Practice Facilitation and Clinical Performance Feedback Using the Electronic Health Record Improved Blood Pressure and Cholesterol Management in Small Primary Care Practices in New York City.

Cardiovascular disease (CVD) disproportionately affects people of color and those with lower household income. Improving blood pressure (BP) and cholesterol management for those with or at risk for CVD can improve health outcomes. The New York City Department of Health implemented clinical performance feedback with practice facilitation (PF) in 134 small primary care practices serving on average over 84% persons of color. Facilitators reviewed BP and cholesterol management data on performance dashboards and guided practices to identify and outreach to patients with suboptimal BP and cholesterol management. Despite disruptions from the COVID-19 pandemic, practices demonstrated significant improvements in BP (68%-75%, P < .001) and cholesterol management (72%-78%, P = .01). Prioritizing high-need neighborhoods for impactful resource investment, such as PF and data sharing, may be a promising approach to reducing CVD and hypertension inequities in areas heavily impacted by structural racism.

Associations of Residential Socioeconomic, Food, and Built Environments With Glycemic Control in Persons With Diabetes in New York City From 2007-2013.

In the present study, we examined the longitudinal associations between residential environmental factors and glycemic control in 182,756 adults with diabetes in New York City from 2007 to 2013. Glycemic control was defined as a hemoglobin A1c (HbA1c) level less than 7%. We constructed residential-level measures and performed principle component analysis to formulate a residential composite score. On the basis of this score, we divided residential areas into quintiles, with the lowest and highest quintiles reflecting the least and most advantaged residential environments, respectively. Several residential-level environmental characteristics, including more advantaged socioeconomic conditions, greater ratio of healthy food outlets to unhealthy food outlets, and residential walkability were associated with increased glycemic control. Individuals who lived continuously in the most advantaged residential areas took less time to achieve glycemic control compared with the individuals who lived continuously in the least advantaged residential areas (9.9 vs. 11.5 months). Moving from less advantaged residential areas to more advantaged residential areas was related to improved diabetes control (decrease in HbA1c = 0.40%, 95% confidence interval: 0.22, 0.55), whereas moving from more advantaged residential areas to less advantaged residential areas was related to worsening diabetes control (increase in HbA1c = 0.33%, 95% confidence interval: 0.24, 0.44). These results show that residential areas with greater resources to support healthy food and residential walkability are associated with improved glycemic control in persons with diabetes.

Gender and Race Disparities in Cardiovascular Disease Risk Factors among New York City Adults: New York City Health and Nutrition Examination Survey (NYC HANES) 2013-2014.

While gender and racial/ethnic disparities in cardiovascular disease (CVD) risk factors have each been well characterized, few studies have comprehensively examined how patterns of major CVD risk factors vary and intersect across gender and major racial/ethnic groups, considered together. Using data from New York City Health and Nutrition Examination Survey 2013-2014-a population-based, cross-sectional survey of NYC residents ages 20 years and older-we measured prevalence of obesity, hypertension, hypercholesterolemia, smoking, and diabetes across gender and race/ethnicity groups for 1527 individuals. We used logistic regression with predicted marginal to estimate age-adjusted prevalence ratio by gender and race/ethnicity groups and assess for potential additive and multiplicative interaction. Overall, women had lower prevalence of CVD risk factors than men, with less hypertension (p = 0.040), lower triglycerides (p < 0.001), higher HDL (p < 0.001), and a greater likelihood of a heart healthy lifestyle, more likely not to smoke and to follow a healthy diet (p < 0.05). When further stratified by race/ethnicity, however, the female advantage was largely restricted to non-Latino white women. Non-Latino black women had significantly higher risk of being overweight or obese, having hypertension, and having diabetes than non-Latino white men or women, or than non-Latino black men (p < 0.05). Non-Latino black women also had higher total cholesterol compared to non-Latino black men (184.4 vs 170.5 mg/dL, p = 0.010). Despite efforts to improve cardiovascular health and narrow disparities, non-Latino black women continue to have a higher burden of CVD risk factors than other gender and racial/ethnic groups. This study highlights the importance of assessing for intersectionality between gender and race/ethnicity groups when examining CVD risk factors.

Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

BACKGROUND: Self-monitoring of blood pressure (BP) appears to reduce BP in hypertension but important questions remain regarding effective implementation and which groups may benefit most. This individual patient data (IPD) meta-analysis was performed to better understand the effectiveness of BP self-monitoring to lower BP and control hypertension. METHODS AND FINDINGS: Medline, Embase, and the Cochrane Library were searched for randomised trials comparing self-monitoring to no self-monitoring in hypertensive patients (June 2016). Two reviewers independently assessed articles for eligibility and the authors of eligible trials were approached requesting IPD. Of 2,846 articles in the initial search, 36 were eligible. IPD were provided from 25 trials, including 1 unpublished study. Data for the primary outcomes-change in mean clinic or ambulatory BP and proportion controlled below target at 12 months-were available from 15/19 possible studies (7,138/8,292 [86%] of randomised participants). Overall, self-monitoring was associated with reduced clinic systolic blood pressure (sBP) compared to usual care at 12 months (-3.2 mmHg, [95% CI -4.9, -1.6 mmHg]). However, this effect was strongly influenced by the intensity of co-intervention ranging from no effect with self-monitoring alone (-1.0 mmHg [-3.3, 1.2]), to a 6.1 mmHg (-9.0, -3.2) reduction when monitoring was combined with intensive support. Self-monitoring was most effective in those with fewer antihypertensive medications and higher baseline sBP up to 170 mmHg. No differences in efficacy were seen by sex or by most comorbidities. Ambulatory BP data at 12 months were available from 4 trials (1,478 patients), which assessed self-monitoring with little or no co-intervention. There was no association between self-monitoring and either lower clinic or ambulatory sBP in this group (clinic -0.2 mmHg [-2.2, 1.8]; ambulatory 1.1 mmHg [-0.3, 2.5]). Results for diastolic blood pressure (dBP) were similar. The main limitation of this work was that significant heterogeneity remained. This was at least in part due to different inclusion criteria, self-monitoring regimes, and target BPs in included studies. CONCLUSIONS: Self-monitoring alone is not associated with lower BP or better control, but in conjunction with co-interventions (including systematic medication titration by doctors, pharmacists, or patients; education; or lifestyle counselling) leads to clinically significant BP reduction which persists for at least 12 months. The implementation of self-monitoring in hypertension should be accompanied by such co-interventions.

Effects of Return-to-Office, Public Schools Reopening, and Vaccination Mandates on COVID-19 Cases Among Municipal Employee Residents of New York City.

OBJECTIVE: On September 13, 2021, teleworking ended for New York City municipal employees, and Department of Education employees returned to reopened schools. On October 29, COVID-19 vaccination was mandated. We assessed these mandates' short-term effects on disease transmission. METHODS: Using difference-in-difference analyses, we calculated COVID-19 incidence rate ratios (IRRs) among residents 18 to 64 years old by employment status before and after policy implementation. RESULTS: IRRs after (September 23-October 28) versus before (July 5-September 12) the return-to-office mandate were similar between office-based City employees and non-City employees. Among Department of Education employees, the IRR after schools reopened was elevated by 28.4% (95% confidence interval, 17.3%-40.3%). Among City employees, the IRR after (October 29-November 30) versus before (September 23-October 28) the vaccination mandate was lowered by 20.1% (95% confidence interval, 13.7%-26.0%). CONCLUSIONS: Workforce mandates influenced disease transmission, among other societal effects.

Metabolic syndrome among adults in New York City, 2004 New York City Health and Nutrition Examination Survey.

