Multilevel perceptions of the virtual delivery of the University of California Diabetes Prevention Program on RE-AIM domains due to COVID-19 mandates.

Background: The University of California's Diabetes Prevention Program (UC DPP) Initiative was implemented across all 10 UC campuses in 2018. The COVID-19 pandemic and accompanying mandates required swift changes to program delivery, including pivoting from in-person to virtual delivery (i.e., Zoom). Our goal was to assess multilevel constituent perceptions of the use of a virtual platform to deliver UC DPP due to COVID-19 mandates. Methods: We conducted qualitative interviews with 68 UC DPP participants, coordinators, and leaders to examine the use of virtual platform delivery on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of UC DPP. Transcripts were analyzed using rapid qualitative analysis and emergent themes were categorized using domains corresponding to RE-AIM framework. Results: Among UC DPP participants (n = 42), virtual delivery primarily impacted perceptions of UC DPP effectiveness and implementation. Some participants perceived program effectiveness to be negatively impacted, given their preference for in-person sessions, which they felt provided more engagement, peer support, and accountability. Implementation challenges included problems with virtual format (e.g., "Zoom fatigue"); however, several benefits were also noted (e.g., increased flexibility, maintenance of DPP connections during campus closures). UC DPP coordinators (n = 18) perceived virtual delivery as positively impacting UC DPP reach, since virtual platforms provided access for some who could not participate in-person, and negatively impacting effectiveness due to reduced engagement and lower peer support. UC leaders (n = 8) perceived that use of the virtual format had a positive impact on reach (e.g., increased availability, accessibility) and negatively impacted effectiveness (e.g., less intensive interactions on a virtual platform). Across constituent levels, the use of a virtual platform had little to no impact on perceptions of adoption and maintenance of UC DPP. Conclusion: Perceptions of the reach, effectiveness, and implementation of UC DPP using a virtual platform varied across constituents, although all groups noted a potential negative impact on overall program effectiveness. Unanticipated program adaptations, including virtual delivery, present potential benefits as well as perceived drawbacks, primarily across the effectiveness domain. Understanding differential constituent perceptions of the impact of virtual delivery can help maximize RE-AIM and inform future UC DPP delivery strategies.

Text vs Patient Portal Messaging to Improve Influenza Vaccination Coverage: A Health System-Wide Randomized Clinical Trial.

Importance: Increasing influenza vaccination rates is a public health priority. One method recommended by the US Centers for Disease Control and Prevention and others is for health systems to send reminders nudging patients to be vaccinated. Objective: To evaluate and compare the effect of electronic health record (EHR)-based patient portal reminders vs text message reminders on influenza vaccination rates across a health system. Design, Setting, and Participants: This 3-arm randomized clinical trial was conducted from September 7, 2022, to April 30, 2023, among primary care patients within the University of California, Los Angeles (UCLA) health system. Interventions: Arm 1 received standard of care. The health system sent monthly reminder messages to patients due for an influenza vaccine by portal (arm 2) or text (arm 3). Arm 2 had a 2 × 2 nested design, with fixed vs responsive monthly reminders and preappointment vs no preappointment reminders. Arm 3 had 1 × 2 design, with preappointment vs no preappointment reminders. Preappointment reminders for eligible patients were sent 24 and 48 hours before scheduled primary care visits. Fixed reminders (in October, November, and December) involved identical messages via portal or text. Responsive portal reminders involved a September message asking patients about their plans for vaccination, with a follow-up reminder if the response was affirmative but the patient was not yet vaccinated. Main Outcomes and Measures: The primary outcome was influenza vaccination by April 30, 2023, obtained from the UCLA EHR, including vaccination from pharmacies and other sources. Results: A total of 262 085 patients (mean [SD] age, 45.1 [20.7] years; 237 404 [90.6%] adults; 24 681 [9.4%] children; 149 349 [57.0%] women) in 79 primary care practices were included (87 257 in arm 1, 87 478 in arm 2, and 87 350 in arm 3). At the entire primary care population level, none of the interventions improved influenza vaccination rates. All groups had rates of approximately 47%. There was no statistical or clinically significant improvement following portal vs text, preappointment reminders vs no preappointment reminders (portal and text reminders combined), or responsive vs fixed monthly portal reminders. Conclusions and Relevance: At the population level, neither portal nor text reminders for influenza vaccination were effective. Given that vaccine hesitancy may be a major reason for the lack of impact of portal or text reminders, more intensive interventions by health systems are needed to raise influenza vaccination coverage levels. Trial Registration: ClinicalTrials.gov Identifier: NCT05525494.

