Receipt of Diabetes Specialty Care and Management Services by Older Adults With Diabetes in the U.S., 2015-2019: An Analysis of Medicare Fee-for-Service Claims.

OBJECTIVE: We characterized the receipt of diabetes specialty care and management services among older adults with diabetes. RESEARCH DESIGN AND METHODS: Using a 20% random sample of fee-for-service Medicare beneficiaries aged ≥65 years, we analyzed cohorts of type 1 diabetes (T1D) or type 2 diabetes (T2D) with history of severe hypoglycemia (HoH), and all other T2D annually from 2015 to 2019. Outcomes were receipt of office-based endocrinology care, diabetes education, outpatient diabetes health services, excluding those provided in primary care, and any of the aforementioned services. RESULTS: In the T1D cohort, receipt of endocrinology care and any service increased from 25.9% and 29.2% in 2015 to 32.7% and 37.4% in 2019, respectively. In the T2D with HoH cohort, receipt of endocrinology care and any service was 13.9% and 16.4% in 2015, with minimal increases. Age, race/ethnicity, residential setting, and income were associated with receiving care. CONCLUSIONS: These findings suggest that many older adults may not receive specialty diabetes care and underscore health disparities.

A Cost Analysis of Rethink the Strip: De-implementing a Low-value Practice in Primary Care.

BACKGROUND: Routine self-monitoring of blood glucose is a low-value practice that provides limited benefit for patients with non-insulin-treated type 2 diabetes mellitus. OBJECTIVES: We estimated the costs of Rethink the Strip (RTS), a multistrategy approach to the de-implementation of self-monitoring of blood glucose in primary care. RESEARCH DESIGN: RTS was conducted among 20 primary care clinics in North Carolina. We estimated the non-site-based and site-based costs of the 5 RTS strategies (practice facilitation, audit and feedback, provider champions, educational meetings, and educational materials) from the analytic perspective of an integrated health care system for 12 and 27-month time horizons. Material costs were tracked through project records, and personnel costs were assessed using activity-based costing. We used nationally based wage estimates. RESULTS: Total RTS costs equaled $68,941 for 12 months. Specifically, non-site-based costs comprised $16,560. Most non-site-based costs ($11,822) were from the foundational programming and coding updates to the electronic health record data to develop the audit and feedback reports. The non-site-based costs of educational meetings, practice facilitation, and educational materials were substantially lower, ranging between ~$400 and $1000. Total 12-month site-based costs equaled $2569 for a single clinic (or $52,381 for 20 clinics). Educational meetings were the most expensive strategy, averaging $1401 per clinic. The site-based costs for the 4 other implementation strategies were markedly lower, ranging between $51 for educational materials and $555 for practice facilitation per clinic. CONCLUSIONS: This study provides detailed cost information for implementation strategies used to support evidence-based programs in primary care clinics.

Community-engaged research in vascular surgery: An approach to decrease amputation disparities and effect population-level change.

Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including them throughout the research process. Such engagement increases the relevance and meaning of research, improves the translation of research findings into sustainable health policy and practice, and ultimately enhances mutual trust among academic, clinical, and community partners for ongoing research partnership. There are a number of key principles that must be considered in the planning, design, and implementation of CEnR. These principles are focused on inclusive representation and participation, community empowerment, building community capacity, and protecting community self-determination. Although vascular surgeons may not be equipped to address these issues from the ground up by themselves, they should work with a team who can help them incorporate these elements into their CEnR project designs and proposals. This may be best accomplished by collaborating with researchers and community-based organizations who already have this expertise and have established social capital within the community. This article describes the theory and principles of CEnR, its relevance to vascular surgeons, researchers, and patients, and how using CEnR principles in vascular surgery practice, research, and outreach can benefit our patient population, with a specific focus on reducing disparities related to amputation.

Assessment of third-year medical students' comfort and preparedness for navigating challenging clinical scenarios with patients, peers, and supervisors.

