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  • Measure Summary
  • NQMC:010255
  • May 2012

Distal symmetric polyneuropathy (DSP): percentage of patients age 18 years and older with a diagnosis of DSP who had electrodiagnostic studies conducted, documented and reviewed within 6 months of initial evaluation for DSP.

American Academy of Neurology (AAN). Distal symmetric polyneuropathy: performance measurement set. St. Paul (MN): American Academy of Neurology (AAN); 2012 May 30. 40 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy (DSP) who had electrodiagnostic (EDX) studies conducted, documented and reviewed within 6 months of initial evaluation for DSP.

Rationale

Appropriate diagnosis is critical to ensuring that the patient receives the best possible treatment. Electrodiagnostic studies are one of the three main criteria used for the most accurate diagnosis of distal symmetric polyneuropathy (DSP). Electrodiagnostic studies provide a higher level of specificity for the diagnosis (Dyck et al., 1997; Feldman et al., 1994; Teunissen et al., 1997; Dyck et al., 1992). Electrodiagnostic studies are sensitive, specific, and validated measures of the presence of polyneuropathy (England et al., 2005).

The following evidence statements are quoted verbatim from the referenced clinical guidelines or consensus papers:

  • The combination of neuropathic symptoms, signs, and abnormal electrodiagnostic studies provides the most accurate diagnosis of distal symmetric polyneuropathy (England et al., 2005).
  • Electrodiagnostic studies are recommended as part of the clinical research case definition since they are objective and validated tests of peripheral nerve function. Abnormal electrodiagnostic studies increase the likelihood of the presence of DSP and provide a higher level of specificity to the case definition. Electrodiagnostic studies should not be used alone to make the diagnosis since their sensitivity and specificity are not perfect (England et al., 2005).
  • The simplified minimal requirements for Nerve Conduction Study (NCS) protocol is as follows:
    1. Sural sensory and peroneal motor NCSs are performed in one lower extremity. Taken together, these NCSs are the most sensitive for detecting a distal symmetric polyneuropathy. If both studies are normal, there is no evidence of typical DSP. In such a situation, no further NCSs are necessary (England et al., 2005).
    2. If sural sensory or peroneal motor NCSs are abnormal, the performance of additional NCSs is recommended. This should include NCS of at least the ulnar sensory, median sensory, and ulnar motor nerves in one upper extremity. A contralateral sural sensory and one tibial motor NCS may also be performed according to the discretion of the examiner. Caution is warranted when interpreting median and ulnar studies since there is a possibility of abnormality due to compression of these nerves at the wrist or ulnar neuropathy at the elbow (England et al., 2005).
    3. If a response is absent for any of the nerves studied (sensory or motor, a NCS of the contralateral nerve should be performed (England et al., 2005).
    4. If a peroneal motor response is absent, an ipsilateral tibial motor NCS should be performed (England et al., 2005).
  • Electrodiagnostic studies are not required for field or epidemiologic studies, but the likelihood of diagnosis must be downgraded accordingly (England et al., 2005).

Evidence for Rationale

American Academy of Neurology (AAN). Distal symmetric polyneuropathy: performance measurement set. St. Paul (MN): American Academy of Neurology (AAN); 2012 May 30. 40 p.

Dyck PJ, Davies JL, Litchy WJ, O'Brien PC. Longitudinal assessment of diabetic polyneuropathy using a composite score in the Rochester Diabetic Neuropathy Study cohort. Neurology. 1997 Jul;49(1):229-39. PubMed External Web Site Policy

Dyck PJ, Karnes JL, O'Brien PC, Litchy WJ, Low PA, Melton LJ. The Rochester Diabetic Neuropathy Study: reassessment of tests and criteria for diagnosis and staged severity. Neurology. 1992 Jun;42(6):1164-70. PubMed External Web Site Policy

England JD, Gronseth GS, Franklin G, Miller RG, Asbury AK, Carter GT, Cohen JA, Fisher MA, Howard JF, Kinsella LJ, Latov N, Lewis RA, Low PA, Sumner AJ, American Academy of Neurology, American Association of Electrodiagnostic Medicine, American Academy of Physical Medicine and Rehabilitation. Distal symmetric polyneuropathy: a definition for clinical research: report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2005 Jan 25;64(2):199-207. PubMed External Web Site Policy

Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N, Greene DA. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabetes Care. 1994 Nov;17(11):1281-9. PubMed External Web Site Policy

Teunissen LL, Notermans NC, Franssen H, van der Graaf Y, Oey PL, Linssen WH, van Engelen BG, Ippel PF, van Dijk GW, Gabreëls-Festen AA, Wokke JH. Differences between hereditary motor and sensory neuropathy type 2 and chronic idiopathic axonal neuropathy. A clinical and electrophysiological study. Brain. 1997 Jun;120 (Pt 6):955-62. PubMed External Web Site Policy