INTRODUCTION: The objective of this study was to describe the prevalence of and factors associated with metabolic syndrome among adult New York City residents. METHODS: The 2004 New York City Health and Nutrition Examination Survey was a population-based, cross-sectional study of noninstitutionalized New York City residents aged 20 years or older. We examined the prevalence of metabolic syndrome and its components as defined by the National Cholesterol Education Program's Adult Treatment Panel III revised guidelines, according to demographic subgroups and comorbid diagnoses in a probability sample of 1,263 participants. We conducted bivariable and multivariable analyses to identify factors associated with metabolic syndrome. RESULTS: The age-adjusted prevalence of metabolic syndrome was 26.7% (95% confidence interval, 23.7%-29.8%). Prevalence was highest among Hispanics (33.9%) and lowest among whites (21.8%). Prevalence increased with age and body mass index and was higher among women (30.1%) than among men (22.9%). More than half (55.4%) of women and 33.0% of men with metabolic syndrome had only 3 metabolic abnormalities, 1 of which was abdominal obesity. The most common combination of metabolic abnormalities was abdominal obesity, elevated fasting blood glucose, and elevated blood pressure. Adjusting for other factors, higher body mass index, Asian race, and current smoking were positively associated with metabolic syndrome; alcohol use was inversely associated with metabolic syndrome among women but increased the likelihood of metabolic syndrome among men. CONCLUSION: Metabolic syndrome is pervasive among New York City adults, particularly women, and is associated with modifiable factors. These results identify population subgroups that could be targeted for prevention and provide a benchmark for assessing such interventions.

Incidence of self-reported diabetes in New York City, 2002, 2004, and 2008.

INTRODUCTION: Prevalence and incidence of diabetes among adults are increasing in the United States. The purpose of this study was to estimate the incidence of self-reported diabetes in New York City, examine factors associated with diabetes incidence, and estimate changes in the incidence over time. METHODS: We used data from the New York City Community Health Survey in 2002, 2004, and 2008 to estimate the age-adjusted incidence of self-reported diabetes among 24,384 adults aged 18 years or older. Multiple logistic regression analysis was performed to examine factors associated with incident diabetes. RESULTS: Survey results indicated that the age-adjusted incidence of diabetes per 1,000 population was 9.4 in 2002, 11.9 in 2004, and 8.6 in 2008. In multivariable-adjusted analysis, diabetes incidence was significantly associated with being aged 45 or older, being black or Hispanic, being overweight or obese, and having less than a high school diploma. CONCLUSION: Our results suggest that the incidence of diabetes in New York City may be stabilizing. Age, black race, Hispanic ethnicity, elevated body mass index, and low educational attainment are risk factors for diabetes. Large-scale implementation of prevention efforts addressing obesity and sedentary lifestyle and targeting racial/ethnic minority groups and those with low educational attainment are essential to control diabetes in New York City.

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.

Heart Age, Cardiovascular Disease Risk, and Disparities by Sex and Race/Ethnicity Among New York City Adults.

OBJECTIVES: Cardiovascular disease (CVD) is the leading cause of mortality in the United States. The risk for developing CVD is usually calculated and communicated to patients as a percentage. The calculation of heart age-defined as the predicted age of a person's vascular system based on the person's CVD risk factor profile-is an alternative method for expressing CVD risk. We estimated heart age among adults aged 30-74 in New York City and examined disparities in excess heart age by race/ethnicity and sex. METHODS: We applied data from the 2011, 2013, and 2015 New York State Behavioral Risk Factor Surveillance System to the non-laboratory-based Framingham risk score functions to calculate 10-year CVD risk and heart age by sex, race/ethnicity, and selected sociodemographic groups and risk factors. RESULTS: Of 6117 men and women in the study sample, the average heart age was 5.7 years higher than the chronological age, and 2631 (43%) adults had a predicted heart age ≥5 years older than their chronological age. Mean excess heart age increased with age (from 0.7 year among adults aged 30-39 to 11.2 years among adults aged 60-74) and body mass index (from 1.1 year among adults with normal weight to 11.8 years among adults with obesity). Non-Latino white women had the lowest mean excess heart age (2.3 years), and non-Latino black men and women had the highest excess heart age (8.4 years). CONCLUSIONS: Racial/ethnic and sex disparities in CVD risk persist among adults in New York City. Use of heart age at the population level can support public awareness and inform targeted programs and interventions for population subgroups most at risk for CVD.

