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

描述(由申请人提供)：对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的糖尿病成年人也有持续的好处。这种现象被称为血糖控制的“遗留效应”，并未在血压控制中观察到。遗传效应的存在意味着血糖控制的时机，例如，在病程的早期和后期，可能会产生临床后果。这提出了新的基础糖尿病转化研究问题。在临床实践中，患者在确诊后多长时间内实现血红蛋白A1C(A1C)和血压(BP)的控制？不同的长期控制模式如何影响未来的健康结果？关于治疗的时机如何以及何时实现A1C和BP的控制，患者相信什么会影响他们的健康结果？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，以及如何将这种来自临床试验的新观察转化为改进的临床护理。利用北加州凯撒永久医院的一大批新诊断为糖尿病的成年人(1995-2005年)的观察队列，我将(目标1)描述在E10年的随访中a)A1C和b)BP控制的常见模式，(目标2)比较a)A1C和b)BP控制的不同10年模式的患者在E15年的随访中的并发症/死亡率。然后，为了建立一个理论模型，让患者在他们与糖尿病相关的健康决策中如何感知时间概念，我将对2型糖尿病患者进行半结构化访谈，以(目的3)探索他们对A1C和BP控制时间的看法。这些研究的结果将被用于未来的R01行为干预，重点是通过有效的风险沟通和适当的时机努力加强A1C和BP控制来改善患者结果。在这个职业发展奖期间，我将与我的导师Elbert Huang博士和我的导师Andrew Karter博士密切合作，他是全国公认的糖尿病老年医疗决策研究员，也是芝加哥大学芝加哥糖尿病翻译研究中心(P30)定量分析核心和丰富项目主任；我的共同导师Andrew Karter博士是Kaiser Permanente North California Research部门的资深糖尿病流行病学家，此外，我还将与我的顾问小组在纵向数据分析、内分泌学、健康经济学和行为心理学方面的领导者组成。这项拟议的研究，加上高级流行病学、生物统计学和行为心理学方面的额外培训，以及我的指导团队的专业知识，将帮助我实现成为一名独立的临床调查员的长期目标，拥有2型糖尿病治疗的最佳时机及其风险沟通方面的专业知识。

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.