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. 2012;7(6):e38707.
doi: 10.1371/journal.pone.0038707. Epub 2012 Jun 5.

Differential effects of comorbidity on antihypertensive and glucose-regulating treatment in diabetes mellitus--a cohort study

Jaco Voorham  1 , Flora M Haaijer-Ruskamp, Bruce H R Wolffenbuttel, Dick de Zeeuw, Ronald P Stolk, Petra Denig
Affiliations

Differential effects of comorbidity on antihypertensive and glucose-regulating treatment in diabetes mellitus--a cohort study

Jaco Voorham et al. PLoS One. 2012.

Abstract

Background: Comorbidity is often mentioned as interfering with "optimal" treatment decisions in diabetes care. It is suggested that diabetes-related comorbidity will increase adequate treatment, whereas diabetes-unrelated comorbidity may decrease this process of care. We hypothesized that these effects differ according to expected priority of the conditions.

Methods: We evaluated the relationship between comorbidity and treatment intensification in a study of 11,248 type 2 diabetes patients using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. We formed a cohort of patients with a systolic blood pressure ≥ 140 mmHg (6,820 hypertensive diabetics), and a cohort of patients with an HbA1c ≥ 7% (3,589 hyperglycemic diabetics) in 2007. We differentiated comorbidity by diabetes-related or unrelated conditions and by priority. High priority conditions include conditions that are life-interfering, incident or requiring new medication treatment. We performed Cox regression analyses to assess association with treatment intensification, defined as dose increase, start, or addition of drugs.

Results: In both the hypertensive and hyperglycemic cohort, only patients with incident diabetes-related comorbidity had a higher chance of treatment intensification (HR 4.48, 2.33-8.62 (p<0.001) for hypertensives; HR 2.37, 1.09-5.17 (p = 0.030) for hyperglycemics). Intensification of hypertension treatment was less likely when a new glucose-regulating drug was prescribed (HR 0.24, 0.06-0.97 (p = 0.046)). None of the prevalent or unrelated comorbidity was significantly associated with treatment intensification.

Conclusions: Diabetes-related comorbidity induced better risk factor treatment only for incident cases, implying that appropriate care is provided more often when complications occur. Diabetes-unrelated comorbidity did not affect hypertension or hyperglycemia management, even when it was incident or life-interfering. Thus, the observed "undertreatment" in diabetes care cannot be explained by constraints caused by such comorbidity.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. Patient selection for hypertensive (A) and hyperglycemia (B) study cohort.
See this image and copyright information in PMC

References

    1. Voorham J, Haaijer-Ruskamp FM, van der Meer K, de Zeeuw D, Wolffenbuttel BH. Identifying targets to improve treatment in type 2 diabetes; the Groningen Initiative to aNalyse Type 2 diabetes Treatment (GIANTT) observational study. Pharmacoepidemiol Drug Saf. 2010;19:1086. - PubMed
    1. Voorham J, Haaijer-Ruskamp FM, Wolffenbuttel BH, Stolk RP, Denig P. Cardiometabolic treatment decisions in patients with type 2 diabetes: the role of repeated measurements and medication burden. Qual Saf Health Care. 2010;19:415. - PubMed
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    1. Safford MM, Shewchuk R, Qu H, Williams JH, Estrada CA. Reasons for not intensifying medications: differentiating “clinical inertia” from appropriate care. J Gen Intern Med. 2007;22:1655. - PMC - PubMed

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