The Role of Telehealth in Improving Care Connections and Outcomes for Community Health Center Patients with Diabetes.

INTRODUCTION: Does telehealth decrease health disparities by improving connections to care or simply result in new barriers for vulnerable populations who often lack access to technology? This study aims to better understand the role of telehealth and social determinants of health in improving care connections and outcomes for Community Health Center patients with diabetes. METHODS: This retrospective analysis of Electronic Health Record (EHR) data examined the relationship between telehealth utilization and glycemic control and consistency of connection to the health care team ("connectivity"). EHR data were collected from 20 Community Health Centers from July 1, 2019 through December 31, 2021. Descriptive statistics were calculated, and multivariable linear regression was used to assess the associations between telehealth use and engagement in care and glycemic control. RESULTS: The adjusted analysis found positive, statistically significant associations between telehealth use and each of the 2 primary outcomes. Telehealth use was associated with 0.89 additional months of hemoglobin A1c (HbA1c) control (95% confidence interval [CI], 0.73 to 1.04) and 4.49 additional months of connection to care (95% CI, 4.27 to 4.70). DISCUSSION: The demonstrated increased engagement in primary care for telehealth users is significant and encouraging as Community Health Center populations are at greater risk of lapses in care and loss to follow up. CONCLUSIONS: Telehealth can be a highly effective, patient-centered form of care for people with diabetes. Telehealth can play a critical role in keeping vulnerable patients with diabetes connected to their care team and involved in care and may be an important tool for reducing health disparities.

Using Consistently Low Performance to Identify Low-Quality Physician Groups.

Importance: There has been a growth in the use of performance-based payment models in the past decade, but inherently noisy and stochastic quality measures complicate the assessment of the quality of physician groups. Examining consistently low performance across multiple measures or multiple years could potentially identify a subset of low-quality physician groups. Objective: To identify low-performing physician groups based on consistently low performance after adjusting for patient characteristics across multiple measures or multiple years for 10 commonly used quality measures for diabetes and cardiovascular disease (CVD). Design, Setting, and Participants: This cross-sectional study used medical and pharmacy claims and laboratory data for enrollees ages 18 to 65 years with diabetes or CVD in an Aetna health insurance plan between 2016 and 2019. Each physician group's risk-adjusted performance for a given year was estimated using mixed-effects linear probability regression models. Performance was correlated across measures and time, and the proportion of physician groups that performed in the bottom quartile was examined across multiple measures or multiple years. Data analysis was conducted between September 2020 and May 2021. Exposures: Primary care physician groups. Main Outcomes and Measures: Performance scores of 6 quality measures for diabetes and 4 for CVD, including hemoglobin A1c (HbA1c) testing, low-density lipoprotein testing, statin use, HbA1c control, low-density lipoprotein control, and hospital-based utilization. Results: A total of 786 641 unique enrollees treated by 890 physician groups were included; 414 655 (52.7%) of the enrollees were men and the mean (SD) age was 53 (9.5) years. After adjusting for age, sex, and clinical and social risk variables, correlations among individual measures were weak (eg, performance-adjusted correlation between any statin use and LDL testing for patients with diabetes, r = -0.10) to moderate (correlation between LDL testing for diabetes and LDL testing for CVD, r = .43), but year-to-year correlations for all measures were moderate to strong. One percent or fewer of physician groups performed in the bottom quartile for all 6 diabetes measures or all 4 cardiovascular disease measures in any given year, while 14 (4.0%) to 39 groups (11.1%) were in the bottom quartile in all 4 years for any given measure other than hospital-based utilization for CVD (1.1%). Conclusions and Relevance: A subset of physician groups that was consistently low performing could be identified by considering performance measures across multiple years. Considering the consistency of group performance could contribute a novel method to identify physician groups most likely to benefit from limited resources.

Is Uncontrolled Diabetes Mellitus Associated with Incidence of Complications After Posterior Instrumented Lumbar Fusion? A National Claims Database Analysis.

