Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions.

Data suggest that more men than women are dying of coronavirus disease 2019 (COVID-19) worldwide, but it is unclear why. A biopsychosocial approach is critical for understanding the disproportionate death rate among men. Biological, psychological, behavioral, and social factors may put men at disproportionate risk of death. We propose a stepwise approach to clinical, public health, and policy interventions to reduce COVID-19-associated morbidity and mortality among men. We also review what health professionals and policy makers can do, and are doing, to address the unique COVID-19-associated needs of men.

Clinical Identification and Referral of Adults With Prediabetes to a Diabetes Prevention Program.

PURPOSE AND OBJECTIVES: Community programs to prevent or delay the onset of type 2 diabetes are effective, but implementing these programs to maximize their reach and impact remains a challenge. The American Medical Association (AMA) partnered with the YMCA of the USA, as part of a Centers for Medicare and Medicaid Innovation demonstration project, to develop, implement, and evaluate innovative quality improvement strategies to increase routine screening, testing, and referral of Medicare patients with prediabetes to diabetes prevention programs (DPPs) at local YMCAs. INTERVENTION APPROACH: AMA recruited 26 primary care practices and health systems in 17 US communities to implement point-of-care and retrospective methods (or a combination of both) for screening, testing, and referral of Medicare patients with prediabetes. EVALUATION METHODS: We assessed changes in rates of referral and enrollment of patients among participating practices. We used a mixed-methods pretest-posttest evaluation design to determine if use of certain tools and resources, coupled with systems changes, led to increased screening and referrals. RESULTS: Practices referred a total of 5,640 patients, of whom 1,050 enrolled in a YMCA DPP (19%; range, 2%-98%). Practices (n = 12) that used retrospective (ie, electronic medical record [EMR]) systems to identify eligible Medicare patients via a registry referred more people (n = 4,601) to the YMCA DPP than practices (n = 10) that used a point-of-care method alone (n = 437 patients) or practices (n = 4) that used a combination of these approaches (n = 602 patients). All approaches showed increased enrollment with point-of-care methods being most successful. IMPLICATIONS FOR PUBLIC HEALTH: Lessons learned from this intervention can be used to increase diabetes prevention in the United States and support the Centers for Medicare and Medicaid Services (CMS) decision to expand Medicare coverage to include the DPP for all Medicare beneficiaries.

Trends and Inequalities in Diabetes-Related Complications Among U.S. Adults, 2000-2020.

OBJECTIVE: We examined national trends in diabetes-related complications (heart failure [HF], myocardial infarction [MI], stroke, end-stage renal disease [ESRD], nontraumatic lower-extremity amputation [NLEA], and hyperglycemic crisis) among U.S. adults with diagnosed diabetes during 2000-2020 by age-group, race and ethnicity, and sex. We also assessed trends in inequalities among those subgroups. RESEARCH DESIGN AND METHODS: Hospitalization rates for diabetes-related complications among adults (≥18 years) were estimated using the 2000-2020 National (Nationwide) Inpatient Sample. The incidence of diabetes-related ESRD was estimated using the United States Renal Data System. The number of U.S. adults with diagnosed diabetes was estimated from the National Health Interview Survey. Annual percent change (APC) was estimated for assessment of trends. RESULTS: After declines in the early 2000s, hospitalization rates increased for HF (2012-2020 APC 3.9%, P < 0.001), stroke (2009-2020 APC 2.8%, P < 0.001), and NLEA (2009-2020 APC 5.9%, P < 0.001), while ESRD incidence increased (2010-2020 APC 1.0%, P = 0.044). Hyperglycemic crisis increased from 2000 to 2020 (APC 2.2%, P < 0.001). MI hospitalizations declined during 2000-2008 (APC -6.0%, P < 0.001) and were flat thereafter. On average, age inequalities declined for hospitalizations for HF, MI, stroke, and ESRD incidence but increased for hyperglycemic crisis. Sex inequalities increased on average for hospitalizations for stroke and NLEA and for ESRD incidence. Racial and ethnic inequalities declined during 2012-2020 for ESRD incidence but increased for HF, stroke, and hyperglycemic crisis. CONCLUSIONS: There was a continued increase of several complications in the past decade. Age, sex, and racial and ethnic inequalities have worsened for some complications.

Impact of changes in diabetes screening guidelines on testing eligibility and potential yield among adults without diagnosed diabetes in the United States.

