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

BACKROUND: Guidelines recommend tight control of hemoglobin A1c (HbA1c), 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 HbA1c, 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. MEASUREMENTS: We defined simultaneous control of outcomes using 1997 VA Guidelines (in place in 2000) (HbA1c < 9.0%; LDL-C < 130 mg/dL; systolic BP < 140 mmHg; and diastolic BP < 90 mmHg) and 2004 ADA guidelines (HbA1c < 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: HbA1c (82%), LDL-C (77%), and BP (48%). Using ADA guidelines, 4% had simultaneous control. Control levels of individual outcomes were: HbA1c (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 HbA1c (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 HbA1c 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 HbA1c and LDL-C was high, these data indicate a low level of simultaneous control of HbA1c, LDL-C, and BP among patients with diabetes.