Chronic poor diabetes control in a large, integrated healthcare system

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SUN 281-290-Comparative Effectiveness/Health Outcomes/Quality Improvement/Patient or Provider Education/Endocrine Emergencies
Sunday, June 16, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SUN-285
J. Sonya Haw*1, Darin Erik Olson2, Sandra L Jackson3, Qi Long3, Diana Barb4, Christine Jasien5, Mary Kyung Rhee6, Anne Tomolo3, Arun Mohan3, Phyllis Watson-Williams3, Wenqiong Xue3 and Lawrence S Phillips7
1Emory University, Atlanta, GA, 2Emory Univ and the Atlanta VA, Decatur, GA, 3Emory University, 4Emory University School of Medic, Decatur, GA, 5Atlanta VA Medical Center, 6Emory Univ School of Med, Duluth, GA, 7Emory Univ, Atlanta, GA
Diabetes patients with chronically high A1c levels are a concern to providers, healthcare systems, and insurance stakeholders due to associated increases in morbidity, mortality, resource use, and costs. However, we have limited understanding of either the cause of such poor control, or how best to improve management – particularly in healthcare systems where care is generally good. The VA is the largest integrated healthcare system in the US, and diabetes care in the VA has been shown to be superior to that in managed care systems. To determine the extent to which poor diabetes control is a problem in the VA, and to evaluate potential contributors, we utilized a database of veterans from SC, GA, and AL. For 2001 through 2011, we examined 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. The numbers of such patients increased steadily from 37,757 in 2001 to 85,041 in 2011 (p<0.001). Within each cohort, the percentage of patients with “poor control” (at least one A1c >9%) decreased significantly from 2001-2011 (p<0.001), but remained substantial – 18.5% in 2011. Patients with “chronic poor control” (a repeat A1c at 2-6 months that fell less than 0.5%) were less common, and the percentage also decreased significantly 2001-2011 (p<0.001) – 2.6% in 2011. However, the majority of these patients (67% in 2011, 1.8% of the diabetes population) had >2 PCP visits in their index year, including one within 6 mo of the index high A1c – 1,514 patients in 2011 with “chronic poor control” despite “established care”. They had average initial A1c 10.2% (sd 1.1), follow-up A1c 11.2% (1.5), age 62 yr, and BMI 33, and were 94% male, 43% white, 46% black, and 11% other/unknown race – younger, heavier, and more likely to be black compared to the entire diabetes population (all p<0.001).  To search for potential contributors, we reviewed 25 records selected randomly from 256 such patients at the Atlanta VA in 2011. The patients had an average of 22 (12.8) visits, phone calls, and letters from providers in 2011; 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.

Conclusions: Poor diabetes control with A1c >9% is a common problem even in the VA – about 20% of all patients with diabetes. Although 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. Potential contributors appear to include medication non-adherence, insufficient attention to diabetes during primary care visits, and mental health disorders; because of such heterogeneity, improved management is likely to require a highly individualized approach.

Disclosure: DEO: Clinical Researcher, Novo Nordisk, Clinical Researcher, Lilly USA, LLC, Clinical Researcher, Roche Pharmaceuticals, Clinical Researcher, PhaseBio, Clinical Researcher, Amylin Pharmaceuticals. SLJ: Clinical Researcher, Amylin Pharmaceuticals, Clinical Researcher, Novo Nordisk. LSP: Clinical Researcher, Cystic Fibrosis Foundation, Clinical Researcher, Phasebio, Ad Hoc Consultant, Boeringer Mannheim, Clinical Researcher, Roche Pharmaceuticals, Clinical Researcher, Sanofi, Clinical Researcher, Novo Nordisk, Clinical Researcher, Merck & Co., Clinical Researcher, Eli Lilly & Company, Clinical Researcher, Amylin Pharmaceuticals, Employee, VA Medical Center. Nothing to Disclose: JSH, QL, DB, CJ, MKR, AT, AM, PW, WX

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