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Tseng CL, Pogach LM, Lu SE, Soroka O, Aron DC. Association of Serious Hypoglycemic Events in Older Adults With Changes in Glycemic Performance Measures. Med Care 2021; 59:612-615. [PMID: 34100463 DOI: 10.1097/mlr.0000000000001528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Reducing serious hypoglycemic events is a Federal-wide objective. Despite studies of trends for rates of serious hypoglycemia in existing literature, rigorous evaluation of links between the observed trends and changes in professional guidelines or performance measures for glycemic control is lacking. OBJECTIVE To evaluate whether changes in professional society guidelines and performance measures for glycemic control correspond to changes in rates of serous hypoglycemia. RESEARCH DESIGN This was a retrospective observational study. We merged Veterans Health Administration (VHA) and Medicare patient-level databases of VHA patients and identified those aged 65 years and above and receiving hypoglycemic agents. We derived age-adjusted and sex-adjusted annual rates and constructed piecewise Poisson regression models adjusting for age and sex to assess time trends of the rates. SUBJECTS VHA patients, 2002-2015. MEASURES The main outcome was the annual rates (2004-2015) of serious hypoglycemia, defined as hypoglycemia-related emergency department visits or hospitalizations. Secondary outcomes were annual rates of hemoglobin (Hb) A1c level <7% and >9%. Age and sex were additional variables. RESULTS The annual rate for hypoglycemia decreased by 4.8% (rate ratio: 0.952; 95% confidence interval, 0.949-0.956) for 2008-2015 but did not change (1.001; 0.994-1.001) in 2004-2008. In 2008-2015, the annual rate for HbA1c <7% decreased by 5.0% (0.950; 0.949-0.951) but for HbA1c >9%, increased by 7.9% (1.079; 1.076-1.082). CONCLUSION The cooccurrence of decreasing rates for HbA1c<7% and serious hypoglycemia since 2008 supports the possibility that withdrawal of a <7% HbA1c measure in 2008 impacted clinical practice and patient outcomes.
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Affiliation(s)
- Chin-Lin Tseng
- Department of Veterans Affairs-New Jersey Health Care System, East Orange
| | - Leonard M Pogach
- Department of Veterans Affairs-New Jersey Health Care System, East Orange
| | - Shou-En Lu
- Department of Veterans Affairs-New Jersey Health Care System, East Orange
- Department of Biostatistics and Epidemiology, Rutgers University-School of Public Health, Piscataway, NJ
| | - Orysya Soroka
- Department of Veterans Affairs-New Jersey Health Care System, East Orange
| | - David C Aron
- Louis Stokes Department of Veterans Affairs Medical Center
- School of Medicine, Case Western Reserve University, Cleveland, OH
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2
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Tseng CL, Aron DC, Soroka O, Lu SE, Myers CE, Pogach LM. Racial differences in trends of serious hypoglycemia among higher risk older adults in US Veterans Health Administration, 2004-2015: Relationship to comorbid conditions, insulin use, and hemoglobin A1c level. J Diabetes Complications 2020; 34:107475. [PMID: 31948777 PMCID: PMC9880802 DOI: 10.1016/j.jdiacomp.2019.107475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 01/31/2023]
Abstract
AIMS To evaluate temporal trends in racial/ethnic groups in rates of serious hypoglycemia among higher risk patients dually enrolled in Veterans Health Administration and Medicare fee-for-service and assess the relationship(s) between hypoglycemia rates, insulin/secretagogues and comorbid conditions. METHODS Retrospective observational serial cross-sectional design. Patients were ≥65 years receiving insulin and/or secretagogues. The primary outcome was the annual (period prevalence) rates (2004-2015), per 1000 patient years, of serious hypoglycemic events, defined as hypoglycemic-related emergency department visits or hospitalizations. RESULTS Subjects were 77-83% White, 7-10% Black, 4-5% Hispanic, <2% women; 38-58% were ≥75 years old; 72-75% had ≥1 comorbidity. In 2004-2015, rates declined from 63.2 to 33.6(-46.9%) in Blacks; 29.7 to 20.3 (-31.6%) in Whites; and 41.8 to 29.6 (-29.3%) in Hispanics. The Black-White rate differences narrowed regardless of insulin use, hemoglobin A1c level, and frequency and various combinations of comorbid conditions. Among insulin users, the Black-White contrast decreased from 34.7 (98.5 vs. 63.8) in 2004 to 13.2 (43.6 vs. 30.4) in 2015; in non-insulin users, the contrast was 25.7 (44.1 vs. 18.4) in 2004 and 10.1 (18.9 vs. 8.8) in 2015. CONCLUSION Marked declines in serious hypoglycemia events occurred across race, medications, and comorbidities, suggesting significant changes in clinical practice.
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Affiliation(s)
- Chin-Lin Tseng
- Department of Veterans Affairs-New Jersey Health Care System, East Orange, NJ, USA.
| | - David C Aron
- Louis Stokes Department of Veterans Affairs Medical Center, Cleveland, OH, USA; School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Orysya Soroka
- Department of Veterans Affairs-New Jersey Health Care System, East Orange, NJ, USA
| | - Shou-En Lu
- Department of Veterans Affairs-New Jersey Health Care System, East Orange, NJ, USA; Department of Biostatistics and Epidemiology, Rutgers University - School of Public Health, Piscataway, NJ, USA
| | - Catherine E Myers
- Department of Veterans Affairs-New Jersey Health Care System, East Orange, NJ, USA; Department of Physiology, Pharmacology, & Neuroscience, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Leonard M Pogach
- Department of Veterans Affairs-New Jersey Health Care System, East Orange, NJ, USA
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3
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Aron DC, Tseng CL, Soroka O, Pogach LM. Balancing measures: identifying unintended consequences of diabetes quality performance measures in patients at high risk for hypoglycemia. Int J Qual Health Care 2018; 31:246-251. [DOI: 10.1093/intqhc/mzy151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 05/10/2018] [Accepted: 06/20/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- David C Aron
- Medical Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chin-Lin Tseng
- Research Service, Department of Veterans Affairs-New Jersey Healthcare System, East Orange, NJ, USA
| | - Orysya Soroka
- Research Service, Department of Veterans Affairs-New Jersey Healthcare System, East Orange, NJ, USA
| | - Leonard M Pogach
- Office of Specialty Care Services, Department of Veterans Affairs, Washington, DC, USA
- Department of Medicine, Rutgers New Jersey School of Medicine, Newark, NJ, USA
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4
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Good CB, Pogach LM. Should Metformin Be First-line Therapy for Patients With Type 2 Diabetes and Chronic Kidney Disease?: Informed Patients Should Decide. JAMA Intern Med 2018; 178:911-912. [PMID: 29868705 DOI: 10.1001/jamainternmed.2018.0301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Chester B Good
- Center for Value-Based Pharmacy Initiatives, UPMC Health Plan, Pittsburgh, Pennsylvania.,Veteran Affairs Center for Medication Safety (VA MedSafe), Hines, Illinois
| | - Leonard M Pogach
- Research Service, Department of Veterans Affairs New Jersey Healthcare System, East Orange
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5
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Pogach LM, Aron DC. Defining and measuring population health quality of outpatient diabetes care in Israel: lessons from the quality indicators in community health program. Isr J Health Policy Res 2018; 7:22. [PMID: 29724239 PMCID: PMC5932887 DOI: 10.1186/s13584-018-0216-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 04/19/2018] [Indexed: 12/12/2022] Open
Abstract
In Israel, as in other Organization for Economic Co-operation and Development countries, performance measurement is a key public health strategy in monitoring and improving population health outcomes. The Israeli Quality Indicators in Community Healthcare (QICH) program has utilized electronic health records to monitor ambulatory care for the entire Israeli population since 2002. In 2006 the measures were updated to include laboratory values. They have been subsequently revised by stratifying by age, duration, adding medications, and changing frequency of testing for certain process measures. However, the QICH glycemic control measures do not address co-morbid conditions either thru exclusion criteria or higher target ranges. They also do not address potential over treatment in patients with complex medication conditions. In the United States there have also been changes in nationally endorsed diabetes specific performance measures since 2007. However, there have also been public disagreements among United States professional societies, government agencies, and performance measurement organizations as to whether the current glycemic dichotomous (“all or none”) threshold measures, without exclusion criteria, are consistent with the most recent evidence. Specifically, most guidelines now recommend individualized target goals based upon co-morbid conditions, risk of harms from medications, and patient preferences. Concerns have been raised that the current glycemic performance measures have resulted in inappropriate care, such as medication over-treatment, and serious harms, such as hypoglycemia, especially in older adults. There currently are no national surveillance systems or measures that monitor these untoward outcomes. We recommend several actions that QICH could consider to advance diabetes specific performance measurement science and population health: Convene an international conference; implement technical modifications of current measures and surveillance systems; and, most importantly, acknowledge patient autonomy by developing measures that document individualization of target values using shared decision making.
