Voorham Jaco, Haaijer-Ruskamp Flora M, Wolffenbuttel Bruce H R, de Zeeuw Dick, Stolk Ronald P, Denig Petra
Department of Clinical Pharmacology, Faculty of Medical Science, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
PLoS One. 2012;7(6):e38707. doi: 10.1371/journal.pone.0038707. Epub 2012 Jun 5.
Comorbidity is often mentioned as interfering with "optimal" treatment decisions in diabetes care. It is suggested that diabetes-related comorbidity will increase adequate treatment, whereas diabetes-unrelated comorbidity may decrease this process of care. We hypothesized that these effects differ according to expected priority of the conditions.
We evaluated the relationship between comorbidity and treatment intensification in a study of 11,248 type 2 diabetes patients using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. We formed a cohort of patients with a systolic blood pressure ≥ 140 mmHg (6,820 hypertensive diabetics), and a cohort of patients with an HbA1c ≥ 7% (3,589 hyperglycemic diabetics) in 2007. We differentiated comorbidity by diabetes-related or unrelated conditions and by priority. High priority conditions include conditions that are life-interfering, incident or requiring new medication treatment. We performed Cox regression analyses to assess association with treatment intensification, defined as dose increase, start, or addition of drugs.
In both the hypertensive and hyperglycemic cohort, only patients with incident diabetes-related comorbidity had a higher chance of treatment intensification (HR 4.48, 2.33-8.62 (p<0.001) for hypertensives; HR 2.37, 1.09-5.17 (p = 0.030) for hyperglycemics). Intensification of hypertension treatment was less likely when a new glucose-regulating drug was prescribed (HR 0.24, 0.06-0.97 (p = 0.046)). None of the prevalent or unrelated comorbidity was significantly associated with treatment intensification.
Diabetes-related comorbidity induced better risk factor treatment only for incident cases, implying that appropriate care is provided more often when complications occur. Diabetes-unrelated comorbidity did not affect hypertension or hyperglycemia management, even when it was incident or life-interfering. Thus, the observed "undertreatment" in diabetes care cannot be explained by constraints caused by such comorbidity.
合并症常被提及会干扰糖尿病护理中的“最佳”治疗决策。有人认为，与糖尿病相关的合并症会增加充分治疗的可能性，而与糖尿病无关的合并症可能会减少这一护理过程。我们假设这些影响会因病情的预期优先级不同而有所差异。
在一项使用GIANTT（格罗宁根2型糖尿病治疗分析倡议）数据库对11248例2型糖尿病患者进行的研究中，我们评估了合并症与治疗强化之间的关系。我们在2007年组建了一个收缩压≥140 mmHg的患者队列（6820例高血压糖尿病患者）和一个糖化血红蛋白≥7%的患者队列（3589例高血糖糖尿病患者）。我们根据与糖尿病相关或不相关的病情以及优先级对合并症进行了区分。高优先级病情包括干扰生活、新发或需要新药物治疗的病情。我们进行了Cox回归分析，以评估与治疗强化的关联，治疗强化定义为药物剂量增加、开始用药或添加药物。
在高血压和高血糖队列中，只有新发与糖尿病相关合并症的患者有更高的治疗强化机会（高血压患者的风险比为4.48，2.33 - 8.62（p<0.001）；高血糖患者的风险比为2.37，1.09 - 5.17（p = 0.030））。当开具新的血糖调节药物时，强化高血压治疗的可能性较小（风险比为0.24，0.06 - 0.97（p = 0.046））。既往存在的或不相关的合并症均与治疗强化无显著关联。
与糖尿病相关的合并症仅在新发病例中促使更好地治疗危险因素，这意味着并发症发生时更常提供适当的护理。与糖尿病无关的合并症即使是新发的或干扰生活的，也不会影响高血压或高血糖的管理。因此，在糖尿病护理中观察到的“治疗不足”不能用此类合并症造成的限制来解释。
