Component A: A multi-level study of community context and type 2 diabetes and coronary heart disease using electronic health record and new primary data across nested geographies in Pennsylvania

项目摘要 在美国，2型糖尿病是第六大主要死亡原因，主要是由于心脏新陈代谢 并发症，如冠心病(CHD)。T2D的患病率从不到4%到近18%不等 在全国各地的县。地理上的差异可以部分地用几个地点级别来解释 环境因素，但县级指标解释的差异比例因地区而异。为 例如，虽然主要是社会经济、种族/族裔和建立的九项县级措施的组合 环境特征可以解释中西部T2D患病率高达94%的变化，这些相同 包括宾夕法尼亚州(宾夕法尼亚州)在内的大西洋中部各县的差异很小。我们的研究 重点关注我们假设会影响PA的T2D和CHD结果的四个背景领域：慢性 环境污染、社会环境、食物环境和身体活动环境(两者 功利性[步行]和娱乐性身体活动)。我们将评估通过哪些机制 这些因素可能影响T2D和CHD。潜在的途径包括物质和社会的影响 环境背景因素对压力、睡眠质量、心理健康、医疗保健系统有效性的影响 与肥胖相关的行为。使用不同比例的嵌套地理信息进行多层次研究是必要的 理清与T2D相关的背景因素和个人因素的作用及其后果。因此，我们 将对T2D和CHD的发病和控制进行两项嵌套式多水平研究。每一项的设置为 盖辛格健康系统服务的宾夕法尼亚州广阔而多样的地区，使我们能够将背景因素与 电子健康记录(EHR)中包含的丰富的个人级别数据。每个人都将根据具体情况进行评估 主效应，然后是调节和调节这些效应。这两项相关的研究代表了一种 高效的大数据研究方法，同时提供对T2D的深入情景检查 和先心病。第一项(38个县的EHR研究[38co-EHR])将使用30,000名T2D和T2D患者的现有数据。 20万名未接受T2D治疗的患者。这项纵向研究将在38个县进行比较协会 在县和较小的地区，嵌套地理(多尺度)与T2D发病和控制以及CHD发病有关。 第二项(4个县的行为和生物标记研究[4CO-BBS])将在其中4个项目中研究T2D控制 T2D负担高和低的县，评估较小地理区域的横断面关联。4CO- BBS将通过使用唾液收集主要数据来补充电子健康记录措施和次要背景数据 皮质醇、社区直接观察和患者问卷。4CO-BBS研究将拓宽 检查的路径范围，收集关于健康行为、卫生系统不信任和社区的数据 感知。确定对T2D和T2D患病率影响最大的环境因素 PA的心脏代谢并发症对于了解地区差异至关重要，并将为 制定有针对性的一级和二级预防战略。

Project Summary Type 2 diabetes is the sixth leading cause of death in the U.S., largely as a result of cardiometabolic complications such as coronary heart disease (CHD). T2D ranges in prevalence from under 4% to almost 18% in counties across the country. The geographic variation can be explained in part by several place-level contextual factors, but the proportion of variance explained by county-level indicators differs regionally. For example, while a combination of nine county-level measures of mainly socioeconomic, race/ethnicity, and built environmental features explain up to 94% of the variation in T2D prevalence in the Midwest, these same factors explain very little variation in Mid-Atlantic counties, including those in Pennsylvania (PA). Our study focuses on four contextual domains that we hypothesize impact T2D and CHD outcomes in PA: chronic environmental contamination, social environment, food environment, and physical activity environment (both utilitarian [walkability] and recreational physical activity). We will evaluate multiple mechanisms through which these factors could impact T2D and CHD. Potential pathways include the influence of physical and social environmental contextual factors on stress, sleep quality, mental health, health care system effectiveness, and obesity-related behaviors. Multilevel studies using nested geographies at several scales are necessary to disentangle the role of contextual and individual factors associated with T2D and its consequences. Thus, we will conduct two nested multilevel studies of T2D and CHD onset and control of T2D. The setting for each is the large, diverse region of PA served by the Geisinger Health System, allowing us to link contextual factors to the wealth of individual-level data contained in electronic health records (EHR). Each will evaluate contextual main effects and then mediation and moderation of these effects. The two connected studies represent an efficient, big data approach to research while simultaneously offering a deep contextual examination of T2D and CHD. The first (38-county EHR study [38co-EHR]) will use existing data on 30,000 patients with T2D and 200,000 patients without T2D. This longitudinal study will be conducted in 38 counties comparing associations in counties and smaller, nested geographies (multi-scale) in relation to T2D onset and control and CHD onset. The second (4-county Behavior and Biomarker Study [4co-BBS]) will study T2D control in four of these counties with high and low T2D burden, evaluating cross-sectional associations in smaller geographies. 4co- BBS will supplement EHR measures and secondary contextual data with primary data collection using saliva cortisol, direct observation of communities, and patient questionnaires. The 4co-BBS study will broaden the scope of pathways examined, collecting data on health behaviors, health system distrust, and community perceptions. Identifying the contextual factors with the greatest influence on the prevalence of T2D and T2D cardiometabolic complications in PA is critical to understanding regional differences and will inform the development of targeted primary and secondary prevention strategies.