Interplay of Chronic Illness, Race, Age and Sex in Glycemic Control

项目背景：实现血糖控制是最困难的要素 据估计，130万退伍军人管理局糖尿病患者中的许多人都需要进行管理。退伍军人事务部 在绩效衡量方面，与私营部门相比是有利的。然而， 使用汇总数据掩盖了退伍军人中血糖控制不足的情况 较年轻，少数族裔身份，和/或有精神健康状况。尽管广泛传播 认识到CCI在糖尿病管理中的重要性，目前尚不清楚他们是如何 与人口统计因素(年龄、性别、种族)相互关联，以影响服药依从性和 临床惰性是血糖控制的主要调节因素。的具体作用 患有长期糖尿病的退伍军人的胰岛素启动惰性也是如此 在新近发病的退伍军人中开始和加强口服药物治疗 疾病也是未知的。 项目目标：我们的总体目标是评估CCI、 不同年龄、性别和年龄的退伍军人的人口学因素和血糖治疗 种族/民族群体。我们的具体目标是：(1)评估CCI中的差异 与HbA1c在流行和新近发病个体中的趋势差异有关 糖尿病。(2)评估CCI差异与反-CCI差异之间的关系 血糖治疗，包括临床惰性(缺乏药物强化或 增加用药剂量和/或新处方(如有需要)和糖尿病 服药不依从性。(3)评估糖尿病护理的差异程度 种族/族裔群体之间的差异与CCI存在的差异有关。 项目方法：该项目将是一个动态队列的回顾分析 从1999-2006年间确定患有糖尿病的退伍军人，并跟踪调查到2009年。我们会 确定流行的共病情况，并将其归类为“不一致”或“不一致” 基于Piette和Kerr开发的概念模型。将进行分析 单独用于患有普遍或偶发糖尿病的退伍军人。对于第一个目标， 结果将重复个别HbA1c测量，我们将使用生长曲线 根据季节性进行调整的模型(随机效应)，以评估个体HbA1c趋势 (即坡度)。使用分层和回归的方法，我们将评估 CCI和人口统计变量对HbA1c趋势的影响。使用COX、Logistic和线性 多变量回归模型，我们将评估CCI和RACE的关系 临床惰性和用药依从性。

Project Background: Achieving glycemic control is the most difficult element of management for many of the estimated 1.3 million VA patients with diabetes. The VA compares favorably with the private sector based upon performance measures. However, the use of aggregate data masks inadequate glycemic control among veterans who are younger, of minority status, and/or have mental health conditions. Despite wide-spread recognition of the importance of CCI in diabetes management, it is not known how they inter-relate with demographic factors (age, sex, race) to impact medication adherence and clinical inertia that are the major mediators of glycemic control. The specific role of inertia in insulin initiation in veterans with prevalent diabetes of longer duration, as well as initiation and intensification of oral medication in veterans with more recent onset disease is also not known. Project Objectives: Our overarching aim is to evaluate the relationship between CCI, demographic factors and glycemic treatment in veterans of different age, sex and racial/ethnic groups. Our specific objectives are: (1) To evaluate how differences in CCI are related to differences in HbA1c trends for individuals with prevalent and recent-onset diabetes. (2) To evaluate how differences in CCI are related to differences in anti- glycemic treatment, including both clinical inertia (lack of medication intensification or step up in medication dose and/or new prescription when indicated) and diabetes medication non-adherence. (3) To evaluate the extent to which variation in diabetes care among racial/ethnic groups is related to differences in the presence of CCI. Project Methods: This project will be a retrospective analysis of dynamic cohorts of veterans with diabetes identified from 1999-2006, and followed through 2009. We will identify prevalent co- morbid conditions and assign them as "concordant" or "discordant" based upon a conceptual model developed by Piette and Kerr. Analyses will be conducted separately for veterans with prevalent or incident diabetes. For the first objective, the outcome will be repeated individual HbA1c measurements and we will use growth curve models (random effects) that adjust for seasonality to evaluate individual HbA1c trend (i.e., slope). Using stratification as well as regression, we will evaluate the interaction of CCI and demographic variables on the HbA1c trend. Using Cox, logistic and linear multivariable regression models, we will evaluate the relationship of CCI and race with clinical inertia and medication adherence.