VHA Innovations in Care
By Leonard Pogach, MD, MBA, FACP, National Director of Medicine, Specialty Care Services, VHA, VACO
The prevalence of diabetes in the U.S. population increased from 18.0 million (6.3%) in 2002 to 25.7 million (8.3%) in 2009 [including one-third undiagnosed]. The number of veterans with diagnosed diabetes receiving care in the Veterans Health Administration increased from about 600,000 (19.6%) in 2000 to about 1.45 million (23.7%) in 2010. In 2010, about 52% of veterans with diabetes were younger than 65 years compared with about 36% in 2000.Diabetes remains the major cause of visual loss, dialysis and amputation.
Because the individual needs of veterans vary by disease duration, comorbid conditions and age, the first version of the VA-Department of Defense (DoD) Diabetes Guidelines (1997) and all subsequent versions have emphasized the concept of risk stratification. This approach emphasizes individual goal-setting based upon the likelihood (i.e., absolute rRisk reduction) of benefits and risks of treatment and the veteran’s preferences. In each instance, the guidelines have incorporated a non-biased review of evidence by VA and DoD professionals. The guidelines include an algorithmic format allowing providers to follow a linear approach to critical information needed at the major decision points in the clinical process. The recommendations for individualized glucose control targets were validated and updated in 2010 by incorporating the landmark clinical trials — ADVANCE, ACCORD and the VA Diabetes Trial. The original framework of risk stratification from VA-DoD guidelines was recently adopted in other guidelines, including the American Diabetes Association 2012 Clinical Practice Guidelines and consensus statements.
Patient-Aligned Care Team
Most veterans with diabetes receive care within the new VHA system of primary care — the Patient-Aligned Care Team (PACT) — which is modeled after the Patient-Centered Medical Home. Within these teams, providers and staff members from multiple disciplines work together at the top of their scope of practice to provide the best possible care, consistent with the evidence and patient preferences.
In order to communicate key aspects of the diabetes guidelines into every day practice, a pocket card for diabetes shared decision-making was developed to educate and empower providers to engage patients in evidence-based discussions around medications and clinical measures in diabetes. A target range for HbA1c, based upon life expectancy, microvascular complications and co-morbid conditions, is a starting point for shared decision-making with patients. Patients are encouraged to make the final decision about a specific target value of glycemic control after a full discussion of the risks and benefits of therapy with his or her provider. Health numeracy (i.e., interpreting numeric values) is critical. The VA-DoD provider tool on A1c accuracy was adapted and published by the National Institutes of Health Diabetes Clearing House.