Quorum Consulting, Inc., New York, New York, United States of America.
Icahn School of Medicine at Mount Sinai, New York City, New York, United States of America.
PLoS One. 2018 Jun 12;13(6):e0199011. doi: 10.1371/journal.pone.0199011. eCollection 2018.
Assess the relationship between timely treatment intensification and hemoglobin A1C (HbA1C) control quality-of-care performance measures, i.e., HbA1C levels, among patients with uncontrolled type 2 diabetes.
Electronic medical records and diabetes registry data from a large, accountable care organization (ACO) were used to isolate a sample of adult patients with type 2 diabetes who received at least one oral antidiabetes agent and had at least one HbA1C level measurement ≥8.0% (64 mmol/mol; i.e., uncontrolled diabetes) between 7/1/2011 and 6/30/2015. Treatment intensification status was evaluated for each patient during a 120-day treatment intensification window following the index HbA1c measure. Two-level hierarchical generalized linear models, with patients aggregated at the physician level, were used to assess the association between treatment intensification and achieving HbA1C quality performance measures.
547 patients met study selection criteria and 480 patients had at least one HbA1C test after the treatment intensification window and were used for the statistical analyses. About 40% of patients who had uncontrolled diabetes received treatment intensification during the 120-day window. Greater index HbA1C, greater patient body mass index, and fewer unique pre-index oral antidiabetes agents were significantly associated with greater likelihood of receiving timely treatment intensification. The odds of receiving treatment intensification were about 1.8 times higher (P = 0.0027) among patients with poor index HbA1C control (HbA1c level >9.0% [75 mmol/mol]) compared to other patients (index HbA1c 8.0% - 9.0%). Hispanic patients (compared to White patients) were significantly more likely to exhibit poor control after treatment intensification (odds ratio [OR] 2.91, P = 0.0304), underscoring the difficulty of controlling diabetes in this vulnerable group. In contrast, being male and being treated primarily by an internist (compared to primary treatment by a family medicine specialist) were both significantly associated with achieving superior control (HbA1c level <8.0%) after treatment intensification (OR 0.53 [P = 0.0165]; OR 0.41 [P = 0.0275], respectively).
Timely treatment intensification was significantly associated with greater likelihood of patients achieving superior HbA1C control (<8.0%) and better HbA1C control quality performance for the practice. Even in an ACO with resources dedicated to diabetes control, it is incumbent upon clinicians to readily identify and open dialogues with patients who may benefit from closely supervised, individualized attention.
评估在未得到控制的 2 型糖尿病患者中，及时加强治疗与血红蛋白 A1C（HbA1C）控制质量的关系，即 HbA1C 水平。
使用大型责任制医疗组织（ACO）的电子病历和糖尿病登记数据，筛选出 2011 年 7 月 1 日至 2015 年 6 月 30 日期间至少接受过一次口服抗糖尿病药物治疗且至少有一次 HbA1C 水平≥8.0%（64mmol/mol；即未控制的糖尿病）的成年 2 型糖尿病患者。在指数 HbA1c 测量后的 120 天治疗强化窗口内，评估每位患者的治疗强化状态。使用患者在医生层面上被聚集的两水平分层广义线性模型，评估治疗强化与实现 HbA1C 质量表现指标之间的关联。
共有 547 名患者符合研究选择标准，且有 480 名患者在治疗强化窗口后至少进行了一次 HbA1C 检测，用于统计分析。大约 40%患有未控制糖尿病的患者在 120 天的窗口内接受了治疗强化。更大的指数 HbA1C、更大的患者体重指数和更少的独特预指数口服抗糖尿病药物与更有可能接受及时治疗强化显著相关。与其他患者（指数 HbA1c 8.0%-9.0%）相比，指数 HbA1C 控制较差（HbA1c 水平>9.0%[75mmol/mol]）的患者接受治疗强化的可能性高约 1.8 倍（P=0.0027）。与白人患者相比，西班牙裔患者在治疗强化后更有可能表现出较差的控制（优势比[OR]2.91，P=0.0304），突显了在这一弱势群体中控制糖尿病的困难。相比之下，男性和主要由内科医生治疗（而非家庭医学专家）都与治疗强化后实现更好的控制（HbA1c 水平<8.0%）显著相关（OR 0.53[P=0.0165]；OR 0.41[P=0.0275]）。
及时的治疗强化与患者更有可能实现 HbA1C 控制（<8.0%）的优势以及实践中更好的 HbA1C 控制质量表现显著相关。即使在一个有专门资源用于控制糖尿病的 ACO 中，临床医生也有责任迅速识别并与可能受益于密切监督、个体化关注的患者进行对话。
