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Adoption of New Medication Recommendations for Diabetes

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.

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Objectives: Intensive treatment using multi-medication regimes has been found to decrease complications and improve quality of life for diabetic patients. In 1997 VHA issued clinical guidelines recommending multi-medication regimes when sulfonylurea mono-therapy becomes ineffective. This study examines adoption of new regimes within the VHA, and differences between diabetes specialists and primary care providers.Methods: We linked FY97-FY99 pharmacy, laboratory, and administrative databases (OPC, PTF) from VISN1 and VISN8 to identify veterans with diabetes. We selected veterans with two diagnoses of diabetes (ICD9-CM Codes 250.00-250.93) in administrative databases (April 1, 1997-March 31,1998), and who were on diabetes medications at some point between FY97 and FY99 (N = 20,639). Medication regimes and clinic visits were classified each year. Traditional Regimes included insulin and sulfonylurea mono-therapies, and Novel Regimes included multiple oral medications, insulin and oral medications, and newer medications. Veterans seen in a diabetes clinic had a specialty visit coded for current and subsequent years. Logistic regression models fit using generalized estimating equations determined if adoption of new regimes occurred, and if adoption varied by generalists and specialists. Analyses controlled for age, gender, race, geographic location, presence of diabetes complications, and glycemic control (HbA1c). Results: Control variables were examined in step 1. Veterans who were from VISN8 (OR: 1.42), younger (OR: 1.14 per 10 years), non-whites (OR: 1.15), had high HbA1c levels (OR: 1.14 per point), and diabetic complications (OR: 1.42) were more likely to receive Novel Regimes. With the exception of diabetic complications (OR: 0.98), odds ratios for control variables remained unchanged when time and clinic variables were added to the equation. Novel Regimes were prescribed more often in FY98 and FY99 [OR = 1.70 and 2.41 respectively], and were more likely to be prescribed for veterans seen in a diabetes clinic (OR 1.21) than those seen only in primary care. Conclusions: Novel regimes are being adopted, however, patterns suggest a delay in dissemination of recommendations to primary care providers which may impact quality of care. Implications: If care is increasingly to be provided by generalists, methods of disseminating new information to them will be critical. Research examining alternative methods of dissemination may result in higher quality care.

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