Health Services Research & Development

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Spotlight: Improving Health and Care for Veterans with Diabetes

June 2014


Additional Resources:

For information about the Diabetes-QUERI Peer-to-Peer Program, please contact Angela Larkin at Angela.Larkin@va.gov.

The American Diabetes Association.

National Diabetes Information Clearinghouse (NDIC).

Centers for Disease Control and Prevention (CDC), National Diabetes Prevention Program.

Diabetes affects more than 26 million Americans.1,2 Type 2 diabetes also affects nearly 1 in 4 VA patients. Moreover, diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults. Up to 80% of patients with diabetes will develop or die from macrovascular disease, such as heart attack and stroke. 2

VA/HSR&D's Diabetes Quality Enhancement Research Initiative (Diabetes-QUERI) is committed to research and collaborations that promote effective care strategies to help Veterans who have diabetes or who are at risk of diabetes, to live longer and healthier lives. Part of this commitment is improving Veterans' self-management of the disease, which includes the integration of Veterans' formal disease management with information support from their social networks. One promising approach, the Peer-to-Peer Program, is increasing mutual support among Veterans with diabetes who face similar health and behavioral challenges. Another approach, Technology-Enhanced Coaching (TEC), will expand on the success of the peer support programs by putting innovative tools into the hands of Veterans with diabetes. Veteran coaches who have demonstrated effective control of their own diabetes are trained to use communication skills to guide their peers through a diabetes education and decision aid, utilizing an iPad.

For general information about Diabetes-QUERI, please contact Nicholas Yankey, M.P.H., M.S.W., Diabetes-QUERI Administrative Coordinator, at Nicholas.Yankey@va.gov .

HSR&D and QUERI Research on Diabetes

Following are descriptions of just a few of the studies that HSR&D and QUERI investigators conduct on an array of issues related to improving the quality of health and care for Veterans with diabetes.

Medicare Drug Beneficiaries with Diabetes Use 2 to 3 Times More Brand-Name Drugs than VA Patients, at Substantial Cost

Medicare Part D provides drug coverage to nearly 30 million beneficiaries and contracts with more than 1,000 private plans to administer drug benefits. In contrast, VA drug benefits are managed by a central pharmacy benefits manager with a single formulary, or common list of medications that can be prescribed within the VA healthcare system. This HSR&D study compared the use of brand-name medications among patients using Medicare or VA drug benefits, and estimated how spending would change if the use of brand-name drugs in one system mirrored the other. Using Medicare and VA data from 2008, investigators identified a national sample of 1,061,095 Part D beneficiaries and 510,485 Veterans age 65 years and older with diabetes. Investigators focused on prescription use for four medication groups commonly used for the treatment of diabetes: 1) oral hypoglycemics, 2) long-acting insulins (analogues), 3) statins, and 4) ACE inhibitors/ARBs.

Findings show that Medicare beneficiaries with diabetes are more than twice as likely to use brand-name drugs than a comparable group within VA: 35% vs. 13% for oral hypoglycemics, 51% vs. 18% for statins, 43% vs. 21% for ACEs/ARBs, and 75% vs. 27% for insulin analogues. If brand use in Medicare matched that in VA for these four medication groups, investigators estimated more than $1.4 billion in avoidable spending (or 39% less) by Medicare on brand-name drugs in 2008 alone. Conversely, spending in VA would have increased by $108 million (57%) for these drugs if Veterans used brand-name drugs at the same rate as in Medicare.

Gellad WF, Donohue JM, Zhao X, et al. Brand-name prescription drug use among diabetes patients in the VA and Medicare Part D: A national comparison. Annals of Internal Medicine. July 2013;159(2):105-114.

Receiving VA Care is Stronger Predictor of Appropriate Care vs. Medicare Fee-for-Service for Veterans with Diabetes

This HSR&D study examined whether quality of diabetes care was associated with care continuity – or Veterans' usual source of primary care – comparing Medicare-eligible Veterans who obtain all of their care in the VA healthcare system versus those who have all of their care through the Medicare fee-for-services (FFS) program. 'Continuity of care' was measured as longitudinal continuity, defined as an ongoing interaction between patient and provider (or care team) that occurs in the same place with the same medical record. Using VA data, investigators identified 1,867 Medicare-eligible Veterans with diabetes that had two or more primary care visits at any of 72 VAMCs and 108 community clinics across the country (except Alaska) in 2001 to 2004. Investigators then examined three diabetes quality measures: HbA1c testing, eye exams, and urine microalbumin testing, which were performance measures tracked in VA and Medicare from 2001 to 2004.

Findings show that reliance on VA primary care vs. Medicare FFS primary care was a stronger predictor of guideline concordant diabetes care than continuity of care. For example, when both over-provision (getting more tests than needed) and under-provision (getting fewer tests than needed) were examined for the three quality measures, reliance on VA care was a stronger predictor of appropriate care than continuity of care.

