Parchman Michael L, Zeber John E, Romero Raquel R, Pugh Jacqueline A
Veterans Affairs HSR&D, South Texas Veterans Health Care System (VERDICT), University of Texas Health Science Center, San Antonio, Texas 78229-4404, USA.
Med Care. 2007 Dec;45(12):1129-34. doi: 10.1097/MLR.0b013e318148431e.
Modifiable risks for coronary heart disease (CHD) in type 2 diabetes include glucose, blood pressure, lipid control, and smoking. The chronic care model (CCM) provides an organizational framework for improving these outcomes.
To examine the relationship between CHD risk attributable to modifiable risk factors among patients with type 2 diabetes and whether care delivered in primary care settings is consistent with the CCM.
SUBJECTS/METHODS: Approximately 30 patients in each of 20 primary care clinics. CHD risk factors were assessed by patient survey and chart abstraction. Absolute 10-year CHD risk was calculated using the UK Prospective Diabetes Study risk engine. Attributable risk was calculated by setting all 4 modifiable risk factors to guideline indicated values, recalculating the risk, and subtracting it from the absolute risk. In each clinic, the consistency of care with the CCM was evaluated using the Assessment of Chronic Illness Care (ACIC) survey.
Only 15.4% had guideline-recommended control of A1c, blood pressure, and lipids. The absolute 10-year risk CHD was 16.2% (SD 16.6). One-third of this risk, 5.0% (SD 7.4), was attributable to poor risk factor control. After controlling for patient and clinic characteristics, the ACIC score was inversely associated with attributable risk: a 1 point increase in the ACIC score was associated with a 16% (95% CI, 5-26%) relative decrease in attributable risk.
The degree to which care delivered in a primary care clinic conforms to the CCM is an important predictor of the 10-year risk of CHD among patients with type 2 diabetes.
2型糖尿病患者冠心病（CHD）的可改变风险因素包括血糖、血压、血脂控制和吸烟。慢性病护理模式（CCM）提供了一个改善这些结果的组织框架。
研究2型糖尿病患者中可改变风险因素所致冠心病风险之间的关系，以及初级保健机构提供的护理是否符合慢性病护理模式。
对象/方法：20家初级保健诊所，每家诊所约30名患者。通过患者调查和病历摘要评估冠心病风险因素。使用英国前瞻性糖尿病研究风险引擎计算10年绝对冠心病风险。通过将所有4个可改变风险因素设定为指南推荐值，重新计算风险，并从绝对风险中减去该风险来计算归因风险。在每家诊所，使用慢性病护理评估（ACIC）调查评估护理与慢性病护理模式的一致性。
只有15.4%的患者的糖化血红蛋白、血压和血脂得到了指南推荐的控制。10年绝对冠心病风险为16.2%（标准差16.6）。其中三分之一的风险，即5.0%（标准差7.4），可归因于风险因素控制不佳。在控制了患者和诊所特征后，ACIC评分与归因风险呈负相关：ACIC评分每增加1分，归因风险相对降低16%（95%CI，5-26%）。
初级保健诊所提供的护理符合慢性病护理模式的程度是2型糖尿病患者10年冠心病风险的重要预测因素。