Twelve-Month Reach and Effectiveness of a University-Based Diabetes Prevention Initiative.

INTRODUCTION: The University of California (UC) implemented the Diabetes Prevention Program (DPP) to address diabetes and obesity risk. This project examined the reach and effectiveness of this university-based DPP delivery approach. METHODS: This project compared 12-month weight change among three groups of UC beneficiaries with overweight/obesity: (1) those who received invitation letters and enrolled in UC DPP, (2) those mailed invitation letters but did not enroll, and (3) those who were not mailed letters and did not enroll (controls). Using 2012-2022 EHR, administrative and DPP cohort data, an interrupted time series was conducted in 2022-2023 to compare group differences in rate of weight change. RESULTS: Among 6,231 beneficiaries (132 UC DPP aware enrollees, 1,750 DPP aware non-enrollees, 4,349 controls), UC DPP enrollees were older (mean age 49), mostly women (76%), and more diverse (33% Asian, 8% Black, 20% Hispanic, 4% Multi/Other). Over 12 months of follow-up, UC DPP enrollee postenrollment rate of weight loss was -0.68 lbs./month. UC DPP enrollees had significantly greater weight change from pre- to post-enrollment than DPP aware non-enrollees (adjusted Δ-1.02 vs. Δ-0.07 lbs./month, difference= -0.95, p<0.001). Weight change among all participants who received letters with/without DPP enrollment was similar to controls. CONCLUSIONS: UC DPP reached a diverse group and was effective for weight loss at 12-month follow-up. However, UC DPP invitation letters to raise prediabetes and DPP awareness were not associated with significant weight change in the absence of DPP enrollment. University-based approaches to DPP delivery are effective and may enhance reach of DPP among at-risk adults.

The Effectiveness of Shared Decision-making for Diabetes Prevention: 24- and 36-Month Results From the Prediabetes Informed Decision and Education (PRIDE) Trial.

OBJECTIVE: We conducted a cluster-randomized, shared decision-making (SDM) trial offering lifestyle change, metformin, or both options, to adults at risk for diabetes in a primary care network (n = 20 practices). RESEARCH DESIGN AND METHODS: We used propensity score matching to identify control patients and used electronic health record data to compare weight loss at 24 and 36 months of follow-up and diabetes incidence at 36 months of follow-up. RESULTS: In adjusted post hoc analyses, SDM participants (n = 489) maintained modestly greater 24-month weight loss of -3.1 lb and 36-month weight loss of -2.7 lb versus controls (n = 1,430, both comparisons P < 0.001). SDM participants who chose both lifestyle change and metformin sustained weight loss at 36 months of -4.1 lb (P < 0.001 vs. controls). We found no differences in incident diabetes (15% of SDM participants, 14% of control participants; P = 0.64). CONCLUSIONS: This is one of the first studies to demonstrate weight loss maintenance up to 36 months after diabetes prevention SDM.

A Qualitative Study of Perceptions and Preferences Regarding Social and Behavioral Risk Screening Among Primary Care Patients.

