Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database

Clin Cardiol. 2017 Nov;40(11):1055-1060. doi: 10.1002/clc.22769. Epub 2017 Aug 25.

Abstract

Background: Intensive glycemic and blood pressure (BP) control in diabetic patients is associated with improved cardiovascular outcomes.

Hypothesis: We hypothesized that there is suboptimal glycemic and BP control with significant facility-level variation in patients with diabetes.

Methods: We identified patients with diabetes receiving care in 130 facilities in the Veterans Affairs Health Care System. We assessed facility-level rates of glycemic (hemoglobin [Hb]A1c <7%), BP (BP <140/90 mmHg), and combined glycemic and BP control (HbA1c <7% and BP <140/90 mmHg), and their facility-level variation in using median rate ratios (MRR).

Results: Among 1 103 302 patients with diabetes, 50.2% participants had an HbA1c <7%, 77.5% had a BP <140/90 mmHg, and 39.8% had both, HbA1c <7% and BP <140/90 mmHg. Median facility-level rates were 50.3% (interquartile range [IQR], 47.9%-52.4%) for glycemic control, 78.4% (IQR, 75.2%-80.0%) for BP control, and 39.9% (IQR, 38.14%-42.34%) for combined glycemic and BP control. Unadjusted MRR for glycemic control was 1.61 (95% confidence interval [CI]: 1.51-1.70) which decreased to 1.16 (95% CI: 1.14-1.19) after adjusting for patient and facility-level variables, indicating a 16% variation in glycemic control between 2 identical patients receiving care at 2 random facilities. Unadjusted MRR for BP control was 1.49 (95% CI: 1.41-1.56), which decreased to 1.25 (95% CI: 1.21-1.28), whereas unadjusted MRR for combined glycemic and BP control was 1.59 (95% CI: 1.50-1.68), which decreased to 1.15 (95% CI: 1.13-1.17) after adjustment.

Conclusions: Facility-level rates for BP control and glycemic control remain low with significant facility-level variation. Much of this is explained by patient and facility-level variables although 16%, 25%, and 15% variation in glycemic, BP, and combined glycemic and BP control remains unexplained.

Keywords: Blood Pressure; Diabetes; Facility Variation; Hypertension; Veterans.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Antihypertensive Agents / therapeutic use*
  • Biomarkers / blood
  • Blood Glucose / drug effects*
  • Blood Glucose / metabolism
  • Blood Pressure / drug effects*
  • Databases, Factual
  • Diabetes Mellitus / blood
  • Diabetes Mellitus / diagnosis
  • Diabetes Mellitus / drug therapy*
  • Female
  • Glycated Hemoglobin A / metabolism
  • Healthcare Disparities*
  • Humans
  • Hypertension / diagnosis
  • Hypertension / drug therapy*
  • Hypertension / physiopathology
  • Hypoglycemic Agents / therapeutic use*
  • Male
  • Middle Aged
  • Time Factors
  • Treatment Outcome
  • United States
  • United States Department of Veterans Affairs*
  • Young Adult

Substances

  • Antihypertensive Agents
  • Biomarkers
  • Blood Glucose
  • Glycated Hemoglobin A
  • Hypoglycemic Agents
  • hemoglobin A1c protein, human