi-stakeholder diabetes community united in advancing evidence-based, high-quality, person-centered, and equitable access to care, technology, and services. ​

Diabetes is one of the most widespread chronic conditions in the US, affecting more than 37 million people and costing $327 billion annually. New treatment modalities and medical devices are regularly being developed to improve outcomes for people with diabetes (PWD). Currently, a lag exists between the advent of new technologies and their incorporation into standards of care—in part due to clinical inertia, defined as “the failure to start a new therapy or adjust intensification of existing therapies, when appropriate,” and in part due to the time needed to build a compelling evidence base demonstrating the value of new care approaches. While efforts are ongoing to modernize diabetes quality, currently there is a lack of a trusted, unbiased third party with experience managing complex governance structures and relationships across the healthcare spectrum that can coordinate these efforts and ultimately generate evidence that will support shifts in standards of care.

High-Level Proceedings

Avalere, on behalf of the iDQI, convened measure stewards, current corporate partners, and a broad range of stakeholders with an interest in diabetes, including patient advocacy groups, clinicians, and other industry representatives. The goal of the meeting was to share the iDQI’s recent progress and historic wins and to engage partners in discussion about the future of diabetes care and technology.

Gaps in Optimal Diabetes Care

After sharing the history of iDQI and spotlighting the initiative’s recent efforts, roundtable participants engaged in robust discussion about gaps in optimal quality of diabetes care, including the biggest challenges to modernizing diabetes care.

Key points from the discussion include:

• Evidence-based practice is slow. It takes time to build up sufficient evidence needed to update standards of care and practice guidelines. Because guidelines are foundational to coverage policies—which are a key driver of clinical practice—significant lags may occur before emerging evidence is integrated into care to improve overall public health. Paradoxically, the volume of evidence being released at conferences (e.g., through abstracts, presentations, publications) and in academic journals can be overwhelming. Education of both clinicians and PWD could encourage better diabetes management and care.
• The system gets in its own way. Along all steps of the care and payment continuum, inefficiencies and bottlenecks impede quality outcomes and care experience. One participant shared research findings that estimated the annual cost of providing guideline-recommended care to PWD in an adult practice could range as high as $750,000. Better synthesized evidence with focused recommendations—paired with better technology integration—may be able to mitigate the current state of clinical inertia. Participants concurred that designing the future of diabetes care with provider burden in mind and understanding and optimizing clinical workflows is imperative for making sustainable system-level improvements.
• Incentives are not aligned to outcomes. Many participants shared that current coverage policies do not support the needed time, education, and staffing models (e.g., certified diabetes care and education specialists) for optimal care delivery.
• Access to emerging diabetes technologies is not equitable. The inequities are driven by disparities in care, language barriers, geography, cost, coverage, and provider support and awareness. Participants shared the following considerations related to technology access:
  • An aspect of ongoing care management will be incorporating person-centered outcomes as part of a quality program.
  • Interventions (e.g., consistent access to monitoring, availability of technology, and education regarding self-monitoring blood glucose (SMBG)) to address social determinants of health should be reflected in new quality measures.
  • It is important to recognize how PWD’s overall financial and health security may fluctuate over the course of disease progression (e.g., loss of insurance, changing jobs, onset of comorbidities) and impact adherence and disease management strategies. Each of these changes can alter daily decisions and requires proactive management from a comprehensive care team.

Opportunities

Discussion in the roundtable illuminated potential priority areas for iDQI to address barriers to technology adoption and optimal diabetes care. A resounding opportunity is for continued dialogue with other measure developers and leaders in the diabetes quality space to build upon lessons learned from analog measures (e.g., those related to tobacco cessation), harmonize efforts, and ultimately drive complementary outcomes. A shared understanding of the policy and coverage landscape will compound independent efforts. Therefore, an opportunity is available for coordinated tracking and analysis to cut through the noise.

In the broader policy environment, the Centers for Medicare & Medicaid Services (CMS) issued an updated Local Coverage Determination (LCD) on February 28. The expansion of coverage within the LCD provides an avenue for application of continuous glucose monitoring (CGM) technology (adjunctive and non-adjunctive) to improve health outcomes for Medicare beneficiaries with diabetes who do not administer insulin at least three times daily, as evidenced by a clinically significant reduction in HbA1c, increased time in range, or a reduction in rate or severity of hypoglycemic events compared to when conducting SMBG. Notably, CGMs can now be used to make treatment decisions without the need for a stand-alone blood glucose monitoring to confirm testing results. This can provide an opportunity for broader use of CGM at the primary care level.

Additional opportunities are highlighted in Figure 2.

Avalere applies our expertise in stakeholder convenings, real world evidence generation, learning collaboratives, and diabetes technology to help healthcare stakeholders understand the diabetes landscape to reach their corporate objectives. If you have any questions about iDQI or are interested in learning more about ways to get involved, connect with us.