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Treating a Million Diabetes Patients, VA Stays at Cutting Edge Cont.
- Categorized in: Department of Veterans Affairs (VA), Diabetes, November 2011
Treating the individual
Just as individualized glycemic targets are recommended by VA, so, says Pogach, is individualized treatment. While the aforementioned algorithms are useful guidelines, a patient’s treatment also depends upon where they present in the cycle of the disease.Treatment recommendations for most veterans with new onset diabetes include diet and exercise, with the oral medication Metformin. “An appropriate medication can be used, but we want to stress diet and exercise as really being the keystone of management,” says Pogach. He says the MOVE! program in VA and DoD is the best approach to try to get individuals to “hook into a more formalized approach to diet and exercise.”
MOVE! was developed in 2004 by the VA National Center for Health Promotion and Disease Prevention and includes modules on physical activity, nutrition and behavioral health. As more than 70% of veterans are overweight or obese, the VA MOVE! program uses a public-health approach to screen all veterans with weight problems, provide counseling about health risks and offer enrollment in MOVE!. As part of MOVE! enrollment, patients complete an online questionnaire, the MOVE!23. It asks them about their medical history, what they eat, how active they are and other issues that may be affecting their ability to manage their weight. The MOVE!23 produces a detailed individual profile with self-care recommendations for the veteran, with a brief summary and guidance for staff in treating and counseling the veteran. Both reports can be automatically imported into the VA computerized medical record.
VA is moving towards a team approach in the treatment of many conditions, particularly diabetes, with care provided by Patient Aligned Care Teams (PACT). A PACT typically includes a primary-care provider, a nurse care manager, a clinical associate, and an administrative clerk. Most importantly, the veteran is considered to be at the center of the team, with the goals of the program being improved patient satisfaction, clinical quality and safety.
VA/DoD Diabetes Practice Guidelines Working Group Hemoglobin A1c targets
|
Major comorbidity or Physiologic age |
Microvascular complications |
||
|
Absent or mild |
Moderate |
Advanced |
|
|
Absent > 10 years of life expectancy |
< 7 |
< 8 |
8-9 |
|
Present 5-10 years of life expectancy |
< 8 |
< 8 |
8-9 |
|
Marked < 5 years of life expectancy |
8-9 |
8-9 |
8-9 |
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It is laudable and appropriate for the VA to have been on the vanguard of individualizing treatment goals for patients. However, some of the recommendations may benefit from clarification or may not be correct.
For example, there may not to be a role to establish a higher goal range of 8-9%, in any setting. It would seem more prudent to use A1c as a monitoring tool without any goal once prevention of microvasclar complications is no longer necessary. It would be better to state treatment goals of avoiding both hypoglycemia and symptomatic hyperglycemia at those times. A1c might alert the provider to higher risk of hypoglycemia or hyperglycemia, but no longer be a goal of therapy.
It also seems inaccurate to raise the goal A1c in most patients with established complications. It may be greater benefit to reduce the rate of progression of established complications to delay severe disability from blindness or dialysis, and this would recommend improving A1c from whatever level that led to he onset of the microvascular complication.
It is harder to codify this into a simple table, but to paraphrase H.L Mencken: there may be a simple, elegant, attractive solution, but it is often wrong.
The 8-9% A1c range is used because that was the target for standard control in the VA Diabetes Trial (VADT).