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Frontiers of Medicine

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Front. Med.    2022, Vol. 16 Issue (1) : 126-138    https://doi.org/10.1007/s11684-021-0897-7
RESEARCH ARTICLE
Effectiveness of quality of care for patients with type 2 diabetes in China: findings from the Shanghai Integration Model (SIM)
Chun Cai1, Yuexing Liu1, Yanyun Li2, Yan Shi2, Haidong Zou3, Yuqian Bao1, Yun Shen1, Xin Cui4, Chen Fu2(), Weiping Jia1(), the SIM Study Group
1. Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, National Office for Primary Diabetes Care, Shanghai Technical Center for Diabetes Prevention and Clinical Care, Shanghai Key Laboratory of Diabetes Mellitus, Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China
2. Shanghai Municipal Center for Disease Control & Prevention, Shanghai 200336, China
3. Shanghai Eye Disease Prevention and Treatment Center/Shanghai Eye Hospital, Shanghai Key Laboratory of Ocular Fundus Diseases; Shanghai General Hospital, Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai 200040, China
4. Shanghai Municipal Health Commission Information Center, Shanghai 200040, China
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Abstract

This cross-sectional study aimed to investigate the quality of care of diabetes in Shanghai, China. A total of 173 235 patients with type 2 diabetes in 2017 were included in the analysis. Profiles of risk factors and intermediate outcomes were determined. The patients had a mean age of 66.43±8.12 (standard deviation (SD)) years and a mean diabetes duration of 7.95±5.53 (SD) years. The percentage of patients who achieved the target level for HbA1c (<7.0%) was 48.6%. Patients who achieved the target levels for blood pressure (BP)<130/80 mmHg and low-density lipoprotein-cholesterol (LDL-c)<2.6 mmol/L reached 17.5% and 34.0%, respectively. A total of 3.8% achieved all three target levels, and the value increased to 6.8% with an adaptation of the BP target level (<140/90 mmHg) for those over 65 years. Multivariable analysis identified the factors associated with a great likelihood of achieving all three target levels: male, young age, short diabetes duration, low body mass index, macrovascular complications, no microvascular complications, prescribed with lipid-lowering medication, and no prescription of antihypertensive medication. In conclusion, nearly 50% and one-third of the patients with diabetes met the target levels for HbA1c and LDL-c, respectively, with a low percentage achieving the BP target level. The percentage of patients who achieved all three target levels needs significant improvement.
Keywords type 2 diabetes      quality of care      macrovascular complication      microvascular complication      treatment pattern      epidemiology     
Corresponding Author(s): Chen Fu,Weiping Jia   
Just Accepted Date: 28 September 2021   Online First Date: 22 October 2021    Issue Date: 29 March 2022
 Cite this article:   
Chun Cai,Yuexing Liu,Yanyun Li, et al. Effectiveness of quality of care for patients with type 2 diabetes in China: findings from the Shanghai Integration Model (SIM)[J]. Front. Med., 2022, 16(1): 126-138.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-021-0897-7
https://academic.hep.com.cn/fmd/EN/Y2022/V16/I1/126
Fig.1  Flow diagram of recruitment of participants. CHC, community health center; T1D, type 1 diabetes; T2D, type 2 diabetes.
