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. 2022 Oct 4;11(19):e025603.
doi: 10.1161/JAHA.122.025603. Epub 2022 Sep 21.

Longitudinal Adherence to Diabetes Quality Indicators and Cardiac Disease: A Nationwide Population-Based Historical Cohort Study of Patients With Pharmacologically Treated Diabetes

Nura Abdel-Rahman  1 , Ronit Calderon-Margalit  1 , Arnon Cohen  2 , Einat Elran  3 , Avivit Golan Cohen  4 , Michal Krieger  1 , Ora Paltiel  1 , Liora Valinsky  5 , Arie Ben-Yehuda  6 , Orly Manor  1
Affiliations

Longitudinal Adherence to Diabetes Quality Indicators and Cardiac Disease: A Nationwide Population-Based Historical Cohort Study of Patients With Pharmacologically Treated Diabetes

Nura Abdel-Rahman et al. J Am Heart Assoc. .

Abstract

Background Evidence of the cardiovascular benefits of adherence to quality indicators in diabetes care over a period of years is lacking. Methods and Results We conducted a population-based, historical cohort study of 105 656 people aged 45 to 80 with pharmacologically treated diabetes and who were free of cardiac disease in 2010. Data were retrieved from electronic medical records of the 4 Israeli health maintenance organizations. The association between level of adherence to national quality indicators (2006-2010: adherence assessment) and incidence of cardiac outcome; ischemic heart disease or heart failure (2011-2016: outcome assessment) was estimated using Cox proportional hazards models. During 529 551 person-years of follow-up, 19 246 patients experienced cardiac disease. An inverse dose-response association between the level of adherence and risk of cardiac morbidity was shown for most of the quality indicators. The associations were modified by age, with stronger associations among younger patients (<65 years). Low adherence to low-density lipoprotein cholesterol testing (≤2 years) during the first 5 years was associated with 41% increased risk of cardiac morbidity among younger patients. Patients who had uncontrolled low-density lipoprotein cholesterol in all first 5 years had hazard ratios of 1.60 (95% CI, 1.49-1.72) and 1.23 (95% CI, 1.14-1.32), among patients aged <65 and ≥65 years, respectively, compared with those who achieved _target level. Patients who failed to achieve _target levels of glycated hemoglobin or blood pressure had an increased risk (hazard ratios, 1.50-1.69) for cardiac outcomes. Conclusions Longitudinal adherence to quality indicators in diabetes care is associated with reduced risk of cardiac morbidity. Implementation of programs that measure and enhance quality of care may improve the health outcomes of people with diabetes.

Keywords: diabetes; heart failure; ischemic heart disease; longitudinal adherence; national cohort; quality indicators; quality of diabetes care.

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Figures

Figure 1
Figure 1. Flowchart of study population.
*Cardiac disease: ischemic heart disease (IHD) or heart failure. Cardiac procedure: coronary artery bypass surgery or interventional cardiac catheterization.
Figure 2
Figure 2. Adjusted hazard ratio (95% CI) for cardiac outcome$ (2011–2016) by number of years with achieved _target level (2006–2010).
$Cardiac outcome: the first occurrence of either ischemic heart disease or heart failure. Lack of measurement was considered as uncontrolled, 0 (never controlled during 2006–2010) and 5 (controlled in each year). Circles denote hazard ratio, and horizontal lines represent 95% CIs. HbA1c ≤9% (75 mmol/mol), HbA1c ≤7% (53 mmol/mol) among patients aged ≤74 years or HbA1c ≤8% (64 mmol/mol) among patients aged ≥75 years. *Significant interaction between the intermediate indicator and age group. Age in 2006. # Nage<65=55 555 and Nage≥65=41778. Adjusted for age, sex, body mass index, socioeconomic position, smoking, and health maintenance organization. HbA1c indicates glycated hemoglobin; LDL, low‐density lipoprotein.
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