VHA DIABETES CARE: TODAY S BENCHMARK TOMORROW S FUTURE

1. VHA DIABETES CARE: TODAY�S BENCHMARKTOMORROW�S FUTURE December 1, 2005 US Medicine Diabetes Roundtable Presenter: Len Pogach MD, MBA National Program Director, Diabetes VACO Office Patient Care Services �Healthcare Value�: �The right care in the right place at the right time� Are two of the the slogans that have been used to underscore the objectives of translating evidence into practice. Today, using diabetes as the model, I will attempt to provide you-the leadership--an overview of the barriers within VA that must we acknowledge and address together if we are to achieve our goals of standardizing deliver of care so that we can improve outcomes in the most efficacious way. . �Healthcare Value�: �The right care in the right place at the right time� Are two of the the slogans that have been used to underscore the objectives of translating evidence into practice. Today, using diabetes as the model, I will attempt to provide you-the leadership--an overview of the barriers within VA that must we acknowledge and address together if we are to achieve our goals of standardizing deliver of care so that we can improve outcomes in the most efficacious way. .

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 This QUERI slide operationalizes the concept of translation in the context of disease state management from the system perspective In some instances evidence is best translated into practice by policy changes�for example, a directive from the Under Secretary to standardize the performance of HbA1c. Or, as another example, we o constrain clinician choices through the judicious use of formularies.Translation is more than knowledge �it is behavioral change for individuals and systems Finally, translation is best achieved when we work through existing mechanisms to gain support� This QUERI slide operationalizes the concept of translation in the context of disease state management from the system perspective In some instances evidence is best translated into practice by policy changes�for example, a directive from the Under Secretary to standardize the performance of HbA1c. Or, as another example, we o constrain clinician choices through the judicious use of formularies.Translation is more than knowledge �it is behavioral change for individuals and systems Finally, translation is best achieved when we work through existing mechanisms to gain support�

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 Outcomes�Functional Status Health Outcomes-Quality of Life Patient Satisfaction with access and quality of care

7. Reminders based on patient data found in Electronic Medical Record (VistA) Provide Information at Point of Care Allow Entry of Documentation and Data Reporting Reminders based on patient data found in Electronic Medical Record (VistA) Provide Information at Point of Care Allow Entry of Documentation and Data Reporting

10. Jha et al NEJM 2003

11. Kerr et al Annals 2004 The VA-TRIAD Study compared the quality of diabetes care among patients in the VA and commercial managed care (CMC) (Kerr E, et al . "A Comparison of Diabetes Care Quality in the Veterans Healthcare System and Commercial Managed Care." Annals of Internal Medicine 2004;141(4)272-281) The VA-TRIAD Study compared the quality of diabetes care among patients in the VA and commercial managed care (CMC) (Kerr E, et al . "A Comparison of Diabetes Care Quality in the Veterans Healthcare System and Commercial Managed Care." Annals of Internal Medicine 2004;141(4)272-281)

12. Kerr et al Annals 2004

14. VACO Office of Quality and Performance 2005 VHA Diabetes Performance Measurement FY05 HbA1c test (96%), 85 percent of HbA1c values less than 9 percent; ~65% <8%, ~41% <7% 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. Office of Patient Care Services FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among Patients With Diabetes

16. VISN Service Support Center--demonstration database Unique Patient by Defined Diabetes Cohorts(FY05 data only through 2nd quarter)

17. VISN Service Support Center demonstration cube Last A1c Values for Defined �Diabetes Cohorts�

18. VISN Service Support Center developmental database Diabetes Data MartLatest Results of Critical Labs

20. iCare Desktop� Monitoring

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.