New Study Says VA System Provides Better Care For Patients With Diabetes

By Brian McCurdy, Associate Editor

How does the care of diabetic patients at Department of Veterans Affairs (VA) facilities stack up against care given by professionals in managed care plans? A new study involving over 8,000 people suggests patients with diabetes receive superior care at the VA facilities. The study, which was recently published in the Annals of Internal Medicine, tracked nearly 1,300 patients with diabetes in five VA centers and compared their care to that which was received by 6,900 patients with diabetes in eight managed care health plans. According to the study, 98 percent of the patients with diabetes at the VA facilities underwent annual foot exams whereas 84 percent of those in managed care plans underwent annual foot exams (see chart below). Researchers also found that 91 percent of the diabetic patients at the VA facilities received annual eye exams whereas 75 percent of diabetic patients in managed care plans had annual eye exams. “I truly believe that the VA health care system excels in providing comprehensive care to diabetic patients because of the managed team approach to patients,” says John Rainieri, DPM, Podiatry Program Manager at the VA Hudson Valley Healthcare System in Montrose, N.Y. “This has been fostered in all VA health care areas, both inpatient and outpatient, but has really become a recognized asset in ambulatory care.” Jeffrey M. Robbins, DPM, concurs, emphasizing that the managed care environment facilitates a strong emphasis on preventive screening within the VA facilities. Dr. Robbins, Director of the Podiatry Service of the VA Central Office in Cleveland, says patients are initially screened by primary care doctors and receive appropriate referrals to specialty care within the VA system. Once patients are diagnosed with diabetes, Dr. Robbins says there is a “set of mandatory screenings” for possible morbid complications such as hypertension and adverse effects on the foot. In particular, Dr. Robbins notes that the Veterans Healthcare Administration (VHA) has the Preservation Amputation Care and Treatment (PACT), a prevention program that requires patients with diabetes to undergo an annual foot screening, which includes palpation of pedal pulses, a protection sensation examination and an inspection for foot deformities. After the screening, Dr. Robbins says the VA then assigns the following risk assessment categories: 0 for normal risk, 1 for low risk, 2 for moderate risk and 3 for high risk. From that point, the VA’s care algorithm includes making referrals for foot care, prosthetics or vascular surgery, depending on the condition. Dr. Robbins says the VHA has been able to reduce the overall amputation rates, especially proximal amputations among patients, including those with diabetes. “VHA is dedicated to providing even more preventive interventions and patient education programs in order to change our healthcare culture from one of disease care to one of healthcare and health promotion,” explains Dr. Robbins. Understanding The Impact Of Performance Measures And Electronic Documentation Dr. Rainieri says national performance measures play an important role when it comes to the treatment standards at the VA facilities. He says each VA facility and clinic collects real time data and it is analyzed on a quarterly basis. According to Dr. Rainieri, an external peer review process (EPRP) reviews different facets of care. For example, the peer review process may assess the number of patients with diabetes who had a HbA1c drawn within six months or the number of patients with diabetes who have had a monofilament test for sensation on the feet within a year. Once these performance measures are documented, they are tied into a ranking system both for facility management and for individual providers. As Dr. Rainieri notes, the Joint Commission on Accreditation of Hospital Organizations is utilizing what it calls ORYX measures, similar to how VA facilities are utilizing EPRP. “I am sure this has impacted positively on the larger healthcare organizations and they will all follow with some sort of a standardized computerized record program from which quality data can be extracted remotely, real time by all users as we have in VHA,” he says. The VA system has the support of CPRS/VISTA, an electronic charting system that has been employed with “great success” in the VA system, according to Dr. Rainieri.

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