Clocks Moving at Different Speeds: Cultural Variation in the Satisfaction With Wait Time for Outpatient Care.

OBJECTIVE: To explore racial/ethnic differences in satisfaction with wait time of scheduled office visits by comparing electronic health record (EHR)-based, patient-reported, and patient satisfaction with wait time STUDY SETTING: : A large multispecialty ambulatory care organization in Northern California. Patient experience surveys were collected between 2010 and 2014. Surveys were mailed after randomly selected nonurgent visits. Returned survey data were linked to EHR data for surveyed visits. STUDY DESIGN: Observational, retrospective study designed to assess differences in patient-reported wait time, wait-time satisfaction, and actual EHR-recorded wait time with respect to self-reported race/ethnicity. Multivariate regression models with provider random effects were used to evaluate differences. RESULTS: Asian subgroups (Chinese, Asian Indian, Filipino, Japanese, Korean, and Vietnamese) and Latinos gave poorer ratings for wait time than non-Hispanic whites (NHWs). The average wait time reported by Asians was longer than that reported by NHWs. On the basis of EHR data, however, no minority group was likely to wait longer, and all, except for Japanese (10%), were more likely to be late for the appointment (16%: Filipino and 23%: Asian Indian), than NHWs (13%). CONCLUSIONS: Given actual wait times, Asians perceive longer wait time and were less satisfied with wait times. Asians may have different expectations about wait time at the clinic.

First Trimester Hemoglobin A1c Prediction of Gestational Diabetes.

Objective The objective of this study is to examine whether a first trimester hemoglobin A1c (A1C) of 5.7 to 6.4% predicts an abnormal second trimester oral glucose tolerance test (OGTT). Methods We conducted a retrospective cohort study of all women screened with A1C through 13 (6/7) weeks' gestation between January 1, 2011, and December 31, 2012. Prediabetic women (A1C of 5.7-6.4%) were compared with women with a normal first trimester A1C (< 5.7%). The primary outcome was an abnormal 2-hour, 75-g OGTT as defined by the International Association of Diabetes and Pregnancy Study Groups. Results There were 2,812 women who met inclusion criteria of whom 6.7% (n = 189) were prediabetic. Women with prediabetes were more likely to have gestational diabetes mellitus (GDM) even after adjusting for potential confounders (29.1 vs. 13.7%; adjusted relative risk, 1.48; 95% confidence interval, 1.15-1.89). There were no statistically significant differences in secondary outcomes except that women with prediabetes had less excessive gestational weight gain. A prediabetic-range A1C in the first trimester was associated with a 13% sensitivity and a 94% specificity for predicting GDM Conclusion Although women with prediabetes by first trimester A1C are significantly more likely to have GDM, the low sensitivity of an A1C in this range renders it a poor test to identify women who will develop GDM.

Racial/ethnic differences in dyslipidemia patterns.

BACKGROUND: No studies have comprehensively examined the prevalence of dyslipidemia, a major risk factor for cardiovascular disease, among diverse racial/ethnic minority groups. The primary aim of this study was to identify racial/ethnic differences in dyslipidemia among minorities including Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, or Vietnamese), Mexican Americans, and blacks compared with non-Hispanic whites. METHODS AND RESULTS: Using a 3-year cross section (2008-2011), we identified 169 430 active primary care patients (35 years or older) from an outpatient healthcare organization in northern California. Age-standardized prevalence rates were calculated for 3 dyslipidemia subtypes: high triglycerides (fasting laboratory value ≥150 mg/dL), low levels of high-density lipoprotein cholesterol (fasting laboratory value <40 mg/dL [men] and <50 mg/dL [women]), and high levels of low-density lipoprotein cholesterol (fasting laboratory value ≥130 mg/dL or taking low-density lipoprotein-lowering agents). Odds ratios were calculated by multivariable logistic regression, with adjustment for patient characteristics (age, measured body mass index, smoking). Compared with non-Hispanic whites, every minority subgroup had an increased prevalence of high triglycerides except blacks. Most minority groups had an increased prevalence of low high-density lipoprotein cholesterol, except for Japanese and blacks. The prevalence of high low-density lipoprotein cholesterol was increased among Asian Indians, Filipinos, Japanese, and Vietnamese compared with non-Hispanic whites. CONCLUSIONS: Minority groups, except for blacks, were more likely to have high triglyceride/low high-density lipoprotein cholesterol dyslipidemia. Further research is needed to determine how racial/ethnic differences in dyslipidemia affect racial/ethnic differences in cardiovascular disease rates.

