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

Rehman H, Akeroyd JM, Ramsey D, Ahmed ST, Merchant AT, Navaneethan SD, Petersen LA, Virani SS. Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database. Clinical Cardiology. 2017 Nov 1; 40(11):1055-1060.

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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.