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BACKGROUND/RATIONALE:
Early recognition and appropriate management are the keys to longterm glycemic control - limiting the inflammation and oxidative stress which adversely impact beta cell mass and function, and lead to a rise in glucose levels over time; individuals with new-onset diabetes are candidates for intensive control since they are largely free of microvascular disease and major comorbidity. However, the VA has no programs for systematic detection and early management, and our preliminary data show that the disease is recognized late and not managed aggressively. All program development and evaluation, including assessment of potential disparities in care, must begin with diagnosis, but the initial diagnosis of diabetes in the VA has never been validated - the focus of this proposal.
OBJECTIVE(S):
We will test the hypothesis that the first outpatient use of ICD-9 code 250.xx by a VA primary care provider will be accurate in (i) reflecting diagnostic antecedent hyperglycemia, and (ii) predicting subsequent prescription of diabetes-specific medications or high A1c. Our goal is to show that the addition of diabetes to problem lists by primary care providers at outpatient visits is sufficiently accurate to permit use in real time as both (a) a signal to prompt initiation of standardized care paradigms aimed at control of both glycemia and risk factors for cardiovascular disease, and (b) a marker to permit evaluation of care provided during a critical period in the natural history of the disease. If our project succeeds as expected, future work will include proposals aimed at both objectives. Since better control helps preserve beta-cell function and reduces cost, the end results should be lower longterm A1c, complications, and costs.
METHODS:
AIM #1. ACCURACY IN DIAGNOSIS: To test diagnostic accuracy, we will use abstraction of text in Atlanta VAMC CPRS records by diabetes-trained reviewers, allowing analysis to determine whether first use of the diagnostic code is justified by antecedent hyperglycemia. Comparison of such "test" patients (randomly selected from the Corporate Data Warehouse) with randomly selected "control" patients - who are similar in age, sex, BMI, and race but lack use of the code - will allow determination of positive and negative predictive value, and ascertainment of the proportion of code-(+) patients in the population of VA patients with diabetes will allow estimation of sensitivity and specificity using Bayes' rule. AIM #2. ACCURACY IN PREDICTION: To test predictive accuracy, we will utilize VISN 7 Corporate Data Warehouse deidentified data to determine the extent to which initial use of the diagnostic code is associated with subsequent prescription of diabetes-specific medications or high A1c, with both tests for proportions and Kaplan-Meier analysis. This will also provide preliminary data for subsequent national VA database studies to determine the extent to which the level of predictive accuracy found in VISN 7 is reliably generalizable to other regions.
FINDINGS/RESULTS:
No results at this time.
IMPACT:
Diabetes is a VA health problem of epidemic proportions - a major challenge to both quality of care and financial stability. Many veterans have diabetes control which is suboptimal, even in patients who lack mitigating comorbidities. Diabetes control is easiest to achieve and most cost-effective early in the natural history of the disease, but we have no well-validated basis to act upon recognition of the disease by providers. Our proposal targets this problem, and will be essential to enable both evaluation of care, and development of programs to facilitate management during this critical period. The work will involve the priority areas of Complex, Chronic Condition Care, Equity and Health Disparities, and Implementation and Management Research; systematic management of early diabetes should be efficacious and cost-effective - improving the health of individual veterans, reducing health care resource use and costs, and helping to spare VA funds for management of other disorders.
PUBLICATIONS:
None at this time.
DRA:
none
DRE:
none
Keywords:
none
MeSH Terms:
none
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