BACKGROUND: Despite its relevance for healthcare settings, social and behavioral risk screening is not systematically performed by clinicians or healthcare systems. OBJECTIVE: To address clinician concerns, such as social and behavioral risk screening disrupting the clinician-patient relationship and lack of resources to respond, we interviewed primary care patients at an academic medical center regarding their perceptions and preferences on social and behavioral risk screening. PARTICIPANTS: Between September and December 2020, we recruited a convenience sample of 14 English-speaking primary care patients 18 years + from three clinics affiliated with an academic medical center. APPROACH: Using a semi-structured interview guide, we asked about the importance of social and behavioral risk screening, whether or not and how to share social and behavioral risk factors, and how social and behavioral risk factors are addressed. We used a multi-step analytic process to identify the range and commonality of participants' responses thematically. KEY RESULTS: Participants recognized that social and behavioral risk factor domains were relevant to primary care and important for treating the patient as a whole person. Participants preferred a conversation regarding social and behavioral risk factor with their primary care providers (PCPs), and suggested that, if surveys are used, they be followed with an open-ended, in-person discussion. Participants also suggested framing the discussion as something that is done routinely with all patients so that patients do not feel judged. Participants felt comfortable sharing social and behavioral risk factors when they trusted their PCPs, and felt that discussing social and behavioral risk factors with their PCPs built trust. Participants recognized that resources exist outside of the clinic, and suggested that PCPs distribute lists of relevant community resources to patients. CONCLUSION: In our study of primary care patients on perceptions and preferences about screening and addressing social and behavioral risk factors, we found that patients were willing to share social and behavioral risk factors with their PCP, preferred an in-person discussions with or without a survey, and wanted a list of community resources to address their needs.

Differential Impact of a Plan-Led Standardized Complex Care Management Intervention on Subgroups of High-Cost High-Need Medicaid Patients.

Interventions to better coordinate care for high-need high-cost (HNHC) Medicaid patients frequently fail to demonstrate changes in hospitalizations or emergency department (ED) use. Many of these interventions are modeled after practice-level complex care management (CCM) programs. The authors hypothesized that a national CCM program may be effective for some subgroups of HNHC patients, and the overall null effect may obfuscate subgroup-level impact. They used a previously published typology defining 6 subgroups of high-cost Medicaid patients and evaluated program impact by subgroup. The analysis used an individual-level interrupted time series with a comparison group. Intervention subjects were high-cost adult Medicaid patients who enrolled in 1 of 2 national CCM programs implemented by UnitedHealthcare (UHC) (n = 39,687). The comparators were patients who met CCM program criteria but were ineligible due to current enrollment in another UHC/Optum led program (N = 26,359). The intervention was a CCM program developed by UHC/Optum to provide "whole person care" delivering standardized interventions to address medical, behavioral, and social needs for HNHC Medicaid patients, and the outcome was probability of hospitalization or ED use in a given month, estimated at 12 months postenrollment. A reduction in risk of ED utilization for 4 of 6 subgroups was found. A reduction in risk of hospitalization for 1 of 6 subgroups was also found. The authors conclude that standardized health plan led CCM programs demonstrate effectiveness for certain subgroups of HNHC patients in Medicaid. This effectiveness is principally in reducing ED risk and may extend to the risk of hospitalization for a small number of patients.

Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial.

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

"Positive Kidney Health": Implementation and design of a pharmacist-led intervention for patients at risk for development or progression of chronic kidney disease.

