Facility‐level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database. Issue 11 (25th August 2017) - Rehman, Hasan
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.