Economic Costs of Diabetes in the U.S. in 2022.

OBJECTIVE: This study updates previous estimates of the economic burden of diagnosed diabetes, with calculation of the health resource use and indirect costs attributable to diabetes in 2022. RESEARCH DESIGN AND METHODS: We combine the demographics of the U.S. population in 2022 with diabetes prevalence, from national survey data, epidemiological data, health care cost data, and economic data, into a Cost of Diabetes Economic Model to estimate the economic burden at the population and per capita levels. Health resource use and associated medical costs are analyzed by age, sex, race/ethnicity, comorbid condition, and health service category. Data sources include national surveys (2015-2020 or most recent available), Medicare standard analytic files (2020), and administrative claims data from 2018 to 2021 for a large commercially insured population in the U.S. RESULTS: The total estimated cost of diagnosed diabetes in the U.S. in 2022 is $412.9 billion, including $306.6 billion in direct medical costs and $106.3 billion in indirect costs attributable to diabetes. For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes. On average people with diabetes incur annual medical expenditures of $19,736, of which approximately $12,022 is attributable to diabetes. People diagnosed with diabetes, on average, have medical expenditures 2.6 times higher than what would be expected without diabetes. Glucose-lowering medications and diabetes supplies account for ∼17% of the total direct medical costs attributable to diabetes. Major contributors to indirect costs are reduced employment due to disability ($28.3 billion), presenteeism ($35.8 billion), and lost productivity due to 338,526 premature deaths ($32.4 billion). CONCLUSIONS: The inflation-adjusted direct medical costs of diabetes are estimated to rise 7% from 2017 and 35% from 2012 calculations (stated in 2022 dollars). Following decades of steadily increasing prevalence of diabetes, the overall estimated prevalence in 2022 remains relatively stable in comparison to 2017. However, the absolute number of people with diabetes has grown and contributes to increased health care expenditures, particularly per capita spending on inpatient hospital stays and prescription medications. The enormous economic toll of diabetes continues to burden society through direct medical and indirect costs.

Role of prices in driving the variation in spending across medical groups.

OBJECTIVE: To understand the relative role of prices versus utilization in the variation in total spending per patient across medical groups. DATA SOURCES: We conducted a cross-sectional analysis of medical claims for commercially insured adults from a large national insurer in 2018. STUDY DESIGN: After assigning patients to a medical group based on primary care visits in 2018, we calculated total medical spending for each patient in that year. Total spending included care provided by clinicians within the medical group and care provided by other providers, including hospitals. It did not include drug spending. We estimated the case mix adjusted spending per patient for each medical group. Within each market, we categorized medical groups into quartiles based on the group's spending per patient. To decompose spending variation into price versus utilization, we compared spending differences between highest and lowest quartile medical groups under two scenarios: (1) using actual prices (2) using a standardized price (same price used for a given service across the nation). PRINCIPAL FINDINGS: In total, 3,921,736 patients were assigned to 7284 medical groups. Per-patient spending in the highest quartile of spending medical groups was $1813 higher than per-patient spending in the lowest spending quartile of medical groups (50% higher relative spending). This overall difference was primarily driven by differences in inpatient care, imaging, and specialty care. In the scenario where we used standardized prices, the difference in spending between medical groups in the top and bottom quartiles decreased to $1425, implying that 79% of the $1813 difference in spending between the top and bottom quartile groups is explained by utilization and the remaining 21% by prices. The likely explanation for the modest impact of prices is that patients cared for by a given medical group receive care across a wide range of providers. CONCLUSIONS: Prices explained a modest fraction of the differences in spending between medical groups.

Treatment modification after initiating second-line medication for type 2 diabetes.

