Health Services Research & Development

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American Diabetes Month

November 2016


November is American Diabetes Month. Nearly one-quarter of Veterans who receive VA healthcare have diabetes,1 and the Centers for Disease Control and Prevention (CDC) estimate that more than 29 million Americans are living with this disease, in addition to 86 million who have prediabetes - a serious health condition that increases the risk of type 2 diabetes and other chronic diseases. Diabetes is the leading cause of kidney failure, lower-limb amputation, and adult-onset blindness, and was the 7th leading cause of death in 2013.2 Rates of diabetes are highest among American Indians/Alaskan Natives (16%) followed by non-Hispanic Blacks (13%), Hispanics (13%), Asian American (9%), and non-Hispanic Whites (8%).3

HSR&D Research on Diabetes

Following are descriptions and findings from several specific research projects conducted by HSR&D investigators on diabetes among Veterans.

Typology for Veterans with Diabetes who Use VA Healthcare and Medicare

Dual healthcare use is anticipated to increase as the Affordable Care Act and Veterans Choice Act enhance Veterans' access to care outside VA, and as more Veterans qualify for Medicare. However, dual use may lead to fragmented care and worse outcomes. This HSR&D study used latent class analysis to establish a typology of VA and Medicare diabetes health service utilization (i.e., office visits, laboratory tests, test strips, and medications) among dually-enrolled Veterans. Using data from VA and the Centers for Medicare and Medicaid Services, investigators identified 316,775 community-dwelling Veterans age > 65 with type 2 diabetes who were dually-enrolled in VA and Medicare from FY2008 to FY2009. They then compared the amount of healthcare use between classes and identified key factors associated with latent class membership (i.e. demographics, Medicaid enrollment, priority group, and distance to the nearest VA). Findings show:

  • There were four latent classes that represent the most common ways dually-enrolled Veterans receive diabetes care:
    • Veterans in Class 1 (n= 170,750; 54%) had high probabilities of VA use and low probabilities of Medicare use across all facets of diabetes services.
    • Veterans in Class 2 (n= 54, 606; 17%) had a high probability of VA use across all care and a high probability of Medicare use for outpatient visits (88%) and lab tests (48%).
    • Veterans in Class 3 (n=69,158; 22%) had a nearly 0% probability of receiving glucose test strips from VA, but a 70% probability of receiving them through Medicare.
    • Veterans in Class 4 (n= 22,261; 7%) had a 50% probability of receiving a diabetes medication through VA, but nearly a 100% probability of receiving one through Medicare.
  • Living >40 miles from a VA predicted membership in classes 3 and 4, while Medicaid eligibility predicted membership in class 4.

Implications: By recognizing common characteristics associated with dual users in classes at greatest risk of care fragmentation, (e.g., dual medication users), study findings may be integrated into decision-support tools to help coordinate the care of certain Veterans, and actively address drivers of dual use.

Radomski T, Zhao X, Thorpe C, Thorpe J, Good C, Mor M, Fine M, and Gellad W. VA and Medicare utilization among dually-enrolled Veterans with type 2 diabetes: A latent class analysis. Journal of General Internal Medicine. May 2016;31(5):524-531.

VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers

The United States has fewer primary care physicians (PCPs) per capita than any other industrialized country, and it is estimated that the U.S. will face a shortage of 45,000 PCPs by 2020. A possible solution has been to expand the scope of practice laws to advanced practice providers (APPs, including nurse practitioners and physician assistants) to perform their clinical duties independently. However, questions remain about whether the quality of chronic disease care delivered by physicians and APPs is comparable. This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by APPs compared to physicians. Using VA data, investigators identified Veterans who received primary care for diabetes or CVD from VA in FY2014 at 130 VAMCs. The diabetes cohort included 1,022,588 Veterans: 811,872 who received care from a physician, and 210,716 who received care from an APP. The CVD cohort included 1,187,035 Veterans: 934,950 who received care from a physician, and 252,085 who received care from an APP. Investigators then compared quality of care for various performance measures separately for Veterans with diabetes and CVD receiving care from a physician or APP. Findings show:

  • The quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD - irrespective of their provider type - did not meet performance measures geared toward control of multiple risk factors.
  • Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures.

Implications: Results suggest that a care delivery model with more expansion of the role for APPs could address healthcare access issues without compromising the basic quality of CVD and diabetes care delivery. However, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.

Virani S, Akeroyd J, Ramsey D, et al. Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act. American Heart Journal. November 2016;181:74-82.

Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes

Little is known about menopausal symptom patterns in women with type 2 diabetes, an increasingly common chronic health condition during middle age. This QUERI-funded study sought to describe the postmenopausal symptom experience in women with type 2 diabetes - and to examine the association between glucose control and symptom severity. Using VA data, investigators identified 327 women Veterans who were placed into three categories: no diabetes (n=90); diabetes with optimal or better glucose control (n=135); and diabetes with suboptimal or worse glucose control (n=102). Self-administered surveys were mailed to all study participants and included information on: menopause status, postmenopausal symptom experience, health status, comorbid conditions, diabetes symptoms and self-management behaviors, sociodemographics, body mass index (BMI), and current medications. Findings show:

  • Despite higher body mass index and increased comorbidities in women Veterans with diabetes compared to those without diabetes, the pattern of menopause symptoms did not differ by group. Symptom severity scores were highest for muscle and joint aches, followed by hot flashes and trouble sleeping, while headaches received the lowest severity scores. Measures of mental health (i.e., anxiety, depressed mood) were similar across groups.
  • Among women Veterans with diabetes, worse glucose control, smoking, and a diagnosis of altered mood demonstrated a positive association with perceived menopause symptom severity, even after adjusting for other covariates.

