Publication Briefs

Publication Briefs
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Veterans with COVID-19 have Greater Risk of Potentially Preventable Hospitalization than Non-infected Veterans This study sought to determine whether infection with SARS-CoV-2 is associated with an increased risk of a potentially preventable hospitalization and, if so, how long this association persists after infection. Findings showed that Veterans with COVID-19 had three times greater risk of potentially preventable hospitalization than matched uninfected Veterans within 30 days after infection and more than 40% greater risk at 1 year. Potentially preventable hospitalizations for acute conditions (i.e., bacterial pneumonia, urinary tract infection) accounted for 20% of all preventable hospitalizations; those for exacerbations of chronic conditions (e.g., diabetes complications, asthma) accounted for the remainder. Although exploratory, subgroup results suggest sub-optimal access to ambulatory care either before or after infection increases the risk of a potentially preventable hospitalization in those with COVID-19. Solutions are needed to mitigate preventable hospitalization after COVID-19. Date: April 10, 2024 Higher Preventive Health Inventory Use Associated with Improved Quality of Care This study examined associations between Preventive Health Inventory (PHI) adoption and clinical quality measures at 216 VA primary care clinics nationwide that implemented the PHI and had the highest and lowest PHI use as of February 2021. Findings showed that higher uptake of the PHI was associated with improved quality of diabetes and hypertension care. Compared to the lowest use clinics, the highest use clinics had fewer Veterans with an HbA1c >9 or missing, more Veterans with an annual HbA1c measurement, and more Veterans with adequate blood pressure control. The highest use clinics completed an average of 32,997 notes per 100,000 Veterans compared to 57 notes per 100,000 Veterans at the lowest use clinics. Results indicate that a proactive care management intervention can significantly improve the quality of care, including chronic disease care that has been disrupted by the COVID-19 pandemic. Date: April 17, 2023 Intervention for Patient-Family Dyads Improves Outcomes for Veterans with Diabetes Researchers designed the Caring Others Increasing Engagement in Patient Aligned Care Teams (CO-IMPACT) intervention to provide training and tools to adult patient-supporter dyads. This randomized clinical trial evaluated the CO-IMPACT intervention compared with standard care among Veterans with diabetes and HbA1c>8% or systolic blood pressure (SBP)>150mmHg, each with an adult supporter (239 dyads). Findings showed that CO-IMPACT successfully engaged patient-supporter dyads and led to improved patient activation, diabetes self-efficacy, and healthy eating. Most (97% Veterans, 93% supporters) said they would “definitely” or “probably” recommend CO-IMPACT to others like them, and 83% of supporters felt they and the patient improved how they worked together to manage diabetes. Diabetes-specific cardiac risk and glycemic control improved similarly in both groups. Date: November 14, 2022 Traumatic Brain Injury May Be a Potentially Novel Risk Factor for Cardiovascular Disease in Veterans This study sought to determine the association between TBI and subsequent cardiovascular disease (CVD) in post-9/11 era Veterans. Findings showed that post-9/11 Veterans with mild TBI, moderate to severe TBI, and penetrating TBI were more likely to develop CVD compared to Veterans without TBI. Although the risk was highest shortly after injury, TBI remained significantly associated with CVD for years after the initial injury. All TBI categories increased the risk of stroke, coronary artery disease, and peripheral artery disease. Mild and moderate to severe TBI categories were also associated with an increased risk of CVD mortality. Veterans with TBI were more likely to have a history of smoking, substance use disorder, obesity, obstructive sleep apnea, insomnia, PTSD, depression, and anxiety. Conversely, hyperlipidemia, kidney disease, hypertension, and diabetes were more common in Veterans without TBI. Date: September 6, 2022 Disability Compensation for Vietnam-Era Veterans with Diabetes is Associated with VA Patient Outcomes This study evaluated a July 2001 change in VA disability policy that qualified some Vietnam-era Veterans (those with “boots on the ground”) with diabetes for disability compensation. Specifically, the study examined the association between eligibility for disability compensation with mortality and hospitalizations. Findings showed that among Veterans newly eligible for disability compensation, the annual proportion receiving disability compensation payments increased from 7% during the pre-policy period to 76% during the later post-policy period. Despite increases, there was no evidence of lower mortality rates for these Veterans. Among Veterans concurrently enrolled in VA and Medicare, eligibility for disability compensation was associated with a substantial reduction in acute hospitalizations. Declines increased from 10% to 21%, coinciding with increased disability compensation and larger payments. Compared to non-eligible Veterans, eligible Veterans received $8,025, $14,412, and $17,162 more in annual disability compensation in the early, middle, and later post-policy periods, respectively. There was no evidence that the association between disability compensation and outcomes varied by race and ethnicity, socioeconomic status, or number of comorbidities at baseline. Date: July 1, 2022 Shift to Virtual Visits for Veterans with Type 2 Diabetes During the Pandemic Was Not Associated with Adverse Outcomes This study sought to describe the changes in management, control, and outcomes in older people with type 2 diabetes (T2D) associated with the shift from in-person to virtual visits. Findings showed that despite a shift to virtual visits and decreased A1c measurement rates during the pandemic, no association with A1c level or short-term T2D-related outcomes (i.e., ER visit or hospitalization for hypo or hyperglycemia) was observed, providing some reassurance about the adequacy of virtual visits. Relative to baseline, among the 740,602 Veterans in this study, there were 55% fewer in-person visits and 824% more virtual visits, with a net result of 10% more total visits during the pandemic relative to the pre-pandemic period. There also were 6% fewer A1c measurements, and 14% more treatment intensifications. Date: January 6, 2022 Social and Behavioral Risk Factors Are Not Associated with Higher Mortality among VA Patients with COVID-19 This study sought to determine if social and behavioral risk factors were associated with mortality from COVID-19 among Veterans, and whether the association was modified by race/ethnicity. Findings showed that despite relatively high levels of social and behavioral risk among Veterans in this study, no association with mortality from COVID-19 was found. Housing problems, financial hardship, current tobacco, alcohol, and substance use did not have statistically significant associations with mortality. Analyses by race/ethnicity did not find associations between mortality and these risk factors. Predictors of mortality in this study were consistent with other studies, including older age, Asian and American Indian or Alaska Native race, and certain comorbid conditions, such as diabetes, chronic kidney disease, dementia, and cirrhosis or hepatitis. This study highlights how integrated health systems such as VA can transcend social vulnerabilities and serve as models of support services for COVID-affected households and at-risk populations. Date: June 9, 2021 VA Researchers Develop Model to Estimate Risk of COVID-19 Related Deaths among Veterans for Use in Prioritizing Vaccine This study sought to develop a model to estimate the risk of COVID-19 related death in the general population to aid vaccination prioritization. In estimating the risk, COVIDVax (the model developed) used the following 10 patient characteristics: sex, age, race, ethnicity, body mass index (BMI), Charlson Comorbidity Index (CCI), diabetes, chronic kidney disease, congestive heart failure, and the Care Assessment Need (CAN) score. Using COVIDVax to prioritize vaccination was estimated to prevent 64% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than prioritizing vaccination based on age (46%) or the CDC phases of vaccine allocation (41%). Even under conditions when vaccine supply is no longer limited, the model can help target individuals who might not yet be vaccinated but are at highest risk from COVID. Date: April 6, 2021 Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment among Veterans with Diabetes Geography is a well-known determinant of health and an improved understanding of the relationships between geographic factors (social and environmental) and diabetes outcomes may lead to targeted interventions. This retrospective cohort study sought to answer the following questions: 1) Do rates of metabolic control exhibit geographic patterning or “hotspots”? and 2) Does patterning vary by race-ethnicity? Findings showed that after adjusting for age, gender, race-ethnic group, service-connected disability, marital status and comorbidities, the prevalence of uncontrolled diabetes varied by VA catchment area, with values ranging from 19% to 29%. These differences persisted after further adjustment for medication use and adherence, as well as use and access metrics. Disparities in sub-optimal control appeared consistent across most but not all catchment areas, with Black and Hispanic Veterans having higher odds of sub-optimal control than White Veterans. Prevalence of uncontrolled diabetes in the VA catchment area with the poorest control rates was estimated as high as 28% for Whites, 30% for Blacks, and 35% for Hispanics. Patterns of uncontrolled diabetes within VA did not mirror patterns of diabetes prevalence across the country. While high diabetes prevalence in the general population overlapped with sub-optimal diabetes control in parts of Appalachia, Georgia, Alabama, Mississippi, and Tennessee, parts of the Diabetes Belt had lower than average rates of uncontrolled diabetes in