OBJECTIVES: To describe changes in antidiabetic medication (ADM) use and characteristics associated with changes in ADM use after initiation of noninsulin second-line therapy. STUDY DESIGN: Retrospective cohort study. METHODS: This study analyzed private health plan claims for adults with type 2 diabetes who initiated 1 of 5 index ADM classes: sulfonylureas, dipeptidyl peptidase 4 inhibitors (DPP4is), sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or thiazolidinediones. Analyses evaluated 3 treatment modification outcomes-discontinuation, switching, and intensification-over 12-month follow-up. RESULTS: Of 82,624 included adults, nearly two-thirds (63.6%) experienced any treatment modification. Discontinuation was the most common modification (38.6%), especially among patients prescribed GLP-1 RAs (50.3%). Switching occurred in 5.2% of patients and intensification in 19.8%. In adjusted analysis, compared with patients prescribed sulfonylureas, discontinuation risk was 7% higher (HR, 1.07; 95% CI, 1.04-1.10) among patients prescribed DPP4is and 28% higher (HR, 1.28; 95% CI, 1.23-1.33) among patients prescribed GLP-1 RAs. Compared with sulfonylureas, all other index ADM classes had higher risks of switching and lower risks of intensification. Younger age group and female sex were both associated with higher risks of all modifications. Compared with index ADM prescription by a family medicine or internal medicine physician, index prescription by an endocrinologist was associated with both lower discontinuation risk and higher intensification risk. CONCLUSIONS: Most patients experienced a treatment modification within 1 year. Results highlight the need for new prescribing approaches and patient supports that can maximize medication adherence and reduce health system waste.

Variation in spending associated with primary care practices.

OBJECTIVES: To measure variation in spending and inpatient prices associated with the primary care physician (PCP) practice to which patients are attributed. STUDY DESIGN: Cross-sectional analysis of claims data. METHODS: We used random effect models to estimate case mix-adjusted spending across large PCP practices within 3-digit zip codes. We compare inpatient prices for patients in high-spending practices with those in low-spending practices. RESULTS: The physician practice to which a patient was attributed is associated with significant differences in spending after controlling for patient comorbidities and geography. Patients attributed to practices in the top quartile of total medical expenses have about 30% higher spending than patients attributed to practices in the bottom quartile of adjusted spending in their 3-digit zip code. If patients attributed to practices in the top 2 quartiles had spending equivalent to those in the median practice, total spending would drop by 8%. Price variation accounts for a meaningful amount of the variation, with inpatient prices 17% higher in top-quartile vs bottom-quartile practices. We cannot disaggregate the large variation in utilization into practice patterns and unmeasured case mix (including unmeasured differences in patients' socioeconomic status) vs random health shocks, but correlation in spending patterns across years suggests that some persistent differences in spending patterns exist. CONCLUSIONS: There are meaningful opportunities to reduce spending by changing patient PCP selection, encouraging patients to use lower-priced specialists and hospitals, and eliminating wasteful care. Attention must be paid to the best ways to reap these savings.

Costs for commercially insured adults prescribed second-line diabetes medications.

OBJECTIVES: To examine differences in health care costs associated with choice of second-line antidiabetes medication (ADM) for commercially insured adults with type 2 diabetes. STUDY DESIGN: Retrospective cohort study with multiple pretests and posttests. METHODS: Included patients initiated second-line ADM therapy between 2011 and 2015, with variable follow-up through 2017. The 6 index medication classes were sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), basal insulin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and thiazolidinediones (TZDs). Multivariable regression models compared between-class changes in adjusted quarterly costs after second-line ADM initiation. RESULTS: The study cohort included 34,963 adults. Most were prescribed a sulfonylurea (46.0%) or DPP-4 inhibitor (30.4%). Adjusted quarterly index medication costs were significantly higher for all patients receiving nonsulfonylurea medications, ranging from $108 (95% CI, $99-$118) for TZDs to $742 (95% CI, $720-$765) for GLP-1 RAs. Changes in quarterly total health care costs were significantly higher for all nonsulfonylurea classes. Conversely, changes in quarterly nonpharmacy medical costs were significantly lower for patients receiving DPP-4 inhibitors (-$67; 95% CI, -$92 to -$43), GLP-1 RAs (-$43; 95% CI, -$85 to -$1), and SGLT-2 inhibitors (-$46; 95% CI, -$87 to -$6); changes in all other quarterly costs besides the index medication were significantly lower for patients receiving DPP-4 inhibitors (-$60; 95% CI, -$94 to -$26) and SGLT-2 inhibitors (-$113; 95% CI, -$169 to -$57). CONCLUSIONS: The higher cost of nonsulfonylurea medications was the main driver of relative increases in total costs. Relative decreases in nonpharmacy medical costs among patients receiving newer ADM classes reflect these medications' potential value.

