Associations between attainment of incentivized primary care indicators and incident lower limb amputation among those with type 2 diabetes: a population-based historical cohort study.
Associations between attainment of incentivized primary care indicators and incident lower limb amputation among those with type 2 diabetes: a population-based historical cohort study.
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DOI：
10.1136/bmjdrc-2020-002069
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发表时间：
2021-04
影响因子：
4.1
通讯作者：
McKay AJ
中科院分区：
文献类型：
--
作者：
Gunn LH;Vamos EP;Majeed A;Normahani P;Jaffer U;Molina G;Valabhji J;McKay AJ
英国通过质量和结果框架 (QOF) 和国家糖尿病审计 (NDA) 等项目在糖尿病护理方面投入了大量资金。计划指标与截肢等临床终点之间的关联仍不清楚。我们研究了初级保健指标与下肢截肢事件之间的关联。这项基于人群的回顾性队列研究涵盖 2010 年至 2017 年，研究对象为英格兰患有 2 型糖尿病且无下肢截肢史的成年人。基线（2010-2011）的暴露是QOF糖化血红蛋白（HbA1c）、血压和总胆固醇指标的达到情况，以及完成的NDA流程的数量。进行倾向评分匹配，并使用每次暴露的匹配样本拟合多变量 Cox 比例风险模型，调整疾病相关、合并症、生活方式和社会人口统计学因素。来自 330 个英国初级保健机构的 83 688 人被纳入其中。平均随访时间为 3.9 (SD 2.0) 年，观察到 521 例 (0.6%) 小截肢或大截肢（每 1000 人年 1.62 例）。 HbA1c 和胆固醇指标的达到与小截肢或大截肢的风险显着降低相关（调整后的 HR；95% CI）分别为 0.61（0.49 至 0.74；p<0.0001）和 0.67（0.53 至 0.86；p=0.0017）。没有观察到血压指标达到与截肢之间存在关联的证据（调整后的 HR 0.88（0.73 至 1.06；p=0.1891））。在完成较多 NDA 护理流程的患者中观察到截肢率显着降低（调整后的 HR 为 0.45（0.24 至 0.83；p=0.0106）、0.67（0.47 至 0.97；p=0.0319）和 0.38（0.20 至 0.70；p=0.0022），与 4-6 组相比分别为 0-3、7-9 与 0-3、7-9 与 4-6 过程）。仅主要截肢的 HbA1c 和血压结果相似，但胆固醇指标达到情况并不显着。以综合初级保健为基础的二级预防可以为糖尿病相关截肢提供相当大的保护。这对于糖尿病管理和患者医疗决策以及 2 型糖尿病质量改善计划具有重要意义。
England has invested considerably in diabetes care through such programs as the Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA). Associations between program indicators and clinical endpoints, such as amputation, remain unclear. We examined associations between primary care indicators and incident lower limb amputation. This population-based retrospective cohort study, spanning 2010–2017, was comprised of adults in England with type 2 diabetes and no history of lower limb amputation. Exposures at baseline (2010–2011) were attainment of QOF glycated hemoglobin (HbA1c), blood pressure and total cholesterol indicators, and number of NDA processes completed. Propensity score matching was performed and multivariable Cox proportional hazards models, adjusting for disease-related, comorbidity, lifestyle, and sociodemographic factors, were fitted using matched samples for each exposure. 83 688 individuals from 330 English primary care practices were included. Mean follow-up was 3.9 (SD 2.0) years, and 521 (0.6%) minor or major amputations were observed (1.62 per 1000 person-years). HbA1c and cholesterol indicator attainment were associated with considerably lower risks of minor or major amputation (adjusted HRs; 95% CIs) 0.61 (0.49 to 0.74; p<0.0001) and 0.67 (0.53 to 0.86; p=0.0017), respectively). No evidence of association between blood pressure indicator attainment and amputation was observed (adjusted HR 0.88 (0.73 to 1.06; p=0.1891)). Substantially lower amputation rates were observed among those completing a greater number of NDA care processes (adjusted HRs 0.45 (0.24 to 0.83; p=0.0106), 0.67 (0.47 to 0.97; p=0.0319), and 0.38 (0.20 to 0.70; p=0.0022) for comparisons of 4–6 vs 0–3, 7–9 vs 0–3, and 7–9 vs 4–6 processes, respectively). Results for major-only amputations were similar for HbA1c and blood pressure, though cholesterol indicator attainment was non-significant. Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.
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影响因子：
168.9
作者：
Dormandy, JA;Charbonnel, B;Taton, J
通讯作者：
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