Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study

Context Few studies have compared the quality of care between the Veterans Affairs (VA) and commercial managed care systems. Contribution In this study, diabetes care, assessed through patient sur-veys and medical record reviews, was compared between 1285 patients in 5 VA systems and 6920 patients in 8 commercial managed care sites. Compared with patients in commercial managed care, the patients in the VA system more often received hemoglobin A1c testing, counseling about aspirin use, and eye and foot examinations; they also had better lipid control. Patients in both systems had poor blood pressure control but reported high satisfaction with care. Implications The VA system delivered better diabetes care than did several commercial managed care organizations. The Editors Type 2 diabetes mellitus affects approximately 17 million people and contributes to more than 200000 deaths annually in the United States (1). Despite many cost-effective treatments (2-6), diabetes care remains suboptimal (5). As a result, the Institute of Medicine (IOM) labeled diabetes as a priority area for quality improvement (7) and suggested that changes in how we deliver health care services, such as more effectively using information technology, aligning payment policies with quality improvement, and reengineering care processes, may close the gap between our knowledge of effective management strategies and the implementation of those processes into practice (8). More than 800000 patients with diabetes receive care through the Department of Veterans Affairs (VA) health care system (9). Beginning in 1995, the VA system embarked on a nationwide effort to reengineer many of its organizational policies in order to improve both the efficiency and effectiveness of its services. Many changes reflected recommendations of the IOM and treatment standards already espoused by commercial managed care organizations (10-12). In contrast to previous criticisms about the quality of VA care, most recent studies comparing care received by patients in the VA system with that received by Medicare recipients suggest that the VA system may provide similar or even better care for certain conditions and procedures (11, 13, 14). However, most comparison studies have examined only inpatient care (13, 15, 16), compared care in the VA system to care received by fee-for-service Medicare recipients but not those covered by other insurance types (11, 14), and examined only a few aspects of care for each condition. Jha and colleagues (11) compared the quality of chronic disease care between pa tients in the VA system and fee-for-service Medicare recipients. Rates of all 3 measures of diabetes care processes that they examined were better in patients in the VA system than in Medicare recipients, but the measures reflected only a small subset of diabetes quality and the data collection methods differed between the VA and Medicare samples (11). To date, no published studies have examined care quality for chronic, primarily outpatient conditions by using equivalent data collection methods and measures or have compared care in the VA system with commercial or Medicare managed care. Therefore, we compared the quality of diabetes care among patients in the VA system and commercial managed care organizations by using similar sampling, data collection, and quality measurement methods. Methods Overall Design We collected data for the current study as part of the Translating Research into Action for Diabetes (TRIAD) initiative, a collaborative effort to evaluate the quality of diabetes care in commercial managed care organizations and in the VA system, funded jointly by the Centers for Disease Control and Prevention (CDC); the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK); and the VA Health Services Research and Development Service (HSR&D). The design of the TRIAD study has been previously described (17). Briefly, a cohort of patients with diabetes was identified from 6 translational research centers collaborating with 10 health plans that serve approximately 180000 people with diabetes in 6 geographic regions (central Indiana, northern California, southern Texas, New Jersey and Pennsylvania, southeastern Michigan, and Hawaii). These plans were selected on the basis of an invitation to participate in the TRIAD study from a principal investigator at 1 of the 6 translational research centers. We identified a second cohort that received care through 5 VA facilities serving the same geographic areas as 5 of the 6 previously identified translational research centers. The 2 Hawaii plans participating in the TRIAD study were not included in the current analysis because local institutional review board regulations precluded the collection of similar data from Hawaii VA facilities and patients. In both the commercial managed care and VA samples, cohort members answered baseline surveys and agreed to have their medical records reviewed. Using equivalent data collection instruments (17), we collected information on quality of diabetes care and satisfaction with care over the previous 12 to 18 months for both the commercial managed care and VA samples. We then compared quality of care between cohorts by using identically specified quality and satisfaction measures. In the current study, we present cross-sectional findings on the quality of care for these 2 groups. The institutional review boards at all translational research centers and at the 5 participating VA facilities reviewed and approved the study protocol, and all participants provided informed consent. Constructing the Commercial Managed Care and VA Samples The commercial managed care cohort was a stratified random sample of English- or Spanish-speaking adults with diabetes who had been continuously enrolled in 1 of 8 health plans for at least 18 months, were living in the community, were not pregnant, and had filed claims with the participating TRIAD health plan during the 18 months before start of study. The VA cohort consisted of community-dwelling adult patients with diabetes who received care from 1 of the 5 main VA facilities or their associated community-based outpatient clinics and who had documented care between 1 October 1998 and 30 September 1999. For both cohorts, diabetes diagnosis was based on data from the year before enrollment and included the following criteria: diagnostic code for diabetes (for example, 2 outpatient visits with an associated diabetes code [International Classification of Diseases, Ninth Revision, 250.xx] or 1 inpatient stay with an associated diabetes code); a laboratory value suggesting diabetes (for example, 2 hemoglobin A1c tests or diagnostic hemoglobin A1c or fasting blood glucose levels); or a prescription for medications for diabetes (for example, insulin or an oral antidiabetic agent). At the time of the survey, patients who met these initial criteria were included only if they verified that they had diabetes and received most of their diabetes care through the participating TRIAD health plan or through a participating VA facility. Participants completed either a written survey or a computer-assisted telephone interview. We collected additional health care information by reviewing participants' medical records. The Figure shows details of the patient recruitment process. Of the 10285 contacted and eligible persons in the commercial managed care sample, 9160 (89%) responded to the survey (5753 by computer-assisted telephone interview and 3407 by written survey). Of the 2009 contacted and eligible persons in the VA sample, 1694 (84%) completed the survey (1397 by computer-assisted telephone interview and 297 by written survey). However, we could not reach a substantial fraction of individuals in the commercial managed care and VA samples. By using a calculation endorsed by the Council of American Survey Research Organizations (18), which assumes that persons whom we could not contact or for whom we could not confirm eligibility had the same rate of eligibility as those contacted, the survey response rates were 69% in the commercial managed care sample and 57% in the VA sample. This analysis includes participants who responded to the survey and for whom medical records were available to document diabetes processes of care (6920 participants in the commercial managed care sample, and 1285 participants in the VA sample). Mean duration of diabetes, body mass index (BMI), and physical and mental health status did not meaningfully differ between persons whose records were not available and persons whose records were available. Figure. Description of sampling and response rate. VA xx Data Sources The VA and commercial managed care patient surveys assessed participants' sociodemographic characteristics, diabetes care services, duration of diabetes, health status, and satisfaction with care (17). The survey was administered between July 2000 and October 2001 for the commercial managed care sample (75% of surveys were completed before mid-May 2001) and between August 2001 and March 2002 for the VA sample (75% of surveys were completed before late December 2001). Medical record review included data abstracted from paper and electronic medical records for the 18 months before the patient survey. Abstraction elements included dates and findings from physical examinations (for example, visual foot inspection) and laboratory tests (for example, hemoglobin A1c test), as well as the identification of comorbid diagnoses. Medical record abstractors had successfully completed a 2-day training session. Inter-rater reliability () for the main quality measures derived from medical record data ranged from 0.85 to 0.92 for the commercial managed care sample and from 0.70 to 1.00 for the VA sample. Quality-of-Care Measures We examined the process of care quality by using measures such as whether a hemoglobin A1c test was performed, and we examined intermediate outcomes by using measures s