While the population of U.S. veterans is a fairly representative slice of the American population, there are some differences, particularly among veterans enrolled to receive health care in the Veterans Health Administration (VHA). One of the most conspicuous differences is in the prevalence of diabetes, a chronic disease in which the body cannot produce or properly use the metabolic hormone insulin, resulting in elevated blood glucose.

• According to the U.S. Centers for Disease Control and Prevention, an estimated 30.2 million Americans, 9.4 percent of the population, have diabetes. About 9.9 million, or 40 percent, of persons with diabetes are 65 or older.
• Of the more than 5.6 million veterans who received care in the VHA through mid-2017, by contrast, more than 1.5 million – about 27 percent – have diabetes. Among these veterans, about 70 percent are aged 65 or older.

Older adults with diabetes often have significant co-existing conditions or complications, a lack of social support, or food insecurity, circumstances that increase the likelihood of hypoglycemic reactions – episodes of low blood sugar or “insulin shock.” While many Americans with diabetes – a little over half – are estimated to be otherwise healthy, this number is somewhat lower among veterans; about 40 to 45 percent of veterans with diabetes have no serious coexisting disease. The most common form of the disease, type 2 diabetes mellitus, is the leading cause of blindness, end-stage kidney disease, and amputation for VA patients, and often leads to stroke, nerve damage, and contributes to cardiovascular disease – the leading cause of death among all persons with diabetes.

After a generation of World War II veterans suffered through an era in which the benefit of blood glucose management wasn’t well established – “Many patients,” Pogach said, “had the major complications of blindness, dialysis, and amputations” – the VHA was one of the leading organizations in developing the first set of national measures to address the control of blood sugar.

Since 2000, to accommodate the particular needs of patients in the VHA and the Military Health System, the Department of Affairs (VA) and the Department of Defense (DOD) have periodically convened expert panels to review published literature and develop guidelines for diabetes care. The latest version of their “Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care” was published in spring 2017, and was developed in collaboration with ECRI Institute, a nonprofit dedicated to applying scientific research findings to the improvement of patient care. The new guidelines include 25 recommendations for overall care, glycemic control, pharmacological treatment, inpatient care, and complications in treating type 2 diabetes. Most of the guidelines have either been revised or carried forward without review from previous versions.

A few of these recommendations, while not strictly “new,” emphasize elements of diabetes care that are ripe for change in a health care system that’s becoming increasingly patient centered, including:

• Individualized treatment targets for blood sugar levels. A diagnosis of diabetes is often based on what’s known as the A1c test, a two- or three-month average of glycated hemoglobin – the percentage of blood sugar attached to hemoglobin, the oxygen-carrying protein in red blood cells. An A1c result of 6.5 percent or higher on two separate tests indicates diabetes.

The practice of blood glucose control has evolved slowly since Leonard Pogach, M.D., the VA’s former program director for diabetes and now its national director of medicine, began his VA career 36 years ago. After a generation of World War II veterans suffered through an era in which the benefit of blood glucose management wasn’t well established – “Many patients,” Pogach said, “had the major complications of blindness, dialysis, and amputations” – the VHA was one of the leading organizations in developing the first set of national measures to address the control of blood sugar.

In 2003, the VA/DOD guidelines were the first diabetes guidelines to recommend that clinicians develop individual glucose targets that were based upon patient preferences and their individual benefits and risks – especially low blood sugar from insulin. Indeed, major professional society guidelines did not adopt this approach until about 10 years later.

During that time period, a number of organizations aimed for what they called “optimal control” of blood glucose, an A1c target of 7 percent or lower for all patients. While the VHA never signed onto this one-size-fits-all standard, citing a lack of evidence supporting its universal benefit, it proved difficult to avoid, as VHA clinicians were often affiliated with other institutions, including university hospitals.

Despite all the work, study, and consultation that went into the new VA/DOD “Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care” document, Pogach pointed out that making recommendations is the easy part: “The transition from having guidelines to making them work,” he said, “is not an easy one.”

