||Long-term quality-of-care summary score predicts the occurrence of chronic kidney disease in type 2 diabetic patients
||Institute of Environmental and Occupational Health
Type II diabetes
chronic kidney disease
National Health Insurance database
結果：研究族群共有4,754名第二型糖尿病新發生個案，其中1,407名發生慢性腎臟病。研究族群平均追蹤時間為9.06年，平均年齡為55.3歲，有54.8%為男性。在Cox比例風險模型分析中，遵循糖化血色素檢查比起平均每年檢查次數小於一次者，其危險對比值在校正其他干擾因子後為0.59 (95% CI= 0.51-0.68)；照護品質綜合量表分數為25分以上者以及介於10-20之族群，比起分數在5分以下者，其危險對比值在校正其他干擾因子後分別為0.42 (95% CI= 0.32-0.56)以及0.85 (95% CI= 0.76-0.95)。
Background: Diabetes mellitus is at top 5 of leading causes of death in Taiwan for 30 years. Patients with diabetes are at high risk of causing multiple complications. But little is known about whether adherence to process or intermediate outcome indicators recommendation is effective in predicting the occurrence of chronic kidney disease (CKD) in type 2 diabetic patients. The aim of study was to investigate whether adherence to frequency of HbA1c test recommendation and a quality of care summary score is able to predict the occurrence of CKD in type 2 diabetic patients.
Methods: From 1999 to 2003, incident type 2 diabetes patients were identified from Longitudinal Cohort of Diabetes Patients database of National Health Insurance program and medical records of a medical center in Taiwan, and followed up to 2011. It is recommended that HbA1c test was performed at least twice a year. The long-term and comprehensive quality-of-care summary score were calculated by using process and intermediate outcome indicators (HbA1c, blood pressure, low-density lipoprotein cholesterol, microalbuminuria, foot exam, and eye exam) in the last 3 years before censored date, with scores ranged from 0 to 45. Cox proportional hazard regression model was employed to evaluate the association between diabetic care and CKD.
Results: Overall, 4,754 patients were enrolled, of whom 1,407 developed CKD events after a mean follow-up of 9.06 years. The average age was 55.3 years old, and 54.8 % were male. The adjusted hazard risk (HR) for CKD for those adherence to proposed HbA1c test guideline was 0.59 (95% confidence interval (CI= 0.51-0.68) compared to patients with poor adherence (< 2 times/year). On the other hand, the adjusted HR for CKD for those patients with a score of ≥ 25 and 10-20 were 0.42 (95% CI= 0.32-0.56) and 0.85 (95% CI= 0.76-0.95), respectively, compared to patients with score of ≤ 5.
Conclusion: Adherence to recommended HbA1c test significantly decreases the occurrence of CKD in diabetic patients. The quality of care summary score is reversely associated with the occurrence of CKD. The scoring system which contains process and intermediate outcome indicators may be used to predict the occurrence of CKD in type 2 diabetic patients.
I. Introduction 1
I.1 Diabetes mellitus 1
I.1.1 Classification 1
I.1.2 Diagnosis 1
I.1.3 Diabetic complications 2
I.1.4 Epidemiology 4
I.2 Glucose control on diabetic complications 6
I.3 Diabetes care 7
I.3.1 Recommendations and guidelines of diabetes care 7
I.3.2 Diabetes care-related literatures review 7
I.3.3 Diabetes care in Taiwan 9
I.4 Chronic kidney disease 10
I.4.1 Epidemiology 10
I.4.2 The relationship between diabetes and chronic kidney disease 11
I.5 Objective 11
II. Materials and Methods 13
II.1 Study design 13
II.1.1 Study type 13
II.1.2 Data source 13
II.1.3 Disease and drug classification 15
II.1.4 Subjects selection 15
II.1.5 Exclusion criteria of study subjects 16
II.2 Definition of variables 17
II.2.1 Independent variable definitions 17
II.2.2 Dependent variable definitions 17
II.3 Flowchart and data linking illustration 17
II.3.1 Flowchart of subjects selection 17
II.3.2 Guidelines of data linking 17
II.4 Quality-of-diabetes-care summary score 17
II.5 Statistical analyses and tools 19
II.5.1 Descriptive statistics 19
II.5.2 Statistical inference 19
II.5.3 Statistical tools 20
III. Results 21
III.1 Demographic characteristics of study subjects. 21
III.2 Kaplan-Meier plot (HbA1c frequency) 21
III.3 Kaplan-Meier plot (Score group) 22
III.4 Risk of CKD event 22
III.4.1 Univariate analysis 22
III.4.2 Multivariate analysis 23
III.5 The differences of the previous and present summary score systems on predicting the risk of CKD event. 23
IV. Discussion 24
V. Conclusion 28
VI. References 29
VII. Tables and Figures 35
Table 1. Criteria for the diagnosis of diabetes (American Diabetes 2014) 35
Table 2. Recommendations of screening and goals of treatment for type 2 diabetes patients 35
Table 3. Content in registration and original claim data of NHIRD 36
Table 4. Content in the medical center data 37
Table 5. Diagnostic codes used in this study 37
Table 6. Independent variable definitions 39
Table 7. Dependent variable definitions 41
Table 8. Quality-of-care scoring system 42
Table 9. Characteristics of quality-of-care score of type 2 diabetic patients 43
Table 10. Univariate analysis - Relative Hazards of CKD in type 2 diabetes patients 45
Table 11. Multivariate analysis - Relative Hazards of CKD in type 2 diabetes patients 47
Table 12. Association between 5 points increasing of summary score and the risk of CKD (n=4,754) 47
Table 13. Association between each score group of summary score and the risk of CKD (n=4,754) 48
Table 14. Comparisons of the number and percentage in each score of study subjects group defined by present and previous score systems 48
Table 15. Association between each score group of summary score developed and modified in previous studies and the risk of CKD (n=4,754) 48
Figure 1. Flowchart with details of selection of study subjects 50
Figure 2. Guidelines of data linking of Longitudinal Cohort of Diabetes Patients database (LHDB) 50
Figure 3. Kaplan-Meier plot (HbA1c frequency) 51
Figure 4. Kaplan-Meier plot (Score group) 52
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