The Promising Success of Project Extension for Community Healthcare Outcomes (ECHO) Diabetes: Case Series.

BACKGROUND: In the United States, there are over 37 million people with diabetes but only 8000 endocrinologists. Therefore, many people with diabetes receive care exclusively from primary care providers (PCPs). To democratize knowledge regarding insulin-requiring diabetes through tele-education, Stanford University and the University of Florida developed Project Extension for Community Healthcare Outcomes (ECHO) Diabetes. OBJECTIVE: ECHO Diabetes uses a Hub and Spoke model connecting specialists (the "Hub") with PCPs (the "Spokes"). One-hour, weekly sessions include Hub diabetes didactic presentations and Spoke deidentified case presentations. Lessons learned during these sessions target provider knowledge and confidence surrounding diabetes management and patient care. METHODS: Spokes were asked to provide short descriptions of people with diabetes whose diabetes management improved directly or indirectly from their providers' participation or their involvement with a Diabetes Support Coach (DSC). We provide a case series to describe individuals and outcomes. Because this study was not a randomized controlled trial and was a prospective observation of patients with the intervention delivered to providers, the trial is not registered in a public trials registry. RESULTS: A case series of 11 people with diabetes was compiled from 10 PCPs and 1 DSC from California and Florida between 2021 and 2022. The principal impact of ECHO Diabetes is the education amplified from PCPs and DSCs to people with diabetes. In all cases, people with diabetes reported increased engagement and improved diabetes management. Several cases reflected increased access to diabetes technology, improvement in glycemic outcomes, and positive trends in mental health measures. CONCLUSIONS: This case series elucidates the potential value of the ECHO Diabetes program to people with diabetes who receive their diabetes care from PCPs. Those matched with a DSC saw clinically significant improvements in hemoglobin A1c and mental health outcomes.

Cardiometabolic correlates of low type 2 diabetes incidence in western Alaska Native people - The WATCH study.

AIMS: Previously rare among Alaska Native (AN) people, type 2 diabetes (DM2) prevalence as indicated by registry data has increased by as much as 300% in some western Alaska regions. We sought to determine prevalence and incidence of DM2 and analyze associated cardiometabolic risk factors in western AN people. METHODS: DM2 and prediabetes prevalence and incidence were determined by the Western Alaska Tribal Collaborative for Health using consolidated data from cohort studies conducted during 2000-2010. Crude and age-adjusted incidence for DM2 and prediabetes were calculated using 2010 American Diabetes Association criteria. Effects of covariates on DM2 and prediabetes were determined using univariate and multivariate Cox proportional hazards analyses, adjusted for age and sex. RESULTS: Excluding baseline diabetes (n=124, 4.5%), 53 cases of new DM2 were identified among 2630 participants. Age- and sex-adjusted DM2 incidence was 4.3/1000 (95% CI 2.9, 5.0) person-years over an average 5.9-year follow up. After excluding baseline prediabetes, 387 new cases of prediabetes were identified among 1841 participants; adjusted prediabetes incidence was 44.5/1000 (95% CI 39.5, 49.5) person years. Independent predictors for DM2 included age, impaired fasting glucose, and metabolic syndrome; family history of diabetes and obesity were additional independent predictors for prediabetes. CONCLUSIONS: DM2 incidence in western AN people is substantially lower than that for U.S. whites; however, incidence of prediabetes is more than 10-fold higher than western AN DM2 incidence and more closely aligned with U.S. rates. Interventions aimed at achieving healthy lifestyles are needed to minimize risk factors and maximize protective factors for DM2 in this population.

All-cause, cardiovascular, and cancer mortality in western Alaska Native people: western Alaska Tribal Collaborative for Health (WATCH).

OBJECTIVES: We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths. METHODS: Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics. RESULTS: Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7). CONCLUSIONS: We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents.

