Regional, Geographic, and Racial/ Ethnic Variation in Glycemic Control in a National Sample of Veterans With Diabetes

OBJECTIVE—We performed a retrospective analysis of a national cohort of veterans with diabetes to better understand regional, geographic, and racial/ethnic variation in diabetes control as measured by HbA1c. RESEARCH DESIGN AND METHODS—A retrospective cohort study was conducted in a national cohort of 690,968 veterans with diabetes receiving prescriptions for insulin or oral hypoglycemic agents in 2002 that were followed over a 5-year period. The main outcome meas-ures were HbA1c levels (as continuous and dichotomized at $8.0%). RESULTS—Relative to non-Hispanic whites (NHWs), HbA1c levels remained 0.25 % higher in non-Hispanic blacks (NHBs), 0.31 % higher in Hispanics, and 0.14 % higher in individuals with other/unknown/missing racial/ethnic group after controlling for demographics, type of medication used, medication adherence, and comorbidities. Small but statistically significant geographic differences were also noted with HbA1c being lowest in the South and highest in the Mid-Atlantic. Rural/urban location of residence was not associated with HbA1c levels. For the dichotomous outcome poor control, results were similar with race/ethnic group being strongly associated with poor control (i.e., odds ratios of 1.33 [95 % CI 1.31–1.35] and 1.57 [1.54–1.61] for NHBs and Hispanics vs. NHWs, respectively), geographic region being weakly associated with poor control, and rural/urban residence being negligibly associated with poor control. CONCLUSIONS—In a national longitudinal cohort of veterans with diabetes, we found racial/ethnic disparities in HbA1c levels and HbA1c control; however, these disparities were largely, but not completely, explained by adjustment for demographic characteristics, medica-tion adherence, type of medication used to treat diabetes, and comorbidities. D iabetes affects more than 23 millionAmericans, is the seventh leadingcause of death in the U.S., and is prevalent worldwide (1,2). However, de-spite decades of effective treatments for di-abetes, control rates for the disease remain below goals set by experts (3,4). A number of studies report higher HbA1c levels i