AIMS: Recent USPSTF and ADA guidelines expanded criteria of whom to test to identify prediabetes and diabetes. We described which Americans are eligible and report receiving glucose testing by USPSTF 2015 and 2021 as well as ADA 2003 and 2022 recommendations, and performance of each guideline. METHODS: We analyzed cross-sectional data from 6,007 non-pregnant U.S. adults without diagnosed diabetes in the 2013-2018 National Health and Nutrition Examination Surveys. We reported proportions of adults who met each guideline's criteria for glucose testing and reported receiving glucose testing in the past three years, overall and by key population subgroups,. Defining prediabetes (FPG 100-125 mg/dL and/or HbA1c 5.7-6.4 %) or previously undiagnosed diabetes (FPG ≥ 126 mg/dL and/or HbA1c ≥ 6.5 %), we assessed sensitivity and specificity. RESULTS: During 2013-2018, 76.7 million, 90.4 million, 157.7 million, and 169.5 million US adults met eligibility for glucose testing by USPSTF 2015, 2021, and ADA 2003 and 2022 guidelines, respectively. On average, 52 % of adults reported receiving glucose testing within the past 3 years. Likelihood of receiving glucose testing was lower among younger adults, men, Hispanic adults, those with less than high school completion, those living in poverty, and those without health insurance or a usual place of care than their respective counterparts. ADA recommendations were most sensitive (range: 91.0 % to 100.0 %) and least specific (range: 18.3 % to 35.3 %); USPSTF recommendations exhibited lower sensitivity (51.9 % to 66.6 %), but higher specificity (56.6 % to 74.5 %). CONCLUSIONS: An additional 12-14 million US adults are eligible for diabetes screening. USPSTF 2021 criteria provide balanced sensitivity and specificity while ADA 2022 criteria maximize sensitivity. Glucose testing does not align with guidelines and disparities remain.

Trends in the Prevalence and Treatment of Diabetic Macular Edema and Vision-Threatening Diabetic Retinopathy Among Commercially Insured Adults Aged <65 Years.

OBJECTIVE: Examine the 10-year trend in the prevalence and treatment of diabetic macular edema (DME) and vision-threatening diabetic retinopathy (VTDR) among commercially insured adults with diabetes. RESEARCH DESIGN AND METHODS: We analyzed the 10-year trend (2009-2018) in health care claims for adults aged 18-64 years using the IBM MarketScan Database, a national convenience sample of employer-sponsored health insurance. We included patients continuously enrolled in commercial fee-for-service health insurance for 24 months who had a diabetes ICD-9/10-CM code on one or more inpatient or two or more different-day outpatient claims in the index year or previous calendar year. We used diagnosis and procedure codes to calculate the annual prevalence of patients with one or more claims for 1) any DME, 2) either DME or VTDR, and 3) antivascular endothelial growth factor (anti-VEGF) injections and laser photocoagulation treatment, stratified by any DME, VTDR with DME, and VTDR without DME. We calculated the average annual percent change (AAPC). RESULTS: From 2009 to 2018, there was an increase in the annual prevalence of patients with DME or VTDR (2.1% to 3.4%; AAPC 7.5%; P < 0.001) and any DME (0.7% to 2.6%; AAPC 19.8%; P < 0.001). There were sex differences in the annual prevalence of DME or VTDR and any DME, with men having a higher prevalence than women. Annual claims for anti-VEGF injections increased among patients with any DME (327%) and VTDR with DME (206%); laser photocoagulation decreased among patients with any DME (-68%), VTDR with DME (-54%), and VTDR without DME (-62%). CONCLUSIONS: Annual claims for DME or VTDR and anti-VEGF injections increased whereas those for laser photocoagulation decreased among commercially insured adults with diabetes.

Diabetes Prevalence and Incidence Inequality Trends Among U.S. Adults, 2008-2021.

INTRODUCTION: This study examined national trends in age, sex, racial and ethnic, and socioeconomic inequalities for diagnosed diabetes prevalence and incidence among U.S. adults from 2008 to 2021. METHODS: Adults (aged ≥18 years) were from the National Health Interview Survey (2008-2021). The annual between-group variance (BGV) for sex, race, and ethnicity; and the slope index of inequality (SII) for age, education, and poverty-to-income ratio along with the average annual percentage change (AAPC) were estimated in 2023 to assess trends in inequalities over time in diabetes prevalence and incidence. For BGV and SII, a value of 0 represents no inequality, whereas a value further from 0 represents greater inequality. RESULTS: On average over time, poverty-to-income ratio inequalities in diabetes prevalence worsened (SII= -8.24 in 2008 and -9.80 in 2021; AAPC for SII= -1.90%, p=0.003), whereas inequalities in incidence for age (SII=17.60 in 2008 and 8.85 in 2021; AAPC for SII= -6.47%, p<0.001), sex (BGV=0.09 in 2008, 2.05 in 2009, 1.24 in 2010, and 0.27 in 2021; AAPC for BGV= -12.34%, p=0.002), racial and ethnic (BGV=4.80 in 2008 and 2.17 in 2021; AAPC for BGV= -10.59%, p=0.010), and education (SII= -9.89 in 2008 and -2.20 in 2021; AAPC for SII=8.27%, p=0.001) groups improved. CONCLUSIONS: From 2008 to 2021, age, sex, racial and ethnic, and education inequalities in the incidence of diagnosed diabetes improved but persisted. Income-related diabetes prevalence inequalities worsened over time. To close these gaps, future research could focus on identifying the factors driving these trends, including the contribution of morbidity and mortality.

Screening for Prediabetes and Diabetes: Clinical Performance and Implications for Health Equity.