Maciejewski M, Wang V, Burgess Jr. J, et al. The continuity and quality of primary care. Medical Care Research and Review October 2013;70(5):497-513.

Literature Review Compares Bariatric Surgery to Non-Surgical Interventions among Non-Morbidly Obese Patients with Diabetes

Bariatric surgical procedures are being advocated as a treatment for diabetes in less-obese individuals (BMI of 30 to 35); however, this practice remains controversial. For example, in 2006 the Centers for Medicare & Medicaid Services would not approve coverage for patients with lower BMI and diabetes, whereas the FDA has approved gastric banding for individuals with a BMI of 30 to 35 who have an obesity-related comorbidity. Given the lack of consistency, as well as uncertainties regarding the effectiveness of different procedures, HSR&D investigators conducted a literature review of the risks and benefits associated with surgical and non-surgical therapies for treating diabetes or impaired glucose tolerance in patients with a BMI of less than 35. Literature databases were searched for study results that were published from 1985 through September 2012. Of more than 1,200 articles that were screened, investigators included 32 surgical studies, 11 systematic reviews on non-surgical treatments, and 11 large non-surgical studies published after those reviews. Evidence from this review suggests that for patients with diabetes and a BMI of 30 to 35, bariatric surgery is associated with greater short-term (12 to 24 months) weight loss and improvements in HbA1c, fasting blood glucose levels, blood pressure, and hyperlipidemia than non-surgical interventions such as medication, diet, and behavioral changes. However, the evidence was insufficient to reach definitive conclusions about long-term outcomes.

Maggard-Gibbons M, Maglione M, Livhits M, Ewing B, Maher A, Hu J, Li Z, and Shekelle P. Bariatric surgery for weight loss and glycemic control in non-morbidly obese adults with diabetes. JAMA. June 5, 2013;309(21):2250-61.

Evaluating Unintended Consequences of Diabetes Performance Measures

Performance measures of intermediate outcomes among Veterans with diabetes have shown striking improvements over time, but there are concerns that rates of over-treatment and other unintended consequences are increasing as a result of the pressure to meet increasingly stringent goals and benchmarks. This ongoing QUERI study is assessing the gaps and unintended consequences of implementing existing and new diabetes-related performance measures in VA in order to provide feedback to VA's office of Analytics and Business Intelligence (OABI) regarding ways to improve performance measures. Study investigators have interviewed 59 leaders and staff from four VAMCs in four different VISNs. Thus far, findings show that performance measures are often translated to clinical reminders, which help providers remember to address routine, preventive care with their patients. Moreover, high-priority goals trigger quality improvement initiatives, such as introducing Shared Medical Appointments, and establishing integrated diabetes clinics. Investigators also identified several unintended consequences, such as: perceived lack of inclusion of providers in the development and implementation of performance measures; lack of clearly defined performance measures, and that they are largely dichotomous; and primary care providers shoulder a disproportionate share of the burden to meet performance goals. Final results of this study will be translated into specific recommendations for OABI partners to improve performance measures.

No publications at this time.

Pre-Diabetes Prevention Program

The Diabetes Prevention Program (DPP) showed that lifestyle interventions can reduce the incidence of type 2 diabetes by 58% in this high-risk group. However, little is known about the incidence of pre-diabetes among Veterans in the VA healthcare system because routine screening for pre-diabetes is not an established practice. With a few exceptions, lifestyle modification interventions that target individuals with pre-diabetes and follow the DPP curriculum are not available to Veterans in VA. In order to address this gap in evidence-based clinical services, the National Center for Health Promotion and Disease Prevention (NCP) funded a VA Diabetes Prevention Program Demonstration Project (VA DPP). Investigators in this QUERI study are evaluating this project.

A total of 1,577 Veterans were referred to MOVE! (VA's national weight management program to help Veterans lose weight) between August 2012 and December 2013 at three VA medical centers across the country and were then screened for the VA DPP program. Of these, 378 Veterans met eligibility criteria for pre-diabetes: 275 Veterans were assigned to the DPP program, and 103 were assigned to the MOVE! program. Baseline surveys were completed by 197 Veterans (53%) participating in these programs. Of the survey respondents, 90% said they were motivated to lose weight, 86% were motivated to exercise, and 87% were motivated to eat a healthy diet. These initial data suggest that large-scale implementation of the Diabetes Prevention Program in VA could yield significant population-level benefits. Results of this project also will contribute to the evidence base used by QUERI partners at the NCP to develop and implement lifestyle interventions that reflect the needs of Veterans at risk of developing diabetes.

No publications at this time.

References:

  1. Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet. May 2014.

  2. Diabetes-QUERI Fact Sheet . VA/HSR&D. June 2013.