Albright Rachel H, Fleischer Adam E
The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, 1 Rope Ferry Rd., Hanover, NH 03755, USA.
Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, USA.
J Diabetes Complications. 2021 May;35(5):107903. doi: 10.1016/j.jdiacomp.2021.107903. Epub 2021 Mar 3.
The purpose of this study was to assess the utilization rates and trends of preventative outpatient visits to providers in a population of people with diabetes, and evaluate which preventative services may offer protection against poor outcomes (i.e. all-cause hospitalization).
The National Health and Nutrition Examination Survey (NHANES) was used to examine the relationship between select outpatient services and risk of all-cause hospitalization in people with diabetes. NHANES data from 2011 to 2016 were included. We assessed five outpatient services commonly recommended to prevent future complications in patients with diabetes: (1) routine examination from a physician (2) assessment of hemoglobin A1C (3) eye exam with pupil dilation (4) foot exam and (5) assessment from a diabetes specialist. Logistic regression models were performed to assess the independent association of outpatient services used in the past 1 year, and hospitalization within that same year.
The prevalence of diabetes within the NHANES population was 10.5% (n = 3054). Hospitalization was significantly more common among diabetics who were older, had lower income levels (i.e. under $20,000) and those who considered themselves in 'fair' or 'poor health'. After adjustment for important covariates, patients who received a preventative foot exam within the last year (i.e. 1-4 times per year) were 33% less likely to be hospitalized within that year (OR 0.67, 95%CI 0.46, 0.96). Those visiting a diabetes specialist were 44% less likely to be hospitalized that year (OR 0.56, 95%CI 0.39, 0.82) if the visit was preventative in nature (i.e. occurred more than one year before the hospitalized event). No other outpatient services displayed an independent association with hospitalization.
Outpatient Services were consistently being used annually by the diabetic population. Receiving a preventative foot exam and visiting a diabetes specialist were associated with protection against hospitalization, resulting in a 33% and 44% decreased risk, respectively.
Evidence before this study: Current guidelines focus on preventative care measures to avert diabetes complications. In a 2018 national database study of approximately one-third of the Italian population, guidelines for prevention were not consistently being met among the diabetes population, however, patients who regularly received all the recommended preventative measures experienced a 20% risk reduction in hospitalization. The study's preventative measures included periodic lab monitoring including glycated hemoglobin and lipid profiles and dilated eye exams. Added value of this study: In our study, we used a national database representing the United States' non-institutionalized population to identify the prevalence of prevention measures being utilized in adults with diabetes and further examine their relationship with all-cause hospitalization. Logistic regression analysis identified two preventative measures with inconsistent utilization, however, when these measures were used according to guidelines, they contributed to a risk reduction in all-cause hospitalization. Implications of all the available evidence: Current preventative guidelines can contribute to a risk reduction in hospitalization among adults with diabetes. National guidelines and quality improvement initiatives should be aimed at improving the utilization of foot exams as a preventative measure and referral to a diabetes specialist before complications incur.
本研究旨在评估糖尿病患者群体中预防性门诊就诊的利用率和趋势，并评估哪些预防性服务可能有助于预防不良结局（即全因住院）。
利用美国国家健康与营养检查调查（NHANES）来研究特定门诊服务与糖尿病患者全因住院风险之间的关系。纳入了2011年至2016年的NHANES数据。我们评估了通常推荐用于预防糖尿病患者未来并发症的五项门诊服务：（1）医生常规检查；（2）糖化血红蛋白评估；（3）散瞳眼科检查；（4）足部检查；（5）糖尿病专科医生评估。进行逻辑回归模型分析，以评估过去1年中使用的门诊服务与同年住院之间的独立关联。
NHANES人群中糖尿病患病率为10.5%（n = 3054）。年龄较大、收入水平较低（即低于20,000美元）以及自认为健康状况“一般”或“较差”的糖尿病患者住院情况更为常见。在对重要协变量进行调整后，过去一年接受过预防性足部检查（即每年1 - 4次）的患者同年住院的可能性降低了33%（OR 0.67，95%CI 0.46，0.96）。如果就诊具有预防性（即在住院事件发生前一年以上），那么看糖尿病专科医生的患者同年住院的可能性降低了44%（OR 0.56，95%CI 0.39，0.82）。没有其他门诊服务显示出与住院有独立关联。
糖尿病患者群体每年都持续使用门诊服务。接受预防性足部检查和看糖尿病专科医生与预防住院有关，分别使风险降低了33%和44%。
本研究之前的证据：当前指南侧重于预防糖尿病并发症的护理措施。在2018年一项对约三分之一意大利人口的全国性数据库研究中，糖尿病患者群体中预防指南并未得到一致遵循，然而，定期接受所有推荐预防措施的患者住院风险降低了20%。该研究的预防措施包括定期实验室监测，包括糖化血红蛋白和血脂谱以及散瞳眼科检查。本研究的附加价值：在我们的研究中，我们使用了一个代表美国非机构化人口的全国性数据库，以确定糖尿病成年人中预防措施的使用情况，并进一步研究它们与全因住院的关系。逻辑回归分析确定了两项使用不一致的预防措施，但当按照指南使用这些措施时，它们有助于降低全因住院风险。现有所有证据的意义：当前的预防指南有助于降低糖尿病成年人的住院风险。国家指南和质量改进举措应旨在提高足部检查作为预防措施的利用率，并在并发症发生前将患者转诊至糖尿病专科医生处。