Assessment of COPD-related outcomes in patients initiating a once daily or twice daily ICS/LABA.

BACKGROUND: Use of inhaled corticosteroids and long acting beta agonist (ICS/LABA) combination therapy has been shown to decrease the frequency of exacerbations in patients with chronic obstructive pulmonary disease (COPD). In this population, adherence to treatment is associated with better disease control and lower risk of COPD-related exacerbations in the future. Using a treatment with a more convenient regimen or easier-to-use device could improve patient adherence, improve disease control, decrease the frequency of exacerbations and minimize the COPD-related economic burden. Real-world information on the impact on healthcare costs and exacerbation risk of initiating once-daily or twice daily ICS/LABA in this patient population is limited. The objective of this study was to assess COPD-related healthcare costs, adherence, and exacerbations in COPD patients initiating treatment with fluticasone furoate/vilanterol 100/25 (FF/VI) or budesonide/formoterol 160/4.5 (BUD/F) using a large managed care database in the US. METHODS: This was a retrospective cohort study among COPD patients initiating FF/VI or BUD/F between January 01, 2014 and June 30, 2016. The analysis used the Optum Research Database (ORD) which contains patients from commercial and Medicare Advantage Prescription Drug (MAPD) plans. The study included new initiators of ICS/LABA as either FF/VI or BUD/F for COPD, ≥40 years of age at index, ≥15 months of continuous enrollment (12 months pre-index and ≥3 months post-index). New users of FF/VI or BUD/F were matched on baseline characteristics using propensity score matching (PSM) methods. Multivariate models including ordinary least squares regression, Lin's regression, logistic regression, and Cox proportional hazards were used to assess differences between the cohorts on outcomes of interest. RESULTS: A total of 18,652 subjects met all inclusion and exclusion criteria with 5044 initiating FF/VI and 13,608 initiating BUD/F. Of these, 9026 subjects were matched at a 1:1 ratio (4513 patients in each cohort) and were included in the final analyses. Proportion of days covered (PDC), was significantly better for FF/VI (mean PDC [SD]: FF/VI: 0.46 [0.31], BUD/F: 0.41 [0.29], p < 0.001) while FF/VI was associated with a 9% lower risk (adj. hazard ratio (HR): 0.91, 95% CI: 0.85-0.96) of having a moderate or severe COPD-related exacerbation. However, COPD-related healthcare costs were not significantly different, $11,521 vs $10,986, p = 0.41 for FF/VI and BUD/F, respectively. CONCLUSIONS: Patients initiating once-daily FF/VI were more adherent, and were associated with a lower risk of subsequent COPD-related exacerbations compared with twice-daily BUD/F, however this was not associated with a significant difference in costs. (GSK Study HO1617333/206702).

Assessment of Adherence and Asthma Medication Ratio for a Once-Daily and Twice-Daily Inhaled Corticosteroid/Long-Acting ß-Agonist for Asthma.

BACKGROUND: Although efficacy and safety of fluticasone furoate/vilanterol (FF/VI) and budesonide/formoterol (BUD/F) have been demonstrated in clinical studies, real-world comparisons of utilization have not been performed. OBJECTIVE: To compare similar patients with asthma initiating FF/VI or BUD/F on measures of adherence, persistence, and the asthma medication ratio (AMR). METHODS: This was a retrospective cohort study of commercial and Medicare Advantage with Part D enrollees initiating FF/VI or BUD/F for asthma. Adult patients (≥18 years) with at least 15-month (12-month preindex and 3-month postindex) continuous enrollment and 1 or more asthma diagnosis code were eligible for the study. Patients with a history of fixed-dose inhaled corticosteroid/long-acting ß-agonist and other respiratory disorders (chronic obstructive pulmonary disease, cystic fibrosis, acute respiratory failure) in the baseline period were excluded. Propensity-score matching was used to balance cohorts on baseline characteristics. Logistic regression and Cox-proportional hazard models were used to assess differences. RESULTS: A total of 9951 patients met all criteria. After propensity-score matching, 1725 patients were matched in each cohort. Subjects who initiated FF/VI had a significantly higher mean proportion of days covered (P < .001), had 86% greater odds of having a proportion of days covered value of greater than or equal to 0.80 (adjusted odds ratio, 1.86; 95% CI, 1.51-2.30), 26% lower risk of discontinuation (adjusted hazard ratio, 0.74; 95% CI, 0.69-0.79), and 36% greater odds of an AMR of greater than or equal to 0.50 (adjusted odds ratio, 1.36; 95% CI, 1.23-1.50) compared with BUD/F. CONCLUSIONS: Adherence and treatment persistence were low in both cohorts; however, patients initiating once-daily FF/VI were more likely to be adherent, have an AMR of greater than or equal to 0.5, and were less likely to discontinue therapy compared with patients initiating twice-daily BUD/F (GlaxoSmithKline Study HO1617302/206482).

