Aspirin Use and Counseling About Aspirin Among Patients With Diabetes SARAH L. KREIN, PHD, RN 1,2,3 SANDEEP VIJAN, MD, MS 1,2,3 LEONARD M. POGACH, MD, MBA 4,5 MARY M. HOGAN, PHD, RN 1 EVE A. KERR, MD, MPH 1,2 OBJECTIVE — Despite being a safe, effective therapy for lowering cardiovascular risk, only 20% of diabetic patients were using aspirin in the early 1990s. This study examines current physician practices and the use of aspirin therapy by individuals with diabetes. RESEARCH DESIGN AND METHODS — A random sample of diabetic patients re- ceiving care in the Department of Veterans Affairs health care system were surveyed during January-March 2000. The association between aspirin counseling, aspirin use, and reported coronary vascular disease (CVD) and classical CVD risk factors were examined using logistic regression. The effect of increasing aspirin use on risk of myocardial infarction (MI) and cardio- vascular mortality was demonstrated by simulation. RESULTS — Seventy-one percent of respondents reported being counseled about aspirin use, and 66% were taking daily aspirin. Individuals with known CVD were more likely to be coun- seled (odds ratio [OR] 4.9, 95% CI 2.9 – 8.1) and to use aspirin (2.1, 1.2–3.7). The factor most strongly associated with aspirin use was having been counseled about aspirin therapy by a doctor. We estimate that for this population, increasing daily aspirin use to 90% could prevent an additional 11,000 MIs and potentially save 8,000 lives. CONCLUSIONS — Compared with previous reports, a substantial proportion of these di- abetic patients have been counseled about and use aspirin. Most clinicians recognize aspirin as an important treatment for patients with preexisting coronary disease. However, since diabetes is now considered a CVD equivalent, it is imperative that clinicians include counseling about aspirin therapy as a care priority for all their diabetic patients, as this simple intervention may prevent many cardiovascular events and deaths. Diabetes Care 25:965–970, 2002 C ardiovascular disease is the leading cause of complications and death in people with diabetes (1–3). Middle- aged diabetic subjects are at two to four times higher risk of macrovascular disease (including coronary artery disease, stroke, and peripheral vascular disease) and overall mortality compared with sim- ilar nondiabetic individuals (4 – 8). Due to this elevated risk, the use of proven cardiovascular preventive therapies is im- perative for individuals with diabetes. Perhaps the easiest, safest, and least expensive preventive practice is the use of aspirin (9 –12). Research shows that aspi- rin therapy is effective for both primary and secondary prevention of cardiovascu- lar events and cardiac mortality (9 – 11,13–16). Studies also suggest that individuals with diabetes receive the same relative benefit from aspirin use as those without diabetes, (9,11,14,16) but due to their markedly higher baseline risk, the absolute benefit of aspirin therapy may be two to four times higher. In addition, as- pirin therapy does not increase risk of ret- inal or vitreous hemorrhage and can be safely used in patients with diabetes who do not have other contraindications (e.g., allergy, bleeding tendency, anticoagulant therapy, active liver disease) (12,16). In 1997, the American Diabetes Asso- ciation (ADA) published its first recom- mendations for the use of low-dose aspirin therapy as a secondary prevention strategy or for primary prevention in high-risk diabetic patients (e.g., individ- uals with high blood pressure) (12,17). In their January 2000 publication, the ADA explicitly recommended using aspirin as a primary prevention strategy not only for individuals with specific risk factors but for anyone with diabetes who is 30 years of age and has no known contrain- dications (18). Despite evidence of the benefits of as- pirin use and specific recommendations by the ADA, studies suggest that this im- portant intervention may be underused, especially for primary prevention (19 – 22). Estimates of the use of aspirin as a secondary prevention strategy range from 37% of the U.S. adult population with di- abetes and known coronary vascular dis- ease (CVD) to 62% of Medicare beneficiaries with diabetes discharged af- ter an acute myocardial infarction (MI) to 63% of patients with one or more macro- vascular complication who are attending the outpatient diabetes clinics of a large public hospital (20,21,23). On the other hand, only 13% of adults with diabetes who had one or more CVD risk factors but no established CVD were taking aspirin on a regular basis during 1988 –1994 (20). Although this previous research points to the potential need for more ag- gressive interventions to promote the use of aspirin among patients with diabetes, especially those without known cardio- ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Department of Veterans Affairs’ Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; the 2 Department of Internal Medicine, University of Mich- igan, Ann Arbor, Michigan; the 3 Michigan Diabetes Research and Training Center, Ann Arbor, Michigan; the 4 VA New Jersey Healthcare System, East Orange, New Jersey; and the 5 University of Medicine and Dentistry of New Jersey, Newark, New Jersey. Address correspondence and reprint requests to Sarah L. Krein, Ann Arbor VA HSR&D, P.O. Box 130170, Ann Arbor, MI 48113. Hand-delivered mail must be sent to 24 Frank Lloyd Wright Dr., 3rd floor, Lobby L, Ann Arbor, MI 48106. E-mail: skrein@umich.edu. Received for publication 14 November 2001 and accepted in revised form 21 February 2002. Abbreviations: CVD, coronary vascular disease; DQIP, Diabetes Quality Improvement Project; MI, myocardial infarction; OR, odds ratio; VA, Veterans Affairs; VISN, veterans integrated service network. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. Clinical Care/Education/Nutrition O R I G I N A L A R T I C L E DIABETES CARE, VOLUME 25, NUMBER 6, JUNE 2002 965