Characteristics Total Male Female Age<65 years Age≥65 years
Participants (n (%)) 173 235 (100.0) 78 042 (45.0) 95 193 (55.0) 69 201 (39.9) 104 034 (60.1)
Demographics
Age (year) 66.43±8.12 66.39±8.23 66.47±8.03 58.76±4.96 71.53±5.32
Sex (male/female) (%) 45.0/55.0 NA NA 44.3/55.7 45.5/54.5
Current smoker (%) 9.5 17.3 3.1 12.9 7.2
Current drinker (%) 6.9 11.7 3.1 8.9 5.6
Family history of diabetes (%) 31.0 30.6 31.4 35.9 27.7
Diabetes duration
Mean±SD (year) 7.95±5.53 7.77±5.49 8.10±5.55 6.92±5.01 8.65±5.75
0 to<5 years (%) 30.9 32.2 29.9 36.7 27.0
5 to<10 years (%) 35.2 35.3 35.1 36.6 34.2
≥10 years (%) 33.9 32.5 35.0 26.7 38.8
Metabolic and related complications
BMI
Mean±SD (kg/m2) 25.02±3.09 24.99±2.88 25.04±3.25 25.00±3.07 25.03±3.10
<24 kg/m2 (%) 38.5 37.3 39.5 38.6 38.5
24 to<28 kg/m2 (%) 44.4 47.6 41.8 44.6 44.3
≥28 kg/m2 (%) 17.1 15.1 18.7 16.8 17.2
Waist circumference (cm) 87.78±8.99 89.60±8.50 86.29±9.10 87.09±8.96 88.25±8.98
Central obesitya (%) 53.2 50.2 55.6 50.0 55.4
SBP (mmHg) 142.19±18.91 140.86±18.43 143.28±19.24 139.08±18.57 144.28±18.86
DBP (mmHg) 80.21±10.09 81.12±10.01 79.46±10.09 81.68±9.94 79.23±10.07
FPG (mmol/L) 7.64±1.95 7.75±1.97 7.56±1.93 7.79±2.01 7.55±1.91
HbA1c (%) 7.22±1.24 7.29±1.26 7.16±1.23 7.27±1.28 7.18±1.22
TC (mmol/L) 4.93±1.02 4.67±0.98 5.14±1.00 5.02±1.00 4.87±1.03
TG (mmol/L) 1.58±0.70 1.51±0.70 1.64±0.70 1.61±0.73 1.56±0.69
HDL-c (mmol/L) 1.31±0.32 1.23±0.31 1.37±0.32 1.30±0.32 1.31±0.32
LDL-c (mmol/L) 2.97±0.88 2.83±0.85 3.09±0.89 3.03±0.87 2.94±0.88
uACR
Median (Quartiles 25%, 75%) (mg/g) 16.17 (7.82, 41.00) 14.22 (6.69, 40.00) 17.75 (8.94, 41.90) 14.20 (7.10, 34.62) 17.80 (8.40, 45.90)
Albuminuria (≥30 mg/g) (%) 31.8 30.5 32.8 28.1 34.2
eGFR
Mean±SD (mL/min/1.73 m2) 85.72±16.34 85.08±16.32 86.24±16.33 93.76±14.03 80.34±15.54
Impaired eGFR (<60 mL/min/1.73 m2) (%) 8.1 8.3 7.9 2.9 11.6
DR (%) 19.3 19.0 19.6 20.5 18.4
One or more microvascular complicationsb (%) 44.7 43.4 45.8 40.8 47.7
One or more macrovascular complicationsc (%) 51.0 46.9 54.3 41.5 57.3
Treatment patterns
Glucose-lowering medication 80.3 80.5 80.0 79.6 80.7
Insulin 11.7 12.3 11.3 11.7 11.7
Antihypertensive medication 70.1 67.1 72.6 61.3 76.0
RAS inhibitors 33.4 32.1 34.5 30.6 35.2
Lipid-lowering medication 29.3 26.4 31.6 23.9 32.8
Statins 22.5 21.0 23.7 17.6 25.7
Aspirin 6.3 5.7 6.7 4.1 7.7
Tab.1  Gender-specific and age-stratified characteristics of 173 235 patients with T2D in Shanghai, China
HbA1c<7% BP LDL-c<2.6 mmol/L All three targetsa met All three age-stratified targetsb met
<130/80 mmHg <130/80 mmHg (<65 years) <140/90 mmHg (≥65 years)
