Race and Long-Term Diabetes Self-Management in an HMO

描述(由申请人提供)：该项目将检查综合体 种族、糖尿病自我管理(包括自我监测)的关系 血糖和糖尿病药物治疗)、血糖控制和糖尿病 管理护理环境中的并发症在九年期间。非洲 患有糖尿病的美国人不太可能处于血糖控制状态，这是一种主要风险 并发症的发生因素，包括肾病、视网膜病变、 和外周血管疾病。随机对照试验表明 糖尿病自我管理，包括患者教育、药物治疗、 饮食和定期锻炼可以改善非裔美国人的血糖控制 人口。然而，几乎没有流行病学证据表明 种族/民族作为坚持推荐糖尿病的决定因素的作用 自我管理实践，或关于两者之间的关系 自我管理、血糖控制和随后的临床结果。此外， 以前关于种族和糖尿病自我管理的研究受到以下限制 研究周期短，样本量不足，依赖自我报告 自我监测血糖的措施。 这项研究的临床环境是哈佛先锋医学协会 (HVMA)，一个隶属于哈佛大学的大型多站点、多专业团体 朝圣者医疗保健。HVMA由14个健康中心组成，为30多万人提供服务 波士顿地区的人们。我们将使用开放队列设计来招收所有 1991年至1999年期间有24个月或更长时间的成年(18岁)患者 在确定非妊娠期后不间断地参加HVMA 糖尿病，定义为(1)糖尿病的出院诊断，(2) 门诊诊断糖尿病，HbAlc实验室检测结果8.0，或使用 一种糖尿病药物(胰岛素、磺脲或二甲双胍)。我们估计， 队列将包括大约1800名被确认为非裔美国人的成年人 还有5000人被确认为高加索人。访问HVMA计算机化的医疗记录， 医院急诊室和住院患者的索赔、实验室和药房数据将允许 美国将创建可靠、客观的自我监测措施(家庭血糖 监测试纸的使用)，药物治疗。血糖控制(HbAlc实验室结果)， 和糖尿病并发症(在门诊、急诊室测量 探视和住院)。按药物治疗类型分层 (胰岛素/联合疗法与口服疗法)，我们将使用描述性分析， 广义线性混合模型和比例风险模型(1) 确定自我管理做法和与糖尿病相关的种族差异 随着时间的推移健康结果；(2)评估非裔美国人种族是否是一种 自我监测实践或坚持用药方案的独立预测因素； 以及(3)男女之间的联系是否存在种族/民族差异 自我管理和特定的临床终点，包括血糖控制 (HbAlc&lt；8.0)和过去一年糖尿病相关并发症的发生率 九年的学习期。

DESCRIPTION (provided by applicant): This project will examine the complex relationships between race, diabetes self-management (including self-monitoring of blood glucose and diabetes drug therapy), glycemic control, and diabetes complications in a managed care setting over a nine-year period. African Americans with diabetes are less likely to be in glycemic control, a major risk factor for development of complications, including nephropathy, retinopathy, and peripheral vascular disease. Randomized controlled trials suggest that diabetes self-management including patient education, drug therapy, changes in diet, and regular exercise can improve glycemic control in the African American population. However, there is little epidemiological evidence regarding the role of race/ethnicity as a determinant of adherence to recommended diabetes self-management practices, or regarding the relationship between self-management, glycemic control, and subsequent clinical outcomes. Further, previous studies of race and diabetes self-management have been limited by short study periods, inadequate sample size, and reliance on self-reported measures of self-monitoring of blood glucose. The clinical setting for this study is Harvard Vanguard Medical Associates (HVMA), a large multi-site, multi-specialty group affiliated with Harvard Pilgrim Health Care. HVMA consists of 14 health centers serving over 300,000 people in the Boston area. We will use an open cohort design to enroll all adult (l8 years) patients between 1991 and 1999 who have 24 months or more of uninterrupted enrollment in HVMA following ascertainment of non-gestational diabetes, defined by (1) hospital discharge diagnosis of diabetes mellitus, (2) outpatient diagnoses of diabetes mellitus, HbAlc lab test result 8.0, or use of a diabetes drug (insulin, sulfonylurea, or metformin). We estimate that the cohort will include approximately 1,800 adults identified as African American and 5,000 identified as Caucasian. Access to HVMA computerized medical records, hospital emergency room and inpatient claims, lab, and pharmacy data will allow us to create reliable, objective measures of self-monitoring (home glucose monitor test strip use), drug therapy. glycemic control (HbAlc lab results), and diabetes complications (as measured in outpatient visits, emergency room visits, and hospitalizations). Stratifying by type of drug therapy (insulin/combined therapy vs. oral therapy), we will use descriptive analyses, generalized linear mixed models, and proportional hazards models to (1) identify racial differences in self-management practices and diabetes-related health outcomes over time; (2) assess whether African American race is an independent predictor of self-monitoring practice or adherence to drug regimen; and (3) whether there are racial/ethnic differences in the association between self-management and specific clinical endpoints, including glycemic control (HbAlc<8.0) and the incidence of diabetes-related complications over the nine-year study period.