Control of Blood Pressure and Other Cardiovascular Risk Factors at Different Practice Settings: Outcomes of Care Provided to Diabetic Women Compared to Men

Abstract

Cardiovascular disease (CVD) is the major cause of morbidity and mortality in diabetes. To determine the proportion of patients who met the American Diabetes Association guidelines for control of CVD risk factors and to assess the achievement of these guidelines in women compared with men, we conducted a cross‐sectional study of 3678 diabetic cohorts followed at seven medical centers, two Veteran Administration hospitals, three urban clinics, and two suburban clinics. Overall, 28% met the target blood pressure of <130/80 mm Hg, 48.8% achieved a goal low‐density lipoprotein cholesterol of <100 mg/dL, and 35.8% had hemoglobin A1c of <7%. Gender comparisons of 2788 diabetic patients at urban and suburban centers showed that women had a lower percentage of low‐density lipoprotein cholesterol <100 mg/dL (45.8 vs. 51.3, p<0.01) and a lower percentage of screening for retinopathy (54 vs. 60, p<0.01) and nephropathy (37 vs. 49, p<0.01). However, overall there were no gender differences in the percentage of patients who achieved a goal blood pressure <130/80 mm Hg or hemoglobin A1c <7%. Control of blood pressure and other CVD risk factors in diabetic patients was largely suboptimal, especially for diabetic women. These observations underscore the need for better strategies for control of CVD risk in the diabetic population in general, and women in particular.

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes accounting for up to 80% of mortality in this population. ¹ , ² , ³ , ⁴ Risk factors for CVD in type 2 diabetes in the United Kingdom Prospective Diabetes Study (UKPDS) ⁵ were hypertension, hyperglycemia, increased low‐density lipoprotein (LDL) cholesterol, low levels of high‐density lipoprotein (HDL) cholesterol, and smoking. While tight control of blood glucose in both type 1 and type 2 diabetes reduces microvascular complications, its effect on CVD risk is less clear. ⁶ , ⁷ , ⁸ However, rigorous treatment of hypertension reduces both microvascular and macrovascular complications in the diabetic population. ⁹ , ¹⁰ Furthermore, in diabetic patients, aggressive control of dyslipidemia reduces CVD events to an even greater extent than in non‐diabetic persons. ¹¹ , ¹² The use of aspirin has also been shown to reduce CVD events in this patient population. ¹⁰ , ¹³

Diabetic women have a substantially increased relative risk for CVD. ¹⁴ The risk of myocardial infarction is five times greater in diabetic women compared with women without diabetes. ¹⁵ , ¹⁶ Over the past decade, age‐adjusted heart disease mortality declined 27% in nondiabetic women, but increased 23% in women with diabetes. ¹⁵ Whether this is related to the quality of the heath care delivered to diabetic women remains unclear.

There are national guidelines regarding the treatment goals for CVD risk factors in diabetic patients. ¹⁷ , ¹⁸ , ¹⁹ However, apart from small reports, there are no data on the achievement of these goals, particularly in women. ²⁰ , ²¹ Using the American Diabetes Association (ADA) guidelines, we evaluated the care provided to diabetic patients in a representative sample of different clinical practice settings from seven institutions across five US cities with emphasis on the quality of care provided to diabetic women.

STUDY DESIGN

Using a cross‐sectional, multicenter chart review approach, we evaluated the achievement of the ADA guidelines at seven medical centers, representing three different practice systems: Veteran Administration (VA), urban centers (Urban) and suburban institutions (Suburban). The VA hospitals were Brooklyn VA Medical Center, Brooklyn, NY, and Detroit VA Medical Center, Detroit, MI. Urban institutions included Kings County/Woodhull (KCH/WH), two New York City municipal hospitals in Brooklyn, NY, Wayne State University Health Center (WSU‐UHC), Detroit, MI, and Rush‐Presbyterian‐St. Luke's Medical Center, Chicago, IL. Suburban clinics included Staten Island University Hospital (SIUH), Staten Island, NY, and North East Medical Center (NEMC), Concord, NC.