Over the past 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. The rapid emergence of childhood T2DM poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline was developed to provide evidence-based recommendations on managing 10- to 18-year-old patients in whom T2DM has been diagnosed. The American Academy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with the support of the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association). These groups collaborated to develop an evidence report that served as a major source of information for these practice guideline recommendations. The guideline emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. Recommendations are made for situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM. The recommendations suggest integrating lifestyle modifications (ie, diet and exercise) in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring hemoglobin A1c (HbA1c) and finger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent peer review before it was approved by the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, and its recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated. The AAP acknowledges that some primary care clinicians may not be confident of their ability to successfully treat T2DM in a child because of the child's age, coexisting conditions, and/or other concerns. At any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DM is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatrician partners with parents to ensure that all health needs are met.

Management of type 2 diabetes mellitus in children and adolescents.

OBJECTIVE: Over the last 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. This technical report describes, in detail, the procedures undertaken to develop the recommendations given in the accompanying clinical practice guideline, "Management of Type 2 Diabetes Mellitus in Children and Adolescents," and provides in-depth information about the rationale for the recommendations and the studies used to make the clinical practice guideline's recommendations. METHODS: A primary literature search was conducted relating to the treatment of T2DM in children and adolescents, and a secondary literature search was conducted relating to the screening and treatment of T2DM's comorbidities in children and adolescents. Inclusion criteria were prospectively and unanimously agreed on by members of the committee. An article was eligible for inclusion if it addressed treatment (primary search) or 1 of 4 comorbidities (secondary search) of T2DM, was published in 1990 or later, was written in English, and included an abstract. Only primary research inquiries were considered; review articles were considered if they included primary data or opinion. The research population had to constitute children and/or adolescents with an existing diagnosis of T2DM; studies of adult patients were considered if at least 10% of the study population was younger than 35 years. All retrieved titles, abstracts, and articles were reviewed by the consulting epidemiologist. RESULTS: Thousands of articles were retrieved and considered in both searches on the basis of the aforementioned criteria. From those, in the primary search, 199 abstracts were identified for possible inclusion, 58 of which were retained for systematic review. Five of these studies were classified as grade A studies, 1 as grade B, 20 as grade C, and 32 as grade D. Articles regarding treatment of T2DM selected for inclusion were divided into 4 major subcategories on the basis of type of treatment being discussed: (1) medical treatments (32 studies); (2) nonmedical treatments (9 studies); (3) provider behaviors (8 studies); and (4) social issues (9 studies). From the secondary search, an additional 336 abstracts relating to comorbidities were identified for possible inclusion, of which 26 were retained for systematic review. These articles included the following: 1 systematic review of literature regarding comorbidities of T2DM in adolescents; 5 expert opinions presenting global recommendations not based on evidence; 5 cohort studies reporting natural history of disease and comorbidities; 3 with specific attention to comorbidity patterns in specific ethnic groups (case-control, cohort, and clinical report using adult literature); 3 reporting an association between microalbuminuria and retinopathy (2 case-control, 1 cohort); 3 reporting the prevalence of nephropathy (cohort); 1 reporting peripheral vascular disease (case series); 2 discussing retinopathy (1 case-control, 1 position statement); and 3 addressing hyperlipidemia (American Heart Association position statement on cardiovascular risks; American Diabetes Association consensus statement; case series). A breakdown of grade of recommendation shows no grade A studies, 10 grade B studies, 6 grade C studies, and 10 grade D studies. With regard to screening and treatment recommendations for comorbidities, data in children are scarce, and the available literature is conflicting. Therapeutic recommendations for hypertension, dyslipidemia, retinopathy, microalbuminuria, and depression were summarized from expert guideline documents and are presented in detail in the guideline. The references are provided, but the committee did not independently assess the supporting evidence. Screening tools are provided in the Supplemental Information.

Diabetes prevalence, incidence, complications and mortality among Alaska Native people 1985-2006.

