Uptake, retention, and outcomes of the National Diabetes Prevention Program by enrollee characteristics and program type.

AIMS: To describe National Diabetes Prevention Program (NDPP) uptake, retention, and outcomes by enrollee characteristics and program type. METHODS: We studied 776 adult University of Michigan employees, dependents, and retirees with prediabetes and overweight or obesity who enrolled in one of four CDC-recognized NDPPs at no out-of-pocket cost. Programs included 1) an in-person classroom-based program led by certified diabetes educators in an endocrinology outpatient clinic; 2) an in-person classroom-based program led by trained peer instructors in community settings; 3) an in-person fitness-focused program led by trained lifestyle coaches; and 4) an online digital program led by personal health coaches with virtual group meetings. Data from the insurer and surveys were analyzed. RESULTS: Older individuals with hypertension and cardiovascular disease were more likely to enroll in classroom-based programs. Program time, location, and perceived focus on diet or physical activity influenced program selection. Retention, weight loss, and physical activity were greater among enrollees in in-person classroom-based programs. Changes in blood pressure, lipid levels, self-rated health, and health-related quality-of-life did not differ by program, nor did Type 2 diabetes mellitus incidence. CONCLUSIONS: Individuals with prediabetes who enrolled in a NDPP achieved health benefits regardless of the type of program they chose.

Study protocol: Behavioral economics and self-determination theory to change diabetes risk (BEST Change).

BACKGROUND: The Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions. METHODS: In this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives for DPP participation or metformin use. Tailored Messages Arm participants will receive the Control Arm intervention plus tailored messages promoting autonomous motivation for preventing T2DM. Combined Arm participants will receive the Incentives Arm and Tailored Messages Arm interventions plus messages to increase the personal salience of financial incentives. The primary outcome is change in hemoglobin A1c from baseline to 12 months. Secondary outcomes are change in body weight, DPP participation, and metformin use. DISCUSSION: If effective, these scalable and sustainable approaches to increase patient motivation to prevent T2DM can be deployed by health systems, health plans, and employers to help individuals with prediabetes lower their risk for developing T2DM.

Domains from the health belief model predict enrollment in the National Diabetes Prevention Program among insured adults with prediabetes.

AIMS: To examine enrollment in the National Diabetes Prevention Program (DPP) by insured adults with prediabetes according to domains of the Health Belief Model (HBM). METHODS: Between 2015 and 2019, University of Michigan employees, retirees, and dependents with prediabetes were offered the National DPP at no out-of-pocket cost. Individuals with prediabetes were identified and mailed letters encouraging them to enroll. We surveyed those who enrolled and a random sample of those who did not using the HBM as a framework to examine factors associated with enrollment. Analyses were performed using multivariable logistic regression models. RESULTS: Of 64,131 employees, retirees, and dependents, 8131 were identified with prediabetes and 776 (9.5%) enrolled in the National DPP. Of those surveyed, 532 of 776 National DPP enrollees and 945 of 2673 non-enrollees responded to the survey (adjusted response rates 74% and 43%, respectively). Among survey respondents, factors associated with National DPP enrollment included older age, female sex, higher BMI, prediabetes awareness, greater perceived benefits of health-protective action, and one or more cues to action. CONCLUSIONS: Optimizing National DPP enrollment among adults with prediabetes will require identifying individuals with prediabetes, increasing personal awareness of the diagnosis, increasing perceived benefits of enrollment, and providing strong cues to action.

The Effectiveness of a Proactive, Three-Level Strategy to Identify People With Prediabetes in a Large Workforce With Employer-Sponsored Health Insurance.

