Room for improvement in quality of diabetes care provided to US veterans with HIV: lessons for HIV care providers

The quality of diabetes care provided to HIV-positive patients is good, but there is room for improvement, investigators from the US Department of Veteran’s Affairs report in the May edition of AIDS Patient Care and STDs.

Using the Healthcare Effectiveness Data and Information Set (HEDIS) Comprehensive Diabetes Care (CDC) measures, the researchers evaluated seven aspects of the care provided to over 3000 HIV-positive patients with diabetes.

The results were compared to the care provided by the Department of Veteran’s Affairs (VA) to HIV-negative diabetic patients, as well as the care provided by other public and private facilities.

“VA performance rates on the HEDIS CDC measures for HIV-infected patients with diabetes are generally high but slightly lower than the general VA diabetes population, which suggests room for improvement,” comment the investigators.

Effective antiretroviral therapy has transformed the prognosis of many HIV-positive patients. Diseases of ageing, such as diabetes, are an increasingly important cause of illness and death in patients with HIV. The routine care for HIV-positive patients should now include screening for these diseases.

Investigators wished to assess the quality of diabetes care provided to HIV-positive patients who received their care from the VA.

In 2009, over 100 VA facilities provided free care to over 24,000 HIV-positive individuals, of whom approximately 20% had diabetes. The current analysis included 3006 individuals.

The investigators calculated the proportion of these patients who in 2009 received the standard of care recommended by HEDIS CDC.

Several areas of care were assessed:

1. HbA_1c testing: the percentage of patients who had a haemoglobin A_1c test.

2. HbA_1c poor control: the percentage of patients who had a HbA_1c result greater than 9% on their last test.

3. LDL screening: the percentage of patients who had their LDL cholesterol monitored.

4. LDL control: the proportion of patients who had LDL cholesterol below 100 mg/dl in their latest test.

5. Blood pressure control: the percentage of patients who had blood pressure below 140/90.

6. Eye examination: the proportion of patients who had an eye test to screen for diabetic renal disease.

7. Renal monitoring: the percentage of patients who had tests to screen for kidney disease.

Performance was also assessed according the number of patients with HIV/diabetes which each centre looked after.

Overall, the standard of care provided by the VA for HIV/diabetes patients was good, and 91% of patients had a haemoglobin test, 93% had their LDL cholesterol measured, 78% had an eye examination, and 87% had their kidney function monitored.

However, the level of screening varied between centres and was as low as 63% at some smaller centres, but larger facilities often screened all their patients.

The overall level of screening was slightly lower than that provided to HIV-negative patients with diabetes within VA facilities (haemoglobin testing, 98%; LDL screening, 96%; eye exam, 88%; kidney function testing; 95%). However, it was comparable, or better than that provided by Medicare, Medicaid or commercial facilities.

Outcomes were also good for patients with HIV/diabetes. LDL cholesterol was controlled by 57% of patients and 74% had blood pressure control. These results were comparable to those of Medicare, Medicaid and commercial patients. However, they were slightly poorer than outcomes for HIV-negative diabetic patients at VA centres (LDL control, 69%; blood pressure control, 80%).

“Attention needs to be focused on the quality of general medical care for this [HIV/diabetes] population,” comment the investigators.

They conclude: “The fact that some large facilities were able to achieve high performance rates on multiple CDC measures demonstrates that extremely high performance can be achieved and is a reasonable expectation at all facilities.”