VA, indicating that areas of high diabetes prevalence can have below average rates of uncontrolled diabetes. Geographic as well as racial-ethnic differences in diabetes control rates were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, healthcare use, access metrics, or medication adherence, suggesting there is a geographic component to diabetes control that needs to be further explored. Date: October 1, 2020 Primary Care Intensive Management Teams Impact Medication Management for Diabetes and Hyperlipidemia This study examined the impact of primary care intensive management (PIM) on adherence to medications and medication adjustments including changes in number of drugs filled, switches between drug classes, added or discontinued prescriptions, and dose changes. Findings showed that PIM teams appear to have contributed to medication management for diabetes and hyperlipidemia. Medication adherence improved for DPP-4 inhibitors (class of drugs used to control high blood sugar in adults with type 2 diabetes), and more hyperlipidemia drugs were prescribed for PIM patients. There was a 12% increase (79% to 91%) in predicted mean adherence to DPP-4 inhibitors for diabetes in PIM patients between pre- and post-randomization, while usual care PACT patients had a 4% decrease (71% to 67%) in predicted mean adherence. PIM patients had a significantly higher mean number of hyperlipidemia drugs at study end due to more hyperlipidemia prescriptions. Date: August 7, 2020 Contextualized Care Planning Results in Improved Veteran Outcomes and Significant Cost Savings Contextualizing care is the process of adapting research evidence to patient context. For example, recognizing that a patient is not managing their diabetes because they cannot afford the medication and switching them to a less costly alternative is a contextualized care plan. This study evaluated the effectiveness of a quality improvement program in which providers receive ongoing feedback on their attention to patient contextual factors based on audio recordings of their clinical encounters. Findings showed that contextualized care planning was associated with a significantly greater likelihood of improved outcomes – and resulted in significant cost savings from avoided hospitalizations. At baseline, providers addressed 413 of out 618 contextual factors in their care plans (67%). Following either standard or enhanced feedback, they addressed 1,707 out of 2,367 contextual factors (72%), a significant improvement. In a budget impact analysis, estimated savings from avoided hospitalizations were $25.2 million at a cost of $337,000 for the intervention. Giving clinicians ongoing feedback on their attention to the life challenges that their patients face may be an effective strategy for heightening their awareness and attention to social determinants of health, which may significantly improve healthcare outcomes and reduce costs. QI programs may be well advised to consider routine incorporation of training in contextualizing care through audit and feedback. Date: July 31, 2020 Common Drugs for Hypertension and Diabetes Not Associated with Severe COVID-19 Illness or Testing Positive for COVID-19 Originally requested by the World Health Organization (WHO), this systematic review examined the relationship between angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB) use and COVID-19 illness. Findings showed that high-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 illness, and moderate-certainty evidence suggests no association between the use of these medications and positive SARS-CoV-2 test results among symptomatic patients. Findings from this rapidly expanding literature show no indication to prophylactically stop ACEI or ARB treatment because of concerns about COVID-19. Moreover, withdrawal of long-term ACEIs or ARBs may be harmful, especially in patients with heart failure, because observational studies and trials have suggested that discontinuation of ACEI or ARB therapy is associated with worse outcomes. Date: May 15, 2020 Weight Management as Effective as Medication Intensification for Glycemic Control among Veterans with Type 2 Diabetes This randomized clinical trial sought to determine whether adding intensive weight management to group medical visits (WM/GMV) improves glycemia compared with GMV alone, while enhancing weight loss and decreasing medication intensity in patients with uncontrolled type 2 diabetes. Findings showed that for Veterans with diabetes who attended group medical visits, adding intensive weight management using low-carbohydrate nutrition counseling showed comparable glycemic improvement in addition to other clinical advantages (i.e., reduced weight, medication burden, and hypoglycemic events). The largest differences between the GMV vs. the WM/GMV arms occurred at 16 weeks after the intensive initial phase of the WM/GMV 48-week program. The WM/GMV intervention decreased HbA1c levels by 1.7% from baseline, which was 0.7% lower than the GMV arm. The intervention also led to a 5.6 point difference in diabetes distress symptoms (i.e., stress, depression). The estimated intervention cost per patient was $1,513.42 for patients in the WM/GMV arm, and $1,264.49 for patients in the GMV arm. Thus, weight management using a low-carbohydrate diet can be as effective for glycemic improvement as medication intensification, with additional benefits (i.e., weight reduction, fewer hypoglycemic events, less medication use); however, strategies are needed to help patients sustain these improvements. Date: November 4, 2019 Cardiovascular Benefits of Intensive Glucose Control in Veterans with Type 2 Diabetes Did Not Persist in Long-term Post-Trial Follow-Up Long-term follow-up of glucose lowering in patients with type 2 diabetes may help clarify the duration of any potential cardiovascular disease (CVD) benefit. Investigators here report on the full 15-year follow-up of Veterans with type 2 diabetes who were randomly assigned to receive either intensive or standard glucose control as part of the Veterans Affairs Diabetes Trial. Findings showed that Veterans with type 2 diabetes at high CVD risk, with 5.6 years of intensive glucose lowering to a HbA1c of 6.9%, DID NOT experience reduced major cardiovascular events over 13.6 years of follow-up or reduced total mortality or improved quality of life over 15 years of total follow-up. Although there was a 17% reduction in major CVD events during the approximate 10-year period when HbA1c levels were separated between the intensive and standard therapy groups, there was no evidence of a beneficial legacy effect in the subsequent 5-year period once levels equalized among the groups. Results suggest there are modest long-term cardiovascular benefits of intensive glucose lowering therapy in patients with more advanced diabetes, but that long-term maintenance of lower levels may be required to maintain these improvements. Date: June 6, 2019 VA Nurse Practitioners and Physician Assistants Lower Cost of Care for Complex Primary Care Patients with Diabetes This study compared health services use and costs depending on whether a Veteran’s primary care provider was a physician, NP, or PA. Findings showed that Veterans in this study were medically complex, averaging almost seven chronic conditions each and 3.5 times the complexity of the typical Medicare patient. Investigators found greater rates of hospitalizations and ED visits and higher healthcare expenditures among primary care patients of physicians compared to those of NPs or PAs. Mean per patient inpatient costs were $1,328 and $914 less for NPs and PAs, respectively, and pharmacy costs were about $300 less, compared to physicians. In sum, NP and PA patients had about $2,000 lower annual total care costs than patients of physicians. This study addressed a long-standing concern that NPs and PAs might practice in ways that increase total costs of care and found no evidence to support this concern. Findings suggest that NPs and PAs can effectively manage primary care for medically complex patients with diabetes without increasing total care costs. Findings also provide further evidence that NPs and PAs may be appropriately used as primary care providers for complex patients, as opposed to being limited to supplementing the care of physicians within primary care settings. Date: June 1, 2019 No Difference in Intermediate Outcomes for Veterans with Diabetes by Type of Primary Care Provider This study examined whether intermediate diabetes outcomes differed among Veterans treated at one of 568 VA primary care facilities by a physician, nurse practitioner (NP), or physician assistant (PA) primary care provider. Findings showed that there were no clinically significant differences in intermediate diabetes outcomes – or the control of those outcomes – among patients with NP, PA, or physician primary care providers. There also was no clinically significant difference in the proportions of NP, PA, and physician-treated patients with diabetes who used endocrinology or specialty diabetes services during the year outcomes were calculated. This study provides further evidence that using NPs and PAs as primary care providers may represent a mechanism for expanding access to primary care while maintaining quality standards. Date: December 18, 2018 Preoperative Surgical Screening for Asymptomatic Bacteriuria is Not Beneficial Strong evidence that preoperative screening for bacteria in the urine, and treatment with antibiotics if found to be positive, improves clinical outcomes is lacking. This study sought to measure the association between asymptomatic bacteriuria (ASB) and key postoperative infectious outcomes, including surgical-site infection (SSI) and UTI, and determine if directed antimicrobial therapy was associated with reduced rates of infection after major surgical procedures. Findings showed that routine screening of preoperative urine cultures before major cardiac, orthopedic, and vascular surgical procedures was a low-yield clinical practice. ASB was identified in 4% of urine cultures, and after adjustments for other factors associated with postoperative infections (age, American Society of Anesthesiologists physical status class, smoking status, demographics, and diabetes status), Veterans with or without ASB had similar