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      Associations between attainment of incentivized primary care indicators and incident lower limb amputation among those with type 2 diabetes: a population-based historical cohort study

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          Abstract

          Introduction

          England has invested considerably in diabetes care through such programs as the Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA). Associations between program indicators and clinical endpoints, such as amputation, remain unclear. We examined associations between primary care indicators and incident lower limb amputation.

          Research design and methods

          This population-based retrospective cohort study, spanning 2010–2017, was comprised of adults in England with type 2 diabetes and no history of lower limb amputation. Exposures at baseline (2010–2011) were attainment of QOF glycated hemoglobin (HbA1c), blood pressure and total cholesterol indicators, and number of NDA processes completed. Propensity score matching was performed and multivariable Cox proportional hazards models, adjusting for disease-related, comorbidity, lifestyle, and sociodemographic factors, were fitted using matched samples for each exposure.

          Results

          83 688 individuals from 330 English primary care practices were included. Mean follow-up was 3.9 (SD 2.0) years, and 521 (0.6%) minor or major amputations were observed (1.62 per 1000 person-years). HbA1c and cholesterol indicator attainment were associated with considerably lower risks of minor or major amputation (adjusted HRs; 95% CIs) 0.61 (0.49 to 0.74; p<0.0001) and 0.67 (0.53 to 0.86; p=0.0017), respectively). No evidence of association between blood pressure indicator attainment and amputation was observed (adjusted HR 0.88 (0.73 to 1.06; p=0.1891)). Substantially lower amputation rates were observed among those completing a greater number of NDA care processes (adjusted HRs 0.45 (0.24 to 0.83; p=0.0106), 0.67 (0.47 to 0.97; p=0.0319), and 0.38 (0.20 to 0.70; p=0.0022) for comparisons of 4–6 vs 0–3, 7–9 vs 0–3, and 7–9 vs 4–6 processes, respectively). Results for major-only amputations were similar for HbA1c and blood pressure, though cholesterol indicator attainment was non-significant.

          Conclusions

          Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.

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          Most cited references35

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          MatchIt: Nonparametric Preprocessing for Parametric Causal Inference

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            Data Resource Profile: Clinical Practice Research Datalink (CPRD)

            The Clinical Practice Research Datalink (CPRD) is an ongoing primary care database of anonymised medical records from general practitioners, with coverage of over 11.3 million patients from 674 practices in the UK. With 4.4 million active (alive, currently registered) patients meeting quality criteria, approximately 6.9% of the UK population are included and patients are broadly representative of the UK general population in terms of age, sex and ethnicity. General practitioners are the gatekeepers of primary care and specialist referrals in the UK. The CPRD primary care database is therefore a rich source of health data for research, including data on demographics, symptoms, tests, diagnoses, therapies, health-related behaviours and referrals to secondary care. For over half of patients, linkage with datasets from secondary care, disease-specific cohorts and mortality records enhance the range of data available for research. The CPRD is very widely used internationally for epidemiological research and has been used to produce over 1000 research studies, published in peer-reviewed journals across a broad range of health outcomes. However, researchers must be aware of the complexity of routinely collected electronic health records, including ways to manage variable completeness, misclassification and development of disease definitions for research.
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              Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34)

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                Author and article information

                Journal
                BMJ Open Diabetes Res Care
                BMJ Open Diabetes Res Care
                bmjdrc
                bmjdrc
                BMJ Open Diabetes Research & Care
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2052-4897
                2021
                26 April 2021
                : 9
                : 1
                : e002069
                Affiliations
                [1 ]departmentDepartment of Public Health Sciences , University of North Carolina at Charlotte , Charlotte, North Carolina, USA
                [2 ]departmentSchool of Data Science , University of North Carolina at Charlotte , Charlotte, North Carolina, USA
                [3 ]departmentDepartment of Primary Care and Public Health , Imperial College London , London, UK
                [4 ]departmentImperial Vascular Unit , Imperial College London NHS Healthcare Trust , London, UK
                [5 ]departmentDepartment of Surgery and Cancer , Imperial College London , London, UK
                [6 ]departmentDivision of Metabolism, Digestion & Reproduction, Faculty of Medicine , Imperial College London , London, UK
                [7 ]departmentDepartment of Diabetes and Endocrinology, St. Mary's Hospital , Imperial College Healthcare NHS Trust , London, UK
                [8 ]NHS England and NHS Improvement , London, UK
                Author notes
                [Correspondence to ] Dr Laura H Gunn; laura.gunn@ 123456uncc.edu
                Author information
                http://orcid.org/0000-0003-3962-4526
                Article
                bmjdrc-2020-002069
                10.1136/bmjdrc-2020-002069
                8076942
                33903115
                2b09ccc4-71ab-4947-b615-cd3c4fca8ed9
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/.

                History
                : 14 December 2020
                : 18 February 2021
                : 03 April 2021
                Funding
                Funded by: National Institute for Health Research (NIHR) North West London Applied Research Collaboration;
                Award ID: N/A
                Funded by: NIHR Academic Clinical Fellowship;
                Award ID: N/A
                Categories
                Pathophysiology/Complications
                1506
                1869
                Custom metadata
                unlocked

                diabetic foot,primary healthcare,diabetes mellitus,type 2

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