Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment.
Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment.
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DOI：
10.1161/circoutcomes.112.966697
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发表时间：
2013-01-01
期刊：
影响因子：
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通讯作者：
Diabetes Clinical Action Measures Workgroup
中科院分区：
文献类型：
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作者：
Beard AJ;Hofer TP;Downs JR;Lucatorto M;Klamerus ML;Holleman R;Kerr EA;Diabetes Clinical Action Measures Workgroup
仅强调治疗达标方法的性能指标可能会促使高剂量他汀类药物过度治疗，可能导致不良事件和不必要的费用。我们开发了一种用于糖尿病患者脂质管理的临床行动性能指标，旨在鼓励使用中等剂量他汀类药物进行适当治疗，同时尽量减少过度治疗。我们检查了2010年7月至2011年6月期间964，818名年龄≥ 18岁的糖尿病患者的VA初级保健数据。我们定义了3个条件为成功满足50-75岁患者的临床行动措施：1）LDL < 100 mg/dL; 2）接受中等剂量他汀类药物治疗，无论LDL水平或测量结果如何;或3）如果LDL > 100 mg/dL，则接受适当的临床行动（开始，转换或加强他汀类药物治疗）。我们通过检查没有缺血性心脏病的患者中使用高剂量他汀类药物的比例，来检查18岁及以上患者可能的过度治疗。然后，我们使用两个层次的多变量logistic模型研究了881个设施的测量实现的变异性。在668，209例年龄在50-75岁的糖尿病患者中，84.6%通过了临床行动措施：67.2%的LDL <100 mg/dL; 13.0%的LDL >=100 mg/dL并接受中等剂量他汀类药物（7.5%）或适当的临床行动（5.5%）; 4.4%的LDL指数至少接受中等剂量他汀类药物。在年龄≥ 18岁的整个队列中，13.7%可能是过度治疗。满足当前阈值测量（LDL <100 mg/dL）的比率较高的设施具有较高的潜在过度治疗率（p <0.001）。使用一个性能指标，信贷适当的临床行动表明，几乎85%的糖尿病退伍军人年龄50-75正在接受适当的血脂异常管理。然而，许多患者可能过度使用高剂量他汀类药物。
Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes that is designed to encourage appropriate treatment with moderate dose statins while minimizing overtreatment. We examined data from July 2010 to June 2011 for 964,818 active VA primary care patients >=18 years with diabetes. We defined 3 conditions as successfully meeting the clinical action measure for patients 50-75 years old: 1) LDL < 100 mg/dL; 2) On a moderate dose statin, regardless of LDL level or measurement; or 3) If LDL > 100 mg/dL, received appropriate clinical action (starting, switching or intensifying statin therapy). We examined possible overtreatment for patients 18 and older by examining the proportion of patients without ischemic heart disease who were on a high dose statin. We then examined variability in measure attainment across 881 facilities using two level hierarchical multivariable logistic models. Of 668,209 patients with diabetes aged 50-75 years, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL; 13.0% with LDL >=100 mg/dL and on either a moderate dose statin (7.5%) or with appropriate clinical action (5.5%); and 4.4% with no index LDL on at least a moderate dose statin. Of the entire cohort aged >=18 years, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (p <0.001). Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic Veterans aged 50-75 are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high dose statins.