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ACEi or ARB Use in Diabetes Mellitus (Types 1 and 2) with CKD in the Military Health System

Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use among Military Health System (MHS) beneficiaries with types 1 and 2 diabetes mellitus and chronic kidney disease (CKD) decreased from 69.7% to 63.6% (age-standardized) between 2016 and 2023. Use was generally higher during the period among adults aged over 60 years (crude) and males (age-standardized).

Data Source: MHS

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ACEi/ARB Use in DM with CKD, Overall

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ACEi/ARB use in Dm with CKD (%) Military Health System
2016	2017	2018	2019	2020	2021	2022	2023
80.4	79.3	78.8	77.6	76.5	76.1	76.2	76.1

ACEi/ARB use in Dm with CKD (%) Military Health System
2016	2017	2018	2019	2020	2021	2022	2023
69.7	68.0	66.8	66.3	64.4	64.1	64.3	63.6

Data includes CKD stages 1–5. Estimates were standardized to the 2010 U.S. Census population for adults.

The Military Health System (MHS) provides comprehensive primary and specialty care for more than 9.6 million active-duty personnel and military retirees and their families worldwide. The MHS Data Repository (MDR) is the administrative claims database for all care received through MHS, including direct care received in military treatment facilities and purchased care received in civilian treatment facilities. The MDR does not capture health care delivery in combat zones or care received in the VHA system. All patients were in the TRICARE Prime managed care option. Data are from both the direct care (military facilities) and private care (private facilities through TRICARE coverage) systems.

De-identified patient data were obtained from the MHS data repository. Data contain both the estimated glomerular filtration rate (eGFR) definition of chronic kidney disease (CKD) and claims-based CKD defined by using ICD-9-CM and ICD-10-CM codes diagnosis codes with at least one inpatient or two outpatient CKD diagnoses. To be included in analyses, service members and their dependents had to have at least one inpatient or outpatient record during the fiscal year (October 1 to September 30). Data cells with 10 or fewer patients were suppressed.

Disclaimer: The views expressed are those of the authors and do not reflect the official policy of the Uniformed Services University, Departments of Army/Navy/Air Force, Department of War, Centers for Disease Control and Prevention, Department of Health and Human Services, or US government.

