在个性化医疗时代重新审视2007 - 2010年美国国家健康与营养检查调查（NHANES）中成年糖尿病患者的医疗质量差异
Revisiting Disparities in Quality of Care Among US Adults With Diabetes in the Era of Individualized Care, NHANES 2007-2010.
作者信息
Laiteerapong Neda, Fairchild Paige C, Chou Chia-Hung, Chin Marshall H, Huang Elbert S
机构信息
Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL.
出版信息
Med Care. 2015 Jan;53(1):25-31. doi: 10.1097/MLR.0000000000000255.
BACKGROUND
Diabetes quality of care standards promote uniform goals and are used routinely for performance measurement and reimbursement. Diabetes health disparities have been characterized using these universal goals. However, guidelines emphasize individualized goals.
OBJECTIVES
To assess diabetes care disparities using individualized goals to (1) determine their racial/ethnic distribution and (2) compare disparities using individualized versus uniform goals.
RESEARCH DESIGN, SUBJECTS, AND MEASURES: A nationally representative sample of non-Hispanic white, non-Hispanic black, and Hispanic adults with self-reported diabetes aged 20 years or more in the National Health and Nutrition Examination Survey, 2007-2010. Individualized glycemic goals (A1C<6.5%, <7.0%, or <8.0%) assigned based on age, duration, complications, and comorbidity, and cholesterol goals [low-density lipoprotein cholesterol (LDL) <70 or <100 mg/dL] assigned based on cardiovascular history.
RESULTS
More Hispanics were recommended an individualized A1C<7.0% compared with whites (54% vs. 42%, P=0.008). Fewer blacks and Hispanics were recommended an individualized LDL<70 mg/dL than whites (21% and 19% vs. 28%, P=0.02 and 0.001). Fewer Hispanics had adequate individualized A1C control (56% vs. 68%, P<0.001), and fewer blacks and Hispanics had adequate individualized LDL control (31% and 36% vs. 51%, P≤0.001 and P=0.004). A uniform A1C<7% goal did not reveal disparities in glycemic control; individualized A1C and LDL, blood pressure <140/90 mm Hg, and nonsmoking was achieved by few adults (18%), and fewer blacks and Hispanics than whites (6% and 11% vs. 22%, P<0.001 and P=0.005).
CONCLUSIONS
Individualized goals for diabetes care may unearth greater racial/ethnic disparities in clinical performance compared with uniform goals. Diabetes performance measures should include individualized goals to prevent worsening disparities in diabetes outcomes.
背景
糖尿病护理质量标准促进了统一目标的制定，并常规用于绩效评估和报销。糖尿病健康差异已通过这些通用目标得以描述。然而，指南强调个体化目标。
目的
使用个体化目标评估糖尿病护理差异，以（1）确定其种族/族裔分布，以及（2）比较使用个体化目标与统一目标时的差异。
研究设计、研究对象与测量方法：在2007 - 2010年国家健康与营养检查调查中，选取年龄20岁及以上、自我报告患有糖尿病的非西班牙裔白人、非西班牙裔黑人及西班牙裔成年人作为具有全国代表性的样本。根据年龄、病程、并发症和合并症确定个体化血糖目标（糖化血红蛋白[A1C]<6.5%、<7.0%或<8.0%），并根据心血管病史确定胆固醇目标[低密度脂蛋白胆固醇（LDL）<70或<100mg/dL]。
结果
与白人相比，更多西班牙裔被推荐个体化A1C<7.0%（54%对42%，P = 0.008）。与白人相比，推荐个体化LDL<70mg/dL的黑人和西班牙裔更少（分别为21%和19%对28%，P = 0.02和0.001）。西班牙裔实现充分个体化A1C控制的比例更低（56%对68%，P<0.001），黑人和西班牙裔实现充分个体化LDL控制的比例也更低（分别为31%和36%对51%，P≤0.001和P = 0.004）。统一的A1C<7%目标未揭示血糖控制方面的差异；很少有成年人（18%）实现个体化A1C、LDL、血压<140/90mmHg以及不吸烟的目标，且实现这些目标的黑人和西班牙裔少于白人（分别为6%和11%对22%，P<0.001和P = 0.005）。
结论
与统一目标相比，糖尿病护理个体化目标可能会揭示出更大的临床绩效种族/族裔差异。糖尿病绩效评估应纳入个体化目标，以防止糖尿病结局差异加剧。
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