ORIGINAL ARTICLE Risk of Coronary Artery Disease in Type 2 Diabetes and the Delivery of Care Consistent With the Chronic Care Model in Primary Care Settings A STARNet Study Michael L. Parchman, MD,*† John E. Zeber, PhD,*‡ Raquel R. Romero, MD,*† and Jacqueline A. Pugh, MD*§ Background: Modifiable risks for coronary heart disease (CHD) in type 2 diabetes include glucose, blood pressure, lipid control, and smoking. The chronic care model (CCM) provides an organizational framework for improving these outcomes. Objective: To examine the relationship between CHD risk attribut- able to modifiable risk factors among patients with type 2 diabetes and whether care delivered in primary care settings is consistent with the CCM. Subjects/Methods: Approximately 30 patients in each of 20 pri- mary care clinics. CHD risk factors were assessed by patient survey and chart abstraction. Absolute 10-year CHD risk was calculated using the UK Prospective Diabetes Study risk engine. Attributable risk was calculated by setting all 4 modifiable risk factors to guideline indicated values, recalculating the risk, and subtracting it from the absolute risk. In each clinic, the consistency of care with the CCM was evaluated using the Assessment of Chronic Illness Care (ACIC) survey. Results: Only 15.4% had guideline-recommended control of A1c, blood pressure, and lipids. The absolute 10-year risk CHD was 16.2% (SD 16.6). One-third of this risk, 5.0% (SD 7.4), was attributable to poor risk factor control. After controlling for patient and clinic characteristics, the ACIC score was inversely associated with attributable risk: a 1 point increase in the ACIC score was associated with a 16% (95% CI, 5–26%) relative decrease in attributable risk. Discussion: The degree to which care delivered in a primary care clinic conforms to the CCM is an important predictor of the 10-year risk of CHD among patients with type 2 diabetes. Key Words: primary care, type 2 diabetes, chronic disease, myocardial infarction, organization of care (Med Care 2007;45: 1129 –1134) P eople with type 2 diabetes are at considerable risk of excessive morbidity and mortality from coronary heart disease (CHD). 1 Although there has been a decline in the rate of incident CHD events among adults with diabetes, the absolute risk of CHD is 2-times higher than among patients without diabetes. 2 Multiple risk factors for CHD among patients with type 2 diabetes have been identified including control of glucose, blood pressure (BP), and lipids, as well as smoking status. 3 Additional risk factors for CHD include age, race/ethnicity, duration of diabetes, and gender. These latter factors may be considered fixed, although the former risk factors are potentially modifiable. Current clinical practice guidelines recommend the following target levels for potentially modifiable risk factors: A1c 7.0 mg%; BP 130/80 mm Hg; and low-density lipoprotein cholesterol 100 mg/dL (if no documented heart disease). 4 Despite wide dissemination of evidence-based guidelines and the availability of new therapeutic classes of medications, there has been little improvement in CHD risk factors, specifically A1c and BP control, and only small improvements in lipid control among people with type 2 diabetes over the past decade. 5 Thus, a wide gap exists between established evidence for control of these risk factors and what is actually achieved in the setting where most patients with type 2 diabetes receive their diabetes care: the primary care clinic. Several approaches to improving the care of patients with a chronic illness have been developed including, most notably, the chronic care model (CCM). The CCM suggests that the presence of 6 specific organizational characteristics should result in improvements in outcomes for patients with From the *Veterans Affairs HSR&D, South Texas Veterans Health Care System (VERDICT); and Departments of †Family and Community Medicine, ‡Psychiatry, and §Medicine, University of Texas Health Science Center, San Antonio, Texas. Supported by the Agency for Healthcare Research and Quality (Grant #K08 HS013008-02) and the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Presented in part at the 2005 PBRN Research Conference sponsored by the Agency for Healthcare Research and Quality, Washington, DC. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Reprints: Michael Parchman, MD, VERDICT Center (11C6), South Texas Veterans Health Care System, Audie L. Murphy Division, 7400 Merton Minter Boulevard, San Antonio, TX 78229-4404. E-mail: parchman@ uthscsa.edu. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 0025-7079/07/4512-1129 Medical Care • Volume 45, Number 12, December 2007 1129