OBJECTIVE -To develop a risk adjustment method for HbA 1c based solely on administrative data and to determine the extent to which risk-adjusted HbA 1c changes the identification of high-or low-performing medical facilities.
RESEARCH DESIGN AND METHODS-Through use of pharmacy records, 204,472 diabetic patients were identified for federal fiscal year 1996 (FY96). Complete information (HbA 1c levels, demographic data, inpatient records, outpatient pharmacy utilization records) was available on 38,173 predominantly male patients from 48 Veterans Health Administration (VHA) medical facilities. Hierarchical mixed-effects models were used to estimate risk-adjusted unique facility-level HbA 1c .RESULTS -Predicted HbA 1c demonstrated expected patterns for major factors known to influence glycemic control. Poorer glycemic control was seen in minorities and patients with greater disease severity, longer duration of disease (using treatment type or presence of amputation as surrogates), and more extensive comorbidity (measured by an adapted Charlson index). Better glycemic control was seen in Caucasians, older diabetic patients, and patients with higher outpatient utilization. The number of performance outliers was reduced as a result of risk adjustment. For mean HbA 1c levels, 7 facilities that were initially identified as statistically significant outliers were no longer outliers after risk adjustment. For high-risk HbA 1c (Ͼ9.5%) rates, 12 facilities that were initially identified as statistically significant outliers were no longer outliers after risk adjustment.CONCLUSIONS -Risk adjustment using only administrative data resulted in substantial changes in identification of high or low performers compared with non-risk-adjusted HbA 1c . Although our findings are exploratory, risk adjustment using administrative data may be a necessary and achievable step in quality assessment of diabetes care measured by rates of high-risk HbA 1c (Ͼ9.5%).
This study demonstrates the feasibility of using a pharmacy-based electronic diabetes database in a payor system that can track both claims and individual classes of medication based on a unique identifier number. While the prevalence of diabetes in the VHA is high relative to other health care systems and the general population, patterns of medication usage, pharmacy costs, and relative admission frequency are comparable to results from the private sector.
Veterans with diabetes but no recently coded heart disease, older individuals, and African Americans could benefit from programs targeted to introduce LLMs. Up to one third of individuals given LLMs remained above the target level of 130 mg/dL for low-density lipoprotein cholesterol.
OBJECTIVE—To determine pharmacy costs for glycemic treatment and its relationship to glycemic control in the Department of Veterans Affairs (VA) between 1994 and 2000.
RESEARCH DESIGN AND METHODS—Patients with diabetes in the VA in FY1994, FY1996, FY1998, and FY2000 were identified using an ambulatory care pharmacy-derived database. Total drug acquisition costs, as well as expenditures for insulin, oral glycemic control agents, and self–blood glucose monitoring strips, were determined for these veterans. HbA1c levels for the corresponding time periods were also obtained. Pharmacy costs (medications and monitoring) were examined by glycemic control treatment type.
RESULTS—In FY2000, 18% (n = 535,016) of all VA pharmacy patients were identified as having diabetes, and they received 30% of all pharmacy prescriptions. Overall, 23% of pharmacy expenditures for these patients were related to glycemic control medications and monitoring supplies. Annual pharmacy costs increased from FY1994 to FY2000. The greatest change was the higher expenditure for monitoring supplies through FY1998, which then decreased in FY2000. Increased pharmacy costs were associated with improved glycemic control. In FY2000, the mean last HbA1c level (n = 446,384) fell to 7.6% from 7.8% in FY1998 (n = 204,136) and 8.4% in 1996 (n = 53,348).
CONCLUSIONS—Diabetes was associated with high pharmacy costs. Increasing medication expenditures were associated with improved HbA1c levels at the aggregated national level. Policies concerning dispensing monitoring supplies and several diabetes quality improvement projects were initiated during this interval. Future challenges include initiatives to further optimize care while controlling costs.
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