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Linking the Legacy Effect in Type 2 Diabetes to Clinical Decision Making

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Observational follow-up of the landmark United Kingdom Prospective Diabetes Study revealed that early tight glycemic control had persistent benefits among adults with newly diagnosed diabetes even a decade after the trial had ended. This phenomenon has been dubbed the legacy effect of glycemic control and has not been observed for blood pressure control. The existence of the legacy effect implies that the timing of glycemic control, for example, early vs. late in the disease course, may have clinical consequences. This raises new fundamental diabetes translational research questions. In clinical practice, how soon after diagnosis do patients achieve hemoglobin A1C (A1C) and blood pressure (BP) control and for how long? How do different long-term patterns of control affect future health outcomes? And what do patients believe regarding how and when the timing of therapies to achieve A1C and BP control affects their health outcomes? I am an internist who is committed to exploring whether the legacy effect exists in clinical practice and how to translate this novel observation from clinical trials into improved clinical care. Using a large, observationl cohort of adults from Kaiser Permanente Northern California with newly diagnosed diabetes (1995-2005), I will (Aim 1) characterize common patterns of a) A1C and b) BP control over e10 years of follow-up and (Aim 2) compare complications/mortality rates over e15 years of follow-up among patients with various 10-year patterns of a) A1C and b) BP control. Then in order to develop a theoretical model for how patients perceive the concept of time in their diabetes-related health decisions, I will conduct semi-structured interviews with patients with Type 2 diabetes to (Aim 3) explore their beliefs regarding the timing of A1C and BP control. The results of these studies will be used to inform a future R01 behavioral intervention focused on improving patient outcomes through effective risk communication and appropriately timed efforts to intensify A1C and BP control. During this career development award, I will work closely with my mentor, Dr. Elbert Huang, who is a nationally- recognized investigator in medical decision making for older adults with diabetes and Director of the Quantitative Analysis Core and Enrichment Programs of the Chicago Center for Diabetes Translation Research (P30) at the University of Chicago, and my co-mentor, Dr. Andrew Karter, an accomplished diabetes epidemiologist at Kaiser Permanente Northern California Division of Research, in addition to my advisory panel of leaders in longitudinal data analysis, endocrinology, health economics and behavioral psychology. This proposed research, along with additional training in advanced epidemiology, biostatistics and behavioral psychology, and the expertise of my mentorship team will help me achieve my long-term goal of becoming an independent clinical investigator with expertise in the optimal timing of Type 2 diabetes treatments and its risk communication.
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