A Study of Barriers and Supports to Individualizing Diabetes Care in Older Veterans
Denise Feil MD MPH
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: October 2011 - September 2013

BACKGROUND/RATIONALE:
In the VA Healthcare System, almost 20% of Veterans have Diabetes Mellitus (DM), with the highest prevalence over age 65. Pharmacy costs for Veterans with DM account for 28% of all VA pharmacy expenditures. Thus, management of DM is an important clinical area for VA and is a key focus of VA's Quality Enhancement Research Initiative (QUERI). The VHA/DOD Clinical Practice Guideline for the Management of DM (VA DM Guidelines), recommends adjusting DM care goals based on DM severity, life expectancy, other co-morbid medical conditions, and patient preferences. However, little is known on the extent to which healthcare providers individualize diabetes care in older physically vulnerable Veterans.

OBJECTIVE(S):
(1) Document and interpret clinician perceptions of barriers and supports to individualizing DM care for older, at-risk Veterans (2) Document and interpret Veteran and caregiver perceptions of barriers and supports to individualizing DM care for older, at-risk Veterans (3) Employ an expert opinion approach for designing a multi-faceted strategy for achieving individualized DM care treatment of older Veterans based on identified barriers and supports.

METHODS:
We will conduct individual semi-structured interviews of providers (n=33), Veterans (n=30) and caregivers (n=30) at multiple VA sites. These sites include WLA, Loma Linda, CBOC (Bakersfield and San Luis Obispo) , Sepulveda & WLA Nursing Homes (including the Veterans Home). Veteran and caregiver interviews will only take place at WLA. All interviews will be conducted in-person or by phone.

Providers: Based on the pre-identified script themes the research team will establish a set of codes and relational domains. The study team (geriatric psychiatrist, geriatrician, senior qualitative social scientist, survey specialist and senior project manager) will then read the transcribed interviews to identify relevant domains of meaning and relational patterns between domains. Additional new codes will be identified, and codes that are rarely used will be dismissed. Using grounded theory methods, emerging themes will be identified and confirmed. Specifically we will analyze topics at several levels for common overarching themes that emerge in interviews, e.g., system barriers and enablers, guideline awareness and interpretation of risk stratification, differences in perspective associated with position within the care delivery system or specialty. With each subsequent transcript, constant comparison method will be applied until relevant themes reach saturation. We will code with NVIVO qualitative software.

Veterans and Caregivers: The methods for analyzing Veteran and Caregiver interviews are the same as for the provider interviews. Veteran and caregiver interviews will be analyzed separately searching for common emerging themes e.g. perceived views, barriers, differences with regard to risk stratification and other aspects of individualizing the DM care plan.

FINDINGS/RESULTS:
Not Applicable

IMPACT:
This study is one of the first to examine the discrepancy between the DM care guidelines and actual care provided to older physically vulnerable Veterans within VISN 22. The research team will summarize the findings for an expert panel to guide in the development of an implementation strategy aimed at aligning clinical care with VA DM Care Guidelines. This study will help to identify potential barriers to individualizing diabetes care and propose strategies to improve care. The study findings will help the VA streamline care and reduce unnecessary pharmacy costs related to DM.

PUBLICATIONS:
None at this time.

DRA: Diabetes and Related Disorders, Aging, Older Veterans' Health and Care
DRE: none
Keywords: QUERI Implementation
MeSH Terms: none