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Abstract
AIM To expand the existing United States Agency for Health Research and Quality (AHRQ) Diabetes composite (AHRQ-DC) to include additional preventable hospitalizations specific or relevant to diabetes. METHODS A cross-sectional analysis of 834,696 veteran patients with diabetes aged ≥65 years in 2012. An Expanded Diabetes Composite (Expanded-DC) was developed utilizing: (1) the diabetes-specific category: the AHRQ-DC (short-term and long-term complications, uncontrolled diabetes, lower extremity amputations) and two proposed conditions: hypoglycemia and lower extremity ulcers/inflammation/infections (LEU) and (2) the diabetes-relevant category: the AHRQ-Acute Composite (dehydration, pneumonia, urinary tract infections) and one proposed condition, acute kidney injury (AKI). RESULTS The study population was 98% male, 80% White, 10% Black, and 5% Hispanic; 71% had complex comorbidities. There were 64,243 (77.0 admissions/1000 patients) hospitalizations in the Expanded-DC, compared to 13,523 (16.2) in the AHRQ-DC, a 4.7 fold increase. Hospitalizations from AHRQ-Acute Composite and the three proposed conditions added 79% to the Expanded-DC. LEU and hypoglycemia added 39% to the diabetes-specific category. AKI added 18% to the diabetes-relevant category. Blacks incurred more preventable hospitalizations (85.9) than Whites (74.7); as did patients with complex comorbidities (93.6) versus those without (34.6). CONCLUSION The AHRQ-DC substantially underestimates rates of clinically important preventable hospitalizations in older diabetes patients.
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Affiliation(s)
- Chin-Lin Tseng
- Department of Veterans Affairs-New Jersey Healthcare System, 385 Tremont Avenue, East Orange, NJ, United States.
| | - Orysya Soroka
- Department of Veterans Affairs-New Jersey Healthcare System, 385 Tremont Avenue, East Orange, NJ, United States
| | - Leonard M Pogach
- Department of Veterans Affairs-New Jersey Healthcare System, 385 Tremont Avenue, East Orange, NJ, United States
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7
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Wright SM, Hedin SC, McConnell M, Burke BV, Watts SA, Leslie DM, Aron DC, Pogach LM. Using Shared Decision-Making to Address Possible Overtreatment in Patients at High Risk for Hypoglycemia: The Veterans Health Administration's Choosing Wisely Hypoglycemia Safety Initiative. Clin Diabetes 2018; 36:120-127. [PMID: 29686450 PMCID: PMC5898165 DOI: 10.2337/cd17-0060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
IN BRIEF Successful management of patients with diabetes requires individualizing A1C and treatment goals in conjunction with identifying and managing hypoglycemia risk. This article describes the Veterans Health Administration's Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI), a voluntary program that aims to reduce the occurrence of hypoglycemia through shared decision-making about deintensifying diabetes treatment in a dynamic cohort of patients identified as being at high risk for hypoglycemia and potentially overtreated. The CW-HSI incorporates education for patients and clinicians, as well as clinical decision support tools, and has shown decreases in the proportions of high-risk patients potentially overtreated and impacts on the frequency of reported hypoglycemia.
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Affiliation(s)
| | - Sandra C. Hedin
- VA Great Lakes Health Care System (VISN 12), Westchester, IL
| | | | | | | | - Donna M. Leslie
- VA Great Lakes Health Care System (VISN 12), Westchester, IL
| | - David C. Aron
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH
| | - Leonard M. Pogach
- Veterans Health Administration Office of Specialty Care Services, Washington, DC
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8
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Helmer DA, Rowneki M, Feng X, Tseng CL, Rose D, Soroka O, Fried D, Jani N, Pogach LM, Sambamoorthi U. State-Level Variability in Veteran Reliance on Veterans Health Administration and Potentially Preventable Hospitalizations: A Geospatial Analysis. Inquiry 2018; 55:46958018756216. [PMID: 29490533 PMCID: PMC5846924 DOI: 10.1177/0046958018756216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Most Veterans who use the Veterans Health Administration (VHA) also utilize private-sector health care providers. To better inform local and regional health care planning, we assessed the association between reliance on VHA ambulatory care and total and system-specific preventable hospitalization rates (PHRs) at the state level. We conducted a retrospective dynamic cohort study using Veterans with diabetes mellitus, aged 66 years or older, and dually enrolled in VHA and Medicare parts A and B from 2004 to 2010. While controlling for median age and proportion of males, we measured the association between reliance on VHA ambulatory care and PHRs at the state level using multivariable ordinary least square regression, geographically weighted regression, and generalized additive models. We measured geospatial patterns in PHRs using global Moran’s I and univariate local indicator spatial analysis. Approximately 30% of hospitalized Veterans experienced a preventable hospitalization. Reliance on VHA ambulatory care at the state level ranged from 13.92% to 67.78% and was generally not associated with PHRs. Geospatial analysis consistently identified a cluster of western states with low PHRs from 2006 to 2010. Given the generally low reliance on VHA ambulatory care and lack of association between this reliance and PHRs, policy changes to improve Veterans’ health care outcomes should address private-sector care in addition to VHA care.
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Affiliation(s)
- Drew A Helmer
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA.,2 Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Mazhgan Rowneki
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA
| | - Xue Feng
- 3 West Virginia University, School of Pharmacy, Morgantown, USA
| | - Chin-Lin Tseng
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA
| | - Danielle Rose
- 4 Veteran Affairs Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Orysya Soroka
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA
| | - Dennis Fried
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA
| | - Nisha Jani
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA.,5 Rutgers University, School of Public Health, Newark, NJ, USA
| | - Leonard M Pogach
- 1 War Related Illness and Injury Study Center, Veterans Affairs New Jersey Medical Center, East Orange, NJ, USA
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9
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Helfrich CD, Rose AJ, Hartmann CW, van Bodegom-Vos L, Graham ID, Wood SJ, Majerczyk BR, Good CB, Pogach LM, Ball SL, Au DH, Aron DC. How the dual process model of human cognition can inform efforts to de-implement ineffective and harmful clinical practices: A preliminary model of unlearning and substitution. J Eval Clin Pract 2018; 24:198-205. [PMID: 29314508 PMCID: PMC5900912 DOI: 10.1111/jep.12855] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 11/29/2022]
Abstract
RATIONALE AND OBJECTIVES One way to understand medical overuse at the clinician level is in terms of clinical decision-making processes that are normally adaptive but become maladaptive. In psychology, dual process models of cognition propose 2 decision-making processes. Reflective cognition is a conscious process of evaluating options based on some combination of utility, risk, capabilities, and/or social influences. Automatic cognition is a largely unconscious process occurring in response to environmental or emotive cues based on previously learned, ingrained heuristics. De-implementation strategies directed at clinicians may be conceptualized as corresponding to cognition: (1) a process of unlearning based on reflective cognition and (2) a process of substitution based on automatic cognition. RESULTS We define unlearning as a process in which clinicians consciously change their knowledge, beliefs, and intentions about an ineffective practice and alter their behaviour accordingly. Unlearning has been described as "the questioning of established knowledge, habits, beliefs and assumptions as a prerequisite to identifying inappropriate or obsolete knowledge underpinning and/or embedded in existing practices and routines." We hypothesize that as an unintended consequence of unlearning strategies clinicians may experience "reactance," ie, feel their professional prerogative is being violated and, consequently, increase their commitment to the ineffective practice. We define substitution as replacing the ineffective practice with one or more alternatives. A substitute is a specific alternative action or decision that either precludes the ineffective practice or makes it less likely to occur. Both approaches may work independently, eg, a substitute could displace an ineffective practice without changing clinicians' knowledge, and unlearning could occur even if no alternative exists. For some clinical practice, unlearning and substitution strategies may be most effectively used together. CONCLUSIONS By taking into account the dual process model of cognition, we may be able to design de-implementation strategies matched to clinicians' decision-making processes and avoid unintended consequence.
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Affiliation(s)
- Christian D Helfrich
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, USA
| | - Adam J Rose
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research (CHOIR) Bedford VA Medical Center, Bedford, USA.,Boston University School of Public Health, Boston, USA
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Suzanne J Wood
- Graduate Program in Health Services Administration, Department of Health Sciences, School of Public Health, University of Washington, Seattle, USA
| | - Barbara R Majerczyk
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh healthcare System, Department of Veterans Affairs, Pittsburgh, USA.,Medical Advisory Panel for Pharmacy Benefits Management, Department of Veterans Affairs, Washington, USA.,University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Leonard M Pogach
- Office of Specialty Care, Veterans Health Administration, Washington, USA.,VA New Jersey Health Care System, East Orange, USA
| | - Sherry L Ball
- Louis Stokes Cleveland VA Medical Center, Department of Veterans Affairs, Cleveland, USA
| | - David H Au
- VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, USA
| | - David C Aron
- Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, USA.,Division of Clinical and Molecular Endocrinology and Adjunct Professor Dept. of Organizational Behavior, Weatherhead School of Management, Case Western Reserve University, Cleveland, USA
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10
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Tschanz MP, Watts SA, Colburn JA, Conlin PR, Pogach LM. Overview and Discussion of the 2017 VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care. Fed Pract 2017; 34:S14-S19. [PMID: 30766312 PMCID: PMC6375527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The 2017 diabetes mellitus guidelines emphasize shared decision making, dietary changes, and HbA1c target range for optimal control of diabetes mellitus.
