Interplay of Chronic Illness, Race, Age and Sex in Glycemic Control

项目背景：实现血糖控制是最困难的因素， 估计有130万患有糖尿病的VA患者中的许多人的管理。退伍军人管理局 根据绩效衡量标准，与私营部门相比毫不逊色。然而，在这方面， 汇总数据的使用掩盖了退伍军人中血糖控制不足的问题， 年轻人、少数民族和/或有精神健康问题。尽管广泛传播 虽然认识到CCI在糖尿病管理中的重要性，但尚不清楚他们如何 与人口统计学因素（年龄、性别、种族）相互关联，以影响药物依从性， 临床惰性是血糖控制的主要介质。的具体作用 糖尿病持续时间较长的退伍军人胰岛素启动惰性，以及 作为最近发病的退伍军人口服药物的开始和强化 疾病也是未知的。 项目目标：我们的首要目标是评估CCI之间的关系， 不同年龄、性别和性别的退伍军人的人口学因素和血糖治疗 种族/民族团体。我们的具体目标是：（1）评估CCI的差异 与流行和近期发作个体的HbA 1c趋势差异相关 糖尿病(2)为了评估CCI的差异如何与抗- 血糖治疗，包括临床惰性（缺乏药物强化或 增加药物剂量和/或新处方）和糖尿病 药物不依从。(3)评估糖尿病护理中的变化程度 种族/民族群体之间的差异与CCI存在的差异有关。 项目方法：本项目将是一个回顾性分析的动态队列， 从1999年到2006年发现的患有糖尿病的退伍军人，并随访至2009年。我们将 确定普遍的共病情况，并将其指定为“一致”或“不一致” 基于Piette和Kerr开发的概念模型。将进行分析 分别针对患有糖尿病或偶发糖尿病的退伍军人。对于第一个目标， 结果将是重复的个体HbA 1c测量，我们将使用生长曲线 调整季节性以评估个体HbA 1c趋势的模型（随机效应） (i.e.,斜率）。使用分层以及回归，我们将评估的相互作用， CCI和人口统计学变量对HbA 1c趋势的影响。使用考克斯、逻辑和线性 多变量回归模型，我们将评估CCI和种族的关系， 临床惰性和药物依从性。

Project Background: Achieving glycemic control is the most difficult element of management for many of the estimated 1.3 million VA patients with diabetes. The VA compares favorably with the private sector based upon performance measures. However, the use of aggregate data masks inadequate glycemic control among veterans who are younger, of minority status, and/or have mental health conditions. Despite wide-spread recognition of the importance of CCI in diabetes management, it is not known how they inter-relate with demographic factors (age, sex, race) to impact medication adherence and clinical inertia that are the major mediators of glycemic control. The specific role of inertia in insulin initiation in veterans with prevalent diabetes of longer duration, as well as initiation and intensification of oral medication in veterans with more recent onset disease is also not known. Project Objectives: Our overarching aim is to evaluate the relationship between CCI, demographic factors and glycemic treatment in veterans of different age, sex and racial/ethnic groups. Our specific objectives are: (1) To evaluate how differences in CCI are related to differences in HbA1c trends for individuals with prevalent and recent-onset diabetes. (2) To evaluate how differences in CCI are related to differences in anti- glycemic treatment, including both clinical inertia (lack of medication intensification or step up in medication dose and/or new prescription when indicated) and diabetes medication non-adherence. (3) To evaluate the extent to which variation in diabetes care among racial/ethnic groups is related to differences in the presence of CCI. Project Methods: This project will be a retrospective analysis of dynamic cohorts of veterans with diabetes identified from 1999-2006, and followed through 2009. We will identify prevalent co- morbid conditions and assign them as "concordant" or "discordant" based upon a conceptual model developed by Piette and Kerr. Analyses will be conducted separately for veterans with prevalent or incident diabetes. For the first objective, the outcome will be repeated individual HbA1c measurements and we will use growth curve models (random effects) that adjust for seasonality to evaluate individual HbA1c trend (i.e., slope). Using stratification as well as regression, we will evaluate the interaction of CCI and demographic variables on the HbA1c trend. Using Cox, logistic and linear multivariable regression models, we will evaluate the relationship of CCI and race with clinical inertia and medication adherence.