OBJECTIVE: Rates of diagnosis of prediabetes and uptake of the National Diabetes Prevention Program (NDPP) are low. We evaluated a proactive three-level strategy to identify individuals with prediabetes in a population with employer-sponsored health insurance. RESEARCH DESIGN AND METHODS: We studied 64,131 insured employees, dependents, and retirees ≥18 years of age without diagnosed diabetes, 19,397 (30%) of whom were estimated to have prediabetes. Individuals with prediabetes were identified by 1) searching claims diagnoses and previously performed HbA1c test results, 2) risk stratifying people 40-64 years of age without diabetes, prediabetes, or documented normal HbA1c to identify individuals at higher risk and encourage them to be tested, and 3) using a media campaign to encourage employees not otherwise targeted to self-screen and, if at higher risk, to be tested. RESULTS: Using claims and laboratory data, 11% of the population was identified as having prediabetes. Of those 40-64 years of age, 25% were identified as being at higher risk, and 27% of them were tested or diagnosed within 1 year. Of employees exposed to the media campaign, 14% were tested or diagnosed within 1 year. Individuals with prediabetes were older, heavier, and more likely to have hypertension and dyslipidemia. Testing and diagnosis were associated with receiving medical care and provider outreach. A total of 8,129 individuals, or 42% of those with prediabetes, were identified. CONCLUSIONS: Analysis of existing health insurance data facilitated the identification of individuals with prediabetes. Better identification of people with prediabetes is a first step in increasing uptake of the NDPP.

Changes in Health Insurance Coverage Under the Affordable Care Act: A National Sample of U.S. Adults With Diabetes, 2009 and 2016.

OBJECTIVE: To assess national changes in health insurance coverage and related costs before and after implementation of the Affordable Care Act (ACA) among U.S. adults with diabetes. RESEARCH DESIGN AND METHODS: Data were cross-sectional from the 2009 and 2016 National Health Interview Surveys (NHIS). Participants were adults age ≥18 years with a previous diagnosis of diabetes who self-reported on their health insurance coverage, demographic information, diabetes-related factors, and amount spent on medical expenses and insurance premiums (N = 6,220). RESULTS: Among adults with diabetes age 18-64 years, health insurance coverage increased from 84.7% in 2009 to 90.1% in 2016 (P < 0.001). Coverage remained near universal for those age ≥65 years (99.5%). For adults age 18-64 years, coverage increased for almost all subgroups and significantly for men; non-Hispanic whites, non-Hispanic blacks, and Hispanics; those who were married; those with less than or more than a high school education, family income <$35,000, or diabetes duration <5 or >15 years; and those taking oral agents (P < 0.05 for all). Among adults age 18-64 years, Medicaid coverage significantly increased between 2009 and 2016 (19.4% vs. 24.3%, P = 0.006), and for those with private insurance, 7.8% acquired their plan through HealthCare.gov. For adults age ≥65 years, private insurance decreased and Medicare Part D increased (P < 0.007 for both). Among those age 18-64 years with an income <$35,000, the proportion of income spent on family medical costs decreased (6.3% vs. 4.8% for 2009 vs. 2016, respectively; P = 0.004). CONCLUSIONS: Health insurance coverage among adults with diabetes age 18-64 years increased significantly after implementation of the ACA, and medical costs to families decreased among those with lower incomes.

Why Are Diabetes Medications So Expensive and What Can Be Done to Control Their Cost?

PURPOSE OF REVIEW: The purposes of this study were to describe how medication prices are established, to explain why antihyperglycemic medications have become so expensive, to show trends in expenditures for antihyperglycemic medications, and to highlight strategies to control expenditures in the USA. RECENT FINDINGS: In the U.S., pharmaceutical manufacturers set the prices for new products. Between 2002 and 2012, expenditures for antihyperglycemic medications increased from $10 billion to $22 billion. This increase was primarily driven by expenditures for insulin which increased sixfold. The increase in insulin expenditures may be attributed to several factors: the shift from inexpensive beef and pork insulins to more expensive genetically engineered human insulins and insulin analogs, dramatic price increases for the available insulins, physician prescribing practices, policies that limit payers' abilities to negotiate prices, and nontransparent negotiation of rebates and discounts. The costs of antihyperglycemic medications, especially insulin, have become a barrier to diabetes treatment. While clinical interventions to shift physician prescribing practices towards lower cost drugs may provide some relief, we will ultimately need policy interventions such as more stringent requirements for patent exclusivity, greater transparency in medication pricing, greater opportunities for price negotiation, and outcomes-based pricing models to control the costs of antihyperglycemic medications.