IMPLICATIONS: Targeting glucose control may improve postmenopausal experiences of women with diabetes.

Rouen P, Krein S, and Reame N. Postmenopausal symptoms in female Veterans with type 2 diabetes: Glucose control and symptom severity. Journal of Women's Health. June 2015;24(6):496-505.

Study Suggests Cardiovascular Benefits of Tight-Glucose Control in Diabetes

Patients with type 2 diabetes have a greatly increased risk of cardiovascular events; therefore, learning whether improved glucose control reduces cardiovascular events is critically important. The VA Diabetes Trial (VADT) previously reported that intensive glucose lowering, compared to standard therapy, did not significantly reduce major cardiovascular events in 1,791 Veterans. The study ended on May 29, 2008, with investigators analyzing an additional five years of observational follow-up data on VADT participants (through December 2013), thus achieving a total follow-up of 11.8 years for most study measures. For this study, VA, Medicare, and U.S. National Death Index data also were used to identify procedures, hospitalizations, and death (cohort, 92% follow-up). The primary outcome was a composite of major cardiovascular events that included: heart attack, stroke, new congestive heart failure, amputation for ischemic gangrene, or cardiovascular-related death. Secondary outcomes included cardiovascular and all-cause mortality. Findings show:

  • The separation of hemoglobin A1C between the intensive and standard glucose control arms averaged 1.5% during the trial itself (median, 6.9% vs. 8.4%, respectively), and declined to 0.2-0.3% by three years after the trial ended.
  • Veterans with type 2 diabetes randomized to intensive glucose control for a median of 5.6 years had a significant 17% relative reduction in major cardiovascular events after almost 10 years of total follow-up compared to Veterans who received standard glucose therapy. However, intensive glucose control was not associated with a significant decrease in all-cause mortality after almost 12 years of follow-up.

IMPLICATIONS: Results provide further evidence that improved glycemic control can reduce major cardiovascular events. This potential benefit may be considered in conversations with patients, but balanced with the burdens and safety data for the specific glucose-lowering treatment being considered.

Hayward R, Reaven P, Wiitala W, et al. Follow-up of Glycemic Control and Cardiovascular Outcomes in Type 2 Diabetes. New England Journal of Medicine. June 4, 2015;372(23):2197-2206.

Appropriate Prescribing for Veterans with Diabetes at High Risk for Hypoglycemia

Evidence is accumulating that older individuals with diabetes have little to gain from the treatment burdens of stringent blood glucose control. Moreover, some older patients with diabetes might be at risk for hypoglycemia-related harms from medications prescribed to meet standard hemoglobin A1c (HbA1c) targets. This study examined the beliefs of primary care healthcare professionals (PCPs) who might receive such recommendations. Investigators surveyed a national sample of 594 PCPs (physicians, nurse practitioners, and physician assistants) practicing in the VA healthcare system from October 2014 to December 2014. The survey included questions about practice characteristics, performance incentives, beliefs about decreasing use of inappropriate services, and demographics. In addition, study participants were asked to rate the level of difficulty they anticipated in following the Choosing Wisely recommendations to "avoid using medications other than metformin to achieve HbA1c less than 7.5% in most older adults." Findings show:

  • Almost half of the PCPs in this study reported that they would not worry about harms of tight control for an older patient with an HbA1c level of 6.5% who is at high risk of hypoglycemia.
  • Of the 594 PCPs in this study, 161 (29%) agreed it would be somewhat or very difficult to follow the Choosing Wisely HbA1c recommendation for older adults.
  • The PCPs who agreed that maintaining the HbA1c level below 7% would benefit the patient and who reported worrying about malpractice claims were more likely to report difficulty following the recommendations. Conversely, PCPs who reported worrying that the patient would be harmed with tight blood glucose control were less likely to report difficulty following HbA1c recommendations.

IMPLICATIONS: Providers need more explicit support in de-intensifying treatment for older Veterans with diabetes. VA recently launched a hypoglycemia safety initiative to decrease over-treatment among Veterans. To overcome provider misperceptions about the benefits of stringent blood glucose control - and concerns about negative repercussions following de-intensification of therapy, safety initiatives should be national and span multiple practices.

Caverly T, Fagerlin A, Zikmund-Fisher B, Kirsh S, Kullgren J, Prenovost K, and Kerr E. Appropriate prescribing for patients with diabetes at high risk for hypoglycemia: National survey of Veterans Affairs health care professionals. Research Letter. JAMA Internal Medicine. December 2015;175(12):1994-1996.


Resources

The American Diabetes Association provides an online Diabetes Risk Test.

Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases.

References

1. Close to 25 Percent of VA Patients have Diabetes. Veterans Health Administration.

2. Working to Reverse the U.S. Epidemic, At A Glance 2016. Diabetes. CDC.

3. Statistics about Diabetes. American Diabetes Association.