Injury mechanism, epidemiology, and Hospital trends of scapula fractures: A 10-year retrospective study of the National Trauma Data Bank.

BACKGROUND: This 10 year retrospective study of the NTDB is the first to describe trends in scapula fracture diagnosis frequency, epidemiology, injury mechanisms and the type of hospital where the condition is treated. METHODS: Demographics, ISS scores, hospital data, mechanism of injury, complications, and hospital length of stay were recorded for patients with diagnosed scapula fractures (ICD-9, 811.0) recorded in the NTDB, v7.2 (2002-2012). Mean and standard deviation for continuous variables and proportions for binary variables are calculated. RESULTS: The prevalence of scapula fractures in all patients submitted to the NTDB (2002-2012) was 1.74%. Between 2006-2007, the reported incidence doubled from 1% to 2.2%. There was a predominance of injury to white males (75% and 78% respectively). Forty-one percent were treated at a Level 1 trauma center and had a mean ISS of 20.1 (SD-11.8). Scapula fracture rates declined in patients 0-19 years and increased in the 60-79 and 80+ age groups. The increasing incidence of the aged population is also reflected in the increase of falls as the mechanism of injury in the elderly population. CONCLUSION: This study is the first to describe a full decade of scapula fracture epidemiology on a national scale. The number of diagnosed scapula fractures increased substantially in the NTDB between 2002-2012. Scapula fractures diagnosed in the geriatric demographic and fractures resulting from falls are both on the rise, whereas the reported incidence is decreasing in the younger demographic. Additionally, fractures as a result of motor vehicle accidents also decreased precipitously during the reported decade.

Comparison of healthcare resource utilization and costs in patients with type 2 diabetes initiating dapagliflozin versus sitagliptin.

AIMS: To compare healthcare costs and utilization in patients with type 2 diabetes (T2D) who initiated dapagliflozin (DAPA) with costs and utilization in those who initiated sitagliptin (SITA) in a real-world setting. MATERIALS AND METHODS: This was a retrospective study of health plan enrollees in two US commercial claims databases or Medicare Part D. The study population comprised adult patients with T2D who initiated DAPA or SITA between January 1, 2014 and April 30, 2015. DAPA and SITA initiators were propensity-score-matched, and healthcare utilization and costs during the 1-year follow-up period were compared. Analyses were conducted separately for patients with evidence of oral antidiabetic drug (OAD) monotherapy use at baseline. RESULTS: A total of 2722 patients were included in each matched cohort. Follow-up unadjusted all-cause costs ($16 065 and $17 281; P = 0.135) and diabetes-related costs ($9697 and $9354; P = 0.539) were similar in the DAPA and SITA cohorts. Higher office and outpatient visit costs in the SITA group were offset by higher pharmacy costs in the DAPA group. In the subgroup of 1804 patients with OAD monotherapy use at baseline, patients in the SITA group had higher total all-cause costs compared with those in the DAPA group ($14 884 vs. $12 353; P = 0.026). CONCLUSION: Patients who initiated DAPA or SITA had similar all-cause and diabetes-related healthcare costs over 1 year of follow-up. In the subgroup of patients treated with OAD monotherapy at baseline (84% metformin monotherapy), those who initiated DAPA as add-on therapy had lower costs than patients who added SITA.

Potentially Preventable Hospital and Emergency Department Events: Lessons from a Large Innovation Project.

INTRODUCTION: There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. METHODS: Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. RESULTS: Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. CONCLUSION: Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

Burden of Illness Associated with Tenosynovial Giant Cell Tumors.

