Diabetes in the Department of Veterans Affairs

doi:10.2337/diacare.27.suppl_2.B1

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Original Article

Diabetes in the Department of Veterans Affairs

Gayle E. Reiber, PHD, MPH¹^,2^,4^,5, Edward J. Boyko, MD, MPH¹^,3^,4^,5^,6, Charles Maynard, PHD¹^,5, Thomas D. Koepsell, MD, MPH¹^,4^,5^,6 and Leonard M. Pogach, MD, MBA⁷^,8

¹ Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
² Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
³ Primary and Specialty Medical Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
⁴ Department of Epidemiology, University of Washington, Seattle, Washington
⁵ Department of Health Services, University of Washington, Seattle, Washington
⁶ Department of Medicine, University of Washington, Seattle, Washington
⁷ VA New Jersey Health Care System, East Orange, New Jersey
⁸ University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, New Jersey

Address correspondence and reprint requests to Gayle E. Reiber, MPH, PhD, VA Puget Sound Health Care System (152), 1660 South Columbian Way, Seattle, WA 98108. E-mail: greiber{at}u.washington.edu

Abbreviations: ERIC, Epidemiologic Research and Information Center • VA, Department of Veterans Affairs

A core mission of the Department of Veterans Affairs (VA) EpidemiologicResearch and Information Centers (ERICs) is to contribute toknowledge on the frequency and causes of health conditions andtheir outcomes in U.S. veterans. The Seattle ERIC selected thegrowing burden of diabetes in veterans as a priority area andwith our colleagues prepared this supplement. Our goals are1) to provide an overview of VA services, benefits, and diabetesadvances to the diabetes community and 2) to describe researchfindings based on our veterans with diabetes.

The VA is the second largest of the 15 U.S. cabinet departmentsand operates nationwide programs for health care, financialassistance, and burial benefits. VA 2003 budget projectionsincluded $32.8 billion for benefits, $25.9 billion for healthcare, and $909 million for all VA construction, administration,and cemetery operations (1).

Veterans have a distinct sociodemographic profile that reflectstheir entry into military service in times of peace and conflict.Among those discharged from military service (veterans), thepriority for VA health care goes first to those with service-connecteddisabilities and then to others based on income and medicalneed. VA financial benefits are provided to 3.3 million people.About 2.7 million of them are veterans, and the remainder arespouses, children, and parents of deceased veterans. Benefitsinclude disability compensation, death compensation, and pensions.

A VA mission is to ensure that the health care needs of America’sveterans are served by providing primary care, specialized care,and related medical and social support services. The VA employs $~$ 180,000 individuals who work in 163 medical centers, 800 communityand facility-based clinics, 40 residential facilities, and 135nursing homes.

A number of events over the last 30 years have shaped the VAdiabetes care program (Table 1). VA clinicians and researchershave also helped shape the diabetes agenda in the U.S. In 2002, $~$ 4.5 million of the 26 million living veterans (17%) receivedVA health care. VA treated 564,700 veterans in VA and contracthospitals and registered 46.5 million outpatient visits. VAhas experienced unprecedented growth in medical system workloadsover the past few years. The number of patients treated increased9.5% between 2001 and 2002.

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Table 1— Events in the last 30 years that have shaped the VA Diabetes Care Program

VA’s health care education and training programs helpto assure an adequate supply of clinical care providers forveterans and the nation. The VA manages the largest medicaleducation and health professions training program in the U.S.VA facilities are affiliated with 107 medical schools, 55 dentalschools, and >1,200 other U.S. schools that train healthprofessionals. More than 81,000 health professionals are trainedin VA facilities each year (1).

The VA research program contributes to the nation’s knowledgeabout disease and disability. VA scientists are contributingto diabetes research on topics including genetics, etiology,diagnosis, therapy, epidemiology, health services, and rehabilitation.

The articles in this supplement cover a wide range of diabetestopics. We begin with two articles that describe the veteransserved by the VA. In the first article, we identified VA diabetesprevalence, behavioral risk factors, and comorbidity based onVA administrative data and self-reported diabetes data froma nationwide telephone survey, the Behavioral Risk Factor SurveillanceSystem (BRFSS). The next article is a methodologic report oncomputing the VA diabetes prevalence based on the rich diabetesepidemiology cohort (DEpiC), which includes VA administrativepatient data, Medicare claims data, pharmacy and laboratoryrecords, and a veteran survey. The strategies used to enumeratediabetes prevalence in a dynamic cohort will be relevant tohealth maintenance organizations (HMOs) and the insurance industry.

Next follows an article describing the wealth of data resourcesavailable to qualified investigators to conduct research ondiabetes and other chronic diseases. The next five articlesaddress several major diabetes complications, such as cardiovasculardisease, lower-limb amputation, and renal and eye complications.They convey the burdens experienced by veterans with these diabetescomplications and suggest areas where more aggressive managementof risk factors may be warranted. They are followed by an articleon the Diabetes Quality Enhancement Research Initiative (QUERI-DM),which sets an agenda of issues to guide VA diabetes qualityimprovement initiatives.

The next article presents the findings from a group-randomizedtrial providing synthesized state-of-the-art feedback to primarycare providers who treat veterans with diabetes in seven interventionfirms; the article compares improvements in patient outcomeswith those of control firms. The next two articles emphasizecost considerations, the first computing inpatient and outpatientutilization and cost, excluding outpatient pharmacy costs. Thesecond addresses pharmacy costs and shows how the VA was ableto achieve improved glycemic control in patients with diabetes.Improvements in HbA_1c levels were associated with increasesin pharmacy costs attributed to diabetes medications and supplies.

Next are two companion articles. The first article describesthe design and decision-making process used in developing VAand Department of Defense guidelines for patients with diabetes.The second article describes how evidence-based guidelines werelinked to the develop-ment of performance measures. The resultantimplementation-of-accountability measures improved both thecare-delivery process and intermediate diabetes outcomes. Thefinal article describes diabetes research in the VA during twotime intervals and highlights research and development opportunities.

The VA has made advances in the quality of care provided toveterans, including those with diabetes. There are still manyopportunities for improvement. We hope that by making the informationin this supplement widely available, more researchers will bedrawn to investigate this area and the quality of diabetes carefor this deserving population will continue to improve.

Acknowledgments

The authors wish to thank Kristin Bonacker, BA, for her invaluableassistance during the development of this supplement. We thankthe editorial team of Diabetes Care for collaborating with uson this supplement.

Footnotes

A table elsewhere in this issue shows conventional and SystèmeInternational (SI) units and conversion factors for many substances.

Funding for this supplement was provided by The Seattle EpidemiologicResearch and Information Center and the VA Cooperative StudiesProgram.

Received for publication July 1, 2003. Accepted for publication July 25, 2003.

References

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