Telemedicine's Impact on Diabetes Care during the COVID-19 Pandemic: A Cohort Study in a Large Integrated Healthcare System.

Introduction: To examine if patients exposed to primary care telemedicine (telephone or video) early in the COVID-19 pandemic had higher rates of downstream HbA1c measurement and improved HbA1c levels in the second year of the pandemic. Research Design and Methods: In a cohort of 242, 848 Kaiser Permanente Northern California patients with diabetes, we examined associations between early-pandemic patient-initiated telemedicine visit and downstream HbA1c monitoring and results during the second year of the pandemic. Results: Adjusted HbA1c measurement rates were significantly higher among patients with telemedicine exposure in the early-pandemic prior year than those with no visits in the prior year (91.0% testing for patients with video visits, 90.5% for telephone visits, visits, 86.7% for no visits, p < 0.05). Among those with HbA1c measured, the rates of having an HbA1c < 8% in the second year of the COVID-19 pandemic were also statistically significantly higher among patients with telemedicine exposure in the early-pandemic prior year than those with no visits in the prior year (68.5% with HbA1c< 8% for video visits, 67.3% for telephone visits, 66.6% for no visits, p < 0.05). Conclusions: Access to telephone and video telemedicine throughout the early COVID-19 pandemic was associated with patients' continued engagement in recommended diabetes care. Although our study analyzed telemedicine use during a pandemic, telemedicine visits may continue to support ongoing health care access and positive clinical outcomes.

Telemedicine Versus In-Person Primary Care: Treatment and Follow-up Visits.

BACKGROUND: Beyond initial COVID-19 pandemic emergency expansions of telemedicine use, it is unclear how well primary care telemedicine addresses patients' needs. OBJECTIVE: To compare treatment and follow-up visits (office, emergency department, hospitalization) between primary care video or telephone telemedicine and in-person office visits. DESIGN: Retrospective design based on administrative and electronic health record (EHR) data. SETTING: Large, integrated health care delivery system with more than 1300 primary care providers, between April 2021 and December 2021 (including the COVID-19 pandemic Delta wave). PATIENTS: 1 589 014 adult patients; 26.5% were aged 65 years or older, 54.9% were female, 22.2% were Asian, 7.4% were Black, 22.3% were Hispanic, 46.5% were White, 21.5% lived in neighborhoods with lower socioeconomic status, and 31.8% had a chronic health condition. MEASUREMENTS: Treatment outcomes included medication or antibiotic prescribing and laboratory or imaging ordering. Follow-up visits included in-person visits to the primary care office or emergency department or hospitalization within 7 days. Outcomes were adjusted for sociodemographic and clinical characteristics overall and stratified by clinical area (abdominal pain, gastrointestinal concerns, back pain, dermatologic concerns, musculoskeletal pain, routine care, hypertension or diabetes, and mental health). RESULTS: Of 2 357 598 primary care visits, 50.8% used telemedicine (19.5% video and 31.3% telephone). After adjustment, medications were prescribed in 46.8% of office visits, 38.4% of video visits, and 34.6% of telephone visits. After the visit, 1.3% of in-person visits, 6.2% of video visits, and 7.6% of telephone visits had a 7-day return in-person primary care visit; 1.6% of in-person visits, 1.8% of video visits, and 2.1% of telephone visits were followed by an emergency department visit. Differences in follow-up office visits were largest after index office versus telephone visits for acute pain conditions and smallest for mental health. LIMITATIONS: In the study setting, telemedicine is fully integrated with ongoing EHRs and with clinicians, and the study examines an insured population during the late COVID-19 pandemic period. Observational comparison lacks detailed severity or symptom measures. Follow-up was limited to 7 days. Clinical area categorization uses diagnosis code rather than symptom. CONCLUSION: In-person return visits were somewhat higher after telemedicine compared with in-person primary care visits but varied by specific clinical condition. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Patient-reported Primary Care Video and Telephone Telemedicine Preference Shifts During the COVID-19 Pandemic.

