Outcomes of Blood Pressure Management in Diabetes Patients with Comorbidities

描述（由申请人提供）：拟议研究的目的是调查糖尿病和共存健康状况患者血压（BP）管理的预测因素、模式和结果，以便利用这些信息优化现有的BP指南。我们将使用一个链接的注册-索赔数据库来研究通过合并症控制血压的模式，评估血压与不良后果之间的关系，并为具有复杂健康状况的糖尿病患者的血压管理制定指南原型。具体目的是：(1)评估特定血管和非血管合并症对2型糖尿病患者长期血压模式的影响。我们假设具有特定共存条件和不同管理干预措施的糖尿病患者的BP轨迹会有所不同。(2)。评估糖尿病患者合并症负担、血压控制和血压水平变化与不良临床结局（卒中、缺血性心脏事件、住院和死亡）之间的关系。我们假设，复杂的健康状况，而不是血压水平，将更有力地预测糖尿病患者的多种合并症和脆弱性的不良事件。然而，对于那些没有复杂健康状况的患者，我们假设血压水平将是不良结果的预测因子。(3)利用具体目标1和2的结果，制定指南原型，最大限度地减少复杂患者不良事件的可能性。我们将使用关于特定合并症的BP轨迹信息和预测不良临床结果的回归模型数据，以产生将其他数据元素纳入现有复杂糖尿病患者BP指南的可能性。这是一项分析性流行病学研究。它将使用临床糖尿病登记处的二级数据分析，该登记处包含糖尿病管理措施（HbA1c、LDL水平、血压水平等），这些措施将与健康维护组织和医疗保险的索赔相关联。医疗保险索赔可通过密歇根大学参与医师团体实践（PGP）医疗保险示范项目获得。该项目为澳大分配了一批在澳大接受医疗保险服务的收费患者；大多数医疗保险患者在糖尿病登记被分配。参与者将是2005-2008年登记的约20,000名患者，其中约70%的患者将在登记中有索赔和多种血压测量。本研究将利用这些关联的注册表数据，调查具有不同合并症负担的中老年至老年糖尿病患者的血压水平。主要结局包括中风、新的缺血性心脏事件、死亡和住院率增加。最能预测糖尿病患者血压水平和临床结果的协变量是冠状动脉疾病、复杂健康状况（定义为合并症负担）和年龄。本研究结果将为改善糖尿病及复杂健康状况患者的血压管理提供实用的临床依据。

DESCRIPTION (provided by applicant): The goal of the proposed research is to investigate predictors, patterns and outcomes of blood pressure (BP) management among patients with diabetes and coexisting health conditions, in order to use this information to optimize existing BP guidelines. We will use a linked registry-claims database to investigate the pattern of BP control by comorbidities, assess the relation between BP and adverse outcomes, and develop guideline prototypes for BP management in diabetes patients with complex health status. The Specific Aims are: (1) To assess the effect of specific vascular and nonvascular comorbidities on BP patterns over time in patients with type 2 diabetes mellitus. We hypothesize that trajectories of BP will be different in diabetes patients who have specific coexisting conditions and different management interventions. (2). To evaluate the association between comorbidity burden, BP control and changes in BP level, and adverse clinical outcomes (stroke, ischemic cardiac events, hospitalization, and death) in diabetes patients. We hypothesize that complex health status, rather than BP level, will more strongly predict adverse events in diabetes patients with multiple comorbidities and vulnerabilities. For those patients without a complex health status, however, we hypothesize that BP level will be a predictor of adverse outcomes. (3) Using the results from Specific Aims 1 and 2, to develop guideline prototypes that minimize the probability of adverse events in complex patients. We will use information regarding the trajectories of BP for specific comorbidities and data from the regression models which predict adverse clinical outcomes, to generate the probabilities of incorporating additional data elements into existing BP guidelines for complex diabetes patients. This is an analytic epidemiology study. It will use secondary data analysis of a clinical diabetes registry containing measures of diabetes management (HbA1c, LDL level, BP level, among others) that will be linked to claims from a Health Maintenance Organization and Medicare. Medicare claims are available through the University of Michigan's participation in the Physician Group Practice (PGP) Medicare Demonstration Project. This project assigns UM a population of fee-for service Medicare patients cared for at UM; most Medicare patients in the diabetes registry are assigned. Participants will be the approximately 20,000 registry patients from 2005-2008, approximately 70% of whom will have claims and multiple BP measures on the registry. Using this linked registry data, this research will investigate blood pressure (BP) level among patients with diabetes from middle to advanced old age, with different comorbidity burdens. Major outcomes include stroke, new ischemic cardiac event, death, and increased hospitalization. Covariates of most interest as predictors of both BP level and clinical outcomes in diabetes are coronary artery disease, complex health status (defined as comorbidity burden) and age. Results of this research will provide practical clinical evidence for modifying BP management in patients with diabetes and complex health status.