Diabetes in the Department of Veterans Affairs

A core mission of the Department of Veterans Affairs (VA) Epidemiologic Research and Information Centers (ERICs) is to contribute to knowledge on the frequency and causes of health conditions and their outcomes in U.S. veterans. The Seattle ERIC selected the growing burden of diabetes in veterans as a priority area and with our colleagues prepared this supplement. Our goals are 1) to provide an overview of VA services, benefits, and diabetes advances to the diabetes community and 2) to describe research findings based on our veterans with diabetes.

The VA is the second largest of the 15 U.S. cabinet departments and operates nationwide programs for health care, financial assistance, and burial benefits. VA 2003 budget projections included $32.8 billion for benefits, $25.9 billion for health care, and $909 million for all VA construction, administration, and cemetery operations (1).

Veterans have a distinct sociodemographic profile that reflects their entry into military service in times of peace and conflict. Among those discharged from military service (veterans), the priority for VA health care goes first to those with service-connected disabilities and then to others based on income and medical need. VA financial benefits are provided to 3.3 million people. About 2.7 million of them are veterans, and the remainder are spouses, children, and parents of deceased veterans. Benefits include disability compensation, death compensation, and pensions.

A VA mission is to ensure that the health care needs of America’s veterans are served by providing primary care, specialized care, and related medical and social support services. The VA employs ∼180,000 individuals who work in 163 medical centers, 800 community and facility-based clinics, 40 residential facilities, and 135 nursing homes.

A number of events over the last 30 years have shaped the VA diabetes care program (Table 1). VA clinicians and researchers have also helped shape the diabetes agenda in the U.S. In 2002, ∼4.5 million of the 26 million living veterans (17%) received VA health care. VA treated 564,700 veterans in VA and contract hospitals and registered 46.5 million outpatient visits. VA has experienced unprecedented growth in medical system workloads over the past few years. The number of patients treated increased 9.5% between 2001 and 2002.

VA’s health care education and training programs help to assure an adequate supply of clinical care providers for veterans and the nation. The VA manages the largest medical education and health professions training program in the U.S. VA facilities are affiliated with 107 medical schools, 55 dental schools, and >1,200 other U.S. schools that train health professionals. More than 81,000 health professionals are trained in VA facilities each year (1).

The VA research program contributes to the nation’s knowledge about disease and disability. VA scientists are contributing to diabetes research on topics including genetics, etiology, diagnosis, therapy, epidemiology, health services, and rehabilitation.

The articles in this supplement cover a wide range of diabetes topics. We begin with two articles that describe the veterans served by the VA. In the first article, we identified VA diabetes prevalence, behavioral risk factors, and comorbidity based on VA administrative data and self-reported diabetes data from a nationwide telephone survey, the Behavioral Risk Factor Surveillance System (BRFSS). The next article is a methodologic report on computing the VA diabetes prevalence based on the rich diabetes epidemiology cohort (DEpiC), which includes VA administrative patient data, Medicare claims data, pharmacy and laboratory records, and a veteran survey. The strategies used to enumerate diabetes prevalence in a dynamic cohort will be relevant to health maintenance organizations (HMOs) and the insurance industry.

Next follows an article describing the wealth of data resources available to qualified investigators to conduct research on diabetes and other chronic diseases. The next five articles address several major diabetes complications, such as cardiovascular disease, lower-limb amputation, and renal and eye complications. They convey the burdens experienced by veterans with these diabetes complications and suggest areas where more aggressive management of risk factors may be warranted. They are followed by an article on the Diabetes Quality Enhancement Research Initiative (QUERI-DM), which sets an agenda of issues to guide VA diabetes quality improvement initiatives.

The next article presents the findings from a group-randomized trial providing synthesized state-of-the-art feedback to primary care providers who treat veterans with diabetes in seven intervention firms; the article compares improvements in patient outcomes with those of control firms. The next two articles emphasize cost considerations, the first computing inpatient and outpatient utilization and cost, excluding outpatient pharmacy costs. The second addresses pharmacy costs and shows how the VA was able to achieve improved glycemic control in patients with diabetes. Improvements in HbA_1c levels were associated with increases in pharmacy costs attributed to diabetes medications and supplies.

Next are two companion articles. The first article describes the design and decision-making process used in developing VA and Department of Defense guidelines for patients with diabetes. The second article describes how evidence-based guidelines were linked to the develop-ment of performance measures. The resultant implementation-of-accountability measures improved both the care-delivery process and intermediate diabetes outcomes. The final article describes diabetes research in the VA during two time intervals and highlights research and development opportunities.

The VA has made advances in the quality of care provided to veterans, including those with diabetes. There are still many opportunities for improvement. We hope that by making the information in this supplement widely available, more researchers will be drawn to investigate this area and the quality of diabetes care for this deserving population will continue to improve.