All 48.6 17.5 20.4 41.0 34.0 3.8 6.8
Sex
Female 50.7 17.0 20.4 38.7 29.3 3.3 5.9
Male 46.0* 18.0* 20.3 43.6* 39.6* 4.3* 7.8*
Age
<65 years 47.2 20.4 20.4 NA 31.3 3.9 3.9
≥65 years 49.5* 15.5* NA 41.0 35.7* 3.7# 8.7*
Current smoker
No 48.7 17.0 19.9 40.6 33.8 3.7 6.7
Yes 45.0* 21.6* 23.2* 45.3* 35.8* 4.4* 6.8
Current drinker
No 48.3 17.2 20.3 40.8 33.8 3.7 6.7
Yes 48.7 19.8* 21.4# 42.3# 36.0* 4.5* 7.1
Durationc
0 to<5 years 60.5α,γ 18.2α,γ 20.3 43.2α,γ 33.1 4.4α,γ 7.8α,γ
5 to<10 years 49.2α,β 17.2 20.2 39.8 33.0 3.8α,β 6.5α,β
≥10 years 37.4β,γ 17.5 21.4β,γ 39.8 35.3β,γ 3.1β,γ 6.0β,γ
BMI
<24 kg/m2 52.1 23.1 27.6 47.6 34.8 5.2 8.6
≥24 kg/m2 46.8* 14.2* 16.3* 37.2* 34.2# 3.0* 5.8*
Central obesity
No 52.3 21.3 24.5 46.5 34.7 4.8 8.1
Yes 45.6* 13.9* 16.0* 36.4* 33.9* 2.8* 5.5*
One or more microvascular complicationsd
No 55.6 21.2 23.7 46.3 33.4 4.6 7.9
Yes 41.3* 13.5* 15.3* 34.2* 35.2* 2.6* 5.1*
One or more macrovascular complicationsd
No 47.1 18.3 20.8 40.6 31.1 3.5 5.8
Yes 50.0* 16.6* 19.7* 41.3# 36.7* 4.0* 7.7*
Tab.2  HbA1c, BP, LDL-c and all three targets control rates (%) by subgroups of demographic characteristics and risk factors in T2D participants (n = 173 235)
Part A (binary outcomes) HbA1c<7%
OR (95% CI)		 BP<130/80 mmHg
OR (95% CI)		 LDL-c<2.6 mmol/L
OR (95% CI)		 All three targets meta
OR (95% CI)
Age 1.020 (1.018, 1.022) 0.983 (0.981, 0.985) 1.007 (1.005, 1.009) 0.994 (0.990, 0.999)
Male (vs. female) 0.800 (0.780, 0.821) 0.983 (0.951, 1.016) 1.703 (1.659, 1.749) 1.288 (1.204, 1.378)
Diabetes duration 0.935 (0.932, 0.937) 1.004 (1.001, 1.007) 1.002 (1.000, 1.005) 0.972 (0.965, 0.978)
Current smoker (vs. none) 0.832 (0.785, 0.881) 1.395 (1.303, 1.494) 0.944 (0.892, 0.999) 1.117 (0.973, 1.283)
Current drinker (vs. none) 1.307 (1.225, 1.394) 0.932 (0.862, 1.007) 1.070 (1.004, 1.141) 1.104 (0.946, 1.289)
BMI 0.957 (0.953, 0.961) 0.893 (0.888, 0.898) 0.986 (0.982, 0.990) 0.877 (0.867, 0.887)
One or more microvascular diseases (vs. none) 0.613 (0.597, 0.629) 0.633 (0.612, 0.654) 1.074 (1.046, 1.102) 0.608 (0.566, 0.653)
One or more macrovascular diseases (vs. none) 1.246 (1.214, 1.279) 1.119 (1.082, 1.158) 1.187 (1.156, 1.219) 1.241 (1.158, 1.330)
Glucose-lowering medication (vs. none) 0.417 (0.404, 0.431) NA NA 0.955 (0.880, 1.036)
Antihypertensive medication (vs. none) NA 0.655 (0.633, 0.678) NA 0.838 (0.777, 0.903)
Lipid-lowering medication (vs. none) NA NA 1.839 (1.788, 1.892) 1.743 (1.622, 1.872)
Part A: a All three targets met was defined as HbA1c<7.0%, BP<130/80 mmHg, and LDL-c<2.6 mmol/L.
