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Veterans Administration (VA) Diabetes Guidelines
March 15 2003 • Volume 36 • Number 6
Clinical Rounds
Average HBA1c now down to 7.4%
Guidelines, Feedback Can Improve Diabetes Care
Miriam E. Tucker
Senior Writer
NEW YORK — Systematic use of evidence-based guidelines, performance
measures,
and clinical feedback can substantially improve the quality of diabetes
care,
Dr. Clark T. Sawin said at a conference sponsored by the American Diabetes
Association.
Such an approach has yielded significant gains in recent years within the
Veterans Health Administration. For example, the average hemoglobin A1c f
(HbA1c) level among more than 450,000 diabetic patients in the VHA system in
2001-2002 was 7.4%, down from 7.7% in 1998-1999, said Dr. Sawin, medical
inspector for the VHA in Washington.
Although there's still room for improvement, the progress made so far
is “pretty remarkable for a system with several thousand physicians taking
care of all these folks. It can be done,” he told this newspaper.
The VHA itself has changed dramatically since 1995. About half of the
hospital beds have been closed, with a corresponding rise in ambulatory
care.
At the same time, the number of patients served has risen from 2.5 million
to
more than 4 million today, and the number continues to rise.
About 18%-19% of individuals served by the VHA have diabetes, among the
highest burdens of any national health care system. One-fourth of all
pharmacy costs in the VHA are for drugs to treat patients with diabetes
(including their comorbidities), totaling more than $500 million a year.
The VHA system itself comprises over 140 hospitals with clinics and more
than
600 separate primary care community clinics, with widely varying approaches
to diabetes care.
A centerpiece of the approach—from the Veterans Administration's Office of
Quality and Performance—was the development of evidence-based guidelines,
first issued in December 1999 and since updated. Another was to hire a
company that sends reviewers into practices nationwide on a monthly basis to
survey records of 20,000-35,000 randomly chosen diabetic patients. Feedback
is sent quarterly to the hospital and network directors, who use it both for
information and as a performance assessment tool, said Dr. Sawin, of Boston
University, whose job involves monitoring the quality of medical care in the
VA.
The results have been dramatic. In 1995, HbA1c levels were measured annually
in only 59% of the VHA's diabetic patients. By 2002, that number had risen
to
94%. At the same time, the proportion of patients with HbA1c levels below 8%
rose from 59% in 1998-1999 to 65% in 2001-2002, while the percentage
reaching
the American Diabetes Association's target HbA1c of less than 7% was 41% in
2001-2002, up from 37% in 2000.
Other diabetes-related measures also have improved. From 1995 to 2002, the
proportion receiving an annual eye exam rose from 44% to 72%, while
documented foot exams increased from 77% to 92%. And from 1997 to 2002, the
rate of annual microalbuminuria measurement increased from 23% to 78% and
measurement of LDL cholesterol rose from 47% to 95%.
The mean LDL cholesterol for about 380,000 diabetic veterans was 111 mg/dL
in
1999; by 2001, it was down to 105 mg/dL. “That's not bad,” Dr. Sawin said.
Some measures, while having improved, still need work. The proportion with
blood pressures of less than 140/90 mm Hg was 58% in 2001-2002, up from 44%
in 1998-1999. But the ADA recommends a target blood pressure of less than
130/80 mm Hg in individuals with diabetes. “Much needs to be done just to
reach a value of 140/90, let alone a lower value,” Dr. Sawin noted.
Influenza vaccinations were given to 68% of diabetic veterans in 2001-2002,
lower than the 81% who got the pneumococcal vaccine. In 1995, those numbers
were 34% and 29%, respectively. “This kind of comprehensive care will
require
ongoing effort,” he said.
Current efforts include development of a registry to document long-term
outcomes in diabetic cohorts to help target limited resources. One registry
already in place has shown a 50% reduction in amputations among veterans
with
diabetes since the mid-1990s. The goal is to link those data with other risk
factors to find ways to reduce that number further.
That, however, is easier said than done. One problem is that patients who
become Medicare eligible when they turn 65 often obtain care from both
health
systems. And the two databases currently are not linked.
The Veterans Affairs guidelines are available at www.va.gov/diabetes.
Copyright © 2003 by International Medical News Group. Click for restrictions.
http://www.va.gov/diabetes
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