Differential Effects of Comorbidity on Antihypertensive and Glucose-Regulating Treatment in Diabetes Mellitus – A Cohort Study

Voorham, Jaco; Haaijer‐Ruskamp, Flora; Wolffenbuttel, Bruce H. R.; Zeeuw, Dick de; Stolk, Ronald P.; Denig, Petra

doi:10.1371/journal.pone.0038707

Cited by 27 publications

(33 citation statements)

References 30 publications

(57 reference statements)

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“…That is, that sicker patients with more comorbidity, who will have poorer outcomes, may be less aggressively treated for their diabetes. However, in a previous study we found no evidence that comorbid conditions decrease the likelihood to intensify medication treatment in patients with diabetes [28]. Moreover, the absence of associations between the indicators measuring lipid- and blood pressure-lowering treatment intensification and hard outcomes also makes this explanation less likely.…”

Section: Discussioncontrasting

confidence: 58%

Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes?

et al. 2013

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BackgroundLandmark clinical trials have led to optimal treatment recommendations for patients with diabetes. Whether optimal treatment is actually delivered in practice is even more important than the efficacy of the drugs tested in trials. To this end, treatment quality indicators have been developed and tested against intermediate outcomes. No studies have tested whether these treatment quality indicators also predict hard patient outcomes.MethodsA cohort study was conducted using data collected from >10.000 diabetes patients in the Groningen Initiative to Analyze Type 2 Treatment (GIANTT) database and Dutch Hospital Data register. Included quality indicators measured glucose-, lipid-, blood pressure- and albuminuria-lowering treatment status and treatment intensification. Hard patient outcome was the composite of cardiovascular events and all-cause death. Associations were tested using Cox regression adjusting for confounding, reporting hazard ratios (HR) with 95% confidence intervals.ResultsLipid and albuminuria treatment status, but not blood pressure lowering treatment status, were associated with the composite outcome (HR = 0.77, 0.67–0.88; HR = 0.75, 0.59–0.94). Glucose lowering treatment status was associated with the composite outcome only in patients with an elevated HbA1c level (HR = 0.72, 0.56–0.93). Treatment intensification with glucose-lowering but not with lipid-, blood pressure- and albuminuria-lowering drugs was associated with the outcome (HR = 0.73, 0.60–0.89).ConclusionTreatment quality indicators measuring lipid- and albuminuria-lowering treatment status are valid quality measures, since they predict a lower risk of cardiovascular events and mortality in patients with diabetes. The quality indicators for glucose-lowering treatment should only be used for restricted populations with elevated HbA1c levels. Intriguingly, the tested indicators for blood pressure-lowering treatment did not predict patient outcomes. These results question whether all treatment indicators are valid measures to judge quality of health care and its economics.

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Section: Discussioncontrasting

confidence: 58%

Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes?

et al. 2013

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“…Another potential reason for our concordance findings is that patients with more concordant conditions might receive better diabetes care due to a greater sense of urgency in providers and patients to optimize diabetes care for patients who already have diabetic complications and have a greater need for diabetes care goal achievement (American Diabetes Association, 2011; Kerr et al, 2007; Laiteerapong et al, 2011; Voorham et al, 2012). Past studies support this rationale.…”

Section: Discussionmentioning

confidence: 95%

“…Past studies support this rationale. In one study, providers only intensified blood sugar treatment in uncontrolled diabetes for patients who had a new-onset complication (Voorham et al, 2012). In another study, patients with microvascular-concordant conditions expressed higher self-care priority for diabetes care goals than did patients without these concordant conditions (Kerr et al, 2007).…”

Section: Discussionmentioning

confidence: 99%

“…There is conflicting evidence that the presence of concordant and discordant conditions leads to differences in the receipt of recommended diabetes care (Desai et al, 2002; Kerr et al, 2007; Krein et al, 2009; Pentakota et al, 2012; Redelmeier et al, 1998; Sales et al, 2009; Thorpe et al, 2012; Vitry et al, 2010; Voorham et al, 2012). For example, concordant conditions have been associated with a higher likelihood of HbA1c and cholesterol control in one study (Woodard et al, 2011) but only with cholesterol control in another (Pentakota et al, 2012).…”