Ascertainment of outpatient visits by patients with diabetes: The National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS).

AIMS: To estimate and evaluate the sensitivity and specificity of providers' diagnosis codes and medication lists to identify outpatient visits by patients with diabetes. METHODS: We used data from the 2006 to 2010 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. We assessed the sensitivity and specificity of providers' diagnoses and medication lists to identify patients with diabetes, using the checkbox for diabetes as the gold standard. We then examined differences in sensitivity by patients' characteristics using multivariate logistic regression models. RESULTS: The checkbox identified 12,647 outpatient visits by adults with diabetes among the 70,352 visits used for this analysis. The sensitivity and specificity of providers' diagnoses or listed diabetes medications were 72.3% (95% CI: 70.8% to 73.8%) and 99.2% (99.1% to 99.4%), respectively. Diabetic patients ≥75 years of age, women, non-Hispanics, and those with private insurance or Medicare were more likely to be missed by providers' diagnoses and medication lists. Diabetic patients who had more diagnosis codes and medications recorded, had glucose or hemoglobin A1c measured, or made office- rather than hospital-outpatient visits were less likely to be missed. CONCLUSIONS: Providers' diagnosis codes and medication lists fail to identify approximately one quarter of outpatient visits by patients with diabetes.

Revisit frequency and its association with quality of care among diabetic patients: Translating Research Into Action for Diabetes (TRIAD).

OBJECTIVE: To describe patient and provider characteristics associated with outpatient revisit frequency and to examine the associations between the revisit frequency and the processes and intermediate outcomes of diabetes care. RESEARCH DESIGN AND METHODS: We analyzed data from Translating Research Into Action for Diabetes (TRIAD), a prospective, multicenter, observational study of diabetes care in managed care. RESULTS: Our analysis included 6040 eligible adult participants with type 2 diabetes (42.6% ≥65 years of age, 54.1% female) whose primary care providers were the main provider of the participants' diabetes care. The median (interquartile range) revisit frequency was 4.0 (3.7, 6.0) visits per year. Being female, having lower education, lower income, more complex diabetes treatment, cardiovascular disease, higher Charlson comorbidity index, and impaired mobility were associated with higher revisit frequency. The proportion of participants who had annual assessments of HbA1c and LDL-cholesterol, foot examinations, advised or documented aspirin use, and influenza immunizations were higher for those with higher revisit frequency. The proportion of participants who met HbA1c (<9.5%) and LDL-cholesterol (<130 mg/dL) treatment goals were higher for those with a higher revisit frequency. The predicted probabilities of achieving more aggressive goals, HbA1c <8.5%, LDL-cholesterol <100mg/dL, and blood pressure <130/85 or even <140/90 mmHg were not associated with higher revisit frequency. CONCLUSIONS: Revisit frequency was highly variable and was associated with both sociodemographic characteristics and disease severity. A higher revisit frequency was associated with better processes of diabetes care, but the association with intermediate outcomes was less clear.

Very-low-energy diet for type 2 diabetes: an underutilized therapy?

BACKGROUND: Current approaches to the management of type 2 diabetes focus on the early initiation of novel pharmacologic therapies and bariatric surgery. OBJECTIVE: The purpose of this study was to revisit the use of intensive, outpatient, behavioral weight management programs for the management of type 2 diabetes. DESIGN: Prospective observational study of 66 patients with type 2 diabetes and BMI ≥ 32 kg/m² who enrolled in a program designed to produce 15% weight reduction over 12 weeks using total meal replacement and low- to moderate-intensity physical activity. RESULTS: Patients were 53 ± 7 years of age (mean ± SD) and 53% were men. After 12 weeks, BMI fell from 40.1 ± 6.6 to 35.1 ± 6.5 kg/m². HbA1c fell from 7.4% ± 1.3% to 6.5% ± 1.2% (57.4 ± 12.3 to 47.7 ± 12.9 mmol/mol) in patients with established diabetes: 76% of patients with established diabetes and 100% of patients with newly diagnosed diabetes achieved HbA1c <7.0% (53.0 mmol/mol). Improvement in HbA1c over 12 weeks was associated with higher baseline HbA1c and greater reduction in BMI. CONCLUSIONS: An intensive, outpatient, behavioral weight management program significantly improved HbA1c in patients with type 2 diabetes over 12 weeks. The use of such programs should be encouraged among obese patients with type 2 diabetes.

