Control Of Disease Risk Factors Research Articles

Abstract 03: Cardiovascular Disease Risk Factor Control Following Release From Carceral Facilities

Background: Incarceration is a social determinant of cardiovascular disease (CVD) but is rarely addressed in clinical settings or cardiovascular prevention efforts. People who have been incarcerated are more likely to develop CVD at younger ages and have worse cardiovascular outcomes compared with the general population, even after controlling for traditional risk factors. The objective of this study is to identify incarceration-specific factors that are associated with uncontrolled CVD risk factors and identify potential targets for prevention specific to this population. Methods: Using data from Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE), a prospective cohort study of individuals released from incarceration with CVD risk factors, we examine the association between incarceration-specific and psychosocial factors and CVD risk factor control, including systolic blood pressure (SBP≥140 mmHg, diastolic blood pressure (DBP)≥90, body mass index (BMI)≥40, glycosylated hemoglobin (HbA1c) ≥8%, and low-density lipoprotein cholesterol (LDL-c) ≥160). Incarceration-specific factors include the conditions of confinement (jail vs. prison, time spent in solitary confinement), the carceral health care delivery system (co-payment, medication self-management, discharge planning), and collateral sanctions following release (barriers to housing, food, employment due to criminal record). Psychosocial factors included perceived discrimination and stress, self-efficacy, and lifetime adversity. Results: The mean age of participants (N=417) was 45.2 ±SD 10.7 years and disproportionately men (92%), racially minoritized groups (80%), and poor (66% without an income). Over half (53%) had at least one uncontrolled CVD risk factor. Having been incarcerated in a jail, as compared with prison, was associated with an increased odds of having an uncontrolled CVD risk factor, even after adjusting for age, race and ethnicity, gender, perceived stress, depression symptoms, and life adversity score (AOR 1.79, 95% CI 1.08-2.94). People held in jail, as compared with prison, had higher rates of smoking, uncontrolled hypertension, fewer opportunities to manage one’s own medications while incarcerated, or receive medications prior to release. Discussion: Release from jail is associated with worse CVD risk factor control and requires tailored intervention focused on smoking cessation, hypertension control, and improved discharge planning. These data are especially informative as states design and implement the Centers of Medicare & Medicaid Services new Medicaid Reentry Section 1115 Demonstration Opportunity, which allow Medicaid programs for the first time in history to cover services prior to release from correctional facilities that address chronic health conditions like cardiovascular disease and its risk factors.

Cardiovascular Disease Risk Factor Control in People With and Without HIV.

Management of hypertension, dyslipidemia, diabetes and other modifiable factors may mitigate the cardiovascular disease (CVD) risk in people with human immunodeficiency virus (HIV, PWH) compared with people without HIV (PWoH). This was a retrospective cohort study of 8285 PWH and 170 517 PWoH from an integrated health system. Risk factor control was measured using a novel disease management index (DMI) accounting for amount/duration above treatment goals (0% to 100% [perfect control]), including 2 DMIs for hypertension (diastolic and systolic blood pressure), 3 for dyslipidemia (low-density lipoprotein, total cholesterol, triglycerides), and 1 for diabetes (HbA1c). CVD risk by HIV status was evaluated overall and in subgroups defined by DMIs, smoking, alcohol use, and overweight/obesity in adjusted Cox proportional hazards models. PWH and PWoH had similar DMIs (80%-100%) except for triglycerides (worse for PWH) and HbA1c (better for PWH). In adjusted models, PWH had an elevated risk of CVD compared with PWoH (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.07-1.31). This association was attenuated in subgroups with controlled dyslipidemia and diabetes but remained elevated for PWH with controlled hypertension or higher total cholesterol. The strongest HIV status association with CVD was seen in the subgroup with frequent unhealthy alcohol use (HR, 2.13; 95% CI, 1.04-4.34). Control of dyslipidemia and diabetes, but not hypertension, attenuated the HIV status association with CVD. The strong association of HIV and CVD with frequent unhealthy alcohol use suggests enhanced screening and treatment of alcohol problems in PWH is warranted.

