Effectiveness of non-enforced clinical guidelines in achieving defined cardiovascular risk factor endpoints in diabetes

Abstract

Diabetic patients are at high-risk and utilize an inordinate amount of healthcare resources. Diabetes often coexists with hypertension and hyperlipidemia which if inadequately treated, contribute to diabetic complications such as nephrology and arterial disease. Target blood pressure, total cholesterol and LDL cholesterol values for patients treated in the VA include blood pressure <140/90, total cholesterol <200 mg/dl, and LDL <130 mg/dl. This medical center has developed a database of 1788 patients who have been treated for the 3 years spanning implementation of these guidelines. These patients are treated (80%) in general internal medicine clinic or diabetic specialty clinic (20%). All diabetic patients have been aggressively treated. HbA1C values averaged 7.43% in FY 97, 6.8% in FY 98, and 7.16% in FY 99 with values being recorded for 84%–90% of patients. Total cholesterol values averaged 205 mg/dl in FY 97, 187 mg/dl in FY 98, and 184 mg/dl in FY 99. LDL cholesterol averaged 122 mg/dl in FY 97, 108 mg/dl in FY 98, and 107 mg/dl in FY 99. Associated with this improvement in total and LDL cholesterol was an increase in the percentage of patients using HMG-CoA-reductase inhibitors from 22.8% in FY 97 to 37.9% in FY 99. Using a goal LDL level of <130, 79% were at goal. With a goal of <100, 42% were at goal. Average diastolic and systolic blood pressure changed little over the 3 years of observation being 146/76 in FY 97, 145/76 in FY 98, and 146/75 in FY 99. The preferred first line antihypertensive for most diabetics was an angiotensin converting enzyme inhibitor. In FY 97, 57.5% of patients had ACEI prescribed. In FY 98, 62.8%, and in FY 99, 64.3%. On average, patients were taking 1.8 antihypertensives. The most common other drugs used included diuretics in 47.1% of patients, calcium channel blockers in 38.9%, β-blockers in 28.7%, and α-blockers in 28.4%.