METHODS

Prior to the conduct of the study, institutional review board approval/exemption was obtained at each participating site. Active adult clinic patients with diabetes receiving care between January 2002 and December 2002 were identified using diagnostic billing codes. Patients not seen for over 1 year or followed for less than 1 year were excluded. Medical records of all qualified patients were reviewed and data were extracted on a standardized data collection sheet for all centers and entered into a database using uniform coding at a central location. Unfortunately, data concerning patients' ethnic backgrounds were not consistently available at each center. Therefore, specific data regarding ethnicity were not obtained. We compared the quality of care parameters for diabetic women compared with men followed at the non‐VA institutions (Urban and Suburban centers), where women represented 57% of the population. In this analysis, we excluded the VA hospitals since the vast majority of those patients (93%) were men.

STATISTICAL ANALYSIS

Data were analyzed, using a cross tabulation to examine the proportion of patients at each institution who achieved the stated goals for CVD risk factor control. For categorical variables, chi‐square analysis and for continuous variables, analysis of variance (ANOVA), were performed using general linear model with Tukey's post hoc analysis. Data are presented as mean ± SEM, unless otherwise specified. Analysis was performed using SPSS, version 10 (SPSS, Chicago, IL).

Demographics

The mean age of the entire cohort of 3678 patients was 61.5±0.22. Body mass index (BMI) was 31.2±0.1 kg/m²; 72.2% had a BMI >27 kg/m²; and only 15% of the patients had a normal BMI of <25 kg/m². Women represented 57.5% of the urban and suburban clinics combined (non‐VA) (Table I).

Table I.

Quality of Care Provided for Diabetic Women, Compared With Men, at Urban and Suburban (Non‐VA) Clinics

	Men n=1185 (42.5%)	Women n=1603 (57.5%)	p Value
Age (yr) (mean±SEM)	59.3±0.40	59.8±0.34	NS
BMI (kg/m2)	31.86±0.31	31.89±0.21	NS
% with hypertension	75.6	76.1	NS
HbA1c (%)	7.9±0.08	8.1±0.07	0.01
LDL‐cholesterol (mg/dL)	102±1.2	110±1.2	<0.01
Systolic BP	138±0.84	141±0.64	<0.01
Diastolic BP	78±0.49	78±0.37	NS
BP <130/80 mm Hg (%)	27.3	25.2	NS
BP <120/80 mm Hg (%)	15.7	13.5	NS
BP >160/100 mm Hg (%)	12.7	16.4	0.03
LDL <100 mg/dL (%)	51.3	45.8	<0.01
HbA1c <7% (%)	34.5	32.5	NS
HbA1c >8% (%)	44.4	45.7	NS
Prescribed aspirin or other antiplatelet agents (%)	36.2	35.1	NS
Prescribed ACE inhibitor (%)	57.6	53.3	NS
Prescribed statin (%)	40.3	43.2	NS
Received annual dilated eye exam (%)	60.2	54.2	<0.01
Assessed for nephropathy by urine microalbumin (%) measurement	49.5	37.4	<0.01
Current cigarette smokers (%)	14.8	9.5	<0.01
BMI=body mass index, BP=blood pressure, HbA1c=hemoglobin A1c, LDL=low‐density lipoprotein, ACE=angiotensin‐converting enzyme

Significant differences in age (68±0.37 vs. 58±0.38 vs. 61±0.38 years, p<0.001), and BMI (29.8±0.19 vs. 31.4±0.22 vs. 32.5±0.30, p<0.001) were observed for the VA vs. Urban vs. Suburban institutions, respectively (Table II.)

Table II.

