, Volume 21, Issue 10, pp 1050-1056

Simultaneous control of intermediate diabetes outcomes among veterans affairs primary care patients

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BACKGROUND: Guidelines recommend tight control of hemoglobin Alc (HbAlc), low-density lipoprotein cholesterol (LDL-C), and blood pressure (BP) for patients with diabetes. The degree to which these intermediate outcomes are simultaneously controlled has not been extensively described.

OBJECTIVE: Describe the degree of simultaneous control of HbAlc, LDL-C, and BP among Veterans Affairs (VA) diabetes patients defined by both VA and American Diabetes Association (ADA) guidelines.

DESIGN: Cross-sectional cohort.

PATIENTS: Eighty-thousand two hundred and seven VA diabetes patients receiving care between October 1999 and September 2000.

MEASURMENTS: We defined simultaneous control of outcomes using 1997 VA Guidelines (in place in 2000) (HbAlc<9.0%; LDL-C<130 mg/dL; systolic BP<140mmHg; and diastolic BP<90mmHg) and 2004 ADA guidelines (HbAlc<7.0%; LDL-C<100 mg/dL; systolic BP<130 mmHg; and diastolic BP<80 mmHg). A patient is considered to have simultaneous control of the intermediate outcomes for a given definition if the average of measurements for each outcome was below the defined threshold during the study period.

RESULTS: Using VA guidelines, 31% of patients had simultaneous control. Control levels of individual outcomes were: HbAlc (82%), LDL-C (77%), and BP (48%). Using ADA guidelines, 4% had simultaneous control. Control levels of individual outcomes were: HbAlc (36%), LDL-C (41%), and BP (23%). Associations between individual risk factors were weak. There was a modest association between LDL-C control and control of HbAlc (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.44, 1.58). The association between LDL-C and BP control was clinically small (1.26: 1.21, 1.31), and there was an extremely small association between BP and HbAlc control (0.95; 0.92, 0.99). Logistic regression modeling indicates greater body mass index, African American or Hispanic race-ethnicity, and female gender were negatively associated with simultaneous control.

CONCLUSION: While the proportion of patients who achieved minimal levels of control of HbAlc and LDL-C was high, these data indicate a low level of simultaneous control of HbAlc, LDL-C, and BP among patients with diabetes.

Preliminary results were presented at the American Public Health Association Annual Meeting in Washington, DC, on November 9, 2004 and VA Health Services Research & Development National Meeting in Baltimore, MD, on February 17, 2005.
He is currently a Veterans Affairs Health Services Research & Development Merit Review Entry Program awardee (VA grant MRP 05-312). Dr. Weinberger is a VA Health Services Research & Development Senior Career Scientist awardee. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.