Long-term maintenance of glucose control in veterans with type 2 diabetes mellitus using oral agents.

PURPOSE OF STUDY: The aim of this study was to evaluate long-term glycemic control in individuals with type 2 diabetes mellitus on oral hypoglycemic agents. METHODS: We identified the cohort of veterans prescribed hypoglycemic agents every year from July, 1992, through June, 2007 (n=191). Glycosylated hemoglobin (HbA1c) was used to assess glycemic control. Data are expressed as mean±standard deviation (SD); statistics are expressed by t-test and chi-squared. P<0.05 was considered significant. RESULTS: In the first year, 96 of the select group of 191 veterans identified above received oral agents only (OAO), 74 insulin only, and 21 both insulin and oral agents. Fifteen years later, 59 were OAO, 78 insulin only, and 54 both. Six patients receiving insulin in 1992-1993 were OAO-treated in 2006-2007. In the subgroup on OAO both at baseline and at the end (n=53), HbA1c decreased from 7.89±1.21 to 7.09±1.13 (P<0.001). These veterans were older at baseline (62.4±6.2) and leaner at the 15-year follow-up [body mass index (BMI) 28.1±4.9] than those who received insulin in 2006-2007 (n=43; age=57.9±9.6; BMI=32.3±7.9; P<0.05 and 0.005, respectively). Patients in the stable OAO group (n=53) were 74.0% Caucasian, compared to 51.2% in former-OAO [n=43; P<0.05 (chi-squared)]. CONCLUSIONS: Over half (n=53; 55%) of patients originally in the OAO group remained so 15 years later. These stable patients were in better glycemic control, both at baseline and follow-up, less obese, older, and more likely to be Caucasian, than those who eventually received insulin. Currently used oral agents often maintain, or even improve, glucose control, over 2 decades after diagnosis of diabetes mellitus.

Prevalence of osteoporosis in men in a VA rehabilitation center.

OBJECTIVE: To evaluate the prevalence of previously unrecognized osteoporosis in men admitted for long-term rehabilitation nursing home care. DESIGN: Cross-sectional study. METHODS: A total of 1179 consecutive admissions to a VA rehabilitation center were reviewed. Men who were already diagnosed with osteoporosis, had confounding medical illness, were unable to complete the study, or who declined to participate were excluded. A total of 153 patients were enrolled and 106 were evaluated. Measurements included dual-energy X-ray absorptiometry of the hip and lumbar spine, biochemical and hormonal studies, and functional evaluation. RESULTS: A total of 33 patients (31.1%) had osteoporosis (T-score at any site lumbar spine, total hip, or femoral neck <-2.5). Patients with osteoporosis were significantly older than those without: 68.4 +/- 13.2 years versus 62.7 +/- 12.1 years (P <.05), respectively. Body mass index (BMI) and weight were lower in men with osteoporosis: 23.4 +/- 3.9 kg/m2 versus 28.7 +/- 7.08 kg/m2 and 72.6 +/- 14.4 kg versus 90.3 +/- 23.8 kg, respectively (both, P <.001). There were no differences in use of medications thought to affect bone metabolism or functional status, or in hormonal and metabolic measurements. Hip and spine bone density were correlated (r = 0.3, P <.05). Multivariate analysis showed that hip bone density was independently associated with BMI. CONCLUSION: Hip osteoporosis is common in this unscreened population, suggesting that screening should be more widely performed in veterans admitted to rehabilitation units. These data suggest that nutritional status could impact osteoporosis risk.

Computer confirmation of improved blood pressure control in diabetic patients.

In order to evaluate efforts to improve blood pressure (BP) control in veterans with diabetes, the authors performed a retrospective review of computerized health records in the Veterans Affairs Northern California Health Care System (VANCHCS). A total of 6624 diabetic patients with BP data were identified and a comparison was made to earlier surveys. There was an overall improvement in BP control. In a cohort of 1791 patients followed since 1999, there was a progressive improvement in both systolic BP (patients at goal increased from 28% to 35%; P<.001, chi(2)) and diastolic BP (patients at goal increased from 69% to 79%; P<.001). There was a corresponding increase in both number of drug classes used and use of antiangiotensin treatment. The authors conclude that the improvement in BP control in these veterans with diabetes was temporally associated with intensification in antihypertensive pharmacotherapy and sustained provider education and patient-specific computerized reminders.