Assessing the burden of diabetes mellitus in emergency departments in the United States: the National Hospital Ambulatory Medical Care Survey (NHAMCS).

OBJECTIVE: To evaluate the performance of three alternative methods to identify diabetes in patients visiting Emergency Departments (EDs), and to describe the characteristics of patients with diabetes who are not identified when the alternative methods are used. RESEARCH DESIGN AND METHODS: We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2009 and 2010. We assessed the sensitivity and specificity of using providers' diagnoses and diabetes medications (both excluding and including biguanides) to identify diabetes compared to using the checkbox for diabetes as the gold standard. We examined the characteristics of patients whose diabetes was missed using multivariate Poisson regression models. RESULTS: The checkbox identified 5,567 ED visits by adult patients with diabetes. Compared to the checkbox, the sensitivity was 12.5% for providers' diagnoses alone, 20.5% for providers' diagnoses and diabetes medications excluding biguanides, and 21.5% for providers' diagnoses and diabetes medications including biguanides. The specificity of all three of the alternative methods was >99%. Older patients were more likely to have diabetes not identified. Patients with self-payment, those who had glucose measured or received IV fluids in the ED, and those with more diagnosis codes and medications, were more likely to have diabetes identified. CONCLUSIONS: NHAMCS's providers' diagnosis codes and medication lists do not identify the majority of patients with diabetes visiting EDs. The newly introduced checkbox is helpful in measuring ED resource utilization by patients with diabetes.

The impact of weight loss on health-related quality-of-life: implications for cost-effectiveness analyses.

PURPOSE: To assess the impact of weight loss on health-related quality-of-life (HRQL), to describe the factors associated with improvements in HRQL after weight loss, and to assess the relationship between obesity as assessed by body mass index (BMI) and HRQL before and after weight loss. METHODS: We studied 188 obese patients with BMI ≥ 32 kg/m(2) with one or more comorbidities or ≥35 kg/m(2). All patients had baseline and follow-up assessments of BMI and HRQL using the EuroQol (EQ-5D) and its visual analog scale (VAS) before and after 6 months of medical weight loss that employed very low-calorie diets, physical activity, and intensive behavioral counseling. RESULTS: At baseline, age was 50 ± 8 years (mean ± SD), BMI was 40. 0 ± 5.0 kg/m(2), EQ-5D-derived health utility score was 0.85 ± 0.13, and VAS-reported quality-of-life was 0.67 ± 0.18. At 6-month follow-up, BMI decreased by 7.0 ± 3.2 kg/m(2), EQ-5D increased by 0.06 [interquartile range (IQR) 0.06-0.17], and VAS increased by 0.14 (IQR 0.04-0.23). In multivariate analyses, improvement in EQ-5D and VAS were associated with lower baseline BMI, greater reduction in BMI at follow-up, fewer baseline comorbidities, and lower baseline HRQL. For any given BMI category, EQ-5D and VAS tended to be higher at follow-up than at baseline. CONCLUSION: Measured improvements in HRQL between baseline and follow-up were greater than predicted by the reduction in BMI at follow-up. If investigators use cross-sectional data to estimate changes in HRQL as a function of BMI, they will underestimate the improvement in HRQL associated with weight loss and underestimate the cost-utility of interventions for obesity treatment.

The impact of a managed care obesity intervention on clinical outcomes and costs: a prospective observational study.

