Mangala Rajan

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.

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.

Costs and consequences associated with newer medications for glycemic control in type 2 diabetes

OBJECTIVE Newer medications offer more options for glycemic control in type 2 diabetes. However, they come at considerable costs. We undertook a health economic analysis to better understand the value of adding two newer medications (exenatide and sitagliptin) as second-line therapy to glycemic control strategies for patients with new-onset diabetes. RESEARCH DESIGN AND METHODS We performed a cost-effectiveness analysis for the U.S. population aged 25–64. A lifetime analytic horizon and health care system perspective were used. Costs and quality-adjusted life years (QALYs) were discounted at 3% annually, and costs are presented in 2008 U.S. dollars. We compared three glycemic control strategies: 1) glyburide as a second-line agent, 2) exenatide as a second-line agent, and 3) sitagliptin as a second-line agent. Outcome measures included QALYs gained, incremental costs, and the incremental cost-effectiveness ratio associated with each strategy. RESULTS Exenatide and sitagliptin conferred 0.09 and 0.12 additional QALYs, respectively, relative to glyburide as second-line therapy. In base case analysis, exenatide was dominated (cost more and provided fewer QALYs than the next most expensive option), and sitagliptin was associated with an incremental cost-effectiveness ratio of

Personal and treatment factors associated with foot self-care among veterans with diabetes.

169,572 per QALY saved. Results were sensitive to assumptions regarding medication costs, side effect duration, and side effect–associated disutilities. CONCLUSIONS Exenatide and sitagliptin may confer substantial costs to health care systems. Demonstrated gains in quality and/or quantity of life are necessary for these agents to provide economic value to patients and health care systems.

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

We developed and validated a survey of foot self-care education and behaviors in 772 diabetic patients with high-risk feet at eight Department of Veterans Affairs medical centers. Principal components analysis identified six subscales with satisfactory internal consistency: basic foot-care education, extended foot-care education, basic professional foot care, extended professional foot care, basic foot self-care, and extended foot self-care (alpha = 0.77-0.91). Despite high illness burden, adherence to foot self-care recommendations was less than optimal; only 32.2% of participants reported looking at the bottom of their feet daily. Independent predictors of greater adherence to basic foot self-care practices included African-American or Hispanic background, perceived neuropathy, foot ulcers in the last year, prior amputation (beta = 0.08- 0.12, p < 0.04-0.001), and provision of greater basic and extended education (beta = 0.16, p < 0.004, and beta = 0.15, p < 0.007). The survey subscales can now be used for evaluating foot care and education needs for persons with high-risk feet.

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

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.

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.

Foot care education and self management behaviors in diverse veterans with diabetes

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.