Edelman David, Olsen Maren K, Dudley Tara K, Harris Amy C, Oddone Eugene Z
Center for Health Services Research in Primary Care, Durham VA Medical Center, North Carolina 27705, USA.
Diabetes Care. 2003 Feb;26(2):367-71. doi: 10.2337/diacare.26.2.367.
Screening for diabetes has the potential to be an effective intervention, especially if patients have intensive treatment of their newly diagnosed diabetes and comorbid hypertension. We wished to determine the process and quality of diabetes care for patients diagnosed with diabetes by systematic screening.
A total of 1,253 users of the Durham Veterans Affairs Medical Center aged 45-64 years who did not report having diabetes were screened for diabetes with an HbA(1c) test. All subjects with an HbA(1c) level > or =6.0% were invited for follow-up blood pressure and fasting plasma glucose (FPG) measurements. A case of unrecognized diabetes was defined as HbA(1c) > or =7.0% or FPG > or =126 mg/dl. For each of the 56 patients for whom we made a new diagnosis of diabetes, we notified the patient's primary care provider of this diagnosis. One year after diagnosis, we reviewed these patients' medical records for traditional diabetes performance measures as well as blood pressure. Follow-up blood pressure was also ascertained from medical record review for all subjects with HbA(1c) > or =6.0% who did not have diabetes. We compared blood pressure changes between patients with and without diabetes.
Among patients diagnosed with diabetes at screening, 34 of 53 (64%) had evidence of diet or medical treatment for their diabetes, 42 of 53 (79%) had HbA(1c) measured within the year after diagnosis, 32 of 53 (60%) had cholesterol measured, 25 of 53 (47%) received foot examinations, 29 of 53 (55%) had eye examinations performed by an eye specialist, and 16 of 53 (30%) had any measure of urine protein. The mean blood pressure decline over the year after diagnosis for patients with diabetes was 2.3 mmHg; this decline was similar to that found for 183 patients in the study without diabetes (change in blood pressure, -3.6 mmHg). At baseline, 48% of patients with diabetes had blood pressure <140/90, compared with 40% of patients without diabetes; 1 year later, the same 48% of patients with diabetes had blood pressure <140/90, compared with 56% of patients without diabetes (P = 0.31 for comparing the change in percent in control between groups).
Patients with diabetes diagnosed at screening achieve less tight blood pressure control than similar patients without diabetes. Primary care providers do not appear to manage diabetes diagnosed at screening as intensively as long-standing diabetes and do not improve the management of hypertension given the new diagnosis of diabetes.
糖尿病筛查有可能成为一种有效的干预措施，尤其是当患者对新诊断出的糖尿病及合并的高血压进行强化治疗时。我们希望确定通过系统筛查诊断出糖尿病的患者的糖尿病护理过程及质量。
对达勒姆退伍军人事务医疗中心1253名年龄在45 - 64岁且未报告患有糖尿病的使用者进行糖化血红蛋白（HbA₁c）检测以筛查糖尿病。所有HbA₁c水平≥6.0%的受试者均被邀请进行后续血压及空腹血糖（FPG）测量。未被识别的糖尿病病例定义为HbA₁c≥7.0%或FPG≥126mg/dl。对于我们新诊断出患有糖尿病的56名患者中的每一位，我们都将这一诊断结果告知了患者的初级保健提供者。诊断一年后，我们查阅了这些患者的病历以获取传统糖尿病指标以及血压情况。对于所有HbA₁c≥6.0%但未患糖尿病的受试者，我们也通过查阅病历确定了其后续血压情况。我们比较了糖尿病患者和非糖尿病患者之间的血压变化。
在筛查中被诊断出患有糖尿病的患者中，53名患者中有34名（64%）有糖尿病饮食或药物治疗的证据，53名患者中有42名（79%）在诊断后的一年内进行了HbA₁c检测，53名患者中有32名（60%）进行了胆固醇检测，53名患者中有25名（47%）接受了足部检查，53名患者中有29名（55%）由眼科专家进行了眼部检查，53名患者中有16名（3%）进行了任何尿蛋白检测。糖尿病患者在诊断后的一年中平均血压下降了2.3mmHg；这一下降幅度与研究中183名未患糖尿病的患者相似（血压变化为 - 3.6mmHg）。基线时，48%的糖尿病患者血压<140/90，而未患糖尿病的患者为40%；一年后，同样48%的糖尿病患者血压<140/90，未患糖尿病的患者为56%（两组间对照组百分比变化的比较P = 0.31）。
筛查诊断出的糖尿病患者血压控制不如类似的非糖尿病患者严格。初级保健提供者对筛查诊断出的糖尿病的管理似乎不如对长期存在的糖尿病那样强化，并且在新诊断出糖尿病的情况下并未改善高血压的管理。