chances of surgical site infection (2.4% vs 1.6%). Antibiotic treatment of asymptomatic patients with ASB did not lead to improvement in any measurable postoperative clinical outcome. The incidence of SSI, UTI, and positive wound and urine culture results were the same in patients who were treated as in those who were untreated. This study – the largest and most robust to date – provides strong evidence that preoperative screening is of little value and should be discontinued as routine clinical practice. Date: December 12, 2018 Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury. Date: March 1, 2018 Online Game Improves Glucose Control in Veterans with Diabetes This randomized trial sought to determine whether a team-based game on diabetes self-management education (DSME) topics delivered to VA patients with type 2 diabetes could generate sustained improvements in their HbA1c levels. Findings showed that the game delivering DSME content generated significant improvements in HbA1c over 12 months among Veterans with type 2 diabetes, with the difference between cohorts (DSME vs. civics game) manifesting primarily in the 6 months following the games. Among DSME game patients with elevated HbA1c at baseline, the overall reduction in HbA1c was comparable to that of starting a new diabetes medication. The online, interactive methodology used in this intervention may be an effective and scalable method by which to improve health outcomes in Veterans with diabetes and other chronic diseases. Date: September 1, 2017 PACT Initiative Did Not Reduce Most Disparities in Improved Hypertension or Diabetes Control among VA Patients This study sought to determine whether PACTs helped mitigate national racial/ethnic disparities in VA clinical outcomes, after adjusting for variable implementation and social determinants of health. Findings showed that improvements in clinical outcomes for hypertension and diabetes control had not been achieved for whites or most racial/ethnic groups four years into VA’s system-wide roll-out of the PACT initiative. Greater PACT implementation was associated with higher percentages of Veterans who achieved hypertension or diabetes control, but most racial/ethnic disparities in achieving control persisted. Authors suggest that to promote health equity, healthcare innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Date: June 1, 2017 Current Diagnosis of PTSD is Risk Factor for Pregnant Women This analysis evaluated the associations between PTSD and antepartum complications to explore how PTSD’s pathophysiology impacts pregnancy in a large cohort of women Veterans. Findings showed that a current diagnosis of PTSD increases the risk of hypertensive/ischemic placental complications of pregnancy, specifically preeclampsia, and is a risk factor for gestational diabetes. PTSD also was associated with an increased risk of prolonged (>4 day) delivery hospitalization and repeat hospitalization. Authors suggest that pregnancies in women with currently active PTSD should be identified as potentially high-risk, high-need pregnancies. Date: May 1, 2017 VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by advanced practice providers (APPs) compared to physicians. Findings showed that 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. Thus, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans. Date: November 1, 2016 Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities. Date: September 22, 2016 VA Captures More Complete Quality Performance Data Compared to Medicare Advantage Investigators in this study examined the agreement between VA and Medicare Advantage (MA) quality assessments for a group of dually-enrolled Veterans, testing the hypothesis that private health plans under-report quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Findings showed that despite assessing the same Veterans using identical performance measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. For example, VA’s performance advantage ranged from 10 percentage points (46% for VA vs. 36% for MA) for HbA1c <7.0% in diabetes to 55 percentage points (80% for VA vs. 25% for MA) for blood pressure <140/90mmHg in diabetes. In analyses limited to Veterans having at least 10 MA outpatient encounters, VA reported better performance than MA for 11 of 12 measures – ranging from 10 percentage points to 36 percentage points. Findings suggest that neither Medicare Advantage plans nor VA fully capture quality of care information for dually-enrolled Veterans. However, VA captures significantly more information than MA. Date: March 31, 2016 Investigators Establish Typology for Veterans with Diabetes who Utilize Both VA Healthcare and Medicare This study sought to establish a typology of VA and Medicare utilization among dually-enrolled Veterans with type 2 diabetes, to better understand specific patterns of dual use. Findings showed that Veterans with diabetes can be grouped into four distinct classes of dual health system use. This classification has applications for identifying patients facing differential risk from care fragmentation. 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. Date: February 22, 2016 The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use. Date: February 1, 2016 Among Older Veterans with Diabetes, Few with Low Glucose or Blood Pressure Levels Undergo Treatment De-intensification This study sought to describe the frequency and predictors of treatment de-intensification among potentially over-treated older Veterans with diabetes. Findings showed that among older Veterans with diabetes who were treated for BP or blood glucose control, Veterans’ BP or A1c levels had only a weak relationship to the likelihood of de-intensification. There was a modest association between a Veteran’s estimated life expectancy and de-intensification rates, but there was no consistent interaction between life expectancy, de-intensification rates, and BP or A1c levels. Authors suggest that practice guidelines and performance measures should focus more on reducing over-treatment through de-intensification. Date: December 1, 2015 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. Findings showed that 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 PCPs in this study, 29% agreed it would be somewhat or very difficult to follow the Choosing Wisely HbA1Crecommendation for older adults. 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. Date: December 1, 2015 Telemedicine-Based Intervention Improves Outcomes for Veterans with Poorly Controlled Diabetes Investigators in this pilot trial developed the Advanced Comprehensive Diabetes Care (ACDC) intervention, which bundles four evidence-based telemedicine approaches – telemonitoring, self-management support, medication management, and depression management – and is designed for practical delivery by existing VA Home Telehealth program nurses using standard VA equipment. Findings showed that the ACDC intervention significantly reduced HbA1c by 1.0% versus usual care. Veterans receiving ACDC had significantly better diabetes self-care at six months versus usual care, but depressive symptoms did not differ between groups. Although ACDC did not address hypertension, Veterans in the intervention group had significantly lower systolic and diastolic blood pressure versus usual care. By utilizing Home Telehealth infrastructure that is ubiquitous at VA centers nationwide, ACDC represents a potentially scalable approach to reducing the burden of diabetes within VA. Date: November 5, 2015 Inpatient Conditions Associated with Increased Risk for Recurrent Acute Kidney Injury among Veterans This study sought to identify clinical risk factors for recurrent acute kidney injury (AKI) that were present during the index hospitalization for AKI. Findings showed that, in addition to known demographic and comorbid risk factors for AKI (i.e., older age, diabetes, dementia), Veterans at highest risk for hospitalization with recurrent AKI were those whose index AKI hospitalization included congestive heart failure as a primary diagnosis, decompensated advanced liver disease, cancer with or without chemotherapy, acute coronary syndrome, and intravascular volume depletion. Of the Veterans in this cohort, 49% were hospitalized at least once during the follow-up period, and 25% were hospitalized with recurrent AKI within 12 months of discharge. Median time to recurrent AKI was 64 days. The one-year mortality from time of discharge was 23%, and approximately 40% of Veterans who died were re-hospitalized with recurrent AKI before death. Date: August 11, 2015 Long-Term Follow-Up of VADT Study Suggests Cardiovascular Benefits of Tight-Glucose Control in Diabetes Veterans Affairs Diabetes Trial (VADT) participants were randomly assigned to receive either intensive or standard glucose control. The study ended on May 29, 2008, with a median follow-up of 5.6 years. This study analyzed 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. Findings showed that 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 (8.6 events prevented per 1,000 person-years) 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. 