Primary Health Components

Distal symmetric polyneuropathy (DSP); electrodiagnostic studies

Denominator Description

All patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy (DSP) (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Patients who had electrodiagnostic (EDX) studies conducted, documented, and reviewed within 6 months of initial evaluation for distal symmetric polyneuropathy (DSP) (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Importance of Topic

Prevalence and Incidence

  • DSP is the most common variety of neuropathy and a type of diabetic neuropathy (Ziegler, 2008; England et al., 2009).
  • Peripheral neuropathy is estimated to affect more than 20 million Americans (The Neuropathy Association, 2010). The overall prevalence is approximately 2,400 (2.4%) per 100,000 population, but in individuals older than 55 years, the prevalence rises to approximately 8,000 (8%) per 100,000 (Martyn & Hughes, 1997; England & Asbury, 2004). Older people are among the top spenders on healthcare. They make up 13% of the U.S. population in 2002, yet they consumed 63% of health care expenses (Shaw et al., 2003). Improving the effectiveness of diagnosis and optimizing patient outcomes will become increasingly important as the population of the United States ages.
  • Neuropathies affect up to 50% of patients with diabetes (Lin & Quan, 2010). DSP affects at least one in four diabetic patients (Ziegler, 2008). Diabetes is one of the five major chronic conditions that affect 25% of the U.S. community population (Stanton, 2006) and amounted to more than $62.3 billion health care costs in 1996 (Druss et al., 2001).
  • The incidence of DSP is 2% per year (Shaw et al., 2003).

Mortality and Morbidity

  • Neuropathies also cause great morbidity because the symptoms severely decrease patients' quality of life. The secondary complications of neuropathy such as falls, foot ulcers, cardiac arrhythmias, and ileus are significant and can lead to fractures, amputations, and even death in patients with diabetes (Lin & Quan, 2010).
  • Pain associated with diabetic neuropathy exerts a substantial impact on the quality of life, particularly by causing considerable interference in sleep and enjoyment of life (Galer, Gianas, & Jensen, 2000). Despite this significant impact, 25% and 39% of the diabetic patients, respectively, had no treatment for their pain in two surveys (Daousi et al., 2004; Chan et al., 1990).
  • Another complication in diabetic neuropathy is the development of foot ulcers, and some reports have estimated that this occurs in approximately 2.5% of patients with diabetes (Lin & Quan, 2010).

Office Visits and Hospital Stays

  • The distal symmetric sensory or distal sensorimotor polyneuropathy represents the most relevant clinical manifestation, affecting 30% of the hospital-based population and 25% of community-based samples of diabetic patients (Shaw et al., 2003).

Family Caregiving

  • Patients describe pain-related interference in multiple health related quality of life (HR-QOL) and functional domains, as well as reduced ability to work and reduced mobility due to their pain. The substantial costs to society of DSP derive from direct medical costs, loss of the ability to work, loss of caregivers' ability to work and possibly greater need for institutionalization or other living assistance (Shojana et al., 2004).

Cost

  • A 1999 survey found that 8% to 9% of Medicare recipients have peripheral neuropathy as their primary or secondary diagnosis. The annual cost to Medicare exceeds $3.5 billion (The Neuropathy Association, 2010)

Opportunity for Improvement

  • DSP is often difficult to diagnose reliably. It is often misdiagnosed or erroneously associated as the side effect of another disease like kidney failure (The Neuropathy Association, 2010). Undiagnosed and untreated neuropathy may lead to disability and poor quality of life. Neuropathy needs to be diagnosed early to prevent complications, such as neuropathic pain or the diabetic foot.
  • Since DSP is the major contributory factor for diabetic foot ulcers and the lower-limb amputation rates in diabetic subjects are 15 times higher than in the non-diabetic population, an early detection of DSP by screening and appropriate diagnosis is of utmost importance. (Boulton et al., 2004). This is even more imperative because many patients with DSP are asymptomatic or have only mild symptoms.
  • Neuropathic pain is often more difficult to treat than many other types of chronic pain. Patients with neuropathic pain have great medical co-morbidity burden than age- and sex-adjusted controls (Shojana et al., 2004). Data collected between 1988 and 1995 (derived from the Centers for Disease Control and Prevention's population-based Behavioral Risk Factor Surveillance System [BRFSS], as well as the National Health and Nutrition Examination [NHANES] surveys) reveal significant quality gaps in the treatment of diabetes and in screening for diabetes-related complications (Lin & Quan, 2010). Diabetics also do not receive appropriate screening measures: only 55% obtain annual foot examinations (Deeb et al., 1988).