BACKGROUND: Patients with early chronic kidney disease (CKD) or underlying risk factors are often unaware of their kidney test results, common causes of CKD, and ways to lower risk of disease onset/progression. OBJECTIVE: To test feasibility of a pharmacist-led intervention targeting patient education and risk factors in patients with early CKD and those at risk for CKD. PRACTICE DESCRIPTION: Ambulatory care pharmacists in community-based primary care clinics delivered kidney health education, ordered labs, and recommended medication adjustments. PRACTICE INNOVATION: We identified patients with a moderate rate of decline (≥2 mL/min/1.73 m2 per year) in estimated glomerular filtration (eGFR) at-risk for CKD or early stage CKD. An interactive workbook was designed to teach patients about kidney test results and self-management of risk factors including hypertension, type 2 diabetes, cigarette smoking, and chronic oral nonsteroidal anti-inflammatory drug use. EVALUATION METHODS: Outcomes included visit uptake, completion of annual albuminuria screening, and initiation of guideline-directed medications for CKD. Patients were surveyed pre- and post-intervention for kidney health knowledge and perceptions regarding pharmacist-provided information. RESULTS: Our sample of 20 participants had a mean eGFR of 59 mL/min/1.73 m2 and the mean eGFR decline was -4.6 mL/min/1.73 m2 per year. There were 47 visits during the pilot period from February 2021 to October 2021. Thirteen patients were missing albuminuria screening within 12 months; 2 of 9 patients with resulting labs had new microalbuminuria and were started on renoprotective medications. Patients had improved understanding of their kidney function test results and most did not consider the information scary or confusing. CONCLUSION: Barriers to enrollment included fewer participants with multiple risk factors for CKD. The pharmacists were able to engage patients in learning the importance of monitoring and self-management of kidney health. A collaborative practice agreement may enhance a similar intervention that includes initiation of renoprotective medications.

The Diabetes Health Plan and Healthcare Utilization Among Beneficiaries with Low Incomes.

BACKGROUND: The socioeconomic status (SES) gradient in hospital and emergency room utilization among adults with type 2 diabetes (T2DM) is partially driven by cost-related non-adherence. OBJECTIVE: To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific health plan incorporating value-based insurance design principles on healthcare utilization among low-income adults with T2DM. DESIGN: To examine the impact of the DHP on healthcare utilization, we employed a difference-in-differences (DID) study design with a propensity-matched comparison group. We modeled count and dichotomous outcomes using Poisson and logit models, respectively. PARTICIPANTS: Cohort of adults (18-64) with T2DM, with an annual household income <$ 30,000, and who were continuously enrolled in an employer-sponsored UnitedHealthcare plan for at least 2 years between 2009 and 2014. INTERVENTIONS: The DHP reduces or eliminates out-of-pocket costs for disease management visits, diabetes-related medicines, and diabetes self-monitoring supplies. The DHP also provides access to diabetes-specific telephone case management as well as other online resources. MAIN MEASURES: Number of disease management visits (N = 1732), any emergency room utilization (N = 1758), and any hospitalization (N = 1733), within the year. KEY RESULTS: DID models predicting disease management visits suggested that DHP-exposed beneficiaries had 1.7 fewer in-person disease management visits per year (- 1.70 [95% CI: - 2.19, - 1.20], p < 0.001), on average, than comparison beneficiaries. Models for emergency room (0.00 [95% CI: - 0.06, 0.06], p = 0.966) and hospital utilization (- 0.03 [95% CI: - 0.08, - 0.01], p = 0.164) did not demonstrate statistically significant changes associated with DHP exposure. CONCLUSIONS: While no relationship between DHP exposure and high-cost utilization was observed in the short term, fewer in-person disease management visits were observed. Future studies are needed to determine the clinical implications of these findings.

A randomized controlled trial of a shared decision making intervention for diabetes prevention for women with a history of gestational diabetes mellitus: The Gestational diabetes Risk Attenuation for New Diabetes (GRAND study).