BACKGROUND: Patient perceptions of primary care telephone and video telemedicine and whether COVID-19 pandemic-related telemedicine exposure shifted patients' visit preference is unknown. OBJECTIVES: We examined patient surveys to understand the health care experience of patients seeking primary care through telemedicine and how patients expected their preferences to shift as a result of the COVID-19 pandemic. RESEARCH DESIGN/SUBJECTS: In an integrated delivery system that shifted to a "telemedicine-first" health care model during the COVID-19 pandemic, we sampled monthly and collected 1000 surveys from adults with primary care telemedicine visits scheduled through the online patient portal between 3/16/2020 and 10/31/2020. MEASURES: Participants reported their preferred primary care visit modality (telephone, video, or in-person visits) across 3 time points: before, during and (hypothetically) after the COVID-19 pandemic, and reported their general assessment of primary care visits during the pandemic. RESULTS: The majority of participants preferred in-person visits before (69%) and after the COVID-19 pandemic (57%). However, most participants reported a preference for telemedicine visits during the pandemic and continue to prefer telemedicine visits at a 12% higher rate post-pandemic. Many participants (63%) expressed interest in using telemedicine at least some of the time. Among participants reporting a recent telemedicine visit, 85% agreed that the visit addressed their health needs. CONCLUSION: As primary care visit modality preferences continue to evolve, patients anticipate that they will continue to prefer telemedicine visits, both video and telephone, at an increased rate than before the COVID-19 pandemic.

Acceptability of PrEP among MSM and transgender communities-Qualitative findings from two metropolitan cities in India.

BACKGROUND: Global evidence suggests that Pre-Exposure Prophylaxis (PrEP) plays a pivotal role in reducing new HIV-infections among key populations (KP). However, the acceptability of PrEP differs across different geographical and cultural settings and among different KP typologies. Men who have sex with men (MSM) and transgender (TG) communities in India have around 15-17 times higher prevalence of human immunodeficiency virus (HIV) than the general population. The low rates of consistent condom use and poor coverage of HIV testing and treatment among the MSM and transgender communities highlight the need for alternative HIV prevention options. METHODS: We used data from 20 in-depth interviews and 24 focused group discussions involving 143 MSM and 97 transgender individuals from the two metropolitan cities (Bengaluru and Delhi) in India to qualitatively explore their acceptability of PrEP as a HIV prevention tool. We coded data in NVivo and conducted extensive thematic content analysis. RESULTS: Awareness and use of PrEP were minimal among the MSM and transgender communities in both cities. However, on being provided with information on PrEP, both MSM and transgender communities expressed willingness to use PrEP as an additional HIV-prevention tool, to complement inability to consistently use condoms. PrEP was also perceived as a tool that could enhance the uptake of HIV-testing and counseling services. PrEP awareness, availability, accessibility and affordability were identified as determining factors that could influence its acceptability. Challenges such as stigma and discrimination, interrupted supply of drugs and non-community-friendly drug dispensing sites were identified barriers to continuing PrEP. CONCLUSIONS: Using qualitative data from two Indian settings, this study provides community perspectives and recommendations to stakeholders and policymakers for introduction of PrEP into programs as a prevention tool among MSM and transgender communities in India.

Primary care video and telephone telemedicine during the COVID-19 pandemic: treatment and follow-up health care utilization.

OBJECTIVES: Telemedicine use expanded greatly during the COVID-19 pandemic, and broad use of telemedicine is expected to persist beyond the pandemic. More evidence on the efficiency and safety of different telemedicine modalities is needed to inform clinical and policy decisions around telemedicine use. To evaluate the efficiency and safety of telemedicine, we compared treatment and follow-up care between video and telephone visits during the COVID-19 pandemic. STUDY DESIGN: Observational study of patient-scheduled telemedicine visits for primary care. METHODS: We used multivariate logistic regression to compare treatment (medication prescribing, laboratory/imaging orders) and 7-day follow-up care (in-person office visits, emergency department visits, and hospitalizations) between video and telephone visits, adjusted for patient characteristics. RESULTS: Among 734,442 telemedicine visits, 58.4% were telephone visits. Adjusted rates of medication prescribing and laboratory/imaging orders were higher in video visits than telephone visits, with differences of 3.5% (95% CI, 3.3%-3.8%) and 3.9% (95% CI, 3.6%-4.1%), respectively. Adjusted rates of 7-day follow-up in-person office visits, emergency department visits, and hospitalizations were lower after video than telephone visits, with differences of 0.7% (95% CI, 0.5%-0.9%), 0.3% (95% CI, 0.2%-0.3%), and 0.04% (95% CI, 0.02%-0.06%), respectively. CONCLUSIONS: Among telemedicine visits with primary care clinicians, return visits were not common and downstream emergency events were rare. Adjusted rates of treatment measures were higher and adjusted rates of follow-up care were lower for video visits than telephone visits. Although video visits were marginally more efficient than telephone visits, telephone visits may offer an accessible option to address patient primary care needs without raising safety concerns.