OBJECTIVE: To evaluate the impact of a managed care obesity intervention that requires enrollment in an intensive medical weight management program, a commercial weight loss program, or a commercial pedometer-based walking program to maintain enhanced benefits. DESIGN AND METHODS: Prospective observational study involving 1,138 adults with BMI ≥ 32 kg m(-2) with one or more comorbidities or BMI ≥ 35 kg m(-2) enrolled in a commercial, independent practice association-model health maintenance organization. Body mass index, blood pressure, lipids, HbA1c or fasting glucose, and per-member per-month costs were assessed 1 year before and 1 year after program implementation. RESULTS: Program uptake (90%) and 1 year adherence (79%) were excellent. Enrollees in all three programs exhibited improved clinical outcomes and reduced rates of increase in direct medical costs compared to members who did not enroll in any program. CONCLUSIONS: A managed care obesity intervention that offered financial incentives for participation and a variety of programs was associated with excellent program uptake and adherence, improvements in cardiovascular risk factors, and a lower rate of increase in direct medical costs over 1 year.

Temporal trends in recording of diabetes on death certificates: results from Translating Research Into Action for Diabetes (TRIAD).

OBJECTIVE: To determine the frequency that diabetes is reported on death certificates of decedents with known diabetes and describe trends in reporting over 8 years. RESEARCH DESIGN AND METHODS: Data were obtained from 11,927 participants with diabetes who were enrolled in Translating Research into Action for Diabetes, a multicenter prospective observational study of diabetes care in managed care. Data on decedents (N=2,261) were obtained from the National Death Index from 1 January 2000 through 31 December 2007. The primary dependent variables were the presence of the ICD-10 codes for diabetes listed anywhere on the death certificate or as the underlying cause of death. RESULTS: Diabetes was recorded on 41% of death certificates and as the underlying cause of death for 13% of decedents with diabetes. Diabetes was significantly more likely to be reported on the death certificate of decedents dying of cardiovascular disease than all other causes. There was a statistically significant trend of increased reporting of diabetes as the underlying cause of death over time (P<0.001), which persisted after controlling for duration of diabetes at death. The increase in reporting of diabetes as the underlying cause of death was associated with a decrease in the reporting of cardiovascular disease as the underlying cause of death (P<0.001). CONCLUSIONS: Death certificates continue to underestimate the prevalence of diabetes among decedents. The increase in reporting of diabetes as the underlying cause of death over the past 8 years will likely impact estimates of the burden of diabetes in the U.S.

Primary language, income and the intensification of anti-glycemic medications in managed care: the (TRIAD) study.

BACKGROUND: Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity. OBJECTIVE: To examine the associations between primary language, income, and medication intensification. DESIGN: Cohort study with 18-month follow-up. PARTICIPANTS: One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care. MEASUREMENTS: Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan. RESULTS: Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race. CONCLUSIONS: Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.

Thiazolidinediones, cardiovascular disease and cardiovascular mortality: translating research into action for diabetes (TRIAD).

BACKGROUND: Studies have associated thiazolidinedione (TZD) treatment with cardiovascular disease (CVD) and questioned whether the two available TZDs, rosiglitazone and pioglitazone, have different CVD risks. We compared CVD incidence, cardiovascular (CV), and all-cause mortality in type 2 diabetic patients treated with rosiglitazone or pioglitazone as their only TZD. METHODS: We analyzed survey, medical record, administrative, and National Death Index (NDI) data from 1999 through 2003 from Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Medications, CV procedures, and CVD were determined from health plan (HP) administrative data, and mortality was from NDI. Adjusted hazard rates (AHR) were derived from Cox proportional hazard models adjusted for age, sex, race/ethnicity, income, history of diabetic nephropathy, history of CVD, insulin use, and HP. RESULTS: Across TRIAD's 10 HPs, 1,815 patients (24%) filled prescriptions for a TZD, 773 (10%) for only rosiglitazone, 711 (10%) for only pioglitazone, and 331 (4%) for multiple TZDs. In the seven HPs using both TZDs, 1,159 patients (33%) filled a prescription for a TZD, 564 (16%) for only rosiglitazone, 334 (10%) for only pioglitazone, and 261 (7%) for multiple TZDs. For all CV events, CV, and all-cause mortality, we found no significant difference between rosiglitazone and pioglitazone. CONCLUSIONS: In this relatively small, prospective, observational study, we found no statistically significant differences in CV outcomes for rosiglitazone- compared to pioglitazone-treated patients. There does not appear to be a pattern of clinically meaningful differences in CV outcomes for rosiglitazone- versus pioglitazone-treated patients.

