External validation of the UK Prospective Diabetes Study (UKPDS) risk engine in patients with type 2 diabetes
Tóm tắt
Treatment guidelines recommend the UK Prospective Diabetes Study (UKPDS) risk engine for predicting cardiovascular risk in patients with type 2 diabetes, although validation studies showed moderate performance. The methods used in these validation studies were diverse, however, and sometimes insufficient. Hence, we assessed the discrimination and calibration of the UKPDS risk engine to predict 4, 5, 6 and 8 year cardiovascular risk in patients with type 2 diabetes. The cohort included 1,622 patients with type 2 diabetes. During a mean follow-up of 8 years, patients were followed for incidence of CHD and cardiovascular disease (CVD). Discrimination and calibration were assessed for 4, 5, 6 and 8 year risk. Discrimination was examined using the c-statistic and calibration by visually inspecting calibration plots and calculating the Hosmer–Lemeshow χ2 statistic. The UKPDS risk engine showed moderate to poor discrimination for both CHD and CVD (c-statistic of 0.66 for both 5 year CHD and CVD risks), and an overestimation of the risk (224% and 112%). The calibration of the UKPDS risk engine was slightly better for patients with type 2 diabetes who had been diagnosed with diabetes more than 10 years ago compared with patients diagnosed more recently, particularly for 4 and 5 year predicted CVD and CHD risks. Discrimination for these periods was still moderate to poor. We observed that the UKPDS risk engine overestimates CHD and CVD risk. The discriminative ability of this model is moderate, irrespective of various subgroup analyses. To enhance the prediction of CVD in patients with type 2 diabetes, this model should be updated.
Tài liệu tham khảo
Koskinen P, Manttari M, Manninen V, Huttunen JK, Heinonen OP, Frick MH (1992) Coronary heart disease incidence in NIDDM patients in the Helsinki Heart Study. Diabetes Care 15:820–825
Conroy RM, Pyörälä K, Fitzgerald AP et al (2003) Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 24:987–1003
Pencina MJ, D’Agostino RB Sr, Larson MG, Massaro JM, Vasan RS (2009) Predicting the 30-year risk of cardiovascular disease. The Framingham Heart Study. Circulation
Simmons RK, Coleman RL, Price HC et al (2009) Performance of the UK prospective diabetes study risk engine and the Framingham risk equations in estimating cardiovascular disease in the EPIC-Norfolk cohort. Diabetes Care 32:708–713
Guzder RN, Gatling W, Mullee MA, Mehta RL, Byrne CD (2005) Prognostic value of the Framingham cardiovascular risk equation and the UKPDS risk engine for coronary heart disease in newly diagnosed type 2 diabetes: results from a United Kingdom study. Diabet Med 22:554–562
Stephens JW, Ambler G, Vallance P, Betteridge DJ, Humphries SE, Hurel SJ (2004) Cardiovascular risk and diabetes. Are the methods of risk prediction satisfactory? Eur J Cardiovasc Prev Rehabil 11:521–528
Yang X, So WY, Kong AP et al (2008) Development and validation of a total coronary heart disease risk score in type 2 diabetes mellitus. Am J Cardiol 101:596–601
Stevens RJ, Kothari V, Adler AI, Stratton IM (2001) The UKPDS risk engine: a model for the risk of coronary heart disease in type II diabetes (UKPDS 56). Clin Sci (Lond) 101:671–679
Cederholm J, Eeg-Olofsson K, Eliasson B, Zethelius B, Nilsson PM, Gudbjornsdottir S (2008) Risk prediction of cardiovascular disease in type 2 diabetes: a risk equation from the Swedish National Diabetes Register. Diabetes Care 31:2038–2043
Chamnan P, Simmons RK, Sharp SJ, Griffin SJ, Wareham NJ (2009) Cardiovascular risk assessment scores for people with diabetes: a systematic review. Diabetologia 52:2001–2014
van der Heijden AA, Ortegon MM, Niessen LW, Nijpels G, Dekker JM (2009) Prediction of coronary heart disease risk in a general, pre-diabetic, and diabetic population during 10 years of follow-up: accuracy of the Framingham, SCORE, and UKPDS risk functions: The Hoorn Study. Diabetes Care 32:2094–2098
Kengne AP, Patel A, Colagiuri S et al (2010) The Framingham and UK Prospective Diabetes Study (UKPDS) risk equations do not reliably estimate the probability of cardiovascular events in a large ethnically diverse sample of patients with diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) Study. Diabetologia 53:821–831
NHG-Standaard Cardiovasculair risicomanagement. Available from http://nhg.artsennet.nl/kenniscentrum/k_richtlijnen/k_nhgstandaarden/NHGStandaard/M84_std.htm#Risicoschatting, accessed 7 June 2010
National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guideline for management in primary and secondary care (update). www.nice.org.uk/nicemedia/pdf/CG66FullGuideline0509.pdf, accessed 7 June 2010
Guidelines & Protocols Advisory Committee. Cardiovascular disease—primary prevention. Available from www.bcguidelines.ca/gpac/pdf/cvd.pdf, accessed 7 June 2010
Beulens JW, Monninkhof EM, Verschuren WM et al (2009) Cohort profile: the EPIC-NL study. Int J Epidemiol. doi:10.1093/ije/dyp217
Boeing H, Korfmann A, Bergmann MM (1999) Recruitment procedures of EPIC-Germany. European Investigation into Cancer and Nutrition. Ann Nutr Metab 43:205–215
Herings RMC, Bakker A, Stricker BHC, Nap G (1992) Pharmaco-morbidity linkage: a feasibility study comparing morbidity in two pharmacy based exposure cohorts. J Epidemiol Community Health 46:136–140
Bergmann MM, Bussas U, Boeing H (1999) Follow-up procedures in EPIC-Germany—data quality aspects. European Prospective Investigation into Cancer and Nutrition. Ann Nutr Metab 43:225–234
Donders ART, van der Heijden GJMG, Stijnen T, Moons KGM (2006) Review: a gentle introduction to imputation of missing values. J Clin Epidemiol 59:1087–1091
Harrell FE Jr (2001) Regression modeling strategies. Springer, New York
Zoungas S, de Galan BE, Ninomiya T et al (2009) The combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes; new results from ADVANCE. Diabetes Care 32:2068–2074
Petersen S, Peto V, Rayner M, Leal J, Luengo-Fernandez R, Gray A (2005) European cardiovascular disease statistics. British Heart Foundation, London, pp 57. Available from www.heartstats.org/uploads/documents%5CPDF.pdf, accessed 7 June 2010
Sandbaek AF, Griffin SJ, Rutten GF et al (2008) Stepwise screening for diabetes identifies people with high but modifiable coronary heart disease risk. The ADDITION study. Diabetologia 51:1127–1134
Altman DG, Vergouwe Y, Royston P, Moons KG (2009) Prognosis and prognostic research: validating a prognostic model. BMJ 338:b605
Moons KG, Altman DG, Vergouwe Y, Royston P (2009) Prognosis and prognostic research: application and impact of prognostic models in clinical practice. BMJ 338:b606