Building a multistate model from electronic health records data for modeling long-term diabetes complications

Abstract

Objective: The progression of long-term diabetes complications has led to a decreased quality of life. Our objective was to evaluate the adverse outcomes associated with diabetes based on a patient's clinical profile by utilizing a multistate modeling approach.

Methods: This was a retrospective study of diabetes patients seen in primary care practices from 2013 to 2017. We implemented a five-state model to examine the progression of patients transitioning from one complication to having multiple complications. Our model incorporated high dimensional covariates from multisource data to investigate the possible effects of different types of factors that are associated with the progression of diabetes.

Results: The cohort consisted of 10,596 patients diagnosed with diabetes and no previous complications associated with the disease. Most of the patients in our study were female, White, and had type 2 diabetes. During our study period, 5928 did not develop complications, 3323 developed microvascular complications, 1313 developed macrovascular complications, and 1129 developed both micro- and macrovascular complications. From our model, we determined that patients had a 0.1334 [0.1284, .1386] rate of developing a microvascular complication compared to 0.0508 [0.0479, .0540] rate of developing a macrovascular complication. The area deprivation index score we incorporated as a proxy for socioeconomic information indicated that patients who reside in more disadvantaged areas have a higher rate of developing a complication compared to those who reside in least disadvantaged areas.

Conclusions: Our work demonstrates how a multistate modeling framework is a comprehensive approach to analyzing the progression of long-term complications associated with diabetes.

Keywords: Diabetes; diabetes complications; electronic health records; multistate modeling; transition probability.

Figure 1.

Flowchart of patient selection. A total of 10,596 patients were selected for our study population. DM = diabetes mellitus.

Figure 2.

Model diagnostic plot of final model, observed vs expected (estimated) patients for each state over time. Tables of observed number of patients for each state.

Figure 3.

Five-state model for examining the progression of diabetes-related complications using electronic health records among diabetes patients. N, number of censored patients at the end of follow-up or loss to follow-up; n, number of observed transitions; TI [], transition intensity [95% CI]. Transition from diabetes state to Both State is not an allowable transition. Both State refers to patients who have a micro- and macrovascular complication. Death is the final absorbing state.