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Affiliation(s)
- Mark P Tschanz
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Sharon A Watts
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Jeffrey A Colburn
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Paul R Conlin
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Leonard M Pogach
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
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11
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Pogach LM, Aron DC. Comment on Bloomgarden et al. Is HbA 1c <7% a Marker of Poor Performance in Individuals >65 Years Old? Diabetes Care 2017;40:526-528. Diabetes Care 2017; 40:e152-e153. [PMID: 28931710 DOI: 10.2337/dc17-0893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Leonard M Pogach
- Office of Specialty Care Services, Department of Veterans Affairs, Washington, DC
| | - David C Aron
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH .,Case Western Reserve University School of Medicine, Cleveland, OH
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12
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Jasuja GK, Bhasin S, Rose AJ, Reisman JI, Hanlon JT, Miller DR, Morreale AP, Pogach LM, Cunningham FE, Park A, Wiener RS, Gifford AL, Berlowitz DR. Provider and Site-Level Determinants of Testosterone Prescribing in the Veterans Healthcare System. J Clin Endocrinol Metab 2017; 102:3226-3233. [PMID: 28911150 PMCID: PMC5587071 DOI: 10.1210/jc.2017-00468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 05/26/2017] [Indexed: 01/05/2023]
Abstract
CONTEXT Testosterone prescribing rates have increased substantially in the past decade. However, little is known about the context within which such prescriptions occur. OBJECTIVE We evaluated provider- and site-level determinants of receipt of testosterone and of guideline-concordant testosterone prescribing. DESIGN This study was cross-sectional in design. SETTING This study was conducted at the Veterans Health Administration (VA). PARTICIPANTS Study participants were a national cohort of male patients who had received at least one outpatient prescription within the VA during fiscal year (FY) 2008 to FY 2012. A total of 38,648 providers and 130 stations were associated with these patients. MAIN OUTCOME MEASURE This study measured receipt of testosterone and guideline-concordant testosterone prescribing. RESULTS Providers ranging in age from 31 to 60 years, with less experience in the VA [all adjusted odds ratio (AOR), <2; P < 0.01] and credentialed as medical doctors in endocrinology (AOR, 3.88; P < 0.01) and urology (AOR, 1.48; P < 0.01) were more likely to prescribe testosterone compared with older providers, providers of longer VA tenure, and primary care providers, respectively. Sites located in the West compared with the Northeast [AOR, 1.75; 95% confidence interval (CI), 1.45-2.11] and care received at a community-based outpatient clinic compared with a medical center (AOR, 1.22; 95% CI, 1.20-1.24) also predicted testosterone use. Although they were more likely to prescribe testosterone, endocrinologists were also more likely to obtain an appropriate workup before prescribing compared with primary care providers (AOR, 2.14; 95% CI, 1.54-2.97). CONCLUSIONS Our results highlight the opportunity to intervene at both the provider and the site levels to improve testosterone prescribing. This study also provides a useful example of how to examine contributions to prescribing variation at different levels of the health care system.
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Affiliation(s)
- Guneet K. Jasuja
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
| | - Shalender Bhasin
- Research Program in Men’s Health, Aging and Metabolism, Boston Claude D. Pepper Older Americans Independence Center, Brigham and Women’s Hospital, Harvard Medical School Boston, Boston, Massachusetts 02115
| | - Adam J. Rose
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Joseph T. Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania 15213
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
| | - Anthony P. Morreale
- Clinical Pharmacy Services and Healthcare Services Research, VA Pharmacy Benefits Management Services VACO, San Diego, California 92161
| | - Leonard M. Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, East Orange, New Jersey 07018
| | | | - Angela Park
- New England Veterans Engineering Resource Center, Boston, Massachusetts 02130
| | - Renda S. Wiener
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Medicine, The Pulmonary Center, Boston University, Boston, Massachusetts 02118
| | - Allen L. Gifford
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts 02118
| | - Dan R. Berlowitz
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM VAMC, Bedford, Massachusetts 01730
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts 02118
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Tseng CL, Lafrance JP, Lu SE, Soroka O, Miller DR, Maney M, Pogach LM. Variability in estimated glomerular filtration rate values is a risk factor in chronic kidney disease progression among patients with diabetes. BMC Nephrol 2015; 16:34. [PMID: 25885708 PMCID: PMC4377072 DOI: 10.1186/s12882-015-0025-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 02/24/2015] [Indexed: 12/22/2022] Open
Abstract
Background It is unknown whether variability of estimated Glomerular Filtration Rate (eGFR) is a risk factor for dialysis or death in patients with chronic kidney disease (CKD). This study aimed to evaluate variability of estimated Glomerular Filtration Rate (eGFR) as a risk factor for dialysis or death to facilitate optimum care among high risk patients. Methods A longitudinal retrospective cohort study of 70,598 Veterans Health Administration veteran patients with diabetes and CKD (stage 3–4) in 2000 with up to 5 years of follow-up. VHA and Medicare files were linked to derive study variables. We used Cox proportional hazards models to evaluate association between time to initial dialysis/death and key independent variables: time-varying eGFR variability (measured by standard deviation (SD)) and eGFR means and slopes while adjusting for prior hospitalizations, and comorbidities. Results There were 76.7% older than 65 years, 97.5% men, and 81.9% Whites. Patients were largely in early stage 3 (61.2%), followed by late stage 3 (28.9%), and stage 4 (9.9%); 29.1%, 46.8%, and 73.3%, respectively, died or had dialysis during the follow-up. eGFR SDs (median: 5.8, 5.1, and 4.0 ml/min/1.73 m2 ) and means (median: 54.1, 41.0, 27.2 ml/min/1.73 m2) from all two-year moving intervals decreased as CKD advanced; eGFR variability (relative to the mean) increased when CKD progressed (median coefficient of variation: 10.9, 12.8, and 15.4). Cox regressions revealed that one unit increase in a patient’s standard deviation of eGFRs from prior two years was significantly associated with about 7% increase in risk of dialysis/death in the current year, similarly in all three CKD stages. This was after adjusting for concurrent means and slopes of eGFRs, demographics, prior hospitalization, and comorbidities. For example, the hazard of dialysis/death increased by 7.2% (hazard ratio:1.072; 95% CI = 1.067, 1.080) in early stage 3. Conclusion eGFR variability was independently associated with elevated risk of dialysis/death even after controlling for eGFR means and slopes. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0025-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chin-Lin Tseng
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA. .,Department of Preventive Medicine and Community Health, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
| | | | - Shou-En Lu
- Department of Biostatistics, Rutgers School of Public Health, Piscataway, NJ, USA.
| | - Orysya Soroka
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA.
| | - Donald R Miller
- Bedford VA Medical Center, Center for Health Quality, Outcomes and Economic Research, Bedford, MA, USA. .,Boston University, School of Public Health, Boston, MA, USA.
| | - Miriam Maney
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA.
| | - Leonard M Pogach
- Department of Veteran Affairs-New Jersey Health Care System, 385 Tremont Avenue, Mail Stop#15, East Orange, NJ, 07018, USA. .,Department of Preventive Medicine and Community Health, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
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Frayne SM, Holmes TH, Berg E, Goldstein MK, Berlowitz DR, Miller DR, Pogach LM, Laungani KJ, Lee TT, Moos R. Mental illness and intensification of diabetes medications: an observational cohort study. BMC Health Serv Res 2014; 14:458. [PMID: 25339147 PMCID: PMC4282515 DOI: 10.1186/1472-6963-14-458] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 09/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mental health condition (MHC) comorbidity is associated with lower intensity care in multiple clinical scenarios. However, little is known about the effect of MHC upon clinicians' decisions about intensifying antiglycemic medications in diabetic patients with poor glycemic control. We examined whether delay in intensification of antiglycemic medications in response to an elevated Hemoglobin A1c (HbA1c) value is longer for patients with MHC than for those without MHC, and whether any such effect varies by specific MHC type. METHODS In this observational study of diabetic Veterans Health Administration (VA) patients on oral antiglycemics with poor glycemic control (HbA1c ≥8) (N =52,526) identified from national VA databases, we applied Cox regression analysis to examine time to intensification of antiglycemics after an elevated HbA1c value in 2003-2004, by MHC status. RESULTS Those with MHC were no less likely to receive intensification: adjusted Hazard Ratio [95% CI] 0.99 [0.96-1.03], 1.13 [1.04-1.23], and 1.12 [1.07-1.18] at 0-14, 15-30 and 31-180 days, respectively. However, patients with substance use disorders were less likely than those without substance use disorders to receive intensification in the first two weeks following a high HbA1c, adjusted Hazard Ratio 0.89 [0.81-0.97], controlling for sex, age, medical comorbidity, other specific MHCs, and index HbA1c value. CONCLUSIONS For most MHCs, diabetic patients with MHC in the VA health care system do not appear to receive less aggressive antiglycemic management. However, the subgroup with substance use disorders does appear to have excess likelihood of non-intensification; interventions targeting this high risk subgroup merit attention.