Disparities

  • There is currently no consistent data that shows disparities between minorities and whites for diabetes-related neuropathy and peripheral vascular disease (Carter, Pugh, & Monterrosa, 1996). DSP is more common in older adults. Older people are among the top spenders on healthcare. They make up 13% of the US population in 2002, yet they consumed 63% of health care expenses (Shaw et al., 2003). Improving the effectiveness of diagnosis and optimizing patient outcomes will become increasingly important as the population of the United States ages.
  • No definite racial predilection has been demonstrated for diabetic neuropathy. However, members of minority groups (e.g., Hispanics, African Americans) have more secondary complications from diabetic neuropathy, such as lower-extremity amputations, than whites (Carter, Pugh, & Monterrosa, 1996; Dorsey et al., 2009). They also have more hospitalizations for neuropathic complications.
  • Men with type 2 diabetes may develop diabetic polyneuropathy earlier than women, and neuropathic pain causes more morbidity in women than in men (Aaberg et al., 2008).

Evidence for Additional Information Supporting Need for the Measure

Aaberg ML, Burch DM, Hud ZR, Zacharias MP. Gender differences in the onset of diabetic neuropathy. J Diabetes Complications. 2008 Mar-Apr;22(2):83-7. PubMed External Web Site Policy

American Academy of Neurology (AAN). Distal symmetric polyneuropathy: performance measurement set. St. Paul (MN): American Academy of Neurology (AAN); 2012 May 30. 40 p.

Boulton AJ, Malik RA, Arezzo JC, Sosenko JM. Diabetic somatic neuropathies. Diabetes Care. 2004 Jun;27(6):1458-86. PubMed External Web Site Policy

Carter JS, Pugh JA, Monterrosa A. Non-insulin-dependent diabetes mellitus in minorities in the United States. Ann Intern Med. 1996 Aug 1;125(3):221-32. PubMed External Web Site Policy

Chan AW, MacFarlane IA, Bowsher DR, Wells JC, Bessex C, Griffiths K. Chronic pain in patients with diabetes mellitus: comparison with non-diabetic population. Pain Clin. 1990;3:147-59.

Daousi C, MacFarlane IA, Woodward A, Nurmikko TJ, Bundred PE, Benbow SJ. Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. Diabet Med. 2004 Sep;21(9):976-82. PubMed External Web Site Policy

Deeb LC, Pettijohn FP, Shirah JK, Freeman G. Interventions among primary-care practitioners to improve care for preventable complications of diabetes. Diabetes Care. 1988 Mar;11(3):275-80. PubMed External Web Site Policy

Dorsey RR, Eberhardt MS, Gregg EW, Geiss LS. Control of risk factors among people with diagnosed diabetes, by lower extremity disease status. Prev Chronic Dis. 2009 Oct;6(4):A114. PubMed External Web Site Policy

Druss BG, Marcus SC, Olfson M, Tanielian T, Elinson L, Pincus HA. Comparing the national economic burden of five chronic conditions. Health Aff (Millwood). 2001 Nov-Dec;20(6):233-41. PubMed External Web Site Policy

England JD, Asbury AK. Peripheral neuropathy. Lancet. 2004 Jun 26;363(9427):2151-61. [97 references] PubMed External Web Site Policy

England JD, Gronseth GS, Franklin G, Carter GT, Kinsella LJ, Cohen JA, Asbury AK, Szigeti K, Lupski JR, Latov N, Lewis RA, Low PA, Fisher MA, Herrmann DN, Howard JF Jr, Lauria G, Miller RG, Polydefkis M, Sumner AJ. Practice Parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Neurology. 2009 Jan 13;72(2):177-84. [56 references] PubMed External Web Site Policy

Galer BS, Gianas A, Jensen MP. Painful diabetic polyneuropathy: epidemiology, pain description, and quality of life. Diabetes Res Clin Pract. 2000 Feb;47(2):123-8. PubMed External Web Site Policy

Lin HC, Quan D. Diabetic neuropathy. [internet]. [accessed 2010 Dec 16].

Martyn CN, Hughes RA. Epidemiology of peripheral neuropathy. J Neurol Neurosurg Psychiatry. 1997 Apr;62(4):310-8. PubMed External Web Site Policy

Shaw JE, Zimmet PZ, Gries FA, Ziegler D. Epidemiology of diabetic neuropathy. In: Gries FA, Cameron NE, Low PA. Textbook of diabetic neuropathy. 2003. p. 64-82.