OBJECTIVES: To examine trends in diabetes prevalence, incidence, complications and mortality between 1985 and 2006 among Alaska Native people. STUDY DESIGN: We used data from the population-based Alaska Native Diabetes Registry, which includes all people who receive care in the Alaska Tribal Health System. METHODS: We compared the periods of 1986-1990 and 2002-2006 for diabetes-related amputations, renal replacement and mortality using Poisson regression. Complications and mortality data were examined for trends using Poisson regression. Survival analyses for those diagnosed since 31 December 1985 were performed using the Cox proportional hazard model. RESULTS: Age-adjusted diabetes prevalence increased from 17.3 in 1985 to 47.6/1,000 in 2006. The number of Alaska Native people living in Alaska with diabetes increased from 610 in 1985 to 3,386 in 2006. Diabetes incidence rates have also increased. Comparing age-adjusted rates for the 5-year periods 1986-1990 and 2002-2006, amputations decreased from 5.3 to 2.6/1,000, renal replacement decreased from 3.3 to 1.2/1,000 and mortality decreased from 41.7 to 33.2/1,000. Yearly analyses showed a downward trend for amputations, renal replacement and mortality rates. Survival analyses showed a significantly higher hazard ratio for any amputations, major amputations and renal replacement for the earlier time period compared to the most recent time period. CONCLUSIONS: An increase in risk factors, awareness, funding and case-finding may be contributing to the increase in prevalence and incidence of diagnosed diabetes. While diabetes prevalence and incidence are increasing among Alaska Native people, our results suggest that even in remote, rural areas, complications and mortality can be reduced.

Metabolic syndrome: prevalence among American Indian and Alaska native people living in the southwestern United States and in Alaska.

BACKGROUND: Metabolic syndrome occurs commonly in the United States. The purpose of this study was to measure the prevalence of metabolic syndrome among American Indian and Alaska Native people. METHODS: We measured the prevalence rates of metabolic syndrome, as defined by the National Cholesterol Education Program, among four groups of American Indian and Alaska Native people aged 20 years and older. One group was from the southwestern United States (Navajo Nation), and three groups resided within Alaska. Prevalence rates were age-adjusted to the U.S. adult 2000 population and compared to rates for U.S. whites (National Health and Nutrition Examination Survey [NHANES] 1988-1994). RESULTS: Among participants from the southwestern United States, metabolic syndrome was found among 43.2% of men and 47.3% of women. Among Alaska Native people, metabolic syndrome was found among 26.5% of men and 31.2% of women. In Alaska, the prevalence rate varied by region, ranging among men from 18.9% (western Alaska) to 35.1% (southeast), and among women from 22.0% (western Alaska) to 38.4 % (southeast). Compared to U.S. whites, American Indian/Alaska Native men and women from all regions except western Alaska were more likely to have metabolic syndrome; men in western Alaska were less likely to have metabolic syndrome than U.S. whites, and the prevalence among women in western Alaska was similar to that of U.S. whites. CONCLUSION: The prevalence rate of metabolic syndrome varies widely among different American Indian and Alaska Native populations. Differences paralleled differences in the prevalence rates of diabetes.

Regional variation in cardiovascular disease risk factors among American Indians and Alaska Natives with diabetes.

OBJECTIVE: To compare by region risk factors for cardiovascular disease among American Indian populations with diabetes. RESEARCH DESIGN AND METHODS: Trained providers from 185 federal, urban, and tribally operated facilities reviewed the records from systematic random samples of the patients included in the local diabetes registries in the 1998 Indian Health Service (IHS) Diabetes Care and Outcomes Audit. Selected measures of cardiovascular risk were aggregated by region and adjusted to calculate regional rates for patients <45 years of age (n = 2,595) and those aged > or =45 years (n = 8,294). RESULTS: Among the younger group of patients with diabetes, the rates of elevated HbA(1c) (> or =9%) and tobacco use varied significantly among regions. High rates of obesity (78%) and elevated HbA(1c) (56%) were found in the Southwest. High rates of tobacco use (55%) but the lowest rates of elevated HbA(1c) (27%) were found in Alaska. Among patients aged > or =45 years, all measures including rates of proteinuria, cholesterol > or =200 mg/dl, and mean blood pressure > or =130/85 varied significantly among all regions. Tobacco use was highest in the Great Lakes (44%) and Great Plains (42%) regions and lowest in the Southwest (14%) and Colorado Plateau (8%) regions. Proteinuria was found most frequently in the Southwest (35%), Colorado Plateau (30%), and Pacific regions (35%). Older individuals with diabetes were more likely than younger individuals to have proteinuria and blood pressure > or =130/85. CONCLUSIONS: American Indians and Alaska Natives with diabetes carry a large burden of potentially modifiable cardiovascular risk factors, but there is significant regional variation.