# Presentation: 383709

##  VHA Clinical User Demographics: Implications for Translation of the DPP 

- Len Pogach MD,MBA,FACP
- 	National Program Director, Diabetes
- Veterans Health Administration
- DMICC Meeting 3/11/02

## Veterans Health Administration

- Nation’s largest integrated health care system
- Largest geriatric health care system
- Congressional oversight, public accountability
- 22 Networks, 173 facilities, 131 nursing homes, >600 outpatient clinics
- 3.3 million veterans treated FY00
- Enrollment system with global budget and capitation

## Transformation-1995 to  Present

- Assignment of all patients to an identified primary care provider;
- Development of performance measurement system for management accountability;
- Development of clinical care guidelines for common conditions, including diabetes mellitus;
- Implementation of electronic medical records, including “clinical reminders”; and
- Emphasis on prevention, care coordination, chronic disease and pain management.

## Veteran Demographics

**In the year 2000:**
- Median age of veterans was 59 years *(vs. 36 yrs for general U.S. population).*
- 38% of vet population was age 65+  -  9.3 million of  24.3 million vets (*vs. 13% of general U.S. population*).
- 1.7 % of  vet population was 85+ (*vs. 1.6% of general population*).
**In the year 2020**:
- 51% vets will be age 65+ (8.2 million) and 8% will be age 85+ (_*1.2 million*_).

## Diabetes Prevalence

| 
 | FY98 | FY99 | FY00 |
| --- | --- | --- | --- |
| Veteran Users | 2,923,663 | 3,088,126 | 3,318,158 |
| Diabetes Cohort (VA sensitive) | 561,134
 | 686,524
 | 899.000 |
|  
HAIG Diabetes Cohort (VA specific HEDIS)   | 420,486  | 503,371 (16% Prevalence) | 634,000 (19% prevalence) |
| Diabetes Cohort VA-CMS (HEDIS) | (FY97-FY98)
515,000 | N/A | N/A |

## Diabetes Prevalence in VA, FY1998, By age (rate/100 patients)

| 
Age
 | All |  |  | Men |  |  | Women |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
|  |  | VA | US |  | VA | US |  | VA | US |
| All |  | 14.3 | 7.6 |  | 14.4 | 8.7 |  | 11. | 6.5 |
| 18-44 |  | 3.4 | 2.2 |  | 3.6 | 1.9 |  | 2.2 | 1.8 |
| 45-64 |  | 13.6 | 11.8 |  | 13.8 | 13.2 |  | 9.3 | 10.4 |
| 65-74 |  | 18.2 | 14.5 |  | 18.3 | 17.4 |  | 14.3 | 13.0 |
| 75+ |  | 18.2 | 14.5 |  | 18.3 | 17.4 |  | 14.3 | 13.0 |

**Notes:**
VA rates are standardized both to the VA population (Fy98) and the CDC diabetes population for FY97

Oveall VA prevalence is high because of average age of veteran population.. However, VA age-adjusted prevalence is also higher even age standardized to  US population with diabetes. This may reflect increased VA utilization by persons with diabetes due to disability and cost.

## FY99 Demographics – Patients With Diabetes

## Comorbidities in Veterans with Diabetes (VHA data)

| Category | National |
| --- | --- |
| PCS/MCS (LVHS) | 36.9/45.1 |
| Primary Dx 250 | 6.7 |
| Cardiovascular Disease | 32.4 |
| CHF | 6.4 |
| Hypertension | 66 |
| Mental Health | 19.1 |
| Renal Disease | 3.3 |

## Hypertension Summary Information FY99 :

***16%***

**Prevalence of Hypertension in the VA Population Overall **

**(****1,248,854/3,088,126) = **

***40.4%***

**Prevalence of Hypertension Among Patients With Diabetes **

**Overall (330,257/503,607) = **

***65.6%***

**Hypertension Summary Information FY99 :**

## VA-Private Sector Comparisons 2000

| Measure | VA | HCFA FFS | Top HMO | NCQA Ave
(Regions) |
| --- | --- | --- | --- | --- |
| A1c test | 94 | 75 | 93 (84-93) | 75 (70-85) |
| “poor HbA1c” | 25 | N/A | --- | 44 (33-51) |
| Lipid Screen (biennial) | 89 | 57 | 91(69-91) | 69 (65-75) |
| LDL-C <130 | 76 | N/A | ------------ | 37 (34-42) |
| Eye Exam | 67 | 69 | 91(65-91) | 45 (36-61) |
| BP <140/90 | 53 | --- | --- | 48 |
| Kidney Monitored | 54 | N/A | 97 (56-97) | 36 (36-52) |

## Unresolved Issues Regarding Treatment of IFG

- Generalizability (effectiveness) of lifestyle intervention to a non-volunteer population, or those with co-morbidity and disabilities
- Metformin efficacy for participants with  BMI <30 and  age >60 less than for overall study population
- Side effects in general population, older age group?
- Impact on morbidity and mortality unknown
- Efficacy of aggressive  blood pressure and cholesterol control in preventing morbidity and mortality in IFG population needs further study

## Reduced coronary events in simvastatin-treated patients with coronary heart disease and diabetes or impaired fasting glucose levels: subgroup analyses in the 4S Study  Haffner, 1999.

- In impaired fasting glucose (IFG) subjects, simvastatin use significantly reduced the number of major coronary events (RR = 0.62; P = .003), revascularizations (RR = 0.57; P = .009), and total (RR = 0.57; P = .02) and coronary (RR = 0.45; P = .007) mortality

## Summary

- Increased awareness of importance of opportunistic screening for IFG and diabetes in veterans with risk factors warranted
- Access to  dietary and lifestyle education, distribution of NDEP materials
- Recommendation for translation of metformin findings should await further DPP analyses
- Evidence  of treatment efficacy of hyperlipidemia in persons with IFG (4S)
- Emphasis on improved blood pressure control (at least <140/90)

## http://vaww.va.gov/health/diabeteshttp://www.va.gov/health/diabetes/default.htm