Chan Kam Suen, Wan Eric Yuk Fai, Chin Weng Yee, Yu Esther Yee Tak, Mak Ivy Lynn, Cheng Will Ho Gi, Ho Margaret Kay, Lam Cindy Lo Kuen
Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong Special Administrative Region, China.
Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong Special Administrative Region, China.
Diabetes Care. 2022 May 1;45(5):1162-1169. doi: 10.2337/dc21-1217.
Cardiovascular diseases (CVD) are a long-term sequela of diabetes. Better individual-based continuity of care has been reported to reduce the risk of chronic complications among patients with diabetes. Maintaining a one-to-one patient-physician relationship is often challenging, especially in public health care settings. This study aimed to evaluate the relationship between higher team-based continuity of care, defined as consultations provided by the same physician team, and CVD risks in patients with diabetes from public primary care clinics.
This was a retrospective cohort study in Hong Kong of 312,068 patients with type 2 diabetes and without any history of CVD at baseline (defined as the earliest attendance at a doctor's consultation in a public-sector clinic between 2008 and 2018). Team-based continuity of care was measured using the usual provider continuity index (UPCI), calculated by the proportion of consultations provided by the most visited physician team in the 2 years before baseline. Patients were divided into quartiles based on their UPCI, and the characteristics of the quartiles were balanced using propensity score fine stratification weights. Multivariable Cox regression was applied to assess the effect of team-based continuity of care on CVD incidence. Patient demographics, smoking status, physiological measurements, number of attendances, comorbidities, and medications were adjusted for in the propensity weightings and regression analyses.
After an average follow-up of 6.5 years, the total number of new CVD events was 52,428. Compared with patients in the 1st quartile, patients in the 2nd, 3rd, and 4th quartiles of the UCPI had a CVD hazard ratio (95% CI) of 0.95 (0.92-0.97), 0.92 (0.89-0.94), and 0.87 (0.84-0.89), respectively, indicating that higher continuity of care was associated with lower CVD risks. The subtypes of CVD, including coronary heart disease and stroke, also showed a similar pattern. Subgroup analyses suggested that patients <65 years of age had greater benefits from higher team-based continuity of care.
Team-based continuity of care was associated with lower CVD risk among individuals with type 2 diabetes, especially those who were younger. This suggests a potential flexible alternative implementation of continuity of care in public clinics.
心血管疾病（CVD）是糖尿病的长期后遗症。据报道，更好的基于个体的连续性护理可降低糖尿病患者慢性并发症的风险。维持一对一的医患关系往往具有挑战性，尤其是在公共卫生保健环境中。本研究旨在评估更高的基于团队的连续性护理（定义为由同一医生团队提供的会诊）与公立基层医疗诊所糖尿病患者CVD风险之间的关系。
这是一项在香港进行的回顾性队列研究，研究对象为312,068例2型糖尿病患者，基线时无任何CVD病史（定义为2008年至2018年期间最早在公立诊所就诊）。基于团队的连续性护理采用常规提供者连续性指数（UPCI）进行衡量，该指数通过基线前2年中就诊最多的医生团队提供的会诊比例计算得出。根据UPCI将患者分为四分位数，并使用倾向评分精细分层权重使四分位数的特征达到平衡。应用多变量Cox回归评估基于团队的连续性护理对CVD发病率的影响。在倾向权重和回归分析中对患者人口统计学、吸烟状况、生理测量、就诊次数、合并症和用药情况进行了调整。
平均随访6.5年后，新发生的CVD事件总数为52,428例。与第一四分位数的患者相比，UPCI第二、第三和第四四分位数的患者CVD风险比（95%CI）分别为0.95（0.92 - 0.97）、0.92（0.89 - 0.94）和0.87（0.84 - 0.89），表明更高的连续性护理与更低的CVD风险相关。CVD的亚型，包括冠心病和中风，也呈现出类似的模式。亚组分析表明，65岁以下的患者从更高的基于团队的连续性护理中获益更大。
基于团队的连续性护理与2型糖尿病患者较低的CVD风险相关，尤其是年轻患者。这表明在公立诊所中连续性护理可能有潜在的灵活替代实施方式。