BACKGROUND: Previous research has shown that diabetes mellitus (DM) is associated with postoperative complications, including surgical site infections (SSIs). However, evidence for the association between diabetes control and postoperative complications in patients with DM is mixed. Prior studies relied on a single metric for defining uncontrolled DM, which does not account for glycemic variability, and it is unknown whether a more comprehensive assessment of diabetes control is associated with postoperative complications. QUESTIONS/PURPOSES: (1) Is there a difference in the incidence of SSI after lumbar spine fusion in patients with uncontrolled DM, defined with a comprehensive assessment of glycemic control, compared with patients with controlled DM? (2) Is there a difference in the incidence of other select postoperative complications after lumbar spine fusion in patients with uncontrolled DM compared with patients with controlled DM? (3) Is there a difference in total reimbursements between these groups? METHODS: We used the PearlDiver Patient Records Database, a national administrative claims database that provides access to the full continuum of perioperative care. We included 46,490 patients with DM undergoing posterior lumbar fusion with instrumentation. Patients were required to be continuously enrolled in the database for at least 1 year before and 90 days after the index procedure. Patients were divided into uncontrolled and controlled DM cohorts, as defined by ICD-9 diagnostic codes. These are based on a comprehensive assessment of glycemic control, including consideration of patient self-monitoring of blood glucose levels, hemoglobin A1c, and the presence/severity of diabetes-related comorbidities. The cohorts differed only by age, insurance type, and Elixhauser comorbidity score. The primary outcome was the incidence of SSI, divided into superficial and deep, within 90 days postoperatively. Secondary complications included the incidence of cerebrovascular events, acute kidney injury, pulmonary embolism, pneumonia, urinary tract infection, blood transfusion, and total reimbursements. These are the sum of reimbursements occurring within 90 days of surgery, which capture the total professional and facility cost burden to the health payer (such as the insurer). We constructed multivariable logistic regression models to adjust for the effects of age, insurance type, and comorbidities. RESULTS: After adjusting for potentially confounding variables including age, insurance type, and comorbidities, we found that patients with uncontrolled DM had an odds ratio for deep SSI of 1.52 (95% confidence interval 1.16 to 1.95; p = 0.002). Similarly, patients with uncontrolled DM had adjusted odds ratios of 1.25 (95% CI 1.01 to 1.53; p = 0.03) for cerebrovascular events, 1.36 (95% CI 1.18 to 1.57; p < 0.001) for acute kidney injury, 1.55 (95% CI 1.16 to 2.04; p = 0.002) for pulmonary embolism, 1.30 (95% CI 1.08 to 1.54; p = 0.004) for pneumonia, 1.33 (95% CI 1.19 to 1.49; p < 0.001) for urinary tract infection, and 1.27 (95% CI 1.04 to 1.53; p = 0.02) for perioperative transfusion. Patients with uncontrolled DM had higher median 90-day total reimbursements than patients with controlled DM: USD 27,915 (interquartile range 5472 to 63,400) versus USD 10,263 (IQR 4101 to 49,748; p < 0.001). CONCLUSION: Our findings encourage surgeons to take a full diabetic history beyond the HbA1c value, including any self-monitoring of glucose measurements, time in acceptable range for continuous glucose monitors, and/or consideration of the presence/severity of diabetes-related complications before lumbar spine fusion, as HbA1c does not fully capture glycemic control or variability. We emphasize that uncontrolled DM is a clinical, rather than laboratory, diagnosis. Comprehensive diabetes histories should be incorporated into existing preoperative diabetes care pathways and elective surgery could be deferred to improve glycemic control. Future development of an index measure incorporating multidimensional measures of diabetes control (such as continuous or self-glucose monitoring, diabetes-related comorbidities) is warranted. LEVEL OF EVIDENCE: Level III, therapeutic study.

Association between Grit Scales and adherence to regular hospital visits among Japanese patients with type 2 diabetes: Prospective observational study.

This study examined the association between Grit Scales and adherence to a schedule of regular hospital visits among Japanese type 2 diabetes patients. Patients with type 2 diabetes who visited the outpatient clinic as new patients comprised the study's participants. Self-administered Short Grit Scale data were obtained from 122 patients at the first consultation and were then observed for 1 year. As the results, 21 participants failed to attend the hospital. In a logistic regression analysis, the Grit Scale as a continuous variable was positively associated with adherence to regular clinical visits. Its odds ratio and 95% confidential interval was 9.68 and 2.87-32.65 (P = 0.0003). In conclusion, it is likely that the Grit Scale is closely associated with adherence to regular hospital visits among Japanese type 2 diabetes patients.

Telemedicine and urban diabetes during COVID-19 pandemic in Milano, Italy during lock-down: epidemiological and sociodemographic picture.

