Accounting for Clinical Action Reduces Estimates of Gender Disparities in Lipid Management for Diabetic Veterans

BACKGROUND: Women with diabetes have higher low-density lipoprotein (LDL) levels than men, resulting in apparent disparities between genders on quality indicators tied to LDL thresholds. OBJECTIVE: To investigate whether gender disparities persist when accounting for clinical action with statins or cardiovascular risk. DESIGN: Retrospective cohort study. PARTICIPANTS: Veterans Health Administration patients (21,780 women and 646,429 men) aged 50–75 with diabetes. MAIN MEASURES: Threshold measure: LDL < 100 mg/dL; clinical action measure: LDL < 100 mg/dL; or LDL ≥ 100 mg/dL and the patient was prescribed a moderate or high-dose statin at the time of the test; or LDL ≥ 100 mg/dL and the patient received other appropriate clinical action within 90 days; adherence: continuous multiple interval measure of gaps in dispensed medication (CMG). KEY RESULTS: Women were much less likely to have LDL < 100 mg/dL than were men (55 % vs. 68 %). This disparity narrowed from 13 % to 6 % for passing the clinical action measure (79 % vs. 85 %). These gender differences persisted among those with ischemic heart disease (IHD). Women had a lower odds of passing the clinical action measure (odds ratio 0.68, 95 % confidence interval 0.66–0.71). Among those with IHD, the gender gap increased with age. Differences in pass rates were explained by women’s higher LDL levels, but not by their slightly worse adherence (3 % higher CMG). CONCLUSIONS: Women and men veterans receive more similar quality of care for lipids in diabetes than previously indicated. Less reassuringly, the remaining gender differences appear to be as common in women at high cardiovascular risk as in those at low risk. Rather than focus on simply improving LDL levels in all women with diabetes, future efforts should ensure that patients with high cardiovascular risk are appropriately treated with statins when clinically indicated, feasible, and concordant with patient preferences.