Cross-Sectional Association of Patient Language and Patient-Provider Language Concordance with Video Telemedicine Use Among Patients with Limited English Proficiency.

BACKGROUND: Telemedicine's dramatic increase during the COVID-19 pandemic elevates the importance of addressing patient-care gaps in telemedicine, especially for patients with limited English proficiency. OBJECTIVE: To examine the associations of patient language and patient-provider language concordance with telemedicine visit type (video versus telephone visit). DESIGN: Cross-sectional automated data study of patient-scheduled primary care telemedicine appointments from March 16, 2020, to October 31, 2020. SETTING: Northern California integrated healthcare delivery system. PARTICIPANTS: All 22,427 completed primary care telemedicine visits scheduled by 13,764 patients with limited English proficiency via the patient portal. MEASUREMENTS: Cross-sectional association of electronic health record-documented patient language (Spanish as referent) and patient-provider language concordance with patients' choice of a video (versus telephone) visit, accounting for patient sociodemographics, technology access, and technology familiarity factors. RESULTS: Of all patient-scheduled visits, 34.5% (n = 7747) were video visits. The top three patient languages were Spanish (42.4%), Cantonese (16.9%), and Mandarin (10.3%). Adjusting for sociodemographic and technology access and familiarity factors and compared to patients speaking Spanish, video visit use was higher among patients speaking Cantonese (OR = 1.34, 95% CI: 1.18-1.52), Mandarin (OR = 1.33, 95% CI: 1.16-1.52), or Vietnamese (OR = 1.27, 95% CI: 1.09-1.47), but lower among patients speaking Punjabi (OR = 0.75, 95% CI: 0.75, 0.62-0.91). Language concordance was associated with lower video visit use (OR = 0.86, 95% CI: 0.80-0.93) and moderated associations of speaking Spanish, Cantonese, and Korean with video visit use. In addition, for all language groups, those with prior video visit use were more likely to re-use video visits compared to those with no prior use (p < .05 for all languages except Hindi with p = 0.06). CONCLUSIONS: Among linguistically diverse patients with limited English proficiency, video telemedicine use differed by specific language. Disaggregating patient subpopulation data is necessary for identifying those at greatest risk of being negatively impacted by the digital divide.

Racial and Ethnic Differences in Medication Initiation Among Adults Newly Diagnosed with Type 2 Diabetes.

OBJECTIVE: Given persistent racial/ethnic differences in type 2 diabetes outcomes and the lasting benefits conferred by early glycemic control, we examined racial/ethnic differences in diabetes medication initiation during the year following diagnosis. METHODS: Among adults newly diagnosed with type 2 diabetes (2005-2016), we examined how glucose-lowering medication initiation differed by race/ethnicity during the year following diagnosis. We specified modified Poisson regression models to estimate the association between race/ethnicity and medication initiation in the entire cohort and within subpopulations defined by HbA1c, BMI, age at diagnosis, comorbidity, and neighborhood deprivation index (a census tract-level socioeconomic indicator). RESULTS: Among the 77,199 newly diagnosed individuals, 47% started a diabetes medication within 12 months of diagnosis. The prevalence of medication initiation ranged from 32% among Chinese individuals to 58% among individuals of Other/Unknown races/ethnicities. Compared to White individuals, medication initiation was less likely among Chinese (relative risk: 0.78 (95% confidence interval 0.72, 0.84)) and Japanese (0.82 (0.75, 0.90)) individuals, but was more likely among Hispanic/Latinx (1.27 (1.24, 1.30)), African American (1.14 (1.11, 1.17)), other Asian (1.13 (1.08, 1.18)), South Asian (1.10 (1.04, 1.17)), Other/Unknown (1.31 (1.24, 1.39)), American Indian or Alaska Native (1.11 (1.04, 1.18)), and Native Hawaiian/Pacific Islander (1.28 (1.19, 1.37)) individuals. Racial/ethnic differences dissipated among individuals with higher HbA1c values. CONCLUSIONS: Initiation of glucose-lowering treatment during the year following type 2 diabetes diagnosis differed markedly by race/ethnicity, particularly for those with lower HbA1c values. Future research should examine how patient preferences, provider implicit bias, and shared decision-making contribute to these early treatment differences.

