Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Veterans Crisis Line Badge
Go to the ORD website
Go to the QUERI website

IIR 04-266 – HSR&D Study

New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects

IIR 04-266
Why Are Intermediate Outcomes in Diabetic Veterans Still Sub-Optimal?
Ellen Funkhouser DrPH MS BS
Birmingham VA Medical Center, Birmingham, AL
Birmingham, AL
Funding Period: January 2006 - December 2009

BACKGROUND/RATIONALE:
There has been substantial progress toward better quality of diabetes care for veterans; however, improvement in risk factor levels, specifically, HbA1c, lipids (LDL), and blood pressure (BP), have not kept the same pace. Control of these risk factors is critical to improving diabetes outcomes. Current quality measures focus mainly on assessment. A logical next step is to focus on clinical actions, e.g., medication intensification, that should lead to risk factor control.

OBJECTIVE(S):
Ascertaining the following: 1) whether the presence of multiple uncontrolled comorbid conditions (MUCC) affect blood pressure intensification rate among diabetics with uncontrolled hypertension, 2) whether the lack of intensification is clinical inertia or appropriate clinical inaction, and 3) whether administrative data can be used to determine if physicians recognize non-adherent patients and appropriately do not intensify medications.

METHODS:
There were 3 separate study designs for each objective. For #1 we observed 946 consecutive patients of 13 clinicians in 2 primary care clinics in 2006; we analyzed the 387 patients who presented with uncontrolled BP. At each visit, the patient's BP was recorded as was the value and date of the most recent HbA1c and LDL levels; clinicians recorded whether BP medications were intensified, and if not, reason. Patients were categorized into one of four clinical scenarios: uncontrolled hypertension AND 1) no diabetes or hyperlipidemia; 2) controlled diabetes and/or hyperlipidemia; 3) either uncontrolled diabetes or hyperlipidemia; or 4) both UNcontrolled diabetes and hyperlipidemia. Independent associations with BP medication intensification were ascertained. For #2: an external survey of 138 primary care providers was conducted in 2009 based on reasons given for not intensifying BP medications by the 13 VA clinicians to ascertain appropriateness of reasons for not intensifying. For #3: all veterans with diabetes seen in primary care clinics at one VAMC 2001-2005 who had uncontrolled BP (>140/90 mmHg) on two consecutive visits were studied. Nonadherence was defined as being off/out of all BP medications for at least 7 days immediately prior to the second visit.

FINDINGS/RESULTS:
Overall, 34.9% (135/387) of directly observed patients with UNcontrolled BP had their BP medications intensified at the visit. We observed a U-shaped relationship between the clinical scenarios and intensification: the lowest intensification rates were among those with controlled diabetes or hyperlipidemia, slightly higher for patients without either condition, and increased as the number of uncontrolled conditions rose. Intensification rates reached 80% for patients with MUCC who were at least 10 mmHg above systolic BP goal. The provider survey suggests that only 12% of patients were who not intensified represents clinical inertia, and this may be lower, namely, 3-6%. Of 4,711 black and white diabetic men with uncontrolled BP seen at one VAMC 2001-05, the overall BP intensification rate was 55.5%. A total of 244 were nonadherent, of whom 33.6% were intensified; all had a change in class of BP medications, none had a dose increase.

IMPACT:
Quality indicators that capture medication intensification and permit the monitoring of both appropriate clinical actions and inactions are needed to maximize high quality, patient-centered care.

PUBLICATIONS:

