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Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database.

ABSTRACT: BACKGROUND:Intensive glycemic and blood pressure (BP) control in diabetic patients is associated with improved cardiovascular outcomes. HYPOTHESIS:We hypothesized that there is suboptimal glycemic and BP control with significant facility-level variation in patients with diabetes. METHODS:We identified patients with diabetes receiving care in 130 facilities in the Veterans Affairs Health Care System. We assessed facility-level rates of glycemic (hemoglobin [Hb]A1c <7%), BP (BP <140/90?mmHg), and combined glycemic and BP control (HbA1c <7% and BP <140/90?mmHg), and their facility-level variation in using median rate ratios (MRR). RESULTS:Among 1 103 302 patients with diabetes, 50.2% participants had an HbA1c <7%, 77.5% had a BP <140/90?mmHg, and 39.8% had both, HbA1c <7% and BP <140/90?mmHg. Median facility-level rates were 50.3% (interquartile range [IQR], 47.9%-52.4%) for glycemic control, 78.4% (IQR, 75.2%-80.0%) for BP control, and 39.9% (IQR, 38.14%-42.34%) for combined glycemic and BP control. Unadjusted MRR for glycemic control was 1.61 (95% confidence interval [CI]: 1.51-1.70) which decreased to 1.16 (95% CI: 1.14-1.19) after adjusting for patient and facility-level variables, indicating a 16% variation in glycemic control between 2 identical patients receiving care at 2 random facilities. Unadjusted MRR for BP control was 1.49 (95% CI: 1.41-1.56), which decreased to 1.25 (95% CI: 1.21-1.28), whereas unadjusted MRR for combined glycemic and BP control was 1.59 (95% CI: 1.50-1.68), which decreased to 1.15 (95% CI: 1.13-1.17) after adjustment. CONCLUSIONS:Facility-level rates for BP control and glycemic control remain low with significant facility-level variation. Much of this is explained by patient and facility-level variables although 16%, 25%, and 15% variation in glycemic, BP, and combined glycemic and BP control remains unexplained.

SUBMITTER: Rehman H

PROVIDER: S-EPMC6490345 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database.

Rehman Hasan H Akeroyd Julia M JM Ramsey David D Ahmed Sarah T ST Merchant Anwar T AT Navaneethan Sankar D SD Petersen Laura A LA Virani Salim S SS

Clinical cardiology 20170825 11

<h4>Background</h4>Intensive glycemic and blood pressure (BP) control in diabetic patients is associated with improved cardiovascular outcomes.<h4>Hypothesis</h4>We hypothesized that there is suboptimal glycemic and BP control with significant facility-level variation in patients with diabetes.<h4>Methods</h4>We identified patients with diabetes receiving care in 130 facilities in the Veterans Affairs Health Care System. We assessed facility-level rates of glycemic (hemoglobin [Hb]A1c <7%), BP ( ...[more]

PMID: 28841246

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Project description:ImportanceCurrent guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities.ObjectiveTo assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use.Design, setting, and participantsThis cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System. Data analysis was conducted from August 1, 2019, to September 1, 2020.ExposuresThe primary exposure was the VA facility in which patients received most of their care before the onset of incident kidney failure defined as the first occurrence of either a sustained estimated glomerular filtration rate of less than 15 mL/min/1.73 m2 or the initiation of maintenance dialysis.Main outcomes and measuresThe primary outcomes were dialysis use and mortality within 2 years of incident kidney failure. Median rate ratio was used to quantify facility-level variation, and variance partition coefficient was used to quantify the sources of unexplained variation.ResultsThe cohort included 8695 older veterans with a mean (SD) age of 78.8 (7.5) years who were predominantly male (8573 [99%]) and White (6102 [70%]) individuals treated at 108 VA facilities. The observed frequency of dialysis use across facilities ranged from 25.0% to 81.4%, with a median (interquartile range [IQR]) rate of 51.7% (48.4%-60.0%). The observed frequency of mortality across facilities ranged from 27.2% to 60.0%, with a median (IQR) rate of 45.2% (41.2%-48.6%). The median rate ratio (adjusted for multiple patient and facility characteristics) was 1.40 for dialysis use and 1.08 for mortality. The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics. No correlation was found between dialysis use and mortality at the facility level (correlation coefficient = 0.03).Conclusions and relevanceThis study found sizable variation in dialysis use for older adults that was poorly correlated with facility-level mortality rates and was not accounted for by differences in measured patient and facility characteristics. These findings suggest opportunities to improve the degree to which dialysis use practices align with the values, goals, and preferences of older adults with kidney failure.

Project description:BackgroundHeterogeneity of existing physician burnout studies impairs analyses of longitudinal trends, geographic distribution, and organizational factors impacting physician burnout. The Department of Veterans Affairs (VA) is one of the largest integrated healthcare systems in the USA, offering a unique opportunity to study burnout across VA sites and time.ObjectiveTo characterize longitudinal burnout trends of VA physicians and assess organizational characteristics and geographic distribution associated with physician burnout.DesignLongitudinal study of the VA All Employee Survey during 2013-2017.ParticipantsSelf-identified physicians practicing in one of nine clinical service areas at 140 VA sites nationwide.Main measuresWe identified burnout using a validated definition adapted from the Maslach Burnout Inventory and characterized burnout trends for physicians in different clinical service areas. We used clustering analysis to categorize sites based on their burnout rates over time, and compared organizational characteristics and geographic distribution of high, medium, and low burnout categories.Key resultsWe identified 40,382 physician responses from 140 VA sites. Mean burnout rates across all physicians ranged from 34.3% in 2013 to a high of 39.0% in 2014. Primary care physicians had the highest burnout. High burnout sites were more likely to be rural and non-teaching, have lower complexity (i.e., offer fewer advanced clinical services), and have fewer unique patients per site.ConclusionsVA physician burnout was lower than previously described in many non-VA studies and was relatively stable over time. These findings may be due to unique characteristics of the VA practice environment. Nonetheless, with over a third of VA physicians reporting burnout, organizational interventions are needed. Primary care physicians and those practicing at small, rural sites have higher rates of burnout and may warrant more focused attention. Our results can guide targeted interventions to promote VA physician well-being and inform efforts to address burnout in diverse clinical settings.

Dataset Information

Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database.

Publications

Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database.

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