Control of Obesity and Dyslipidemia in Diabetic Patients at Different Clinical Practice Settings

					p Value*
Practice Setting	VA (1)	Urban (2)	Suburban (3)	1 vs. 2 vs. 3	1 vs. 2	1 vs. 3	2 vs. 3
n (%)	889 (24.2)	1500 (40.8)	1289 (35)
Age (yr)
mean±SEM	68±0.37	58±0.38	61±0.38	<0.01	<0.01	<0.01	<0.01
Range	21–96	19–98	13–97
Men (%)	93.2	34.8	50.2	<0.01	<0.01	<0.01	<0.01
Women (%)	6.8	65.5	49.8	<0.01	<0.01	<0.01	<0.01
Type 2 DM (%)	99.1	95.5	82.2	<0.01	<0.01	<0.01	<0.01
BMI (kg/m2)	29.8±0.19	31.4±0.22	32.5±0.30	<0.01	<0.01	<0.01	<0.01
(mean±SEM)
Female	31.2±0.91	32.1±0.28	31.4±0.35	NS	NS	NS	NS
Male	29.8±0.19	29.9±0.35	32.5±0.30	<0.01	NS	<0.01	<0.01
BMI (kg/m2) <25 (n[%])	141(16.4)	166 (16.5)	82 (11.2)	0.04	NS	0.04	0.03
BMI (kg/m2) 25–<27	130 (15.1)	119 (11.8)	83 (11.4)	0.04	0.04	0.03	NS
(n[%])
BMI (kg/m2) 27–30	220 (25.6)	191 (18.9)	131 (17.9)	<0.01	0.01	<0.01	NS
(n[%])
BMI (kg/m2) >30 (n[%])	369 (42.9)	532 (52.8)	434 (59.5)	<0.01	<0.01	<0.01	<0.01
LDL (mg/dL) (mean±SEM)	106±2.6	113±1.3	100±1.0	<0.01	<0.01	0.03	<0.01
n	777	1258	1181
LDL <100 mg/dL (%)	49.9	39.8	56.5	0.03	<0.01	<0.01	<0.01
LDL 101–130 mg/dL (%)	32	30.0	27.0	<0.01	<0.01	0.03	<0.01
LDL 131–160 mg/dL (%)	12.5	18.6	11.1	<0.01	<0.01	0.04	<0.01
LDL >160 mg/dL (%)	5.5	11.5	5.4	<0.01	<0.01	NS	<0.01
HDL mg/dL	42.0±0.47	53.4±0.48	44.5±0.49	<0.01	<0.01	<0.01	<0.01
(mean±SEM)
Men >40 mg/dL (%)	50.5	72.8	64.4	<0.01	<0.01	<0.01	<0.01
Women >40 mg/dL	76.5	84.6	63.8	<0.01	<0.01	<0.01	<0.01
Women >50 mg/dL	39.2	61.4	27.1	<0.01	<0.01	<0.01	<0.01
TG (mg/dL)	155±4.4	146±3.0	168±4.1	<0.01	NS	NS	<0.01
(mean±SEM)
TG <150 mg/dL (%)	63.6	66.7	53.5	<0.01	NS
Non‐HDL cholesterol	162±3.5	179±5.6	175±4.3	NS	NS	NS	NS
(mg/dL) (mean±SEM)
Non‐HDL <130 mg/dL (%)	22.4	16.8	20.9	<0.01	<0.01	NS	<0.01
VA=Veterans Administration; BMI=body mass index; DM=diabetes mellitus; LDL=low‐density lipoprotein; HDL=high‐density lipoprotein; TG=triglycerides; NS=nonsignificant; *significant level of 0.05

