MANAGEMENT BRIEF

July 1996 Created by the Management Decision & Research Center, HSR&D, Office of Research & Development. Number 4

Diabetes Health Services Research: Providing the Energy for Change

"VA puts veterans first, and in so doing recognizes the substantial impact Diabetes has on each

veteran and his or her quality of life. Diabetes health services research reflects VA's commitment to

 help the more than 500,000 diabetic veterans enjoy the highest possible quality of life and

 treatment for this debilitating chronic disease."

John Feussner, M.D., Chief Research and Development Officer, VHA.

What is Diabetes Health Services Research?

Diabetes is the third most common diagnosis in VA

patients affecting 30% of the veteran population.

Kidney failure, blindness, blood pressure problems,

foot ulcers, and other painful conditions often

complicate the diabetic veterans' quality of life.

Over half the VHA's lower extremity amputations

are performed on diabetic patients. Some of the

diabetic veteran’s burden decreases when health care

practices and programs address all aspects of a

diabetic veteran's health and lifestyle. Diabetes

health services research examines all aspects of

diabetes care. Health services researchers investigate the organization, management, and economics

of diabetes care examining the health care delivery,

quality, cost, and treatment outcomes.

Why is Diabetes health services research important to managers?

Diabetes is an expensive, chronic problem,

even in the most motivated diabetic veterans. For

diabetic veterans compromised by other lifestyle

behaviors like alcohol, tobacco, or lack of motivation, complications can quickly overwhelm the

patient and the health care system's ability to follow,

manage, and truly help these veterans. Health

services researchers help design and test diabetic

health care interventions and programs, as well as

identify interventions and programs that may need

changing. Managers, armed with these research

findings can make informed decisions in targeting

and planning diabetic health care programs.

For example, diabetic foot ulcers are crippling, often

leading to the more costly and disabling amputations

noted above. One Seattle HSR&D/Rehabilitation

Research & Development Service (RR&D) researcher has proposed a RR&D study to explore the

preventive value of therapeutic footwear for diabetic

veterans at high risk of amputation. Another study,

the ongoing Veteran's Health Study (VHS), has

scientifically demonstrated the link between diabetes

severity and quality of life which while generally

apparent to eyewitnesses, has been difficult to

demonstrate. Bedford and Boston HSR&D researchers identified two quantitative measures: increased

blood sugar levels indicate illness severity in the

short term; and diabetic complications, numbers,

types and severity, indicate reduced quality of life in

the long term. These measures can now reliably

paint the big picture for evaluating the severity of

diabetes effects in different patient groups over time,

and for evaluating how best to deliver diabetes care.

Thus, as health services research broadens our view

of diabetes care, strategies emerge for savings in

suffering and possibly savings in health care dollars.

The reports below reveal the potential of health

services research for significantly changing the way

Diabetic veterans receive care and treatment.
Diabetic veterans improve blood sugar control and

patient satisfaction with a primary care practice

model.

This Durham HSR&D study found enhanced access

and coordination of care with a primary care practice

model, a case manager and consistent follow up care,

results in better blood sugar control, fewer complications, and higher patient satisfaction.

Weinberger M, Kirkman MS, Samsa GP, et al: A nurse

coordinated intervention for primary care patients with

non-insulin-dependent diabetes mellitus - impact on

glycemic control and health-related quality of life.

J Gen Intern Med, 10: 59-66, 1995, Feb.

Providers reach out and touch their diabetic

patients.

In this feasibility study, weekly automated phone calls

from a patient's health care practitioner, provided

diabetic veterans in a primary care setting with a

unique degree of access and support for their diabetes

care. This automated voice messaging system gathered

blood sugar level information and helped clinicians

identify problems before they worsened. This study

suggests that regular calls, as part of diabetes care,

could ease suffering and costs associated with diabetic

complications, as well as increasing the diabetic

patient's awareness of his health status.

Mah CA, Piette JD, et al. The feasibility of automated

voice messaging as an adjunct to diabetes outpatient

care. Paper presented at the Annual Meeting of the

Health Services Research and Development Service.

March 1996.

Intense treatment prevents blindness and kidney

failure in diabetics at risk.

A decision system identifying at-risk diabetics resulted

from this Ann Arbor HSR&D statistical modelling

study. This system guides practitoners in estimating

expected benefits from intensified blood glucose control

in diabetic patients with early onset diabetes (before age

50) versus late onset diabetes (after age 65). The early

onset patients are at higher risk for blindness or kidney

problems. Targeting them for intensified insulin therapy

can potentially prevent or substantially delay the onset

of blindness or end stage kidney disease. This information can be used for patient counseling and for planning

more cost-effective ambulatory care programs.

Vijan S, Hofer TP, Hayward RA: The benefits of glycemic control in type II diabetes. Submitted for publication April 1996.

What about the other foot?

This ongoing, Seattle HSR&D outcomes study is

looking at the results of patients receiving treatment for

newly diagnosed foot ulcers at five study sites. Outcomes studies look at results of care: recovery rates,

complications, days of work lost, functional disability,

infection rates, mortality and morbidity. One part of

this study found foot ulcer patients did not always get

an exam of their opposite foot or instructions on how to

avert problems on the opposite foot. Many of these foot

ulcers are caused by poor footwear. The study found

that approximately 75% of patients went home wearing

the very same shoes that may have initiated the foot

ulcer. These findings reinforce the need and opportunity

to develop a system for examination and treatment of

diabetic patients at high risk for foot ulcers and amputations.

Celnik C, Carter J, Fotieo G, and Reiber G. Paper

presented at the Annual Meeting of the Health Services

Research and Development Service. March 1996.

CURRENT DIABETES RESEARCH

FINDINGS

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