Improving Care for Veterans with Very Elevated Hemoglobin A1c at Initial Testing

Background: One-fourth of Veterans have diabetes, which can lead to serious complications, such as lower- extremity amputation (LEA). Diabetes is often diagnosed on routine testing, but many Veterans with no known diabetes (or not known to the VA) have very elevated hyperglycemia at initial VA testing. My preliminary analysis finds that, among Veterans with an initial hemoglobin A1c (HbA1c) in the diabetes range (≥6.5%), 11% had a very elevated HbA1c (i.e., ≥9%). Relative to those with less hyperglycemia at initial testing, Veterans with a very elevated HbA1c at initial testing were at an over fourfold increased risk of LEA in the following 5 years. While much is known about Veterans who progress to an elevated HbA1c despite receiving care, Veterans with a very elevated HbA1c (≥9%) at initial testing are a distinct and understudied population. When comparing the 5 years after initially testing with a HbA1c≥9% for this population to the 5 years after developing a HbA1c≥9% for Veterans initially testing with a HbA1c<9% and later developing a very elevated HbA1c (≥9%), the former population still has a threefold higher rate of LEA than the latter population. Earlier identification and intervention may be particularly impactful for Veterans with a very elevated HbA1c (≥9%) at initial testing. Significance: This research explores a high-risk and understudied group: Veterans with very elevated HbA1c at initial VA testing, who may have a disproportionate percentage of complications Veterans with diabetes experience. Understanding and designing interventions for those at risk of being in this population may reduce rate of complications for Veterans with diabetes. Findings from this work may be applicable to Veterans with other chronic conditions. This research addresses three HSR Research Priorities: 1) Access (exploring gap between VA healthcare enrollment and primary care use), 2) Health Equity (Veterans from racial and ethnic minority groups are more likely to have very elevated HbA1c at initial testing), and 3) Primary Care Practice. Innovation/Impact: This research focuses on a high-risk but understudied Veteran population with diabetes. The longitudinal nature of assembled data allows for a better understanding of how complications evolve for Veterans with very elevated HbA1c at initial testing. This research is novel in its focus on the gaps between VA healthcare enrollment and initial VA primary care use. Findings from this study will inform improvements in diabetes care and may inform work that addresses gaps in care for Veterans with other chronic conditions. Specific Aims: Aim 1: Identify Veteran characteristics associated with a very elevated HbA1c at initial testing. Aim 2: Examine patient and primary care provider perceptions of barriers to care for this population. Aim 3: Develop and pilot a multi-component intervention for those at risk of entering this population. Methodology: For Aim 1, using VA data, I will examine characteristics pointing to modifiable mechanisms for having a very elevated HbA1c at initial testing and distinguishable characteristics of this Veteran population. For Aim 2, I will interview Veterans and providers to understand barriers to and facilitators of entering primary care earlier and receiving timely testing. For Aim 3, I will develop a multi-component intervention for Veterans who, absent intervention, may be at risk of later having a very elevated HbA1c. Intervention components may include contacting Veterans enrolled in VA health care to schedule first primary care visits and giving providers information on untested patients they already see who are at high risk of having a very elevated HbA1c. Next Steps/Implementation: This work has support of local Veterans and leadership, as well as operational partners such as the Office of Primary Care. In Year 3, I will apply for a VA IIR that will identify Veterans eligible for screening for diabetes and for other chronic diseases, and examine provi Project Number: 1IK2HX003836-01A2 | Fiscal Year: 2025 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Dan Ly | Institution: VA GREATER LOS ANGELES HEALTHCARE SYSTEM, LOS ANGELES, CA | Activity Code: IK2 | Study Section: Research Career Scientist[MRA0] View on NIH RePORTER: https://reporter.nih.gov/project-details/11103977