Declining mortality following acute myocardial infarction in the Department of Veterans Affairs Health Care System.

BACKGROUND: Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. METHODS: We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. RESULTS: Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). CONCLUSION: Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.

Trends in care practices and outcomes among Medicare beneficiaries with diabetes.

BACKGROUND: While diabetes is a major issue for the aging U.S. population, few studies have described the recent trends in both preventive care practices and complications among the Medicare population with diabetes. Using the Medicare Quality Monitoring System (MQMS), this 2004 study describes these trends from 1992 to 2001 and how these rates vary across demographic subgroups. METHODS: Outcomes include age- and gender-adjusted rates of 15 indicators associated with diabetes care from 1992 to 2001, the absolute change in rates from 1992 to 2001, and 2001 rates by demographic subgroups. The data were cross-sectional samples of Medicare beneficiaries with diabetes from 1992 to 2001 from the Medicare 5% Standard Analytic Files. RESULTS: Use of preventive care practices rose from 1992 to 2001: 45 percentage points for HbA1c tests, 51 for lipid tests, 8 for eye exams, and 38 for self-monitoring of glucose levels (all p<0.05). Rates for short-term and some long-term complications of diabetes (e.g., lower-extremity amputations and cardiovascular conditions) fell from 1992 to 2001 (p<0.05). However, rates of other long-term complications such as nephropathy, blindness, and retinopathy rose during the period (p<0.05). Nonwhites and beneficiaries aged <65 and >85 exhibited consistently higher complication rates and lower use of preventive services. CONCLUSIONS: The Medicare program has seen some significant improvement in preventive care practices and significant declines in lower-limb amputations and cardiovascular conditions. However, rates for other long-term complications have increased, with evidence of subgroup disparities. The MQMS results provide an early warning for policymakers to focus on the diabetes care provided to some vulnerable subgroups.

A national progress report on diabetes: successes and challenges.

Over the last few decades, numerous public health agencies and other private and public organizations have sought to prevent and delay the disabling complications of diabetes by increasing the use of preventive care practices and reducing risk factors for complications among people with diabetes. Now, federal diabetes surveillance activities are yielding encouraging reports that progress is being made in increasing the use of preventive care practices, reducing risk factors for complications, and preventing or delaying diabetes complications. However, although several gains have been noted, levels of preventive care practices remain suboptimal, risk factors for diabetes complications are too prevalent, and diabetes complications are too pervasive. Furthermore, with compelling evidence that the onset of diabetes can be prevented or delayed among adults at high risk, prevention of diabetes has become a major new challenge. Additional efforts are needed to address the growing problems of obesity and physical inactivity, to identify the most efficacious and cost-effective prevention strategies and interventions, and to implement surveillance activities that allow us to gauge our success. Although progress has been made against diabetes complications, the current epidemic of diabetes increases the urgency of primary prevention efforts.

The relationship between organizational systems and clinical quality in diabetes care.

OBJECTIVE: To assess the clinical quality of diabetes care and the systems of care in place in Medicare managed care organizations (MCOs) to determine which systems are associated with the quality of care. STUDY DESIGN: Cross-sectional, observational study that included a retrospective review of 2001 diabetes Health Plan Employer and Data Information Set (HEDIS) measures and a mailed survey to MCOs. METHODS: One hundred and thirty-four plans received systems surveys. Data on clinical quality were obtained from HEDIS reports of diabetes measures. RESULTS: Ninety plans returned the survey. Composite diabetes quality scores (CDSs) were based on averaging scores for the 6 HEDIS diabetes measures. For the upper quartile of responding plans, the average score was 77.6. The average score for the bottom quartile was 53.9 (P < .001). The mean number of systems or interventions for the upper-quartile group and the bottom-quartile group was 17.5 and 12.5 (P < .01), respectively. There were significant differences in the 2 groups in the following areas: computer-generated reminders, physician champions, practitioner quality-improvement work groups, clinical guidelines, academic detailing, self-management education, availability of laboratory results, and registry use. After adjusting for structural and geographic variables, practitioner input and use of clinical-guidelines software remained as independent predictors of CDS. Structural variables that were independent predictors were nonprofit status and increasing number of Medicare beneficiaries in the MCO. CONCLUSIONS: MCO structure and greater use of systems/interventions are associated with higher-quality diabetes care. These relationships require further exploration.

Variation in diabetes care among states: do patient characteristics matter?

OBJECTIVE: To examine state variability in diabetes care for Medicare beneficiaries and the impact of certain beneficiary characteristics on those variations. RESEARCH DESIGN AND METHODS: Medicare beneficiaries with diabetes, aged 18-75 years, were identified from 1997 to 1999 claims data. Claims data were used to construct rates for three quality of care measures (HbA(1c) tests, eye examinations, and lipid profiles). Person-level variables (e.g., age, sex, race, and socioeconomic status) were used to adjust state rates using logistic regression. RESULTS: A third of 2 million beneficiaries with diabetes aged 18-75 years did not have annual HbA(1c) tests, biennial eye examinations, or biennial lipid profiles. There was wide variability in the measures among states (e.g., receipt of HbA(1c) tests ranged from 52 to 83%). Adjustment using person-level variables reduced the variance in HbA(1c) tests, eye examinations, and lipid profiles by 30, 23, and 27%, respectively, but considerable variability remained. The impact of the adjustment variables was also inconsistent across measures. CONCLUSIONS: Opportunities remain for improvement in diabetes care. Large variations in care among states were reduced significantly by adjustment for characteristics of state residents. However, much variability remained unexplained. Variability of measures within states and variable impact of the adjustment variables argues against systems effects operating with uniformity on the three measures. These findings suggest that a single approach to quality improvement is unlikely to be effective. Further understanding variability will be important to improving quality.