BACKGROUND: Since 2010, more than half of World population lives in Urban Environments. Urban Diabetes has arisen as a novel nosological entity in Medicine. Urbanization leads to the accrual of a number of factors increasing the vulnerability to diabetes mellitus and related diseases. Herein we report clinical-epidemiological data of the Milano Metropolitan Area in the contest of the Cities Changing Diabetes Program. Since the epidemiological picture was taken in January 2020, on the edge of COVID-19 outbreak in the Milano Metropolitan Area, a perspective addressing potential interactions between diabetes and obesity prevalence and COVID-19 outbreak, morbidity and mortality will be presented. To counteract lock-down isolation and, in general, social distancing a pilot study was conducted to assess the feasibility and efficacy of tele-monitoring via Flash Glucose control in a cohort of diabetic patients in ASST North Milano. METHODS: Data presented derive from 1. ISTAT (National Institute of Statistics of Italy), 2. Milano ATS web site (Health Agency of Metropolitan Milano Area), which entails five ASST (Health Agencies in the Territories). A pilot study was conducted in 65 screened diabetic patients (only 40 were enrolled in the study of those 36 were affected by type 2 diabetes and 4 were affected by type 1 diabetes) of ASST North Milano utilizing Flash Glucose Monitoring for 3 months (mean age 65 years, HbA1c 7,9%. Patients were subdivided in 3 groups using glycemic Variability Coefficient (VC): a. High risk, VC > 36, n. 8 patients; Intermediate risk 20 < VC < 36, n. 26 patients; Low risk VC < 20, n. 4 patients. The control group was constituted by 26 diabetic patients non utilizing Flash Glucose monitoring. RESULTS: In a total population of 3.227.264 (23% is over 65 y) there is an overall prevalence of 5.65% with a significant difference between Downtown ASST (5.31%) and peripheral ASST (ASST North Milano, 6.8%). Obesity and overweight account for a prevalence of 7.8% and 27.7%, respectively, in Milano Metropolitan Area. We found a linear relationship (R = 0.36) between prevalence of diabetes and aging index. Similarly, correlations between diabetes prevalence and both older people depending index and structural dependence index (R = 0.75 and R = 0.93, respectively), were found. A positive correlation (R = 0.46) with percent of unoccupied people and diabetes prevalence was also found. A reverse relationship between diabetes prevalence and University level instruction rate was finally identified (R = - 0.82). Our preliminary study demonstrated a reduction of Glycated Hemoglobin (p = 0.047) at 3 months follow-up during the lock-down period, indicating Flash Glucose Monitoring and remote control as a potential methodology for diabetes management during COVID-19 lock-down. HYPOTHESIS AND DISCUSSION: The increase in diabetes and obesity prevalence in Milano Metropolitan Area, which took place over 30 years, is related to several environmental factors. We hypothesize that some of those factors may have also determined the high incidence and virulence of COVID-19 in the Milano area. Health Agencies of Milano Metropolitan Area are presently taking care of diabetic patients facing the new challenge of maintaining sustainable diabetes care costs in light of an increase in urban population and of the new life-style. The COVID-19 pandemic will modify the management of diabetic and obese patients permanently, via the implementation of approaches that entail telemedicine technology. The pilot study conducted during the lock-down period indicates an improvement of glucose control utilizing a remote glucose control system in the Milano Metropolitan Area, suggesting a wider utilization of similar methodologies during the present "second wave" lock-down.

Quantifying Worsened Glycemic Control During the COVID-19 Pandemic.

AIMS: We hypothesized that glycemic control in outpatients, measured by HbA1c, was worse during the early months of the COVID-19 pandemic than in 2019. We sought to quantify how much worse and to determine if social determinants of health were associated with these differences. MATERIALS AND METHODS: Data were extracted from the electronic medical records of 2 cohorts of patients seen in the family medicine clinic of a southeastern academic health center. Three hundred patients with baseline HbA1c results as well as HbA1c results in May 2019 or May 2020 were evaluated. RESULTS: The groups had similar mean baseline HbA1c (7.65, SD = 1.50 for 2019; 7.61, SD = 1.71 for 2020; P = .85). Mean May HbA1c decreased from baseline in 2019 (7.19, SD = 1.45) but rose in 2020 (7.63, SD = 1.73), a statistically significant difference (P < .01). Controlling for age, gender, race, and insurance status, HbA1c in May 2020 (meanadj = 7.73) was significantly higher than in May 2019 (meanadj = 7.16). CONCLUSIONS: During the early months of the COVID-19 pandemic, glycemic control in our patient population was significantly worse than during the same period in 2019 (mean HbA1c difference = 0.57). Contrary to our expectations, we did not find associations between patient demographic variables and glycemic control, including race.

Continuous glucose monitoring: A review of the evidence in type 1 and 2 diabetes mellitus.

CONTEXT AND AIM: Continuous glucose monitoring (CGM) is becoming widely accepted as an adjunct to diabetes management. Compared to standard care, CGM can provide detailed information about glycaemic variability in an internationally standardised ambulatory glucose profile, enabling more informed user and clinician decision making. We aimed to review the evidence, user experience and cost-effectiveness of CGM. METHODS: A literature search was conducted by combining subject headings 'CGM' and 'flash glucose monitoring', with key words 'type 1 diabetes' and 'type 2 diabetes', limited to '1999 to current'. Further evidence was obtained from relevant references of retrieved articles. RESULTS: There is a strong evidence for CGM use in people with type 1 diabetes, with benefits of reduced glycated haemoglobin and hypoglycaemia, and increased time in range. While the evidence for CGM use in type 2 diabetes is less robust, similar benefits have been demonstrated. CGM can improve diabetes-related satisfaction in people with diabetes (PWD) and parents of children with diabetes, as well as the clinician experience. However, CGM does have limitations including cost, accuracy and perceived inconvenience. Cost-effectiveness analyses have indicated that CGM is a cost-effective adjunct to type 1 diabetes management that is associated with reduced diabetes-related complications and hospitalisation. CONCLUSIONS: Continuous glucose monitoring is revolutionising diabetes management. It is a cost-effective adjunct to diabetes management that has the potential to improve glycaemic outcomes and quality of life in PWD, especially type 1 diabetes.

