Chronic illness with complexity: implications for performance measurement of optimal glycemic control.
OBJECTIVE
To evaluate the association between chronic illness with complexity (CIC) and optimal glycemic control.


METHODS
Cross-sectional and longitudinal analyses of Diabetes Epidemiologic Cohort database of Veterans Health Administration (VHA) users with diabetes, less than 75 years old, with HbA1c tests in fiscal year (FY) 1999 and 2000, alive at FY2000 end (N = 95,423).


METHODS
Outcomes were HbA1c < 7% in each FY. CIC included three domains: nondiabetes physical illness, diabetes-related, and mental illness/substance abuse conditions. Other independent variables included age, gender, race, marital status, VHA priority status, and diabetes severity. Longitudinal analyses were restricted to patients with HbA1c >or= 7% in FY1999 and included hospitalizations between final HbA1c's in FY1999 and FY2000. Multiple logistic regressions examined associations between CIC categories and HbA1c.


RESULTS
In FY1999, 33% had HbA1c <7%. In multivariate analyses, patients with nondiabetes physical illness and mental illness/substance abuse were more likely to have HbA1c <7% in FY1999 [adjusted odds ratios for cancer (AOR), 1.31; 95% CI (1.25-1.37); mental illness only, 1.18; 95% CI (1.14-1.22)]. Those with diabetes-related complications were less likely to have HbA1c <7% in FY1999. Associations generally held in FY2000. However, conditions in the mental illness/substance abuse complexity domain were less strongly associated with HbA1c <7%. Macrovascular-related hospitalizations were positively associated with HbA1c <7% [AOR, 1.41; 95% CI (1.34-1.49)].


CONCLUSIONS
The association between CIC and HbA1c <7% is heterogeneous and depends on the domain of complexity. The varying associations of CIC categories with optimal glycemic control suggest the need for appropriate risk adjustment when using HbA1c <7% as a valid performance measure for diabetes quality of care.
Meduru
Pramod
P
Center for Healthcare Knowledge Management, VA New Jersey Healthcare System, 385 Tremont Ave. (129), East Orange, NJ 07018, USA. pramod.meduru@va.gov
Helmer
Drew
D
Rajan
Mangala
M
Tseng
Chin-Lin
CL
Pogach
Leonard
L
Sambamoorthi
Usha
U
D000368:Aged; D002908:Chronic Disease; D015897:Comorbidity; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000097:blood*; D006442:Glycated Hemoglobin / Q000032:analysis*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000150:complications; D008875:Middle Aged; D019966:Substance-Related Disorders / Q000150:complications
D006442:Glycated Hemoglobin