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Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study
- Eve A. Kerr, MD, MPH;
- Robert B. Gerzoff, MS;
- Sarah L. Krein, PhD, RN;
- Joseph V. Selby, MD, MPH;
- John D. Piette, PhD;
- J. David Curb, MD, MPH;
- William H. Herman, MD, MPH;
- David G. Marrero, PhD;
- K.M. Venkat Narayan, MD, MSc, MBA;
- Monika M. Safford, MD;
- Theodore Thompson, MS; and
- Carol M. Mangione, MD, MSPH
- From Veterans Affairs Ann Arbor Healthcare System, Center for Practice Management and Outcomes Research, and University of Michigan, Ann Arbor, Michigan; Centers for Disease Control and Prevention, Atlanta, Georgia; Kaiser Permanente, Oakland, California; Pacific Health Research Institute, Honolulu, Hawaii; Indiana University School of Medicine, Indianapolis, Indiana; University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey; and David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
Abstract
Background: No studies have compared care in the Department of Veterans Affairs (VA) with that delivered in commercial managed care organizations, nor have studies focused in depth on care comparisons for chronic, outpatient conditions.
Objective: To compare the quality of diabetes care between patients in the VA system and those enrolled in commercial managed care organizations by using equivalent sampling and measurement methods.
Design: Cross-sectional patient survey with retrospective review of medical records.
Setting: 5 VA medical centers and 8 commercial managed care organizations in 5 matched geographic regions.
Participants: 8205 diabetic patients: 1285 in the VA system and 6920 in commercial managed care.
Measurements: We compared scores on identically specified quality measures for 7 diabetes care processes and 3 diabetes intermediate outcomes and on 4 dimensions of satisfaction. Scores were expressed as the percentage of patients receiving indicated care and were adjusted for patients' demographic and health characteristics.
Results: Patients in the VA system had better scores than patients in commercial managed care on all process measures (for example, 93% vs. 83% for annual hemoglobin A1c; P = 0.006; 91% vs. 75% for annual eye examination; P < 0.001). Blood pressure control was poor in both groups (52% to 53% of persons had blood pressure < 140/90 mm Hg), but patients in the VA system had better control of low-density lipoprotein cholesterol and hemoglobin A1c (for example, 86% vs. 72% for low-density lipoprotein cholesterol level < 3.37 mmol/L [<130 mg/dL]; P = 0.002). Satisfaction was similar in the 2 groups.
Limitations: Our results may not be generalizable to all regions or health plans, and some of the differences in performance could reflect differences in documentation.
Conclusions: Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care. However, both VA and commercial managed care had room for improvement, especially for blood pressure control.
Article and Author Information
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Acknowledgments: The authors thank the VA site investigators (Gale Rutan, MD, MPH; Jacqueline A. Pugh, MD; and Todd Wagner, PhD) and members of the Translating Research into Action for Diabetes (TRIAD) study group (Appendix 1) for their significant contributions.
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Grant Support: By the Department of Veterans Affairs, Health Services Research and Development Service, Washington, DC, SDR 01-019; Centers for Disease Control and Prevention, Atlanta, Georgia; and National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland (grant CCU916380-04). Dr. Kerr was funded by an Advanced Research Career Development Award from the Department of Veterans Affairs, Health Services Research and Development Service (RCD #97323-B).
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Potential Financial Conflicts of Interest:Employment: W.H. Herman (University of Michigan Health System).
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Requests for Single Reprints: Eve A. Kerr, MD, MPH, Veterans Affairs Center for Practice Management and Outcomes Research, PO Box 130170, Ann Arbor, MI 48113-0170; e-mail, ekerr{at}umich.edu.
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Current Author Addresses: Drs. Kerr, Krein, and Piette: Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research, 2215 Fuller Road (11H), Ann Arbor, MI 48105.
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Mr. Gerzoff, Dr. Narayan, and Mr. Thompson: Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS K-10, Atlanta, GA 30341.
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Dr. Selby: Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612.
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Dr. Curb: Pacific Health Research Institute, 846 South Hotel Street, Suite 303, Honolulu, HI 96813.
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Dr. Herman: Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Health System, 1500 East Medical Center Drive, 3920 Taubman Center, Ann Arbor, MI 48109-0354.
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Dr. Marrero: Diabetes Training and Research Center, Indiana University, 250 University Boulevard, Room 122, Indianapolis, IN 46202.
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Dr. Safford: Department of Preventive Medicine, University of Alabama at Birmingham, MT 643, 1717 11th Avenue South, Birmingham, AL 35294-4410.
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Dr. Mangione: David Geffen School of Medicine, 911 Broxton Avenue, Los Angeles, CA 90024.
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