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. Date: June 4, 2015 Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes This 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. Findings showed that, despite higher BMI 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. Women without diabetes were younger, of lower BMI, had fewer self-reported comorbid conditions, and reported better physical health. Date: June 1, 2015 Study Shows No Evidence that Dual Use of VA and Medicare Advantage Results in Worse Patient Outcomes This study assessed characteristics of Veterans who were dually enrolled in both VA and Medicare Advantage (MA) – managed care plans administered by private health insurance companies that contract with the Centers for Medicare and Medicaid Services. This study also compared quality of care using intermediate quality outcomes among Veterans exclusively receiving outpatient care in VA with Veterans receiving outpatient care in both systems. No evidence was found that Veterans with dual use of VA and Medicare Advantage experienced either improved or worsened intermediate outcomes compared with Veterans who exclusively used VA healthcare. Outcomes were marginally better for VA-only users on the measures related to hypertension control and CHD control. Conversely, dual VA-MA users experienced slightly better outcomes on measures relating to diabetes control. Dually-enrolled Veterans with fewer VA outpatient visits had comparable outcomes to Veterans with many VA outpatient visits, suggesting the absence of a threshold number of VA visits for achieving better intermediate outcomes in diabetes, hypertension, and heart disease. Date: April 6, 2015 Bariatric Surgery Compared to Usual Care May Lower Mortality Rates among Obese Veterans This study examined long-term survival in a large multi-site cohort of obese Veterans who underwent bariatric surgery compared to matched controls. Findings showed that when compared to matched control patients who did not have the surgery, obese Veterans who underwent bariatric surgery in the VA healthcare system had lower all-cause mortality starting at 5 years and up to 14 years following the procedure. After a mean follow up of 6.9 years in the surgical group and 6.6 years in the matched control group, there were a total of 263 deaths and 1,277 deaths, respectively, at the end of the 14-year study period. Study analyses estimated 1-year, 5-year and 10-year mortality rates that were 2.4%, 6.4% and 13.8% for Veterans who underwent bariatric surgery, and 1.7%, 10.4% and 23.9% for Veterans who did not undergo bariatric surgery. There were no significant differences in the association of bariatric surgery on mortality found across groups defined by sex, diabetes diagnosis, period of surgery, or super-obesity. These study results provide further evidence for the beneficial association between surgery and survival that has been demonstrated in younger, predominantly female, non-VA populations. Date: January 6, 2015 Compared to Thiazolidinediones, Sulfonylureas May Be More Likely to Cause Death and Hospitalization for Veterans with Diabetes This study compared long-term outcomes of the two most commonly used second-line oral hypoglycemic medications in the VA healthcare system – sulfonylureas (SUs) and thiazolidinediones (TZDs). Findings showed that Veterans with diabetes who started on SUs compared to TZDs as a second-line agent after metformin were significantly more likely to die or have an ambulatory care sensitive condition hospitalization. Patients in this study were elderly (mean age 69), primarily white (88%), and had high rates of cardiovascular comorbidities (e.g., chronic pulmonary disease, hypertension), and obesity (41%). Date: December 1, 2014 Veterans with Non-Obstructive Coronary Artery Disease at Significantly Greater Risk of MI and Mortality This study compared incidence of myocardial infarction (MI) and mortality between patients with non-obstructive coronary artery disease (CAD), obstructive CAD, and no apparent CAD in a national cohort of Veterans receiving VA care. Findings showed that compared to Veterans with no apparent CAD, Veterans with non-obstructive CAD were at significantly greater risk of MI and all-cause mortality at one year. The one-year risk of MI progressively increased by extent of CAD, rather than abruptly increasing between non-obstructive and obstructive CAD. For example, among Veterans with no apparent CAD, the one-year MI rate was 0.11%, while the one-year MI rate for 1-vessel non-obstructive CAD was 0.24%, increasing to 0.59% for 3-vessel non-obstructive CAD. One-year mortality rates also were associated with increasing extent of CAD, ranging from 1.4% among Veterans with no apparent CAD to 4% for Veterans with 3-vessel or LM (left main) obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel non-obstructive CAD and mortality, but there were significant associations with mortality for 3-vessel non-obstructive CAD and 1-, 2-, and 3-vessel or LM obstructive CAD. Age and cardiovascular risk factors (e.g., hypertension, hyperlipidemia, and diabetes) all increased with increasing extent of CAD. The frequency of prescriptions for post-angiography cardiovascular medications and rates of coronary revascularization also increased with CAD extent. Findings suggest that non-obstructive CAD is common, confers significant risk for MI and mortality, and warrants immediate consideration of preventative therapies for patients with this condition. Date: November 5, 2014 Women Veterans, Particularly Black Veterans, Have Worse Risk Factor Control for Cardiovascular Disease than Male Veterans This study compared gender and racial differences in three risk factors that predispose individuals to cardiovascular disease: diabetes, hypertension, and hyperlipidemia. Findings showed that overall, female Veterans had significantly higher LDL cholesterol levels than male Veterans, despite being almost ten years younger, on average. These differences are similar to gender disparities previously reported both within and outside VHA and represent a clinically significant difference. African-American women Veterans had worse blood pressure control than White women Veterans, and among Veterans with diabetes, male African-Americans had worse control of higher blood pressure, LDL, and HbA1c levels than White males. Date: September 1, 2014 Most Patients with Type 2 Diabetes Obtain Little or No Benefit from Current Treatment for Tighter Glycemic Control This study examined how considering treatment burden would affect the benefits of intensive versus moderate glycemic control in patients with type 2 diabetes. Findings showed that for most patients over the age of 50 with an A1c below 9% who were on metformin, further glycemic treatment usually offered, at most, modest benefits. Across all ages, patients who viewed treatment as modestly burdensome experienced a net loss in quality of life years from treatments to lower A1c. The current approach of broadly advocating intensive glycemic control for millions of patients with diabetes should be reconsidered; instead, treating A1cs of less than 9% should be individualized based on estimates of benefit weighted against the patient’s view of treatment burden. Date: June 30, 2014 Cardiovascular Outcomes after Addition of Insulin Versus Sulfonylureas in Veterans with Diabetes Taking Metformin This study compared time to a combined outcome of acute myocardial infarction (AMI), stroke, or death among Veterans with diabetes that were initially treated with metformin, and subsequently added either insulin or sulfonylurea. Compared to those who added a sulfonylurea, Veterans who added insulin to metformin therapy had a 30% higher risk of the combined outcome of heart attack, stroke, and all-cause mortality. Although new heart attacks and strokes occurred at similar rates in both groups, mortality was higher in patients who added insulin. Although sulfonylurea use predominated as add-on therapy, there was increasing use of insulin intensification over the study years (increasing by an average of 17% per year). Reasons may include a growing prevalence of obesity and insulin resistance, emphasis on metrics such as glycemic targets, increasing comfort with newer analog insulins, and/or the benefit in microvascular outcome prevention. Date: June 11, 2014 Costs Associated with Surgical Site Infections This study sought to determine the excess costs associated with both superficial and deep surgical site infections (SSIs) among all VA operations performed in FY10, including five high-volume surgical specialties – neurosurgery, orthopedic, general surgery, peripheral vascular, and urology. Findings showed that SSIs were associated with a significant increase in attributable post-surgical costs, even after adjusting for patient-level, surgical-level, and facility-level factors. Patients with deep SSIs had costs 1.93 times higher than patients without site infections. Moreover, if VA hospitals in the highest 10th percentile (e.g., worst) reduced their SSI rates to the rates found in the 50th percentile, the VA healthcare system could save about $6.7 million per year. The greatest mean cost attributable to SSI was among neurosurgery patients, followed by orthopedic surgery, general surgery, peripheral vascular surgery, and urology. Among 54,233 Veterans who underwent surgery in FY10, 3% experienced an SSI. Overall, 0.8% of the cohort had a deep SSI and 2.4% had a superficial SSI. Veterans who experienced an SSI were more likely to have pre-operative comorbid conditions (e.g., diabetes, chronic obstructive pulmonary disease) and were more likely to drink more than two drinks per day in the two weeks before the operation. They also were more likely to have a more severe wound classification – and to undergo emergent surgery. Date: May 21, 2014 Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care. Date: March 1, 2014 Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication. Date: February 1, 2014 Potential Over-Treatment of Hypoglycemia among Veterans with Diabetes Using VA Healthcare This study evaluated rates of intensive glycemic control as an indication of potential over-treatment among Veterans. Findings showed that intensive control, which may represent possible over-treatment, is common among older and/or sicker Veterans receiving VA healthcare. Of those Veterans who were either older than 75 years, and/or had renal insufficiency, and/or cognitive impairment (31% of the sample), about 1 in 10 patients had an A1c value below 6.0%, 29% below 6.5%, and half had values below 7.0%. Rates of possible over-treatment were only slightly lower using a more expansive definition of Veterans at high hypoglycemic risk, which included those with advanced diabetes-related complications, serious comorbid conditions, including cancer or serious neurological conditions, and cardiovascular or ischemic disease. Variation in over-treatment rates by VISN ranged from 9%-14% (for A1c <6%) to 46%-53% (for A1c <7%). The magnitude of variation by facility was larger, with rates ranging from 6%-23% (for A1c <6%) to 40%-65% (for A1c <7%). Study results suggest the need for greater efforts to promote individualized treatment targets, especially for elderly Veterans with chronic conditions. Date: December 9, 2013 Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders. Date: December 6, 2013 Electronic Patient Portals and their Effect on Health