Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California.
Stanford Health Policy, Stanford University, Stanford, California.
JAMA Netw Open. 2019 Sep 4;2(9):e1912060. doi: 10.1001/jamanetworkopen.2019.12060.
Among people with diabetes, co-occurring mental health (MH) or substance use (SU) disorders increase the risk of medical complications. Identifying how to effectively promote long-term medical benefits for at-risk populations, such as people with MH or SU disorders, is essential. Knowing more about how health care accessed before the onset of diabetes is associated with health benefits after the onset of diabetes could inform treatment planning and population health management.
To analyze how preexisting MH or SU disorders and primary care utilization before a new diabetes diagnosis are associated with the long-term severity of diabetes complications.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study analyzed medical record data from US Department of Veterans Affairs health care systems nationwide and used mixed-effects regressions to test associations between prediabetes patient or health care factors and longitudinal progression of diabetes complication severity from 2006 to 2015. Participants included patients who received a new diabetes diagnosis in 2008 and who were aged 18 to 85 years at the time of their diagnosis. Data analysis was conducted from March to August 2017.
Patients were assigned to groups on the basis of a 2-year look-back period for MH or SU disorders status (MH disorder only, SU disorder only, MH and SU disorder, or no MH or SU disorder diagnoses) and on the basis of the amount of primary care utilization before diabetes was diagnosed.
Nine-year trajectories of Diabetes Complication Severity Index (DCSI) scores.
Among 122 992 patients with newly diagnosed diabetes, the mean (SD) age was 62.3 (11.1) years, 118 810 (96.6%) were male, and 28 633 (23.3%) had preexisting MH or SU disorders diagnoses. From the onset of diabetes to 7 years later, patients' mean estimated DCSI scores increased from 0.84 (95% CI, 0.82-0.87) to 1.42 (95% CI, 1.36-1.47). Controlling for sociodemographic characteristics and medical comorbidities, SU disorders only (decrease in DCSI score, -0.09; 95% CI, -0.13 to -0.04; P < .001) or both MH and SU disorders (decrease in DCSI score, -0.13; 95% CI, -0.16 to -0.09; P < .001), but not MH disorders only, were associated with lower DCSI scores at the time of the onset of diabetes compared with no MH or SU disorders. More than 90% of patients with MH or SU disorders had primary care visits before diabetes was newly diagnosed, compared with approximately 58% of patients without MH or SU disorders. Patients who had primary care visits before the onset of diabetes had lower baseline DCSI scores, compared with patients who did not have primary care visits (decrease in DCSI score, -0.41 [95% CI, -0.43 to -0.39] for 1-2 visits, -0.50 [95% CI, -0.52 to -0.48] for 3-4 visits, -0.39 [95% CI, -0.41 to -0.37] for 5-8 visits, and -0.15 [95% CI, -0.17 to -0.12] for ≥9 visits; P < .001 for all). Patients with MH or SU disorders had lower overall, but more rapidly progressing, mean DCSI scores through year 7 after the onset of diabetes (MH disorder only, 0.006 [95% CI, 0.005-0.008], P < .001; SU disorder only, 0.005 [95% CI, 0.001-0.008], P = .004; or both MH and SU disorders, 0.008 [95% CI, 0.006-0.011], P < .001), compared with patients without MH or SU disorders.
Access to and engagement in integrated health care may be associated with modest, albeit impermanent, long-term health benefits for patients with MH and/or SU disorders with newly diagnosed diabetes.
重要性：在患有糖尿病的人群中，同时存在心理健康（MH）或物质使用（SU）障碍会增加发生医疗并发症的风险。确定如何有效地为有风险的人群（如患有 MH 或 SU 障碍的人群）促进长期的医疗获益至关重要。更多地了解在糖尿病发作之前获得的卫生保健服务如何与糖尿病发作后的健康获益相关，可以为治疗计划和人群健康管理提供信息。
目的：分析新诊断出糖尿病前的 MH 或 SU 障碍和初级保健利用情况与糖尿病并发症严重程度的长期进展之间的关系。
设计、地点和参与者：这项队列研究分析了来自美国退伍军人事务部全国医疗保健系统的医疗记录数据，并使用混合效应回归检验了糖尿病前期患者或医疗保健因素与 2006 年至 2015 年期间糖尿病并发症严重程度的纵向进展之间的关联。参与者包括在 2008 年被诊断患有新的糖尿病且在诊断时年龄在 18 岁至 85 岁之间的患者。数据分析于 2017 年 3 月至 8 月进行。
暴露：根据 MH 或 SU 障碍状况的 2 年回顾期（仅 MH 障碍、仅 SU 障碍、MH 和 SU 障碍或无 MH 或 SU 障碍诊断）和在糖尿病确诊前初级保健利用量对患者进行分组。
主要结果和措施：9 年糖尿病并发症严重程度指数（DCSI）评分轨迹。
结果：在 122992 名新诊断为糖尿病的患者中，平均（SD）年龄为 62.3（11.1）岁，118810 名（96.6%）为男性，28633 名（23.3%）有先前存在的 MH 或 SU 障碍诊断。从糖尿病发病到 7 年后，患者的平均估计 DCSI 评分从 0.84（95%CI，0.82-0.87）增加到 1.42（95%CI，1.36-1.47）。在控制了社会人口统计学特征和合并症后，仅 SU 障碍（DCSI 评分降低，-0.09；95%CI，-0.13 至-0.04；P<.001）或 MH 和 SU 障碍均存在（DCSI 评分降低，-0.13；95%CI，-0.16 至-0.09；P<.001）与糖尿病发病时的 DCSI 评分较低相关，而仅 MH 障碍与无 MH 或 SU 障碍的患者相比，这与 DCSI 评分较低相关。与没有 MH 或 SU 障碍的患者相比，患有 MH 或 SU 障碍的患者中有超过 90%的患者在糖尿病新诊断前接受过初级保健，而约有 58%的患者没有接受过。与没有接受过初级保健的患者相比，在糖尿病发病前接受过初级保健的患者的基线 DCSI 评分较低（DCSI 评分降低，1-2 次就诊，-0.41[95%CI，-0.43 至-0.39]；3-4 次就诊，-0.50[95%CI，-0.52 至-0.48]；5-8 次就诊，-0.39[95%CI，-0.41 至-0.37]；≥9 次就诊，-0.15[95%CI，-0.17 至-0.12]；所有 P<.001）。患有 MH 或 SU 障碍的患者在糖尿病发病后 7 年内的总体 DCSI 评分较低，但进展速度较快（仅 MH 障碍，0.006[95%CI，0.005-0.008]，P<.001；仅 SU 障碍，0.005[95%CI，0.001-0.008]，P=0.004；或 MH 和 SU 障碍均存在，0.008[95%CI，0.006-0.011]，P<.001），与没有 MH 或 SU 障碍的患者相比。
结论和相关性：获得和参与综合卫生保健服务可能与新诊断出患有糖尿病的 MH 和/或 SU 障碍患者的适度但暂时的长期健康获益相关。