Computer-based screening of veterans for metabolic syndrome.

BACKGROUND: The worldwide obesity epidemic has focused attention on the prevalence of the metabolic syndrome, which is greater than previously believed. However, estimates of its overall prevalence vary widely. We wished to ascertain the prevalence of metabolic syndrome in the Veteran Affairs Northern California Health Care System (VANCHCS). METHODS: We used the VA computerized clinical database and modified Adult Treatment Panel III (ATP III) criteria of fasting blood glucose (FBG) >or=110 mg/dL, blood pressure >or=130/>or=85, triglyceride >or=150 mg/dL, high-density lipoprotein cholesterol (HDL-C) <40 mg/dL (men) or <50 mg/dL (women), but body mass index (BMI) >or=30 in lieu of waist circumference >102 cm (40 inches) for men and 88 cm (35 inches) for women. We also accepted current pharmacotherapy for diabetes as qualifying for elevated fasting blood sugar (FBS); current therapy with niacin, gemfibrozil, or fenofibrate for elevated triglyceride concentrations; and recent use of multiple International Classification of Diseases, 9(th) Revision (ICD-9) codes for hypertension for elevated blood pressure. RESULTS: We examined all clinical records for veterans registered in VANCHCS who filled any prescription between July 1, 2004, and June 30, 2005 (n = 51,026). Their average age was 63 years; 93% were male. In all 25% (n = 13,010) were diagnosed as having metabolic syndrome by meeting at least 3 of the above 5 criteria. Because only 60% (n = 30,727) of the population had data for 3 or more criteria, the actual percent with metabolic syndrome is probably substantially higher. CONCLUSIONS: Over one quarter of veterans in the VANCHCS may have metabolic syndrome based on our modified ATP III criteria. We urge screening more veterans with fasting laboratory testing. Computerized screening of a large clinical database can provide an effective strategy to aid clinicians in identifying more patients at risk for cardiovascular disease.

Reduction in self-monitoring of blood glucose in persons with type 2 diabetes results in cost savings and no change in glycemic control.

OBJECTIVE: Recent Veterans Affairs (VA) guidelines recommend that persons with stable type 2 diabetes controlled on oral agents or diet therapy perform self-monitoring of blood glucose (SMBG) twice weekly. We assessed the impact of a modification of these guidelines on hemoglobin A1c (HbA1c) and monitoring cost. STUDY DESIGN: Retrospective, noncrossover clinical trial. PATIENTS AND METHODS: We instructed persons with type 2 diabetes to perform SMBG testing according to modified adapted VA guidelines. We compared patients' baseline average testing frequency and HbA1c with those obtained during a 6-month interval beginning 2 months after implementation of the modified guidelines. The impact on the cost of monitoring was calculated. RESULTS: At baseline, 913 of 1,213 SMBG users with diabetes on oral hypoglycemic agents had HbA1c tested (HbA1c = 7.83% +/- 1.34%); their frequency of SMBG was 1.36 +/- 0.95 strips per patient per day. Postimplementation, 974 of 1,278 persons with diabetes had HbA1c tested (HbA1c = 7.86% +/- 1.54%; P= .63 vs baseline); frequency of SMBG decreased by 46% to 0.74 +/- 0.50 strips per patient per day (P < .0001). At baseline, 154 of 254 SMBG users with diabetes on diet therapy had HbA1c tested (HbA1c = 6.85% +/- 0.97%); their frequency of SMBG was 1.07 +/- 0.90 strips per patient per day. Postimplementation, 177 of 282 diet-treated persons with diabetes had HbA1c tested (HbA1c = 6.78% +/- 1.20%; P = .56 vs baseline); frequency of SMBG decreased by 35% to 0.70 +/- 0.51 strips per patient per day (P < .0001). Similar findings were observed in a cohort of 421 drug-treated patients with paired HbA1c data before and after implementation, and a cohort of 50 diet-treated patients with paired HbA1c data. Linear regression analysis showed no significant impact on individuals' HbA1c with reduction in strip use. Average monthly cost savings were $8,800, or $6.37 per patient per month. CONCLUSIONS: This program decreased the frequency of SMBG in persons with type 2 diabetes, resulting in substantial cost savings without affecting glucose control.