Outcomes Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Date: November 19, 2013 Receiving VA Care is Stronger Predictor of Appropriate Care for Veterans with Diabetes than Continuity of Care This study examined whether quality of diabetes care was associated with care continuity or Veterans’ usual source of primary care. Findings showed that reliance on VA primary care vs. Medicare fee-for-service (FFS) primary care was a stronger predictor of guideline-concordant diabetes care than continuity of care. When both over-provision (getting more tests than needed) and under-provision (getting fewer tests than needed) were examined for three diabetes quality measures, reliance on VA care was a stronger predictor of appropriate care than continuity of care. For example, Veterans who relied only on Medicare FFS for primary care were more likely to be under-provided HbA1c testing than Veterans who relied only on VA primary care. However, dual users of VA and Medicare FFS primary care were significantly more likely to be over-provided HbA1c and microalbumin testing than Veterans who used only VA primary care. In both VA and Medicare FFS, under-provision of diabetes care was more common than over-provision during this period (from 2001 to 2004). Date: October 1, 2013 Redundant Lipid Testing in Veterans with CHD Repeat lipid testing for coronary heart disease (CHD) patients who have already attained guideline-recommended LDL-C treatment targets and receive no treatment intensification may represent overutilization and possibly waste of healthcare resources. This study sought to determine the frequency and correlates of repeat lipid testing in Veterans with CHD who had already attained the LDL-C treatment target, and who received no treatment intensification. Findings showed that one-third of the Veterans with CHD who had attained guideline-recommended LDL-C levels had additional lipid testing performed without treatment intensification in the 11 months following their initial lipid panel. Collectively, these patients had 12,686 additional lipid panels performed, with an annual extra cost of $203,990 for the one VA network included in the study. This does not include the cost of the patients’ time to undergo testing, or the providers’ time to manage results and notify the patient. Veterans with concomitant diabetes, hypertension, and higher illness burden, and those who had more frequent primary care visits were more likely to undergo repeat lipid testing, while Veterans with good medication adherence were less likely to undergo repeat testing. Date: July 1, 2013 Medicare Drug Beneficiaries with Diabetes Use 2 to 3 Times More Brand-Name Drugs than VA Patients, at Substantial Cost This 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. Findings showed that Medicare beneficiaries with diabetes are more than twice as likely to use brand-name drugs than a comparable group within VA. If brand use in Medicare matched that in VA, investigators estimated more than $1 billion in avoidable spending by Medicare on brand-name drugs in 2008 alone. Conversely, spending in VA would have increased by 57% if Veterans used brand-name drugs at the same rate as in Medicare. Substantial regional variation exists in brand-name use in both Medicare and VA. For each drug group, however, the highest-using VA regions still had lower rates of brand use than the lowest using Medicare regions. Date: June 11, 2013 Literature Review Compares Bariatric Surgery to Non-Surgical Interventions among Non-Morbidly Obese Patients with Diabetes Given the lack of consistency, as well as uncertainties regarding the comparative effectiveness of different procedures for bariatric surgery, investigators conducted a systematic review of the relative 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. Findings showed that, for patients with diabetes and a BMI of 30 to 35, current evidence suggests that bariatric surgery is associated with greater short-term 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. Date: June 5, 2013 Adoption of PACT Features is Significantly Associated with Lower Risk of Avoidable Hospitalization The primary outcome measured in this study was potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSC) that included: asthma, angina without procedure, pneumonia, dehydration, COPD, congestive heart failure, complications related to diabetes, hypertension, perforated appendix, and urinary tract infection. In addition, the total number and costs of ACSC hospitalizations were measured for each Veteran during a 12-month follow-up period. Findings showed that greater adoption of medical home features by VA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations. Veterans in clinics with the highest medical home adoption had significantly lower ACSC rates (20 per 1,000) compared to Veterans in clinics with the lowest (25 per 1,000) and medium (26 per 1,000) adoption of medical home features. If clinics were transformed from the mean level of medical home adoption to the maximum level, the reduction in hospitalization costs in an average-sized clinic with 3,500 Veterans could be as much as $83,000 annually. Two PACT features were independently related to lower risk of ACSC hospitalization: access and scheduling, and care coordination/transitions in care. For example, Veterans in clinics with the highest scores on access and scheduling had 17% lower odds of having an ACSC admission compared to the lowest scoring clinics. Date: March 26, 2013 Performance Measure for Lipid Management in Veterans with Diabetes Encourages Treatment with Moderate Dose Statins Clinical action performance measures are increasingly being recommended to help make performance measurement more clinically meaningful. Investigators developed a clinical action performance measure for lipid management in Veterans with diabetes that is designed to encourage appropriate treatment with moderate dose statins, while minimizing overtreatment. They then assessed what proportion of Veterans received appropriate lipid management according to this new clinical action measure vs. the treat-to-target measure of LDL <100mg/dl that was in place at the time of the study. Findings showed that, of Veterans aged 50-75 years in this study, 85% passed the new clinical action measure, compared to 67% using the existing metric of LDL <100. Veterans who did not meet the clinical action measure had fewer primary care visits, on average, during the measurement period than Veterans who did meet the measure. Of the entire cohort aged >=18 years, 14% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100) had higher rates of potential overtreament. Findings suggest that continued use of threshold measures for lipid management may promote overtreatment. A modified version of the clinical action performance measure is being implemented in the VA healthcare system. Date: December 11, 2012 Comparing Cardiovascular Outcomes for Two Common Anti-Diabetes Drugs among Veterans This study compared cardiovascular disease (CVD) outcomes and all-cause mortality in a cohort of Veterans who received regular VA healthcare and were prescribed metformin or sulfonylureas – the two most commonly used anti-diabetic drugs. Findings showed a modest but clinically important 21% increased risk of hospitalization for heart attack or stroke, or death from any cause associated with the initiation of sulfonylurea compared with metformin therapy. The sulfonylurea group had higher rates of hospitalizations and deaths due to cardiovascular disease: 18 per 1,000 person years for those taking a sulfonylurea and 10 per 1,000 person years for those taking metformin. These findings suggest that for 1,000 patients who are initiating treatment for diabetes using metformin rather than sulfonylureas, there are 2 fewer heart attacks, strokes, or deaths per year of treatment. The findings do not clarify whether the difference in CVD risk is due to harm from sulfonylureas, benefit from metformin, or both. Date: November 6, 2012 Construction of a Clinical Indicator for the Risk of Over-Treatment among Elderly Patients with Diabetes The publication of three major trials, including the VA Diabetes Trial (VADT), has prompted greater attention to the potential harms of overly tight glycemic control among patients with diabetes, especially in the elderly and those with cardiovascular disease. The high frequency of risk factors for hypoglycemia and its adverse impact, the marginal benefits of tight control in individuals with short life expectancy, and potential for inaccurate measures suggest a need for a quality measure to reduce over-treatment, particularly among elderly patients. This Commentary discusses these issues and explores the construction of a clinical indicator for the risk of over-treatment. Date: September 10, 2012 Veterans with Greater Clinical Complexity Receive Higher Quality of Care for Diabetes This study examined the impact of clinical complexity on three quality indicators for diabetes care: glycemic, blood pressure (BP), and lipid control. Findings showed that of the Veterans in this study,18% were controlled for all three quality indicators at index, and 19% were controlled at 90-day follow-up. Veterans with the greatest levels of clinical complexity received higher quality of care for diabetes based on BP, glycemic, and lipid quality indicators compared to less complex patients, regardless of the definition of complexity. Date: September 1, 2012 Treatment Intensification for Hypertension Not Significantly More Likely to Occur in Veterans with Diabetes and at Higher CV Risk Treatment intensification for hypertension was not significantly more likely to occur in Veterans with diabetes and at higher CV risk, compared with patients at low to medium risk. However, physicians were more likely to advance therapy in patients with higher and more consistently elevated blood pressures. Several individual risk factors were associated with higher rates of treatment intensification: systolic BP, mean BP in the prior year, and higher hemoglobin A1c, while self-reported home BP <140/90 was associated with lower rates of TI. The authors suggest that incorporating CV risk into TI decision algorithms could prevent an estimated 38% of cardiac events without increasing the number of patients being