title: Should mitigating comorbidities be considered in assessing healthcare plan performance in achieving optimal glycemic control?
abstract: 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%.
  
  
  METHODS
  Retrospective longitudinal administrative data analysis from 144 Veterans Health Administration medical centers.
  
  
  METHODS
  Veterans with diabetes mellitus younger than 65 years who were users of Veterans Health Administration healthcare in fiscal years 1999 and 2000. MAJOR OUTCOME VARIABLES: The proportions, 5-year mortality, and glycemic control of individuals with and without major comorbid conditions, as well as changes in league table rankings of facilities achieving an A1C threshold of less than 7% with and without the inclusion of seriously ill individuals.
  
  
  RESULTS
  There were 220 922 subjects identified from 144 facilities. We identified 75 296 individuals (mean +/- SD facility range of excluded individuals, 33.3% +/- 5.3%) with conditions that would decrease the benefits or increase risks of glycemic control. The 5-year unadjusted mortality was 36.0% in 48 001 subjects (21.7%) excluded for major medical or neurological conditions, 14.9% in 17 515 subjects (7.9%) excluded for major mental health conditions, and 16.5% in 9780 subjects (4.4%) excluded for 2 or more other serious comorbid medical or psychological conditions, compared with 8.8% in the remaining subjects. A comparison of industry league table rankings indicated that 20% of the best and worse facilities changed 1 decile when ranking using exclusion criteria.
  
  
  CONCLUSIONS
  One in 3 veterans has comorbid conditions that would increase the risks or decrease the benefits of intensive glycemic control. We propose that a public reporting measure for A1C of less than 7% be subjected to exclusion criteria rather than be applied to all persons with diabetes mellitus.
authors.affiliation: Health Services Research and Development Center for Healthcare Knowledge Management Research, Department of Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave, E Orange, NJ 07018, USA. leonard.pogach@va.gov
authors.forename: Leonard M
authors.initials: LM
authors.lastname: Pogach
authors.forename: Anjali
authors.initials: A
authors.lastname: Tiwari
authors.forename: Miriam
authors.initials: M
authors.lastname: Maney
authors.forename: Mangala
authors.initials: M
authors.lastname: Rajan
authors.forename: Donald R
authors.initials: DR
authors.lastname: Miller
authors.forename: David
authors.initials: D
authors.lastname: Aron
mesh_terms: D000328:Adult; D001786:Blood Glucose / Q000032:analysis; D015331:Cohort Studies; D015897:Comorbidity; D003922:Diabetes Mellitus, Type 1 / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D005260:Female; D006442:Glycated Hemoglobin / Q000592:standards*; D019538:Health Care Surveys; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods*; D019984:Quality Indicators, Health Care; D012720:Severity of Illness Index; D016019:Survival Analysis; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007328:Insulin