糖尿病治疗有进展但仍存不足

《新英格兰医学杂志》4月25日在线发表的一项研究显示，自1999年以来，成人糖尿病治疗在依从预防措施和控制糖尿病并发症危险因素方面取得了明显进展。然而，仍有半数的患者未达到血糖控制、血压和血脂控制目标，并且半数患者表示未接受过糖尿病教育、常被忽视而未接受推荐的每年1次的疫苗接种、牙科检查和眼部检查(N. Engl. J. Med. 2013;368:1613-24)。

在这项研究中，亚特兰大疾病防控中心的Mohammed K. Ali博士及其同事采用数次全国健康与营养调查(NHANES 1999~2002、2003~2006和2007~2010)和行为危险因素监测系统调查(BRFSS 2000、2004和2008)的数据，研究了糖尿病治疗随时间推移的进展情况。这两种调查纳入的均为具有全国代表性的人群样本，并且均依赖于对健康相关行为的自我报告。

在该研究中，研究者对报告患有糖尿病的3,355名NHANES受访者和97,310名BRFSS受访者的数据进行了分析。

结果显示，在最早一次调查(1999~2002)和最近一次调查(2007~2010)之间，血糖控制不佳的患者比例降低了5.8%，而达到推荐的糖化血红蛋白、血压和LDL胆固醇目标水平的患者比例分别显著增加7.9%、11.7%和20.8%。

同样，随着时间推移，糖化血红蛋白水平、LDL胆固醇水平和血压水平的人群分布均获得显著改善。平均糖化血红蛋白水平降低0.4%，平均LDL胆固醇水平降低17.7 mg/dl至99.5 mg/dl。平均血压降低4/2 mmHg至130/68 mmHg。在同期内，无微量白蛋白尿的成人糖尿病患者比例增加4.0%，10年冠心病风险显著降低2.8%。

然而，最近的调查显示，半数的糖尿病患者仍未达到糖化血红蛋白、血压或LDL胆固醇的目标水平，超过22%的患者仍吸烟。仅14.3%的受访者达到所有4个危险因素的目标。仅22.4%的受访者接受推荐的每年1次的流感疫苗注射、每年1次的眼部检查和每年1次的脚部检查。

根据患者年龄对数据进行分析发现，年龄较小(≤44岁)的成人糖尿病患者在达到治疗目标或遵循预防建议方面并无改善，原因尚不清楚，但这一结果表明需进一步关注较年轻的成人糖尿病患者。

获取医疗服务的渠道有限的患者和社会经济地位较低的患者在整个研究期间比其他患者更易存在危险因素控制不佳的情况。研究者表示，这与既往研究结果一致，即扩大医疗保险覆盖面有助于较好地控制危险因素及促进对预防措施的依从。令人遗憾的是，在研究期间，虽然平均收入和教育水平均有所提高，但无医保的糖尿病患者比例仍保持不变。

研究者声明无经济利益冲突。

随刊述评：值得庆祝，但仍有很长的路要走

《新英格兰医学杂志》编辑Graham T. McMahon博士和和Robert G. Dluhy博士表示，该研究观察到血糖、血压和血脂达标率改善，这点值得庆祝，但数据也显示，要使糖尿病治疗质量真正达到患者要求还有很长的路要走。通过加强质量改进，以及从零散治疗转变为长期治疗和专家组管理模式，可能有助于进一步改善糖尿病的施治。另外，设置面向临床医生的奖励机制也有助于改善糖尿病的施治。此类奖励可采取金钱形式，也可采取其他形式，如给予公共和学术上的声望。McMahon博士和Dluhy博士无其他经济利益冲突(N. Engl. J. Med. 2013;368:1650-1)。

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By: MARY ANN MOON, Cardiology News Digital Network

Adults with diabetes made substantial gains since 1999 in adherence to preventive practices and in control of risk factors for diabetic complications, according to a report published online April 25 in the New England Journal of Medicine.

