Linking the Legacy Effect in Type 2 Diabetes to Clinical Decision Making

描述（由申请人提供）：具有里程碑意义的英国前瞻性糖尿病研究的观察性随访显示，即使在试验结束十年后，早期严格的血糖控制对新诊断糖尿病的成年人也有持续的益处。这种现象被称为血糖控制的“遗留效应”，在血压控制中尚未观察到。遗留效应的存在意味着血糖控制的时机，例如，病程的早期与晚期，可能具有临床后果。这提出了新的基础糖尿病转化研究问题。在临床实践中，患者在诊断后多久达到血红蛋白A1 C（A1 C）和血压（BP）控制以及多久？不同的长期控制模式如何影响未来的健康结果？患者对实现A1 C和BP控制的治疗时机如何以及何时影响他们的健康结果有何看法？我是一名内科医生，致力于探索临床实践中是否存在遗留效应，以及如何将临床试验中的这一新观察转化为改善的临床护理。使用来自北方加州Kaiser Permanente的新诊断糖尿病成年人的大型观察队列（1995-2005年），我将（目的1）描述10年随访期间a）A1 C和B）BP控制的常见模式，（目的2）比较15年随访期间a）A1 C和B）的各种10年模式患者的并发症/死亡率血压控制。然后，为了开发一个理论模型，患者如何感知时间的概念，在他们的糖尿病相关的健康决策，我将进行半结构化的采访与2型糖尿病患者（目的3）探索他们的信念，关于A1 C和BP控制的时间。这些研究的结果将用于为未来的R 01行为干预提供信息，该干预旨在通过有效的风险沟通和适当的时间努力来加强A1 C和BP控制，从而改善患者的结局。在这个职业发展奖期间，我将与我的导师埃尔伯特黄博士密切合作，他是一位全国公认的老年糖尿病患者医疗决策研究者，也是芝加哥大学芝加哥糖尿病转化研究中心（P30）定量分析核心和富集项目主任。他是凯萨医疗机构北方加州分部的一位有成就的糖尿病流行病学家，此外还有我的纵向数据分析、内分泌学、卫生经济学和行为心理学方面的顾问小组。这项拟议的研究，沿着在先进的流行病学，生物统计学和行为心理学的额外培训，以及我的导师团队的专业知识将帮助我实现我的长期目标，成为一名独立的临床研究者，在2型糖尿病治疗的最佳时机及其风险沟通方面具有专业知识。

DESCRIPTION (provided by applicant): Observational follow-up of the landmark United Kingdom Prospective Diabetes Study revealed that early tight glycemic control had persistent benefits among adults with newly diagnosed diabetes even a decade after the trial had ended. This phenomenon has been dubbed the "legacy effect" of glycemic control and has not been observed for blood pressure control. The existence of the legacy effect implies that the timing of glycemic control, for example, early vs. late in the disease course, may have clinical consequences. This raises new fundamental diabetes translational research questions. In clinical practice, how soon after diagnosis do patients achieve hemoglobin A1C (A1C) and blood pressure (BP) control and for how long? How do different long-term patterns of control affect future health outcomes? And what do patients believe regarding how and when the timing of therapies to achieve A1C and BP control affects their health outcomes? I am an internist who is committed to exploring whether the legacy effect exists in clinical practice and how to translate this novel observation from clinical trials into improved clinical care. Using a large, observationl cohort of adults from Kaiser Permanente Northern California with newly diagnosed diabetes (1995-2005), I will (Aim 1) characterize common patterns of a) A1C and b) BP control over e10 years of follow-up and (Aim 2) compare complications/mortality rates over e15 years of follow-up among patients with various 10-year patterns of a) A1C and b) BP control. Then in order to develop a theoretical model for how patients perceive the concept of time in their diabetes-related health decisions, I will conduct semi-structured interviews with patients with Type 2 diabetes to (Aim 3) explore their beliefs regarding the timing of A1C and BP control. The results of these studies will be used to inform a future R01 behavioral intervention focused on improving patient outcomes through effective risk communication and appropriately timed efforts to intensify A1C and BP control. During this career development award, I will work closely with my mentor, Dr. Elbert Huang, who is a nationally- recognized investigator in medical decision making for older adults with diabetes and Director of the Quantitative Analysis Core and Enrichment Programs of the Chicago Center for Diabetes Translation Research (P30) at the University of Chicago, and my co-mentor, Dr. Andrew Karter, an accomplished diabetes epidemiologist at Kaiser Permanente Northern California Division of Research, in addition to my advisory panel of leaders in longitudinal data analysis, endocrinology, health economics and behavioral psychology. This proposed research, along with additional training in advanced epidemiology, biostatistics and behavioral psychology, and the expertise of my mentorship team will help me achieve my long-term goal of becoming an independent clinical investigator with expertise in the optimal timing of Type 2 diabetes treatments and its risk communication.