Value, Evidence, and Outcomes | Real World Analytics, Eli Lilly and Company, Indianapolis, Indiana, USA.
Real World Evidence, STATinMED Research, Plano, Texas, USA.
Diabetes Obes Metab. 2023 Jun;25(6):1677-1687. doi: 10.1111/dom.15022. Epub 2023 Mar 23.
To identify patient clusters with poor glucose control among type 2 diabetes mellitus (T2DM) patients with obesity who are receiving basal-bolus insulin and to identify the potential therapeutic inertia factors associated with poor control.
Glycated haemoglobin (HbA1c) trajectories across a 3-year period were structured at 6-month intervals for a retrospective cohort of T2DM patients with obesity on basal-bolus insulin from the Veterans' Health Administration database. Based on each patient's longitudinal HbA1c features, an unsupervised clustering procedure was used to determine the numbers of clusters and associated trajectory patterns. Multinomial logistic regression was used to examine the association between HbA1c trajectory clusters and patient characteristics/treatment patterns.
A total of 51 273 patients were included, of whom 11.2% were in a subgroup with persistent missingness of HbA1c values. For those with sufficient HbA1c observations, cluster analysis indicated six distinct HbA1c trajectories: stable low (35.8%); stable high (20.8%); descending low (10.5%); ascending low (10.2%); descending high (5.7%); and ascending high (5.7%). Being of Black ethnicity, not initiating noninsulin antihyperglycaemic agents (sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists or thiazolidinediones) or concentrated insulin, low adherence (measured by proportion of days covered), and reduced insulin prescription refills were factors associated with poorer HbA1c clusters; similar factors were associated with persistent HbA1c missingness.
The present study found the potential for therapeutic inertia among a significant proportion of T2DM patients with obesity on basal-bolus insulin. Subgrouping T2DM patients based on HbA1c missingness and HbA1c trajectories can inform disease management strategies.
鉴定接受基础-餐时胰岛素治疗的肥胖 2 型糖尿病（T2DM）患者中血糖控制不佳的患者聚类，并确定与控制不佳相关的潜在治疗惰性因素。
从退伍军人健康管理局数据库中，对接受基础-餐时胰岛素治疗的肥胖 T2DM 患者进行回顾性队列研究，以 6 个月为间隔构建 3 年的糖化血红蛋白（HbA1c）轨迹。根据每个患者的纵向 HbA1c 特征，采用无监督聚类程序确定聚类的数量和相关轨迹模式。采用多项逻辑回归分析来检验 HbA1c 轨迹聚类与患者特征/治疗模式之间的关联。
共纳入 51273 例患者，其中 11.2%的患者存在 HbA1c 值持续缺失的亚组。对于有足够 HbA1c 观察值的患者，聚类分析表明存在 6 种不同的 HbA1c 轨迹：稳定低（35.8%）；稳定高（20.8%）；下降低（10.5%）；上升低（10.2%）；下降高（5.7%）；上升高（5.7%）。黑人种族、未起始非胰岛素类降糖药（钠-葡萄糖协同转运蛋白 2 抑制剂、胰高血糖素样肽-1 受体激动剂或噻唑烷二酮类药物）或集中胰岛素、低依从性（以比例日覆盖度衡量）以及减少胰岛素处方续药是与较差的 HbA1c 聚类相关的因素；类似的因素与持续的 HbA1c 缺失相关。
本研究发现，在接受基础-餐时胰岛素治疗的肥胖 T2DM 患者中，存在相当一部分潜在的治疗惰性。根据 HbA1c 缺失和 HbA1c 轨迹对 T2DM 患者进行分组，可以为疾病管理策略提供信息。
