With responsibility for treating diabetes in more than a million veterans in its primary-care population, VA is at the leading edge of care for the metabolic disease.

For example, an article this spring in the Annals of Internal Medicine focused on an ongoing debate in medical circles: Whether a “one-size-fits-all” target level for Hemoglobin A1c in diabetes is the best approach, or whether an individualized approach is more appropriate.

The authors supported the latter approach — one that VA has long endorsed.

“The VA/DoD Clinical Practice Guidelines for Diabetes have for more than 10 years included stratified targets based on life expectancy and co-comorbidities,” wrote a group of authors responding to the study on behalf of the VA/DoD Diabetes Practice Guidelines Working Group. “Moreover, all of the trials referred to in their article were utilized in updating the guidelines which were released in August, 2010.”

Unlike the more specific glycemic targets recommended by the authors in the Annals article, however, the VA/DoD Diabetes Practice Guidelines Working Group, the response noted, “Recommends target ranges rather than single targets — from <7%, 7-8%, and 8-9%.” (Please see the table on final page.)

“What I can tell you is that, over time, many of the VA-DoD recommendations that seemed controversial at the time because they did not agree with professional society guidelines now seem to be good science —that is, our experts were properly cautious,” said Leonard M. Pogach, MD, MBA, the Veterans Health Administration national program director for endocrinology and diabetes, Office of Specialty Care, Patient Care Services, chair of the VA/DoD Diabetes Working Group, director of CHeKM, and professor of Medicine, UMDNJ-New Jersey Medical School. Pogach also noted that VA removed Avandia from its formulary in late 2007, about three years before the FDA took action, adding, “So you might want to categorize our approach as ‘safety first.’”

VA First With Performance Measures

VA implemented the first national performance measures for diabetes in 1996; it was the first national delivery system to standardize Hemoglobin A1c (1999); and started a tele-retinopathy demonstration project in 1999.

 “Diabetes was also one of the original Quality Improvement Research Enhancement Initiatives in 1998,” Pogach recounted. All of this was well prior to the 2000 Institute of Medicine report that first mentioned a possible link between Agent Orange and type 2 diabetes. “It was already recognized that diabetes was a major health issue for veterans,” Pogach notes. Between 20% and 25% of the veterans in the VHA primary care population (over 5 million in all) have diabetes, according to the Working Group.

VA added type 2 diabetes to the list of "presumptive diseases associated with herbicide exposure" in 2000, following a report from the National Academy of Sciences that found "limited/suggestive" evidence of an association between the chemicals used in herbicides during the Vietnam War, such as Agent Orange, and type 2 diabetes.