PURPOSE: Little is known about the burden of illness in patients with tenosynovial giant cell tumors (TGCT), which are rare, typically benign, lesions of the synovial tissue including giant cell tumor of the tendon sheath (GCT-TS) and pigmented villonodular synovitis (PVNS). The objective of this study was to describe health care resource use and costs for patients with GCT-TS and PVNS, which are rare and typically benign TGCT. METHODS: A retrospective cohort study design was used to analyze administrative claims for adult commercial and Medicare Advantage health plan enrollees with evidence of GCT-TS and PVNS from January 1, 2006 through March 31, 2015. Participants were continuously enrolled for 12 months before (pre-index period) and 12 months after (post-index period) the date of the first tenosynovial giant cell tumor (TGCT) claim (index date). Preindex and postindex measures were compared using the McNemar test and Wilcoxon signed-rank test. Results were stratified by TGCT type. FINDINGS: The study identified 4664 patients with TGCT, 284 with GCT-TS, and 4380 with PVNS. Mean age (GCT-TS group: 50 years; PVNS group: 51 years) and sex distributions (GCT-TS group: 60.2% female; PVNS group: 59.5% female) were similar for each group. Most patients with GCT-TS (78.2%) had at least one postindex surgery, compared with 38.7% of patients with PVNS. Mean total health care costs increased from $8943 in the preindex period to $14,880 in the postindex period (P < 0.001) for GCT-TS and from $13,221 in the preindex period to $17,728 in the postindex period (P < 0.001) for PVNS. Preindex to postindex ambulatory costs increased nearly 120% for patients with GCT-TS ($4340 to $9570, P < 0.001) and 50% for patients with PVNS ($6782 to $10,278, P < 0.001), and physical therapy use increased significantly during the same period (GCT-TS: 18% to 40%, P < 0.001; PVNS: 38% to 60%, P < 0.001). IMPLICATIONS: Costs increased substantially 1 year after the first TGCT claim, with more than half the costs covering ambulatory care. These results suggest a high health care burden once TGCT is identified.

Searching for the Smoker's Paradox in Acute Stroke Patients Treated With Intravenous Thrombolysis.

BACKGROUND: Inconsistent evidence supports better outcome in smokers after stroke. Our study examines this association in a large sample of ischemic stroke treated with intravenous thrombolysis. METHOD: Virtual International Stroke Trials Archive (VISTA) database, composed of individual patient data of multiple clinical trials, was queried. The primary outcome was functional independence at 3 months noted by modified Rankin Scale (mRS; a 7-point scale ranging from 0 [no deficit] to 6 [death]) score≤ 2. The secondary outcomes were National Institutes of Health Stroke Scale (NIHSS; stroke severity measure, ranging from 0 [no deficit] to 42 [most severe]) score at 24 hours and the occurrence of symptomatic intractracranial hemorrhage. RESULTS: A total of 5383 patients were included: 1501 current smokers and 3882 nonsmokers. Smokers were younger (60 ± 13 vs. 71 ± 12 years, p < .0001) and had lower median NIHSS score at baseline (12 [8-17] vs. 13 [9-18], p < .0001). The rate of favorable functional outcome (mRS ≤ 2) at 3 months was significantly higher among current smokers (49.7% vs. 39.5%, p < .0001) and with crude ORs of 1.52, 95% CI 1.33-1.72. The association became non-significant after adjusting for age (OR 1.11, 95% CI 0.97-1.27). Subgroup analysis by age/gender strata showed that current smoking was associated with favorable outcome only in women ≥ 65 years. Current smoking was also associated with lower rates of symptomatic intracranial hemorrhage (adjusted OR 0.55, 95% CI 0.39-0.79). CONCLUSION: Smokers experience their first ever stroke 11 years younger than nonsmokers. This age difference explains the association between current smoking and favorable functional outcome. IMPLICATIONS: Smoking is associated with occurrence of first ever stroke at a younger age, therefore, focus should be on smoking prevention and treatment. The decision to treat ischemic stroke patients with intravenous thrombolysis should not be influenced by the patients' smoking status.

Predicting Hypertension Among Children With Incident Elevated Blood Pressure.