1830. Social determinants of cardiovascular disease risk factor control among people living with HIV

Abstract Background HIV is associated with an elevated risk of cardiovascular disease, yet hypertension and high cholesterol are often sub-optimally treated in people with HIV. The role of racial disparities and social determinants of health in the management of these cardiovascular risk factors is poorly understood. Average systolic blood pressures vs TIS score (hypertension treatment intensity), by Black race TIS (therapeutic intensity score) was calculated by dividing the patient’s antihypertensive medication dosage by the maximum daily dosage approved by the US Food and Drug Administration, then summing this proportion for each antihypertensive medication prescribed. For example, if a patient was prescribed two antihypertensive medications each at 75% of the maximum approved dosage, the TIS score would be calculated as 1.5 (0.75 + 0.75). Methods We performed a cross-sectional analysis of adult patients with HIV among three academic medical centers in the United States. We considered various social determinants of health including race, sex, measures of economic stability, education level, health insurance, health literacy, social deprivation index by zip code, and measures of psychosocial stress. We examined a hybridized outcome of risk factor control (poor or good) and treatment intensity (minimal or maximal) for two key cardiovascular risk factors, hypertension and hyperlipidemia. Multinomial logistic regressions were performed to identify factors associated with cardiovascular risk factor control and intensity, with “good control, maximal treatment” used as the reference group. Results Overall, 371 persons were included in the analysis. Participants were 23.5% female, 59.6% Black, 7.3% Hispanic/Latino, with a median age of 59 (interquartile range 53-64). Among study participants with hypertension, Black participants were more likely to have poor control despite maximal treatment (relative risk ratio [RRR] 2.95, 95% CI: 1.30-6.66). In our hyperlipidemia analysis, having the highest quartile of perceived stress was more common among participants with poor than good cholesterol control (27.0% vs 15.9%, p=0.032). Compared to participants with good control and maximal treatment of high cholesterol, participants with the highest quartile of perceived stress were more likely to have poor control with minimal (RRR: 2.80, 95% CI: 1.02-7.63) or maximal (RRR: 3.64, 95% CI: 1.20-11.1) treatment. Conclusion Race and social determinants of health, including perceived stress, appear to influence cardiovascular disease risk factors among persons with HIV. Disclosures Nwora Lance Okeke, MD MPH, Gilead Sciences: Advisor/Consultant

Brain structural alterations and clinical features of cognitive frailty in Japanese community-dwelling older adults: the Arao study (JPSC-AD)

Cognitive frailty (CF) is a clinical condition defined by the presence of both mild cognitive impairment (MCI) and physical frailty (PF). Elderly with CF are at greater risk of dementia than those with MCI or PF alone, but there are few known clinical or neuroimaging features to reliably distinguish CF from PF or MCI. We therefore conducted a population-based cross-sectional study of community elderly combining physical, cognitive, neuropsychiatric, and multisequence magnetic resonance imaging (MRI) evaluations. The MRI evaluation parameters included white matter (WM) lesion volumes, perivascular and deep subcortical WM lesion grades, lacunar infarct prevalence, microbleed number, and regional medial temporal lobe (MTL) volumes. Participants were divided into 4 groups according to the presence or absence of MCI and PF—(1) no MCI, PF (n = 27); (2) no PF, MCI (n = 119); (3) CF (MCI + PF) (n = 21), (4) normal controls (n = 716). Unique features of CF included shorter one-leg standing time; severe depressive symptoms; and MRI signs of significantly more WM lesions, lacunar infarcts, small-vessel disease lesions, microbleeds, and reduced MTL volumes. These unique deficits suggest that interventions for CF prevention and treatment should focus on motor skills, depressive symptoms, and vascular disease risk factor control.

Being cardiologist at the time of SARS-CoV-2: what do not forget during the post-pandemic phase?

In Italy, the epidemic explosion stage of COVID-19 seems to have been overcome; however, the virus has not been eradicated and the re-emergence of some outbreaks of infection substantiates the danger that the disease may persist. It is therefore necessary to keep the level of surveillance high, to maintain social distancing measures and to act in the control of disease risk factors of a serious or complicated course. Among the risk factors of severe COVID-19 in addition to age, male gender, hypertension and cardiovascular diseases, a major role seems to be played by other cardiovascular risk factors conditioned by an unhealthy lifestyle such as obesity, metabolic syndrome, diabetes and smoking. The new phase requires the maintenance of measures that avoid crowding and close interpersonal contact especially during exercise, in addition to controlled access to hospitals. This will require the reorganization of the traditional methods of cardiovascular prevention and rehabilitation activities, such as gyms and collective educational sessions, and the dilution of outpatient checks. The risk that this scenario may worsen the already suboptimal control of cardiovascular risk factors is therefore real. We do not currently know how long this new phase will last, therefore it is necessary to give impetus to new tele-health initiatives to stimulate the adoption of a healthy lifestyle in primary prevention and tele-monitoring and tele-rehabilitation programs in secondary prevention.