BACKGROUND: Gestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Metformin and lifestyle change through a Diabetes Prevention Program (DPP) are equally effective in preventing diabetes in patients with a GDM history, so women can choose a strategy based on their preferences. This study aims to test whether shared decision making (SDM) can help women with a history of GDM increase adoption of evidence-based strategies and lose weight to lower their risk of incident diabetes in real-world settings. METHODS: This pragmatic randomized controlled trial (RCT) will test the effectiveness of SDM for diabetes prevention among 310 overweight/obese women with a history of GDM and prediabetes from two large health care systems (n = 155 from UCLA Health and n = 155 from Intermountain Healthcare). The primary outcome is the proportion of participants who lose ≥5% body weight at 12 months. Secondary outcomes include uptake of DPP and/or metformin and other patient-reported outcomes such as patient activation and health-related quality of life. Rates of GDM in a subsequent pregnancy will be an exploratory outcome. A descriptive analysis of costs related to SDM implementation will also be conducted. CONCLUSION: This is the first RCT to examine the effectiveness of SDM on weight loss, lifestyle change and/or metformin use, and other patient-reported outcomes in participants with a GDM history at risk of developing diabetes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03766256. Registered on 6 December 2018.

Sodium-Glucose Cotransporter 2 Inhibitors and New-onset Type 2 Diabetes in Adults With Prediabetes: Systematic Review and Meta-analysis of Randomized Controlled Trials.

CONTEXT: The preventive effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors for new-onset diabetes was investigated in secondary analyses of several randomized controlled trials (RCTs). However, the results were inconsistent. OBJECTIVE: This work aimed to synthesize available evidence and evaluate whether SGLT2 inhibitors are effective in preventing new-onset diabetes. METHODS: In this systematic review and meta-analysis of RCTs, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched through February 11, 2022. Two independent authors screened the search results and extracted summary data from eligible RCTs (including original and post hoc analyses) comparing SGLT2 inhibitors and placebo for the risk of new-onset diabetes among adults with prediabetes. Meta-analysis was conducted using random-effects models to calculate risk ratios and 95% CIs. RESULTS: We included 4 RCTs with 5655 participants who had prediabetes. Based on the random-effects meta-analysis, SGLT2 inhibitors were significantly associated with a lower risk of new-onset diabetes (relative risk, 0.79; 95% CI, 0.68-0.93). The relative risks of new-onset diabetes in dapagliflozin and empagliflozin were 0.68 (95% CI, 0.52-0.89) and 0.87 (95% CI, 0.72-1.04), respectively (P-for-heterogeneity = .14). The frequency of severe hypoglycemia was not elevated in the SGLT2 inhibitors group compared to the placebo group. CONCLUSION: In this meta-analysis, SGLT2 inhibitors were associated with a reduced risk of new-onset type 2 diabetes among adults with prediabetes and heart failure or chronic kidney disease. These findings indicate the potential usefulness of SGLT2 inhibitors in preventing diabetes among high-risk populations with prediabetes.

Association of Type 2 Diabetes Risk Perception With Interest in Diabetes Prevention Strategies Among Women With a History of Gestational Diabetes.

Objectives: The aims of this study were to identify predictors of perception of type 2 diabetes risk in women with a history of gestational diabetes mellitus (GDM) and to determine factors associated with interest in evidence-based strategies for type 2 diabetes prevention. Research Design and Methods: We surveyed women with a history of GDM who had not progressed to type 2 diabetes from a large academic medical center. We used multivariate logistic regression to assess predictors of high levels of perception of type 2 diabetes risk. We also tested associations between risk perception and interest in a lifestyle change program and/or metformin therapy. Results: In our diverse sample of 264 women, 28% were unaware that GDM is a risk factor for incident type 2 diabetes after pregnancy, and 48% believed their personal risk of type 2 diabetes was low. In multivariate analyses, family history of diabetes (odds ratio [OR] 2.2, 95% CI 1.2-4.4) and knowledge of GDM as a risk factor for incident type 2 diabetes (OR 4.5, 95% CI 2.1-9.8) were significant predictors of greater perception of type 2 diabetes risk. Women with higher risk perception were more likely to express interest in a lifestyle change program compared with women with lower risk perception (OR 2.4, 95% CI 1.3-4.5). Conclusion: Although some women are aware that GDM is a risk factor for incident type 2 diabetes, many still perceive their own risk of developing type 2 diabetes as low. Higher risk perception predicted interest in an evidence-based diabetes prevention program, highlighting the importance of personalized risk assessment and communication about risk for women who have had GDM.