However, up to half of these patients still failed to meet targets for glycemic control, blood pressure, and lipid control, and approximately half reported that they never received diabetes education, usually neglected getting the recommended yearly vaccinations, and failed to get the recommended annual dental and eye examinations, said Dr. Mohammed K. Ali of the Centers for Disease Control and Prevention, Atlanta, and his associates (N. Engl. J. Med. 2013;368:1613-24).
 
According to a recent report, adults with diabetes have made substantial gains in controlling risk factors for diabetic complications.
 
The investigators examined changes over time in diabetes care by analyzing data from a series of National Health and Nutrition Examination Surveys (NHANES 1999-2002, 2003-2006, and 2007-2010) and Behavioral Risk Factor Surveillance System surveys (2000, 2004, and 2008). Both sets of surveys include nationally representative samples of the population, and both also rely on self-reports of health-related behavior.

For this study, Dr. Ali and his colleagues included data from 3,355 NHANES participants and 97,310 BRFSS participants who reported having diabetes.

Between the earliest (1999-2002) and the most recent (2007-2010) survey, the proportion of patients with poor glycemic control decreased by 5.8 percentage points, while the proportion who met recommended targets for glycated hemoglobin level, blood pressure, and LDL cholesterol levels rose substantially (by 7.9, 11.7, and 20.8 percentage points, respectively).

Similarly, the population distributions of glycated hemoglobin levels, LDL cholesterol levels, and blood pressure levels all improved significantly over time. The mean glycated hemoglobin levels dropped by 0.4 percentage points, and the mean LDL cholesterol level declined by 17.7 mg/dL, to 99.5 mg/dL. The mean blood pressure decreased by 4/2 mm Hg, to 130/68 mm Hg.

At the same time, the proportion of adults with diabetes who were free of microalbuminuria rose by 4.0 percentage points, and the 10-year risk of coronary heart disease dropped significantly by 2.8 percentage points.

However, up to half of the diabetes patients in the most recent surveys still failed to meet targets for glycated hemoglobin level, blood pressure, or LDL cholesterol levels, and more than 22% still smoked. Only 14.3% of the survey participants met the targets for all four risk factors, the investigators said.

Only 22.4% of the respondents got their annual flu vaccines, annual eye exams, and annual foot exams as recommended.

When the data were analyzed by patient age, younger adults with diabetes (those aged 44 years and younger) showed no improvements in meeting their treatment goals or in following preventive recommendations. The reason for this lack of improvement isn’t clear, but the finding "suggests that younger adults with diabetes need further attention," Dr. Ali and his associates said.

Respondents with limited access to health care and those of lower socioeconomic status were more likely than others to have suboptimal control of risk factors throughout the study period.

"Our findings concur with previous reports: Health insurance coverage was significantly and consistently associated with better, more improved risk-factor profiles and preventive practices during the 12 years examined in our study," the investigators noted.

"Unfortunately, the proportion of persons with diabetes who do not have health insurance has remained the same, despite increases in mean income and educational level over the study period," they concluded.

No financial conflicts of interest were reported.

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Reason to celebrate, but a long way to go

There is reason to celebrate the improvements in achieving glycemic, blood-pressure, and lipid targets documented in the study by Dr. Ali and his colleagues, but the data also show "there’s a long way to go to deliver the quality of diabetes care that truly meets our patients’ needs," according to Dr. Graham T. McMahon and Dr. Robert G. Dluhy.

"The next wave of improvement in the delivery of diabetes care will probably come through intensive quality improvement and a movement away from episodic care toward the chronic care model and panel management," they predicted.

Incentive systems for clinicians that reward incremental improvement, not just the achievement of target goals, would be helpful. Such incentives may be financial, but others, such as public profiling "or the provision of credits in a program that allows continuous maintenance of certification, may also be motivational," they added.

Dr. McMahon and Dr. Dluhy are in the division of endocrinology, diabetes, and hypertension at Brigham and Women’s Hospital, Boston. Dr. McMahon is the medical education editor at the New England Journal of Medicine, and Dr. Dluhy is an associate editor at the journal. They reported no other financial conflicts of interest. These remarks were taken from their editorial accompanying Dr. Ali’s report (N. Engl. J. Med. 2013;368:1650-1).