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Affiliation(s)
- Susan M Frayne
- Department of Veterans Affairs HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
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Abstract
IMPORTANCE Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment. OBJECTIVE To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009. MAIN OUTCOMES AND MEASURES Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks. RESULTS There were 652,378 patients who received insulin and/or a sulfonylurea with an HbA1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205,857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c less than 7.0%. When comorbid conditions were included, 430,178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%. CONCLUSIONS AND RELEVANCE Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.
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Affiliation(s)
- Chin-Lin Tseng
- Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey 2Department of Preventive Medicine, Rutgers University-New Jersey Medical School, Newark
| | - Orysya Soroka
- Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey
| | - Miriam Maney
- Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey
| | - David C Aron
- Department of Medicine, Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio4Interprofessional Implementation Research, Evaluation and Clinical Center, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Leonard M Pogach
- Research Service, Department of Veterans Affairs, New Jersey Health Care System, East Orange, New Jersey 2Department of Preventive Medicine, Rutgers University-New Jersey Medical School, Newark
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Feil DG, Pogach LM. Cognitive impairment is a major risk factor for serious hypoglycaemia; public health intervention is warranted. Evid Based Med 2013; 19:77. [PMID: 24195968 DOI: 10.1136/eb-2013-101525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Denise G Feil
- VA Greater Los Angeles Center of Innovation Center of Excellence, Health Services Research and Development, Sepulveda, CA, USA
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McAndrew LM, Napolitano MA, Pogach LM, Quigley KS, Shantz KL, Vander Veur SS, Foster GD. The impact of self-monitoring of blood glucose on a behavioral weight loss intervention for patients with type 2 diabetes. Diabetes Educ 2012; 39:397-405. [PMID: 22735195 DOI: 10.1177/0145721712449434] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of the study was to examine the association of self-monitoring of blood glucose (SMBG) to weight loss and A1C among participants in a behavioral weight loss intervention. METHODS Multivariate analyses were employed to evaluate the relationship between SMBG and changes in patient weight and A1C levels. Bootstrapping was used to determine whether there was an indirect effect of SMBG on weight loss through diet adherence and an indirect effect of SMBG on A1C through weight loss. RESULTS The relationship between increased SMBG and greater weight loss was mediated by better adherence to diet. The relationship of increased SMBG and greater reductions in A1C were mediated by greater weight loss. CONCLUSIONS Results of the study were consistent with the hypothesis that SMBG leads to an increased adherence to dietary recommendations. For patients who are taught to use their diet to lose weight, increased adherence to dietary recommendations is associated with increased weight loss and subsequently better glucose control. SMBG may be of value as an adjunctive intervention in behavioral programs for type 2 diabetes.
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Affiliation(s)
- Lisa M McAndrew
- The Department of Veterans Affairs New Jersey Healthcare System, War Related Illness and Injury Study Center, East Orange, New Jersey (Dr McAndrew),The University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey (Dr Pogach, Dr McAndrew)
| | - Melissa A Napolitano
- Temple University, Departments of Kinesiology and Public Health and Center for Obesity Research and Education, Philadelphia, Pennsylvania (Dr Napolitano)
| | - Leonard M Pogach
- Department of Veterans Affairs New Jersey Healthcare System, Center for Healthcare Knowledge Management, East Orange, NJ (Dr Pogach),The University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey (Dr Pogach, Dr McAndrew)
| | - Karen S Quigley
- The Center for Health Quality, Outcomes, Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, MA, and the Department of Psychology, Northeastern University, Boston, MA (Dr Quigley)
| | - Kerri Leh Shantz
- Temple University, Center for Obesity Research and Education, Philadelphia, Pennsylvania (Dr Foster, Ms. Shantz, Ms. Vander Veur)
| | - Stephanie S Vander Veur
- Temple University, Center for Obesity Research and Education, Philadelphia, Pennsylvania (Dr Foster, Ms. Shantz, Ms. Vander Veur)
| | - Gary D Foster
- Temple University, Center for Obesity Research and Education, Philadelphia, Pennsylvania (Dr Foster, Ms. Shantz, Ms. Vander Veur)
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Pentakota SR, Rajan M, Fincke BG, Tseng CL, Miller DR, Christiansen CL, Kerr EA, Pogach LM. Does diabetes care differ by type of chronic comorbidity?: An evaluation of the Piette and Kerr framework. Diabetes Care 2012; 35:1285-92. [PMID: 22432109 PMCID: PMC3357228 DOI: 10.2337/dc11-1569] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes. RESEARCH DESIGN AND METHODS Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA(1c) and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency. RESULTS Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA(1c) <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83-1.11]) and lower in the discordant (0.90 [0.81-0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category. CONCLUSIONS Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.
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Affiliation(s)
- Sri Ram Pentakota
- Department of Veterans Affairs, Center for Health Care Knowledge and Management, Veterans Affairs New Jersey Health Care System, East Orange, New Jersey, USA.
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Feil DG, Rajan M, Soroka O, Tseng CL, Miller DR, Pogach LM. Risk of hypoglycemia in older veterans with dementia and cognitive impairment: implications for practice and policy. J Am Geriatr Soc 2011; 59:2263-72. [PMID: 22150156 DOI: 10.1111/j.1532-5415.2011.03726.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To examine the relationship between management of diabetes mellitus and hypoglycemia in older adults with and without dementia and cognitive impairment. DESIGN Cross-sectional database analysis of veterans aged 65 years and older stratified according to dementia, cognitive impairment, age, antiglycemic medications, and glycosylated hemoglobin (Hba1c) level. SETTING Research database with linked clinical, laboratory, pharmacy, and International Classification of Diseases, Ninth Revision, Clinical Modification, codes. PARTICIPANTS Four hundred ninety-seven thousand nine hundred veterans aged 65 and older with diabetes mellitus who obtained services from the Department of Veterans Affairs in fiscal years (FYs) 2002 and 2003. MEASUREMENTS Hypoglycemia, the outcome variable, was identified from outpatient visits, emergency department and inpatient admission codes in FY2003. Independent variables (FY2002-03) included dementia and cognitive impairment, comorbid conditions, extended care and nursing home stays, demographics, antiglycemic medication, and HbA1c levels. RESULTS Prevalence of combined dementia and cognitive impairment was 13.1% for individuals aged 65 to 74 and 24.2% for those aged 75 and older. Mean HbA1c levels were 7.0 ± 1.3% for all participants and 6.9 ± 1.3% for those with dementia. The proportion of participants taking insulin was higher in those with dementia or cognitive impairment (30%) than in those with neither condition (24%). Of all participants taking insulin, more with dementia (26.5%) and cognitive impairment (19.5%) were hypoglycemic than of those with neither condition (14.4%). For all participants, unadjusted odds ratios (ORs) for hypoglycemia were 2.42 (95% confidence interval (CI) = 2.36-2.48) for dementia and 1.72 (95% CI = 1.65-1.79) for cognitive impairment; adjusted ORs were 1.58 (95% CI = 1.53-1.62) for dementia and 1.13 (95% CI = 1.08-1.18) for cognitive impairment. CONCLUSION Diabetes mellitus was managed more intensively in older veterans with dementia and cognitive impairment, and dementia and cognitive impairment were independently associated with greater risk of hypoglycemia.
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Affiliation(s)
- Denise G Feil
- Division of Geriatric Psychiatry, West Los Angeles Veterans Affairs Healthcare Center, Los Angeles, California, USA
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20
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Sambamoorthi U, Mitra S, Findley PA, Pogach LM. Decomposing gender differences in low-density lipoprotein cholesterol among veterans with or at risk for cardiovascular illness. Womens Health Issues 2011; 22:e201-8. [PMID: 22133598 DOI: 10.1016/j.whi.2011.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 08/25/2011] [Accepted: 08/26/2011] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To measure the extent to which gender differences in poor lipid control among individuals at risk for cardiovascular diseases could be explained by patient-level characteristics. STUDY DESIGN Cross-sectional analyses of merged Veteran Health Administration (VHA) and Medicare claims data for the fiscal years (FY) 2002 and 2003 consisting of veterans using VHA facilities and were diagnosed with diabetes or heart disease or hypertension during FY 2002 and had recorded LDL cholesterol values in FY2003 (N = 527,568). There were 10,582 women and 516,986 men veterans. Poor lipid control was defined as LDL cholesterol values ≥130 mg/dL. Multivariate techniques consisted of logistic regressions. Based on the parameter estimates and distribution of individual characteristics, we used a decomposition technique to analyze factors that contributed to the gender difference in poor lipid control. PRINCIPAL FINDINGS A significantly higher percent of women (27.4%) than men (17.1%) had LDL cholesterol values ≥130 mg/dL. Of the 10.3 percentage point difference in lipid control, 3.4 percentage points were explained by variables included in the model. The gender difference in poor lipid control was mostly explained by age, physical illnesses, use of lipid lowering medications and depression. CONCLUSIONS Only one-third of the gender difference in poor lipid control could be explained by differences in individual characteristics, some of which are modifiable or could be used to identify groups at risk with poor lipid control. Our findings suggest that gender differences in lipid control could be partially reduced by increasing the prescription of lipid lowering drugs and treating depression among women. Interventions that improve lipid control in the non-elderly will also benefit women. However the largest part of the difference in lipid control between women and men remains unexplained and further research is needed to identify additional modifiable and unmodifiable factors.