OBJECTIVE: To develop a model to predict hypertension risk among children with incident elevated blood pressure (BP); to test the external validity of the model. METHODS: A retrospective cohort study was conducted in 3 organizations: Kaiser Permanente Colorado was the model derivation site; HealthPartners of Minnesota and Kaiser Permanente Northern California served as external validation sites. During study years 2006 through 2012, all children aged 3 through 17 years with incident elevated BP in an outpatient setting were identified. The predictor variables were demographic and clinical characteristics collected during routine care. Cox proportional hazards regression was used to predict subsequent hypertension, and diagnostic statistics were used to assess model performance. RESULTS: Among 5598 subjects at the derivation site with incident elevated BP, 160 (2.9%) developed hypertension during the study period. Eight characteristics were used to predict hypertension risk: age, sex, race, BP preceding incident elevated BP, body mass index percentile, systolic BP percentile, diastolic BP percentile, and clinical setting of the incident elevated BP. At the derivation site, the model discriminated well between those at higher versus lower risk of hypertension (c-statistic = 0.77). At external validation sites, the observed risk of hypertension was higher than the predicted risk, and the model showed poor discrimination (c-statistic ranged from 0.64 to 0.67). CONCLUSIONS: Among children with incident elevated BP, a risk model demonstrated good internal validity with respect to predicting subsequent hypertension. However, the risk model did not perform well at 2 external validation sites, which might limit transportability to other settings.

The financial impact of team-based care on primary care.

OBJECTIVES: Although team-based care can improve coronary heart disease (CHD) risk factors and is considered cost-effective from a healthcare system perspective, little is known about the financial impact of team-based primary care for secondary prevention of CHD. The purpose of this study was to define the impact of team-based care for CHD on utilization, costs, and revenue of a private primary care practice. STUDY DESIGN: Interrupted time series analysis. METHODS: Between March 1, 2010, and March 31, 2013, we assisted a private medical practice, comprising 5 primary care clinic sites, to organize and deliver team-based care for patients with CHD. We used billing records and the registered nurse care manager's diary to calculate the cost of team-based care, differences in the average number of visits per patient, and revenue per patient before and after the implementation of team-based care. RESULTS: The net cost of team-based primary care was $291 per patient over the 1-year period of observation. CONCLUSIONS: The findings from this study are consistent with other economic analyses of team-based care and suggest that payment for care must be restructured if patients are expected to enjoy the benefits of team-based primary care.

Proton pump inhibitor use by aspirin-treated coronary artery disease patients is not associated with increased risk of cardiovascular events.

AIMS: Daily low-dose aspirin is recommended for prevention of cardiovascular events in patients with coronary artery disease (CAD), and proton pump inhibitors (PPIs) are recommended to prevent or treat aspirin-associated gastrointestinal injury. Previous studies have reported contradictory findings regarding the risk of major adverse cardiovascular events (MACE) in patients who use PPI with aspirin therapy. We sought to examine associations between PPI use and MACE and all-cause mortality in aspirin-treated CAD patients. METHODS AND RESULTS: Using electronic medical record and healthcare claims data, we conducted a retrospective population-based cohort study to examine patients 40 years or older with a diagnosis of CAD and documented aspirin use. Patients taking clopidogrel or other antiplatelet or anticoagulant agents were excluded. Risk of MACE and all-cause mortality associated with PPI use vs. no PPI use was analysed by Cox proportional hazards regression with standard covariate adjustment. Of the 2011 patients included in the study, 295 (14.7%) used a PPI. During a mean follow-up of 3.1 years, 294 patients [63 PPI users (21.4%) and 231 PPI non-users (13.5%)] experienced an MACE. In the adjusted model, the risk of MACE with PPI treatment was no different than without PPI treatment [hazard ratio (HR) 1.32 (95% confidence interval 0.8-2.4)]. Likewise, there was no difference between groups for risk of all-cause mortality; 201 patients [47 PPI users (15.9%) and 154 PPI non-users (9.0%)] died of any cause [HR 1.33 (0.9-1.9)]. Results were validated by robust propensity score-matching methods (n = 574). CONCLUSIONS: No evidence was found that PPI use is associated with increased risk of MACE or all-cause mortality in aspirin-treated CAD patients.

A Statewide Effort to Implement Collaborative Care for Depression: Reach and Impact for All Patients With Depression.