Lifestyle and impact on cardiovascular disease risk factor control among coronary patients.. Could prevention semantics and interdisciplinary collaboration help?

Lifestyle and impact on cardiovascular disease risk factor control among coronary patients.. Could prevention semantics and interdisciplinary collaboration help?

Investing in non-communicable disease risk factor control among adolescents worldwide: a modelling study

IntroductionExposure to non-communicable disease (NCD) risk factors is increasing among adolescents in most countries due to demographic, economic and epidemiological forces. We sought to analyse the potential health impact and...

Visit Planning Using a Waiting Room Health IT Tool: The Aligning Patients and Providers Randomized Controlled Trial.

Time during primary care visits is limited. We tested the hypothesis that a waiting room health information technology (IT) tool to help patients identify and voice their top visit priorities would lead to better visit interactions and improved quality of care. We designed a waiting room tool, the Visit Planner, to guide adult patients through the process of identifying their top priorities for their visit and effectively expressing these priorities to their clinician. We tested this tool in a cluster-randomized controlled trial with usual care as the control. Eligible patients had at least 1 clinical care gap (eg, overdue for cancer screening, suboptimal chronic disease risk factor control, or medication nonadherence). The study (conducted March 31, 2016 through December 31, 2017) included 750 English- or Spanish-speaking patients. Compared with usual care patients, intervention patients more often reported "definitely" preparing questions for their doctor (59.5% vs 45.1%, P <.001) and "definitely" expressing their top concerns at the beginning of the visit (91.3% vs 83.3%, P = .005). Patients in both arms reported high levels of satisfaction with their care (86.8% vs 89.9%, P = .20). With 6 months of follow-up, prevalence of clinical care gaps was reduced by a similar amount in each study arm. A simple waiting room-based tool significantly improved visit communication. Patients using the Visit Planner were more prepared and more likely to begin the visit by communicating their top priorities. These changes did not, however, lead to further reduction in aggregate clinical care gaps beyond the improvements seen in the usual care arm.

An Internet-Based Intervention Integrated with the Primary Care Electronic Health Record to Improve Cardiovascular Disease Risk Factor Control: a Mixed-Methods Evaluation of Acceptability, Usage Trends and Persuasive Design Characteristics

An Internet-Based Intervention Integrated with the Primary Care Electronic Health Record to Improve Cardiovascular Disease Risk Factor Control: a Mixed-Methods Evaluation of Acceptability, Usage Trends and Persuasive Design Characteristics

Barriers to medication adherence and links to cardiovascular disease risk factor control: the Framingham Heart Study.

In the elderly, impaired cognition may weaken medication adherence and compromise treatment for cardiovascular disease (CVD). We examined risk factors for medication adherence and the relationship between adherence and levels of CVD risk factors among older participants with hypertension, dyslipidaemia and diabetes in the Framingham Heart Study. The four-item Morisky Medication Adherence Scale was administered to 1559 participants, median age 70 years, 53% women. We created an adherence score, ranging from 0 to 4, with low adherence defined as a score ≥2. CVD risk factors were assessed using standard protocols. Cognition was measured using the Mini-Mental State Examination (MMSE) and depressive symptoms were measured using the Center for Epidemiologic Studies of Depression (CES-D) scale. Among participants who self-reported taking antihypertensive, lipid-lowering and/or hyperglycaemic medication(s), 12% (n = 191) had low medication adherence. The risk of low adherence increased by 45% (95% confidence interval (CI): 25-68%, P < 0.001) per five-unit increase in CES-D score. In participants taking antihypertensive medication (n = 1017), low adherence was associated with higher mean diastolic blood pressure (73 mmHg, 95% CI: 71-75 vs 71 mmHg, 95% CI: 70-71; P = 0.04) after adjusting for covariates. Among participants taking lipid-lowering medication (n = 937), low adherence was associated with higher mean low-density lipoprotein cholesterol (92 mg/dL, 95% CI: 87-96 vs 86 mg/dL, 95% CI: 84-88; P = 0.03). Low adherence was not associated with fasting plasma glucose (P = 0.10) or haemoglobin A1c (P = 0.68) in the subgroup of participants (n = 192) taking hypoglycaemic medication. Depressive symptoms might act as a barrier for medication adherence, which exacerbates CVD risk factors in older-aged adults.

