The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: A decision analysis
The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: A decision analysis
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DOI：
10.7326/0003-4819-149-1-200807010-00005
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发表时间：
2008-07-01
影响因子：
39.2
通讯作者：
Meltzer, David O.
中科院分区：
文献类型：
--
作者：
Huang, Elbert S.;Zhang, Qi;Meltzer, David O.
背景资料：医生不确定老年糖尿病患者何时进行强化血糖控制。目的：评估合并症和功能状态（通过背景死亡率介导）对强化血糖控制预期获益的影响。设计：决策分析。数据来源：糖尿病和老年病的主要临床研究。目标人群：患者60至80岁的2型糖尿病和不同的预期寿命估计从死亡率指数，在人口水平上得到验证。时间范围：患者寿命。视角：卫生保健系统。干预措施：强化血糖控制（血红蛋白A1 c [HbA 1c]水平为7.0）与中度血糖控制（HbA 1c水平为7.9）。结果测量：并发症发生率和平均质量调整天数的终生差异。基础病例分析结果：不同年龄组的健康老年患者预期强化血糖控制的获益范围为51至116质量调整天数。在每个年龄组中，随着共病和功能障碍水平的增加（死亡指数评分，1 - 26分），强化控制的预期获益稳步下降。对于60至64岁的新发糖尿病患者，获益从基线健康状况良好时的106天（预期寿命，14.6年）下降至44天（3个额外指标点）（预期寿命，9.7年）和8天（7个额外指标点）（预期寿命，4.8年）。类似的收益下降发生在糖尿病病程延长的患者中。敏感性分析结果：采用替代模型假设（如Fragrance模型），强化控制的预期收益随着死亡率指数评分的增加而下降。局限性：缺乏虚弱、老年患者的糖尿病临床试验数据。死亡率指数在预测个体水平的预期寿命方面没有得到验证。强化控制的不良影响没有考虑到consider.Conclusion：在老年糖尿病患者中，存在多种共病或功能障碍是一个更重要的预测有限的预期寿命和减少强化血糖控制的预期效益比单独的年龄。
Background: Physicians are uncertain about when to pursue intensive glucose control among older patients with diabetes.Objective: To assess the effect of comorbid illnesses and functional status, mediated through background mortality, on the expected benefits of intensive glucose control.Design: Decision analysis.Data Sources: Major clinical studies in diabetes and geriatrics.Target Population: Patients 60 to 80 years of age who have type 2 diabetes and varied life expectancies estimated from a mortality index that was validated at the population level.Time Horizon: Patient lifetime.Perspective: Health care system. Intervention: Intensive glucose control (hemoglobin A1c [HbA1c] level of 7.0) versus moderate glucose control (HbA1c level of 7.9).Outcome Measures: Lifetime differences in incidence of complications and average quality- adjusted days.Results of Base-Case Analysis: Healthy older patients of different age groups had expected benefits of intensive glucose control ranging from 51 to 116 quality-adjusted days. Within each age group, the expected benefits of intensive control steadily declined as the level of comorbid illness and functional impairment increased (mortality index score, 1 to 26 points). For patients 60 to 64 years of age with new-onset diabetes, the benefits declined from 106 days at baseline good health (life expectancy, 14.6 years) to 44 days with 3 additional index points (life expectancy, 9.7 years) and 8 days with 7 additional index points (life expectancy, 4.8 years). A similar decline in benefits occurred among patients with prolonged duration of diabetes.Results of Sensitivity Analysis: With alternative model assumptions (such as Framingham models), expected benefits of intensive control declined as mortality index scores increased.Limitations: Diabetes clinical trial data were lacking for frail, older patients. The mortality index was not validated for use in predicting individual- level life expectancies. Adverse effects of intensive control were not taken into account.Conclusion: Among older diabetic patients, the presence of multiple comorbid illnesses or functional impairments is a more important predictor of limited life expectancy and diminishing expected benefits of intensive glucose control than is age alone.