Toward personalized diabetes care: Understanding hypoglycemia in older adults

描述（由申请人提供）：低血糖是糖尿病治疗最常见的不良反应。重度低血糖在老年人中比年轻人更常见，并与福尔斯、骨折、痴呆、心血管事件、死亡率和生活质量差的风险增加相关。糖尿病护理质量指标几乎只关注 预防高血糖症及其并发症和奖励基于目标的血糖降低-这可能导致一刀切的临床实践和不良事件的增加。最近的临床指南呼吁糖尿病护理的个性化目标设定，但缺乏关于如何个性化护理以最大限度地提高益处和减少不良事件的数据。需要明确和全面地了解低血糖对患者的负担，并严格检查低血糖的风险因素，以便为老年糖尿病患者的治疗决策提供信息，评估当前护理质量的重要方面，并为可能减轻低血糖负担的干预提供未来目标。候选人的职业目标是成为糖尿病和老年病领域的独立临床研究者，产生知识以帮助指导个性化的糖尿病治疗。在该提案中，候选人将应用严格的流行病学，生物统计学和定性研究方法来评估经历严重低血糖的老年患者，确定低血糖入院的潜在因素，并检查特定血糖目标，降糖治疗和低血糖事件之间的关系，以提供更好的治疗相关不良事件信息并改善临床结局。具体目标1：描述1998年至2010年12年间患有糖尿病的老年医疗保险受益人因低血糖住院的最新趋势，并检查这些趋势中的种族、性别和地理差异。具体目标二：使用定性方法阐明可能导致老年糖尿病患者因低血糖住院风险的因素。具体目标3：评价北方加州（DISTANCE）糖尿病研究中血糖控制、降糖药物和低血糖事件之间的相关性，该研究是一个大型综合医疗保健提供系统中20，000例糖尿病患者的多种族队列。结合大规模监测方法、调查低血糖住院潜在原因的原始数据收集和临床登记的详细分析，将为候选人提供以下方面的额外技能： 大型数据库分析、定性研究方法和流行病学衰老研究-并将导致未来的工作，以全面了解老年人降糖治疗的风险和获益的平衡。

DESCRIPTION (provided by applicant): Hypoglycemia is the most common adverse effect of diabetes treatment. Severe hypoglycemia is more frequent in older adults than their younger counterparts and is associated with increased risk of falls, fractures, dementia, cardiovascular events, mortality, and poor quality of life. Diabetes care quality metrics focus almost exclusively on prevention of hyperglycemia and its complications and reward target-based glucose lowering - this can potentially lead to one-size-fits-all clinical practice and an increase in adverse event. Recent clinical guidelines call for individualized goal-setting in diabetes care, but data on how t personalize care to maximize benefits and minimize adverse events are lacking. A clear and comprehensive understanding of the burden of hypoglycemia on patients and a rigorous examination of risk factors for hypoglycemia are required to inform treatment decisions in older persons with diabetes, assess an important aspect of current quality of care, and provide future targets for intervention that may mitigate the burden of hypoglycemia. The candidate's career goal is to become an independent clinical investigator in the field of diabetes and geriatrics, generating knowledge to help guide personalized diabetes treatment. In this proposal, the candidate will apply rigorous epidemiologic, biostatistical, and qualitative research methods to evaluate older patients who experience severe hypoglycemia, identify potential contributors to hypoglycemia admissions, and examine the relationship between specific glucose targets, glucose-lowering therapies and hypoglycemic events in order to provide better information on treatment-related adverse events and improve clinical outcomes. Specific Aim 1: To characterize recent trends in hospital admissions for hypoglycemia among older Medicare recipients with diabetes for a 12-year period from 1998-2010, and to examine race, gender, and geographic differences in these trends. Specific Aim 2: To elucidate factors that may contribute to the risk of hospitalization for hypoglycemia among a sample of older adults with diabetes using qualitative methods. Specific Aim 3: To evaluate the association between glycemic control, glucose-lowering agents, and hypoglycemic events in the Diabetes Study of Northern California (DISTANCE), a multiethnic cohort of 20,000 patients with diabetes in a large integrated healthcare delivery system. The combination of a large scale surveillance approach, primary data collection to investigate potential reasons for hypoglycemia hospital admissions, and a detailed analysis of a clinical registry will provide the candidate with additional skills in large database analyses, qualitative research methods, and epidemiologic aging research - and will lead to future work to comprehensively understand the balance of risks and benefits of glucose-lowering therapy in older adults.