Care Provided to Diabetic Women

In the 2788 non‐VA patients, there were no differences in age, BMI, or percentage with hypertension between men and women. Compared with men, women had a higher level of LDL‐cholesterol (mg/dL) (110±1.2 vs. 102±1.2, p<0.01), hemoglobin A1c (%) (8.1±0.07 vs. 7.9±0.08, p=0.01), systolic blood pressure (SBP) (141±0.64 vs. 138±0.84 mm Hg, p<0.01) and lower percentage of LDL <100 (45.8 vs. 51.3 mg/dL, p<0.01). There was a relatively higher percentage of women who had BP >160/100 mm Hg (16.4 vs. 12.7, p=0.03) and a lower percentage referred for an annual dilated eye exam (54.2% vs. 60.2%, p<0.01) and measurement of urinary microalbumin (37.4% vs. 49.5%, p<0.01), compared with men. There was a lower percentage of smoking among diabetic women compared with men (9.5% vs. 14.8%, p<0.01). There was no difference between men and women in the percentage prescribed aspirin, angiotensin‐converting enzyme inhibitors or statins. Also, there was no difference in the percentage of women achieving a goal BP of <130/80 mm Hg, or a target A1c <7%, compared with men (Table I).

LDL‐Cholesterol. Of the 3678 patients, 3216 (87.2%) had a fasting lipid profile assessment, with a mean LDL‐cholesterol of 107±0.90 mg/dL. The mean LDL‐cholesterol was highest (113±1.3) at urban institutions (Table II). A goal LDL‐cholesterol of <100 mg/dL was achieved in nearly half (48.4%) of the patients. Fifty‐seven percent of those who did not achieve the target LDL‐cholesterol of <100 mg/dL were at a range of 101‐130 mg/dL. Urban clinics had the highest percentage of those, with LDL >130 mg/dL and twice the percentage of those with LDL >160 mg/dL, compared with VA and Suburban clinics (11.5 vs. 5.5 vs. 5.4%, p<0.001) (Table II). Of the total cohort, only 14.0% of diabetic patients had LDL‐cholesterol <70 mg/dL. Of those diabetic patients with CVD, only 15.8% had an LDL‐cholesterol <70 mg/dL.

Non‐HDL Cholesterol. The National Cholesterol Education Program, Adult Treatment Panel III goal for non‐HDL cholesterol of <30 mg/dL in diabetic patients who had triglycerides >200 mg/dL was achieved in only 20% of patients with the lowest rate of control (16.8%) at the urban clinic (Table II). ¹⁸

Blood Pressure Control. Of our diabetic cohort, 2820 (76.6%) also had hypertension, based on the diagnostic billing code for the disease. Of those who had hypertension, 2705 (95.9%) had a BP checked in their last clinic visit, which is the one considered in this analysis. Mean SBP was 140±0.4 mm Hg, diastolic BP was 77±0.2 mm Hg, and pulse pressure was 65±0.3 mm Hg. Patients at Urban clinics had a significantly higher SBP and diastolic BP compared with those followed at VA and Suburban institutions (Table III). A target BP of <130/80 mm Hg was achieved in 28% of the patients, with the lowest percentage of patients achieving the target BP at urban clinics (Table III).

Table III.

Blood Pressure, Glycemic Control, and Medication Use by Clinical Practice Setting