The association between video or telephone telemedicine visit type and orders in primary care.

INTRODUCTION: Telemedicine is increasingly relied upon for care delivery in primary care, but the impact of visit type on clinical ordering behavior is uncertain. METHODS: Within Kaiser Permanente Northern California, we identified patients who self-scheduled and completed telemedicine encounters with their personal primary care provider or another available primary care provider in the same medical group, between April 1st, 2020, and October 31st, 2020, while physical distancing restrictions for COVID-19 were in place. We collected patient sociodemographic and clinical characteristics, measures of technology access, and categorized the most common primary encounter diagnoses. We measured proportions of patient-scheduled video versus telephone visits for each of eight diagnosis groups (Skin & Soft Tissue, Musculoskeletal Pain, Back Pain, General Gastrointestinal, Hypertension & Diabetes, Mental Health, Upper Respiratory, and Abdominal Pain), and compared physician orders for medications, antibiotics, lab and imaging studies by visit type within each diagnosis group. RESULTS: There were 273,301 included encounters, with 86,676 (41.5%) video visits and 122,051 (58.5%) telephone visits. Of the diagnosis groups, Skin & Soft Tissue conditions had the highest proportion of video visits (59.7%), while Mental Health conditions had the highest proportion of telephone visits (71.1%). After adjusting for covariates, the overall rates of medication orders (46.6% vs. 44.5%), imaging orders (17.3% vs. 14.9%), lab orders (19.5% vs. 17.2%), and antibiotic orders (7.5% vs. 5.2%) were higher during video visits as compared to telephone visits (p < 0.05). The largest difference within diagnosis groups was for Skin & Soft Tissue conditions, where the rate of medication orders was 9.1% higher than during video visits than telephone visits (45.5% vs. 36.5%, p < 0.05). CONCLUSIONS: We observed statistically significant differences in clinician orders by visit type during telemedicine encounters for common primary care conditions. Our findings suggest that, for certain conditions, visual information conveyed during video visits may promote clinical work-up and treatment.

Identifying modifiable obesogenic behaviors among Latino adolescents in primary pediatric care.

Latino adolescents engage in more obesogenic behaviors, including sedentary behaviors and sugary drink consumption, than White adolescents. However, it is unclear whether engagement in obesogenic behaviors differs within the Latino population. Cross-sectional data were examined from Latino adolescents ages 13-17 with a well-child visit (2016-2019) in an integrated healthcare system. Adolescents self-reported on four daily obesogenic behaviors: 1) consuming < 5 servings of fruits/vegetables; 2) drinking > 1 juice/soda; 3) exercising/playing sports < 60 min; and 4) > 2 h screen time. A composite variable of ≥ 3 self-reported behaviors was constructed. Multivariable logistic regression was used to examine associations between obesogenic behaviors with age category (13-15 or 16-17 years), sex, household language preference (English/Spanish), neighborhood deprivation index (NDI quartiles), and body mass index (BMI). Among 77,514 Latino adolescents (mean age 14.7 ± 1.4; 50 % female), 23 % lived in Spanish-speaking households, 43 % resided in census tracts with the highest (most deprived) NDI quartile, and 45 % had an overweight or obese BMI. Older (vs younger) adolescents had higher odds of insufficient fruit/vegetable intake (OR 1.20; CI 1.17-1.24), greater sedentary behavior (OR 1.51; 1.46-1.56), and reporting > 2 h screen time (OR 1.07; 1.03-1.11). Adolescents in the 4th (vs 1st) NDI quartile (OR 1.34; 1.26-1.42) and those with obesity (vs healthy weight) (OR 1.55; 1.42-1.70 for class 3 obesity) had higher odds of ≥ 3 obesogenic behaviors. In conclusion, among Latino adolescents, older age, obesity, and living in more deprived neighborhoods were associated with greater obesogenic behaviors. Identifying adolescents more likely to engage in obesogenic behaviors can inform targeted lifestyle interventions.

