Leonard Pogach

Preventive Foot Care in People With Diabetes

A number of effective, low-cost strategies are available to identify and treat the person at risk for diabetic foot ulcers and lower-extremity amputation. These strategies must be more widely adopted by all diabetic care providers to maintain the integrity and function of the lower limb, and thus improve the quality of life for people with diabetes.

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.

Assessing Potential Glycemic Overtreatment in Persons at Hypoglycemic Risk

IMPORTANCE Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment. OBJECTIVE To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009. MAIN OUTCOMES AND MEASURES Intensive control was defined as the last hemoglobin A1c (HbA1c) measured in 2009 that was less than 6.0%, less than 6.5%, or less than 7.0%. The primary outcome measure was an HbA1c less than 7.0% in patients who were aged 75 years or older who had a serum creatinine value greater than 2.0 mg/dL or had a diagnosis of cognitive impairment or dementia. We also assessed the rates in patients with other significant medical, neurologic, or mental comorbid illness. Variation in rates of possible glycemic overtreatment was evaluated among 139 Veterans Health Administration facilities grouped within 21 Veteran Integrated Service Networks. RESULTS There were 652,378 patients who received insulin and/or a sulfonylurea with an HbA1c test result. Fifty percent received sulfonylurea therapy without insulin; the remainder received insulin therapy. We identified 205,857 patients (31.5%) as the denominator for the primary outcome measure; 11.3% had a last HbA1c value less than 6.0%, 28.6% less than 6.5%, and 50.0% less than 7.0%. Variation in rates by Veterans Integrated Service Network facility ranged 8.5% to 14.3%, 24.7% to 32.7%, and 46.2% to 53.4% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The magnitude of variation by facility was larger, with overtreatment rates ranging from 6.1% to 23.0%, 20.4% to 45.9%, and 39.7% to 65.0% for HbA1c less than 6.0%, less than 6.5%, and less than 7.0%, respectively. The maximum rate was nearly 4-fold compared with the minimum rates for HbA1c less than 6.0%, followed by 2.25-fold for HbA1c less than 6.5% and less than 2-fold for HbA1c less than 7.0%. When comorbid conditions were included, 430,178 patients (65.9%) were identified as high risk. Rates of overtreatment were 10.1% for HbA1c less than 6.0%, 25.2% for less than 6.5%, and 44.3% for less than 7.0%. CONCLUSIONS AND RELEVANCE Patients with risk factors for serious hypoglycemia represent a large subset of individuals receiving hypoglycemic agents; approximately one-half had evidence of intensive treatment. A patient safety indicator derived from administrative data can identify high-risk patients for whom reevaluation of glycemic management may be appropriate, consistent with meaningful use criteria for electronic medical records.

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.

Comparing Clinical Automated, Medical Record, and Hybrid Data Sources for Diabetes Quality Measures

BACKGROUND Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined. METHODS Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use. RESULTS Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record-based measures but would have required about 50% fewer chart reviews. CONCLUSIONS Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.

Department of Veterans Affairs' Quality Enhancement Research Initiative for Diabetes Mellitus

Diabetes is a common disease, which frequently leads to serious, high-cost complications. Estimates show that in fiscal year 1994 (FY94), 12.5% of outpatients in the Veterans Health Administration (VHA) received diabetes-specific medications, accounted for almost 25% of all VHA pharmacy costs, had a hospitalization rate 1.6 times that of veterans without diabetes, and made 3.6 million outpatient visits to VA clinics. Research demonstrates that much of the mortality and morbidity associated with diabetes can be prevented, and rigorous evidence-based guidelines have been developed. The short-term objectives of the Quality Enhancement Research Initiative for Diabetes Mellitus (QUERI-DM) are to (1) gather baseline information on how current VHA diabetes care differs from the VHA guidelines, (2) develop an efficient, validated system for monitoring key diabetes quality standards in the VHA, (3) evaluate the effectiveness of current approaches to diabetes care and the success of guideline implementation initiatives, and (4) initiate 2 to 4 large-scale quality improvement projects to enhance adherence to practice guidelines and evaluate their impact on patient outcomes, including quality of life.

Risk of Stroke, Heart Attack, and Diabetes Complications Among Veterans With Spinal Cord Injury

OBJECTIVES To compare the rates of diabetes and macrovascular conditions in veterans with spinal cord injury (SCI) and to examine variations by patient-level demographic, socioeconomic, access, and health status factors. DESIGN A retrospective analysis. Diabetes status was classified by merging with diabetes epidemiology cohort using a validated algorithm. Chi-square tests and logistic regressions used to compare rates in macro- and microvascular conditions in veterans with and without diabetes. SETTING Veteran Health Administration clinic users in fiscal year (FY) 1999 to FY 2001. PARTICIPANTS SCI patients (N=8769) with diabetes (n=1333), in FY 2000, identified through the SCI registry. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Macrovascular and microvascular conditions in the next year (February 2001). Derived from International Statistical Classification of Diseases, 9th Revision, Clinical Modification, codes in the patient treatment files. RESULTS Overall, 15% of SCI veterans were identified with diabetes but this was an underestimate due to high mortality (8%). Among SCI veterans with diabetes, 49% had at least one macrovascular condition and 54% had microvascular conditions compared with 24% and 25% of those without diabetes (P<.001). CONCLUSIONS Our study highlights the highly significant relationship between diabetes and macro- and microvascular conditions in veterans with SCI. Neurologic deficit combined with increased insulin resistance has a greater macrovascular impact on SCI veterans than on those who do not have diabetes. Increasing age and physical comorbidities compound the problem.

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.

Racial/ethnic differences in diabetes care for older veterans: accounting for dual health system use changes conclusions.

Background:Veterans Health Administration (VHA) databases are used extensively to study racial/ethnic disparities; however, these databases may not capture all care received by VHA patients. Objectives:We examined the extent to which accounting for non-VHA care changed conclusions about racial/ethnic disparities for VHA patients with diabetes. Methods:Using a cross-sectional observational study, we analyzed a national sample of noninstitutionalized Hispanic (n = 5931), black (n = 24,670), and white (n = 149,222) VHA patients with diabetes who were at least 65 years of age for receipt of annual HbA1c testing, low-density lipoprotein (LDL) cholesterol testing, or eye examination from VHA and Medicare administrative files. Results:In VHA alone data, adjusting for patient characteristics, Hispanic and black patients were as likely as white patients to receive HbA1c testing (odds ratio 1.06 [95% confidence interval 0.99–1.13] and 1.04 [1.00–1.07], respectively), and more likely to receive eye examinations (1.31 [1.24–1.38] and 1.33 [1.29–1.37], respectively). Hispanic patients were equally likely (1.01 [0.95–1.07]) and black patients were less likely (0.81 [0.79–0.84]) to receive LDL testing versus white patients. In VHA plus Medicare data, Hispanic and black patients were less likely than white patients to receive HbA1c (0.76 [0.71–0.82] and 0.83 [0.80–0.87], respectively) and LDL testing (0.84 [0.79–0.90] and 0.70 [0.68–0.72], respectively), and equally likely to receive eye examinations (0.91 [0.86–0.96]) and 0.98 [0.95–1.01]), respectively). Accounting for VHA facility had little effect on results. Conclusions:Restricting to VHA data masks racial/ethnic disparities in care of VHA patients. VHA researchers must be aware and supplement VHA data with other sources whenever possible.