A Proposal for an Out-of-Range Glycemic Population Health Safety Measure for Older Adults With Diabetes.

Objective: To evaluate patient-level glycemic control and facility variation of a proposed out-of-range (OOR) measure (overtreatment [OT] [HbA <7% (53 mmol/mol)] or undertreatment [UT] [>9% (75 mmol/mol)]) compared with the standard measure (SM) (HbA <8% [64 mmol/mol]) in high-risk older adults.

Research Design And Methods: Veterans Health Administration patients ≥65 years of age in 2012 who were taking antihyperglycemic agents in 2013 were identified. Patient-level rates and facility-level rates/rankings were calculated by age and comorbid illness burden.

Variability in estimated glomerular filtration rate values is a risk factor in chronic kidney disease progression among patients with diabetes.

Background: It is unknown whether variability of estimated Glomerular Filtration Rate (eGFR) is a risk factor for dialysis or death in patients with chronic kidney disease (CKD). This study aimed to evaluate variability of estimated Glomerular Filtration Rate (eGFR) as a risk factor for dialysis or death to facilitate optimum care among high risk patients.

Methods: A longitudinal retrospective cohort study of 70,598 Veterans Health Administration veteran patients with diabetes and CKD (stage 3-4) in 2000 with up to 5 years of follow-up.

Assessing potential glycemic overtreatment in persons at hypoglycemic risk.

Importance: Although serious hypoglycemia is a common adverse drug event in ambulatory care, current performance measures do not assess potential overtreatment.

Objective: To identify high-risk patients who had evidence of intensive glycemic management and thus were at risk for serious hypoglycemia.

Design, Setting, And Participants: Cross-sectional study of patients in the Veterans Health Administration receiving insulin and/or sulfonylureas in 2009.

A clinical action measure to assess glycemic management in the 65-74 year old veteran population.

Objectives: To evaluate the effect of including of clinical actions within 6 months of a glycosylated hemoglobin (HbA1c) level greater than 8% upon measure adherence (pass rates) and to assess the association between patient factors and the likelihood of not passing.

Setting: Veterans Health Administration.

Design: Retrospective cohort study for FY2002 to FY2004.

Hidden complexities in assessment of glycemic outcomes: are quality rankings aligned with treatment?

Objective: To evaluate facility rankings in achieving <7% A1C levels based on the complexity of glycemic treatment regimens using threshold and continuous measures.

Research Design And Methods: We conducted a retrospective administrative data analysis of Veterans Health Administration Medical Centers in 2003-2004. Eligible patients were identified using National Committee for Quality Assurance (NCQA) measure specifications.

Patient complexity in quality comparisons for glycemic control: an observational study.

Background: Patient complexity is not incorporated into quality of care comparisons for glycemic control. We developed a method to adjust hemoglobin A1c levels for patient characteristics that reflect complexity, and examined the effect of using adjusted A1c values on quality comparisons.

Methods: This cross-sectional observational study used 1999 national VA (US Department of Veterans Affairs) pharmacy, inpatient and outpatient utilization, and laboratory data on diabetic veterans.

Three-dimensional mathematical model for deformation of human fasciae in manual therapy.

Context: Although mathematical models have been developed for the bony movement occurring during chiropractic manipulation, such models are not available for soft tissue motion.

Objective: To develop a three-dimensional mathematical model for exploring the relationship between mechanical forces and deformation of human fasciae in manual therapy using a finite deformation theory.

Methods: The predicted stresses required to produce plastic deformation were evaluated for a volunteer subject's fascia lata, plantar fascia, and superficial nasal fascia.

Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes.

Aims: To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system.

Methods: We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000.

Risk of stroke, heart attack, and diabetes complications among veterans with spinal cord injury.

Objectives: To compare the rates of diabetes and macrovascular conditions in veterans with spinal cord injury (SCI) and to examine variations by patient-level demographic, socioeconomic, access, and health status factors.

Design: A retrospective analysis. Diabetes status was classified by merging with diabetes epidemiology cohort using a validated algorithm.

Department of Veterans Affairs-Medicare dual beneficiaries with stroke: where do they get care?

