Anjali Tiwari

Survival Benefit of Nephrologic Care in Patients With Diabetes Mellitus and Chronic Kidney Disease

BACKGROUND The association of nephrologic care and survival in patients with diabetes mellitus and chronic kidney disease is unknown. METHODS Using data from 1997 to 2000, we conducted a retrospective cohort study of Veterans Health Administration clinic users having diabetes mellitus and stage 3 or 4 chronic kidney disease. The baseline period was 12 months and median follow-up was 19.3 months. Degree of consistency of visits to a nephrologist, defined as the number of calendar quarters in which there was 1 visit or more (range, 0-4 quarters), and covariates were calculated from the baseline period. The outcome measure was dialysis-free death. RESULTS Of 39,031 patients, 70.0%, 22.4%, and 7.6% had early stage 3, late stage 3, and stage 4 chronic kidney disease, respectively, and 3.1%, 9.5%, and 28.2%, respectively, visited a nephrologist. Dialysis-free mortality rates were 9.6, 14.1, and 19.4, respectively, per 100 person-years. More calendar quarters with visits to a nephrologist were associated with lower mortality: adjusted hazard ratios were 0.80 (95% confidence interval, 0.67-0.97), 0.68 (95% confidence interval, 0.55-0.86), and 0.45 (95% confidence interval, 0.32-0.63), respectively, when the groups having 2, 3, and 4 visits were compared with those who had no visits. One visit only was not associated with a difference in mortality when compared with no visits (adjusted hazard ratio,1.02; 95% confidence interval, 0.89-1.16). CONCLUSIONS The consistency of outpatient nephrologic care was independently associated in a graded fashion with lower risk of deaths in patients with diabetes and moderately severe to severe chronic kidney disease. However, only a minority of patients had any visits to a nephrologist.

Opting out of an integrated healthcare system: Dual-system use is associated with poorer glycemic control in veterans with diabetes

AIMS To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system. METHODS We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors. RESULTS In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value. CONCLUSIONS Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.

Guideline-consistent antidepressant treatment patterns among veterans with diabetes and major depressive disorder.

OBJECTIVE This study estimated guideline-consistent antidepressant treatment of depression among veterans with diabetes and examined its variation by patient-level demographic characteristics, socioeconomic characteristics, access to care, and health status. METHODS Data were retrospectively analyzed from Veterans Health Administration (VHA) and Medicare claims of VHA clinic users with diabetes and major depressive disorder (N=3,953). Major depression was identified by using ICD-9-CM codes 296.2 and 296.3. Incident episode was identified by using 120-day negative diagnosis and medication history on or before the first depression diagnosis date in fiscal year 1999. Guideline-consistent depression treatment was defined as the receipt of antidepressants for at least 90 days within a period of six months after the onset of depression. Chi square tests and logistic regressions were used to analyze patterns of guideline-consistent antidepressant treatment. RESULTS Overall, 51% received any antidepressant treatment for diagnosed major depression; among patients using any antidepressants, 62% received guideline-consistent antidepressant treatment. VHA users who received care from a mental health specialist were more likely to have guideline-consistent treatment than those who were not receiving care from a mental health specialist. African Americans, older veterans, and those with substance use disorders were less likely to have guideline-consistent antidepressant treatment. CONCLUSIONS Guideline-consistent depression care was lower for certain subgroups of individuals. Further research is necessary to evaluate the reasons for this finding, so that targeted care coordination strategies could be developed to improve antidepressant treatment. Increased contact with mental health specialty staff, which is now being implemented in the VHA, may increase antidepressant treatment among VHA users with diabetes and major depression.

Can ambulatory care prevent hospitalization for metabolic decompensation

Objective:Metabolic decompensations (MD) are hospitalizations considered preventable with appropriate ambulatory care. We tested for associations between diabetes care and MD. Research Design:We retrospectively compared care between cases (MD; n = 2714) and controls (without MD; n = 10,856) using merged Veterans Health Administration and Medicare data. Logistic regression tested for associations between MD and diabetes care controlling for patient characteristics. Subjects:Veterans Health Administration users with diabetes stratified into high [hemoglobin A1c (HA1c) ≥9%; n = 2532] and low (HA1c <9%; n = 6176) risk groups. Measures:The outcome was hospitalization for MD. Care was defined as quarterly or semiannual diabetes visits and HA1c testing during individualized 12-month baseline periods. Results:Cases averaged more diabetes visits and HA1c tests than controls (P < 0.001 for both) in the 12-month baseline period. Among the high-risk, 29.8% of cases made 4 quarterly visits compared with 29.6% of controls (P = 0.004); among the low-risk, there was no difference in semiannual visits. Among the high-risk, models showed having no visit was associated with higher odds of MD (adjusted odds ratio: 3.05; 95% confidence interval: 1.69–5.49) compared with 4 visits; individuals with 1–4 visits had similar odds of MD. More HA1c testing was weakly associated with higher odds of MD. Conclusions:MD was associated with more diabetes care, even controlling for patient characteristics. This inconsistency with the theoretical association between appropriate ambulatory care and lower MD rates indicates that MD rates may not accurately reflect diabetes care quality.