BACKGROUND/RATIONALE:
This project is designed to support the Patient Care Services (PCS) Systems Redesign effort in Primary Care to improve glycemic control in veterans. Close to 25% of all veterans have diabetes, a major cause of morbidity, mortality, and cost. Studies suggest than only 10% of veterans with diabetes receive care by an endocrinologist within a year; most patients in VHA obtain care in the primary care setting. There is widespread variation in quality of diabetes care as evidenced by the VHA's External Peer Report Program (EPRP) performance measurement reports. Although some of this variation may reflect case-mix differences in patients among facilities, it is possible (likely, in fact) that top-performing facilities use practices not shared by others.

OBJECTIVE(S):
Objectives:
Specific Aim 1: Identify high performing sites for diabetes care.
Assessment/Evaluation Questions:
(a) Which sites in VA provide higher quality of care for diabetes in general and for specific subgroups of patients that present special challenges, e.g., co-morbid mental health conditions?
(b) Is high performance associated with specific site characteristics such as size, location (urban vs rural), complexity, affiliation status and other factors?
Specific Aim 2: Identify best practices for diabetes care.
Assessment/Evaluation Questions:
(a) For patients with diabetes in general, what practices are used by high performing sites and do they differ from those used in low performing sites?
(b) What practices are used by sites that exhibit high performance in terms of care for challenging and other special populations?

METHODS:
A mixed methods approach was used. First, a national VA diabetes registry with data from 2008 was used to identify clinical performance based on percentage of patients with an A1c> 9%. A total of 140 facilities and 582 community based outpatient clinics were included. Sites were stratified into high, mid and low performers. Results were also stratified by urban/rural and selected populations were assessed: insulin users, patients with co-morbid serious mental illness, and age. Semi-structured telephone interviews (31) and site visits (5) of a purposive sample were conducted.

FINDINGS/RESULTS:
Differences were found among the lower performing sites such as a lack of team work between physicians and nurses, insufficient support staff, volume of patients and inadequate time for preparation were reported as the greatest challenges in providing diabetes care. Better performing sites reported shared responsibilities and teamwork, time for non face to face care, and innovative practices to address local needs. Better performing sites reported supportive clinical teams pursuing the common goal of improving health and well-being of diabetes patients with leadership support. Lower performing sites reported difficulties due to inadequate support staff given patient volume. "Best practices" or more appropriately termed "potentially better practices" that may account for inter-facility variations in performance will be shared across the organization to improve diabetes care.

IMPACT:
This project has informed PCS and PACT. Results have been disseminated via the Primary Care Work Group (Dr. S. Kirsh, Chair) and presentations made at PACT Collaboratives and other VISN collaboratives based on the data from this project.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kirsh S, Hein M, Pogach L, Schectman G, Stevenson L, Watts S, Radhakrishnan A, Chardos J, Aron D. Improving outpatient diabetes care. American journal of medical quality : the official journal of the American College of Medical Quality. 2012 May 1; 27(3):233-40. [view]
2. Aron D, Conlin PR, Hobbs C, Vigersky RA, Pogach L. Individualizing glycemic targets in type 2 diabetes mellitus. Annals of internal medicine. 2011 Sep 6; 155(5):340-1. [view]
3. Aron DC. Quality indicators and performance measures in diabetes care. Current Diabetes Reports. 2014 Mar 1; 14(3):472. [view]

DRA: Health Systems, Diabetes and Other Endocrine Disorders
DRE: Treatment - Observational, Treatment - Comparative Effectiveness
Keywords: Diabetes, Outpatient, Quality assurance, improvement
MeSH Terms: none