BACKGROUND: Little is known about the reach and impact of collaborative care for depression outside of clinical trials. OBJECTIVE: The objective of this study was to examine the effect of a collaborative care intervention for depression on the rates of depression diagnosis, use of specific depression codes, and treatment intensification. RESEARCH DESIGN: Evaluation of a staggered, multiple baseline implementation initiative. SUBJECTS: Patients receiving depression care in primary care clinics throughout Minnesota from February 2008 through March 2011. MEASURES: Data regarding depression diagnosis rates and codes, and measures of antidepressant intensification were provided by health insurers. RESULTS: Depression Improvement Across Minnesota: Offering a New Direction (DIAMOND) affected neither rates of depression recognition nor use of depression diagnostic codes, and the overall reach of DIAMOND was disappointingly small. Patients in DIAMOND had more episodes of treatment intensification than non-DIAMOND patients, but we were unable to account for depression severity in our analysis. CONCLUSIONS: DIAMOND did not affect depression recognition or diagnostic coding, but may have affected treatment intensification. Our results suggest that even strongly evidence-based interventions may have little contamination effects on patients not enrolled in the new care model.

Change in Weight Status and Development of Hypertension.

OBJECTIVE: To examine the association of BMI percentile and change in BMI percentile to change in blood pressure (BP) percentile and development of hypertension (HTN). METHODS: This retrospective cohort included 101 606 subjects age 3 to 17 years from 3 health systems across the United States. Height, weight, and BPs were extracted from electronic health records, and BMI and BP percentiles were computed with the appropriate age, gender, and height charts. Mixed linear regression estimated change in BP percentile, and proportional hazards regression was used to estimate risk of incident HTN associated with BMI percentile and change in BMI percentile. RESULTS: The largest increases in BP percentile were observed among children and adolescents who became obese or maintained obesity. Over a median 3.1 years of follow-up, 0.3% of subjects developed HTN. Obese children ages 3 to 11 had twofold increased risk of developing HTN compared with healthy weight children. Obese children and adolescents had a twofold increased risk of developing HTN, and severely obese children had a more than fourfold increased risk. Compared with those who maintained a healthy weight, children and adolescents who became obese or maintained obesity had a more than threefold increased risk of incident HTN. CONCLUSIONS: We observed a strong, statistically significant association between increasing BMI percentile and increases in BP percentile, with risk of incident HTN associated primarily with obesity. The adverse impact of weight gain and obesity in this cohort over a short period underscores the early need for effective strategies for prevention of overweight and obesity.

Using Principles of Complex Adaptive Systems to Implement Secondary Prevention of Coronary Heart Disease in Primary Care.

CONTEXT: Primary care practice. OBJECTIVE: To test whether the principles of complex adaptive systems are applicable to implementation of team-based primary care. DESIGN: We used complex adaptive system principles to implement team-based care in a private, five-clinic primary care practice. We compared randomly selected samples of patients with coronary heart disease (CHD) and diabetes before system implementation (March 1, 2009, to February 28, 2010) and after system implementation (December 1, 2011, to March 31, 2013). MAIN OUTCOME MEASURES: Rates of patients meeting the composite goals for CHD (blood pressure < 140/90 mmHg, low-density lipoprotein cholesterol level < 100 mg/dL, tobacco-free, and using aspirin unless contraindicated) and diabetes (CHD goal plus hemoglobin A1c concentration < 8%) before and after the intervention. We also measured provider and patient satisfaction with preventive services. RESULTS: The proportion of patients with CHD who met the composite goal increased from 40.3% to 59.9% (p < 0.0001) because documented aspirin use increased (65.2%-97.5%, p < 0.0001) and attainment of the cholesterol goal increased (77.0%-83.9%, p = 0.0041). The proportion of diabetic patients meeting the composite goal rose from 24.5% to 45.4% (p < 0.0001) because aspirin use increased (58.6%-97.6%, p < 0.0001). Increased percentages of patients meeting the CHD and diabetes composite goals were not significantly different (p = 0.2319). Provider satisfaction with preventive services delivery increased significantly (p = 0.0017). Patient satisfaction improved but not significantly. CONCLUSION: Principles of complex adaptive systems can be used to implement team-based care systems for patients with CHD and possibly diabetic patients.

Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature.

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables.