VHA DIABETES CARE: TODAYS BENCHMARK TOMORROWS FUTURE

1
VHA DIABETES CARE TODAYS BENCHMARKTOMORROWS
FUTURE

• December 1, 2005 US Medicine Diabetes Roundtable
• Presenter Len Pogach MD, MBA
• National Program Director, Diabetes
• VACO Office Patient Care Services

2
Diabetes Prevalence in VHA

• Has increased from about 561,000 persons with
  diabetes among 2,923,000 clinical users in 1998
  to an estimated 1,040,000 persons among 5,200,000
  clinical users in 2004.
• Mostly men (97) average age 65 multiple
  comorbid conditions
• Younger veterans more minorities and women
• Approximate prevalence of Cardiovascular Disease
  32 CHF 30 chronic kidney disease 30
  stroke/TIA 18 and serious mental health
  disorders 25.

3
VHA Policies and Infrastructure for Integrated
Patient Care and Quality Assessment (1997-Present)

• Assignment of patients to an identified primary
  care provider
• Development of evidence explicit clinical
  guidelines for diabetes mellitus (hypertension,
  lipids, ischemic heart disease, chronic kidney
  disease)
• Development of performance measures and contracts
  for directors in the system
• Development of a national electronic medical
  record with local customization (clinical
  reminders)

4
Translation Integrated Activities at Multiple
Levels

• National
• Policy changes
• Guidelines
• Formulary
• Performance measures

• Local
• Behavior change
• Ongoing organizational improvements
• Integration with existing tools

5
QUERI Translation Feedback and Evaluation
6
Outcomes in Disease Management

• Process Outcomes (examinations, tests,
  medications)
• Intermediate Health Outcomes (laboratory tests)
• Health Outcomes (morbidity/mortality)
• Health OutcomesFunctional Status
• Health Outcomes-Quality of Life
• Patient Satisfaction with access and quality of
  care

7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Adjusted Process of Care Rates


12
Adjusted Intermediate Outcomes

13
Adjusted Process of Care Rates
14
VHA Diabetes Performance Measurement FY05

• HbA1c test (96), 85 percent of HbA1c values
  less than 9 percent 65 lt8, 41 lt7 mean
  7.45
• Lipid profile within 2 years (97 percent 77
  percent of LDL-C values less 120 mg/dl mean 104
  mg/dl
• Blood pressure control, 75 percent less than or
  equal to 140/90
• Dilated retinal examination, 79 percent
• 75 had an influenza vaccination, 89 a
  pneumococcal vaccination within 5 years
• 24 used tobacco in the past 12 months, and 82
  of these individuals were counseled three times
  for tobacco cessation.

15
FY99-04 Changes in Total, Major and Minor
Age-Adjusted Amputation Rates Among Patients With
Diabetes
16
Unique Patient by Defined Diabetes Cohorts(FY05
data only through 2nd quarter)
17
Last A1c Values for Defined Diabetes Cohorts
18
Diabetes Data MartLatest Results of Critical Labs
19
Home-Telehealth Technologies
Remote Physiological Monitoring
20
iCare Desktop Monitoring
Daily Risk StratifiedView of Patient Caseload
21
CARE COORDINATION The Clinic (Care
Coordinator) Becomes Aware that the Patient Is
Beginning to Get Into Trouble, Proactively,
The Patient Is Called To Come Into Clinic . .
. Or Visited at Home! Before S/He Crashes
22
Hey, Doc, I have Heart Failure, Shouldnt I be
on an ACE Inhibitor ?
23
Summary

• VHA has instituted multifaceted,
  multidisciplinary approach to diabetes care,
  based in primary care, supported by EMR
  infrastructure, performance measurement and
  feedback
• VHA performance in intermediate measures is equal
  to or exceeds private sector (FFS Medicare,
  Commercial Plans)
• Adverse outcomes, such as amputation rates based
  upon VHA procedures, are decreasing
• VHA continues to build its informatics
  infrastructure to permit real time evaluation at
  the clinic level, and near real time at the
  National level
• Ongoing efforts to manage other long term
  complications (e.g. CKD through nationwide use of
  eGFR) and to roll out tele-medicine and digital
  retinal screening nationwide.