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More than 800,000 patients with diabetes are cared for by the U.S.Department of Veterans Affairs (VA) health system. Recent studies have shownthat the Veterans Health Administration (VHA) excels in diabetes care comparedwith other health care organizations or insurance plans.
According to a recent study, VHA patients received overall higher qualitychronic and preventive care than patients treatedelsewhere.1 Theyscored particularly better than the national sample—13 percentage pointshigher—for diabetes care.
Building on the Translating Research Into Action for Diabetes (TRIAD)initiative, another study assessed diabetes quality-of-care measures withsurveys and chart reviews of 1,285 patients who received care at one of fiveVA facilities or outpatient clinics and 6,920 patients in eight commercialmanaged-careorganizations.2 Thestudy showed diabetes outcomes for patients in the VA health system werebetter than outcomes for patients in commercial managed care.
After adjustment for demographic and health characteristics, 93% ofpatients in the VA system received an annual test for glycated hemoglobin(A1C) compared with 83% of patients treated in commercial managed care.Further, more VA patients than commercial managed-care patients achieved anA1C value <8.5% (83% vs. 65%), more had an LDL cholesterol level <100mg/dl (52% vs. 36%), more received an annual eye examination (91% vs. 75%),and more received an annual foot examination (98% vs. 84%). Blood pressurelevels were comparable for bothgroups.
STANDARDIZING CARE
The largest health care delivery system in the United States, the VHAincludes 163 medical centers, more than 800 outpatient clinics, 40 residentialfacilities, and 135 nursinghomes.3 We believethe VHA's higher scores in diabetes care can be attributed partially to itsemphasis over the last decade on tracking performance measures throughout thissystem.
In 1996, the VHA Diabetes Advisory Field Group proposed performancemeasures to assess the level of care provided by the VA to the diabeticpatient population. These indicators included the percentage of patientsmeeting designated targets for A1C, LDL cholesterol, and blood pressure, andthe percentage of patients receiving annual eye and foot examinations.
Through the External Peer Review Program (EPRP), the VA's standardizedquality assessment plan, reviewers each quarter survey a sample of patientrecords and calculate performance measures. Color-coded EPRP data (green meansthe standard has been met; red means the standard has not been met) are sharedwith administrators and clinicians to focus attention on indicators that fallbelow targets.
Computerized clinical reminders embedded in an electronic medical recordsystem prompt VHA clinical staff to check lab values, modify medications,perform and document diabetic foot exams, and refer patients for eye exams. Anational joint VA/Department of Defense committee writes evidence-baseddiabetes care guidelines that are disseminated to providers through toolkits,pocket guides, and other educational mechanisms.
The centralized, hierarchical VA structure enables systemwide interventionsto improve care. Divided geographically into 21 Veteran Integrated ServiceNetworks (VISNs), diabetes performance measures are tracked at local andnational levels. VISN leaders and medical center directors are heldaccountable to the VA Office of Quality and Performance for achievingdesignated targets.
VHA facilities universally use the Computerized Patient Record System(CPRS), a completely electronic medical record that allows easy access topertinent clinical-care data generated by providers at any VA setting.Computer-generated prompts and reminders help achieve chronic andpreventive-care targets. Other features include chronic disease-managementmenus and guideline-based diabetes order sets. Of note, CPRS is public-domainsoftware and potentially available to other practice settings.
We believe the VHA achieves higher-quality diabetes care not by providingdifferent care than is available in other settings, but by applying thesetechnological and system-based interventions to all providers and the entirepatient population. The end result is that more diabetic patients getrecommended levels of care and are more likely to achieve treatment targets.Implementation of similar strategies in smaller practice settings almostcertainly would require computerized medical information and an automatedsystem of prompts and reminders. The financial investment and necessary changein operations could present obstacles to adoption for numerous practiceenvironments.
TEAM CARE COORDINATION
Many VA clinical settings have expanded the role of nurses and pharmacistsin co-managing diabetes patients, which allows closer follow-up and enhancesefficiency. Some VA providers conduct group and telephone visits, therebyoffering frequent patient contact and positive reinforcement in a busy clinicsetting. The majority of VA patients with diabetes have attended diabeteseducation classes often geared toward enhancing self-management skills, a keystrategy in managing chronic disease.
We believe the development of clinical-care teams is feasible in smallerpractice settings and potentially would allow physicians to care for morepatients and possibly offset higher costs with additional revenue. A number ofprivate companies market nursing case management that may enhance theefficiency of practitioners who can afford it.
At a national level, the VA has developed a Web site(www.MyHealtheVet.va.gov)that contains patient education modules on various topics, including diabetes.VA patients can access the site from home computers or from many VA libraries.In the future, patients will be able to gain access to their own medicalrecords and to send confidential emails, including glucose-meter data, totheir providers. In several VA service networks, patients are enrolled intelemedicine care programs where they learn to check their vital signs and todownload their glucose-meter data. The information is forwarded via telephoneto a nurse case manager who determines the need for interventions andfollow-up visits. For patients with limited access to VA health carefacilities, the telemedicine system will offer better continuity of care.
In order to accommodate the growing number of patients with diabetesnationwide, every health care system will be faced with the task of developingmore population-based strategies that achieve desired clinical outcomeswithout exceeding financial limitations. With the strides it has made in thelast decade, the VA is uniquely equipped to take a leadership role in thischallenge. 
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Footnotes
EDITOR'S NOTE: The views expressed are those of the authors and do notnecessarily reflect the official opinions of the Department of VeteransAffairs.
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References
2. Kerr EA, Gerzoff RB, Krein SL, et al.: Diabetes care quality in theVeterans Affairs health care system and commercial managed care: The TRIADstudy. Ann Intern Med 141:272–281, 2004.
3. Reiber GE, Boyko EJ, Maynard C, et al.: Diabetes in the Departmentof Veterans Affairs. Diabetes Care 27 (Suppl. 2): B1–B2, 2004.
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