Clinical factors associated with persistently poor diabetes control in the Veterans Health Administration: A nationwide cohort study
Clinical factors associated with persistently poor diabetes control in the Veterans Health Administration: A nationwide cohort study
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DOI：
10.1371/journal.pone.0214679
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发表时间：
2019-03-29
期刊：
影响因子：
3.7
通讯作者：
Crowley, Matthew J.
中科院分区：
文献类型：
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作者：
Alexopoulos, Anastasia-Stefania;Jackson, George L.;Crowley, Matthew J.
持续控制不佳的糖尿病（PPDM）患者尽管参与了基于临床的护理，但糖尿病并发症和费用的风险特别高。了解这一人群的人口统计学、合并症和护理利用率可以指导解决PPDM的策略。我们的特点与PPDM在大样本的退伍军人与2型diabetes.MethodsWe确定了一个队列的退伍军人与药物治疗的2型糖尿病，谁收到退伍军人健康管理局的初级保健在2012年和2013年财政年度。PPDM的定义是2012财年（FY）期间血红蛋白A1 c水平均匀>8.5%，尽管在此期间参与了护理。我们使用2012财年的人口统计学、合并症和药物数据来描述PPDM与控制较好的糖尿病患者的关系，并创建多变量模型来检查临床因素与PPDM之间的关联。我们还构建了多变量模型来探讨PPDM和2013财年护理utilization.ResultsIn我们的糖尿病患者队列（n = 435，820），12%符合PPDM标准之间的关联。PPDM患者比控制较好的患者年轻，已婚的患者较少，黑人/非裔美国人和西班牙裔或拉丁裔/拉丁裔的患者较多。在纳入的合并症中，仅视网膜病变（OR 1.68，95%置信区间（CI）：1.63，1.73）和肾病（OR 1.26，95% CI：1.19，1.34）与PPDM具有临床显著相关性。复合胰岛素方案如预混胰岛素（OR 10.80，95%CI：10.11，11.54）和含餐胰岛素方案（OR 18.74，95%CI：17.73，19.81）与PPDM密切相关。PPDM患者有较高的护理利用率，特别是内分泌护理（RR 3.56，95%CI：3.47，3.66），虽然只有26.4%的患者看到内分泌overall.ConclusionPPDM是密切相关的复杂的糖尿病治疗方案，虽然异质性的护理利用存在。虽然有证据表明利用不足，但现有护理不足也可能导致PPDM。我们的研究结果应告知量身定制的方法，以满足PPDM的需求，他们是最高风险，最高成本的糖尿病患者。
ObjectivePatients with persistent poorly-controlled diabetes mellitus (PPDM) despite engagement in clinic-based care are at particularly high risk for diabetes complications and costs. Understanding this population's demographics, comorbidities and care utilization could guide strategies to address PPDM. We characterized factors associated with PPDM in a large sample of Veterans with type 2 diabetes.MethodsWe identified a cohort of Veterans with medically treated type 2 diabetes, who received Veterans Health Administration primary care during fiscal years 2012 and 2013. PPDM was defined by hemoglobin A1c levels uniformly >8.5% during fiscal year (FY) 2012, despite engagement with care during this period. We used FY 2012 demographic, comorbidity and medication data to describe PPDM in relation to better-controlled diabetes patients and created multivariable models to examine associations between clinical factors and PPDM. We also constructed multivariable models to explore the association between PPDM and FY 2013 care utilization.ResultsIn our cohort of diabetes patients (n = 435,820), 12% met criteria for PPDM. Patients with PPDM were younger than better-controlled patients, less often married, and more often Black/African-American and Hispanic or Latino/Latina. Of included comorbidities, only retinopathy (OR 1.68, 95% confidence interval (CI): 1.63,1.73) and nephropathy (OR 1.26, 95% CI: 1.19,1.34) demonstrated clinically significant associations with PPDM. Complex insulin regimens such as premixed (OR 10.80, 95% CI: 10.11,11.54) and prandial-containing regimens (OR 18.74, 95% CI: 17.73,19.81) were strongly associated with PPDM. Patients with PPDM had higher care utilization, particularly endocrinology care (RR 3.56, 95% CI: 3.47,3.66); although only 26.4% of patients saw endocrinology overall.ConclusionPPDM is strongly associated with complex diabetes regimens, although heterogeneity in care utilization exists. While there is evidence of underutilization, inadequacy of available care may also contribute to PPDM. Our findings should inform tailored approaches to meet the needs of PPDM, who are among the highest-risk, highest-cost patients with diabetes.