BACKGROUND: Medical training focuses heavily on clinical skills but lacks in training for navigating challenging clinical scenarios especially with regard to diversity issues. Our objective was to assess third-year medical students' preparedness to navigate such scenarios. METHODS: A 24-item survey was administered electronically to third-year medical students describing a range of specific interactions with patients, peers, and "upper-levels" or superiors including residents and attendings, spanning subjects including gender, race/ethnicity, politics, age, sexual orientation/identity, disability, and religion. Students rated their level of comfort via a 5-point Likert scale ranging from 1 ("Very Uncomfortable") to 5 ("Very Comfortable"). Basic demographics were collected and data were summarized for trends. RESULTS: Data were analyzed from 120 students (67% response rate, 54.2% female, 60.8% non-Hispanic white). Students reported lower comfort with peer and superiors compared to patient interactions (p < 0.0001). Students reported the highest comfort with sexual orientation/identity- and religion-related interactions (median (IQR): 3.3 (1.3) and 3.4 (10.0), respectively) and the lowest comfort with gender-, race/ethnicity-, and disability- related interactions (median (IQR): 2.3 (1.3), 2.0 (1.0), 2.5 (1.5), respectively). Males reported significantly higher median comfort levels for scenarios with upper-level, gender, and religion related interactions. Males were more likely to be completely comfortable versus females across the 24 scenarios, although multiple male response patterns showed evidence of a bimodal distribution. CONCLUSIONS: Third-year medical students report generally inadequate comfort with navigating complex clinical scenarios, particularly with peers and supervisors and relating to gender-, race/ethnicity-, and disability-specific conflicts. There are differences across gender with regards to median comfort and distribution of scores suggesting that there is a subgroup of males report high/very high comfort with challenging clinical scenarios. Students may benefit from enhanced training modules and personalized toolkits for navigating these scenarios.

Unique cardiovascular risk factors in women.

Despite an overall reduction in cardiovascular disease (CVD) mortality in the USA, the rate of coronary heart disease and CVD mortality is on the rise in younger women aged 35 to 54 years. This has been attributed to an increasing prevalence of CVD risk factors, which can portend disparate outcomes in women versus men. Women with diabetes and those who smoke have an excess relative risk of CVD when compared with their male counterparts. In addition to these discrepancies in traditional risk factors, a number of clinical conditions unique to women have been shown to increase CVD risks such as pre-eclampsia, gestational diabetes, polycystic ovary syndrome, early menopause and autoimmune diseases. The majority of these sex-specific risk factors can be identified at an early age, allowing for aggressive risk factor modification through lifestyle changes and, in certain patients, medications. The recently published 2018 American College of Cardiology and American Heart Association (ACC/AHA) hypercholesterolaemia and 2019 ACC/AHA primary prevention guidelines reflect this, citing pre-eclampsia, early menopause and autoimmune diseases as 'risk enhancers' that if present may favour initiation of statin therapy in borderline or intermediate risk patients. This comprehensive review addresses both traditional and unique risk factors of CVD in women, as well as sex-specific risk stratification and management options.

Health Literacy, Glycemic Control, and Physician-Advised Glucose Self-Monitoring Use in Type 2 Diabetes.

OBJECTIVE: To measure the association between health literacy and both patient-reported and clinical outcomes in patients with non-insulin-treated type 2 diabetes. RESEARCH DESIGN AND METHODS: We surveyed patients with non-insulin-treated type 2 diabetes (n = 448) from 15 primary care practices. The association between health literacy and patient-reported and clinical outcomes, including numeracy of self-monitoring of blood glucose (SMBG) use, how often physicians advised patients to conduct SMBG testing, and glycemic control (as measured by A1C), was investigated. RESULTS: Study participants included 448 patients with non-insulin-treated type 2 diabetes located within central North Carolina. Participants with limited health literacy had poorer glycemic control (A1C 7.7 ± 1.1% vs. 7.5 ± 1.0%, P = 0.016) despite using SMBG testing more frequently (daily SMBG testing 49.3 vs. 30.7%, P = 0.001) compared to individuals with adequate health literacy. The difference in how often physicians advised patients to conduct SMBG testing between limited and adequate health literacy groups was not significant (P = 0.68). CONCLUSION: Limited health literacy was associated with poorer glycemic control and an increased frequency of SMBG testing in patients with non-insulin-treated type 2 diabetes. There was no significant difference in how often physicians advised patients to conduct SMBG testing between patients with limited and adequate health literacy.