Effects of real-time continuous glucose monitoring in type 1 diabetes: a meta-analysis of randomized controlled trials.

AIMS: Self-monitoring of blood glucose (SMBG) represented a major breakthrough in the treatment of type 1 diabetes. The aim of the present meta-analysis is to assess the effect of continues glucose monitoring (CGM) and flash glucose monitoring (FGM), on glycemic control in type 1 diabetes. MATERIALS AND METHODS: The present analysis includes randomized clinical trials comparing CGM or FGM with SMBG, with a duration of at least 12 weeks, identified in Medline or clinicaltrials.gov. The principal endpoint was HbA1c at the end of the trial. A secondary endpoint was severe hypoglycemia. Mean and 95% confidence intervals for HbA1c and Mantel-Haenzel odds ratio [MH-OR] for severe hypoglycemia were calculated, using random effect models. A sensitivity analysis was performed using fixed effect models. In addition, the following secondary endpoints were explored, using the same methods: time in range, health-related quality of life, and treatment satisfaction. Separate analyses were performed for trials comparing CGM with SMBG, and those comparing CGM + CSII and SMBG + MDI and CGM-regulated insulin infusion system (CRIS) and CSII + SMBG. RESULTS: CGM was associated with a significantly lower HbA1c at endpoint in comparison with SMBG (- 0.24 [- 0.34, - 0.13]%); CGM was associated with a significantly lower risk of severe hypoglycemia than SMBG. Treatment satisfaction and quality of life were not measured, or not reported, in the majority of studies. FGM showed a significant reduction in the incidence of mild hypoglycemia and an increased treatment satisfaction, but no significant results are shown in HbA1c. CGM + CSII in comparison with SMBG + MDI was associated with a significant reduction in HbA1c. Only two trials with a duration of at least 12 weeks compared a CRIS with SMBG + CSII; HbA1c between the two treatment arms was not statistically significant (difference in means: - 0.23 [- 0.91; 0.46]%; p = 0.52). CONCLUSION: GCM compared to SMBG has showed a reduction in HbA1c and severe hypoglycemia in patient with type 1 diabetes. The comparison between CGM + CSII and SMBG + MDI showed a large reduction in HbA1c; it is conceivable that the effects of CSII + CGM on glycemic control additives. The only comparison available between FGM and SMBG was conducted in patients in good control.

Assessment of the effect of the COVID-19 lockdown on glycaemic control in people with type 1 diabetes using flash glucose monitoring.

AIM: To describe the effect of the stringent lockdown measures, introduced in the UK on 23 March 2020 to curtail the transmission of COVID-19, on glycaemic control in people with type 1 diabetes using flash glucose monitoring. METHODS: We undertook an observational study of 572 individuals with type 1 diabetes for whom paired flash glucose monitoring data were available between early March and May 2020. The primary outcome was change in flash glucose monitoring variables. We also assessed clinical variables associated with change in glycaemic control. RESULTS: Percentage of time in range increased between March and May 2020 [median (interquartile range) 53 (41-64)% vs 56 (45-68)%; P < 0.001], with associated improvements in standard deviation of glucose (P <0.001) and estimated HbA1c (P <0.001). There was a small reduction in the number of individuals meeting the hypoglycaemia target of <5% per day (64% vs 58%; P = 0.004). Comparing changes in flash glucose monitoring data from March to May in 2019 with the same period in 2020 confirmed that these differences were confined to 2020. Socio-economic deprivation was an independent predictor of a ≥5% reduction in time in range during lockdown (odds ratio 0.45 for people in the two most affluent Scottish Index of Multiple Deprivation quintiles; P <0.001). CONCLUSIONS: Lockdown was not associated with a significant deterioration in glycaemic control in people with type 1 diabetes using flash glucose monitoring. However, socio-economic deprivation appeared to increase the risk of decline in glycaemic control, which has implications for how support is focused in challenging times.

Assessment of the effect of pregnancy planning in women with type 1 diabetes treated by insulin pump.