treated. Date: August 1, 2012 Dramatic Improvement in Blood Pressure Management among Veterans with Diabetes, with Potential Over-Treatment Clinical action measures that reward clinical actions that are strongly tied to evidence might better capture the complexity of clinical decision making about blood pressure management among patients with diabetes. In this study, 713,790 Veterans were eligible for a newly developed clinical action measure. Of these, 94% (n=668,210) met the clinical action measure for BP measurement (82% had a BP <140/90; an additional 12% had BP >=140/90 but appropriate management). This represents a dramatic improvement in BP management over the past decade. Among all Veterans in this study, 197,291 (20%) had a BP <130/65; of these, 80,903 (41% - or slightly more than 8% of the cohort) had potential over-treatment. Facility rates of potential over-treatment varied from 3% to 20%. Facilities with higher rates of meeting the current threshold measure (<140/90) had higher rates of potential over-treatment. Veterans with potential over-treatment were older, had lower mean index BP, and were more likely to be men and have ischemic heart disease. Date: June 25, 2012 The Importance of Testing Interventions in Real-World Settings Using the best evidence from efficacy trials to improve BP control among patients with diabetes and persistent hypertension, investigators in this study designed a pharmacist-led care management program – the Adherence and Intensification of Medications (AIM) intervention. In examining three-month intervals, the AIM program lowered systolic BP among patients more rapidly than usual care did for patients in the control group. However, usual care patients achieved equally low systolic BP (SBP) levels by six months after the intervention. Thus, by six months and throughout the remainder of follow-up, control team patients’ mean SBP were indistinguishable from those of the intervention group participants. There were no differences in health services utilization between eligible intervention and control patients during the 14-month intervention period. Patients in the AIM intervention group were more likely than patients in the control group to undergo medication changes during the 6-month period following their start date, although both groups had high rates of medication changes. Authors note that these findings emphasize the importance of evaluating programs that are found to be effective in efficacy trials in real-life clinical settings before urging widespread adoption. Date: May 8, 2012 Anti-Hypertensive Medication May Reduce Risk of Dementia among Veterans with Diabetes Comorbid hypertension was associated with increased risk of dementia; however, anti-hypertensive medications, particularly ACE inhibitors and ARBs, were associated with reduced risk of dementia, even among Veterans without hypertension. The most protective effect was associated with ARB use (approximately 24% lower risk of dementia), followed by diuretics (14%), ACE inhibitors (11%), CCBs (7%), and beta blockers (4%). Factors associated with higher incidence of dementia included: increasing age (Veterans >85 had more than three times greater risk compared to Veterans age 65), as well as duration of diabetes and higher comorbidity. Also, African Americans and other non-white races were more likely to have dementia. These findings suggest that ARBs and ACE inhibitors be considered when prescribing medication for the control of hypertension among patients with diabetes. Date: April 20, 2012 Missed Opportunities to Improve Management of Poorly Controlled Diabetes at VA Hospital Discharge Despite evidence of poor diabetes control prior to admission, less than one-quarter (22%) of the Veterans in this study received a change in outpatient diabetes therapy upon hospital discharge, suggesting widespread clinical inertia. Nearly one-third of Veterans (32%) had no change in therapy, no documentation of HgbA1c within 60 days of discharge, and no follow-up appointment within 30 days of discharge. Patients admitted to surgical, psychiatric, or rehabilitation services were less likely to have a change in outpatient therapy compared to patients admitted to medical services. In an adjusted analysis, factors associated with higher odds of a change in diabetes therapy included: inpatient endocrinology consultation, higher pre-admission HgbA1c, higher mean blood glucose during admission, occurrence of inpatient hypoglycemia, and inpatient basal insulin therapy. Date: March 30, 2012 Peer Mentorship Improves Glucose Control among African American Veterans with Diabetes Peer mentorship improved glucose control significantly among African American Veterans, and the improvement was greater than usual care or financial incentives. Over six months, HbA1c decreased from 9.8% to 8.7% among Veterans in the peer mentorship group, from 9.5% to 9.1% in the financial incentive group, and from 9.9% to 9.8% in the usual care group. After adjusting for covariates (e.g., patient characteristics, baseline HbA1c), the mean change relative to control was -1.07 points among Veterans in the peer mentorship group and -0.45 points in the financial incentive group. In the exit survey, participants in the mentorship program reported on aspects of the program they most liked, i.e., support provided (14/28), education (9/28), and the ability to commiserate with mentors (6/28). Mentors reported appreciating helping others (12/24), communicating with their mentee (7/24), and the teaching process (7/24). Date: March 20, 2012 Study Compares Effectiveness of Oral Anti-diabetic Drugs on Kidney Function for Veterans with Type 2 Diabetes Among Veterans with type 2 diabetes, initiation of sulfonylureas compared to metformin was associated with an increased risk of clinically significant decline in kidney function, diagnosis of ESRD, or death. Compared to metformin, the use of rosiglitazone was not significantly associated with any outcomes. Compared to sulfonylureas, the use of rosiglitazone was associated with a decreased risk for all three outcomes. Authors suggest that these findings support the current recommendations of metformin as first-line therapy for patients with type 2 diabetes who are in earlier stages of kidney disease. Date: February 1, 2012 Veterans with Serious Mental Illness Using Co-Located/Integrated Primary Care and Outpatient Mental Health Clinic Care have Reduced Cardiovascular Risk Veterans with serious mental illness (SMI) were more likely to attain cardiovascular risk goals after being enrolled in a primary care clinic co-located and integrated into an outpatient mental health clinic. Compared to prior to enrollment, Veterans enrolled in SMIPCC had significantly more primary care visits over six months – and significantly improved BP, LDL, triglycerides, and BMI. There were no significant differences in the attainment of goals for HDL or HbA1c. Prior to enrollment, 49% of primary care visits were on the same day as any scheduled mental health visit; this increased to 86% post-enrollment. Among the 28 Veterans in this study with coronary artery disease and/or diabetes, SMIPCC enrollment was associated with a significant improvement in BP goal attainment, but not with any other measures. Date: February 1, 2012 Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems. Date: December 8, 2011 Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008 This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care. Date: December 1, 2011 Caregivers of Veterans with Chronic Illness This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication. Date: November 22, 2011 Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence. Date: August 1, 2011 Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness This study sought to determine the association between the co-location of primary care services and quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI. Date: August 1, 2011 Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time. Date: June 14, 2011 Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group. Date: June 2, 2011 Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points. Date: April 1, 2011 VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA. Date: March 18, 2011 Improvements Using Patient-Aligned Group Clinics for Diabetes Care This study evaluated the comparative effectiveness of two group self-management interventions for glycemic control among Veterans with treated but uncontrolled diabetes. Findings show that Veterans who participated in the primary care-based “Empowering Patients in Care” (EPIC) intervention had significantly greater improvements in HbA1c levels immediately following the active intervention; these differences remained at one-year follow-up. Thus, primary care-based diabetes group clinics that include patient-aligned approaches to goal-setting (e.g., action plan) for medication management, and diet and exercise changes can significantly improve HbA1c levels. Diabetes self-efficacy measures improved immediately after the intervention in both the EPIC and comparison intervention groups, but were significantly higher in the EPIC group. Self-efficacy was associated with individual changes in HbA1c levels. At 1 year, differences in HbA1c levels between groups remained the same (i.e., there was no return to baseline, but also no further improvements). Self-efficacy levels dropped in both groups at 1 year; but the drop in the EPIC intervention participants was less than the diabetes education participants, resulting in modest (non-significant) differences between the groups at one year. Date: March 14, 2011 Article Challenges Process for Disseminating Diabetes Performance Measures Pressure to develop more stringent measures for “optimal” control of risk factors in patients with diabetes has accelerated, despite the absence of new evidence from 1998 to 2008, and results from recent trials have cast new doubt on the benefits of achieving these “optimal” measures in many patients. This editorial suggests that an examination of Toyota, often portrayed as a leader in quality, may provide some answers as to how diabetes performance measures got ahead of the evidence. Date: February 16, 2011 Hypertension Care Management Program Provided by Clinical Pharmacists Reduces