Using Indirect Measures to Identify Geographic Hot Spots of Poor Glycemic Control: Cross-sectional Comparisons With an A1C Registry.

OBJECTIVE: Focusing health interventions in places with suboptimal glycemic control can help direct resources to neighborhoods with poor diabetes-related outcomes, but finding these areas can be difficult. Our objective was to use indirect measures versus a gold standard, population-based A1C registry to identify areas of poor glycemic control. RESEARCH DESIGN AND METHODS: Census tracts in New York City (NYC) were characterized by race, ethnicity, income, poverty, education, diabetes-related emergency visits, inpatient hospitalizations, and proportion of adults with diabetes having poor glycemic control, based on A1C >9.0% (75 mmol/mol). Hot spot analyses were then performed, using the Getis-Ord Gi* statistic for all measures. We then calculated the sensitivity, specificity, positive and negative predictive values, and accuracy of using the indirect measures to identify hot spots of poor glycemic control found using the NYC A1C Registry data. RESULTS: Using A1C Registry data, we identified hot spots in 42.8% of 2,085 NYC census tracts analyzed. Hot spots of diabetes-specific inpatient hospitalizations, diabetes-specific emergency visits, and age-adjusted diabetes prevalence estimated from emergency department data, respectively, had 88.9%, 89.6%, and 89.5% accuracy for identifying the same hot spots of poor glycemic control found using A1C Registry data. No other indirect measure tested had accuracy >80% except for the proportion of minority residents, which had 86.2% accuracy. CONCLUSIONS: Compared with demographic and socioeconomic factors, health care utilization measures more accurately identified hot spots of poor glycemic control. In places without a population-based A1C registry, mapping diabetes-specific health care utilization may provide actionable evidence for targeting health interventions in areas with the highest burden of uncontrolled diabetes.

Missed opportunities for type 2 diabetes mellitus screening among women with a history of gestational diabetes mellitus.

OBJECTIVES: We sought to determine rates and factors associated with screening for type 2 diabetes mellitus (DM) in women with a history of gestational diabetes mellitus. METHODS: We retrospectively studied women with diagnosed gestational diabetes mellitus who delivered at a university-affiliated hospital (n=570). Data sources included medical and administrative record review. Main outcome measures were the frequency of any type of glucose testing at least 6 weeks after delivery and the frequency of recommended glucose testing. We assessed demographic data, past medical history, and prenatal and postpartum care characteristics. RESULTS: Rates of glucose testing after delivery were low. Any type of glucose testing was performed at least once after 38% of deliveries, and recommended glucose testing was performed at least once after 23% of deliveries. Among women with at least 1 visit to the health care system after delivery (n=447), 42% received any type of glucose test at least once, and 35% received a recommended glucose test at least once. Factors associated with testing were being married, having a visit with an endocrinologist after delivery, and having more visits after delivery. CONCLUSIONS: These findings suggest that most women with gestational diabetes mellitus are not screened for type 2 DM after delivery. Opportunities for DM prevention and early treatment are being missed.

The influence of maternal weight and glucose tolerance on infant birthweight in Latino mother-infant pairs.

OBJECTIVES: We assessed the influence of maternal anthropometric and metabolic variables, including glucose tolerance, on infant birthweight. METHODS: In our prospective, population-based cohort study of 1041 Latino mother-infant pairs, we used standardized interviews, anthropometry, metabolic assays, and medical record reviews. We assessed relationships among maternal sociodemographic, prenatal care, anthropometric, and metabolic characteristics and birthweight with analysis of variance and bivariate and multivariate linear regression analyses. RESULTS: Forty-two percent of women in this study entered pregnancy overweight or obese; at least 36% exceeded weight-gain recommendations. Twenty-seven percent of the women had at least some degree of glucose abnormality, including 6.8% who had gestational diabetes. Maternal multiparity, height, weight, weight gain, and 1-hour screening glucose levels were significant independent predictors of infant birthweight after adjustment for gestational age. CONCLUSION: Studies of birthweight should account for maternal glucose level. Given the increased risk of adverse maternal and infant outcomes associated with excessive maternal weight, weight gain, and glucose intolerance, and the high prevalence of these conditions and type 2 diabetes among Latinas, public health professionals have unique opportunities for prevention through prenatal and postpartum interventions.