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Affiliation(s)
- Usha Sambamoorthi
- School of Pharmacy, Pharmaceutical Systems and Policy, West Virginia University, Morgantown, WV, USA
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21
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McAndrew LM, Horowitz CR, Lancaster KJ, Quigley KS, Pogach LM, Mora PA, Leventhal H. Association between self-monitoring of blood glucose and diet among minority patients with diabetes. J Diabetes 2011; 3:147-52. [PMID: 21599868 PMCID: PMC4303369 DOI: 10.1111/j.1753-0407.2011.00114.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Self-monitoring of blood glucose (SMBG) is used to regulate glucose control. It is unknown whether SMBG can motivate adherence to dietary recommendations. We predicted that participants who used more SMBG would also report lower fat and greater fruit and vegetable consumption. METHODS The present study was a cross-sectional study of 401 primarily minority individuals living with diabetes in East Harlem, New York. Fat intake and fruit and vegetable consumption were measured with the Block Fruit/Vegetable/Fiber and Fat Screeners. RESULTS Greater frequency of SMBG was associated with lower fat intake (r(s) = -0.15; P < 0.01), but not fruit and vegetable consumption. The effects of SMBG were not moderated by insulin use; thus, the relationship was significant for those individuals both on and not on insulin. A significant interaction was found between frequency of SMBG and changing one's diet in response to SMBG on total fat intake. The data suggest that participants who use SMBG to guide their diet do not have to monitor multiple times a day to benefit. CONCLUSION The present study found that the frequency of SMBG was associated with lower fat intake. Patients are often taught to use SMBG to guide their self-management. This is one of the first studies to examine whether SMBG is associated with better dietary intake.
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Affiliation(s)
- Lisa M McAndrew
- War Related Illness and Injury Study Center and REAP Center for Healthcare Knowledge Management, Department of Veterans Affairs, New Jersey Health Care System, East Orange 07018, USA.
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Aron DC, Pogach LM. ACP Journal Club. Intensive glucose control did not reduce a composite of microvascular events more than standard control in type 2 diabetes. Ann Intern Med 2010; 153:JC5-9. [PMID: 21079216 DOI: 10.7326/0003-4819-153-10-201011160-02009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- David C Aron
- Cleveland VA Medical Center, Cleveland, Ohio, USA
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Abstract
OBJECTIVE To evaluate facility rankings in achieving <7% A1C levels based on the complexity of glycemic treatment regimens using threshold and continuous measures. RESEARCH DESIGN AND METHODS We conducted a retrospective administrative data analysis of Veterans Health Administration Medical Centers in 2003-2004. Eligible patients were identified using National Committee for Quality Assurance (NCQA) measure specifications. A complex glycemic regimen (CGR) was defined as receipt of insulin or three oral agents. Facilities were ranked using five ordinal categories based up both z score distribution and statistical significance (P < 0.05). Rankings using the NCQA definition were compared with a subset receiving CGRs using both a <7% threshold and a continuous measure awarding proportional credit for values between 7.9 and <7.0%. Ranking correlation was assessed using the Spearman correlation coefficient. RESULTS A total of 203,302 patients (mean age 55.2 years) were identified from 127 facilities (range 480-5,411, mean 1,601); 26.7% (17.9-35.2%) were receiving CGRs, including 22.0% receiving insulin. Mean A1C and percent achieving A1C <7% were 7.48 and 48% overall and 8.32 and 24.8% for those receiving CGRs using the threshold measure; proportion achieved was 60.1 and 37.2%, respectively, using the continuous measure. Rank correlation between the overall and CGR subset was 0.61; 8 of 24 of the highest or lowest ranked facilities changed to nonsignificance status; an additional five sites changed rankings. CONCLUSIONS Facility rankings in achieving the NCQA <7% measure as specified differ markedly from rankings using the CGR subset. Measurement for public reporting or payment should stratify rankings by CGR. A continuous measure may better align incentives with treatment intensity.
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Affiliation(s)
- Leonard M Pogach
- Department of Veterans Affairs New Jersey Healthcare System, East Orange, New Jersey, USA.
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Abstract
The objective of this study was to examine differences in self-reported diabetes foot care education, self management behaviors, and barriers to good foot care among veterans with diabetes by race and ethnicity. Data was collected using the Veterans Health Administration Footcare Survey, a validated tool that assessed demographic, general health, diabetes and foot self-care information, barriers to foot self-care, receipt of professional foot care, and satisfaction with current care. We mailed surveys to a random sample of patients with diabetes from eight VA medical centers. Study participants were 81% White; 13% African American; 4% Asian, and 2% American Indian and Pacific Islanders. The majority of respondents felt that they did not know enough about foot self-care. There were large gaps between self-reported knowledge and actual foot care practices, even among those who reported "knowing enough" on a given topic. There were significant differences in self-reported foot care behaviors and education by race and ethnicity. These findings document the need for culturally-specific self-management education to address unique cultural preferences and barriers to care.
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Affiliation(s)
| | - Molly T Hogan
- Department of Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Leonard M Pogach
- Department of Veterans Affairs, New Jersey Healthcare System, Center for Healthcare Knowledge Management, East Orange, NJ, USA
| | - Mangala Rajan
- Department of Veterans Affairs, New Jersey Healthcare System, Center for Healthcare Knowledge Management, East Orange, NJ, USA
| | - Gregory J Raugi
- Division of Dermatology, VA Puget Sound Healthcare System, Department of Veterans Affairs, Seattle, WA, USA
- Correspondence: Gayle Reiber, VA HSR&D, 1100 Olive Way, Ste 1400, Seattle, WA 98101, USA, Tel +1 206 764 2089, Fax +1 206 764 2935, Email
| | - Gayle E Reiber
- Research and Development, VA Puget Sound Healthcare System, Department of Veterans Affairs, Seattle, WA, USA
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Banerjea R, Pogach LM, Smelson D, Sambamoorthi U. Mental Illness and Substance Use Disorders among Women Veterans with Diabetes. Womens Health Issues 2009; 19:446-56. [DOI: 10.1016/j.whi.2009.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Revised: 07/24/2009] [Accepted: 07/24/2009] [Indexed: 01/22/2023]
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Banerjea R, Sambamoorthi U, Smelson D, Pogach LM. Chronic Illness with Complexities: Mental Illness and Substance Use Among Veteran Clinic Users with Diabetes. The American Journal of Drug and Alcohol Abuse 2009; 33:807-21. [DOI: 10.1080/00952990701653701] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- Leonard M Pogach
- Department of Veterans Affairs, New Jersey Health Care System, East Orange, NJ 07018, USA.
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Rose AJ, Hermos JA, Frayne SM, Pogach LM, Berlowitz DR, Miller DR. Does opioid therapy affect quality of care for diabetes mellitus? Am J Manag Care 2009; 15:217-224. [PMID: 19355794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To examine whether veterans who received chronic opioid therapy had worse diabetes performance measures than patients who did not receive opioids. STUDY DESIGN Retrospective cohort study. METHODS We identified all patients with diabetes mellitus receiving care in US Department of Veterans Affairs facilities during 2004. Cases received at least 6 prescriptions for chronic opioids during 2004, while controls were randomly selected from among patients with diabetes who received no opioids. We compared process measures (glycosylated hemoglobin and low-density lipoprotein cholesterol levels tested and an eye examination performed) and outcome measures (glycosylated hemoglobin level < or =9.0% and low-density lipoprotein cholesterol level < or =130 mg/dL) between groups. RESULTS Cases (n = 47,756) had slightly worse diabetes performance measures than controls (n = 220,912) after adjustment for covariates. For example, 86.4% of cases and 89.0% of controls had a glycosylated hemoglobin test during fiscal year 2004 (adjusted odds ratio, 0.69; P <.001). Among cases, receipt of higher-dose opioids was associated with additional decrement in diabetes performance measures, with a dose-response relationship. CONCLUSIONS Chronic opioid therapy among patients within the Veterans Affairs system is associated with slightly worse diabetes performance measures compared with patients who do not receive opioids. However, patients receiving higher dosages of opioids had additional decrements in diabetes performance measures; these patients may be appropriate targets for interventions to improve their care for pain and diabetes.