Assessing Potential Confounding and Misclassification Bias When Studying the Safety of the Childhood Immunization Schedule

ObjectivesSome parents are concerned the childhood immunization schedule could increase risk for allergic disorders, including asthma. To inform future safety studies of this speculated association, a parent survey was conducted to examine the risk of misclassification of vaccination status in electronic health record data, and to assess the potential for confounding if asthma risk factors varied by vaccination status. MethodsA survey was conducted among parents of children 19 to 35 months old at 6 medical organizations within the Vaccine Safety Datalink. Parents of children in 4 vaccination groups were surveyed: 1) no vaccines by 12 months of age and a diagnosis of parental vaccine refusal; 2) consistent vaccine limiting (≤2 vaccines per visit); 3) not consistently vaccine limiting but otherwise undervaccinated with a vaccine refusal diagnosis; and 4) fully vaccinated with no delays and no vaccine refusal. Parents were surveyed about their child's vaccination status and whether asthma risk factors existed. ResultsAmong a survey sample of 2043 parents, 1209 responded (59.2%). For receiving no vaccines, the observed agreement between parent report and electronic health record data was 94.0% (κ = 0.79); for receiving all vaccines with no delays, the observed agreement was 87.3% (κ = 0.73). Although most asthma risk factors (allergic rhinitis, eczema, food allergies, family asthma history) reported by parents did not differ significantly between children in the vaccination groups studied, several factors (aeroallergen sensitivity, breastfeeding) differed significantly between groups. ConclusionsMeasurement and control of disease risk factors should be carefully considered in observational studies of the safety of the immunization schedule.

Relationships between Medication Adherence and Cardiovascular Disease Risk Factor Control in Elderly Patients with Diabetes.

The Centers for Medicare and Medicaid Services (CMS) Medicare Star program provides incentives to health plans when their patients with diabetes meet adherence targets to angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs) and statins. While a link between adherence and cardiovascular risk factor control is established, most studies included young patients with few comorbidities. Whether the Star adherence target is associated with reduced blood pressure or low-density lipoprotein cholesterol (LDL-C) in complex older patients is not well understood. Determine correlates of adherence and examine the effect of meeting Star adherence targets on blood pressure and LDL-C in the Medicare-aged diabetes population. Retrospective cohort study of 129,040 patients with diabetes aged 65 or older. Adherence estimated using proportion of days covered target ≥ 0.8; blood pressure < 140/90 mg Hg; LDL-C < 100 mg/dl. Modified Poisson regression used to assess relationships. Adherence differed little across elderly age groups. Compared to no comorbidity, high comorbidity (≥ 4) was associated with lower ACEI/ARB (risk ratio [RR] 0.88 [95% confidence interval (CI) 0.87-0.89]) or statin (RR 0.91 [0.90-0.92]) adherence. ACEI/ARB adherence was not associated with blood pressure < 140/90 mm Hg in patients ≥ 85 years (RR 1.01 [0.96-1.07]) or with multiple comorbidities (e.g., 3: RR 1.04 [0.99-1.08]). Statin adherence and LDL-C < 100 mg/dl were associated in all elderly age groups (e.g., ≥ 85: RR 1.13 [1.09-1.16]) and comorbidity levels (e.g., ≥ 4: RR 1.13 [1.12-1.15]). Adherence to ACEI/ARB is not linked with reduced blood pressure in patients with diabetes who are at least 85 years or with multiple comorbidities.

Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association.

Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.

Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence: A Scientific Statement From the American Heart Association and the American Diabetes Association.

