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; Carol M. Mangione, MD, MSPH
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.
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).
Potential Financial Conflicts of Interest:Employment: W.H. Herman (University of Michigan Health System).
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, firstname.lastname@example.org.
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.
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.
Dr. Selby: Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612.
Dr. Curb: Pacific Health Research Institute, 846 South Hotel Street, Suite 303, Honolulu, HI 96813.
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.
Dr. Marrero: Diabetes Training and Research Center, Indiana University, 250 University Boulevard, Room 122, Indianapolis, IN 46202.
Dr. Safford: Department of Preventive Medicine, University of Alabama at Birmingham, MT 643, 1717 11th Avenue South, Birmingham, AL 35294-4410.
Dr. Mangione: David Geffen School of Medicine, 911 Broxton Avenue, Los Angeles, CA 90024.
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.
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.
Cross-sectional patient survey with retrospective review of medical records.
5 VA medical centers and 8 commercial managed care organizations in 5 matched geographic regions.
8205 diabetic patients: 1285 in the VA system and 6920 in commercial managed care.
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.
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.
Our results may not be generalizable to all regions or health plans, and some of the differences in performance could reflect differences in documentation.
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.
Few studies have compared the quality of care between the Veterans Affairs (VA) and commercial managed care systems.
In this study, diabetes care, assessed through patient sur-veys and medical record reviews, was compared between 1285 patients in 5 VA systems and 6920 patients in 8 commercial managed care sites. Compared with patients in commercial managed care, the patients in the VA system more often received hemoglobin A1c testing, counseling about aspirin use, and eye and foot examinations; they also had better lipid control. Patients in both systems had poor blood pressure control but reported high satisfaction with care.
The VA system delivered better diabetes care than did several commercial managed care organizations.
Description of sampling and response rate.VAxx
Table 1. Specification of Quality-of-Care Measures for Both Veterans Affairs and Commercial Managed Care
Table 2. Demographic and Health-Related Characteristics for Veterans Affairs and Commercial Managed Care Participants
Table 3. Adjusted Quality-of-Care Rates for Veterans Affairs and Commercial Managed Care Participants
Table 4. Adjusted Satisfaction Scores for Veterans Affairs and Commercial Managed Care Participants
Appendix Table 1. Adjusted Quality-of-Care Rates for Veterans Affairs and Commercial Managed Care Male Participants
Appendix Table 2. Adjusted Satisfaction Scores for Veterans Affairs and Commercial Managed Care Male Participants
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Michael A. Patmas, MD, MMM, FACP.
Providence Medical Center. Portland, Oregon.
August 19, 2004
VA vs. "Managed Care"
Kerr and colleagues article in the August 17, 2004 issue of AIM comparing diabetes care in the VA system with "managed care" reflects a deep misunderstanding of what is meant by managed care. Further, their conclusion is self serving and misleading to the readership. The VA system is, in fact, the largest managed care organization in the country. Analagous to a staff model HMO, the VA benefits from having enterprise wide electronic medical records, employed physicians with restrictive formularies and direct control over the practice patterns of those doctors through mandated use of practice guidelines. Commercial managed care plans rely upon contracted physicians who are generally in private practice, are unlikely to have electronic records and are much less under the control of the plan. To draw comparisons between these two widely disparate types of managed care organizations and conclude that a federally sponsored national health care organization would be superior to "managed care" is disingenuous. They should have included a comparison of both models to a completely unmanaged fee for service setting, data for which is available. The VA system is a managed care organization in every sense of the word. If the VA's clinical outcomes are indeed better, they likely stem from the higher intensity of management of care afforded by having greater control over employed physicians. The more accurate conclusion is that managed care improves diabetes quality measures over unmanaged care and that those improvements are related to the intensity of management afforded by the specific model of managed care. Kerr and colleagues attempt to discredit managed care actually makes the case for it. Michael A. Patmas, MD, MMM, FACP. Providence Portland Medical Center Portland, OR. 97213
Eve A. Kerr
VA Ann Arbor Healthcare System and the University of Michigan
October 13, 2004
Re: VA compared to Commercial Managed Care
As we mentioned in our article, the VA's transformation was indeed based on many managed care principles, and as the largest integrated healthcare system in the nation, it could, as Dr. Patmas suggests, be considered the nation's largest managed care organization (1). This is precisely what makes the comparison between diabetes quality in commercial managed care and in the VA so interesting - - one can begin to think about the elements unique to VA that may have further enhanced quality beyond the strategies espoused in the commercial managed care plans. While comparisons between VA and non-managed care systems had previously been published (2), this was the first study to compare diabetes quality in VA to that in high-performing commercial managed care organizations. The plans that participated in the TRIAD study reflected a full spectrum of practice arrangements, including group and staff model plans with employed physicians, network model plans with large and small contracted group practices, and individual practice associations (IPAs). As we noted in the manuscript, when the VA system was compared only to the TRIAD study staff model plans with electronic medical records the findings, were essentially the same. The authors of this article have a variety of affiliations, including of academic institutions, the VA and managed care organizations. Indeed, we made no attempt to discredit managed care, which performed very well in this study by all commercial standards. Rather, we called for further research to examine how specific organizational factors, such as the intensity of management, influence care quality and for a deeper understanding of which VA investments may be worth translating to commercial managed care. These types of investigations could serve to improve care quality for many patients with diabetes, whether they get care in federally sponsored or in commercial managed care organizations.
Kerr EA, Gerzoff RB, Krein SL, Selby JV, Piette JD, Curb JD, et al. Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study. Ann Intern Med. ;141:272–281. doi: 10.7326/0003-4819-141-4-200408170-00007
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Published: Ann Intern Med. 2004;141(4):272-281.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Healthcare Delivery and Policy.
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