The efficacy and cost of alternative strategies for systematic screening for type 2 diabetes in the U.S. population 45-74 years of age.

OBJECTIVE: To simulate the outcomes of alternative strategies for screening the U.S. population 45-74 years of age for type 2 diabetes. RESEARCH DESIGN AND METHODS: We simulated screening with random plasma glucose (RPG) and cut points of 100, 130, and 160 mg/dl and a multivariate equation including RPG and other variables. Over 15 years, we simulated screening at intervals of 1, 3, and 5 years. All positive screening tests were followed by a diagnostic fasting plasma glucose or an oral glucose tolerance test. Outcomes include the numbers of false-negative, true-positive, and false-positive screening tests and the direct and indirect costs. RESULTS: At year 15, screening every 3 years with an RPG cut point of 100 mg/dl left 0.2 million false negatives, an RPG of 130 mg/dl or the equation left 1.3 million false negatives, and an RPG of 160 mg/dl left 2.8 million false negatives. Over 15 years, the absolute difference between the most sensitive and most specific screening strategy was 4.5 million true positives and 476 million false-positives. Strategies using RPG cut points of 130 mg/dl or the multivariate equation every 3 years identified 17.3 million true positives; however, the equation identified fewer false-positives. The total cost of the most sensitive screening strategy was $42.7 billion and that of the most specific strategy was $6.9 billion. CONCLUSIONS: Screening for type 2 diabetes every 3 years with an RPG cut point of 130 mg/dl or the multivariate equation provides good yield and minimizes false-positive screening tests and costs.

Does diabetes care compete with the provision of women's preventive care services?

OBJECTIVE: Care for chronic diseases may compete with preventive health care. To test this hypothesis, we examined the association between diabetes-related processes of care and preventive care in women. RESEARCH DESIGN AND METHODS: Using data from a prospective cohort study of diabetes care in managed care settings, we reviewed the care 540 diabetic women received from 355 primary care providers within 14 provider groups from one health plan. Of the 540 women, 278 were eligible to receive mammograms and 314 were eligible to receive Pap smears. Mammography performance was measured as at least one mammogram over a 2-year period and Pap performance was measured as at least one Pap smear over a 3-year period. To assess the association between diabetes-related processes of care and preventive services, we used hierarchical logistic regression models, accounted for clustering within provider groups, and adjusted for patient age, race, income and education level, diabetes treatment and duration, and health status, as well as physician age, sex, years of practice, and specialty. Diabetes-related processes of care were defined as dilated retinal examinations, urine microalbumin/protein testing, foot examinations, lipid and HbA(1c) testing, recommendations to take aspirin, and influenza vaccinations received over a 1-year period. RESULTS: In this cohort, 73% of eligible women received mammograms and 56% received Pap smears. After adjustment of models, better diabetes-related processes of care, better health status, and non-Medicaid insurance were associated with mammography performance. Better diabetes-related processes of care, younger patient age, and any visit to a gynecologist were associated with Pap performance. CONCLUSIONS: Better processes of diabetes care were associated with better women's preventive health care. Diabetes management did not compete with sex-specific screening.

A multivariate logistic regression equation to screen for diabetes: development and validation.

