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MJ Pugh, Center for Health Quality, Outcomes, and Economic Research; D Berlowitz, Center for Health Quality, Outcomes, and Economic Research

Objectives: The need for intensive treatment of patients with diabetes is increasingly recognized. To help improve glycemic control, new medications are now available, and complex multi-drug regimens are being used. This study examines changing trends in pharmacological management of patients with diabetes within the VA, and geographic differences in patterns of care.

Methods: Data from VA outpatient clinic and VISTA Files were used to explore the medication patterns of diabetic veterans from VISN1 and VISN8. Medication regime was classified into categories empirically based on medications prescribed between July 1, 1996--October 31 1996 (N=8091) and July 1, 1999--Oct 31, 1999 (N=7314). Likihood ratio chi-square analyses were performed to determine if there were differences in prescribing patterns over time, and if there were geographic differences in the extent to which physicians prescribed a single oral agent, multiple oral agents, only insulin, insulin and oral agents, and a combination of acarbose and thiazolidinediones (newer oral hypglycemics; not included in oral agents).

Results: Analyses indicated that more patients were on multi-drug regimes in 1999 (23%) than in 1996 (13%; p<.001). When these data were examined by VISN, geographical differences in patterns became apparent (p<.001). First, patients in VISN1 were more likely to receive multiple oral medications in 1996, and were also were more likely to be treated with newer oral-hypoglycemics than patients in VISN8. Patients from VISN8 were more likely to be on insulin alone. Second, while patients from VISN1 were more likely to be on multiple agents in 1999 than VISN1 patients in 1996, they were less likely to be on multiple agents than their VISN8 counterparts (1999). This appears to be due to the fact that there were more marked changes in therapy for VISN8 patients during this time. In 1996 12% of patients in VISN8 were on multi-drug regimes but that number doubled to 25% by 1999; VISN1 increased from 15% to 18%. Finally, while there were no increase in use of the newer oral-hypoglycemics from 1996 to 1999 in VISN1, patients from VISN8 were more likely to be on newer oral-hypoglycemics in 1999 (1.6%) than they were in 1996 (.3%). So, while VISN1 patients were on more complex regimes in 1996, the more drastic change that occurred in VISN8 resulted in more complex regimes being used for VISN8 patients in 1999.

Conclusions: Patterns of care within the VA changed over this three-year period. VA clinicians are using different pharmacological approaches and many patients are on complex regimes. Geographic differences exist between VISNs in their use of these modalities. Future research can examine these differences and their impact on glycemic control.

Impact: Examination of these clinical practices, and the geographic variations that exist, can help practitioners become aware of more complex regimes and develop new interventions that will improve patient care. Implementation of intensive hypoglycemic regimes may prevent or delay complications of diabetes which would provide a quality of life savings for the patients as well as a cost savings for the VA health system.