Journal Articles

  1. Flanagan M, Arbuckle N, Saleem JJ, Militello LG, Haggstrom DA, Doebbeling BN. Development of a workflow integration survey (WIS) for implementing computerized clinical decision support. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2013 Jun 26; 2011:427-34.
  2. Rawl SM, Skinner CS, Perkins SM, Springston J, Wang HL, Russell KM, Tong Y, Gebregziabher N, Krier C, Smith-Howell E, Brady-Watts T, Myers LJ, Ballard D, Rhyant B, Willis DR, Imperiale TF, Champion VL. Computer-delivered tailored intervention improves colon cancer screening knowledge and health beliefs of African-Americans. Health Education Research. 2012 Oct 1; 27(5):868-85.
  3. Welsh CA, Flanagan ME, Hoke SC, Doebbeling BN, Herwaldt L, Agency for Healthcare Research and Quality Hospital-Acquired Infections Collaborative. Reducing health care-associated infections (HAIs): lessons learned from a national collaborative of regional HAI programs. American journal of infection control. 2012 Feb 1; 40(1):29-34.
  4. Wesorick B, Doebbeling B. Lessons from the field: the essential elements for point-of-care transformation. Medical care. 2011 Dec 1; 49 Suppl:S49-58.
  5. Flanagan ME, Welsh CA, Kiess C, Hoke S, Doebbeling BN, Agency for Healthcare Research and Quality Hospital-Acquired Infections Collaborative. A national collaborative for reducing health care?associated infections: current initiatives, challenges, and opportunities. American journal of infection control. 2011 Oct 1; 39(8):685-9.
  6. Doebbeling BN. Improving the Implementation of Evidence-based Practice and Information Systems in Healthcare: A Social Network Approach. International Journal of Health Information Systems and Informatics. 2011 Jun 1; 6(2):37-59.
  7. Doebbeling BN. Provision of Psychosocial Care for Cancer Patients: Service Delivery in Urban and Rural Settings. Journal of primary care & community health. 2011 Feb 10; 2(4):220-24.
  8. Chou AF, Vaughn TE, McCoy KD, Doebbeling BN. Implementation of evidence-based practices: Applying a goal commitment framework. Health care management review. 2011 Jan 1; 36(1):4-17.
  9. Russ AL, Saleem JJ, Justice CF, Woodward-Hagg H, Woodbridge PA, Doebbeling BN. Electronic health information in use: Characteristics that support employee workflow and patient care. Health Informatics Journal. 2010 Dec 1; 16(4):287-305.
  10. Haggstrom DA, Rosenman M, Myers LJ, Teal E, Doebbeling BN. VA-INPC: Linking Department of Veterans Affairs (VA) and Indiana Network for Patient Care (INPC) data to assess surveillance testing among veterans with colorectal cancer. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2010 Nov 13; 2010:266-70.
  11. Parmar G, Ghuge P, Halanych JH, Funkhouser E, Safford MM. Cardiovascular outcome ascertainment was similar using blinded and unblinded adjudicators in a national prospective study. Journal of clinical epidemiology. 2010 Oct 1; 63(10):1159-63.
  12. Salanitro AH, Funkhouser E, Agee BS, Allison JJ, Halanych JH, Houston TK, Litaker MS, Levine DA, Safford MM. Multiple uncontrolled conditions and blood pressure medication intensification: an observational study. Implementation science : IS. 2010 Jul 19; 5:55.
  13. Salanitro AH, Roumie CL. Blood pressure management in patients with diabetes. Clinical diabetes : a publication of the American Diabetes Association. 2010 Jul 1; 28(3):107-114 .
  14. Islam TM, Fox CS, Mann D, Muntner P. Age-related associations of hypertension and diabetes mellitus with chronic kidney disease. BMC nephrology. 2009 Jun 30; 10:17.
  15. Safford MM, Allison JJ, Kiefe CI. Patient complexity: more than comorbidity. the vector model of complexity. Journal of general internal medicine. 2007 Dec 1; 22 Suppl 3:382-90.
Book Chapters

  1. Doebbeling BN. Toward More Effective Implementation of Evidence based Practice: Relational and Contextual Considerations. In: Yih Y, editor. Handbook on Healthcare Systems. Boca Raton, FL: CRC Press; 2011. Chapter 13. 1-12 p.
Conference Presentations