The cost, quality of life impact, and cost-utility of bariatric surgery in a managed care population.

Our purpose was to assess the cost, quality of life impact, and the cost-utility of bariatric surgery in a managed care population. We studied 221 patients who underwent bariatric surgery between 2001 and 2005. We analyzed medical claims data for all patients and survey data for 122 survey respondents (55% response rate). Patients were generally middle-aged, female, and white. Sixty-four percent underwent open and 33% underwent laparoscopic Roux-en-Y procedures. One year after surgery, mean body mass index fell from 51 to 31 kg/m(2) in women and from 59 to 35 kg/m(2) in men with substantial improvements in comorbidities. Postsurgical mortality and morbidity were low. Total per member per month costs increased in the 6 months before bariatric surgery, were lower in the 12 months after bariatric surgery, but increased somewhat over the next 12 months. When presurgical quality of life was assessed prospectively, average health utility scores improved by 0.14 one year after surgery. In analyses that took a lifetime time horizon, projected future costs based on age and obesity and discounted costs and health utilities at 3% per year, the cost-utility ratio for bariatric surgery versus no surgery was approximately $1,400 per quality-adjusted life-year gained. In sensitivity analyses, bariatric surgery was more cost-effective in women, non-whites, more obese patients, and when performed laparoscopically. Although not cost-saving, bariatric surgery represents a very good value for money. Its long-term cost effectiveness appears to depend on the natural history and cost of late postsurgical complications and the natural history and cost of untreated morbid obesity.

Effect of a managed care disease management program on diabetes care.

OBJECTIVE: To determine if processes and outcomes of diabetes care improved between 2000 and 2006 in a managed care health plan with a comprehensive diabetes disease management program. STUDY DESIGN: Cross-sectional. METHODS: A total of 1650 randomly selected members with diabetes mellitus completed surveys in 2000, and 1256 randomly selected members with diabetes completed surveys in 2006. Survey and medical record data were analyzed using multivariable regression and predictive probabilities adjusted for age, education, and comorbidities. RESULTS: In 2006, patients were more likely to have proteinuria assessed (85% vs 74% in 2000), foot examinations performed (90% vs 86%), glycosylated hemoglobin levels measured (94% vs 87%), lipids measured (81% vs 70%), aspirin use recommended (67% vs 56%), and influenza immunizations administered (70% vs 63%). Glycosylated hemoglobin levels decreased by 0.60% (P <.001), systolic blood pressures by 3 mm Hg (P = .002), and low-density lipoprotein cholesterol levels by 18 mg/dL (P <.001). Those who were continuously enrolled in the health plan were significantly more likely to report having had dilated retinal examinations (P = .003), aspirin use recommendations (P = .049), influenza immunizations (P = .004), and lower low-density lipoprotein cholesterol levels (by 6 mg/dL, P = .003). CONCLUSIONS: Implementation of a disease management program was associated with substantial improvements in processes and outcomes of diabetes care over 6 years. Although secular trend likely contributed somewhat, improvement in other measures was significantly associated with duration of enrollment in the health plan, making secular trend an unlikely explanation for all of our findings.

Risk factors for mortality among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study.