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Affiliation(s)
- Adam J Rose
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, 200 Springs Rd, Bldg 70, Bedford, MA 01730, USA.
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Patel TG, Pogach LM, Barth RH. CKD screening and management in the Veterans Health Administration: the impact of system organization and an innovative electronic record. Am J Kidney Dis 2009; 53:S78-85. [PMID: 19231765 DOI: 10.1053/j.ajkd.2008.07.051] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Accepted: 07/31/2008] [Indexed: 11/11/2022]
Abstract
At the beginning of this decade, Healthy People 2010 issued a series of objectives to "reduce the incidence, morbidity, mortality and health care costs of chronic kidney disease." A necessary feature of any program to reduce the burden of kidney disease in the US population must include mechanisms to screen populations at risk and institute early the aspects of management, such as control of blood pressure, management of diabetes, and, in patients with advanced chronic kidney disease (CKD), preparation for dialysis therapy and proper vascular access management, that can retard CKD progression and improve long-term outcome. The Department of Veterans Affairs and the Veterans Health Administration is a broad-based national health care system that is almost uniquely situated to address these issues and has developed a number of effective approaches using evidence-based clinical practice guidelines, performance measures, innovative use of a robust electronic medical record system, and system oversight during the past decade. In this report, we describe the application of this systems approach to the prevention of CKD in veterans through the treatment of risk factors, identification of CKD in veterans, and oversight of predialysis and dialysis care. The lessons learned and applicability to the private sector are discussed.
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Banerjea R, Sambamoorthi U, Weaver F, Maney M, Pogach LM, Findley T. Risk of stroke, heart attack, and diabetes complications among veterans with spinal cord injury. Arch Phys Med Rehabil 2008; 89:1448-53. [PMID: 18674979 DOI: 10.1016/j.apmr.2007.12.047] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Revised: 11/29/2007] [Accepted: 12/15/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To compare the rates of diabetes and macrovascular conditions in veterans with spinal cord injury (SCI) and to examine variations by patient-level demographic, socioeconomic, access, and health status factors. DESIGN A retrospective analysis. Diabetes status was classified by merging with diabetes epidemiology cohort using a validated algorithm. Chi-square tests and logistic regressions used to compare rates in macro- and microvascular conditions in veterans with and without diabetes. SETTING Veteran Health Administration clinic users in fiscal year (FY) 1999 to FY 2001. PARTICIPANTS SCI patients (N=8769) with diabetes (n=1333), in FY 2000, identified through the SCI registry. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Macrovascular and microvascular conditions in the next year (February 2001). Derived from International Statistical Classification of Diseases, 9th Revision, Clinical Modification, codes in the patient treatment files. RESULTS Overall, 15% of SCI veterans were identified with diabetes but this was an underestimate due to high mortality (8%). Among SCI veterans with diabetes, 49% had at least one macrovascular condition and 54% had microvascular conditions compared with 24% and 25% of those without diabetes (P<.001). CONCLUSIONS Our study highlights the highly significant relationship between diabetes and macro- and microvascular conditions in veterans with SCI. Neurologic deficit combined with increased insulin resistance has a greater macrovascular impact on SCI veterans than on those who do not have diabetes. Increasing age and physical comorbidities compound the problem.
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Affiliation(s)
- Ranjana Banerjea
- Department of Veteran Affairs, Health Services Research and Development Service Center for Health Care Knowledge and Management, East Orange, NJ 07018, USA.
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Banerjea R, Sambamoorthi U, Smelson D, Pogach LM. Expenditures in mental illness and substance use disorders among veteran clinic users with diabetes. J Behav Health Serv Res 2008; 35:290-303. [PMID: 18512155 DOI: 10.1007/s11414-008-9120-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 03/21/2008] [Indexed: 11/29/2022]
Abstract
Few studies have looked at the health-care expenditures of diabetes patients based on the type of co-occurring conditions of mental illness (MI) or substance use disorders (SUD). Our study analyzes the health-care expenditures associated with various diagnostic clusters of co-occurring drug, alcohol, tobacco use, and mental illness in veterans with diabetes. We merged Veteran Health Administration and Medicare fee-for-service claims database (fiscal years 1999 and 2000) for analysis (N = 390,253) using generalized linear models; SUD/MI were identified using International Classification of Diseases, 9th edition codes. The total average expenditures (fiscal year 2000) were lowest ($6,185) in the "No MI and No SUD" and highest ($19,801) for individuals with schizophrenia/other psychoses and alcohol/drug use. High expenditures were associated with both SUD and MI conditions in diabetes patients, and veterans with alcohol/drug use had the highest expenditures across all groups of MI. These findings reinforce the need to target groups with multiple comorbidities specifically those with serious mental illnesses and alcohol/drug use for interventions to reduce health-care expenditures.
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Affiliation(s)
- Ranjana Banerjea
- Center for Healthcare Knowledge Management, VA New Jersey Healthcare System, East Orange, NJ, USA.
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Abstract
OBJECTIVE To examine the role of age and endocrinology care in glycemic testing and control in elderly veterans with diabetes. RESEARCH DESIGN AND METHODS In this retrospective study of Veterans Health Administration clinic users aged > or = 65 years with diabetes, we compared glycemic testing and poor glycemic control (A1C > 9%) between older (> or = 75 years) and younger (65-74 years) veterans in the year 2000. RESULTS Without adjustment, rates for glycemic testing were 70.2% in older and 71.1% in younger veterans, and those for poor control were 9.4% in older and 12.8% in younger veterans. After adjustment, older veterans had 1.8% lower probability of glycemic testing and 2.9% lower probability of poor control than younger veterans. Endocrinology care was associated with a higher probability of both glycemic testing (9.7%) and poor control (1.0%), regardless of age. CONCLUSIONS Glycemic testing and control and effect of endocrinology care were comparable in older and younger veterans with diabetes.
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Affiliation(s)
- Drew A Helmer
- Center for Healthcare Knowledge Management, Veterans Affairs New Jersey Health Care System, East Orange, New Jersey, USA.
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Abstract
BACKGROUND Although momentum is now building nationally for improved informatics, progress has been incremental in most cases. One notable exception is the Veterans Health Administration, which utilizes one of the most widely used electronic medical record systems in the world. OBJECTIVES The articles in this symposium demonstrate the implementation of technology to move beyond the electronic medical record at the time of the medical encounter to improve timeliness and outcomes of care delivery for veterans with diabetes. RESULTS We report on the use of electronic registries and nurse practitioner-based programs across multiple sites to improve glycemic control; the implementation of a digital retinal imaging system in primary care clinics; the use of health information technology to improve patient self-care; and the development of a research database to move beyond performance measurement to evaluate longitudinal outcomes. CONCLUSIONS While these articles demonstrate the ability of a single national system of care to harness the power of technology to novel strategies for the delivery of care and its evaluation, the technology is scalable from small group practices to regional health care systems.
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Affiliation(s)
- David C Aron
- Louis Stokes Veterans Affairs Medical Center, Cleveland, Ohio, USA
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Aron DC, Pogach LM. One Size Does Not Fit All: The Need for a Continuous Measure for Glycemic Control in Diabetes. Jt Comm J Qual Patient Saf 2007; 33:636-43. [DOI: 10.1016/s1553-7250(07)33073-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kahler KH, Rajan M, Rhoads GG, Safford MM, Demissie K, Lu SE, Pogach LM. Impact of oral antihyperglycemic therapy on all-cause mortality among patients with diabetes in the Veterans Health Administration. Diabetes Care 2007; 30:1689-93. [PMID: 17440170 DOI: 10.2337/dc06-2272] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this analysis was to evaluate the impact of several classes of oral antihyperglycemic therapy relative to sulfonylurea monotherapy on all-cause mortality among a cohort of patients with diabetes from the Veterans Health Administration (VHA). RESEARCH DESIGN AND METHODS A retrospective cohort study using data obtained from the VHA Diabetes Epidemiology Cohort was used. Users of oral antihyperglycemic therapy were classified into the following cohorts: sulfonylurea monotherapy, metformin monotherapy, metformin plus sulfonylurea, thiazolidinedione (TZD) use alone or in combination with other oral agents (TZD users), and no drug therapy. All-cause mortality was the outcome of interest. Multivariate mixed models incorporating a propensity score to account for imbalance among cohorts were used to estimate drug effects on mortality with associated 95% CIs. RESULTS A total of 39,721 patients with diabetes were included in the study. Adjusted odds ratios and 95% CIs for all-cause mortality were 0.87 (0.68-1.10) for metformin monotherapy users, 0.92 (0.82-1.05) for metformin plus sulfonylurea users, and 1.04 (0.75-1.46) for TZD users, relative to sulfonylurea monotherapy users. CONCLUSIONS We did not find any significant drug effect on all-cause mortality for any oral treatment cohorts relative to sulfonylurea oral monotherapy.