Cardiovascular disease risk factor control as primary prevention in patients with type 2 diabetes mellitus has changed substantially in the past few years. The purpose of this scientific statement is to review the current literature and key clinical trials pertaining to blood pressure and blood glucose control, cholesterol management, aspirin therapy, and lifestyle modification. We present a synthesis of the recent literature, new guidelines, and clinical targets, including screening for kidney and subclinical cardiovascular disease for the contemporary management of patients with type 2 diabetes mellitus.

Racial/ethnic differences in control of cardiovascular risk factors among type 2 diabetes patients in an insured, ambulatory care population

AimsThis paper examines differences in cardiovascular disease risk factor control among racial/ethnic minorities (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hispanic/Latino, Black/African Americans) with type 2 diabetes compared to Non-Hispanic Whites with type 2 diabetes in an insured, outpatient setting. MethodsA three-year, cross-sectional sample of 15,826 patients with type 2 diabetes was studied between 2008 and 2010. Goal attainment rates for three cardiovascular disease risk factors (HbA1c, BP, LDL) were estimated. Logistic regression was used to determine the association between patient characteristics and control of risk factors. ResultsOnly one fifth (21.1%) of patients achieved simultaneous goal attainment (HbA1c, BP, LDL). After adjustment for patient characteristics and treatment, Black/African American women and men, and Filipino and Hispanic/Latino men were significantly less likely to simultaneously achieve all three goals, compared to Non-Hispanic Whites. Of the three goals, patients were more likely to achieve HbA1c goals (68.7%) than BP (45.7%) or LDL (58.5%) goals. Racial/ethnic differences were more apparent in risk factors that were under better control (i.e. HbA1c). ConclusionsCardiovascular risk factor control in type 2 diabetes is suboptimal, even in an insured population. Special attention may be required for specific racial/ethnic/gender groups.

Physician Utilization, Risk-Factor Control, and CKD Progression Among Participants in the Kidney Early Evaluation Program (KEEP)

Chronic kidney disease (CKD) is a well-known risk factor for cardiovascular mortality, but little is known about the association between physician utilization and cardiovascular disease risk-factor control in patients with CKD. We used 2005-2010 data from the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) to examine this association at first and subsequent screenings. Control of risk factors was defined as control of blood pressure, glycemia, and cholesterol levels. We used multinomial logistic regression to examine the association between participant characteristics and seeing a nephrologist after adjusting for kidney function and paired t tests or McNemar tests to compare characteristics at first and second screenings. Of 90,009 participants, 61.3% had a primary care physician only, 2.9% had seen a nephrologist, and 15.3% had seen another specialist. The presence of 3 risk factors (hypertension, diabetes, and hypercholesterolemia) increased from 26.8% in participants with CKD stages 1-2 to 31.9% in those with stages 4-5. Target levels of all risk factors were achieved in 7.2% of participants without a physician, 8.3% of those with a primary care physician only, 9.9% of those with a nephrologist, and 10.3% of those with another specialist. Of up to 7,025 participants who met at least one criterion for nephrology consultation at first screening, only 12.3% reported seeing a nephrologist. Insurance coverage was associated strongly with seeing a nephrologist. Of participants who met criteria for nephrology consultation, 406 (5.8%) returned for a second screening, of whom 19.7% saw a nephrologist. The percentage of participants with all risk factors controlled was higher at the second screening (20.9% vs 13.3%). Control of cardiovascular risk factors is poor in the KEEP population. The percentage of participants seeing a nephrologist is low, although better after the first screening. Identifying communication barriers between nephrologists and primary care physicians may be a new focus for KEEP.

Impact of Coronary Artery Calcium Scanning on Coronary Risk Factors and Downstream Testing: The EISNER (Early Identification of Subclinical Atherosclerosis by Noninvasive Imaging Research) Prospective Randomized Trial

