Treating Chronically Ill People with Diabetes Mellitus with Limited Life Expectancy: Implications for Performance Measurement

Authors

  • LeChauncy D. Woodard MD, MPH,

    Corresponding author
    1. Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
    • Health Policy and Quality Program, Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
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  • Cassie R. Landrum MPH,

    1. Health Policy and Quality Program, Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
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  • Tracy H. Urech MPH,

    1. Health Policy and Quality Program, Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
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  • Jochen Profit MD, MPH,

    1. Health Policy and Quality Program, Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
    2. Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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  • Salim S. Virani MD,

    1. Health Policy and Quality Program, Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
    2. Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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  • Laura A. Petersen MD, MPH

    1. Health Policy and Quality Program, Health Services Research and Development Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center
    2. Section for Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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  • [See Editorial Comments by Drs. Sei J. Lee and Cynthia M. Boyd, 361–363]
  • The views expressed are solely of the authors and do not necessarily represent those of the Department of Veterans Affairs.

Address correspondence to LeChauncy D. Woodard, Health Services Research and Development (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030. E-mail: woodard.lechauncy@va.gov

Abstract

Objectives

To develop an algorithm to identify individuals with limited life expectancy and examine the effect of limited life expectancy on glycemic control and treatment intensification in individuals with diabetes mellitus.

Design

Individuals with diabetes mellitus and coexisting congestive heart failure, chronic obstructive pulmonary disease, dementia, end-stage liver disease, and/or primary or metastatic cancer with limited life expectancy were identified. To validate the algorithm, 5-year mortality was assessed in individuals identified as having limited life expectancy. Rates of meeting performance measures for glycemic control between individuals with and without limited life expectancy were compared. In individuals with uncontrolled glycosylated hemoglobin (HbA1c) levels, the effect of limited life expectancy on treatment intensification within 90 days was examined.

Setting

One hundred ten Department of Veterans Affairs facilities; October 2006 to September 2007.

Participants

Eight hundred eighty-eight thousand six hundred twenty-eight individuals with diabetes mellitus.

Measurements

HbA1c; treatment intensification within 90 days of index HbA1c reading.

Results

Twenty-nine thousand sixteen (3%) participants had limited life expectancy. Adjusting for age, 5-year mortality was five times as high in participants with limited life expectancy than in those without. Participants with limited life expectancy had poorer glycemic control than those without (glycemic control: 77.1% vs 78.1%; odds ratio (OR) = 0.84, 95% confidence interval (CI) = 0.81–0.86) and less-frequent treatment intensification (treatment intensification: 20.9% vs 28.6%; OR = 0.71, 95% CI = 0.67–0.76), even after controlling for patient-level characteristics.

Conclusion

Participants with limited life expectancy were less likely than those without to have controlled HbA1c levels and to receive treatment intensification, suggesting that providers treat these individuals less aggressively. Quality measurement and performance-based reimbursement systems should acknowledge the different needs of this population.

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