Implementation and Evaluation of Shared Medical Appointments for Type 2 Diabetes at a Free, Student-Run Clinic in Alamance County, North Carolina.

INTRODUCTION: Type 2 diabetes is a significant problem among uninsured patients. Shared medical appointments (SMA) have been shown to improve outcomes in type 2 diabetes. We hypothesized that the SMA model could be adapted for a non-profit clinic in North Carolina that serves uninsured patients with diabetes that have incomes at/below 150% of the federal poverty line. RESEARCH DESIGN AND METHODS: We implemented and sustained a patient-driven, student-led SMA model that incorporated the monthly rotations of students, physician assistant, and undergraduate students as well as pharmacy residents and an endocrinologist who collectively provide diabetes care at the free clinic. SMA groups are 'open' cohorts and include 4-12 patients scheduled for the monthly clinic. Teams of transdisciplinary trainees work together to perform triage, medication reconciliation, brief history, and physical exam, after which patients participate in the SMA. The endocrinologist evaluates SMA patients individually during and after the visit. RESULTS: Between November 2015 and January 2017, we enrolled 29 patients in SMA. There was high variability in HbA1c at baseline. Among eight type 2 diabetes patients seen in endocrine clinic and with complete data one year before and after SMA implementation, the mean (SD) HbA1c before SMA was 9.7% ± 1.7% (83±7 mmol/ mol); mean HbA1c after SMA was 9.2% ± 1.8% (77 ± 8mmol/mol). The median HbA1c before SMA was 9.5% (80 mmol/mol); median HbA1c after SMA was 8.9% (74 mmol/mol). Overall, 6/8 patients showed decreased HbA1c after SMA although there was variability between individuals in response of glycemic control to SMA. SMA increased clinic efficiency and offered an opportunity to integrate transdisciplinary trainees. Trainees gain experience with novel models of care and the complexities of the patient experience of diabetes. CONCLUSIONS: We hope this observation encourages others to implement such programs to enhance the evidence-base for SMA to address health disparities and increase the quality of free diabetes care.

Hemodynamic Assessment Before and After Endovascular Therapy for Critical Limb Ischemia and Association With Clinical Outcomes.

OBJECTIVES: This study sought to determine the relationship between change in ankle-brachial index (ABI) and toe-brachial index (TBI) and outcomes following revascularization of critical limb ischemia (CLI). BACKGROUND: An increase in ABI of 0.15 after revascularization for peripheral artery disease with claudication is considered significant. However, the utility of using change in ABI or TBI to predict outcomes in patients with CLI is unproven. METHODS: This was an observational study of 218 patients with Rutherford class V or VI CLI that underwent endovascular therapy. Receiver-operating characteristic curve analysis determined cutpoints in post-procedure ABI and TBI, as well as change in these values for endpoints of wound healing, major adverse limb events (MALE), and repeat revascularization. RESULTS: After multivariable Cox proportional hazards analysis adjusting for age, diabetes, glomerular filtration rate, smoking, Rutherford class, and baseline ABI or TBI, neither static post-procedure ABI nor post-procedure TBI were associated with wound healing (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.77 to 1.89; p = 0.40; HR: 1.49; 95% CI: 0.98 to 2.27; p = 0.065, respectively). However, change in ABI ≥0.23 was independently associated with wound healing (HR: 1.87; 95% CI: 1.12 to 3.15; p = 0.018) and less repeat revascularization (HR: 0.40; 95% CI: 0.19 to 0.84; p = 0.015), but not MALE. Increase in TBI ≥0.21 was independently associated with wound healing (HR: 1.63; 95% CI: 1.02 to 2.59; p = 0.039), and reduced MALE (HR: 0.27; 95% CI: 0.09 to 0.77; p = 0.014), but not repeat revascularization. CONCLUSIONS: A change in ABI and TBI from pre-procedural values provides prognostic value in determining which patients may have wound healing and reduced MALE.

Diabetes in North Carolina: descriptive epidemiology and meaningful use of electronic health records.

Diabetes is a major public health problem in North Carolina, affecting all sociodemographic groups. This commentary examines diabetes incidence, prevalence, disparities, morbidity, mortality, and costs. It also facilitates discussion about how the meaningful use of electronic health records can create new opportunities for collaboration between public health and clinical care professionals and organizations.