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SL Krein, VA Ann Arbor HSR&D Center of Excellence; EA Kerr, VA Ann Arbor HSR&D Center of Excellence; DM Smith, VA Ann Arbor HSR&D Center of Excellence; MM Hogan, VA Ann Arbor HSR&D Center of Excellence; RA Hayward, VA Ann Arbor HSR&D Center of Excellence

Objectives: Cardiovascular disease is the leading cause of complications and death in people with diabetes. Research suggests that aspirin therapy is twice as effective in lowering cardiovascular risk in diabetics compared with non-diabetics, and the American Diabetes Association recommends aspirin use in all diabetics over age 30. Because aspirin is inexpensive and can be obtained over the counter, automated pharmacy data are not an adequate source for identifying aspirin use among veterans with diabetes. Therefore, we used data from a survey of veterans with diabetes to examine: 1) facility level variation in counseling about aspirin use and the use of aspirin by individuals with diabetes; and 2) the influence of visit frequency, cardiovascular co-morbidities and smoking history on both aspirin counseling and the self-reported use of aspirin by patients.

Methods: 1314 veterans with diabetes from 26 facilities in 4 VISNs responded to a survey about diabetes quality of care (survey response rate, 70%). The survey included questions about services obtained, diabetes related co-morbidities, and socio-demographic characteristics. Visit data were obtained from the Austin Automation Center. The intra-class correlation coefficient was used to assess attributable variation at the facility level, and logistic regression was used to examine the influence of visit frequency, smoking history and cardiovascular disease co-morbidity on aspirin counseling and aspirin use, while controlling for patient characteristics such as age, race, education level, and other diabetes related co-morbidities.

Results: Seventy-two percent of patients reported they had been counseled about aspirin use by their doctor, of whom 11% were told not to take aspirin. Sixty-six percent of patients, excluding those told not to take aspirin, indicated they were taking aspirin on a daily basis. Less than 1% of the variation in both aspirin use and counseling was attributable to the facility level. Patients with cardiovascular co-morbidities were significantly more likely to be counseled and use aspirin, odds ratios (OR) of 2.4 (1.8, 3.3) and 2.2 (1.7, 2.8) respectively. Smoking history was also positively related to both counseling (OR = 1.5 (1.1, 2.1)) and aspirin use (OR = 1.8 (1.3, 2.6)). While visit frequency was significantly associated with aspirin counseling (OR = 1.7 (1.1, 2.7)), the relationship between visit frequency and aspirin use disappeared after adjusting for the presence of cardiovascular co-morbidities.

Conclusions: There is little facility-level variation in aspirin use and counseling across the study sample. However, over one-quarter of these diabetic veterans reported no counseling about the use of aspirin. Patients with existing cardiovascular conditions and a smoking history were more likely to report receiving counseling about aspirin and were more likely to report daily aspirin use.

Impact: Low dose aspirin is a simple and inexpensive therapy that significantly lowers cardiovascular risk among diabetic patients. While aspirin use is recognized as being very important in patients with pre-existing coronary disease, almost all veterans with diabetes are at high risk of cardiovascular related complications. Consequently, providers should be encouraged to consider aspirin therapy as a care priority for all of their patients with diabetes.