Costs and consequences of tight glycemic control in diabetic patients

描述(由申请人提供)： 项目背景：“严格控制血糖”在10年内减少微血管事件的益处是基于UKPDS试验。一项流行病学随访表明，在20年期间，微血管和大血管并发症的改善存在关联。然而，最近的一项前瞻性队列研究表明，在较新发病的疾病中加强血糖控制对心血管的好处可能仅限于疾病负担较低的个人。VADT和ACCORD研究表明，糖尿病病程较长的患者发生低血糖的几率和风险增加。这样的患者仍然比许多退伍军人更健康，这些退伍军人除了糖尿病之外，还有重大的疾病负担。总体而言，在患有其他慢性复杂疾病的患者中，严格控制血糖的相对风险和好处，特别是使用较新的药物，一直未得到充分研究。项目目的为了了解这些新药在VHA糖尿病人群中的价值，我们打算通过采用疾病控制中心的糖尿病结局模型来开发VHA特定的新发糖尿病严格血糖控制模型。这项试点研究的目标是制定一种新的方法，以制定这样一种成本效益模型，其中纳入以下具体目标1至3的投入。在25岁至年龄段新诊断为糖尿病的退伍军人中，我们将：目标1：评估医疗资源利用率和为退伍军人提供糖尿病相关门诊护理的成本，无论是否患有慢性复杂疾病。我们将根据协调性和不协调性并存的慢性复杂疾病的存在来评估不同患者组在使用和费用方面的差异。目标2：评估有和没有慢性复杂疾病的退伍军人糖尿病相关并发症的住院护理的医疗利用和费用。并发症包括大血管、微血管和代谢并发症。目标3：在患有不和谐疾病的退伍军人中，我们将专门探讨患有精神疾病和/或药物滥用的退伍军人的住院和门诊利用情况以及费用，因为这些患者可能需要更多的重症监护来实现严格的血糖控制。项目方法我们将使用利用2003财年和2004财年VHA数据开发的糖尿病流行病学队列(DEPIC)来评估新近诊断为糖尿病的退伍军人在住院和门诊环境中的资源利用情况，使用现有的最新诊断和II型糖尿病的定义。慢性复杂性疾病将被分类为1)无CCI；2)仅和谐状况；3)仅不和谐状况；4)既和谐又不和谐的慢性复杂疾病。分类将以ICD-9和CPT代码为基础，使用在该研究小组内制定的经过验证和确定的协议。成本将从卫生经济资源中心的平均成本数据中得出，以便对提供糖尿病护理、在门诊环境中管理糖尿病并发症以及在住院环境中管理糖尿病并发症的成本进行估算。

DESCRIPTION (provided by applicant): Project Background: The benefit of "tight glycemic control" in decreasing microvascular events over a 10 year period is based upon the UKPDS trial. An epidemiological follow-up demonstrates an association with improved microvascular and macrovascular complications over a 20 year period. However, a recent prospective cohort study suggests that the cardiovascular benefit of tighter glycemic control in more recent onset disease may be limited to individuals with a lower illness burden. The VADT and ACCORD studies demonstrate an increasing rate and risk of hypoglycemia in patients with a longer duration of diabetes. Such patients are still healthier than many veterans who have significant comorbid disease burdens alongside diabetes. Overall, the relative risks and benefits of tight glycemic control, especially with newer medications, have been understudied in patients with additional chronic complex diseases. Project Objectives In order to understand the value of these newer medications on the VHA diabetes population, we intend to develop a VHA specific model of tight glycemic control for new onset diabetes by adapting the Centers for Disease Control Diabetes Outcomes model. The goal of this pilot study is to develop new methodology for developing such a cost-effectiveness model incorporating inputs from specific aims 1 to 3 below. Among veterans aged 25-64 years with newly diagnosed diabetes, we will: Aim 1: Evaluate healthcare resource utilization and costs associated with the provision of diabetes-related outpatient care to veterans, with and without chronic complex illnesses. We will evaluate differences in utilization and costs among patient groups according to the presence of concordant and discordant co-morbid chronic complex illnesses. Aim 2: Evaluate healthcare utilization and costs associated with inpatient care for diabetes-related complications in veterans, with and without chronic complex illnesses. Complications include macrovascular, microvascular and metabolic complications. Aim 3: Among veterans with discordant illnesses, we will specifically explore inpatient and outpatient utilization and costs for veterans with mental illness and/or substance abuse as these patients may require more intensive care to achieve tight glycemic control. Project Methods We will use the Diabetes Epidemiology Cohort (DEpiC), developed using VHA data for FY 2003 and FY 2004, to evaluate resource utilization in the inpatient and outpatient settings for veterans with recently diagnosed diabetes, using existing definitions of recent diagnosis and type II diabetes. Chronic complex illness will be categorized as 1) no CCI; 2) concordant conditions only; 3) discordant conditions only; 4) both concordant and discordant chronic complex illnesses. Categorization will be based on ICD-9 and CPT codes, using a validated and established protocol developed within this research group. Costs will be developed from Health Economics Resource Center average cost data, in order to develop estimates of costs of delivering diabetes care, managing diabetes complications in the outpatient setting and managing diabetes complications in the inpatient setting.