Kirk Julienne K, Huber Kenneth R, Clinch C Randall
Department of Family and Community Medicine, Wake Forest University School of Medicine, USA.
N C Med J. 2005 Nov-Dec;66(6):415-9.
Cardiovascular disease is the leading cause of mortality in patients with diabetes, but goals for reduction of modifable cardiovascular risk factors are difficult to achieve in primary care. We evaluated the change in risk factor control for a cohort of patients with diabetes and hyperlipidemia over a four-year period, as well as the change in proportion of patients meeting clinical practice guideline goals.
Medical records were reviewed from a cohort of 86 randomly selected persons with type 2 diabetes in an academic family medicine setting. Data were abstracted to assess the attainment of and change in five treatment goals related to glycemic, blood pressure, and lipid control from 1999-2003. Descriptive statistics were applied to demographic variables. Mean differences in outcomes were assessed with the paired t-test. The McNemar test was used to assess non-parametric variables, and the Wilcoxon signed ranks test was applied to differences achieved in mean goal scores for outcome variables.
The mean numbers of treatment goals attained were 2.76 (SD = 0.92) in 1999 and 2.48 (SD = 1.1) in 2003. Significant improvements were noted in the mean values of HbA1c (0.4% decrease, p = 0.03), diastolic blood pressure (4.3mmHg decrease, p < 0.001), low-density lipoprotein cholesterol (LDL-C; 10.6 mg/dL decrease, p < 0.01), and high-density lipoprotein cholesterol (HDL-C; 8.3 mg/dL increase, p < 0.001) over the four-year study interval. No significant differences were noted in the percent at goal during the study for HDL-C or for HbA1c. A significant decrease was found in the percent at goal from 1999-2003 for LDL-C from 79% to 40%, respectively). The decrease in the percent LDL-C at goal was explained by the more stringent practice guideline goals introduced in 2001 for diabetes (i.e., LDL-C < 100 mg/dL).
Despite significant improvement in mean values of modifiable risk factors, the percent of patients meeting 2003 guideline goals for HbA1c, systolic blood pressure, and LDL cholesterol did not improve. These findings suggest that patient-level improvements may not be adequate indicators of a practices achievement of guideline recommendations. Percent attainment of guideline goals may be a useful peformance measure of practice-level quality improvement initiatives.
心血管疾病是糖尿病患者死亡的主要原因，但在初级保健中降低可改变的心血管危险因素的目标难以实现。我们评估了一组糖尿病和高脂血症患者在四年期间危险因素控制的变化，以及达到临床实践指南目标的患者比例的变化。
回顾了在学术性家庭医学环境中随机选择的86例2型糖尿病患者的病历。提取数据以评估1999年至2003年期间与血糖、血压和血脂控制相关的五个治疗目标的达成情况和变化。对人口统计学变量应用描述性统计。用配对t检验评估结果的平均差异。用McNemar检验评估非参数变量，用Wilcoxon符号秩检验评估结果变量平均目标得分的差异。
1999年达到的治疗目标平均数量为2.76（标准差=0.92），2003年为2.48（标准差=1.1）。在四年的研究期间，糖化血红蛋白（HbA1c）平均值显著改善（降低0.4%，p=0.03），舒张压（降低4.3mmHg，p<0.001），低密度脂蛋白胆固醇（LDL-C；降低10.6mg/dL，p<0.01），高密度脂蛋白胆固醇（HDL-C；升高8.3mg/dL，p<0.001）。在研究期间，HDL-C或HbA1c达到目标的百分比没有显著差异。1999年至2003年，LDL-C达到目标的百分比分别从79%显著降至40%。LDL-C达到目标百分比的下降是由于2001年引入的更严格的糖尿病实践指南目标（即LDL-C<100mg/dL）。
尽管可改变危险因素的平均值有显著改善，但达到2003年HbA1c、收缩压和LDL胆固醇指南目标的患者百分比并未提高。这些发现表明，患者个体水平的改善可能不是实践中实现指南建议的充分指标。指南目标的达成百分比可能是实践水平质量改进举措的有用绩效指标。