Racial/Ethnic Differences in Gestational Diabetes Prevalence and Contribution of Common Risk Factors.

BACKGROUND: The White House, the American Heart Association, the Agency for Healthcare Research and Quality, and the National Heart, Lung and Blood Institute have all recently acknowledged the need to disaggregate Asian American subgroups to better understand this heterogeneous racial group. This study aims to assess racial/ethnic differences in relative contribution of risk factors of gestational diabetes mellitus (GDM) among Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese), Hispanics, non-Hispanic blacks, and non-Hispanic whites. METHODS: Pregnant women in 2007-2012 were identified through California state birth certificate records and linked to the electronic health records in a large mixed-payer ambulatory care organisation in Northern California (n = 24 195). Relative risk and population attributable fraction (PAF) for specific racial/ethnic groups were calculated to assess the contributions of advanced maternal age, overweight/obesity (Centers for Disease Control and Prevention (CDC) standards and World Health Organization (WHO)/American Diabetes Association (ADA) body mass index cut-offs for Asians), family history of type 2 diabetes, and foreign-born status. RESULTS: GDM was most prevalent among Asian Indians (19.3%). Relative risks were similar across all race/ethnic groups. Advanced maternal age had higher PAFs in non-Hispanic whites (22.5%) and Hispanics (22.7%). Meanwhile family history (Asian Indians 22.6%, Chinese 22.9%) and foreign-borne status (Chinese 40.2%, Filipinos 30.2%) had higher PAFs in Asian subgroups. Overweight/obesity was the most important GDM risk factor for non-Hispanic whites, Hispanics, Asian Indians, and Filipinos when the WHO/ADA cut-off points were applied. Advanced maternal age was the only risk factor studied that was modified by race/ethnicity, with non-Hispanic white and Hispanic women being more adversely affected than other racial/ethnic groups. CONCLUSIONS: Overweight/obesity, advanced maternal age, family history of type 2 diabetes, and foreign-borne status are important risk factors for GDM. The relative contributions of these risk factors differ by race/ethnicity, mainly due to differences in population prevalence of these risk factors.

Dyslipidemia in Special Ethnic Populations.

This article reviews racial/ethnic differences in dyslipidemia-prevalence of dyslipidemia, its relation to coronary heart disease (CHD) and stroke mortality rates, response to lipid-lowering agents, and lifestyle modification. Asian Indians, Filipinos, and Hispanics are at higher risk for dyslipidemia, which is consistent with the higher CHD mortality rates in these groups. Statins may have greater efficacy for Asians, but the data are mixed. Lifestyle modifications are recommended. Culturally-tailored prevention and intervention should be provided to the minority populations with elevated risk for dyslipidemia and considerably more research is needed to determine the best approaches to helping specific subgroups.

Comparative effectiveness of early versus delayed metformin in the treatment of type 2 diabetes.

AIM: The purpose of this study was to evaluate the effectiveness of early versus delayed initiation of metformin in type 2 diabetes. METHODS: We identified 2925 new users of metformin with type 2 diabetes between 2005 and 2012 in the electronic health records of an integrated health system in Northern California. Patients were matched 1:1 on the propensity for receiving early treatment (defined as ≤6 months from first evidence of diabetes). We evaluated the effectiveness of early versus delayed metformin treatment on intermediate clinical outcomes indicated by changes in hemoglobin A1c (HbA1c) and body mass index (BMI), as well as the incidence of therapy intensification (addition or substitution of a second antihyperglycemic agent). RESULTS: A total of 2144 propensity-score matched patients were included in the early or delayed treatment group (n=1072, in each). Early treatment was associated with significantly larger decreases in HbA1c (-0.36%; 95% confidence intervals [CI]: -0.44 to -0.27%; P<0.001) and BMI (-0.46 kg/m(2); 95% CI: -0.64 to -0.29 kg/m(2); P<0.001) relative to delayed treatment. Patients receiving early treatment also had a greater likelihood of attaining an HbA1c<7% (<53 mmol/mol) (odds ratio: 2.00; 95% CI: 1.63-2.45; P<0.001) and a reduced risk of therapy intensification (hazard ratio: 0.72; 95% CI: 0.61-0.85; P<0.001). CONCLUSIONS: Treatment with metformin earlier in the course of type 2 diabetes is associated with better glycemic control, more pronounced weight reduction, and a lower risk for therapy intensification than delayed treatment. Antihyperglycemic therapy should be initiated early after diagnosis to achieve optimal outcomes.