INTRODUCTION: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended prediabetes and diabetes screening for asymptomatic adults aged 35-70 years with overweight/obesity, lowering the age from 40 years in its 2015 recommendation. The USPSTF suggested considering earlier screening in racial and ethnic groups with high diabetes risk at younger ages or lower BMI. This study examined the clinical performance of these USPSTF screening recommendations as well as alternative age and BMI cutoffs in the U.S. adult population overall, and separately by race and ethnicity. METHODS: Nationally representative data were collected from 3,243 nonpregnant adults without diagnosed diabetes in January 2017-March 2020 and analyzed from 2021 to 2022. Screening eligibility was based on age and measured BMI. Collectively, prediabetes and undiagnosed diabetes were defined by fasting plasma glucose ≥100 mg/dL or hemoglobin A1c ≥5.7%. The sensitivity, specificity, and predictive values of alternate screening criteria were examined overall, and by race and ethnicity. RESULTS: The 2021 criteria exhibited marginally higher sensitivity (58.6%, 95% CI=55.5, 61.6 vs 52.9%, 95% CI=49.7, 56.0) and lower specificity (69.3%, 95% CI=65.7, 72.2 vs 76.4%, 95% CI=73.3, 79.2) than the 2015 criteria overall, and within each racial and ethnic group. Screening at lower age and BMI thresholds resulted in even greater sensitivity and lower specificity, especially among Hispanic, non-Hispanic Black, and Asian adults. Screening all adults aged 35-70 years regardless of BMI yielded the most equitable performance across all racial and ethnic groups. CONCLUSIONS: The 2021 USPSTF screening criteria will identify more adults with prediabetes and diabetes in all racial and ethnic groups than the 2015 criteria. Screening all adults aged 35-70 years exhibited even higher sensitivity and performed most similarly by race and ethnicity, which may further improve early detection of prediabetes and diabetes in diverse populations.

Clinical performance and health equity implications of the American Diabetes Association's 2023 screening recommendation for prediabetes and diabetes.

Introduction: The American Diabetes Association (ADA) recommends screening for prediabetes and diabetes (dysglycemia) starting at age 35, or younger than 35 years among adults with overweight or obesity and other risk factors. Diabetes risk differs by sex, race, and ethnicity, but performance of the recommendation in these sociodemographic subgroups is unknown. Methods: Nationally representative data from the National Health and Nutrition Examination Surveys (2015-March 2020) were analyzed from 5,287 nonpregnant US adults without diagnosed diabetes. Screening eligibility was based on age, measured body mass index, and the presence of diabetes risk factors. Dysglycemia was defined by fasting plasma glucose ≥100mg/dL (≥5.6 mmol/L) or haemoglobin A1c ≥5.7% (≥39mmol/mol). The sensitivity, specificity, and predictive values of the ADA screening criteria were examined by sex, race, and ethnicity. Results: An estimated 83.1% (95% CI=81.2-84.7) of US adults were eligible for screening according to the 2023 ADA recommendation. Overall, ADA's screening criteria exhibited high sensitivity [95.0% (95% CI=92.7-96.6)] and low specificity [27.1% (95% CI=24.5-29.9)], which did not differ by race or ethnicity. Sensitivity was higher among women [97.8% (95% CI=96.6-98.6)] than men [92.4% (95% CI=88.3-95.1)]. Racial and ethnic differences in sensitivity and specificity among men were statistically significant (P=0.04 and P=0.02, respectively). Among women, guideline performance did not differ by race and ethnicity. Discussion: The ADA screening criteria exhibited high sensitivity for all groups and was marginally higher in women than men. Racial and ethnic differences in guideline performance among men were small and unlikely to have a significant impact on health equity. Future research could examine adoption of this recommendation in practice and examine its effects on treatment and clinical outcomes by sex, race, and ethnicity.

Proportions and trends of adult hospitalizations with Diabetes, United States, 2000-2018.

AIMS: To report the national proportions and trends of adult hospitalizations with diabetes in the United States during 2000-2018. METHODS: We used the 2000-2018 National Inpatient Sample to identify hospital discharges with any listed and primary diagnoses for diabetes, based on International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) and ICD-10-CM codes. We calculated proportions and trends of adult hospitalizations with diabetes, overall and by subpopulations. We used the Nationwide Readmissions Database to assess calendar-year and 30-day readmission rates. RESULTS: From 2000 to 2018, the proportion of hospitalizations among adults ≥18 years increased from 17.1% to 27.3% (average annual percentage change [AAPC] 2.5%; P < 0.001) for any listed diabetes codes and from 1.5% to 2.1% (AAPC 2.2%; P < 0.001) for primary diagnosis of diabetes. Men, non-Hispanic Black patients, and those from poorer zip codes had higher proportions of hospitalizations with diabetes codes. CONCLUSION: In recent years, approximately one-quarter of adult hospitalizations in the United States had a listed diabetes code, increasing about 2.5% per year from 2000 to 2018. These data are important for benchmarking purposes, especially due to disruptions in health care utilization from the COVID-19 pandemic.