BACKGROUND: Pregnant women with type 1 diabetes (T1D) have high risk of complications despite improved care based on technology advancements. OBJECTIVE: To assess the effects of pregnancy planning on fetal and maternal outcomes in T1D women treated with continuous subcutaneous insulin infusion (CSII). STUDY DESIGN: We retrospectively assessed maternal and neonatal outcomes in T1D women using CSII who had planned or unplanned pregnancies between 2002 and 2018. The study was done in two European countries with similar sustained programs for pregnancy planning over the study period. RESULTS: Data from 107 pregnancies and newborn babies were collected. Seventy-nine pregnancies (73.8%) had been planned. HbA1c was lower in planned versus unplanned pregnancy before and during all three trimesters of pregnancy (p < 0.0001). Pregnancy planning was associated with a reduction in the occurrence of iatrogenic preterm delivery (RR 0.44, 95% CI 0.23-0.95; p = 0.01). Risk reduction persisted after adjustments for mother's age above 40 years and preeclampsia. High HbA1c before or during pregnancy was associated with an increased risk of iatrogenic preterm delivery (RR 3.05, 95% CI 1.78-5.22, p < 0.0001). Premature newborns needed intensive care more often than those at term (RR 3.10, 95% CI 1.53-4.31; p = 0.002). CONCLUSIONS: Pregnancy planning in T1D women using CSII was associated with better glucose control and decreased risk of iatrogenic preterm delivery. Hence preconception care also improves pregnancy outcome in patients using an advanced mode of insulin delivery. Planned pregnancies could further benefit from the use of new metrics of glucose control.

Impact of lockdown for COVID-19 pandemic in Indian children and youth with type 1 diabetes from different socio-economic classes.

OBJECTIVES: In March 2020, lockdown was imposed in India to combat spread of Coronavirus, which was extended till 31st May. Implementation of lockdown and limited outdoor activities resulted in changes in routines of children with diabetes. The aim of this study was to assess the impact of lockdown on glycemic control, weight and body mass index (BMI) patterns of children with type 1 diabetes (T1DM) from different socio-economic (SE) classes. METHODS: This observational study included 77 children and youth (5-20 years) with T1DM having disease duration of ≥6 months. Demographic data and investigations were recorded at two time points (post lockdown when the children came for follow up, pre lockdown data from medical records). RESULTS: Glycemic control improved (pre lockdown HbA1C 79.4±19.2 vs. post lockdown Hba1C 74.5±16.9 mmol/mol, p<0.05) and there was weight gain post lockdown (pre lockdown weight z-score -0.4±0.8 vs. post lockdown weight z-score -0.2±0.8, p<0.05) without any significant change in BMI and insulin requirements. Improved glycemic was seen in the lower SE group control post lockdown (p<0.05), whereas in higher SE group, it remained unchanged. Children whose parents were at home during lockdown showed an improved glycemic control (p<0.05) as compared to children whose parents continued to work during lockdown (p>0.01). CONCLUSIONS: During coronavirus lockdown, glycemic control was adequately maintained in children with T1DM, highlighting importance of stronger family support system leading to more steady daily routine.

Utilização de serviços de urgência e emergência por complicações agudas da hipertensão e/ou diabetes / Uso de servicios de urgencia y emergencia para complicaciones agudas de hipertensión a y / o diabetes / Use of urgency and emergency services for acute hypertension and / or diabetes complications

RESUMO Objetivo analisar a utilização de serviços de urgência e emergência por indivíduos com complicações agudas de Hipertensão Arterial e/ou Diabetes Mellitus. Método estudo retrospectivo realizado nos três serviços públicos de pronto-atendimento em município do Sul do Brasil. Os dados foram coletados mediante consulta aos prontuários eletrônicos das pessoas que compareceram duas ou mais vezes no período de janeiro de 2018 a fevereiro de 2020. Na análise foi utilizado Regressão Logística e georreferenciamento dos endereços residenciais. Resultados das 1.125 pessoas, 72,7% procuraram os serviços por Hipertensão; 18,1% por Diabetes; e 7,3%, por ambas as condições. A maioria não possuía a condição crônica registrada na Atenção Primária e residia próximo aos serviços de pronto-atendimento. Tiveram mais chances de três ou mais comparecimentos os usuários que procuraram concomitantemente as Unidades de Pronto atendimento do Hospital Universitário e as municipais, por ambas as condições, com menor escolaridade e sem companheiro. Conclusão e implicações para a prática informações sobre a utilização dos serviços de urgência e emergência e das pessoas que os procuram por complicações agudas da Hipertensão e/ou Diabetes podem subsidiar a formulação de políticas públicas e a proposição de estratégias mais efetivas na identificação, acompanhamento e busca ativa de pessoas com condições crônicas.

RESUMEN Objetivo analizar el uso de los servicios de urgencia y emergencia por personas con complicaciones agudas de Hipertensión Arterial y / o Diabetes Mellitus. Método estudio retrospectivo realizado en los tres servicios públicos de emergencia de un municipio del sur de Brasil. Los datos se recogieron consultando las historias clínicas electrónicas de las personas que acudieron dos o más veces entre enero de 2018 y febrero de 2020. En el análisis se utilizó la Regresión Logística y la georreferenciación de domicilios. Resultados de las 1125 personas, el 72,7% buscó servicios por hipertensión, el 18,1% por diabetes mellitus y el 7,3% por ambas condiciones. La mayoría no tenía la enfermedad crónica registrada en Atención Primaria y vivía cerca de los servicios de emergencia. Los usuarios que acudieron de forma concurrente a las Unidades Hospitalarias de Urgencias del Hospital Universitario y las municipales, por ambas condiciones, con menor escolaridad y sin pareja tenían más probabilidades de tener tres o más apariciones. Conclusión e implicaciones para la práctica las informaciones sobre el uso de los servicios de urgencia y emergencia y las personas que los buscan por complicaciones agudas de Hipertensión Arterial y / o Diabetes Mellitus pueden apoyar la formulación de políticas públicas y la propuesta de estrategias más efectivas en la identificación, seguimiento y búsqueda activa de personas con enfermedades crónicas.