The problem with aggressively medicating patients to a strict less than 7 percent standard, especially for the generally older veteran population, is that it can sometimes do more harm than good, explained Paul Conlin, M.D., chief of medical service at VA’s Boston Healthcare System and an associate professor of medicine at Harvard Medical School. “Anyone who is treated for diabetes,” he said, “runs the risk of their blood sugar being treated to a level below what we consider to be acceptable.” Low blood sugar, or hypoglycemia, carries symptoms that range from mild – light-headedness, increased heart rate, headache – to severe: Hypoglycemia can cause a person to lose consciousness, which can be the proximate cause of accidents and falls. A 2014 study of patients using Medicare (the federal health insurance program for Americans aged 65 and older) found that there were 40 percent more emergency room visits for low blood sugar than for high blood sugar. “In older adults, hypoglycemia looms large as a potential adverse effect,” said Conlin. “And with any medication, there are unique and infrequent but occasional side effects that can occur. Any medication that carries risks, if it’s not providing benefit, should be re-evaluated. Risk and benefits should be counterbalanced in arriving at an individualized treatment.”

In 2014, the VHA announced the Choosing Wisely Hypoglycemia Safety Initiative, which was based upon an existing program developed by the VISN 12 (VA Great Lakes Health Care System). The program is aimed at reducing glycemic overtreatment, particularly among older patients with comorbidities that increase the risk of serious hypoglycemia. The current guidelines emphasize the importance of this risk/benefit calculus in setting A1c target ranges.

• Race and ethnicity as factors in diagnosis and treatment. One of the problems associated with a fixed 7 percent A1c target is that, for whatever reason, studies of patients, both within and outside the VHA, reveal variations in baseline A1c values among different racial and ethnic groups. Among white and African-American patients who have the same value of one measure of blood sugar, for example, estimated average glucose (eAG), the A1c value for African-American patients tends to be about 0.4 percent higher than white patients. However, there is marked individual variation, and can occur among all races.

“This has been mentioned in previous guidelines,” Conlin said, “but we’ve re-emphasized it.” It’s an important corollary to the emphasis on individualized A1c target ranges for both diagnosis and treatment: “Because race is a complex social construct,” said Pogach, “the guidelines don’t recommend different targets for different individuals based on race. But it is important to recognize that an A1c value can reflect different levels of blood sugar control in different individuals based upon their own biology. If we simply react to a single number that’s within a range, rather than looking at all the available information and asking patients about their preferences, it can lead to an unnecessary increase in medication when it’s not warranted.”

• New nutrition-specific recommendations. Good nutrition is a key aspect of diabetes management, for both weight loss and the regulation of blood sugar, and it’s one of several lifestyle changes, including physical activity, quitting smoking, weight control, and limiting alcohol intake, that has long been a feature of the VA/DOD guidelines for diabetes care. Dietary recommendations tend to be controversial – and the latest version of the guidelines acknowledges that “the ideal distribution of the three main food components, carbohydrates, proteins, and fats, remains unclear.”

Recent studies have brought some nutritional information into clearer focus, however, and led to the inclusion of two new nutrition-specific recommendations. First, the guidelines explicitly recommend – if it aligns with a patient’s values and preferences – the Mediterranean diet, which features an abundance of fruits and vegetables; lean protein sources such as fish and poultry; whole grains; legumes; and olive oil, which contains monounsaturated fats. Studies have shown the Mediterranean diet to have a benefit in reducing symptoms and the risk of cardiovascular disease.

Among patients who don’t choose the Mediterranean diet, the guidelines recommend a reduction in carbohydrate intake. This involves both a lower overall carbohydrate intake and a focus on what’s known as the glycemic index. “If you ate a tablespoon of table sugar,” explained Conlin, “your blood sugar would go up to a much greater extent than if you ate the same amount of sugar in the form of a piece of fruit, or maybe in the form of a complex carbohydrate like a grain or bran. It’s the same amount of carbohydrate, but in a different form, it’s going to cause your blood sugar to change in a different fashion. We encourage people to consider foods that have a lower glycemic index.”