Blood Pressure among Veterans This study evaluated the effectiveness of a hypertensive care management program provided by clinical pharmacists in collaboration with primary care physicians within four VA primary care teams at one urban Midwest VAMC. Findings show that Veterans referred to the hypertension care management program provided by VA clinical pharmacists had a significant reduction in blood pressure, and most met their BP treatment goals. Overall, the change in mean systolic BP at the final visit was –11.2 mm Hg from the initial visit, whereas the change in mean diastolic BP at the final visit was –4.6 mm Hg from the initial visit. By the final visit, 75% of Veterans had reached their BP treatment goals, which was 99.5% of the Veterans who completed the program. For Veterans with diabetes or chronic kidney disease (CKD), both systolic and diastolic BP measurements were significantly reduced from the initial pharmacist visit to the final pharmacist visit. Approximately 60% of all Veterans in the program with diabetes and 56% of those with CKD reached their BP goals. Date: January 1, 2011 Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly. Date: December 22, 2010 Peer Support Improves Diabetes Outcomes This study compared the effectiveness of a peer-support program with nurse care management alone in improving glycemic control in a real-world clinical setting. Findings show that among Veterans with diabetes, periodic nurse-facilitated, patient-driven group sessions supplemented with one-on-one peer-support telephone calls (RPS group) improved glycemic control and other key outcomes more than nurse care management services alone (NCM group). More Veterans assigned to peer-support started insulin than those assigned to nurse care management (8 vs. 1), and peer-support participants reported greater increases in diabetes-specific social support at six months. Date: October 19, 2010 VA Performs Better than Non-VA Healthcare on Quality Measures for Processes of Care Since VA’s organizational transformation in the 1990’s, there have been both favorable and unfavorable reports of the quality of VA care published in the peer-reviewed literature and lay media. In order to better understand the totality of the evidence, this systematic review compared the quality of medical and other non-surgical care in VA and diverse non-VA healthcare settings. Findings show that VA outperforms non-VA healthcare on quality measures assessing adherence to recommended processes of care. For example, studies of care processes after an acute myocardial infarction found greater rates of evidence-based drug therapy in VA settings. In addition, more VA patients than Medicare patients received beta-blockers, angiotensin-converting-enzyme inhibitors, or aspirin at discharge. Studies of diabetes care processes also demonstrated a performance advantage for VA; one study reported that VA outperformed commercial managed care plans on all seven measures of care processes examined. Most studies found no significant differences in mortality rates between VA and non-VA care. Date: October 18, 2010 Threshold for Glycemic Control among Veterans with Diabetes In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences. Date: October 1, 2010 Rapid-Induction Group Clinic May Be Effective Method of Increasing Rates of Hypertension Control This report describes the process of care and outcomes of a QI initiative that used group clinics to rapidly induce hypertension control among Veterans in a VA primary care setting at one VAMC. Findings show that among Veterans with chronically treated but persistently uncontrolled hypertension, more than half (54%) were able to rapidly lower their blood pressures to controlled levels within six weeks using a group clinic quality improvement initiative. Moreover, Veterans maintained BP control over the follow-up period (10 months after QI protocol completion). Adherence to the QI protocol predicted hypertension control at follow-up, even after controlling for multiple baseline variables (e.g., diabetes, body mass index, medication compliance). Two-thirds of Veterans without diabetes achieved hypertension control, including more than 80% of those who adhered to the group-clinic protocol. Date: September 1, 2010 Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains. Date: August 1, 2010 Risk Related to Serious Hypoglycemia among Diabetics is Under-stated by Current Guidelines and Performance Measurements Rapidly evolving evidence from clinical trials and observational studies indicates that serious hypoglycemia is frequent among individuals with type 2 diabetes. Notwithstanding the absence of proven causality between hypoglycemia and mortality, the risks and consequences of hypoglycemia are significant. Despite the significant health burden associated with hypoglycemia, its risks appear to be understated by guideline and performance measurement groups. To increase public and professional awareness about this risk – and to decrease its occurrence, several recommendations are suggested. Date: May 26, 2010 History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status. Date: May 1, 2010 VA Care for Obese Veterans Of those Veterans identified as obese, only 27.7% had an obesity diagnosis in FY02; by 2006, 53.5% had an obesity diagnosis. Although suboptimal, these rates are comparable or better than those recently reported in the public sector. Results also show that an obesity diagnosis, and not BMI per se, was the strongest predictor of receiving obesity-related education. Only about 10-13% of obese Veterans received individual or group outpatient education in nutrition, exercise, or weight management on an annual basis, and only about one-third received any obesity-related education over the five-year study period. Obese Veterans who were older than 65 years, prescribed fewer types of medications, or lacking an EMR diagnosis of obesity or diabetes were less likely to have outpatient obesity-related education. Investigators also found limited utilization of weight loss medications and bariatric surgery, which may be partially due to system barriers such as access to surgery and medications. Date: February 24, 2010 Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the quality of information exchange (e.g., needs assessment, joint care planning). Date: February 16, 2010 Costs and Outcomes Associated with Newer Medications for Glycemic Control in Type 2 Diabetes Investigators in this study conducted a cost-effectiveness analysis to better understand the value of adding either of two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies, compared to an older medication (glyburide), for new-onset type 2 diabetes in persons 25 to 64 years of age. Findings show that newer medications offer more options for glycemic control; however, they come at considerable costs. Exenatide and sitagliptin conferred 0.09 and 0.12 additional quality-adjusted life years respectively, relative to glyburide as second-line therapy. Using sitagliptin as a second-line treatment is associated with additional costs of $20,213 per person over their lifetime compared to a baseline strategy using glyburide as second-line therapy. Using exenatide as a second-line treatment is associated with an additional cost of $23,849 per person over their lifetime compared to glyburide as second-line therapy. Date: January 7, 2010 Assessing New HEDIS Blood Pressure Quality Measure for Diabetes To encourage aggressive treatment of hypertension, the National Committee on Quality Assurance recently adopted a new HEDIS blood pressure performance measure of <130/80 mm Hg for patients with diabetes. Although there is nearly universal agreement on the benefits of aggressive BP treatment (3-4 BP medications) for those with diabetes, the new HEDIS performance measure has generated considerable controversy. This study examined BP levels and medication treatment intensity in patients with diabetes, in order to assess the reasons for failing to meet the new HEDIS measure. Findings suggest that the new diabetes BP measure may not accurately identify poor quality care and could promote overtreatment through its performance incentives. The new measure commonly mislabeled patients as being inadequately treated, especially elderly patients. Thus, the authors recommend that new BP measures be developed to encourage aggressive treatment of hypertension without unduly promoting overtreatment, especially among elderly patients. Date: January 1, 2010 Validity of Mental Health Diagnosis Using VA Administrative Data This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions. Date: January 1, 2010 Increase in VA Drug Co-Payment Resulted in Decrease in Veterans’ Adherence to Some Medications This study examined the impact of the VA medication co-payment increase on adherence to diabetes, hypertension, and hyperlipidemic medications by Veterans with diabetes or hypertension at 4 VAMCs during a 35-month period (2/01--12/03). Findings showed that a medication co-payment increase from $2 to $7 adversely impacted adherence to statins and anti-hypertensives by Veterans subject to the co-payment, but the impact was greatest among Veterans taking oral hypoglycemic medication. Adherence to all medications increased in the short term for all Veterans (12 months after co-payment increase), but then declined in the longer term (subsequent 11-month period). The impact of the co-payment increase was particularly adverse for Veterans with diabetes who were responsible for co-payments. Their adherence to oral hypoglycemic medication in the period 13-23 months after the co-payment increase was 10.3% lower than their pre-period adherence – and 9% lower than comparable Veterans who were exempt from co-payments. Date: January 1, 2010 Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD. Date: January 1, 2010 Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased. Date: November 1, 2009 Effect of Medicare Pharmacy Benefit Coverage on VA Healthcare Users This study examined the influence of Medicare pharmacy benefit coverage on VA pharmacy use among Veterans using the VA healthcare system during 2002, who had diabetes mellitus, ischemic heart disease, or chronic heart failure. Overall, results showed that Veterans dually enrolled in VA and Medicare