An Effectiveness Study of a Primary Care-embedded Clinical Pharmacist-Led Intervention Among Patients With Diabetes and Medicaid Coverage.

OBJECTIVE: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. METHODS: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. RESULTS: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (-.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (-.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (-.35%, P-value= .02). CONCLUSIONS: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.

Does the diabetes health plan have a differential impact on medication adherence among beneficiaries with fewer financial resources?

BACKGROUND: The Diabetes Health Plan (DHP), a value-based insurance plan that reduces cost sharing, was previously shown to modestly increase employer-level medication adherence. It is unclear how the DHP might impact individuals with different incomes. OBJECTIVE: To examine the impact of the DHP on individual-level medication adherence, by income level. METHODS: This is a retrospective, quasiexperimental study. An employer-level propensity score match was done to identify suitable control employers, followed by individual-level propensity score weighing. These weights were applied to difference-in-difference models examining the effect of the DHP and the effect of income on changes in adherence to metformin, statins, and angiotensin-converting enzymes/angiotensin receptor blockers. The weights were then applied to a differences-in-differences-in-differences model to estimate the differential impact of DHP status on changes in adherence by income group. RESULTS: The study population included 2,065 beneficiaries with DHP and 17,704 matched controls. There were no significant differences in changes to adherence for any medications between beneficiaries enrolled in the DHP vs standard plans. However, adherence to all medications was higher among those with incomes greater than $75,000 (year 1: metformin: +7.3 percentage points; statin +4.3 percentage points; angiotensin-converting enzymes/angiotensin receptor blockers: +6.2 percentage points; P < 0.01) compared with those with incomes less than $50,000. The differences-in-differences-in-differences term examining the impact of income on the DHP effect was not significant for any comparisons. CONCLUSIONS: We did not find significant associations between the DHP and changes in individual-level medication adherence, even for low-income beneficiaries. New strategies to improve consumer engagement may be needed to translate value-based insurance designs into changes in patient behavior. DISCLOSURES: Drs Ettner and Moin received grants from the Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases (Principal Investigator: Carol Mangione). Mr Luchs received support for attending meetings and/or travel (minimal-mileage and hotel on 2 occasions). Mr Chan has an employee benefit to purchase stock for UnitedHealth Group.

Evaluating Natural Experiments that Impact the Diabetes Epidemic: an Introduction to the NEXT-D3 Network.

PURPOSE OF REVIEW: Diabetes is an ongoing public health issue in the USA, and, despite progress, recent reports suggest acute and chronic diabetes complications are increasing. RECENT FINDINGS: The Natural Experiments for Translation in Diabetes 3.0 (NEXT-D3) Network is a 5-year research collaboration involving six academic centers (Harvard University, Northwestern University, Oregon Health & Science University, Tulane University, University of California Los Angeles, and University of California San Francisco) and two funding agencies (Centers for Disease Control and Prevention and National Institutes of Health) to address the gaps leading to persisting diabetes burdens. The network builds on previously funded networks, expanding to include type 2 diabetes (T2D) prevention and an emphasis on health equity. NEXT-D3 researchers use rigorous natural experiment study designs to evaluate impacts of naturally occurring programs and policies, with a focus on diabetes-related outcomes. NEXT-D3 projects address whether and to what extent federal or state legislative policies and health plan innovations affect T2D risk and diabetes treatment and outcomes in the USA; real-world effects of increased access to health insurance under the Affordable Care Act; and the effectiveness of interventions that reduce barriers to medication access (e.g., decreased or eliminated cost sharing for cardiometabolic medications and new medications such as SGLT-2 inhibitors for Medicaid patients). Overarching goals include (1) expanding generalizable knowledge about policies and programs to manage or prevent T2D and educate decision-makers and organizations and (2) generating evidence to guide the development of health equity goals to reduce disparities in T2D-related risk factors, treatment, and complications.