					p Value*
Practice Setting	VA (1)	Urban (2)	Suburban (3)	1 vs. 2 vs. 3	1 vs. 2	1 vs. 3	2 vs. 3
n (%)	889 (24.2)	1500 (40.8)	1289 (35)
BP (mm Hg) mean ± SEM
Systolic	140±0.82	144±0.62	133±0.82	<0.01	<0.01	<0.01	<0.01
Diastolic	75±0.46	79±0.34	76±0.49	<0.01	<0.01	NS	<0.01
Pulse pressure	65±0.67	65±0.53	57±0.58	<0.01	NS	<0.01	<0.01
BP<130/80 mm Hg (n[%])	236 (33.3)	252 (21.0)	275 (33.7)	<0.01	<0.01	NS	<0.01
BP<120/80 mm Hg (n[%])	144 (20.3)	133 (11.1)	159 (19.5)	<0.01	<0.01	NS	<0.01
BP>160/100 mm Hg (n[%])	105 (14.8)	235 (19.6)	61(7.5)	<0.01	0.02	<0.01	<0.01
HbA1c (mean±SEM)	7.5±0.006	8.8±0.008	7.1±0.008	<0.01	<0.01	<0.01	<0.01
n (%)	802 (90.2)	1325 (88.3)	1168 (90.6)
HbA1c <7% (n[%])	352 (43.9)	355 (26.8)	474 (40.6)	<0.01	<0.01	NS	<0.01
HbA1c 7%–8% (n[%])	205 (25.6)	219 (16.5)	319 (27.3)	<0.01	<0.01	NS	<0.01
HbA1c 8.1%–9% (n[%])	110 (13.7)	202 (15.2)	174 (14.9)	<0.01	0.04	NS	<0.01
HbA1c >9% (n[%])	135 (16.8)	549 (41.4)	201(17.2)	<0.01	<0.01	NS	<0.01
HbA1c >9.5% (n[%])	91 (11.3)	434 (32.8)	147 (12.6)	<0.01	<0.01	NS	<0.01
Patients prescribed aspirin (%)	45.8	33.5	41.8	<0.01	<0.01	NS	<0.01
Patients prescribed ACE inhibitors (%)	60.6	59.1	43.1	<0.01	NS	<0.01	<0.01
Patients prescribed ARBs (%)	4.8	8.5	13.9	<0.01	<0.01	<0.01	<0.01
Patients prescribed statins (%)	46.3	37.4	56.9	<0.01	<0.01	<0.01	<0.01
Patients with LDL <100 mg/dL prescribed statins (%)	49.7	37.5	63.3	<0.01	<0.01	<0.01	<0.01
Patients LDL >160 mg/dL prescribed statins (%)	58.1	59.3	54.5	NS	NS	NS	NS
Patients receiving a dilated eye exam in the last year (%)	71.3	48.2	80.5	<0.01	<0.01	<0.01	<0.01
Patients screened for microalbuminuria (%)	41.7	28.6	81.6	<0.01	<0.01	<0.01	<0.01
Patients who are current smokers (%)	17.3	10.8	13.7	<0.01	<0.01	<0.01	<0.01
VA=Veterans Administration; BP=blood pressure; HbA1c=hemoglobin A1c; ACE=angiotensin‐converting enzyme; ARB=angiotensin receptor blocker; LDL=low‐density lipoprotein; NS=nonsignificant; *significant level of 0.05

Sixteen percent of the patients had a normal BP of <120/80 mm Hg, as defined by JNC 7 ¹⁹ criteria, while nearly 15% of the cohort had stage II hypertension of >160/100 mm Hg. The highest percentage of patients in the later category was seen at the urban institutions.

Glycemic Control. Ninety percent of the patients had A1c measured with a mean value of 8.0±0.01. The highest A1c (8.8±0.01) was seen at the Urban centers, followed by the VA centers (7.5±0.01), and the lowest (7.1±0.01) at the Suburban centers (Table III).

While over 40% of patients followed at the VA and Suburban centers achieved a target A1c value of <7%, only 26.8% of those followed at Urban centers achieved this treatment goal (Table III). Of the patients followed at Urban centers, 41.4% had A1c values of >9% compared with only 17% of those followed at either VA or Suburban centers.

Antiplatelet Agents. Only 38.7% of the total diabetic cohort had documentations in the medical records for aspirin use. The percentage of patients on aspirin in the Urban, Suburban and VA centers were 33.5%, 41.8%, and 45.8% respectively, (p<0.01).

Antihypertensive Agents. The diabetic patients reviewed required an average of 2.9 medications to achieve a BP goal of <130/80 mm Hg. Those with stage 1 hypertension were receiving 1.9 medications and those with stage 2 hypertension received 2.3 medications, on average. There were 56.7% patients on angiotensin‐converting enzyme inhibitors, 31.4% on calcium channel blockers, 26.9% on diuretics, 20.2% on a p‐blocking agent, and 8.4% on angiotensin receptor blockers. The percentage of patients on α‐blocking agents, centrally acting, and direct vasodilating agents were 6.4, 2.9, and 1.1, respectively.

Lipid‐Lowering Drugs. Of the entire cohort, 43.6% were on statins, and in those who had LDL‐cholesterol >100 mg/dL, only 47.3% were prescribed statins. The percentage of statin use was 49.7%, 37.5%, and 63.3%, p<0.001 at VA, Urban, and Suburban centers, respectively. Of patients with LDL cholesterol of >160 mg/dL, only 58.4% were prescribed statins.

Dilated Eye Exam. Sixty‐one percent of our diabetic cohort had received a dilated eye exam within the previous year; 71.3%, 48.2%, and 80.5%, p<0.001, for VA, Urban, and Suburban clinics respectively (Table III).

Microalbuminuria. Of the total study population, only 42% were screened for nephropathy by urine microalbumin measurements within the previous year; 41.7%, 28.6%, and 81.6%, p<0.001 for the VA, Urban, and Suburban centers, respectively (Table III).

Smoking. The highest number of patients who were current smokers were those at VA centers (13.3%), 17.3% vs. 10.8% vs. 13.7%, p<0.01, for VA, Urban, and Suburban centers respectively (Table III). Surprisingly, patients at the urban centers had the lowest rate of smoking.

Comprehensive Care. Only 4.2% of patients met the combined ADA goal for BP, LDL cholesterol and A1c. ¹⁷

DISCUSSION

Our data indicate that women with diabetes had less favorable outcomes compared with diabetic men. Despite identical age, BMI, and percentage of hypertension among women and men with diabetes in our cohort, diabetic women had higher Alc, LDL‐cholesterol, and SBP compared with men. The percentage of women who achieved LDL cholesterol goal of <100 mg/dL was significantly lower than men. Women also had a higher percentage of stage 2 hypertension, with BP of >160/100 mm Hg, and they were less likely to receive an annual eye exam or albuminuria determination compared with men. However, it is important to emphasize that control of BP to <130/80 mm Hg, hemoglobin A1c <7%, and the use of statins and angiotensin‐converting enzyme‐inhibitors were not different in men and women. Furthermore, the higher percentage of women with BP >160/100 is primarily resulting from an overall higher BP in the Urban cohort and tends to distort the overall data.

Nevertheless, our data support the notion that CVD risk factors are treated less aggressively in women compared with men. ²² Given the higher CVD risk in this group, as suggested by several major trials, ²³ , ²⁴ the rising mortality of CVD in diabetic women compared with their nondiabetic counterparts viable strategies for aggressive control of CVD risk factors in women with diabetes need to be developed. ¹⁴ , ¹⁵ , ¹⁶

The entire cohort of diabetic patients from seven medical centers in four distinct geographical locations was predominately obese, dyslipidemic, and hypertensive (75%), underlying the high prevalence of the metabolic syndrome in people with diabetes. ³ Control of hypertension to a target BP of 130/80 mm Hg was only achieved in 28% of patients with no significant improvement from previously published data. ²⁵ , ²⁶ Urban centers had the poorest control of BP with only one in five patients achieving the goal of 130/80 mm Hg.

Compared with data from National Health and Nutrition Examination Survey (NHANES) III ²⁶ (1991–1994), our study shows no significant improvement in the control of hyperglycemia, with only 35% of the patients achieving a goal A1c <7%. The NHANES report, however, was derived from a much smaller sample (733 patients) than ours. ²⁶ Comparing current data to our previously published report, ²⁵ there was a significant increase in the percentage of patients achieving A1c <7% (35.8% vs. 26.7% reported 2 years ago). Nevertheless, the overall glycemic control remains very low especially at the Urban centers.

