Thursday, 21 August 2003
This presentation is part of : Interface of Medicine and Psychiatry

S096-005 Quality of Diabetes Care for Aging U.S. Military Veterans with Serious Mental Illness

Joel E. Streim1, Bruce Kinosian2, and Steven Sayers1. (1) Psychiatry, University of Pennsylvania, Philadelphia, PA, USA, (2) Medicine, University of Pennsylvania, Philadelphia, PA, USA

Objectives: Aging, schizophrenia, and antipsychotic drugs are all associated with an increased incidence of diabetes mellitus. The Veterans Healthcare Administration (VHA) in the USA provides clinical practice guidelines for common medical conditions such as diabetes, and integrated medical and mental health services for many patients with medical-psychiatric comorbidity; but the quality of general medical care received by mentally ill patients in this healthcare system has not been well-characterized. Aims of this study were (1) to determine the prevalence of undetected diabetes mellitus in aging veterans with serious mental illness (SMI); and (2) to compare the extent of adherence to clinical practice guidelines and glycemic control in known diabetics with and without SMI, treated in VHA facilities.

Design: (1) Cross-sectional prevalence study of diabetes in patients with SMI and no prior diagnosis of diabetes, at two VHA facilities; (2) Query of electronic patient database to ascertain the performance of clinical services, and hemoglobin A1c (HgA1c) values, over a 24-month period for known diabetics at a single VHA facility.

Materials And Methods: 1) A random sample of 1367 veterans over age 45 years with SMI was identified by ICD-9CM diagnoses of schizophrenia, bipolar disorder, or post-traumatic stress disorder in the electronic patient database during 2000-2001. Those without an established diagnosis of diabetes mellitus were invited to participate in screening for diabetes. A HbA1c level was measured in those who consented; fasting blood sugar (FBS) was measured in those found to have HbA1c>6%. Psychotropic medication were recorded. (2) A cohort of 6,084 diabetic veterans was similarly identified, including those with and without SMI. Categorical performance of HbA1c, serum lipids, eye examination, and foot examinations was abstracted from the electronic patient database, and an adherence score was tabulated. Mixed effects models were separately developed to predict good (HbA1c<6.5%) and poor (HbA1c>8.0) glycemic control.

Results: 308 veterans with SMI, mean age 55.1 years, consented and were screened. Forty one (13.3%) had HbA1c>6%; 16 cases of previously undiagnosed diabetes were confirmed by FBS, representing 5.19% of all those who completed a first-level screen. There was no significant association of undetected cases with use of antipsychotic drugs. Among known diabetics, those with SMI had significantly better guideline adherence compared to those without SMI (completion of HbA1c, F=62.45; serum lipids, F=84.92; ophthalmology visit, F=61.20; and foot examination, F=103.5; all p<.0001). Although SMI patients had more HbA1c measurements (3.17 vs. 2.7, p<.0001), they had poorer glycemic control compared to those without SMI (mean HgA1c=7.67% vs 7.50% respectively, p=0.03).

Conclusion: The rate of undetected diabetes in veterans with SMI is nearly twice that reported for the general population in the USA. Despite better adherence to practice guidelines, known diabetics with SMI had poorer glycemic control. Poor control may be a signal to providers for greater adherence to practice guidelines.

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