OBJECTIVE: To develop and validate an empirical equation to screen for diabetes. RESEARCH DESIGN AND METHODS: A predictive equation was developed using multiple logistic regression analysis and data collected from 1,032 Egyptian subjects with no history of diabetes. The equation incorporated age, sex, BMI, postprandial time (self-reported number of hours since last food or drink other than water), and random capillary plasma glucose as independent covariates for prediction of undiagnosed diabetes. These covariates were based on a fasting plasma glucose level >/=126 mg/dl and/or a plasma glucose level 2 h after a 75-g oral glucose load >/=200 mg/dl. The equation was validated using data collected from an independent sample of 1,065 American subjects. Its performance was also compared with that of recommended and proposed static plasma glucose cut points for diabetes screening. RESULTS: The predictive equation was calculated with the following logistic regression parameters: P = 1/(1 - e(-x)), where x = -10.0382 + [0.0331 (age in years) + 0.0308 (random plasma glucose in mg/dl) + 0.2500 (postprandial time assessed as 0 to >/=8 h) + 0.5620 (if female) + 0.0346 (BMI)]. The cut point for the prediction of previously undiagnosed diabetes was defined as a probability value >/=0.20. The equation's sensitivity was 65%, specificity 96%, and positive predictive value (PPV) 67%. When applied to a new sample, the equation's sensitivity was 62%, specificity 96%, and PPV 63%. CONCLUSIONS: This multivariate logistic equation improves on currently recommended methods of screening for undiagnosed diabetes and can be easily implemented in a inexpensive handheld programmable calculator to predict previously undiagnosed diabetes.

Opportunistic screening for diabetes in routine clinical practice.

OBJECTIVE: Since 1997, the American Diabetes Association has recommended that nondiabetic individuals >/=45 years of age be screened for diabetes at least every 3 years. We sought to characterize the frequency, methods, and results of diabetes screening in routine clinical practice. RESEARCH DESIGN AND METHODS: We studied opportunistic screening in nondiabetic members of a health maintenance organization >/=45 years of age who were assigned to a large, integrated, academic health care delivery system. Screening was defined as the first glucose, HbA(1c), or oral glucose tolerance test (OGTT) performed between 1 January 1998 and 31 December 2000. Chart review was performed to determine the prevalence of diabetes risk factors and to describe follow-up. RESULTS: Of 8,286 nondiabetic patients >/=45 years of age, 69% (n = 5,752) were screened. The frequency of screening was greater in patients with one or more primary care visits and increased with age. Women were more likely to be screened than men, and patients with at least one diabetes risk factor were more likely to be screened than those without risk factors. Random plasma glucose was the most common screening test (95%). Four percent (n = 202) of those screened had abnormal results. Only 38% (n = 77) of those with abnormal results received appropriate follow-up, and 17% (n = 35) were diagnosed with diabetes within 6 months of screening. The yield of screening was very low (0.6%, 35 of 5,752). CONCLUSIONS: Despite frequent screening and appropriate targeting of high-risk patients, follow-up of patients with abnormal results is uncommon and the yield of screening is low. Interventions are needed to help physicians recognize and provide appropriate follow-up for patients with potentially abnormal random glucose levels.

Community-based screening for diabetes in Michigan.

OBJECTIVE: To describe and evaluate a community-based diabetes screening program supported by the Michigan Department of Community Health. RESEARCH DESIGN AND METHODS: Between 1 June 1999 and 31 December 1999, community screening for diabetes was conducted by voluntary organizations using a standard protocol, American Diabetes Association (ADA) questionnaires, and ADA capillary plasma glucose criteria. RESULTS: A total of 3506 individuals were screened, 14% of whom did not meet criteria for screening. Of the 3031 individuals appropriately screened, 57% were classified as being at high risk based on the ADA questionnaire and 5% had positive screening tests based on ADA capillary plasma glucose criteria. Despite systematic follow-up, the screening program's yield of individuals with undiagnosed diabetes was <1%. CONCLUSIONS: Community screening for diabetes conducted according to ADA recommendations was extremely inefficient at identifying individuals with undiagnosed diabetes. The ADA diabetes screening questionnaire resulted in many false positive tests, and the ADA criteria for positive plasma glucose tests likely missed a substantial portion of individuals with undiagnosed diabetes. Relying on biochemical tests such as random plasma glucose, changing the criteria for a positive plasma glucose test, targeting racial and ethnic minority groups, and targeting medically underserved individuals might improve the yield of community-based diabetes screening.

Improving diabetes processes of care in managed care.

