Quality Indicators for the Care of Diabetes Mellitus in Vulnerable Elders

Diabetes mellitus (DM) is one of the most important causes of morbidity and mortality in the United States. It has been among the top 10 causes of death for several decades, and it is the leading cause of end-stage renal disease and visual loss in individuals younger than 65. Between 13 million and 15 million people have DM, and each year between 500,000 and 700,000 new cases are diagnosed. The prevalence of DM rises dramatically with age; estimates of the prevalence of DM vary from 10% to 20% for persons aged 60 and older. Almost all of these older patients have type 2 DM. Elderly patients are still at risk for the long-term complications of DM, having two times the risk for myocardial infarction (MI), stroke, and renal insufficiency of persons of the same age without DM. There has been a considerable amount of high-quality research on the prevention and management of complications of DM, but most of these data are not specific to elderly patients, and none are specific to individuals aged 80 and older. Thus, most of the data upon which recommendations for care are based apply to the general population of adult patients with DM, and extrapolation of published data to the vulnerable elderly population is a major challenge for developing quality indicators (QIs) for this group. A related challenge pertains to the time frame required to benefit from the proposed indicators. Many testing and management strategies require a minimum of 2 to 3 years (and in some cases, much longer) to accrue significant benefits. Therefore, except where noted, all of the QIs proposed in this article are intended for persons who have a life expectancy of at least 2 to 3 years. METHODS: A total of 105 articles were considered in this review: 29 identified using a Web search, 67 through reference mining, and seven through the Assessing Care of Vulnerable Elders-3 literature searches. Two articles were added during peer review. RESULTS: Of the 10 potential QIs, the expert panel process judged all to be valid. One additional QI was added from Quality Indicators for the Care of Vision Impairment in Vulnerable Elders. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.