Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA
Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA.
Diabetes Care. 2020 Aug;43(8):1724-1731. doi: 10.2337/dc19-1870. Epub 2020 Jun 19.
Several diabetes clinical practice guidelines suggest that treatment goals may be modified in older adults on the basis of comorbidities, complications, and life expectancy. The long-term benefits of treatment intensification may not outweigh short-term risks for patients with limited life expectancy. Because of the uncertainty of determining life expectancy for individual patients, we sought to develop and validate prognostic indices for mortality in older adults with diabetes.
We used a prevalence sample of veterans with diabetes who were aged ≥65 years on 1 January 2006 ( = 275,190). Administrative data were queried for potential predictors that included patient demographics, comorbidities, procedure codes, laboratory values and anthropomorphic measurements, medication history, and previous health service utilization. Logistic least absolute shrinkage and selection operator regressions were used to identify variables independently associated with mortality. The resulting odds ratios were then weighted to create prognostic indices of mortality over 5 and 10 years.
Thirty-seven predictors of mortality were identified: 4 demographic variables, prescriptions for insulin or sulfonylureas or blood pressure medications, 6 biomarkers, previous outpatient and inpatient utilization, and 22 comorbidities/procedures. The prognostic indices showed good discrimination, with C-statistics of 0.74 and 0.76 for 5- and 10-year mortality, respectively. The indices also demonstrated excellent agreement between observed outcome and predictions, with calibration slopes of 1.01 for both 5- and 10-year mortality.
Prognostic indices obtained from administrative data can predict 5- and 10-year mortality in older adults with diabetes. Such a tool may enable clinicians and patients to develop individualized treatment goals that balance risks and benefits of treatment intensification.
一些糖尿病临床实践指南建议，根据合并症、并发症和预期寿命，可调整老年糖尿病患者的治疗目标。对于预期寿命有限的患者，治疗强化的长期益处可能不会超过短期风险。由于确定个体患者预期寿命的不确定性，我们试图开发和验证用于预测老年糖尿病患者死亡率的预后指数。
我们使用了 2006 年 1 月 1 日年龄≥65 岁的糖尿病退伍军人的患病率样本（n=275190）。查询了行政数据中可能的预测因子，包括患者人口统计学、合并症、程序代码、实验室值和人体测量值、药物史以及之前的卫生服务利用情况。使用逻辑最小绝对收缩和选择算子回归来识别与死亡率独立相关的变量。然后，将这些比值比加权以创建 5 年和 10 年死亡率的预后指数。
确定了 37 个死亡率预测因子：4 个人口统计学变量、胰岛素或磺脲类药物或血压药物的处方、6 个生物标志物、以前的门诊和住院利用情况以及 22 种合并症/程序。预后指数显示出良好的区分度，5 年和 10 年死亡率的 C 统计量分别为 0.74 和 0.76。指数还在观察结果和预测结果之间显示出极好的一致性，5 年和 10 年死亡率的校准斜率均为 1.01。
从行政数据中获得的预后指数可以预测老年糖尿病患者的 5 年和 10 年死亡率。这种工具可以使临床医生和患者能够制定平衡治疗强化风险和益处的个体化治疗目标。