ABSTRACT Objective to analyze the use of urgency and emergency services by individuals with acute complications of Hypertension and/or Diabetes Mellitus. Method a retrospective study conducted in three public emergency care services in a city in southern Brazil. Data was collected by consulting the electronic medical records of people who attended two or more times during the period from January 2018 to February 2020. Logistic Regression and geo-referencing of residential addresses were used in the analysis. Results of the 1,125 people, 72.7% sought the services for hypertension; 18.1% for diabetes; and 7.3% for both conditions. Most did not have the chronic condition registered in Primary Care and lived near the emergency services. Users who sought the Emergency Care Units of the University Hospital and the municipal ones concomitantly, for both conditions, with less education, and without a partner had a greater chance of three or more attendances. Conclusion and implications for practice information on the use of urgency and emergency services and of people who seek them for acute complications of Hypertension and/or Diabetes can subsidize the formulation of public policies and the proposition of more effective strategies in the identification, follow-up and active search for people with chronic conditions.

Improving management of glycaemic control in people with T2DM in primary care: estimation of the impact on the clinical complications and associated costs.

BACKGROUND: To estimate the potential benefits in terms of avoided complications and cost reduction if the Spanish health system would encourage the intensification of treatment for better glycaemic control in adults with Type 2 diabetes from the current HbA1c target used in clinical practice of 68 mmol/mol to a target of 53 mmol/mol. METHODS: The IQVIA Core Diabetes Model (version 9.0) was used to model the impact of these changes in respect of micro- and macrovascular complications and the associated costs. The modelling was based on data derived from the SIDIAP-Q population database from Catalonia, taking a random cohort of 10,000 people with type 2 diabetes and dividing it into sub-groups based on their baseline HbA1c. RESULTS: The CDM modelling showed that the average cost reduction per person varies depending on baseline HbA1c. The model estimates that after 25 years, people with a baseline HbA1c between 48 and 58 mmol/mol and > 75 mmol/mol show an average cost reduction of €6027 and €11,966, respectively. Applying the per-person cost reduction to the cohorts of the prevalent population in Spain (1,910,374) the overall estimated cost reduction was €14.7 billion over 25 years. The improvements in outcomes resulted in an estimated reduction of more than 1.2 million complications cumulatively over 25 years, of which more than 550,000 relate to diabetic foot and more than 170,000 related to renal disease. CONCLUSION: Over a 25 year period, Spain could considerably reduce costs and avoid major complications if, on a population level, more ambitious glycaemic control, according to Spanish or EU guidelines, could be achieved among people with type 2 diabetes by reducing the HbA1c threshold for treatment intensification. Although there is a slower trajectory for benefits in earlier years, there is a much more rapid benefit gain between years 5 and 15.

Geographic and Racial/Ethnic Variation in Glycemic Control and Treatment in a National Sample of Veterans With Diabetes.

OBJECTIVE: Geographic and racial/ethnic disparities related to diabetes control and treatment have not previously been examined at the national level. RESEARCH DESIGN AND METHODS: A retrospective cohort study was conducted in a national cohort of 1,140,634 veterans with diabetes, defined as two or more diabetes ICD-9 codes (250.xx) across inpatient and outpatient records. Main exposures of interest included 125 Veterans Administration Medical Center (VAMC) catchment areas as well as racial/ethnic group. The main outcome measure was HbA1c level dichotomized at ≥8.0% (≥64 mmol/mol). RESULTS: After adjustment for age, sex, racial/ethnic group, service-connected disability, marital status, and the van Walraven Elixhauser comorbidity score, the prevalence of uncontrolled diabetes varied by VAMC catchment area, with values ranging from 19.1% to 29.2%. Moreover, these differences largely persisted after further adjusting for medication use and adherence as well as utilization and access metrics. Racial/ethnic differences in diabetes control were also noted. In our final models, compared with non-Hispanic Whites, non-Hispanic Blacks (odds ratio 1.11 [95% credible interval 1.09-1.14]) and Hispanics (1.36 [1.09-1.14]) had a higher odds of uncontrolled HBA1c level. CONCLUSIONS: In a national cohort of veterans with diabetes, we found geographic as well as racial/ethnic differences in diabetes control rates that were not explained by adjustment for demographics, comorbidity burden, use or type of diabetes medication, health care utilization, access metrics, or medication adherence. Moreover, disparities in suboptimal control appeared consistent across most, but not all, VAMC catchment areas, with non-Hispanic Black and Hispanic veterans having a higher odds of suboptimal diabetes control than non-Hispanic White veterans.