Despite improvement in lipid control suggested by our current data, relative to our prior data and other previously published data, lipid management in the diabetic patients remains suboptimal with only half of the patients achieving a target LDL <100 mg/dL. Several randomized controlled trials have shown that treatment with statins or fibrates significantly reduced CVD events in diabetic patients. ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ Less than half of the patients who did not meet ADA guidelines of LDL <100 mg/dL, were being treated with statins and only 3.8% received a fibrate. ¹⁷ A goal non‐HDL cholesterol of <130 mg/dL in diabetic persons, as recommended as a treatment target by NECP‐ATPIII ¹⁸ was achieved in only 20% of the cohort. Non‐HDL has been shown to be a strong predictor of CVD risk in diabetic patients. ³¹ Our data are the first to examine the achievement of this newly recommended goal, serving as a reference point for future studies. Considering the revised recommendations by NCEP‐ATPIII, with LDL‐cholesterol treatment goal of <70 mg/dL in very high‐risk patients, only 15.8% of diabetic patients with previous CVD events achieved such a goal. ³²

The lower percentage of cigarette smoking (13%) in our cohort compared with NHANES III data, where 22% of diabetic patients were smokers, reflects significant improvement and translation of the ADA guidelines into practice. ¹⁷ , ²⁶

Patients followed at Urban institutions tended to have the poorest outcome in terms of lipid, glycemic, and hypertension control. Our Urban population consistently had a lower rate of measurement of microalbuminuria and referral for a dilated eye exam compared with patients followed at VA and suburban centers. Our study also confirms the results of our previous data from 1999–2000 showing improved care among patients followed at VA hospitals. ²⁵ This observation is in contrast to previously published data suggesting suboptimal care in smaller cohorts at these centers. ³³ , ³⁴ Indeed, results of the current study indicate better achievement of guidelines at the VA hospitals compared with urban institutions and a more favorable outcome of glycemic control compared with suburban centers.

Finally, the overall poor control of CVD risk factors in diabetic patients suggested by this chart review analysis seems to be generalized among various centers, consistent with reports from several institutions in developed countries around the world. ³⁵ , ³⁶ , ³⁷ Collectively, these findings indicate that access and utilization of medical care is not the only issue in achievement of recommended treatment goals, suggesting that CVD risk factors may be inherently difficult to treat in diabetic patients with the currently available tools. Diabetes is generally perceived as a more difficult condition to manage even in the setting of controlled trials. ³⁸ For example, in the United Kingdom Prospective Diabetes Study (UKPDS), ³⁸ long‐term follow‐up showed only a small difference in the mean A1c between the intensively treated and the control group. Other reports also suggest that the specialty of the physicians has little impact on the quality of care such as BP control, glycemic control, and albuminuria. ³⁹ However, better control achieved in VA centers and relatively poor control in Urban centers may provide clues regarding treatment strategies that are more or less successful in this population. Further, our data suggest that more aggressive strategies are especially needed for reduction of CVD risk factors in women with diabetes.

Despite the limitations inherent to the crosssectional design of our study and the lack of specific data on race or ethnicity, the indices of quality of care in our study are sufficiently low as to highlight the compelling need for improved care across all institutions. The fact that <5% of the patients met the combined ADA goals for A1c, BP, and LDL‐cholesterol is alarming, confirming our previous report, as well as reports by other groups. ²⁵ , ⁴⁰ For example, in a statewide study involving 3460 high‐risk hypertensive patients from 57 primary care providers, control of hypertension, hyperlipidemia, and hyperglycemia were achieved only in 6.6% of diabetic patients. ⁴⁰ Our current data are also consistent with nationally representative data from NHANES ⁴¹ survey 1999–2000, where only 7.3% of US adults with diabetes met the A1c goal of <7%, BP<130/80 mm Hg, and total cholesterol <200 mg/dL. ⁴¹

Acknowledgment. The work was supported by grants from the NIH (RO1‐HL63904‐01), the VA Merit Award, and the American Diabetes Association (to J.R.S.) and by grant support for the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medications (DREAM) study from the Population Health Research Institute (PHRI) at McMaster University (Hamilton, Ontario, Canada) and BIRCWH grant K12HD043428 from the NIH to S.I.M., J.J.S., and J.R.S.