• Shared decision-making in planning and treatment. Throughout the VA/DOD diabetes care guidelines, there is an emphasis on patient-centered care that takes individual differences into account – an emphasis so important, in fact, that it’s explicitly stated as the first of the 25 recommendations: “Using shared decision-making, consider all treatment options and develop a treatment plan based on the balance of risks, benefits, and patient-specific goals, values, and preferences.”

Rose Mary Pries, Dr.P.H., who manages the Veterans Health Education and Information Program, pointed out that this recommendation’s inclusion in the guidelines was itself the result of input from veteran patients with diabetes. “Almost unanimously,” she said, “patients who currently have diabetes said they wanted to understand diabetes. They wanted to be offered treatment options and to be asked about their preferences related to treatment options. So we used that information from people with diabetes themselves as our foundation for our approach to shared decision-making: Patients, with their providers, their physicians, and their health care team members, work together to create treatment plans that will be safe and effective for them, and meet their individual lifestyle goals and preferences.”

Of course, being an equal partner in decision-making requires knowledge about both the disease and treatment – and the new guidelines recommend individualized, ongoing education for patients.

 

Putting Guidelines into Practice

Despite all the work, study, and consultation that went into the new VA/DOD “Clinical Practice Guideline for the Management of Diabetes Mellitus in Primary Care” document, Pogach pointed out that making recommendations is the easy part: “The transition from having guidelines to making them work,” he said, “is not an easy one.” The persistence of the fixed less than 7 percent A1c target, for example, has prompted the establishment of VA’s voluntary Hypoglycemia Safety Initiative (HSI).

When the annual A1c test comes due, the VHA’s record system prompts clinicians to decide upon an individualized A1c goal for the patient.

Initiatives such as the HSI are enabled, in part, by the VA’s electronic medical record system and the capability to automatically plant reminders or “flags” in the records of individual patients. The HSI was conceived a few years ago by a group of professionals in the VA’s Great Lakes Health Care System, who created a system of warning flags and prompts that popped up in the records of patients who were at risk for low blood sugar – patients older than 75, for example, or those with cognitive impairment or kidney disease.

When the annual A1c test comes due, the VHA’s record system prompts clinicians to decide upon an individualized A1c goal for the patient. Depending on the A1c value, the system also generates a list of appropriate medications and dosages, and a list of questions for the clinician to ask the patient about whether or not they’ve recently had low blood sugar reactions. It may then prompt the provider to ask the patient if they want to relax their therapy, or maintain their medication regimen.

The HSI is now operating in about 35 VHA facilities, said Pogach, who noted that it remains “strictly voluntary. It’s meant to be a guide, and not a mandate, to help initiate conversations with patients.”

Because those conversations are the key to developing a shared vision for treatment, the VA’s Health Education and Information Program has developed several tools to help veterans with diabetes understand their medical condition and the treatment options they’ll be discussing with providers. The online Veterans Health Library (www.veteranshealthlibrary.org), said Pries, “has two sections: one that discusses diabetes as a medical condition and another section, called Living with Diabetes, that offers patients and family members helpful guidance on how to cope with a chronic disease as complex as diabetes on a day-to-day basis. So we have health sheets that are available for patients. We have videos on partnering with your provider. We have assessment tools. Providers and health care team members can use these tools to help their patients to understand what diabetes is all about.”

In July 2017, the VA’s National Center for Health Promotion and Disease Prevention created a compact resource for clinical teams to distribute to patients, called “Ask About Low Blood Sugars” (www.prevention.va.gov/MPT/2017/docs/July_2017_Resource_Document.pdf) that contains links, in a single PDF document, to all the available information resources that a patient who has diabetes might need: the new “Clinical Practice Guideline,” the Veterans Health Library, a guide to shared decision-making, and more. “We package it in a way that’s very easy for the clinical team to use,” Pries said, “because we know they’re busy. And if we don’t package it well, they may not necessarily have time, in a busy clinical encounter with a veteran, to go searching for information on the internet.”

By making such resources readily available to veterans with diabetes, VHA hopes to satisfy one of the most significant elements of its new clinical care guidelines: enabling veteran patients to become full partners in determining diabetes treatment goals that will reduce the risk of complications and improve their quality of life.