fee-for-service (FFS) were less likely to receive condition-related medications from VA compared with Veterans enrolled in HMOs with lower levels of prescription drug coverage. One implication of the overall study findings is that VA will become less the healthcare system of choice for Veteran beneficiaries if Medicare pharmacy services become more affordable. Moreover, Veterans with chronic conditions that require many medications and who hit a coverage gap in Medicare Part D or have difficulty making the Medicare co-payments may turn to VA as a safety net at intermittent times rather than using VA pharmacy services more steadily. Date: October 1, 2009 Long-Term Impact of Home Telehealth on Preventable Hospitalizations for Veterans with Diabetes This study assessed the longitudinal effect of a VA Care Coordination Home Telehealth (CCHT) program on preventable hospitalizations for Veterans with diabetes. Findings showed a statistically significant reduction in preventable hospitalizations for Veterans enrolled in the CCHT program during the initial 18 months of follow-up compared to Veterans in the control group, even after adjusting for potential socio-demographic and clinical risk factors. However, the program did not demonstrate a significant impact after the initial 18 months, which may largely be due to the fact that the control group had more deaths than the CCHT group during those 18 months, likely resulting in the control group’s decreased use of preventable hospitalizations during the remainder of the study period. Over the entire four-year study period, the CCHT group had a lower death rate and longer survival time than the control group, while the control group had much higher frequency in all diabetes-related ambulatory care sensitive conditions such as lower-extremity amputations, uncontrolled diabetes, and bacterial pneumonia. Date: October 1, 2009 Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%). Date: August 5, 2009 Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes. Date: July 26, 2009 Self-Management Intervention for Hypertension has Modest “Spill-Over” Effect on Diabetes Control This study evaluated the effect of a tailored hypertension self-management intervention that had been shown to have a modest effect on blood pressure control on the unintended targets of diabetes and cholesterol control. Findings show a modest difference in glycemic control between Veterans with diabetes who received the intervention compared to usual care: the mean HbA1c decreased by 0.28% among Veterans in the intervention, while increasing 0.18% for those in usual care. LDL-C decreased over the two-year period in both groups, but there was no significant difference between the intervention group and usual care. Similar to results found in the analysis of HbA1c, Veterans with higher LDL-C at baseline had steeper rates of improvement over the study period; however, there was no differential effect between the intervention and usual care groups. Thus, this study shows some evidence that a telephone administered, nurse self-management intervention targeting hypertension may have a modest “spill-over” effect on diabetes control. Date: July 1, 2009 Review Suggests PTSD Negatively Impacts Physical Health but More Research Needed In this systematic review, investigators searched case reports, comparative studies, meta-analyses, and review articles that examined the relationship between PTSD and specific physical-health diagnoses. Findings suggest that PTSD can have negative effects on physical health, but evidence regarding its association with specific physical disorders is lacking. Evidence suggests a significant association between PTSD and musculoskeletal disorders, especially participant report of arthritis, in the general population – but not in Veterans. There also was an association between PTSD and digestive disorders, particularly ulcers, among non-Veterans. The rest of the associations were either found in single studies or are conflicting, particularly in regard to diabetes, congestive heart failure, and stroke. Authors suggest that large, prospective epidemiological trials are needed to examine the relationship between PTSD and physical illness. Date: June 1, 2009 Healthcare Utilization among American Indian and Alaska Native Veterans Findings show that like other VA healthcare users, American Indian and Alaska Native (AIAN) patients had the same three most frequent diagnoses associated with healthcare encounters: post-traumatic stress disorder, hypertension, and diabetes. VHA-Indian Health Service (IHS) dual-users were more likely to receive primary care from IHS and to receive diagnostic and behavioral healthcare from VA. Many dual-users who had been diagnosed with diabetes, hypertension, and/or cardiovascular disease received overlapping healthcare services in VA and IHS. Therefore, authors suggest that strategies to improve outcomes among the AIAN Veteran population should target those receiving care in both systems and include information sharing or coordination of clinical care to reduce the potential for duplication and for treatment conflicts. Date: June 1, 2009 Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure This study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (nurse practitioners, physician assistants), and to determine reasons for any observed differences. Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers. Date: June 1, 2009 HSR&D Investigators Propose New Measure to Assess Diabetes Care Quality This article discusses a conceptual framework for assessing the efficiency of pharmacologic control of three important risk factors for diabetes (glucose, blood pressure, and cholesterol) because of their central role in diabetes management, and policy implications related to higher medication costs. The authors note that a growing body of evidence indicates a need for more flexible measures of diabetes quality of care. Thus, rather than a single optimal threshold approach, they suggest a new framework for measuring quality of care that incorporates the benefit of incremental improvement among multiple populations that differ by age, diabetes duration, and co-existing illness. The new paradigm would assess pharmaceutical efficiency using quality-adjusted life years (QALYs), calculated separately within multiple age/risk categories, as the output (numerator) and acquisition costs of medications as the input (denominator). The QALYs/cost ratio will provide an assessment of the efficiency of pharmacologic utilization. Therefore, measuring efficiency in the treatment of glucose, blood pressure, and cholesterol in persons with diabetes would incorporate the evaluation of a future healthcare benefit that is “purchased” by direct pharmaceutical costs, linking expected healthcare benefits to actual costs. Date: June 1, 2009 Inhaled Corticosteroids Associated with Higher Glucose Levels in Veterans with Diabetes, but Effect was Dose-Dependent This study examined the association between inhaled corticosteroids and glucose concentration among Veterans who received care at seven VA primary care clinics between 12/96 and 5/01. Of the 1,698 Veterans in this study, 19% also had self-reported diabetes. Findings show that after controlling for systemic corticosteroid use and other potential confounders, no association was found between inhaled corticosteroids and serum glucose for Veterans without diabetes. However, among Veterans with diabetes, every additional 100 mcg of inhaled corticosteroid dose was associated with increased glucose concentration. Given this association, authors suggest that clinicians anticipate an increase in serum glucose for patients with diabetes who are using inhaled corticosteroids and adjust serum glucose monitoring accordingly. Date: May 1, 2009 Evaluating Profiling Program and New Quality Indicators for Diabetes Care This study evaluated the addition of new quality indicators to an ongoing clinician feedback initiative that profiles diabetes care and suggests that rather than relying on benchmarks with high and consistent attainment, profiling programs may want to target indicators that demonstrate low and variant performance to better differentiate care across sites. Date: March 1, 2009 Cardiovascular Risk Reduction Clinic for Veterans with Diabetes The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline. Date: March 1, 2009 Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression. Date: March 1, 2009 Transparency Standards for Diabetes Performance Measures The development and adoption of performance measures must be transparent. Transparency has been defined as “a process by which information about existing conditions, decisions and actions is made accessible, visible and understandable.” This JAMA Commentary discusses several examples of transparency that might help guide the development of hemoglobin A1c performance measures in the future. Authors suggest that, considering the potential effect on millions of patients and the high cost of antiglycemic medications alone, the upfront investment in ensuring evidence-based, transparently developed performance measures would be worthwhile to protect the public health and restore public and professional confidence. Date: January 14, 2009 Need for Better Self-Management Education to Address Cultural Differences among Veterans with Diabetes Although non-white Veterans have documented disparities in the quality of some diabetes care processes and intermediate outcome measures, racial disparities in foot care examinations have not been widely explored. Findings from this study show that there are significant differences in self-reported foot care and education across racial and ethnic groups among Veterans with diabetes. Authors suggest the need for better self-management education to address culture, knowledge, preferences, and unique barriers to care. Date: January 1, 2009 Reducing Cardiovascular Risk for Veterans with Diabetes and Depression The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program. Date: October 1, 2008 Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness. Date: July 1, 2008
What is included in Publication Briefs? HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations. ^ top

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