Guideline Adherence and Health Outcomes in Medicare FFS Patients with Diabetes

描述（由申请人提供）：糖尿病是发病率和死亡率的主要原因，预计在未来几十年将急剧增加，其中75岁以上人群的增幅最大。目前的糖尿病指南认识到，严格控制糖化血红蛋白（A1c）和心血管疾病（CVD）危险因素的治疗建议可能不适合老年患者和有合并症的患者，因为不良事件的风险增加。如果严格控制的好处由于预期寿命缩短而有限，这些增加的风险就更加重要了。如果长期获益不相关，而短期风险较大，则可能没有理由追求严格控制A1c和心血管疾病危险因素，如低密度脂蛋白（LDL）和血压（BP）升高。为了解决这个问题，指南建议对65岁以上的患者进行个体化治疗。不幸的是，很少有证据支持老年糖尿病患者的治疗决策以及那些有合并症的患者。如果对这些患者进行严格控制的结果是已知的，现有的指导方针将得到显著加强。随着治疗指南越来越多地用于制定公开报告的质量指标和指导按绩效付费（P4P）工作，证据基础尤为重要。鉴于指南的这些公共和财务应用，确定用于识别糖尿病患者并将其分配给提供者的定义是否会影响有效性研究的结论是至关重要的。除非获得新的信息来适当地修改指南，否则严格遵守建议的财政激励可能会产生不良影响，实际上可能会降低护理质量。我们的具体目标是：(1)检查患者的A1c、LDL和BP控制水平与短期负面健康结果（急诊室就诊、住院和死亡）之间的关系，并确定这种关系是否取决于(2)合并症充血性心力衰竭和慢性肾脏疾病的存在，以及(3)分配患者给提供者的不同定义。我们的样本包括大约3,559名医疗保险按服务收费的糖尿病患者，这些患者在2003-2004年期间由中西部一个大型多专科医生小组治疗。我们将2003-2004年电子健康记录中的临床结果数据（如糖化血红蛋白、低密度脂蛋白、血压值）与医疗保险管理数据联系起来。我们的分析方法，边际结构模型，利用了我们数据的纵向特性。总的来说，我们的研究结果将对糖尿病治疗指南、质量指标的制定、按绩效付费阈值的构建以及QI干预措施的目标具有重要意义。优先护理对糖尿病和合并症患者至关重要，因为严格遵守糖尿病治疗指南的短期风险可能超过长期益处。我们建议检查严格遵守糖尿病治疗指南对短期负面健康结果的影响，包括那些患有两种常见和严重疾病的糖尿病患者，慢性肾脏疾病和充血性心力衰竭。我们的研究结果将对糖尿病治疗指南、质量指标的制定、按绩效付费的努力以及质量改善干预措施的目标具有重要意义。

DESCRIPTION (provided by applicant): Diabetes, a leading cause of morbidity and mortality, is projected to increase dramatically over the coming decades with the largest percent increase among those older than 75 years. Current diabetes guidelines recognize that treatment recommendations regarding tight control of glycosylated hemoglobin (A1c) and cardiovascular disease (CVD) risk factors may not be appropriate for older patients and those with comorbid conditions due to increased risk for adverse events. These increased risks have even more significance if the benefits of tight control are limited due to shortened life expectancy. If the long-term benefits are not relevant and the short-term risks are significant, there may be little reason to pursue tight control of A1c and CVD risk factors such as elevated low-density lipoprotein (LDL) and blood pressure (BP). To address this, guidelines recommend individualizing treatment for patients over age 65. Unfortunately, little evidence exists to support treatment decisions for older patients with diabetes generally and for those with comorbid conditions. If the outcomes of tight control were known for these patients, existing guidelines would be significantly strengthened. An evidence base is particularly important as treatment guidelines are increasingly used to develop publicly-reported quality metrics and guide pay-for-performance (P4P) efforts. Given these public and financial applications of guidelines, it is critical to determine whether the definitions used to identify patients with diabetes and assign them to a provider influence the conclusions of effectiveness studies. Unless new information is obtained to modify guidelines appropriately, financial incentives to adhere tightly to recommendations could have perverse effects that might actually diminish the quality of care. Our specific aims are to: (1) examine the relationship between patients' control levels for A1c, LDL, and BP and short-term negative health outcomes (ER visits, hospitalizations, and death), and to determine whether this relationship depends on (2) the presence of comorbid congestive heart failure and chronic kidney disease, and (3) different definitions for assigning patients to providers. Our sample includes approximately 3,559 Medicare fee-for-service patients with diabetes who were cared for by a large midwestern multi-specialty physician group during 2003-2004. We link clinical results data (e.g., A1c, LDL, BP values) from the electronic health record to Medicare administrative data from 2003-2004. Our analytic approach, marginal structural modeling, takes advantage of the longitudinal nature of our data. Overall, the results from our investigation will have important implications for diabetes treatment guidelines, development of quality metrics, construction of pay-for-performance thresholds, and targeting of QI interventions. Narrative Prioritization of care is critical for patients with diabetes and comorbid conditions, because the short-term risks of tight adherence to diabetes treatment guidelines may outweigh the long-term benefits. We propose to examine the tight adherence to diabetes treatment guidelines on short-term negative health outcomes for Medicare fee-for-service patients with diabetes, including those who have two common and serious conditions chronic kidney disease and congestive heart failure. The results from our investigation will have important implications for diabetes treatment guidelines, development of quality metrics and pay-for-performance efforts, and targeting of quality improvement interventions.