Chin-Lin Tseng

Risk of Hypoglycemia in Older Veterans with Dementia and Cognitive Impairment:: Implications for Practice and Policy

To examine the relationship between management of diabetes mellitus and hypoglycemia in older adults with and without dementia and cognitive impairment.

Trends in Initial Lower Extremity Amputation Rates Among Veterans Health Administration Health Care System Users From 2000 to 2004

OBJECTIVE To evaluate temporal trends in rates of initial lower extremity amputation (ILEA) among patients with diabetes in the Veterans Health Administration (VHA). RESEARCH DESIGN AND METHODS Retrospective administrative data analysis of VHA clinic users with diabetes in fiscal years (FY) 2000 to 2004 (1 October 1999–30 September 2004). We calculated annual age– and sex–standardized rates of initial major, minor, and total amputations for the overall population and for various racial/ethnic groups (African Americans, Hispanics, and whites). Trends in ILEA risk were evaluated with and without adjustment for demographic characteristics and other potential risk factors, including presence of microvascular and macrovascular diseases, and antiglycemic treatment. RESULTS Study populations of VHA patients with diabetes and without prior amputations ranged from 405,580 in FY 2000 to 739,377 in FY 2004. Age- and sex-standardized ILEA rates decreased by 34% (7.08/1,000 patients in FY 2000 to 4.65/1,000 patients in FY 2005) during the 5-year period. Minor and major amputation rates decreased by 33% (4.59 to 3.06/1,000) and 36% (2.49 to 1.59/1,000), respectively. Of major amputations, below-knee rates decreased from 1.08 to 0.87/1,000 (−19%), and above-knee decreased from 1.41 to 0.72/1,000 (−49%). Similar trends were seen for all racial groups. ILEA risk decreased by 28% (odds ratio 0.72 [95% CI 0.68–0.75]) when FY 2004 was compared with FY 2000 in the model, adjusting for demographic characteristics. This risk decrease was 22% in the model adjusting for all independent variables (odds ratio 0.78 [95% CI 0.74–0.82]). CONCLUSIONS Downward 5-year trends in ILEA rates were observed for all amputation levels and among all racial groups, even after adjustment for risk differences over time.

Does Diabetes Care Differ by Type of Chronic Comorbidity?: An evaluation of the Piette and Kerr framework

OBJECTIVE To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes. RESEARCH DESIGN AND METHODS Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA1c and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency. RESULTS Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA1c <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83–1.11]) and lower in the discordant (0.90 [0.81–0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category. CONCLUSIONS Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.

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.

Are there Gender Differences in Diabetes Care Among Elderly Medicare Enrolled Veterans

AbstractOBJECTIVE: To examine gender differences in diabetes care process measures and intermediate outcomes among veteran clinic users. DESIGN: A retrospective cohort study using Veterans Health Administration (VHA) and Medicare files of VHA clinic users with diabetes. Diabetes care process measures were tests for hemoglobin A1c (HbA1c), low-density lipoprotein (LDL-C) values, and eye exams. Intermediate outcomes were HbA1c and LDL-C values below recommended thresholds. Chi-square tests and logistic regressions were used to assess gender differences. PARTICIPANTS: Study population included 3,225 women and 231,922 men veterans with diabetes, enrolled in Medicare fee-for-service and alive at the end of fiscal year 2000. RESULTS: Overall, there were no significant gender differences in HbA1c or LDL-C testing. However, women had higher rates in these process measures than men among the non-African American minorities. Women were more likely to have completed eye exams (odds ratio [OR]=1.11; 99% confidence interval [CI]=1.10, 1.23) but were less likely to have LDL-C under 130 mg/dL (OR=0.77; 99% CI=0.69, 0.87). CONCLUSIONS: Among VHA patients with diabetes, clinically significant gender inequality was not apparent in most of diabetes care measures. However, there was evidence of better care among nonwhite and non-African American women than their male counterparts. Further research on interaction of race and gender on diabetes care is needed. This includes evaluation of integrated VHA women’s health programs as well as cultural issues. Lower LDL-C control among women suggests areas of unmet needs for women and opportunities for future targeted quality improvement interventions at system and provider levels.

Initial nontraumatic lower-extremity amputations among veterans with diabetes.

Research Objective:We sought to identify initial nontraumatic lower-extremity amputations (ILEAs) and compare rates of ILEAs with different coding algorithms and varying lengths of observation period prior (look-back) to the first observed amputation. Study Design:We used a retrospective design on merged Medicare claims and patient treatment files of the Veteran Healthcare Administration for fiscal years 1998 to 2000 of veterans with diabetes ages 18 years and older. Three different algorithms using least-inclusive to most-inclusive procedure codes and “look-back” periods of 12, 18, and 24 months were used to identify ILEAs. Findings:Overall, 2997 (8.2 per 1000) veterans experienced an amputation in fiscal year 2000. Using 24 months of previous data, the rates of ILEA under the 3 different algorithms I, II, and III were 6.4/1000, 6.2/1000, and 6.0/1000 respectively. Using the most stringent algorithm (III), ILEA rates were 6.6/1000 with 12 months of prior data, 6.2/1000 with 18 months of prior data. Compared with any amputations in fiscal year 2000, 12-, 18-, and 24-month look-back period decreased the ILEA rates by 19%, 24%, and 27%, respectively. Conclusion:These findings highlight the usefulness of administrative data in identifying ILEAs. All 3 algorithms performed comparably well in the detection of ILEAs. The extent of identification was most complete with 24 months prior data, with marginal gains in extending the prior observation period from 18 to 24 months. Policy level analysis should consider reporting ILEAs, in addition to total amputation rates when examining trends and disparities in amputations.

Cost of lower-limb amputation in U.S. veterans with diabetes using health services data in fiscal years 2004 and 2010

The purpose of this study was to estimate healthcare costs associated with diabetes-related lower-limb amputations (LLAs) within the Veterans Health Administration (VHA). We performed a cross-sectional comparative analysis of 3,381 VHA clinic users in fiscal year (FY) 2004 and 3,403 clinic users in FY2010 identified as having type 2 diabetes mellitus and nontraumatic LLA. LLA expenditures related to inpatient medical, inpatient surgical, and outpatient care were estimated using VHA Health Economics Resource Center average cost files. LLA-related pharmaceutical costs were obtained from VHA Decision Support System national extract files. From the Department of Veterans Affairs (VA) perspective, the mean cost associated with care for diabetes-related LLA per patient in the VA healthcare system in FY2004 was

Short-term statin exposure is associated with reduced all-cause mortality in persons with diabetes.

50,351 (95% confidence interval [CI] = 48,939-51,803) in U.S. dollars; the total cost for all 3,381 patients was

Can ambulatory care prevent hospitalization for metabolic decompensation

170,236,037. In FY2010, cost per patient rose to

A Clinical Action Measure to Assess Glycemic Management in the 65-74 Year Old Veteran Population

60,647 (95% CI = 59,143-62,188), with a total cost of