The diabetes health plan and medication adherence among individuals with low incomes.

OBJECTIVE: To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific insurance plan that lowers out-of-pocket costs for diabetes-related medications and clinical visits, on adherence to oral hypoglycemic medications among low-income adults with Type 2 Diabetes (T2DM). DATA SOURCES AND STUDY SETTING: Cohort of adults (18-64) with T2DM, an annual household income

Differences in Weight Loss by Race and Ethnicity in the PRIDE Trial: a Qualitative Analysis of Participant Perspectives.

BACKGROUND: Many Diabetes Prevention Program (DPP) translation efforts have been less effective for underresourced populations. In the cluster-randomized Prediabetes Informed Decision and Education (PRIDE) trial, which evaluated a shared decision-making (SDM) intervention for diabetes prevention, Hispanic and non-Hispanic Black participants lost less weight than non-Hispanic White participants at 12-month follow-up. OBJECTIVE: To explore perspectives about weight loss from PRIDE participants of different racial and ethnic groups. PARTICIPANTS: Sample of participants with prediabetes who were randomized to the PRIDE intervention arm (n=24). APPROACH: We conducted semi-structured interviews within three groups stratified by DPP participation and % weight loss at 12 months: (DPP+/WL+, enrolled in DPP and lost >5% weight; DPP+/WL-, enrolled in DPP and lost <3% weight; DPP-/WL-, did not enroll in DPP and lost <3% weight). Each group was further subdivided on race and ethnicity (non-Hispanic Black (NHB), non-Hispanic White (NHW), Hispanic). Interviews were conducted on Zoom and transcripts were coded and analyzed with Dedoose. KEY RESULTS: Compared to NHW participants, Hispanic and NHB participants more often endorsed weight loss barriers of limited time to make lifestyle changes due to long work and commute hours, inconvenient DPP class locations and offerings, and limited disposable income for extra weight loss activities. Conversely, facilitators of weight loss regardless of race and ethnicity included retirement or having flexible work schedules; being able to identify convenient DPP classes; having a strong, positive support system; and purchasing supplementary resources to support lifestyle change (e.g., gym memberships, one-on-one activity classes). CONCLUSIONS: We found that NHB and Hispanic SDM participants report certain barriers to weight loss more commonly than NHW participants, particularly barriers related to limited disposable income and/or time constraints. Our findings suggest that increased lifestyle change support and flexible program delivery options may be needed to ensure equity in DPP reach, participant engagement, and outcomes.

Association of Intensive Blood Pressure Control and Living Arrangement on Cardiovascular Outcomes by Race: Post Hoc Analysis of SPRINT Randomized Clinical Trial.