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Affiliation(s)
- Kristijan H Kahler
- Center for Health Care Knowledge and Management, VA New Jersey Health Care System, East Orange, New Jersey, USA.
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Pogach LM, Tiwari A, Maney M, Rajan M, Miller DR, Aron D. Should mitigating comorbidities be considered in assessing healthcare plan performance in achieving optimal glycemic control? Am J Manag Care 2007; 13:133-40. [PMID: 17335354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Whether a public reporting measure for glycosylated hemoglobin (A1C) of less than 7% should apply to all persons with diabetes mellitus is a matter of ongoing controversy. OBJECTIVE To evaluate the effect of excluding persons with major medical or mental health conditions on assessment of healthcare system performance in achieving an A1C level of less than 7%. DESIGN AND SETTING Retrospective longitudinal administrative data analysis from 144 Veterans Health Administration medical centers. SUBJECTS Veterans with diabetes mellitus younger than 65 years who were users of Veterans Health Administration healthcare in fiscal years 1999 and 2000. MAJOR OUTCOME VARIABLES: The proportions, 5-year mortality, and glycemic control of individuals with and without major comorbid conditions, as well as changes in league table rankings of facilities achieving an A1C threshold of less than 7% with and without the inclusion of seriously ill individuals. RESULTS There were 220 922 subjects identified from 144 facilities. We identified 75 296 individuals (mean +/- SD facility range of excluded individuals, 33.3% +/- 5.3%) with conditions that would decrease the benefits or increase risks of glycemic control. The 5-year unadjusted mortality was 36.0% in 48 001 subjects (21.7%) excluded for major medical or neurological conditions, 14.9% in 17 515 subjects (7.9%) excluded for major mental health conditions, and 16.5% in 9780 subjects (4.4%) excluded for 2 or more other serious comorbid medical or psychological conditions, compared with 8.8% in the remaining subjects. A comparison of industry league table rankings indicated that 20% of the best and worse facilities changed 1 decile when ranking using exclusion criteria. CONCLUSION One in 3 veterans has comorbid conditions that would increase the risks or decrease the benefits of intensive glycemic control. We propose that a public reporting measure for A1C of less than 7% be subjected to exclusion criteria rather than be applied to all persons with diabetes mellitus.
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Affiliation(s)
- Leonard M Pogach
- Health Services Research and Development Center for Healthcare Knowledge Management Research, Department of Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave, E Orange, NJ 07018, USA.
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Maney M, Tseng CL, Safford MM, Miller DR, Pogach LM. Impact of self-reported patient characteristics upon assessment of glycemic control in the Veterans Health Administration. Diabetes Care 2007; 30:245-51. [PMID: 17259489 DOI: 10.2337/dc06-0771] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this article was to evaluate the impact of self-reported patient factors on quality assessment of Veterans Health Administration medical centers in achieving glycemic control. RESEARCH DESIGN AND METHODS We linked survey data and administrative records for veterans who self-reported diabetes on a 1999 national weighted survey. Linear regression models were used to adjust A1C levels in fiscal year 2000 for socioeconomic status (education level, employment, and concerns of having enough food), social support (marital status and living alone), health behaviors (smoking, alcohol use, and exercise level), physical and mental health status, BMI, and diabetes duration. Medical centers were ranked by deciles, with and without adjustment for patient characteristics, on proportions of patients achieving A1C <7 or <8%. RESULTS There was substantial medical center level variation in patient characteristics of the 56,740 individuals from 105 centers, e.g., grade school education (mean 15.3% [range 2.3-32.7%]), being retired (38.3% [19.9-59.7%]) or married (65.2% [43.7-77.8%]), food insufficiency (13.9% [7.2-24.6%]), and no reported exercise (43.2% [31.1-53.6%]). The final model had an R(2) of 7.8%. The Spearman rank coefficient comparing the thresholds adjusted only for age and sex to the full model was 0.71 for <7% and 0.64 for <8% (P < 0.0001). After risk adjustment, 4 of the 11 best-performing centers changed at least two deciles for the <7% threshold, and 2 of 11 changed two deciles for the <8% threshold. CONCLUSIONS Adjustment for patient self-reported socioeconomic status and health impacts medical center rankings for glycemic control, suggesting the need for risk adjustment to assure valid inferences about quality.
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Affiliation(s)
- Miriam Maney
- VA HSR&D Center for Healthcare Knowledge Management Research, VA New Jersey Healthcare System, 385 Tremont Avenue, East Orange, NJ, USA
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Aron D, Rajan M, Pogach LM. Summary measures of quality of diabetes care: comparison of continuous weighted performance measurement and dichotomous thresholds. Int J Qual Health Care 2006; 19:29-36. [PMID: 17159196 DOI: 10.1093/intqhc/mzl064] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The Institute of Medicine has suggested that related individual measures of quality be combined into summary measures. Averages of adherence on dichotomous measures for intermediate outcomes have shortcomings because control of individual risk factors differs in their health benefit. Therefore, a common metric is necessary to weight measures appropriately. OBJECTIVE Compare health care system performance using continuous measures weighted based on quality adjusted life years saved (QALYsS) versus dichotomous threshold measures. RESEARCH DESIGN Retrospective cross-sectional analysis of 2000-01 chart abstraction data of diabetic patients from 141 Veterans Health Administration medical centers. Outcome variables included correlation of individual level and facility level adherence to and rankings by continuous weighted individual and summary dichotomous measures for glycemic control (<8% A1c), blood pressure (<140/80 mm/Hg), and low-density lipoprotein-cholesterol (LDL-C) <130 mg/dl. RESULTS The 141 facilities had a range of 163-740 (mean 263) subjects. The population (n = 37 142) was largely male (86.1%) and older (mean age 65.9 years, SD +/-11.4 years), with mean overall A1c of 7.58%, systolic blood pressure of 137.2 mm/Hg, and LDL-C 104.8 mg/dl. There was excellent correlation between QALYsS and dichotomous outcomes for A1c (r = 0.86), blood pressure (r = 0.94), LDL-C (r = 0.95), and the summary measure (r = 0.92), but poor correlation among the risk factors (r = 0.19-0.36). There was considerable difference in rankings between the dichotomous and the continuous weighted measures; only 46% of facilities remained within the same or within 1 decile. CONCLUSION Continuous weighted measures for the major risk factors for diabetes-related complications have high correlation with dichotomous measures. We propose that a continuous QALYs-weighted summary measure could function as a global measure for the quality of diabetes care.
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Affiliation(s)
- David Aron
- VA HSR&D Center for Healthcare Knowledge Management Research, VA New Jersey Healthcare System, 385 Tremont Avenue, East Orange, NJ, USA
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Halanych JH, Wang F, Miller DR, Pogach LM, Lin H, Berlowitz DR, Frayne SM. Racial/ethnic differences in diabetes care for older veterans: accounting for dual health system use changes conclusions. Med Care 2006; 44:439-45. [PMID: 16641662 DOI: 10.1097/01.mlr.0000207433.70159.23] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients. OBJECTIVES We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes. METHODS Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files. RESULTS In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99-1.13] and 1.04 [1.00-1.07], respectively), and more likely to receive eye examinations (1.31 [1.24-1.38] and 1.33 [1.29-1.37], respectively). Hispanic patients were equally likely (1.01 [0.95-1.07]) and black patients were less likely (0.81 [0.79-0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71-0.82] and 0.83 [0.80-0.87], respectively) and LDL testing (0.84 [0.79-0.90] and 0.70 [0.68-0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86-0.96]) and 0.98 [0.95-1.01]), respectively). Accounting for VHA facility had little effect on results. CONCLUSIONS Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.
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Affiliation(s)
- Jewell H Halanych
- Center for Health Quality, Outcomes, and Economic Research, Bedford VA Hospital, Bedford, Massachusetts, USA.
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Abstract
OBJECTIVE To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control. DATA SOURCES Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999. STUDY DESIGN Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined. PRINCIPAL FINDINGS Increases in antiglycemic medications occurred at only 9.8 percent of visits despite 39 percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control (p < .001). CONCLUSIONS Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.
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Abstract
OBJECTIVE Quality measures of glycemic control using threshold values do not assess incremental quality improvement. We compared health care system performance using weighted continuous versus dichotomous measures for glycemic control. RESEARCH DESIGN AND METHODS We performed retrospective cross-sectional analysis of chart abstraction data on 37,142 diabetic patients from 141 Veterans Health Administration medical centers in 2000-2001. RESULTS Subjects per facility ranged from 163 to 740 (mean 263). Mean overall HbA(1c) (A1C) was 7.58%. A continuous measure for glycemic control was calculated based on percentage of maximal quality-adjusted life-years saved (QALYsS). Overall mean facility performance using the dichotomous measure was 62% <8% A1C (range 48-75%) and 39% <7% A1C (21-57%), in comparison with 45% maximal QALYsS (31-60%). Correlation between QALYsS and A1C thresholds of <8 (0.848) and <7 (0.838) for facility rankings was excellent; correlation between facility level performance using thresholds of <8 and 7% was poor (r = 0.13, P = 0.14). Comparison of facility rankings between the <7% dichotomous measure and the QALYsS-weighted measure showed that 22% changed their ranking by > or =2 deciles with marked changes in top and bottom deciles. CONCLUSIONS Facility rankings vary by threshold or continuous methodology. However, because significant numbers of individuals are unable to reach "optimal" target goals (thresholds) even in clinical trials with extensive exclusion criteria, we propose that a continuous measure assessing improvement toward optimal A1C, rather than a pass/fail optimal target, is both a fairer assessment clinical practice and a more accurate reflection of population health improvement.
