Phillips LS (Atlanta VAMC), Narayan KV
(Rollins School of Public Health), Wilson PW
(Atlanta VAMC), Twombly JG
(Atlanta VAMC), Zhu M
(Rollins School of Public Health), Long Q
(Rollins School of Public Health), Tsui CW
(Emory University), Michaels JA
(Emory University School of Medicine), Jasien CL
(Atlanta VAMC), Byrd-Sellers JL
The VA needs to identify the onset of diabetes as a potential trigger for initiation and evaluation of care, since veterans with new-onset diabetes are often good candidates for intensive glucose and cardiovascular risk factor management. We asked whether the first use of the diabetes ICD-9 code 250.xx at a primary care visit could constitute an appropriate signal.
“Test” veterans with initial primary care use of 250.xx were compared to “controls” without use of 250.xx (matched for age, BMI, gender, race/ethnicity, and index date), and veterans meeting VA Diabetes Epidemiology Cohort criteria (any use of 250.xx twice and/or diabetes drug Rx, “DEpiCs”). We conducted CPRS chart review of randomly selected Atlanta VAMC “test,” control, and DEpiC pts (n = 100 each) who had follow-up > = 2 yr before and > = 3 yr after the index date, and examined comparable groups in the VISN 7 Corporate Data Warehouse database.
Patients averaged age 63 and BMI 30, and were 2% female and 21% Black. In the Atlanta VAMC, diabetes diagnostic criteria were fulfilled in 74% of “test” patients vs. 1% of controls (p < 0.001), and “test” diagnostic accuracy was non-inferior to that of DEpiC (76%, p = 0.9). Initial primary care use of 250.xx provided sensitivity 86%, specificity 98%, positive predictive value 74%, and negative predictive value 99%. In Kaplan-Meier analyses of 3,081 “test” patients and 13,407 matched controls across VISN 7, initial primary care use of 250.xx was followed within 3 yr by A1c > = 7.0% or diabetes drug Rx in 74% of “test” patients vs. 2% of controls (p < 0.001). In VISN 7, "test” predictive accuracy was lower than that in 10,270 DEpiC pts (91%, p < 0.001). However, the period between fulfillment of diabetes diagnostic criteria and initial “test” primary care diagnosis averaged 25 months across eight facilities (range 21-32 months), whereas DEpiC criteria were met after an average of 35 months (range 31-38 months, p < 0.001).
The initial primary care diagnosis of diabetes in the VA is accurate, and identifies patients who are earlier in their natural histories than those identified by DEpiC criteria.
The initial primary care diagnosis of diabetes could be used programmatically to trigger CPRS reminders aimed to facilitate management. However, since the diagnosis is substantially delayed and the interval prior to diagnosis varies considerably across VISN 7 facilities, systematic screening and provider education may need to be implemented to optimize early recognition of diabetes in the VA.