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. He says CRPS/VISTA facilitates the management of patients via integrated appointment scheduling, progress notes, electronic order entry and clinical reminders. “Over the last 10 years, VA facilities have lapped the proprietary sector in applying information technology to the clinical realm and they are now receiving the recognition for it,” asserts Dr. Rainieri. Why The New York College Is Uniquely Positioned For Research Opportunities By Brian McCurdy, Associate Editor Headquartered in the Manhattan neighborhood of Harlem, the New York College of Podiatric Medicine is at the nexus of both a diverse population and a number of epidemics that have a higher prevalence among members of this population, according to Russell G. Volpe, DPM, a Professor in the Departments of Pediatrics and Orthopedics at the college. Faculty and students can expect to see patients with conditions including diabetes, hypertension and cardiovascular disease. “Exploding developments and extensive research in these fields of medicine provide the faculty at NYCPM with opportunities for clinical research and the patients with access to the most advanced therapeutic interventions for treatment of lower extremity diseases,” says Dr. Volpe, the Chairman of the Department of Pediatrics. Dr. Volpe notes the college will recruit patients for a multitude of clinical trials from the Foot Clinics of New York. Over 35,000 visits occur every year at the clinic, according to Dr. Volpe, who adds that the patient demographics reflect the demographics of Harlem. Noting that the college is expanding its forays into research, Dr. Volpe says two co-directors have assumed leadership of the school’s Research Department. Donna Alfieri, DPM, will concentrate on clinical research while Eileen Chusid, PhD, will focus on basic science research and grant writing. Drs. Alfieri and Chusid say a number of research projects are in the works at the college. Those at the school are looking into systemic antibiotic treatment for diabetic foot infections, venous stasis ulcer treatment and combination therapy for onychomycosis. Other research projects in development include studying a new design for a plantar fascia night splint and exploring the use of ultrasonic correlations of posterior tibial tendon pathology among patients with diabetic neuropathy, using body mass index as a predictor. “The New York College of Podiatric Medicine is committed to furthering the field of podiatric medicine in an academic tradition,” asserts Dr. Volpe. What Might The Future Hold For Research? Looking toward the future, Drs. Chusid and Alfieri suggest a number of research projects that he would want to see the New York College of Podiatric Medicine tackle. They say one such prospective pilot study could examine the motivation of the patients being studied. “Decision Making in Clinical Trial Participation” would examine which factors contribute to patients’ decisions on whether or not to participate in clinical research. Mentors would train students at the college to interview patients and collect data, according to Drs. Chusid and Alfieri. After completing the study, researchers would apply to the National Institutes of Health for funding for a larger study in the same area. Drs. Alfieri and Chusid say they would also like to see the college become involved in researching interventions for treating lower-extremity infections that occur frequently and those that are recurring or persistent. They would also like to see some investigation into alternative interventions for treating peripheral neuropathy. New Coalition Seeks To Raise Awareness Of Peripheral Arterial Disease By Brian McCurdy, Associate Editor The American Podiatric Medical Association is one of the medical organizations participating in the creation of the Peripheral Arterial Disease (PAD) Coalition, which aims to make both practitioners and patients more aware of the dangers of the disease. Peter Blume, DPM, believes the Peripheral Arterial Disease Coalition should emphasize to podiatrists the importance of screening patients for PAD, especially those with multiple risk factors. Dr. Blume says such screenings should involve obtaining a thorough history of all comorbidities and family history. One should also clinically evaluate the lower extremity to prevent future limb loss and improve global long-term ambulation in all populations, notes Dr. Blume, a Clinical Assistant Professor in the Department of Orthopaedics and Rehabilitation at the Yale School of Medicine, and the Director of Limb Preservation at the Yale New Haven Hospital in New Haven, Conn. Between 8 and 12 million Americans have PAD, according to the Vascular Disease Foundation. Dr. Blume says patients with PAD comprise about 50 percent of the diabetic patients he sees in his New Haven, Conn. practice. One of every five people over 70 has peripheral arterial disease and the foundation notes risk factors include diabetes, smoking, age, high cholesterol and hypertension. The majority of people with the disease have no symptoms, according to Peter Sheehan, MD, the American Diabetes Association’s liaison to the PAD Coalition. He says some people simply attribute symptoms such as claudication to getting older. Less than half of people with PAD know they have the condition, according to the Vascular Disease Foundation. Unfortunately, Dr. Sheehan notes that PAD carries an “extremely high” risk of cardiovascular disease. It is estimated that over five years, 20 percent of patients with PAD will have non-fatal myocardial infarctions or strokes and 30 percent will die primarily from cardiovascular disease. Which Testing Methods Are Effective? Dr. Sheehan says the ankle-brachial index (ABI) is an effective test for PAD. Dr. Sheehan was the chairman of a panel that published an ADA consensus statement last December that recommended patients with diabetes over the age of 50 get an ABI test, which he calls noninvasive, very sensitive and specific. Although there are limits to the test, such as when medial arterial calcification falsely elevates blood pressure, Dr. Sheehan says this limitation should not detract from practitioners’ use of the ABI. Dr. Blume concurs, calling the ABI test “an excellent screening tool” for PAD. In Brief PRESENT will present a Webcast “Night at The Lectures: An Evening Of Engaging Education” on October 20 at 9 p.m. The Webcast will feature the latest lecture, “Advances In Healing The Diabetic Wound,” by John Steinberg, DPM, as well as case reviews and other short subjects. For more information, check out Dermik Laboratories has announced its Penlac Nail Lacquer (ciclopirox topical solution 8%) is now available in Canada to treat onychomycosis. Dermik also annouces that those who are prescribed Penlac 6.6 ml can qualify for a $20 rebate by visiting The offer expires Jan. 31. Stratus Pharmaceuticals, Inc. has been awarded a three-year contract with Novation, the supply company of VHA & UHC, for all Stratus products, including papain and urea debriding ointments Kovia and Ziox.

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