Field	Data
Description of Measure	Trends in use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) among MHS beneficiaries with diabetes mellitus (types 1 and 2) and chronic kidney disease (CKD) in the Military Health System (MHS).
Data Set	Source files from MHS Data Repository (MDR). ICD Coding: GENESIS Encounter (BDE 3.0, direct care), GENESIS Admission Table (BDE 3.0, direct care), CAPER (direct care outpatient claims), SIDR (direct care inpatient claims), TED-NI (private care outpatient claims), TED-I Header (private care inpatient claims). Laboratories: CDR Chemistry, SIDR, CADRE Laboratory Enhanced, GENESIS Laboratory Results (BDE 3.0), TED-NI (private-sector laboratory claims). Demographics: VM6BEN (demographic information from the Defense Enrollment Eligibility Reporting System), GENESIS Person (BDE 3.0). Medications: PDTS (Pharmacy Data Transaction Service). BDE: Bulk Data extract, CADRE: Comprehensive Ancillary Data Record Extract, CAPER: Comprehensive Ambulatory/Professional Encounter Record, CDR: Clinical Data Repository, GENESIS: name of the MHS EHR, SIDR: Standard Inpatient Data Record, TED-I: TRICARE Encounter Data – Institutional, TED-NI: TRICARE Encounter Data – Non-Institutional.
Population	Beneficiaries aged ≥ 18 years enrolled in the TRICARE Prime or Plus managed care options.
Years Included	Fiscal years 2016–2023 (October 1, 2015–September 30, 2023).
Numerator	MHS beneficiaries in the denominator population with filled ACEi or ARB prescription during each year.
Denominator	MHS beneficiaries aged ≥ 18 years with diagnosed type 1 diabetes or type 2 diabetes mellitus and CKD each year.
Exclusions	Adults with a diagnosis of dialysis or transplant and females with an ICD-10 code for pregnancy during the year were excluded from the denominator.
Definition of CKD and CKD Stages	CKD is defined as having one of the following: (1) one inpatient or two outpatient CKD ICD-10 codes, or (2) an average estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m² over the fiscal year, or (3) an average urine albumin-to-creatinine ratio ≥ 30 mg/g or average urine protein-to-creatinine ratio ≥ 0.15 g/g. CKD stage 1 is an average eGFR ≥ 90 ml/min/1.73 m² who meet the criteria for either CKD ICD-10 codes or abnormal albuminuria/proteinuria. CKD stage 2 is an average eGFR ≥ 60-89 ml/min/1.73 m² who meet the criteria for either CKD ICD-10 codes or abnormal albuminuria/proteinuria. CKD stage 3 is an average eGFR = 30-59 ml/min/1.73 m². CKD stage 4 is an average eGFR = 15-29 ml/min/1.73 m². CKD stage 5 is an average eGFR < 15 ml/min/1.73 m².
Dialysis and Transplant	Beneficiaries with ≥1 inpatient or ≥2 outpatient encounters with ICD-10 codes for dialysis or transplant were excluded.
Definition of Diabetes	Type 1 and type 2 diabetes are determined using the Stanford algorithm (https://phekb.org/phenotype/1506), which uses one encounter with an ICD code for diabetes plus either the presence of prescribed hypoglycemic medications or the presence of abnormal chemistries (random outpatient glucose > 200 mg/dL or hemoglobin A1C ≥ 6.5%).
ICD-10 Codes for CKD	A18.11, A51.44, A52.75, B58.83, C64.X, C65.X, C66.X, C79.0X, C7A.093, D30.0X, D30.1X, D30.2X, D3A.093, D41.0X, D41.1X, D41.2X, D49.511, D49.512, D49.519, D51.1, D86.84, E08.2X, E09.2X, E10.2X, E11.2X, E13.2X, E26.81, E72.0X, E72.53, E83.31, E87.21, E87.22, I12.X, I13.X, I15.0, I15.1, I72.2, I75.81, I77.73, I77.82, I82.3, M32.14, M32.15, M35.04, M35.0A, N02.X, N03.X, N04.X, N05.X, N06.X, N07.X, N08, N11.X, N12, N13.X, N14.X, N15.X, N16, N18.X, N20.X, N21.X, N22, N23, N25.1, N25.89, N25.9, N26.X, N27.X, N28.0, N28.1, N28.81, N28.82, N28.83, N28.84, N28.86, N28.89, N28.9, N29, O10.2X, O10.3X, O26.831, O26.832, O26.833, O26.839, P96.0, Q27.1, Q27.2, Q27.34, Q60.X, Q61.X, Q62.X, Q63.X, Q79.4, Q79.51, R80.1, R80.3, R80.8, R80.9, R82.991, R82.992, R82.993, R82.994, R88.0, T86.1X, Z48.22, Z49.3X, Z52.4, Z85.520, Z85.528, Z85.53, Z85.54, Z87.441, Z90.5, Z94.0 (x stands for all codes within the main diagnosis).
ICD-10 Codes for Dialysis and Transplant	Dialysis: I95.3, R88.0, T81.502A, T81.502D, T81.502S, T81.512A, T81.512D, T81.512S, T81.522A, T81.522D, T81.522S, T81.532A, T81.532D, T81.532S, T81.592A, T81.592D, T81.592S, T82.41XA, T82.41XD, T82.41XS, T82.42XA, T82.42XD, T82.42XS, T82.43XA, T82.43XD, T82.43XS, T82.49XA, T82.49XD, T82.49XS, T85.611A, T85.611D, T85.611S, T85.621A, T85.621D, T85.621S, T85.631A, T85.631D, T85.631S, T85.691A, T85.691D, T85.691S, T85.71XA, T85.71XD, T85.71XS, Y62.2, Y84.1, Z49.01, Z49.02, Z49.31, Z49.32, Z91.151, Z91.158, Z91.A5, Z99.2. Transplant: T86.10, T86.11, T86.12, T86.13, Z48.22, Z94.0. X stands for all codes within the main diagnosis.
ICD-10 Codes for Diabetes	E08.X, E09.X, E10.X, E11.X, E13.X, O24.X, P70.2, Z79.85, Z86.31. X stands for all codes within the main diagnosis.
Estimated Glomerular Filtration Rate (eGFR)	Based on the CKD-EPI (2021) equation for calibrated creatinine: eGFR=142 x [min (serum creatinine in mg/dL) /κ, 1)] α x [max (serum creatinine/κ, 1)] -1.20 x 0.9938age x (1.012 if female). κ = 0.7 if female and 0.9 if male α = -0.241 if female and -0.302 if male = raise to the power
Serum Creatinine	Laboratory measurements taken during outpatient encounters.
Serum Glucose	Laboratory measurements taken during outpatient encounters.
Hemoglobin A1C	Laboratory measurements taken during inpatient or outpatient encounters.
SGLT2i	Bexagliflozin, canagliflozin, dapagliflozin, empagliflozin.
GLP-1 RA	Dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide, tirzepatide.
ACEi/ARB	ACEi: benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril. ARB: azilsartan, candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan.
Hypoglycemic Medications	Insulin Glucagon GLP-1 RA (see above list) Biguanides: metformin Sulfonylureas: glimepiride, glipizide, glyburide Thiazolidinediones: pioglitazone Meglitinides: nateglinide, repaglinide α-glucosidase inhibitor: acarbose, miglitol DPP-4 inhibitors: alogliptin, linagliptin, saxagliptin, sitagliptin, steglujan, tradjenta SGLT2i (see above list)
Age Standardization	Estimates were standardized to the 2010 U.S. Census population for adults: 18–39 years: 37.1%, 40–59 years: 38.1%, 60–69 years: 12.8%, and 70+ years: 12.0%.
Limitations of Indicator	Approximately 36% of adults with type 2 diabetes in the MHS each year do not have a recorded outpatient serum creatinine result, either due to no testing or testing done privately with inaccessible data. Consequently, the denominators would not include adults with undocumented eGFR < 60 mL/min/1.73 m² unless they also had ICD-10 codes for CKD or abnormal albuminuria or proteinuria. The percentage of adults in the denominator with unknown or unmeasured eGFR ranged from 15.5%–26.9%, with the higher numbers in later years mainly due to an increased proportion of beneficiaries seen in the private sector. The percentage of adults in the denominator with missing race declined from 18.1% to 11.1% from 2016 to 2023, while the percentage with unknown race declined from 11.0% to 5.0%.
Analytical Considerations	Published studies define CKD using different serum creatinine criteria, such as single measurements, averages, or persistence over 90 days; comparisons must be made cautiously.
Disclaimer	The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences, the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Departments of the Army, Navy, or Air Force, or the Department of Health and Human Services.