Initiation of treatment for incident diabetes: evidence from the electronic health records in an ambulatory care setting.

OBJECTIVE: We examined patterns and predictors of initiation of treatment for incident diabetes in an ambulatory care setting in the US. METHODS: Data were extracted from electronic health records (EHR) for active patients ≥ 35 years in a multispecialty, multiclinic ambulatory care organization with 1000 providers. New onset type 2 diabetes and subsequent treatment were identified using lab, diagnosis, medication prescription, and service use data. Time from the first evidence of diabetes until initial treatment, either medication or education/counseling, was examined using a Kaplan-Meier hazards curve. Potential predictors of initial treatment were examined using multinomial logistic models accounting for physician random effects. RESULTS: Of 2258 patients with incident diabetes, 55% received either medication or education/counseling (20% received both) during the first year. Of the treated patients, 68% received a treatment within the first four weeks, and 13% after initial 16 weeks. Strong positive predictors (P < 0.01) of combined treatment were younger age, higher fasting glucose at diagnosis, obesity, and visits with an endocrinologist. CONCLUSIONS: Among insured patients who have a primary care provider in a multispecialty health care system, incident diabetes is treated only half the time. Improved algorithms for identifying incident diabetes from the EHR and team approach for monitoring may help treatment initiation.

Dyslipidemia in special ethnic populations.

This article reviews racial/ethnic differences in dyslipidemia-prevalence of dyslipidemia, its relation to coronary heart disease (CHD) and stroke mortality rates, response to lipid-lowering agents, and lifestyle modification. Asian Indians, Filipinos, and Hispanics are at higher risk for dyslipidemia, which is consistent with the higher CHD mortality rates in these groups. Statins may have greater efficacy for Asians, but the data are mixed. Lifestyle modifications are recommended. Culturally-tailored prevention and intervention should be provided to the minority populations with elevated risk for dyslipidemia and considerably more research is needed to determine the best approaches to helping specific subgroups.

Impact of Education on Weight in Newly Diagnosed Type 2 Diabetes: Every Little Bit Helps.

AIMS: Highly structured, intensive behavioral lifestyle interventions have been shown to be efficacious in research settings for type 2 diabetes management and weight loss. We sought to evaluate the benefit of participation in more limited counseling and/or education among individuals with newly diagnosed type 2 diabetes in more modest real-world clinical settings. METHODS: Electronic Health Records of newly diagnosed type 2 diabetes patients age 35-74 from a large ambulatory group practice were analyzed (n = 1,314). We examined participation in clinic-based lifestyle counseling/education and subsequent weight loss. RESULTS: Of the total cohort, 599 (45.6%) patients received counseling/education with (26.2%) and without (19.4%) medication, 298(22.7%) patients received a prescription for medication alone, and 417(31.7%) patients were only monitored. On average, those who participated in counseling/education attended 2.5 sessions (approximately 2-3 hours). The average weight loss of patients who received counseling/education alone during the follow-up period (up to three years post-exposure to participation) was 6.3 lbs. (3.3% of body weight), and, if received with medication prescription, 8.1 lbs. (4.0% of body weight) (all at P<0.001). The weight loss associated with medication was only 3.5 lbs. (P<0.001). No significant weight change was observed in the monitoring only group. CONCLUSIONS: While efforts to improve both the short-term and long-term effectiveness of behavioral lifestyle interventions in real-world settings are ongoing, it is important for clinicians to continue to utilize less intensive, existing resources. Even relatively small "doses" of health education may help in promoting weight loss and may potentially reduce cardiometabolic risk.

Racial/ethnic differences in hypertension prevalence, treatment, and control for outpatients in northern California 2010-2012.

