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Publication Briefs

Study Suggests Veterans with Greater Clinical Complexity Receive Higher Quality of Care for Diabetes

Among patients with diabetes, studies suggest that an increasing number, severity, and type of certain comorbidities predict poorer self-management skills, which may result in poorer risk factor control. However, recent studies examining the relationship between clinical complexity and quality of chronic illness care have generally found that greater complexity is associated with higher levels of quality. This study examined the impact of clinical complexity on three quality indicators for diabetes care: glycemic, blood pressure (BP), and lipid control. Using VA data, investigators identified 35,872 Veterans with diabetes who had a primary care visit between 7/07 and 6/08 at one of seven Midwestern VAMCs. The quality of diabetes care was assessed using the American Diabetes Association recommendations for BP (<130/80 mm Hg), hemoglobin A1c (<7%), and low-density lipoprotein cholesterol (LDL-C <100 mg/dL). In addition, Veterans' clinical complexity was examined in two ways: a comorbidity count and an illness burden measure. Common comorbid conditions that were assessed included: hypertension, heart disease, hyperlipidemia, depression, arthritis, and chronic obstructive pulmonary disease. Investigators used the Diagnostic Cost Group (DCG) Relative Risk Scores (RRS) to measure burden of illness, grouping patients into four categories of increasing illness severity. Investigators then determined the proportion of patients that were controlled at index and at the end of a 90-day follow-up period for each of the three diabetes quality indicators. Investigators also examined a combined measure of quality (control at index or appropriate follow-up care).


  • Of the 35,872 Veterans in this study, 6,260 (18%) were controlled for all three quality indicators at index, and 6,974 (19%) were controlled at 90-day follow-up.
  • Veterans with the greatest levels of clinical complexity received higher quality of care for diabetes based on BP, glycemic, and lipid quality indicators compared to less complex patients, regardless of the definition of complexity. Veterans with > 3 comorbidities and DCG RRS >2 were more likely than the least complex patients to be controlled for all three measures.
  • Veterans with >3 comorbidities and illness burden >2 also were more likely than the least complex patients to meet the combined quality indicator for all three measures.


  • Data used in this study are from 2007-2008.
  • Investigators assessed only a select number of common comorbidities, which may not reflect all of a patient co-existing conditions. Of these, three conditions were unrelated to diabetes, limiting conclusions about the impact of other unrelated conditions on receipt of quality of care for diabetes.

These findings highlight the challenges of caring for chronically ill patients. Next steps include evaluating the effectiveness of patient-centered approaches to improve risk factor control in diabetes.

This study was partly funded by HSR&D (PPO 09-316) and a Measuring Quality of Care in VISN 12 contract. Dr. Virani was supported by an HSR&D Career Development Award. Drs. Woodard, Virani, and Petersen are part of HSR&D Houston Center for Quality of Care and Utilization Studies.

PubMed Logo Woodard LD, Landrum CR. Urech TH, Wang D, Virani S, and Petersen LA. Impact of Clinical Complexity on the Quality of Diabetes Care. American Journal of Managed Care September 2012;18(9):508-14.

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