Diabetes Mellitus, Comorbid Conditions and Mortality

描述(由申请人提供)： 研究背景和意义。糖尿病是一种日益增长的、使人虚弱的慢性疾病，导致发病率和死亡率。在18岁及以上的成年人中，很少有研究检查糖尿病和合并症及其与9年来死亡率的关系。 目标。对于1997-2006年间在团体健康中连续登记的成年糖尿病登记人群，目的是：1)估计1997-2006年糖尿病及其合并冠状动脉疾病(CAD)、充血性心力衰竭(CHF)、高血压和抑郁症的患病率和发病率，分别描述1997年糖尿病患病率与1998-2006年糖尿病发病率的时间模式；2)估计1998-2006年四种并存疾病的组合相对于单纯糖尿病登记者对死亡率的贡献；3)在1997年的糖尿病患病率参与者中，比较1998-2006年糖尿病患者因治疗失败造成的血糖负担是否低于患有糖尿病的患者；以及4)心血管风险的“反向流行病学”测试，方法是估计较高的糖化血红蛋白和胆固醇水平是否与1998-2006年糖尿病、心力衰竭和/或冠心病患者1998-2006年的较低死亡率有关。 人口。从1997-2006年间连续登记且在该时间间隔内有流行或偶发的1型或2型糖尿病的成年参保者。1997年去世的参赛者被排除在外，1998-2006年在世或死亡的参赛者也包括在内。符合条件的参与者被分为两个相互排斥的队列：1)糖尿病患病率(时间序列所有年份的糖尿病参与者)；2)发病率糖尿病(1998-2006年糖尿病发病参与者)。 研究设计。所有目标将采用纵向队列设计，以1997年为9年(1998-2006年)时间序列的基准年。 数据源。集团健康自动化数据库。 措施。这些因素包括：死亡率、四种并存疾病、调整后的诊断组、糖尿病并发症、糖尿病治疗类型、个人和计划特征、吸烟、肥胖(BMI)、血压、糖化血红蛋白和胆固醇水平、提供者和信息的利用、主治医生的连续性。分析。为实现目标1，将为这两个群体制作描述性统计数据和时间序列图，描述其他四种并存疾病的流行情况和发病情况。将根据时间序列中共病情况的类型和时间构建衡量标准。在AIM 2中，COX比例风险回归模型将估计合并疾病组合与死亡率之间的关联。在AIM中，3个多元回归模型将估计合并疾病组合与血糖负荷之间的关系。AIM 4将使用COX比例风险模型进行反向流行病学测试。

DESCRIPTION (provided by applicant): Background and Significance. Diabetes is a growing, debilitating chronic disease that contributes to morbidity and mortality. Few studies have examined diabetes and comorbid conditions and their relationships to mortality over 9 years among adults aged 18 and over. Aims. For the population of adult enrollees with diabetes mellitus continuously enrolled in Group Health between 1997-2006, aims are to: 1) estimate the prevalence and incidence of diabetes and combinations of comorbid coronary artery disease (CAD), congestive heart failure (CHF), hypertension and depression in 1997-2006, describing temporal patterns separately for enrollees with prevalence diabetes in 1997 versus incidence diabetes in 1998-2006; 2) estimate the contribution of combinations of the four comorbid conditions to mortality in 1998-2006, relative to enrollees with diabetes alone; 3) among prevalence enrollees with diabetes in 1997 and alive through 2006, compare whether glycemic burden from treatment failure in 1998-2006 is lower in enrollees with diabetes alone than in enrollees with comorbid conditions; and 4) test for `reverse epidemiology' of cardiovascular risk by estimating whether greater HbA1c and cholesterol levels are related to lower mortality in 1998-2006 among enrollees with diabetes and CHF and/or CAD in 1997. Population. Group Health adult enrollees who are enrolled continuously from 1997-2006 and who had prevalent or incident type 1 or 2 diabetes during that time interval. Enrollees who died in 1997 are excluded, and enrollees who were alive or died in 1998-2006 are included. Eligible enrollees are divided into two mutually-exclusive cohorts: 1) prevalence diabetes (enrollees with diabetes in all years of the time series); and 2) incidence diabetes (enrollees with diabetes onset in 1998-2006). Study Design. A longitudinal cohort design will be used in all aims, with 1997 a baseline year in the 9-year (1998-2006) time series. Data Sources. Group Health automated data bases. Measures. Mortality, four comorbid conditions, Adjusted Diagnosis Group, diabetes complications, diabetes treatment type, personal and plan characteristics, smoking, obesity (BMI), blood pressure, HbA1c and cholesterol levels, utilization of providers and information, continuity of primary physician. Analyses. For Aim 1 descriptive statistics and time series graphs will be produced for the two cohorts describing the prevalence and onset of other four comorbid conditions. Measures will be constructed of the type and timing of comorbid conditions in the time series. In Aim 2 Cox proportional hazards regression models will estimate the association between the combinations of comorbid conditions and mortality. In Aim 3 multivariate regression models will estimate the relationship between combinations of comorbid conditions and glycemic burden. Aim 4 will test for reverse epidemiology using the Cox proportional hazards model.