Health Care Coverage and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes: Results From the TODAY2 Study.

OBJECTIVE: To examine the relationship between health care coverage and HbA1c in young adults with youth-onset type 2 diabetes who transitioned to community diabetes care after receiving care during the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study. RESEARCH DESIGN AND METHODS: Participants completed questionnaires annually. HbA1c was measured in a central laboratory. Data from 2 years before and after transitioning to community care (2013-2016) were examined and compared between states with and without expanded Medicaid. RESULTS: In 2016 (n = 427; mean age 24 years), 2 years after transitioning to community care, 93% of participants in states with Medicaid expansion had health care coverage compared with 68% (P < 0.0001) in states without Medicaid expansion. Mean HbA1c was 9.8% in participants with government coverage, 9.3% with commercial coverage, and 10.1% in those with no coverage (P = 0.0774). Additionally, 32%, 42%, and 66% of those with government coverage, commercially covered, and no coverage, respectively, were not attending outpatient diabetes visits (P < 0.0001). Of those with government coverage, 83% reported they had adequate coverage for insulin syringes/needles/pens, and 89% for glucose-monitoring supplies, with more limited coverage in those with commercial plans. Participants with commercial coverage had higher education attainment (P < 0.0001); 52% had HbA1c ≥9.0% compared with 64% of those who were government covered and 58% with no coverage (P = 0.0646). CONCLUSIONS: More young adults with type 2 diabetes from the TODAY cohort had health care coverage in states with expanded Medicaid but glycemic control remained poor, regardless of coverage. New therapies and approaches are needed for this vulnerable population.

Diabetes Healthcare Professionals Use Multiple Continuous Glucose Monitoring Data Indicators to Assess Glucose Management.

BACKGROUND: Continuous glucose monitoring (CGM) offers multiple data features that can be leveraged to assess glucose management. However, how diabetes healthcare professionals (HCPs) actually assess CGM data and the extent to which they agree in assessing glycemic management are not well understood. METHODS: We asked HCPs to assess ten de-identified CGM datasets (each spanning seven days) and rank order each day by relative glycemic management (from "best" to "worst"). We also asked HCPs to endorse features of CGM data that were important in making such assessments. RESULTS: In the study, 57 HCPs (29 endocrinologists; 28 diabetes educators) participated. Hypoglycemia and glycemic variance were endorsed by nearly all HCPs to be important (91% and 88%, respectively). Time in range and daily lows and highs were endorsed more frequently by educators (all Ps < .05). On average, HCPs endorsed 3.7 of eight data features. Overall, HCPs demonstrated agreement in ranking days by relative glycemic control (Kendall's W = .52, P < .001). Rankings were similar between endocrinologists and educators (R2 = .90, Cohen's kappa = .95, mean absolute error = .4 [all Ps < .05]; Mann-Whitney U = 41, P = .53). CONCLUSIONS: Consensus in the endorsement of certain data features and agreement in assessing glycemic management were observed. While some practice-specific differences in feature endorsement were found, no differences between educators and endocrinologists were observed in assessing glycemic management. Overall, HCPs tended to consider CGM data holistically, in alignment with published recommendations, and made converging assessments regardless of practice.

Impact of a Telephonic Intervention to Improve Diabetes Control on Health Care Utilization and Cost for Adults in South Bronx, New York.

OBJECTIVE: Self-management education and support are essential for improved diabetes control. A 1-year randomized telephonic diabetes self-management intervention (Bronx A1C) among a predominantly Latino and African American population in New York City was found effective in improving blood glucose control. To further those findings, this current study assessed the intervention's impact in reducing health care utilization and costs over 4 years. RESEARCH DESIGN AND METHODS: We measured inpatient (n = 816) health care utilization for Bronx A1C participants using an administrative data set containing all hospital discharges for New York State from 2006 to 2014. Multilevel mixed modeling was used to assess changes in health care utilization and costs between the telephonic diabetes intervention (Tele/Pr) arm and print-only (PrO) control arm. RESULTS: During follow-up, excess relative reductions in all-cause hospitalizations for the Tele/Pr arm compared with PrO arm were statistically significant for odds of hospital use (odds ratio [OR] 0.89; 95% CI 0.82, 0.97; P < 0.01), number of hospital stays (rate ratio [RR] 0.90; 95% CI 0.81, 0.99; P = 0.04), and hospital costs (RR 0.90; 95% CI 0.84, 0.98; P = 0.01). Reductions in hospital use and costs were even stronger for diabetes-related hospitalizations. These outcomes were not significantly related to changes observed in hemoglobin A1c during individuals' participation in the 1-year intervention. CONCLUSIONS: These results indicate that the impact of the Bronx A1C intervention was not just on short-term improvements in glycemic control but also on long-term health care utilization. This finding is important because it suggests the benefits of the intervention were long-lasting with the potential to not only reduce hospitalizations but also to lower hospital-associated costs.