BACKGROUND: Hypertension (HTN) is a known major cardiovascular disease risk factor, but prevalence, treatment, and control of HTN among rapidly growing minority groups such as Asian Americans and Hispanics are unknown largely due to either underrepresentation in epidemiologic studies or aggregation of Asian American subgroups. METHODS: A three-year cross-section (2010-2012) of patients from a large ambulatory care setting in northern California was examined in the following subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Mexicans, non-Hispanic Blacks (NHBs), and non-Hispanic Whites (NHWs). We defined HTN as two separate nonemergent office visit blood pressure measurements ≥140/90 mm Hg, physician diagnosis of HTN, or use of antihypertensive medications. RESULTS: A total of 208,985 patients were included in the study. Age-adjusted HTN prevalence ranged from 30.0% in Chinese women to 59.9% in Filipino men. Most minority subgroups had lower or similar odds of having HTN compared with NHWs, except for Filipinos and NHBs whose odds were significantly higher after adjusting for patient demographic and clinical characteristics. Asian Americans and NHBs were more likely to be treated for HTN compared with NHWs. Achievement of blood pressure control was lower among Filipino women (odds ratio = 0.82, 99% confidence interval 0.70-0.96) and NHB men (odds ratio = 0.73, 99% confidence interval 0.58-0.91), compared with NHW women and men. CONCLUSIONS: Substantial racial/ethnic variation in HTN prevalence, treatment, and control was found in our study population. Filipino and NHB women and men are at especially high risk for HTN and may have more difficulty in achieving adequate blood pressure control.

Racial/ethnic differences in control of cardiovascular risk factors among type 2 diabetes patients in an insured, ambulatory care population.

AIMS: This paper examines differences in cardiovascular disease risk factor control among racial/ethnic minorities (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hispanic/Latino, Black/African Americans) with type 2 diabetes compared to Non-Hispanic Whites with type 2 diabetes in an insured, outpatient setting. METHODS: A three-year, cross-sectional sample of 15,826 patients with type 2 diabetes was studied between 2008 and 2010. Goal attainment rates for three cardiovascular disease risk factors (HbA1c, BP, LDL) were estimated. Logistic regression was used to determine the association between patient characteristics and control of risk factors. RESULTS: Only one fifth (21.1%) of patients achieved simultaneous goal attainment (HbA1c, BP, LDL). After adjustment for patient characteristics and treatment, Black/African American women and men, and Filipino and Hispanic/Latino men were significantly less likely to simultaneously achieve all three goals, compared to Non-Hispanic Whites. Of the three goals, patients were more likely to achieve HbA1c goals (68.7%) than BP (45.7%) or LDL (58.5%) goals. Racial/ethnic differences were more apparent in risk factors that were under better control (i.e. HbA1c). CONCLUSIONS: Cardiovascular risk factor control in type 2 diabetes is suboptimal, even in an insured population. Special attention may be required for specific racial/ethnic/gender groups.

Racial/ethnic differences in the prevalence of proteinuric and nonproteinuric diabetic kidney disease.

OBJECTIVE: To examine racial/ethnic differences in the prevalence of diabetic kidney disease (DKD), with and without proteinuria, in an outpatient health care organization. RESEARCH DESIGN AND METHODS: We examined electronic health records for 15,683 persons of non-Hispanic white (NHW), Asian (Asian Indian, Chinese, and Filipino), Hispanic, and non-Hispanic black (NHB) race/ethnicity with type 2 diabetes and no prior history of kidney disease from 2008 to 2010. We directly standardized age- and sex-adjusted prevalence rates of proteinuric DKD (proteinuria with or without low estimated glomerular filtration rate [eGFR]) or nonproteinuric DKD (low eGFR alone). We calculated sex-specific odds ratios of DKD in racial/ethnic minorities (relative to NHWs) after adjustment for traditional DKD risk factors. RESULTS: Racial/ethnic minorities had higher rates of proteinuric DKD than NHWs (24.8-37.9 vs. 24.8%) and lower rates of nonproteinuric DKD (6.3-9.8 vs. 11.7%). On adjusted analyses, Chinese (odds ratio 1.39 for women and 1.56 for men), Filipinos (1.57 for women and 1.85 for men), Hispanics (1.46 for women and 1.34 for men), and NHBs (1.50 for women) exhibited significantly (P < 0.01) higher odds of proteinuric DKD than NHWs. Conversely, Chinese, Hispanic, and NHB women and Hispanic men had significantly lower odds of nonproteinuric DKD than NHWs. CONCLUSIONS: We found novel racial/ethnic differences in DKD among patients with type 2 diabetes. Racial/ethnic minorities were more likely to have proteinuric DKD and less likely to have nonproteinuric DKD. Future research should examine diverse DKD-related outcomes by race/ethnicity to inform targeted prevention and treatment efforts and to explore the etiology of these differences.