Differential impact of ambulatory visits to specialist physicians on major cardiovascular events among incident cases of diabetes with or without known coronary heart disease: a cohort study
Notice bibliographique
Résumé
Abstract Background Following a diagnosis of diabetes, specialist physicians may be solicited regarding the prevention of major cardiovascular events (MACE) (stroke, myocardial infarction, cardiovascular death). Patients with established coronary heart disease (CHD) are more susceptible to MACE and may require distinct attention. However, trajectories of visits to specialists are heterogenous and their efficacy preventing MACE remains unexplored. Purpose To assess whether trajectories of ambulatory visits to specialists are associated with MACE among new cases of diabetes, considering the presence or absence of CHD. Methods Using an integrated surveillance system of linked administrative databases dating back to 1996, we identified new diabetes cases aged ≥20 years during fiscal year 2013, with no history of MACE. Trajectory period: Individual trajectories based on the presence/absence of ≥1 ambulatory visit to a specialist (cardiologist/internist/endocrinologist) were compiled from diagnosis across consecutive 3-month periods, up to 2 years. Patients with no specialist visit constituted a "primary care" group, while others were grouped using latent class trajectory analysis. Patients experiencing a MACE during this period were excluded. Explanatory period: Stratifying by the presence or absence of CHD at the end of the trajectory period, we compared MACE risk between groups using a Cox proportional model, from year 2 post-diagnosis up to 12-31-2019, adjusted with inverse probability weighting and presented as adjusted hazard ratio (aHR) with 95% confidence intervals (CI). Results Among the 29,949 patients, we identified 4 trajectory groups (Figure 1). During the trajectory period, the proportion of patients who consulted ≥1 specialist was 64% with known CHD, compared to 35% without CHD. Among patients who met ≥1 specialist, those with CHD were more likely to have consulted a cardiologist (74%) than those without CHD (37%), while they were less likely to have met with an internist (37 vs 50%) or an endocrinologist (11 vs 31%). During the explanatory period, 796 MACE occurred among the 4,783 patients with CHD. Patients who had "early visits only" had a lower risk of MACE, while no difference was observed with "regular/frequent" and "regular/sparce" visits compared with the "primary care" group (Table 1). A total of 1,440 MACE occurred among the 25,166 patients without CHD. Patients with "regular/frequent" visits had no difference in the risk of MACE compared with the "primary care" group, while an increased risk of MACE was observed among those with "early visits only" and "regular/sparce visits". Conclusions While confounding by indication may persist, these results highlight the potential role of specialists in averting MACE in the context of CHD. However, the divergent risks of MACE according to the absence of CHD, visit frequency, and timing, advocate for improvement in the preventive role of specialists post-diabetes diagnosis.
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,000 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,002 | 0,001 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».