Section: Introductionmentioning

confidence: 99%

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The impact of a patient’s concordant and discordant chronic conditions on diabetes care quality measures

Magnan

Palta

Johnson

et al. 2015

Journal of Diabetes and its Complications

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Aims Most patients with diabetes have comorbid chronic conditions that could support (concordant) or compete with (discordant) diabetes care. We sought to determine the impact of the number of concordant and discordant chronic conditions on diabetes care quality. Methods Logistic regression analysis of electronic health record data from 7 health systems on 24,430 patients with diabetes aged 18-75 years. Diabetes testing and control quality care goals were the outcome variables. The number of diabetes-concordant and the number of diabetes-discordant conditions were the main explanatory variables. Analysis was adjusted for health care utilization, health system and patient demographics. Results A higher number of concordant conditions were associated with higher odds of achieving testing and control goals for all outcomes except blood pressure control. There was no to minimal positive association between the number of discordant conditions and outcomes, except for cholesterol testing which was less likely with 4+ discordant conditions. Conclusions Having more concordant conditions makes diabetes care goal achievement more likely. The number of discordant conditions has a smaller, inconsistently significant impact on diabetes goal achievement. Interventions to improve diabetes care need to align with a patient’s comorbidities, including the absence of comorbidities, especially concordant comorbidities.

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“…It would also be useful to gather information about the duration that the patients have had hypertension to see if that plays a role, which was not done here. Previous studies have shown a relationship between higher blood pressure and higher HbA1c (poorer diabetic health), 26, 27 as well as a relationship between these factors and the presence of both retinopathy and macular edema. 28–30 However, to our knowledge, there is only one other study that examined the relationship between blood pressure and retinal thickness measured by OCT in subjects with diabetes.…”

Section: Discussionmentioning

confidence: 97%

Blood Pressure, Vessel Caliber, and Retinal Thickness in Diabetes

Harrison¹,

Chang

Cardenas

et al. 2012

Optometry and Vision Science

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Purpose In this study we examine the association of blood pressure (BP), retinal thickness (RT), and vessel caliber in patients with type 2 diabetes and high HbA1c (elevated long-term blood glucose), either with or without mild or moderate non-proliferative diabetic retinopathy (NPDR). Methods Forty-three type 2 diabetes patients with high HbA1c measures (23 without NPDR and 20 with mild to moderate NPDR) and 22 age-matched, non-diabetic controls participated. BP, RT (Stratus OCT3), fundus photography, and HbA1c were measured. Correlations between BP, HbA1c, vessel caliber, and RT were evaluated. Results 1) Diastolic BP is positively and significantly associated with RT in patients with NPDR (p <0.02). BP was not associated with retinal thickness in patients without NPDR (p = 0.83). 2) There is an association between higher HbA1c and higher diastolic BP within the NPDR group (p<0.02). Furthermore, HbA1c modifies the slope of the relationship between diastolic BP and RT in NPDR patients. 3) Greater venule diameters and a loss of the correlation between decreased arteriole size and increased systolic blood pressure, seen in controls, were observed in patients with and without NPDR. Conclusions The results of this study show that HbA1c and BP together have an impact on the retinal thickness measures of patients with diabetic retinopathy. These measures should be considered when evaluating retinal thickness in patients with diabetic retinopathy, both clinically and in future OCT studies on this population.

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Differential Effects of Comorbidity on Antihypertensive and Glucose-Regulating Treatment in Diabetes Mellitus – A Cohort Study

Cited by 27 publications

References 30 publications

Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes?

Do Treatment Quality Indicators Predict Cardiovascular Outcomes in Patients with Diabetes?

The impact of a patient’s concordant and discordant chronic conditions on diabetes care quality measures

Blood Pressure, Vessel Caliber, and Retinal Thickness in Diabetes

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