Reasons for Poor Diabetes Control in Patients Receiving VA Care

ATLANTA — Poor diabetes control with HbA1c levels exceeding 9% is a common problem, even at the VA where 20% of all patients with diabetes fall into that category despite established care.

Noting that “most poorly controlled patients improve on follow-up, about 2% of patients with diabetes have chronic poor control, most often despite frequent contact with the healthcare system,” according to a poster presentation by researchers from Emory University in Atlanta. Their study of patients treated at the Atlanta VAMC was presented at the Endo 2013 conference in San Francisco.1

The study found that potential contributors to poor diabetes control include medication non-adherence, insufficient attention to diabetes during primary care visits and mental health disorders.

“Because of such heterogeneity,” the authors wrote, “improved management is likely to require a highly individualized approach.”

Noting that the VA is the largest integrated healthcare system in the United States and “diabetes care in the VA has been shown to be superior to that in managed care systems,” the researchers sought to determine sources of the problem. They employed a database of veterans from Georgia, South Carolina and Alabama from 2001 through 2011, examining yearly cohorts of patients who had use of the diabetes ICD-9 code 250.xx, a prescription for a diabetes drug, and at least one A1c measurement.

They noted that the numbers of such patients increased steadily from 37,757 in 2001 to 85,041 in 2011.

Within each cohort, however, the percentage of patients with “poor control” — defined as at least one A1c over 9% — decreased significantly from 2001-2011 (p<0.001) but remained substantial at 18.5% in 2011.

Patients with “chronic poor control, defined as a repeat A1c at two-to-six months that fell less than 0.5%, were less common, although that percentage also decreased significantly, with 2.6% in that category in 2011.

The majority of the patients with inadequate control, 67% in 2011, had more than two primary care visits in their index year, including one within six months of their index high A1c. That meant that 1,514 patients had “chronic poor control” in 2011, despite “established care.” On average, this group had an A1c of 10.2% with a follow-up A1c of 11.2%, were 62-years-old with a BMI of 33. Almost all (94%) were male, 43% white, 46% black and 11% other/unknown race.

In general, according to the researchers, they were more likely to be younger, heavier and more likely to be black compared with the entire diabetes population.

The researchers also reviewed 25 records selected randomly from 256 such patients at the Atlanta VA in 2011, finding that the patients had an average of 22 visits, phone calls and letters from providers in 2011.

Yet, 60% exhibited poor medication adherence; 56% had little documented attention to diabetes during at least one primary care visit; 72% had a mental health diagnosis (ICD-9 290.0-319.0); and 20% had substance abuse. Homelessness, dementia and palliative care were less frequent, they noted.

1.  Haw SJ, et al. (2013, June). Chronic poor diabetes control in a large, integrated healthcare system. Presented at the Endo 2013 meeting, San Francisco, CA

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