We conducted a prospective randomized trial to compare the clinical impact of conventional risk factor modification to that associated with the addition of coronary artery calcium (CAC) scanning.Although CAC scanning predicts cardiac events, its impact on subsequent medical management and coronary artery disease risk is not known.We assigned 2,137 volunteers to groups that either did undergo CAC scanning or did not undergo CAC scanning before risk factor counseling. The primary end point was 4-year change in coronary artery disease risk factors and Framingham Risk Score. We also compared the groups for differences in downstream medical resource utilization.Compared with the no-scan group, the scan group showed a net favorable change in systolic blood pressure (p = 0.02), low-density lipoprotein cholesterol (p = 0.04), and waist circumference for those with increased abdominal girth (p = 0.01), and tendency to weight loss among overweight subjects (p = 0.07). While there was a mean rise in Framingham Risk Score (FRS) in the no-scan group, FRS remained static in the scan group (0.7 ± 5.1 vs. 0.002 ± 4.9, p = 0.003). Within the scan group, increasing baseline CAC score was associated with a dose-response improvement in systolic and diastolic blood pressure (p < 0.001), total cholesterol (p < 0.001), low-density lipoprotein cholesterol (p < 0.001), triglycerides (p < 0.001), weight (p < 0.001), and Framingham Risk Score (p = 0.003). Downstream medical testing and costs in the scan group were comparable to those of the no-scan group, balanced by lower and higher resource utilization for subjects with normal CAC scans and CAC scores ≥400, respectively.Compared with no scanning, randomization to CAC scanning was associated with superior coronary artery disease risk factor control without increasing downstream medical testing. Further study of CAC scanning, including pre-specified treatment recommendations, to assess its impact of cardiovascular outcomes is warranted.

Physicians' Perceptions of Barriers to Cardiovascular Disease Risk Factor Control among Patients with Diabetes: Results from the Translating Research into Action for Diabetes (TRIAD) Study

Many patients with diabetes have poorly controlled blood glucose, lipid, or blood pressure levels, increasing their risk for cardiovascular disease (CVD) and other complications. Relatively little is known about what physicians perceive to be barriers to good CVD risk factor control or their own role in helping patients achieve good control. We interviewed 34 primary care physicians in 4 states to assess their perceptions of patients' barriers to CVD risk factor control. Interviews were coded and analyzed for emergent themes. Physicians attributed barriers primarily to patients (socioeconomic issues, competing medical conditions, and lack of motivation) or to health system barriers (cost of care or lack of a multidisciplinary team). Physicians also expressed high levels of frustration with their efforts to address barriers. Physicians felt that barriers to CVD risk factor control often were beyond their abilities to address. Training physicians or other members of the primary health care team to address patients' personal barriers and health system barriers to good control could help alleviate high frustration levels, improve relationships with patients, and improve the treatment of diabetes. Supporting such efforts with adequate reimbursement should be a focus of health care reform.

The Association of Patient-Physician Gender Concordance with Cardiovascular Disease Risk Factor Control and Treatment in Diabetes

Gender concordance between patients and their physicians is related to prevention screening and other quality indicators. Research suggests female physicians may place greater emphasis on preventive care than male physicians; however, little is known about whether physician gender and patient-physician gender concordance are associated with cardiovascular disease (CVD) risk factor levels and treatment. Our objective was to examine associations between patient gender, physician gender, and their interaction with CVD risk factor control, medication adherence, and treatment intensification in diabetes. In this study, 157,458 Kaiser Permanente Northern California adult diabetes patients with a primary care physician (PCP) were assessed for above target levels of hemoglobin A1c (HbA1c) (>or=8%), low-density lipoprotein cholesterol (LDL-C) (>or=100 mg/dL), and systolic blood pressure (SBP>or=130 mm Hg) in 2005. Medication adherence and appropriate CVD treatment intensification were assessed using pharmacy data. Probit models assessed the adjusted marginal effects of patient gender, PCP gender, and their interaction on control, adherence, and intensification. Female patients had lower adjusted rates of LDL-C (46% vs. 55%, p<0.001) and SBP control (52% vs. 60%, p<0.001) than males. Female patients of female PCPs had the highest adjusted rates of HbA1c control of the four patient-physician gender dyads (70% vs. 66%-68%, p<0.05). Male patients were more likely than female patients to receive treatment intensification for high SBP (60% vs. 57%, p<0.001). Female PCPs were more likely than their male counterparts to intensify therapy for hyperlipidemia and hypertension. Patient and physician gender and gender concordance are modestly associated with CVD risk factor control and treatment in diabetes. Further understanding of these differences could lead to improved CVD outcomes for women.

Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study

BackgroundRacial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes.MethodsWe conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control.ResultsThe study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c ≥ 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control.ConclusionIn our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.