All in the Family: A Qualitative Study of the Early Experiences of Adults with Younger Onset Type 2 Diabetes.

OBJECTIVE: Adults with type 2 diabetes diagnosed at a younger age are at increased risk for poor outcomes. We examined life stage-related facilitators and barriers to early self-management among younger adults with newly diagnosed type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted 6 focus groups that each met twice between November 2017 and May 2018. Participants (n = 41) were aged 21 to 44 years and diagnosed with type 2 diabetes during the prior 2 years. Transcripts were coded using thematic analysis and themes were mapped to the Capability-Opportunity-Motivation-Behavior framework. RESULTS: Participants were 38.4 (±5.8) years old; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified 9 themes that fell into 2 categories: (1) the impact of having an adult family member with diabetes, and (2) the role of nonadult children. Family members with diabetes served as both positive and negative role models, and, for some, personal familiarity with the disease made adjusting to the diagnosis easier. Children facilitated their parents' self-management by supporting self-management activities and motivating their parents to remain healthy. However, the stress and time demands resulting from parental responsibilities and the tendency to prioritize children's needs were perceived as barriers to self-management. CONCLUSIONS: Our results highlight how the life position of younger-onset individuals with type 2 diabetes influences their early experiences. Proactively addressing perceived barriers to and facilitators of self-management in the context of family history and parenthood may aid in efforts to support these high-risk, younger patients.

Primary care telemedicine during the COVID-19 pandemic: patient's choice of video versus telephone visit.

The aim of this study is to examine the association between patient characteristics and primary care telemedicine choice among integrated delivery system patients self-scheduling visits during the COVID-19 pandemic. We used multivariate logistic regression to examine the association between the choice of video versus telephone and patient sociodemographic characteristics and technology access among patient-initiated primary care telemedicine visits scheduled online from March to October 2020. Among 978 272 patient-scheduled primary care telemedicine visits, 39% were video visits. Patients of Black or Hispanic race/ethnicity, or living in low socioeconomic status or low internet access neighborhoods were less likely to schedule video visits. Patients 65 years or older, with prior video visit experience or mobile portal access, or visiting their own personal provider were more likely to schedule video visits. While video adoption was substantial in all patient groups examined, differences in telemedicine choice suggest the persistence of a digital divide, emphasizing the importance of maintaining a telephone telemedicine option.

Primary Care Visits Are Timelier When Patients Choose Telemedicine: A Cross-Sectional Observational Study.

Introduction: Telemedicine could increase timely access to primary care-a key dimension of care quality. Methods: Among patient-scheduled appointments with their own primary care providers using the online portal in a large integrated health care delivery system, we measured the association between visit type (telemedicine or in-person) and appointment timeliness. We calculated the calendar days between the scheduling date and the actual appointment time. Results: Overall, 2,178,440 primary care visits were scheduled and 14% were done through telemedicine. The mean calendar days between the scheduling and the appointment time were 1.80 for telephone visits, 2.29 for video visits, and 3.52 for in-person visits. After multivariate adjustment, 66.61% (confidence interval [95% CI]: 66.44-66.79) of telephone visits, 56.58% (95% CI: 55.90-57.27) of video visits, and 46.49% (95% CI: 46.42-46.57) of in-person visits were scheduled to occur within 1 day of making the appointment. Conclusions: In a setting with comparable in-person and telemedicine scheduling availability, choosing telemedicine was associated with more timely access to primary care.

Engaging patients in population-based chronic disease management: A qualitative study of barriers and intervention opportunities.

