Veterans and Type 2 Diabetes: Excess Monitoring?

Monitoring blood glucose levels can be an important part of daily treatment for diabetes patients, but a recent look at one particular population considered whether some could be overly using their monitoring equipment.

A recent study published in the Journal of the American Medical Association observed whether veterans who receive benefits from the Department of Veterans Affairs and Medicare were unnecessarily monitoring their glucose. This was particularly true for patients not taking insulin.

The study involved more than 300,000 patients aged 65 and older who received test strips in 2009. The researchers defined overuse of test strips as using more than one per day, or more than 365 in a year while taking no medication for diabetes, only oral prescriptions, or long-acting insulin without short-acting insulin. Patients who used more than 4 strips per day, or more than 1,460 strips in a year while taking short-acting insulin were also included.

In total, 260,688 veterans were shown to receive their test strips from the VA, while 82,826 received their supply from Medicare, and 20,482 received their supplies from both entities. The results showed that the patients who received strips from both organizations received a greater number of strips (median, 600; interquartile range [IQR], 350-100). This was higher than the Medicare only group, with members receiving an average of 400 strips with an IQR of 200-700. It was also considerably higher than the VA only group where patients received an average of just 200 strips, with an IQR of 100-500.

With the increase of supply, an increase in overuse was also seen. In the VA group, the dual patients saw an overuse of 55.4% compared to just 15.8% (adjusted odds ratio [OR], 16.3; 95% CL, 14.6-18.1 for no medications; 55.3% vs 6.0%; OR, 19.8, 95% CL, 18.9-20.8 for oral medications; 87.4% vs 65.5%; OR, 3.69; 95% CL, 3.30-4.14 for long-acting insulin; and 32.8% vs. 13.5%; OR, 3.24; 95% CL, 3.05-3.45 for short-acting insulin. “Patterns were similar when using more conservative thresholds of overuse,” the authors added.

Looking at the care the patients receive in both groups the authors noted that “Medicare contractors paid more than $1.2 billion for test strips and/or lancets in 2007, and in the VA, where use and cost are lower, approximately $50 million per year is spent on test strips alone.” They also noted that Medicare patients not treated with insulin were allotted 100 test strips for a 3-month period, as well and 100 strips per month for those treated with insulin. They were also eligible to receive more as needed.

“In 2010 and 2011, the Office of the Inspector General for Medicare reported that most sampled high-use claims for strips were not in line with these guidelines,” the authors added.

VA patients were noted to receive just 50 strips for a 150-day period. Additional strips are available “with proper clinical justification.” Additionally, “For patients using insulin, the VA typically recommends dispensing enough strips to match the number of daily insulin injections.”

The authors cited their report showed a key area that needs to be addressed in a growing portion of the population. “These results illustrate the profound importance of understanding dual VA and Medicare coverage and are emblematic of waste and inefficiency.”

The researchers concluded, “The results are robust to adjustment for clinical characteristics and are especially pronounced in individuals who take no diabetes medications or oral medications only. These findings illustrate the profound importance of understanding dual health system care and are emblematic of waste and inefficiency that must be addressed.”