This study examined care patterns among stroke patients with diabetes who were dually eligible for Department of Veterans Affairs (VA) and Medicare services. We investigated the location (VA hospital or community-based hospital reimbursed by Medicare) of initial and postacute stroke care during a 1-year follow-up period. We used logistic regression to identify the factors associated with the locations of initial and subsequent stroke care.

Survival benefit of nephrologic care in patients with diabetes mellitus and chronic kidney disease.

Background: The association of nephrologic care and survival in patients with diabetes mellitus and chronic kidney disease is unknown.

Methods: Using data from 1997 to 2000, we conducted a retrospective cohort study of Veterans Health Administration clinic users having diabetes mellitus and stage 3 or 4 chronic kidney disease. The baseline period was 12 months and median follow-up was 19.

Should mitigating comorbidities be considered in assessing healthcare plan performance in achieving optimal glycemic control?

Background: Whether a public reporting measure for glycosylated hemoglobin (A1C) of less than 7% should apply to all persons with diabetes mellitus is a matter of ongoing controversy.

Objective: To evaluate the effect of excluding persons with major medical or mental health conditions on assessment of healthcare system performance in achieving an A1C level of less than 7%.

Design And Setting: Retrospective longitudinal administrative data analysis from 144 Veterans Health Administration medical centers.

Facility variation in utilization of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in patients with diabetes mellitus and chronic kidney disease.

Objective: To evaluate facility-level variation in prescription rates of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) medications for patients with diabetes mellitus (DM) and chronic kidney disease (CKD).

Study Design: Retrospective database analysis from 143 Veterans Health Administration facilities.

Methods: Subjects with DM aged 18 to 75 years were identified as having stage 2-4 CKD using estimated glomerular filtration rate (eGFR) based on an index eGFR in 1999 and a subsequent eGFR 90-365 days later.

Impact of self-reported patient characteristics upon assessment of glycemic control in the Veterans Health Administration.

Objective: The purpose of this article was to evaluate the impact of self-reported patient factors on quality assessment of Veterans Health Administration medical centers in achieving glycemic control.

Research Design And Methods: We linked survey data and administrative records for veterans who self-reported diabetes on a 1999 national weighted survey. Linear regression models were used to adjust A1C levels in fiscal year 2000 for socioeconomic status (education level, employment, and concerns of having enough food), social support (marital status and living alone), health behaviors (smoking, alcohol use, and exercise level), physical and mental health status, BMI, and diabetes duration.

Failure of ICD-9-CM codes to identify patients with comorbid chronic kidney disease in diabetes.

Objective: To determine prevalence of chronic kidney disease (CKD) in patients with diabetes, and accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify such patients.

Data Sources/study Setting: Secondary data from 1999 to 2000. We linked all inpatient and outpatient administrative and clinical records of U.

Diabetes healthcare quality report cards: how accurate are the grades?

Objective: To evaluate the accuracy and precision of random sampling in identifying healthcare system outliers in diabetes performance measures.

Study Design: Cross-sectional analysis of 79 Veterans Health Administration facilities serving 250 317 patients with diabetes mellitus between October 1, 1999, and September 30, 2000.

Methods: Primary outcome measures were poor glycosylated hemoglobin (A1C) control and good low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) control.

Postural stability index is a more valid measure of stability than equilibrium score.

Researchers, therapists, and physicians often use equilibrium score (ES) from the Sensory Organization Test, a key test in the NeuroCom EquiTest System (a dynamic posturography system) to assess stability. ES reflects the overall coordination of the visual, proprioceptive, and vestibular systems for maintaining standing posture. In our earlier article, we proposed a new measure of anterior-posterior (A-P) postural stability called the Postural Stability Index (PSI), which accounts for more biomechanical aspects than ES.

Measures of postural stability.

Dynamic posturography has become an important tool for understanding standing balance in clinical settings. A key test in the NeuroCom International (Clackamas, Oregon) dynamic posturography system, the Sensory Organization Test (SOT), provides information about the integration of multiple components of balance. The SOT test leads to an outcome measure called the "equilibrium score" (ES), which reflects the overall coordination of the visual, proprioceptive, and vestibular systems for maintaining standing posture.