OBJECTIVE: We sought to examine demographic, socioeconomic, and biological predictors of all-cause, cardiovascular, and noncardiovascular mortality in patients with diabetes. RESEARCH DESIGN AND METHODS: Survey, medical record, and administrative data were obtained from 8,733 participants in the Translating Research Into Action for Diabetes Study, a multicenter, prospective, observational study of diabetes care in managed care. Data on deaths (n = 791) and cause of death were obtained from the National Death Index after 4 years. Predictors examined included age, sex, race, education, income, duration, and treatment of diabetes, BMI, smoking, microvascular and macrovascular complications, and comorbidities. RESULTS: Predictors of adjusted all-cause mortality included older age (hazard ratio [HR] 1.04 [95% CI 1.03-1.05]), male sex (1.57 [1.35-1.83]), lower income (< $15,000 vs. > $75,000, HR 1.82 [1.30-2.54]; $15,000-$40,000 vs. > $75,000, HR 1.58 [1.15-2.17]), longer duration of diabetes (> or = 9 years vs. < 9 years, HR 1.20 [1.02-1.41]), lower BMI (< 26 vs. 26-30 kg/m2, HR 1.43 [1.13-1.69]), smoking (1.44 [1.20-1.74]), nephropathy (1.46 [1.23-2.73]), macrovascular disease (1.46 [1.23-1.74]), and greater Charlson index (> or = 2-3 vs. < 1, HR 2.01 [1.04-3.90]; > or = 3 vs. < 1, HR 4.38 [2.26-8.47]). The predictors of cardiovascular and noncardiovascular mortality were different. Macrovascular disease predicted cardiovascular but not noncardiovascular mortality. CONCLUSIONS: Among people with diabetes and access to medical care, older age, male sex, smoking, and renal disease are important predictors of mortality. Even within an insured population, socioeconomic circumstance is an important independent predictor of health.

Preconception care in managed care: the translating research into action for diabetes study.

OBJECTIVES: This study was undertaken to examine the rates of preconception counseling in managed care for women with diabetes and associated patient and physician characteristics. STUDY DESIGN: Participants included women aged 18 to 45 years enrolled in a study of diabetes care in managed care. Women were asked if they recalled discussions regarding glucose control before conception (n = 236) and use of family planning until glucose control was achieved (n = 227). Hierarchical logistic regression models accounted for patient and physician characteristics. RESULTS: Fifty-two percent of women recalled being counseled about glucose control and 37% recalled family planning advice. In adjusted models, patient age (years) (odds ratio [OR] 0.91, 95% CI 0.86-0.96) and body mass index (BMI) (kg/m2) (OR 0.96, 95% CI 0.93-0.99) remained significant predictors of glucose control counseling. Similarly, patient age (years) (OR 0.94, 95% CI 0.89-0.99) and BMI (kg/m2) (0.96, 95% CI 0.93-0.99) remained significant predictors of family planning counseling. CONCLUSIONS: Preconception counseling rates for diabetic women are low and associated with younger age and lower BMI.

Antibiotic prescribing for cystitis: how well does it match published guidelines?

PURPOSE: Cystitis is one of the most common bacterial infections seen by physicians in outpatient settings. Published clinical guidelines by the Infectious Disease Society of America and other organizations have been established to enable effective treatment, while attempting to decrease cost and limit antibiotic resistance. METHODS: Insurance claims data for employees and dependents of a single Midwest corporation, with Preferred Provider Organization coverage, diagnosed with cystitis between 1996 and 1999 were matched to prescription drug claims for those who filled an antibiotic prescription within 3 days of diagnosis. RESULTS: For acute and recurrent cystitis physicians prescribed trimethoprim-sulfamethoxazole 37% and 18% respectively. The other most common antibiotics prescribed were the broad-spectrum flouroquinolones, and nitrofurantoin. The mean duration for these prescriptions was 10 days regardless of whether the infection was acute or recurrent. CONCLUSIONS: The first line recommended antibiotic, trimethoprim-sulfamethoxazole, was prescribed in 37% of acute infections, and for considerably longer than the suggested 3-day course of therapy. Steps should be taken to educate physicians and patients on the choice and dosage of antibiotics for cystitis to minimize emergence of antibiotic resistance.