The Association Between Poor Glycemic Control and Health Care Costs in People With Diabetes: A Population-Based Study.

OBJECTIVE: To analyze the differences in health care costs according to glycemic control in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: Data on health care resource utilization from 100,391 people with type 2 diabetes were extracted from the electronic database used at the Catalan Health Institute. Multivariate regression models were carried out to test the impact of glycemic control (HbA1c) on total health care, hospital admission, and medication costs; model 1 adjusted for a variety of covariates, and model 2 also included micro- and macrovascular complications. Glycemic control was classified as good for HbA1c <7%, fair for ≥7% to <8%, poor for ≥8% to <10%, and very poor for ≥10%. RESULTS: Mean per patient annual direct medical costs were €3,039 ± SD €6,581. Worse glycemic control was associated with higher total health care costs: compared with good glycemic control, health care costs increased by 18% (€509.82) and 23% (€661.35) in patients with very poor and poor glycemic control, respectively, when unadjusted and by €428.3 and €395.1, respectively, in model 2. Medication costs increased by 12% in patients with fair control and by 28% in those with very poor control (model 2). Patients with poor control had a higher probability of hospitalization than those with good control (5% in model 2) and a greater average cost when hospitalization occurred (€811). CONCLUSIONS: Poor glycemic control was directly related to higher total health care, hospitalization, and medication costs. Preventive strategies and good glycemic control in people with type 2 diabetes could reduce the economic impact associated with this disease.

The Longitudinal Influence of Social Determinants of Health on Glycemic Control in Elderly Adults With Diabetes.

OBJECTIVE: This study aimed to understand the longitudinal relationship between financial, psychosocial, and neighborhood social determinants and glycemic control (HbA1c) in older adults with diabetes. RESEARCH DESIGN AND METHODS: Data from 2,662 individuals with self-reported diabetes who participated in the Health and Retirement Study (HRS) were used. Participants were followed from 2006 through 2014. Financial hardship, psychosocial, and neighborhood-level social determinant factors were based on validated surveys from the biennial core interview and RAND data sets. All social determinant factors and measurements of HbA1c from the time period were used and treated as time varying in analyses. SAS PROC GLIMMIX was used to fit a series of hierarchical linear mixed models. Models controlled for nonindependence among the repeated observations using a random intercept and treating each individual participant as a random factor. Survey methods were used to apply HRS weighting. RESULTS: Before adjustment for demographics, difficulty paying bills (ß = 0.18 [95% CI 0.02, 0.24]) and medication cost nonadherence (0.15 [0.01, 0.29]) were independently associated with increasing HbA1c over time, and social cohesion (-0.05 [-0.10, -0.001]) was independently associated with decreasing HbA1c over time. After adjusting for both demographics and comorbidity count, difficulty paying bills (0.13 [0.03, 0.24]) and religiosity (0.04 [0.001, 0.08]) were independently associated with increasing HbA1c over time. CONCLUSIONS: Using a longitudinal cohort of older adults with diabetes, this study found that financial hardship factors, such as difficulty paying bills, were more consistently associated with worsening glycemic control over time than psychosocial and neighborhood factors.

Simple Linear Support Vector Machine Classifier Can Distinguish Impaired Glucose Tolerance Versus Type 2 Diabetes Using a Reduced Set of CGM-Based Glycemic Variability Indices.

BACKGROUND: Many glycemic variability (GV) indices exist in the literature. In previous works, we demonstrated that a set of GV indices, extracted from continuous glucose monitoring (CGM) data, can distinguish between stages of diabetes progression. We showed that 25 indices driving a logistic regression classifier can differentiate between healthy and nonhealthy individuals; whereas 37 GV indices and four individual parameters, feeding a polynomial-kernel support vector machine (SVM), can further distinguish between impaired glucose tolerance (IGT) and type 2 diabetes (T2D). The latter approach has some limitations to interpretability (complex model, extensive index pool). In this article, we try to obtain the same performance with a simpler classifier and a parsimonious subset of indices. METHODS: We analyzed the data of 62 subjects with IGT or T2D. We selected 17 interpretable GV indices and four parameters (age, sex, BMI, waist circumference). We trained a SVM on the data of a baseline visit and tested it on the follow-up visit, comparing the results with the state-of-art methods. RESULTS: The linear SVM fed by a reduced subset of 17 GV indices and four basic parameters achieved 82.3% accuracy, only marginally worse than the reference 87.1% (41-features polynomial-kernel SVM). Cross-validation accuracies were comparable (69.6% vs 72.5%). CONCLUSION: The proposed SVM fed by 17 GV indices and four parameters can differentiate between IGT and T2D. Using a simpler model and a parsimonious set of indices caused only a slight accuracy deterioration, with significant advantages in terms of interpretability.