Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
School of Data Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA.
BMJ Open Diabetes Res Care. 2021 Apr;9(1). doi: 10.1136/bmjdrc-2020-002069.
England has invested considerably in diabetes care through such programs as the Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA). Associations between program indicators and clinical endpoints, such as amputation, remain unclear. We examined associations between primary care indicators and incident lower limb amputation.
This population-based retrospective cohort study, spanning 2010-2017, was comprised of adults in England with type 2 diabetes and no history of lower limb amputation. Exposures at baseline (2010-2011) were attainment of QOF glycated hemoglobin (HbA1c), blood pressure and total cholesterol indicators, and number of NDA processes completed. Propensity score matching was performed and multivariable Cox proportional hazards models, adjusting for disease-related, comorbidity, lifestyle, and sociodemographic factors, were fitted using matched samples for each exposure.
83 688 individuals from 330 English primary care practices were included. Mean follow-up was 3.9 (SD 2.0) years, and 521 (0.6%) minor or major amputations were observed (1.62 per 1000 person-years). HbA1c and cholesterol indicator attainment were associated with considerably lower risks of minor or major amputation (adjusted HRs; 95% CIs) 0.61 (0.49 to 0.74; p<0.0001) and 0.67 (0.53 to 0.86; p=0.0017), respectively). No evidence of association between blood pressure indicator attainment and amputation was observed (adjusted HR 0.88 (0.73 to 1.06; p=0.1891)). Substantially lower amputation rates were observed among those completing a greater number of NDA care processes (adjusted HRs 0.45 (0.24 to 0.83; p=0.0106), 0.67 (0.47 to 0.97; p=0.0319), and 0.38 (0.20 to 0.70; p=0.0022) for comparisons of 4-6 vs 0-3, 7-9 vs 0-3, and 7-9 vs 4-6 processes, respectively). Results for major-only amputations were similar for HbA1c and blood pressure, though cholesterol indicator attainment was non-significant.
Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.
英格兰通过质量和结果框架（QOF）和国家糖尿病审计（NDA）等计划在糖尿病护理方面投入了大量资金。计划指标与截肢等临床终点之间的关联尚不清楚。我们研究了初级保健指标与下肢截肢事件之间的关联。
本基于人群的回顾性队列研究跨越 2010-2017 年，纳入了英格兰患有 2 型糖尿病且无下肢截肢史的成年人。基线（2010-2011 年）的暴露因素包括达到 QOF 糖化血红蛋白（HbA1c）、血压和总胆固醇指标，以及完成的 NDA 流程数量。进行了倾向评分匹配，并使用每个暴露因素的匹配样本拟合了多变量 Cox 比例风险模型，调整了与疾病相关、合并症、生活方式和社会人口统计学因素相关的因素。
来自 330 个英格兰初级保健实践的 83688 名患者纳入研究。平均随访时间为 3.9（SD 2.0）年，观察到 521 例（0.6%）小或大截肢（每 1000 人年 1.62 例）。HbA1c 和胆固醇指标达标与小或大截肢的风险显著降低相关（调整后的 HR；95%CI）0.61（0.49 至 0.74；p<0.0001）和 0.67（0.53 至 0.86；p=0.0017）。未观察到血压指标达标与截肢之间存在关联（调整后的 HR 0.88（0.73 至 1.06；p=0.1891）。完成更多 NDA 护理流程的患者截肢率显著降低（调整后的 HRs 0.45（0.24 至 0.83；p=0.0106），0.67（0.47 至 0.97；p=0.0319）和 0.38（0.20 至 0.70；p=0.0022），比较 4-6 次与 0-3 次、7-9 次与 0-3 次以及 7-9 次与 4-6 次）。HbA1c 和血压的主要截肢结果相似，但胆固醇指标达标无统计学意义。
基于初级保健的综合二级预防可能为糖尿病相关截肢提供相当大的保护。这对糖尿病管理和患者的医疗决策以及 2 型糖尿病质量改进计划具有重要意义。