OBJECTIVE: Cardiovascular disease (CVD) continues to be a leading cause of morbidity in the U.S. Managing CVD risk factors, such as diabetes or hypertension, can be challenging for many individuals. We investigated the barriers experienced by patients who persistently struggled to reach their CVD risk factor control goals. METHODS: This qualitative study examined patient, clinician, and researcher observations of individuals' experiences in a chronic disease management program. All participants (n = 332) were enrolled in a clinical trial testing a skills-based group intervention seeking to improve healthcare engagement. Data were analyzed through a general inductive approach and resulting themes were structured along the Capability-Opportunity-Motivation-Behavior framework. RESULTS: Analyses identified care engagement barriers related to participants' communication skills and activation, care team relationship processes, and emotional factors. Although most participants reported benefitting from skills training, persistent barriers included distrust of their providers, shame about health challenges, and dissatisfaction with care team interactions that were described as impersonal or unresponsive. CONCLUSIONS AND PRACTICE IMPLICATIONS: Efforts to support engagement in CVD risk factor management programs should address whether patients and their care team have the necessary skills, opportunities and confidence to proactively communicate health needs and engage in non-judgmental interactions for goal-setting, rapport-building, and shared decision-making.

Video Telehealth Access and Changes in HbA1c Among People With Diabetes.

INTRODUCTION: Video telehealth can offer people convenient, real-time access to clinicians without arranging transportation or time off work. Among people with diabetes, this study examines the association between video telehealth access and changes in HbA1c. METHODS: This longitudinal cohort study (2016-2019) used linear regression with person-level fixed effects, stratified by baseline HbA1c (last value in 2015), to examine the association between video visit access and changes in HbA1c. HbA1c values were categorized into 3 periods of video visit exposure: (1) before any video visit, (2) during video visit transition year (calendar year of the first video visit), and (3) after video visits. The model compared changes in HbA1c values collected before the patient had any video visits with those collected after the transition year. Analyses were conducted in September 2020. RESULTS: Among 204,301 people with diabetes, video visit access was associated with a statistically significant reduction of 0.15 (95% CI= -0.19, -0.11) percentage points in HbA1c, with greater reductions among patients with an elevated baseline HbA1c value (-0.22 percentage points, 95% CI= -0.32, -0.11) and with no baseline HbA1c measurement (-0.39 percentage points, 95% CI= -0.71, -0.07). CONCLUSIONS: Gaining access to video telehealth was associated with reductions in HbA1c among people with diabetes. Video telehealth offers people with chronic conditions a new, convenient way to access health care, is not associated with worsening HbA1c, and may support better disease management, particularly among patients with higher baseline HbA1c.

The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations.

INTRODUCTION: Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. METHODS: Varied qualitative inquiry methods - in-depth interviews, participant-led neighborhood tours, and clinic visit observations - involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM). RESULTS: Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. CONCLUSION: The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

Visit Content Analysis: Doctor-Patient Communication in Patients with Type 2 Diabetes.

INTRODUCTION: The primary care visit is an important opportunity to discuss and modify diabetes management. OBJECTIVE: To gain insight into doctor-patient communication during primary care visits among English and Spanish speaking patients with type 2 diabetes and suboptimal glycemic control (HbA1c > 7%). METHODS: We conducted a quantitative content analysis of audiotaped primary care visits in 2 patient cohorts. In Study 1 (31 English-speaking patients), we examined factors associated with management changes, and in Study 2 (20 Spanish-speaking patients and their Spanish-speaking providers), we examined the association of question asking with HbA1c control. This study was conducted between November 2017 and January 2020 across 8 primary care practices within Kaiser Permanente Northern California. RESULTS: In Study 1, the only factor significantly associated with a diabetes management change was patient identification of diabetes as a priority prior to the visit (91.7% had a management change vs 52.6% of patients who did not identify diabetes as a priority; p = 0.02). In Study 2, patients with poorer glycemic control (HbA1c ≥ 10.0) asked significantly fewer questions (3.4 ± 1.8 vs 10.7 ± 6.9 questions per 15 minutes; p = 0.004). Overall, despite receiving primary care from language-concordant providers, Spanish-speaking Study 2 patients asked fewer questions than English-speaking Study 1 patients (4.5 ± 2.9 vs 7.5 ± 3.7 questions per 15 minutes, respectively; p = 0.004). CONCLUSION: Our results highlight 2 potential strategies (preparing patients for their visits through identifying priorities and learning how to ask more questions during visits) for improving diabetes primary care.