Veterans Affairs primary care organizational characteristics associated with better diabetes control

Objective: To examine organizational features of Veterans Affairs (VA) primary care programs hypothesized to be associated with better diabetes control, as indicated by hemoglobin A_1c (HbA_1c) levels. Study Design: Cross-sectional cohort. Methods: We established a cohort of 224 221 diabetic patients using the VA Diabetes Registry and Dataset and VA corporate databases. The 1999 VHA (Veterans Health Administration) Survey of Primary Care Practices results were combined with individual patient data. A 2-level hierarchical model was used to determine the relationship between organizational characteristics and HbA_1c levels in 177 clinics with 82 428 cohort members. Results: The following attributes were associated with lower (better) HbA_1c and were statistically significant at P < .05: greater authority to establish or implement clinical policies (lower by 0.21%), greater staffing authority (0.28%), computerized diabetes reminders (0.17%), notifying all patients of their assigned provider (0.21%), hiring needed new staff during fiscal year 1999 (0.18%), having nurses that report only to the program (0.16%), and being a large academic practice (0.27%). Associated with higher (worse) HbA_1c were programs reporting that patients almost always see their assigned provider (greater by 0.18%), having a quality improvement program involving all nurses without all physicians (0.38%), having general internal medicine physicians report only to the program (0.20%), and being located at an acute care hospital (0.20%). Conclusion: Programs that are associated with better diabetes control simultaneously have teams that actively involve physicians in quality improvement, use electronic health information systems, have authority to respond to staffing and programmatic issues, and engage patients in care.