Part B (continuous outcomes) HbA1c SBP DBP LDL-c
β (95% CI) β (95% CI) β (95% CI) β (95% CI)
Age −0.014 (−0.015, −0.013) 0.312 (0.298, 0.327) −0.209 (−0.217, −0.201) −0.004 (−0.004, −0.003)
Male (vs. female) 0.141 (0.127, 0.155) −1.799 (−2.022, −1.576) 1.927 (1.807, 2.047) −0.284 (−0.295, −0.274)
Diabetes duration 0.043 (0.041, 0.044) 0.055 (0.035, 0.075) −0.111 (−0.122, −0.100) −0.001 (−0.002, 0.000)
Current smoker (vs. none) 0.108 (0.076, 0.139) −2.804 (−3.294, −2.315) −1.234 (−1.498, −0.970) 0.007 (−0.016, 0.031)
Current drinker (vs. none) −0.162 (−0.198, −0.127) 1.785 (1.238, 2.333) 0.654 (0.359, 0.949) 0.003 (−0.023, 0.029)
BMI 0.024 (0.022, 0.026) 0.889 (0.853, 0.924) 0.492 (0.473, 0.512) 0.006 (0.004, 0.008)
One or more microvascular diseases (vs. none) 0.373 (0.359, 0.387) 5.553 (5.334, 5.773) 1.553 (1.435, 1.671) −0.017 (−0.028, −0.007)
One or more macrovascular diseases (vs. none) −0.150 (−0.164, −0.136) −1.482 (−1.707, −1.257) −0.547 (−0.668, −0.426) −0.066 (−0.077, −0.055)
Glucose-lowering medication (vs. none) 0.530 (0.513, 0.548) NA NA NA
Antihypertensive medication (vs. none) NA 3.702 (3.457, 3.947) 1.517 (1.386, 1.649) NA
Lipid-lowering medication (vs. none) NA NA NA −0.243 (−0.255, −0.231)
Part B: Model for HbA1c: R= 0.344, R2 = 0.118, R2adj = 0.118, P <0.001; Model for SBP: R= 0.295, R2 = 0.087, R2adj = 0.087, P <0.001; Model for DBP: R= 0.272, R2 = 0.074, R2adj = 0.074, P <0.001; Model for LDL-c: R= 0.211, R2 = 0.044, R2adj = 0.044, P <0.001.
Tab.3  Multivariable logistic and linear regression analysis of potential factors influencing the adequate control of intermediate outcome measures (HbA1c, BP, LDL-c, and all three targets) in T2D participants
Glucose-lowering medication Antihypertensive medication Lipid-lowering medication All three medication treatmentsa
No Yes No Yes No Yes No Yes
Age (year) 66.00±8.07 66.54±8.13* 63.93±8.13 67.50±7.88* 65.80±8.18 67.95±7.77* 65.86±8.15 68.35±7.70*
Diabetes duration (year) 5.81±4.65 8.49±5.60* 7.43±5.27 8.18±5.62* 7.73±5.37 8.51±5.86* 7.65±5.38 8.99±5.89*
HbA1c (%) 6.67±1.09 7.35±1.24* 7.26±1.28 7.20±1.23* 7.23±1.26 7.19±1.21* 7.20±1.25 7.27±1.21*
<7% (%) 69.1 43.4* 47.6 49.0* 48.4 49.0# 49.4 45.8*
SBP (mmHg) 141.89±18.74 142.26±18.96# 138.02±18.50 143.97±18.81* 142.21±18.93 142.12±18.87 141.93±18.91 143.06±18.92*
DBP (mmHg) 80.87±10.04 80.05±10.09* 79.51±9.92 80.51±10.14* 80.53±10.06 79.43±10.10* 80.41±10.07 79.52±10.11*
BP (%)
<130/80 mmHg 17.1 17.6 23.8 14.8* 17.5 17.5 17.8 16.3*
<130/80 mmHg (<65 years) 20.3 20.4 26.9 16.3* 20.4 20.2 20.8 18.3*
<140/90 mmHg (≥65 years) 40.9 41.0 47.9 38.8* 40.2 42.5* 40.9 41.1
LDL-c mmol/L 3.08±0.84 2.95±0.89* 3.06±0.84 2.94±0.90* 3.04±0.84 2.80±0.96* 3.04±0.85 2.76±0.95*
<2.6 mmol/L (%) 28.6 35.3* 29.3 35.9* 29.8 44.1* 30.5 45.7*
<1.8 mmol/L (%)b 7.8 11.8* 7.7 12.0* 7.7 16.8* 8.3 17.5*
All three targetsc met (%) 4.2 3.6* 4.3 3.5* 3.3 5.0* 3.5 4.7*
All three age-stratified targetsd met (%) 7.7 6.5* 6.4 6.9* 5.8 9.3* 6.2 8.9*
Tab.4  General characteristics and HbA1c, BP, LDL-c, and all three targets control rates (%) disaggregated by subgroups of different prescribed medications (n = 173 235)
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