  1. Bonfils KA, McGuire AB, Kukla ME, Myers L, Salyers MP. Participation in Illness Management and Recovery. Poster session presented at: Midwestern Psychological Association Annual Meeting; 2013 May 2; Chicago, IL.
  2. Doebbeling BN. Creating a MRSA Ontology to Support Natural Language Processing. Poster session presented at: American Medical Informatics Association Annual Symposium; 2011 Nov 16; Washington, DC.
  3. Doebbeling BN. Multidisciplinary Perspectives on Best Practices for Understanding and Evaluating Clinical Workflows. Presented at: American Medical Informatics Association Annual Symposium; 2011 Nov 16; Washington, DC.
  4. Doebbeling BN. Clinical Work Composition: Systematic Description of Clinical Activity and Task Structure. Poster session presented at: Mayo Clinic Systems Engineering and Operations Research in Health Care Conference; 2011 Aug 12; Rochester, MN.
  5. Doebbeling BN. Capturing the “True Nature” of Clinical Work: A Methodological Framework. Poster session presented at: Mayo Clinic Systems Engineering and Operations Research in Health Care Conference; 2011 Aug 11; Rochester, MN.
  6. Doebbeling BN. Predictive Modeling of Surgical Demand: Integrating Patient Specific and Population Characteristics. Poster session presented at: Mayo Clinic Systems Engineering and Operations Research in Health Care Conference; 2011 Aug 10; Rochester, MN.
  7. Imperiale TF, Myers L. A Computer-Tailored Intervention Increases Patient-Provider Discussion and Appointment Making for Colorectal Cancer Screening. Poster session presented at: Indiana University Simon Cancer Center Annual Cancer Research Day; 2011 May 26; Indianapolis, IN.
  8. Krier CJ, Skinner CS, Champion CL, Springston J, Perkins SM, Tong Y, Gebregziabher N, Imperiale TF, Brady-Watts T, Myers L, Rawl S. A computer-tailored intervention increases patient-provider discussion and appointment making for colorectal cancer screening. Poster session presented at: American Association for Cancer Research Annual Meeting; 2011 Apr 2; Orlando, FL.
  9. Doebbeling BN. Leveraging Social Network Analysis to Improve the Implementation of Evidence-Based Practices and Systems in Healthcare. Paper presented at: Hawaii Annual International Conference on System Sciences; 2011 Jan 4; Honolulu, HI.
  10. Salanitro AH, Agee B, Burczyk-Brown JJ, Crenshaw K, Horton T, Kaffka JS, Funkhouser E, Halanych JH, Muntner P, Richman JS, Safford MM. Appropriate inaction and 'clinical inertia'. Paper presented at: Society of General Internal Medicine Midwest Regional Annual Meeting; 2010 Apr 29; Minneapolis, MN.
  11. Estrada CA, Salanitro AH, Safford MM, Curry W, Williams J, Ovalle F, Payne-Foster P. A cluster-randomized trial of a web-based physician intervention to improve diabetes care. Paper presented at: Society of General Internal Medicine Southern Regional Annual Meeting; 2010 Feb 25; New Orleans, LA.
  12. Graham K, Safford MM, Agee B, Funkhouser E, Houston T. System factors related to medication gaps in VA medical centers: The YSoHi study. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
  13. Safford MM, Petersen N, Funkhouser E, Agee B, Houston T. Diminishing returns: More blood pressure medications increase chances of running out of medicine. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami Beach, FL.
  14. Salanitro AH, Allison JJ, Halanych JH, Houston TK, Safford MM, Funkhouser E, Levine DA, Andreae SJ. Multiple Uncontrolled Comorbid Conditions and Medication Intensification. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 13; Miami Beach, FL.
  15. Graham K, Safford MM, Agee B, Funkhouser E, Houston T. System factors related to quality of care in VA Medical Centers: The YSoHi study. Poster session presented at: University of Alabama at Birmingham Department of Medicine Trainee Research Annual Symposium; 2009 Mar 4; Birmingham, AL.
  16. Funkhouser E, Christiansen CL, Palnati M, Lafrance JP, Pogach LM, Miller DR. Evaluating Drug Safety in VA: Cardiovascular Disease Risks with Rosiglitazone or Pioglitazone Use. Presented at: VA HSR&D National Meeting; 2009 Feb 14; Baltimore, MD.
  17. Salanitro AH, Funkhouser E, Litaker MS, Allison JJ, Halanych JH, Houston TK, Levine DA, Safford MM. Multiple uncontrolled comorbid conditions and medication intensification. Paper presented at: Society of General Internal Medicine Southern Regional Annual Meeting; 2009 Feb 14; New Orleans, LA.
  18. Salanitro AH, Funkhouser E, Allison JJ, Halanych JH, Houston TK, Litaker MS, Levine DA, Safford MM. Multiple uncontrolled comorbid conditions and medication intensification. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  19. Salanitro AH, Safford M, Houston TK, Williams J, Kiefe CI, Ovalle F, Allison JJ, Estrada CA, Estrada CA. Is patient complexity associated with physician performance on diabetes measures? Presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 11; Pittsburgh, PA.


DRA: Health Systems
DRE: none
Keywords: Adherence, Cardiovascular Disease, Chronic heart failure, Cost effectiveness, Diabetes, Outcomes - Patient, Quality assurance, improvement, Telemedicine
MeSH Terms: none

Questions about the HSR&D website? Email the Web Team.

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.