STATINS AND ACE INHIBITORS IN ADULTS WITH DIABETES AND COMORBID CONDITIONS

描述（由申请人提供）：背景和意义。2003-2005年，集团健康实施了以药品为基础的全系统推广工作，使糖尿病患者的他汀类药物使用率从30%增加到70%。很少有研究调查他汀类药物在人群水平上的大量增加是否有利于成年糖尿病患者的大血管疾病进展，以及不同合并症患者的获益是否相似。这个问题对于比较有效性研究（CER）具有重要意义，因为糖尿病患者中的大多数死亡是由于心血管疾病，通过他汀类药物和血管紧张素转换酶（ACE）抑制剂治疗来减少大血管疾病的进展是糖尿病护理的重要组成部分。目标。针对1997-2010年连续入组的成年糖尿病患者，目的是：1)描述1998-2010年共病组HMG-CoA还原酶抑制剂（他汀类药物）和ACE抑制剂的使用情况；2)通过群体健康外展，评估2006-2010年共病组他汀类药物和ACE抑制剂使用与主要血管事件和临床护理质量之间的关系。人群：6,856名患有1型或2型糖尿病的成人团体健康糖尿病登记者，从1997-2006年连续登记，存活至2006年，并将随访至2010年。合并症包括高血压、冠状动脉疾病、充血性心力衰竭和抑郁症。研究设计。基于人群的回顾性纵向队列研究。数据源。组运行状况自动数据库。措施。全因死亡率、心血管死亡率、非致死性心肌梗死、中风、低密度脂蛋白胆固醇、血压、血红蛋白A1c （HbA1c）、四种合并症、糖尿病并发症、Charlson合并症指数、药物依从性、糖尿病治疗类型、个人和计划特征、吸烟、肥胖（BMI）、提供者的利用和基于网络的健康信息。分析。在目的1中，将生成描述性统计数据和时间序列图来描述1998-2002年推广前、2003-2005年推广前和2006-2010年推广后的他汀类药物和ACE抑制剂暴露时间。将进行双变量统计检验以确定入组者的个人和临床特征是否与他汀类药物和ACE抑制剂在外展前、外展和外展后的暴露有关。在Aim 2中，Cox比例风险和其他回归模型将评估2006-2010年共病组他汀类药物和ACE抑制剂使用与主要血管事件和临床护理质量之间的关系。

DESCRIPTION (provided by applicant): Background and Significance. In 2003-2005 Group Health implemented pharmacy-based, system- wide outreach efforts that increased statin use in enrollees with diabetes from about 30 to 70%. Few studies have examined whether a large, population-level increase in statin use benefits macrovascular disease progression in adults with diabetes, and whether the benefits are similar for patients with different comorbid conditions. The issue is significant for comparative effectiveness research (CER) because most deaths among patients with diabetes are for cardiovascular disease, and reducing macrovascular disease progression through statin and ACE (angiotensin-converting enzyme) inhibitor treatments is an important element of diabetes care. Aims. For the population of adult enrollees with diabetes mellitus continuously enrolled in Group Health in 1997-2010, aims are to: 1) Describe the utilization of HMG-CoA reductase inhibitors (statins) and ACE inhibitors by comorbid group in 1998-2010; and 2) Following Group Health outreach, estimate the associations between statin and ACE inhibitor use and major vascular events and clinical quality of care in 2006-2010 by comorbid group. Population. 6,856 Group Health adult enrollees in Group Health Diabetes Registry with type 1 or 2 diabetes who were enrolled continuously from 1997-2006, survived to 2006, and will be followed through 2010. Co-morbid conditions are hypertension, coronary artery disease, congestive heart failure, and depression. Study Design. Population-based, retrospective longitudinal cohort. Data Sources. Group Health automated data bases. Measures. All-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, stroke, LDL- cholesterol, blood pressure, hemoglobin A1c (HbA1c), four co-morbid conditions, diabetes complications, Charlson co-morbidity index, drug adherence, diabetes treatment type, personal and plan characteristics, smoking, obesity (BMI), utilization of providers and Web-based health information. Analyses. For Aim 1, descriptive statistics and time series graphs will be produced to describe time of exposure to statins and ACE inhibitors for the 1998-2002 pre-outreach years, the 2003-2005 outreach years, and 2006-2010 post-outreach years. Bivariate statistical tests will be performed to determine whether enrollee personal and clinical characteristics are associated with exposure to statins and ACE inhibitors in the pre-outreach, outreach, and post-outreach years. In Aim 2, Cox proportional hazards and other regression models will estimate the associations between statin and ACE inhibitor use and major vascular events and clinical quality of care in 2006-2010 by co-morbid group. PUBLIC HEALTH RELEVANCE: In 2003-2005 Group Health implemented pharmacy-based, system-wide outreach efforts that increased statin use in enrollees with diabetes from about 30 to 70%. Few studies have examined whether a large, population-level increase in statin use has health benefits for adults with diabetes, and whether the benefits are similar for patients with different co-morbid conditions. The issue is significant for comparative effectiveness research (CER) because most deaths among patients with diabetes are for cardiovascular disease, and reducing macrovascular disease progression through statin and ACE inhibitor treatments is an important element of diabetes care.