The 2010 VA/DoD Diabetes Care Guidelines and other recent guidelines support an individualized approach to glycemic control, particularly for vulnerable older Veterans (VE). This individualized approach is especially important for optimizing health-related quality of life and minimizing risks of hypoglycemia and other drug side effects for VE with Diabetes Mellitus (DM). Despite the strong evidence of potential harms and marginal benefits from tight DM control for VE, recent evaluations in the VA and other settings suggest that healthcare Providers are not individualizing glycemic goals and minimizing hypoglycemic complications. This study examined this care quality gap by conducting a qualitative study of barriers (and facilitators) to individualizing DM care within multiple VA settings.
The aims of the study are to: (1) document and interpret Provider perceptions of barriers and supports to individualizing DM care for VE patients; (2) document and interpret VE and Caregiver perceptions of barriers and supports to individualizing DM care and (3) conduct an expert panel to design a multi-faceted strategy for achieving individualized DM care treatment of older Veterans.
1. Determine VA healthcare Providers' barriers and facilitators (including knowledge, attitudes, behaviors and beliefs) about individualizing DM care goals for vulnerable older Veterans (VE), with respect to patient preferences, comorbidity, life expectancy, and quality of life
2. Determine older at-risk Veterans and Caregivers' barriers and facilitators (including knowledge, attitudes, behaviors and beliefs) about individualizing DM care goals
3. Identify a set of potential strategies generated by an expert panel group process that addresses key barriers and supports identified by Providers, Veterans and Caregivers, and prioritize proposed strategies.
To accomplish Aim 1, a semi-structured, qualitative interview methodology was used to interview three groups: healthcare Providers, older, vulnerable Veterans (VE), and Caregivers of VE. A VE is defined as having a Vulnerable Elders 13 item survey (VES-13) score of greater than three points. The research team established a set of codes and relational domains from pre-identified script themes, which were used to identify emerging themes and relational domains from the transcribed interviews. Constant comparison method was applied until relevant themes reached saturation. Final coding was in Atlas.ti qualitative software.
To accomplish Aim 2, expert opinion was solicited in the form of a multidisciplinary expert panel to clarify definitions of individualizing diabetes care, and interpret preliminary findings from qualitative interviews. Based on study results and a literature review, the multidisciplinary panel was tasked with making recommendations to inform quality improvement strategies.
A total of 33 multidisciplinary healthcare Providers were interviewed by the PI; 24 were from the Greater Los Angeles VA Healthcare Center, and 9 were from either the Loma Linda Healthcare Center or a local CBOC. In addition, 45 Caregivers and 39 VE Patients were interviewed. These results report preliminary results on 23 Providers, 19 VE Patients and 21 Caregivers.
I. EXPERT PANEL: An Expert Panel of 12 interdisciplinary healthcare Providers reviewed and ranked 11 barriers presented from qualitative results. The Panel met live for further discussion and final deliberation of the barriers and facilitators. These results are reported below.
Theme 1: The risks of hypoglycemia are tolerated at the expense of tighter control, even in Vulnerable Elderly (VE) patients. Providers seem relatively unaware of hypoglycemia risks in the VE patient population. Patients and Caregivers are unfamiliar with a "low," how to respond to it when it happens, or how to prevent one. Theme 2: Providers tended to retain the belief that "tighter control is better," even for VE patients. Patients and Caregivers are uncomfortable with "looser" glycemic control even in situations where it is necessary to avoid hypoglycemia. Healthcare System and policies have minimally adjusted resources and policies needed to individualize care. Theme 3: VE Patients' serious mental health problems (notably, dementia) affect their quality of life and ability to manage their diabetes. Caregivers lack supportive services (except in GRECC) about how to manage diabetes when patients don't adhere and don't eat, due to memory loss and behavioral problems. Few, if any healthcare resources are directed at the high risk group of VE Patients with DM and comorbid serious mental health problems. No screening for depression or cognitive impairment is performed except in one specialty quality improvement program. Theme 4: Providers limit patient preferences in individualizing diabetes care. Providers have limited understanding of how to elicit and include patient preferences in the decision-making process for individualizing their diabetes care.
PROPOSED FACILITATORS AND RECOMMENDATIONS:
Themes 1 and 2: General recommendations about hypoglycemia included changes in policy at the local and VISN level, structural changes (e.g. clinical care re-organization in PACT at the point of care with clinical back-up, focusing on team-based empowerment of doctors, nurses and pharmacy to "undo" patterns of treatment that cause harm, (e.g., insulin safety clinics to reduce hypoglycemia, informatics, proactive search--Registry), support for clinical Champions to promote education; Theme 3: general recommendations about VE Patients with cognitive impairment were similar to above recommendations, plus making policy changes to exclude this patient group from performance measures; identifying the "truly impaired" Patient group for targeting screening and resources. Theme 4 was not addressed by the Expert Panel.
The anticipated intermediate outcome of this study focusing on vulnerable, older Veterans with DM, is to improve appropriate, guideline-based, individualized diabetes care with the anticipated long-term outcome of reducing harms such as clinical hypoglycemia and associated morbidity assoicated with overtreatment, and to improve quality of life.
- Feil DG, Pogach LM. Cognitive impairment is a major risk factor for serious hypoglycaemia; public health intervention is warranted. Evidence-based medicine. 2014 Apr 1; 19(2):77.