Diabetes: Medical Attention for Nephropathy

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. 

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As the seventh leading cause of death in the U.S., diabetes kills approximately 75,000 people a year (CDC FastStats 2015). Diabetes is a group of diseases marked by high blood glucose levels, resulting from the body's inability to produce or use insulin (CDC Statistics 2014, ADA Basics 2013). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and premature death. (CDC Fact Sheet 2014). 

In 2012, diabetes cost the U.S. an estimated $245 billion: $176 billion in direct medical costs and $69 billion in reduced productivity. This is a 41 percent increase from the estimated $174 billion spent on diabetes in 2007 (ADA Economic 2013).  

In 2011, diabetes accounted for 44% of new kidney failure cases. In the same year, 49,677 diabetics started treatment for kidney failure and 228,924 people of all ages with kidney failure due to diabetes were living on chronic dialysis or with a kidney transplant (CDC Statistics, 2014).

American Diabetes Association (2017):

Screening
- At least once a year, quantitatively assess urinary albumin (eg, spot urinary albumin-to-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes duration of greater than or equal to 5 years in all patients with type 2 diabetes, and in all patients with comorbid hypertension. (Level of evidence: B)

Treatment
- An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal UACR (<30 mg/g), and normal estimated glomerular filtration rate. (Level of evidence: B)
- Either an ACE inhibitor or ARB is suggested for the treatment of the nonpregnant patient with modestly elevated UACR (30-299 mg/day) (Level of evidence: C) and is strongly recommended for those with urinary albumin excretion >=300 mg/day. (Level of evidence: A)
- When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium. (Level of evidence: E)
- Continued monitoring of UACR in patients with albuminuria treated with an ACE inhibitor or ARBs is reasonable to assess progression of diabetic kidney disease. (Level of evidence: E)

American Association of Clinical Endocrinologists (2015): 
- Beginning 5 years after diagnosis in patients with type 1 diabetes (if diagnosed before age 30) or at diagnosis in patients with type 2 diabetes and those with type 1 diabetes diagnosed after age 30, annual assessment of serum creatinine to determine the estimated glomerular filtration rate (eGFR) and urine albumin excretion rate (AER) should be performed to identify, stage, and monitor progression of diabetic nephropathy (Grade C; best evidence level 3). 
- Patients with nephropathy should be counseled regarding the need for optimal glycemic control, blood pressure control, dyslipidemia control, and smoking cessation (Grade B; best evidence level 2). 
- In addition, they should have routine monitoring of albuminuria, kidney function electrolytes, and lipids (Grade B; best evidence level 2). 
- Associated conditions such as anemia and bone and mineral disorders should be assessed as kidney function declines (Grade D; best evidence level 4). 
- Referral to a nephrologist is recommended well before the need for renal replacement therapy (Grade D; best evidence level 4).

Higher score indicates better quality

American Diabetes Association. Microvascular complications and foot care. Sec. 10. In Standards of Medical Care in Diabetes-2017. Diabetes Care 2017;40(Suppl. 1):S88-S98.

American Diabetes Association. 2013. Diabetes Basics. www.diabetes.org/diabetes-basics/?loc=GlobalNavDB.

American Diabetes Association (ADA). April 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. Vol. 36 no. 4 
1033-46. http://care.diabetesjournals.org/content/36/4/1033.full.

Centers for Disease Control and Prevention (CDC). 2014. National Diabetes Statistics Report. 
http://www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the-united-states.pdf

Centers for Disease Control and Prevention (CDC). 2015. FastStats: Deaths and Mortality. www.cdc.gov/nchs/fastats/deaths.htm.

Centers for Disease Control and Prevention. 2014. CDC Features. Diabetes Latest. www.cdc.gov/features/diabetesfactsheet/.

Handelsman Y, Bloomgarden ZT, Grunberger G, Umpierrez G, Zimmerman RS, Bailey TS, et al. (2015) American Association of Clinical Endocrinologists and American College of Endocrinology-Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan-2015. Endocr Pract 21 Suppl 1: 1-87.

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Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included

TBD

Patients 18-75 years of age with diabetes with a visit during the measurement period

Equals Initial Population

Exclude patients who were in hospice care during the measurement year

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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