Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes.

Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk. CONTEXT: Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models. METHODS: Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources. FINDINGS: Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions. CONCLUSIONS: Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Diabetes mellitus and subsite-specific colorectal cancer risks in the Iowa Women's Health Study.

OBJECTIVE: Controversy remains regarding the association between type 2 diabetes mellitus (DM) and colorectal cancer (CRC) risk. To clarify and extend the existing data, we prospectively evaluated the association between self-reported type 2 DM (onset at >30 years of age) and incident CRC, overall and by anatomic subsite, among postmenopausal women in the Iowa Women's Health Study (n = 35,230). METHODS: After 14 years of follow-up, a total of 870 incident CRC cases were identified through annual linkage to the Iowa Cancer Registry. DM was analyzed as reported at baseline and as a time-dependent variable using information obtained during follow-up. CRC risks were estimated using Cox proportional hazards regression models. RESULTS: After adjusting for age, body mass index and other potential confounding variables, the relative risk (RR) for women with DM versus women without DM was modestly increased at 1.4 [95% confidence interval (95% CI), 1.1-1.8]. By anatomic subsite, the RR for proximal colon cancer was statistically significantly increased (RR, 1.9; 95% CI, 1.3-2.6), whereas the RRs for distal colon (RR, 1.1; 95% CI, 0.6-1.8) and rectal cancer (RR, 0.8; 95% CI, 0.4-1.6) were not statistically different from unity. Analyses that included DM ascertained at baseline and follow-up yielded similar results. CONCLUSION: In this large, prospective study of postmenopausal women, the association between DM and incident CRC was found to be subsite specific. If confirmed by others, this finding implies that CRC prevention strategies among type 2 DM patients should include examination of the proximal colon.

Association of aspirin and nonsteroidal anti-inflammatory drug use with breast cancer.

OBJECTIVE: Previous epidemiological studies have suggested that use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) may be associated with reduced risk of breast cancer, but some studies have been limited in their ability to separate the effects of aspirin from other NSAIDs or to account for breast cancer risk factors. METHODS: We examined the incidence of breast cancer in association with self-reported aspirin, as well as other nonaspirin NSAID use in a large prospective cohort of postmenopausal women (n = 27,616). Over 6 years of follow-up, 938 incident breast cancers were identified. RESULTS: After adjustment for other breast cancer risk factors, any current use of aspirin or other NSAIDs compared with no use was associated with a reduction in risk of breast cancer [relative risk (RR) = 0.80, 95% confidence interval (CI) 0.67-0.95]. There was a trend of decreasing risk of incident breast cancer with increasing frequency of aspirin use (P(trend) = 0.0011). The multivariate-adjusted RR of breast cancer was 0.71 (95% CI 0.58-0.87) for women who reported using aspirin six or more times per week compared with women who reported no use. These results did not depend on whether women had early or late stage breast cancer. No association was found between nonaspirin NSAID use and incident breast cancer. The adjusted RR of using other NSAIDs six or more times per week compared with no use was 1.01 (95% CI 0.83-1.25). CONCLUSION: This prospective study corroborates other reports that use of aspirin might reduce risk of breast cancer.

Association between nonsteroidal anti-inflammatory drug use and the incidence of pancreatic cancer.

Laboratory studies indicate that nonsteroidal anti-inflammatory drugs (NSAIDs) may inhibit pancreatic cancer, but epidemiologic data to support this finding are limited. We conducted a prospective study from 1992 through 1999 among 28 283 postmenopausal women who lived in Iowa to examine the association between the self-reported use of aspirin and other NSAIDs and the incidence of pancreatic cancer. Eighty incident cases of pancreatic cancer were identified during 7 years of follow-up. The multivariate-adjusted relative risk of pancreatic cancer associated with any current use of aspirin versus no use was 0.57 (95% confidence interval = 0.36 to 0.90). There was a trend of decreasing risk of pancreatic cancer incidence with increasing frequency of aspirin use per week (P(trend) =.005). Nonaspirin NSAID use was not associated with incident pancreatic cancer. These data indicate that aspirin might be chemopreventive for pancreatic cancer.