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IIR 20-041 – HSR&D Study

IIR 20-041
Quality of Medical Care for Diabetics with Mental Illness
Susan M Frayne, MD MPH
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2001 - October 2004
Quality care is a priority in VA. Identifying subgroups of VA patients at risk of receiving lower quality care for chronic illness is an important step in VA’s quality improvement efforts. One large and particularly vulnerable subgroup of VA patients are those with mental illness; emerging evidence suggests that patients with mental health conditions (MHC) may receive less intensive medical care than those without MHC. This issue may be particularly important in the specific case of diabetes, a condition requiring very active patient participation in care.

We used existing databases to determine whether patients with MHC (and those with specific MHCs or with severe MHC) are over-represented among those not receiving guideline-recommended diabetes care, as defined by the Diabetes Quality Improvement Project (DQIP). We examined the additional effect of patient gender, case mix adjustment, and accounting for non-VA care.

We have drawn our data from a Diabetes Epidemiology Cohort which merged 4 databases needed to meet our analytic goals: VA’s Health Care Analysis Information Group Diabetes Cohort, VA administrative data from centralized files, 1999 Veterans SF36 Large Survey data, and Medicare claims data. We examined 5 DQIP-defined domains of care, each ascertained for FY99: whether the patient received HbA1c testing, LDL-cholesterol testing, eye examination, and whether the HbA1c was <9.5 and the LDL-cholesterol was <130. Presence of diabetes and presence of one or more MHCs were ascertained for FY98.

Failure to receive DQIP domains of diabetes care occurred more often for patients with MHC (N=76,799) than for those without MHC (N=236,787), both before and after case mix adjustment: unadjusted odds ratio was 1.24 for failure to receive HgbA1c testing, 1.25 for failure to receive LDL testing, 1.05 for failure to receive eye examination, 1.32 for poor glycemic control, and 1.17 for poor lipemic control. Disparities were larger in patients with several specific MHCs: psychosis, manic disorder, substance use disorder, and personality disorders. For each DQIP domain, percent of patients not receiving recommended care increased with increasing number of mental health conditions.

Our findings are highly relevant to VA policy-makers and clinicians: quality improvement efforts need to recognize that those with MHC represent a high-risk subgroup of patients with diabetes. Our findings also make clear the need for further evaluation of patient-level, provider-level and institution-level factors explaining this effect. Finally, since we selected diabetes only as a prototype condition, our findings raise the possibility that patients with MHC, who represent over a fourth of VA patients, receive lower quality care for a wide spectrum of medical conditions. This possibility requires immediate investigation, due to its potentially large clinical and economic implications within and outside of VA.

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Journal Articles

  1. Frayne SM, Halanych JH, Miller DR, Wang F, Lin H, Pogach L, Sharkansky EJ, Keane TM, Skinner KM, Rosen CS, Berlowitz DR. Disparities in diabetes care: impact of mental illness. Archives of internal medicine. 2005 Dec 12; 165(22):2631-8. [view]
  2. Halanych JH, Wang F, Miller DR, Pogach LM, Lin H, Berlowitz DR, Frayne SM. Racial/ethnic differences in diabetes care for older veterans: accounting for dual health system use changes conclusions. Medical care. 2006 May 1; 44(5):439-45. [view]
  3. Frayne SM, Miller DR, Sharkansky EJ, Jackson VW, Wang F, Halanych JH, Berlowitz DR, Kader B, Rosen CS, Keane TM. Using administrative data to identify mental illness: what approach is best? American journal of medical quality : the official journal of the American College of Medical Quality. 2010 Jan 1; 25(1):42-50. [view]
Conference Presentations

  1. Pugh M, Pogach L, Berlowitz D. Adoption of New Medication Recommendations for Diabetes. Paper presented at: VA HSR&D National Meeting; 2002 Feb 14; Washington, DC. [view]
  2. Pugh M, Pogach L, Berlowitz D. Adoption of New Pharmacotherapy Recommendations for Type 2 Diabetes: The Effect of Shared Care. Paper presented at: AcademyHealth Annual Research Meeting; 2002 Jun 24; Washington, DC. [view]
  3. Lin H, Frayne S. Cardiovascular complications in diabetic patients with and without mental illness. Paper presented at: VA HSR&D National Meeting; 2003 Feb 1; Washington, DC. [view]
  4. Halanych J, Miller D, Lin H, Wang F, Berlowitz D, Pogach L, Frayne S. Disparities in diabetes care in Hispanic, black, and white veterans who use VHA services. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
  5. Frayne S. Disparities in diabetes outcomes: Impact of mental illness. Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 1; Chicago, IL. [view]
  6. Frayne S. Disparities in glycemic control for patients with mental illness; protective effect of primary care. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 1; San Diego, CA. [view]
  7. Berlowitz D. Do Clinicians Respond to High Hgb AIC Values. Paper presented at: Diabetes National Annual Symposium; 2002 Mar 21; Alexandria, VA. [view]
  8. Halanych J, Frayne S. Effect of Hispanic Ethnicity on Glycemic Testing and Control in Diabetic Patients. Paper presented at: Society of General Internal Medicine Annual Meeting; 2003 Apr 1; Vancouver, Canada. [view]
  9. Halanych J, Frayne S, Lin H, Wang F. Glycemic and lipemic testing and control in ethnic minorities with diabetes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 1; Chicago, IL. [view]
  10. Frayne S, Sharkansky EJ, Keane T, Rosen CS, Lin H, Halanych JH, Miller DR. Glycemic control for patients with PTSD: Primary care effects. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2004 Nov 1; New Orleans, LA. [view]
  11. Frayne S. Using administrative data to identify diagnosed post-traumatic stress disorder. Paper presented at: Society of General Internal Medicine Annual Meeting; 2006 Apr 28; Los Angeles, CA. [view]

DRA: Health Systems, Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology
Keywords: Behavior (patient), Comorbidity, Diabetes
MeSH Terms: none

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