Importance: Living alone, a key proxy of social isolation, is a risk factor for cardiovascular disease. In addition, Black race is associated with less optimal blood pressure (BP) control than in other racial or ethnic groups. However, it is not clear whether living arrangement status modifies the beneficial effects of intensive BP control on reduction in cardiovascular events among Black individuals. Objective: To examine whether the association of intensive BP control with cardiovascular events differs by living arrangement among Black individuals and non-Black individuals (eg, individuals who identified as Alaskan Native, American Indian, Asian, Native Hawaiian, Pacific Islander, White, or other) in the Systolic Blood Pressure Intervention Trial (SPRINT). Design, Setting, and Participants: This secondary analysis incorporated data from SPRINT, a multicenter study of individuals with increased risk for cardiovascular disease and free of diabetes, enrolled at 102 clinical sites in the United States between November 2010 and March 2013. Race and living arrangement (ie, living alone or living with others) were self-reported. Data were collected between November 2010 and March 2013 and analyzed from January 2021 to October 2021. Exposures: The SPRINT participants were randomized to a systolic BP target of either less than 120 mm Hg (intensive treatment group) or less than 140 mm Hg (standard treatment group). Antihypertensive medications were adjusted to achieve the targets in each group. Main Outcomes and Measures: Cox proportional hazards model was used to investigate the association of intensive treatment with the incident composite cardiovascular outcome (by August 20, 2015) according to living arrangement among Black individuals and other individuals. Transportability formula was applied to generalize the SPRINT findings to hypothetical external populations by varying the proportion of Black race and living arrangement status. Results: Among the 9342 total participants, the mean (SD) age was 67.9 (9.4) years; 2793 participants [30%] were Black, 2714 [29%] lived alone, and 3320 participants (35.5%) were female. Over a median (IQR) follow-up of 3.22 (2.74-3.76) years, the primary composite cardiovascular outcome was observed in 67 of 1001 Black individuals living alone (6.7%), 76 of 1792 Black individuals living with others (4.2%), 108 of 1713 non-Black individuals living alone (6.3%), and 311 of 4836 non-Black individuals living with others (6.4%). The intensive treatment group showed a significantly lower rate of the composite cardiovascular outcome than the standard treatment group among Black individuals living with others (hazard ratio [HR], 0.53 [95% CI, 0.33-0.85]) but not among those living alone (HR, 1.07 [95% CI, 0.66-1.73]; P for interaction = .04). The association was observed among individuals who were not Black regardless of living arrangement status. Using transportability, we found a smaller or null association between intensive control and cardiovascular outcomes among hypothetical populations of 60% Black individuals or more and 60% or more of individuals living alone. Conclusions and Relevance: Intensive BP control was associated with a lower rate of cardiovascular events among Black individuals living with others and individuals who were not Black but not among Black individuals living alone. Trial Registration: ClinicalTrials.gov Identifier: NCT01206062.

Effect of Personalized Messages Sent by a Health System's Patient Portal on Influenza Vaccination Rates: a Randomized Clinical Trial.

BACKGROUND: Adult influenza vaccination rates are low. Tailored patient reminders might raise rates. OBJECTIVE: Evaluate impact of a health system's patient portal reminders: (1) tailored to patient characteristics and (2) incorporating behavioral science strategies, on influenza vaccination rates among adults. DESIGN: Pragmatic 6-arm randomized trial across a health system during the 2019-2020 influenza vaccination season. The setting was one large health system-53 adult primary care practices. PARTICIPANTS: All adult patients who used the patient portal within 12 months, stratified by the following: young adults (18-64 years, without diabetes), older adults (≥65 years, without diabetes), and those with diabetes (≥18 years). INTERVENTIONS: Patients were randomized within strata to either (1) pre-commitment reminder alone (1 message, mid-October), (2) pre-commitment + loss frame messages, (3) pre-commitment + gain frame messages, (4) loss frame messages alone, (5) gain frame messages alone, or (6) standard of care control. Patients in the pre-commitment group were sent a message in mid-October, asking if they planned on getting an influenza vaccination. Patients in loss or gain frame groups were sent up to 3 portal reminders (late October, November, and December, if no documented influenza vaccination in the EHR) about importance and safety of influenza vaccine. MAIN MEASURES: Receipt of 1 influenza vaccine from 10/01/2019 to 03/31/2020. KEY RESULTS: 196,486 patients (145,166 young adults, 29,795 older adults, 21,525 adults with diabetes) were randomized. Influenza vaccination rates were as follows: for young adults 36.8%, for older adults 55.6%, and for diabetics 60.6%. On unadjusted and adjusted (for age, gender, insurance, race, ethnicity, and prior influenza vaccine history) analyses, influenza vaccination rates were not statistically different for any study group versus control. CONCLUSIONS: Patient reminders sent by a health system's patient portal that were tailored to patient demographics (young adults, older adults, diabetes) and that incorporated two behavioral economic messaging strategies (pre-commitment and loss/gain framing) were not effective in raising influenza vaccination rates. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (NCT04110314).