BACKGROUND/RATIONALE:
Diabetes is a common disease, both within and outside the Veterans Health Administration (VHA), that affects an estimated 10-16 million people in the United States. Because of its devastating complications, high health care costs, and the presence of effective interventions to prevent many of its complications, diabetes has become the focus of a number of quality monitoring and improvement initiatives. Translating Research Into Action for Diabetes in the VA (TRIAD-VA) is an observational study that is being conducted in collaboration with the Centers for Disease Control and Prevention (CDC), and will for the first time allow us to benchmark diabetes care in VA with the private sector. TRIAD-VA is designed to provide a better understanding of the effectiveness of different systems and organizational features of health care delivery within the VHA to improve the processes and outcomes of care for veterans with diabetes.

OBJECTIVE(S):
The primary objectives of this study are to: 1) collect detailed patient and facility-level organizational information about diabetes care using the TRIAD data collection tools to allow for benchmarking; 2) examine and compare key processes and outcomes of diabetes care, including glycemic testing and control, blood pressure management, lipid testing and control, eye care, foot care, quality of life, health status and patient satisfaction in the VHA and in the community; and 3)examine how variations in the structure and organization of care are associated with key process and outcome quality measures within VA and between VA and community TRIAD project sites.

METHODS:
TRIAD-CDC has a prospective design, consisting of a baseline and 18 month follow up survey of a cohort of up to 15,000 people with diabetes who are members of ten different health plans and cared for by 45 different provider groups. Health plan and provider group surveys are also being conducted. TRIAD-VA is following the same basic design, using the same sampling strategy and standardized measures, as TRIAD-CDC. Patient level information were collected for approximately 1400 patients with diabetes receiving care at five VA medical centers, which serve the same geographic area as 5 of the TRIAD-CDC sites. Patient data were obtained through baseline telephone or written survey, the VA diabetes registry, medical record review, and a follow-up written survey. Facility level organizational information were collected from all the medical centers and most of the affiliated outpatient clinics at the VA study sites and a random sample of VA medical centers and clinics nationwide.

FINDINGS/RESULTS:
Compared to commercial managed care (CMC) patients, patients using VA care were older (65 vs. 61 years, p<0.0001), more likely to be male (98% vs. 46%, p<0.0001), had lower incomes (p< 0.0001). VA patients had better scores than CMC patients on all process measures, ranging from a 10 percentage point difference on performance of an annual A1c (93% versus 83%; p<0.001) to a 25 point difference on aspirin use counseling (75% vs. 49%; p< 0.001). There was no difference in control of blood pressure control between VA and CMC participants, but VA patients had better control of LDL and A1c (86% versus 72% for LDL<130 mg/dl, p<0.01; 92% versus 80% for A1c<9.5%, p<0.01). There were no significant differences in satisfaction between the two cohorts.

IMPACT:
Our results suggest that a federally sponsored national healthcare organization can provide care that is equivalent to or better than that provided by high performing commercial managed care plans. If commercial plans are going to achieve the same levels of diabetes process quality as the VA, they may need to make major parallel investments in multiple domains of clinical care structure, such as information technology, care integration, performance monitoring and payment incentives. Further research should examine how specific organizational factors are associated with better quality, examine the intensity of treatment of intermediate outcomes, and assess which organizational factors that can improve treatment of intermediate outcomes and reduce end-stage diabetes complications.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kerr EA, Smith DM, Hogan MM, Krein SL, Pogach L, Hofer TP, Hayward RA. Comparing clinical automated, medical record, and hybrid data sources for diabetes quality measures. Joint Commission Journal on Quality Improvement. 2002 Oct 1; 28(10):555-65. [view]
2. Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services? Diabetes Care. 2003 Mar 1; 26(3):738-43. [view]
3. Brown AF, Ettner SL, Piette J, Weinberger M, Gregg E, Shapiro MF, Karter AJ, Safford M, Waitzfelder B, Prata PA, Beckles GL. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiologic Reviews. 2004 Jul 1; 26:63-77. [view]
4. Mangione CM, Gerzoff RB, Williamson DF, Steers WN, Kerr EA, Brown AF, Waitzfelder BE, Marrero DG, Dudley RA, Kim C, Herman W, Thompson TJ, Safford MM, Selby JV. The association between quality of care and the intensity of diabetes disease management programs. Annals of internal medicine. 2006 Jul 18; 145(2):107-16. [view]
5. Krein SL, Heisler M, Piette JD, Makki F, Kerr EA. The effect of chronic pain on diabetes patients' self-management. Diabetes Care. 2005 Jan 1; 28(1):65-70. [view]
6. Shrank WH, Asch SM, Adams J, Setodji C, Kerr EA, Keesey J, Malik S, McGlynn EA. The quality of pharmacologic care for adults in the United States. Medical care. 2006 Oct 1; 44(10):936-45. [view]
7. Piette JD, Heisler M, Krein S, Kerr EA. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Archives of internal medicine. 2005 Aug 8; 165(15):1749-55. [view]

Conference Presentations

1. Kerr E, Gerzoff R, Kreian S, Selby J, Piette J, Curb J, Herman W, Marrero D, Narayan V, Safford M, Mangione C. A Comparison of Diabetes Care Quality in VA and Commercial Managed Care: The TRIAD Study. Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 12; Chicago, IL. [view]
2. Krein SL, Heisler M, Piette J, Makki F, Kerr EA. Chronic Pain and Self-management Among Veterans with Diabetes. Paper presented at: VA HSR&D National Meeting; 2004 Mar 1; Washington, DC. [view]
3. Kerr EA. VA and Commercial Managed Care for Diabetes. Paper presented at: Centers for Disease Control and Prevention Division of Diabetes Translation Steering Committee Annual Conference; 2003 Apr 24; Chicago, IL. [view]

DRA: Health Systems Science
DRE: Epidemiology, Treatment - Observational
Keywords: Managed care, Organizational issues, VA/non-VA comparisons
MeSH Terms: none