Shojania KG, Ranji SR, Shaw LK, Charo LN, Lai JC, Rushakoff RJ, McDonald KM, Owens DK. Closing the quality gap: a critical analysis of quality improvement strategies. Volume 2: diabetes mellitus care. Technical review 9 (Contract no. 290-02-0017 to the Stanford University-UCSF Evidence-based Practice Center) AHRQ Pub no. 04-0051-2. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 Sep. 229 p. [68 references]

Stanton MA. The high concentration of US health care expenditures. Older people are much more likely to be among the top-spending profiles. Vol 19. 2006.

The Neuropathy Association. About peripheral neuropathy: facts. [internet]. [accessed 2010 Dec 17].

Ziegler D. Treatment of diabetic neuropathy and neuropathic pain: how far have we come?. Diabetes Care. 2008 Feb;31 Suppl 2:S255-61. PubMed External Web Site Policy

Extent of Measure Testing

The measures in the set are being made available without any prior testing. The American Academy of Neurology (AAN) welcomes the opportunity to promote the initial testing of these measures and to ensure that any results available from testing are used to refine the measures before implementation.

Evidence for Extent of Measure Testing

American Academy of Neurology (AAN). Distal symmetric polyneuropathy: performance measurement set. St. Paul (MN): American Academy of Neurology (AAN); 2012 May 30. 40 p.

State of Use

Current routine use

Current Use

Internal quality improvement

Professional certification

Measurement Setting

Ambulatory/Office-based Care

Ambulatory Procedure/Imaging Center

Assisted Living Facilities

Home Care

Hospital Outpatient

Skilled Nursing Facilities/Nursing Homes

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy (DSP)

Note: Refer to the original measure documentation for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes and Current Procedural Terminology (CPT) Evaluation and Management (E/M) service codes.

Exclusions
Unspecified

Exceptions

  • Documentation of a medical reason for not conducting, documenting and reviewing electrodiagnosis studies (EDX) studies (e.g., patient has a skin conditions which contraindicates EDX)
  • Documentation of a patient reason for not conducting, documenting and reviewing EDX studies (e.g., patient declines to undergo testing)
  • Documentation of a system reason for not conducting, documenting and reviewing EDX studies (e.g., patient does not have insurance to pay for the testing)

Exclusions/Exceptions

Medical factors addressed

Patient factors addressed

System factors addressed

Numerator Inclusions/Exclusions

Inclusions
Patients who had electrodiagnostic (EDX) studies conducted, documented, and reviewed within 6 months of initial evaluation for distal symmetric polyneuropathy (DSP)

Note:

  • It may be necessary to look for findings in the patient medical record or request studies previously conducted from another physician office which may require additional time. Another electrodiagnostic study should not be performed if a satisfactory study has already been done and can be reviewed.
  • Refer to the original measure documentation for reporting instructions.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Does not apply to this measure

Standard of Comparison

Internal time comparison

Original Title

Measure #2: distal symmetric polyneuropathy (DSP) diagnosis criteria-electrodiagnostic studies.

Measure Collection Name

Distal Symmetric Polyneuropathy Quality Measurement Set

Submitter

American Academy of Neurology - Medical Specialty Society

Developer

American Academy of Neurology - Medical Specialty Society

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Work Group Members Distal Symmetric Polyneuropathy

Co-Chairs: John D. England, MD, FAAN; Gary M. Franklin, MD, MPH, FAAN

Quality Measurement and Reporting Subcommittee Facilitator: Richard M. Dubinsky, MD, MS

American Academy of Neurology: Gil Wolfe, MD; William David, MD; Jeffrey Cohen, MD; Jonathan Goldstein, MD; Victoria Lawson, MD; Amanda Peltier, MD; Benn Smith, MD; Mazen Dimachkie, MD

American Diabetes Association: Susan Kirkman, MD

The Neuropathy Association: Thomas Brannagan, MD; Natacha T. Pires, MBBS

American Academy of Physical Medicine and Rehabilitation: Stephen Kishner, MD

American Association of Neuromuscular & Electrodiagnostic Medicine: Pushpa Narayanaswami, MBBS, DM; Catherine French, MAPL

Humana: Charles Stemple, DO

UnitedHealthcare: Edwin Dasso, MD

American Academy of Neurology Staff: Gina Gjorvad; Rebecca J. Swain-Eng, MS; Sarah Tonn, MPH

Methodologist: Rebecca Kresowik

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2012 May

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

Source(s)

American Academy of Neurology (AAN). Distal symmetric polyneuropathy: performance measurement set. St. Paul (MN): American Academy of Neurology (AAN); 2012 May 30. 40 p.

Measure Availability

Source available from the American Academy of Neurology (AAN) Web site External Web Site Policy.

For more information, contact AAN at 201 Chicago Avenue, Minneapolis, MN 55415; Phone: 800-879-1960; Fax: 612-454-2746; Web site: www.aan.com External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on January 26, 2016. The information was not verified by the measure developer.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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