Development and validation of the CHIME simulation model to assess lifetime health outcomes of prediabetes and type 2 diabetes in Chinese populations: A modeling study

Existing predictive outcomes models for type 2 diabetes developed and validated in historical European populations may not be applicable for East Asian populations due to differences in the epidemiology and complications. Despite the continuum of risk across the spectrum of risk factor values, exist...

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Published in:	PLoS medicine Vol. 18; no. 6; p. e1003692
Main Authors:	Quan, Jianchao, Ng, Carmen S, Kwok, Harley H Y, Zhang, Ada, Yuen, Yuet H, Choi, Cheung-Hei, Siu, Shing-Chung, Tang, Simon Y, Wat, Nelson M, Woo, Jean, Eggleston, Karen, Leung, Gabriel M
Format:	Journal Article
Language:	English
Published:	United States Public Library of Science 24-06-2021 Public Library of Science (PLoS)
Subjects:	Aged Amputation Asian People Blood pressure Cardiovascular disease Cerebrovascular disease Cerebrovascular diseases Clinical outcomes Clinical trials Computer Simulation Computer-generated environments Congestive heart failure Coronary artery disease Diabetes Diabetes mellitus (non-insulin dependent) Diabetes Mellitus, Type 2 - diagnosis Diabetes Mellitus, Type 2 - epidemiology Diabetes Mellitus, Type 2 - therapy Diabetic neuropathy Disease Progression Epidemiology Fasting Female Glucose Health aspects Health informatics Health Status Indicators Heart attacks Heart failure Hemoglobin Hong Kong - epidemiology Hospitals Humans Ischemia Male Medicine and Health Sciences Middle Aged Military bases Models, Theoretical Mortality Myocardial infarction Neuropathy Patient outcomes People and places Population studies Prediabetic state Prediabetic State - diagnosis Prediabetic State - epidemiology Prediabetic State - therapy Predictive Value of Tests Prognosis Renal failure Reproducibility of Results Research and Analysis Methods Retinopathy Risk Assessment Risk Factors Statistics Type 2 diabetes Vascular diseases Hong Kong China Hong Kong China East Asia United Kingdom > UK Asia Japan
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Summary:	Existing predictive outcomes models for type 2 diabetes developed and validated in historical European populations may not be applicable for East Asian populations due to differences in the epidemiology and complications. Despite the continuum of risk across the spectrum of risk factor values, existing models are typically limited to diabetes alone and ignore the progression from prediabetes to diabetes. The objective of this study is to develop and externally validate a patient-level simulation model for prediabetes and type 2 diabetes in the East Asian population for predicting lifetime health outcomes. We developed a health outcomes model from a population-based cohort of individuals with prediabetes or type 2 diabetes: Hong Kong Clinical Management System (CMS, 97,628 participants) from 2006 to 2017. The Chinese Hong Kong Integrated Modeling and Evaluation (CHIME) simulation model comprises of 13 risk equations to predict mortality, micro- and macrovascular complications, and development of diabetes. Risk equations were derived using parametric proportional hazard models. External validation of the CHIME model was assessed in the China Health and Retirement Longitudinal Study (CHARLS, 4,567 participants) from 2011 to 2018 for mortality, ischemic heart disease, cerebrovascular disease, renal failure, cataract, and development of diabetes; and against 80 observed endpoints from 9 published trials using 100,000 simulated individuals per trial. The CHIME model was compared to United Kingdom Prospective Diabetes Study Outcomes Model 2 (UKPDS-OM2) and Risk Equations for Complications Of type 2 Diabetes (RECODe) by assessing model discrimination (C-statistics), calibration slope/intercept, root mean square percentage error (RMSPE), and R2. CHIME risk equations had C-statistics for discrimination from 0.636 to 0.813 internally and 0.702 to 0.770 externally for diabetes participants. Calibration slopes between deciles of expected and observed risk in CMS ranged from 0.680 to 1.333 for mortality, myocardial infarction, ischemic heart disease, retinopathy, neuropathy, ulcer of the skin, cataract, renal failure, and heart failure; 0.591 for peripheral vascular disease; 1.599 for cerebrovascular disease; and 2.247 for amputation; and in CHARLS outcomes from 0.709 to 1.035. CHIME had better discrimination and calibration than UKPDS-OM2 in CMS (C-statistics 0.548 to 0.772, slopes 0.130 to 3.846) and CHARLS (C-statistics 0.514 to 0.750, slopes -0.589 to 11.411); and small improvements in discrimination and better calibration than RECODe in CMS (C-statistics 0.615 to 0.793, slopes 0.138 to 1.514). Predictive error was smaller for CHIME in CMS (RSMPE 3.53% versus 10.82% for UKPDS-OM2 and 11.16% for RECODe) and CHARLS (RSMPE 4.49% versus 14.80% for UKPDS-OM2). Calibration performance of CHIME was generally better for trials with Asian participants (RMSPE 0.48% to 3.66%) than for non-Asian trials (RMPSE 0.81% to 8.50%). Main limitations include the limited number of outcomes recorded in the CHARLS cohort, and the generalizability of simulated cohorts derived from trial participants. Our study shows that the CHIME model is a new validated tool for predicting progression of diabetes and its outcomes, particularly among Chinese and East Asian populations that has been lacking thus far. The CHIME model can be used by health service planners and policy makers to develop population-level strategies, for example, setting HbA1c and lipid targets, to optimize health outcomes.
Bibliography:	new_version ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 ObjectType-Undefined-3 The authors have declared that no competing interests exist.
ISSN:	1549-1676 1549-1277 1549-1676
DOI:	10.1371/journal.pmed.1003692