OBJECTIVE: To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practices. RESEARCH DESIGN AND METHODS: Nine practices providing care to managed care patients were randomly assigned as intervention or comparison sites. Intervention-site subjects had Annual Diabetes Assessment Program (ADAP) assessments (HbA(1c), blood pressure, lipids, smoking, retinal photos, urine microalbumin, and foot examination) at years 1 and 2. Comparison-site subjects had ADAP assessments at year 2. At Intervention sites, year 1 ADAP results were reviewed with subjects, mailed to providers, and incorporated into electronic medical records with guideline-generated suggestions for treatment and follow-up. Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessments. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models. RESULTS: Of 284 eligible subjects, 103 of 173 (60%) at the Intervention sites and 71 of 111 (64%) at the comparison sites participated; 83 of 103 (81%) of the intervention-site subjects returned for follow-up at year 2. Performance of the six recommended assessments improved in intervention-site subjects at year 2 compared with year 1 (5.8 vs. 4.3, P = 0.0001) and compared with comparison-site subjects at year 2 (4.2, P = 0.014). No significant changes were noted in intermediate outcomes. CONCLUSIONS: The ADAP significantly improved processes of care but not intermediate outcomes. Additional interventions are needed to improve intermediate outcomes.

The direct medical cost of type 2 diabetes.

OBJECTIVE: To describe the direct medical costs associated with type 2 diabetes, as well as its treatments, complications, and comorbidities. RESEARCH DESIGN AND METHODS: We studied a random sample of 1,364 subjects with type 2 diabetes who were members of a Michigan health maintenance organization. Demographic characteristics, duration of diabetes, diabetes treatments, glycemic control, complications, and comorbidities were assessed by surveys and medical chart reviews. Annual resource utilization and costs were assessed using health insurance claims. The log-transformed annual direct medical costs were fitted by multiple linear regression to indicator variables for demographics, treatments, glycemic control, complications, and comorbidities. RESULTS: The median annual direct medical costs for subjects with diet-controlled type 2 diabetes, BMI 30 kg/m(2), and no microvascular, neuropathic, or cardiovascular complications were 1,700 dollars for white men and 2,100 dollars for white women. A 10-kg/m(2) increase in BMI, treatment with oral antidiabetic or antihypertensive agents, diabetic kidney disease, cerebrovascular disease, and peripheral vascular disease were each associated with 10-30% increases in cost. Insulin treatment, angina, and MI were each associated with 60-90% increases in cost. Dialysis was associated with an 11-fold increase in cost. CONCLUSIONS: Insulin treatment and diabetes complications have a substantial impact on the direct medical costs of type 2 diabetes. The estimates presented in this model may be used to analyze the cost-effectiveness of interventions for type 2 diabetes.

Valuing health-related quality of life in diabetes.

OBJECTIVE: Cost-utility analyses use information on health utilities to compare medical treatments that have different clinical outcomes and impacts on survival. The purpose of this study was to describe the health utilities associated with diabetes and its treatments, complications, and comorbidities. RESEARCH DESIGN AND METHODS: We studied 2,048 subjects with type 1 and type 2 diabetes recruited from specialty clinics at a university medical center. We administered a questionnaire to each individual to assess demographic characteristics, type and duration of diabetes, treatments, complications, and comorbidities, and we used the Self-Administered Quality of Well Being index (QWB-SA) to calculate a health utility score. We then created regression models to fit the QWB-SA-derived health utility scores to indicator variables for type 1 and type 2 diabetes and each demographic variable, treatment, and complication. The coefficients were arranged in clinically meaningful ways to develop models to describe penalties from the health utility scores for nonobese diabetic men without additional treatments, complications, or comorbidities. RESULTS: The utility scores for nonobese diet-controlled men and women with type 2 diabetes and no microvascular, neuropathic, or cardiovascular complications were 0.69 and 0.65, respectively. The utility scores for men and women with type 1 diabetes and no complications were slightly lower (0.67 and 0.64, respectively). Blindness, dialysis, symptomatic neuropathy, foot ulcers, amputation, debilitating stroke, and congestive heart failure were associated with lower utility scores. CONCLUSIONS: Major diabetes complications are associated with worse health-related quality of life. The health utility scores provided should facilitate studies of the health burden of diabetes and the cost-utility of alternative strategies for the prevention and treatment of diabetes.