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Affiliation(s)
- Leonard M Pogach
- New Jersey Veterans Healthcare System, East Orange, New Jersey, USA
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Abstract
OBJECTIVE To estimate all-cause hospitalizations, nursing home admissions, and deaths attributable to diabetes using a new methodology based on longitudinal data for a representative sample of older U.S. adults. RESEARCH DESIGN AND METHODS A simulation model, based on data from the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Followup Study, was used to represent the natural history of diabetes and control for a variety of baseline risk factors. The model was applied to 6,265 NHANES III adults aged 45-74 years. The prevalence of risk factors in NHANES III, fielded in 1988-1994, better represents today's adults. RESULTS For all NHANES III adults aged 45-74 years, a diagnosis of diabetes accounted for 8.6% of hospitalizations, 12.3% of nursing home admissions, and 10.3% of deaths in 1988-1994. For people with diabetes, diabetes alone was responsible for 43.4% of hospitalizations, 52.1% of nursing home admissions, and 47% of deaths. Adjusting for related cardiovascular conditions, which may provide more accurate estimates of attributable risks for people with diabetes, increased these estimates to 51.4, 57.1, and 56.8%, respectively. CONCLUSIONS Risks of institutionalization and death attributable to diabetes are large. Efforts to translate recent trials of primary prevention into practice and continued efforts to prevent complications of diabetes could have a substantial impact on hospitalizations, nursing home admissions, and deaths and their societal costs.
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Affiliation(s)
- Louise B Russell
- Institute for Health, Rutgers University, New Brunswick, NJ 08901, USA.
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Affiliation(s)
- Gayle E Reiber
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA.
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Abstract
OBJECTIVE To evaluate performance of process and outcome measures in the care of patients with diabetes seen in Department of Veterans Affairs (VA) facilities. RESEARCH DESIGN AND METHODS Retrospective audits of records and databases were conducted on randomly selected patients with diabetes over 5 years (1995 [baseline] and 1997-2000) in 22 VA networks. Performance on diabetes-specific and preventive processes was measured. RESULTS Nationally, significant improvements over time were observed for all measures (P < 0.001). For example, the percentage of patients receiving a dilated retinal examination rose from 44% in 1995 to 67% in 2000. The percentage of patients who received a urinary protein test rose from 23% in 1997 to 54% in 2000. Those who received influenza vaccination rose from 34% in 1995 to 78% in 2000. However, there was significant regional variation among all measures. CONCLUSIONS Adherence to diabetes-specific and preventive care measures in the VA improved from 1997 to 2000 compared with a 1995 baseline. The improvement occurred in a setting of the provision of guidelines, the contractual setting of specific targets, and the timely feedback of results to medical center and network directors. Future studies are needed to determine whether adherence to these measures will decrease the rates of complications in VA patients with diabetes.
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Affiliation(s)
- Clark T Sawin
- Office of the Medical Inspector, Department of Veterans Affairs, Washington, D.C., USA
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Pogach LM, Brietzke SA, Cowan CL, Conlin P, Walder DJ, Sawin CT. Development of evidence-based clinical practice guidelines for diabetes: the Department of Veterans Affairs/Department of Defense guidelines initiative. Diabetes Care 2004; 27 Suppl 2:B82-9. [PMID: 15113788 DOI: 10.2337/diacare.27.suppl_2.b82] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe the Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guidelines for diabetes and contrast selected recommendations with those of the American Diabetes Association (ADA). RESEARCH DESIGN AND METHODS We summarize the general structure of the VA/DoD Guidelines and describe the rationale for recommendations issued in 2003 for glycemic control, management of hypertension, and retinopathy screening. We compare the synthesis of evidence and resulting recommendations for these content areas with the 2004 American Diabetes Association Clinical Practice Recommendations. RESULTS The VA/DoD Guidelines and the ADA Clinical Practice Recommendations reported similar strength of evidence findings by content area, but clinical recommendations varied. The VA/DoD Guidelines and practice recommendations emphasize the use of data on absolute risk reduction from available published randomized clinical trials rather than relative risk reduction from observational analyses. The VA/DoD Guidelines employ an algorithm-based methodology to guide clinicians through a risk-stratified approach to managing individual patients rather than promoting a single standard for most or all patients without explicit consideration of competing comorbidities. CONCLUSIONS The VA/DoD Guidelines are intended to guide diabetes care by providing Internet-ready, evidence-based annotations in algorithmic form to help clinicians set and revise individual treatment goals for their patients.
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Affiliation(s)
- Leonard M Pogach
- VA New Jersey Health Care System, East Orange, New Jersey. The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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Miller DR, Safford MM, Pogach LM. Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data. Diabetes Care 2004; 27 Suppl 2:B10-21. [PMID: 15113777 DOI: 10.2337/diacare.27.suppl_2.b10] [Citation(s) in RCA: 339] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To optimize methods for identifying patients with diabetes based on computerized records and to obtain best estimates of diabetes prevalence in Department of Veterans Affairs (VA) patients. RESEARCH DESIGN AND METHODS The VA Diabetes Epidemiology Cohort (DEpiC) is a linked national database of all VA patients since 1998 with data from VA medical visits, Medicare claims, pharmacy and laboratory records, and patient surveys. Using DEpiC, we examined concordance of diabetes indicators, including ICD-9-CM codes (250.xx), prescription drug treatment, HbA(1c) tests, and patient self-report. We determined the optimal criterion for identifying diabetes and used it in estimating diabetes prevalence in the VA. RESULTS The best criterion was a prescription for a diabetes medication in the current year and/or 2+ diabetes codes from inpatient and/or outpatient visits (VA and Medicare) over a 24-month period. This definition had high sensitivity (93%) and specificity (98%) against patient self-report, and reasonable rates of HbA(1c) testing (75%). HbA(1c) testing alone added few additional cases, and a single diagnostic code added many patients, but without confirmation (reduced specificity). However, including codes from Medicare was critical. Applying this definition for 1998-2000, we identified an average of 500,000 VA patients with diabetes per year. We also estimated high and increasing diabetes prevalence rates of 16.7% in FY1998, 18.6% in FY1999, and 19.6% in FY2000 and an incidence estimated to be approximately 2% per year. CONCLUSIONS Development and evaluation of methodology for analyzing computerized patient data can improve the identification of patients with diabetes. The increasing high prevalence of diabetes in VA patients will present challenges for clinicians and health system management.
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Affiliation(s)
- Donald R Miller
- Boston University, School of Public Health, Boston, Massachusetts, USA.
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Abstract
OBJECTIVE To determine pharmacy costs for glycemic treatment and its relationship to glycemic control in the Department of Veterans Affairs (VA) between 1994 and 2000. RESEARCH DESIGN AND METHODS Patients with diabetes in the VA in FY1994, FY1996, FY1998, and FY2000 were identified using an ambulatory care pharmacy-derived database. Total drug acquisition costs, as well as expenditures for insulin, oral glycemic control agents, and self-blood glucose monitoring strips, were determined for these veterans. HbA(1c) levels for the corresponding time periods were also obtained. Pharmacy costs (medications and monitoring) were examined by glycemic control treatment type. RESULTS In FY2000, 18% (n = 535,016) of all VA pharmacy patients were identified as having diabetes, and they received 30% of all pharmacy prescriptions. Overall, 23% of pharmacy expenditures for these patients were related to glycemic control medications and monitoring supplies. Annual pharmacy costs increased from FY1994 to FY2000. The greatest change was the higher expenditure for monitoring supplies through FY1998, which then decreased in FY2000. Increased pharmacy costs were associated with improved glycemic control. In FY2000, the mean last HbA(1c) level (n = 446,384) fell to 7.6% from 7.8% in FY1998 (n = 204,136) and 8.4% in 1996 (n = 53,348). CONCLUSIONS Diabetes was associated with high pharmacy costs. Increasing medication expenditures were associated with improved HbA(1c) levels at the aggregated national level. Policies concerning dispensing monitoring supplies and several diabetes quality improvement projects were initiated during this interval. Future challenges include initiatives to further optimize care while controlling costs.
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Affiliation(s)
- Ruth S Weinstock
- VA Healthcare Network Upstate New York, Syracuse, New York, USA.
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