Relation of Primary Care Practice Variation to the Prevention of CVD and Diabetes

描述（由申请人提供）：糖尿病是心血管疾病（CVD）和致残并发症的主要危险因素。尽管在试图预防这些疾病上花费了大量的言辞和资源，但很少有直接证据表明个体临床实践的变化如何影响糖尿病和心血管疾病危险因素患者的发病率和死亡事件以及医疗保健费用。该项目将使用电子医疗记录系统，在一个大型综合医疗保健系统中登记的16,000名成年糖尿病患者中确定5-10年期间临床预防和管理变化与糖尿病和心血管疾病发病事件轨迹的关系。该研究的重点是随时间变化的护理管理在执业水平。该研究将检查风险因素（体重、血压、血脂等）随时间的变化，并使用研究者开发的个人时间方法将这些变化总结为护理质量指数。疾病管理质量将归纳为两个子量表：1)动脉粥样硬化性心血管疾病（ASCVD）预防指数（PI），包括筛查CVD风险和糖尿病并发症风险；2) CVD和糖尿病风险管理的时间和控制水平（TLC）。然后将这些子量表汇总为总体糖尿病-心血管疾病预防指数（DCPI）。本研究将使用实践和患者特征来预测质量措施，以确定预测良好管理的实践、患者和从业者特征，并确定实践中风险管理质量的变化。最后，本研究将使用质量测量来预测5-10年期间的发病和死亡结果。本研究将证明在管理糖尿病和心血管疾病风险方面，遵守实践指南的范围（初步数据表明范围非常广），以及实践变化与发病事件和医疗保健利用之间的关系。在未来的研究中，这些信息将用于评估反馈和其他干预工具对提高糖尿病和心血管疾病预防护理质量的影响。与公共卫生相关：该项目将直接确定临床从业人员对循证指南的遵守程度与发病率、死亡率和医疗保健使用率之间的关系，这些发病率、死亡率和医疗保健使用率是由遵循与成年糖尿病患者预防和管理实践相关的各种共识指南建议而产生的。这些信息有可能评估各种指南的成本和收益之间的相对权衡，并提供强有力的激励信息来支持遵守循证指南。

DESCRIPTION (provided by applicant): Diabetes is a major risk factor for cardiovascular disease (CVD) and for disabling complications. Although a great deal of rhetoric and resources are expended on trying to prevent these morbidities, there is little direct evidence on how individual clinical practice variations can influence morbid and mortal events and health-care costs among persons with diabetes and CVD risk factors. This project will use an electronic medical record system in a population of 16,000 adult persons with diabetes who are enrolled in a large integrated health-care system to determine the relation of variations in clinical prevention and management to the trajectories of diabetic and CVD morbid events over a 5-10 year period. The study focuses on the variations over time in care management at the practitioner level. The study will examine risk factor change (weight, blood pressure, lipids, etc.) over time, and summarize those changes into quality of care indices using a person-time methodology developed by the investigators. Quality of disease management will be summarized into two subscales: 1) the Atherosclerotic Cardiovascular Disease (ASCVD) Prevention Index (PI), which includes screening for CVD risk and risk of diabetes complications; and 2) the Time and Level of Control (TLC) of CVD and diabetes risk management. These sub-scales are then summarized into an overall Diabetes-CVD Prevention Index (DCPI). The study will use practice and patient characteristics to predict the quality measures in order to identify the practice, patient, and practitioner features that predict good management and to determine the variation in quality of risk management across practices. Finally, the study will use the quality measures to predict morbid and mortal outcomes over the 5-10 year period. This study will demonstrate the range in adherence to practice guidelines (which preliminary data suggest is very wide) in managing diabetes and CVD risk and the relation of that practice variation to morbid events and health care utilization over time. In future research, this information will be used to evaluate the impact of feedback and other intervention tools to improve quality of care for diabetes and cardiovascular disease prevention. PUBLIC HEALTH RELEVANE: This project will directly determine the relationships between the level of adherence by clinical practitioners to evidence-based guidelines and the occurrence of morbidity, mortality, and medical care utilization that result from following various consensus guideline recommendations relating to preventive and management practices among adult patients with diabetes. This information has the potential to evaluate the relative trade- offs between costs and benefits of various guidelines, and to provide powerful motivating information to support adherence to evidence-based guidelines.