Are We Missing an Opportunity? Prediabetes in the U.S. Military.

INTRODUCTION: The prevalence of prediabetes is estimated to be one-third of Americans with approximately 80% of these individuals unaware of the diagnosis. In the active duty military population, the prevalence of prediabetes is largely unexplored. The purpose of this study was to investigate the prevalence of prediabetes in military service members by quantifying those meeting prediabetes screening criteria, those actually being screened, and those being appropriately diagnosed. MATERIALS AND METHODS: Data were analyzed from calendar years 2014 to 2018 for active duty service members 18 years of age or older. Vitals records were collected to obtain body mass index values. Composite Health Care System laboratory data were queried for hemoglobin A1c (HbA1c) results as well as fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) results. The percentage of active duty service members meeting criteria for prediabetes screening was determined by totaling members age 45 and older with members age 18- to 44-year old with a body mass index ≥25.0 kg/m2, then dividing by the total number of members for each respective military branch. The percentage of active duty service members actually screened for prediabetes was determined based on members meeting prediabetes screening criteria who in fact had FPG, OGTT, or HbA1c labs. The total number of labs meeting prediabetes criteria was determined based on those aforementioned labs with results in the prediabetes range (FPG between 100 and 125 mg/dL, OGTT between 140 and 199 mg/dL, or HbA1c range of 5.7%-6.4%). The total number of service members with appropriate prediabetes International Classification of Disease (ICD) code was determined by identifying members with ICD-9 and ICD-10 codes 790.21, 790.22, and R73.01-R73.03 in their medical record. RESULTS: From 2014 to 2018, 53.9% of 332,502, 56% of 543,081, and 47.3% of 531,313 active duty service members in the Air Force, Army and Navy, respectively, met criteria for prediabetes screening. The rates of actually screening for prediabetes were similar across the Air Force (4.8%), Army (6.7%), and Navy (5.5%). The percentage with labs meeting prediabetes criteria ranged from 17.9% to 28.4% in the Air Force, 24.2% to 30.3% in the Army, and 24.2% to 30.9% in the Navy. The rate of ICD coding for prediabetes increased from 2014 to 2018 across all branches (29.8%-65.3% for the Air Force, 24.6%-46.8% for the Army, and 40.0%-45.5% for the Navy). CONCLUSION: Screening for prediabetes in the active duty military population is grossly inadequate, and even of those screened, diagnosing those meeting prediabetes criteria is similarly inadequate. Although this scenario is not unique to the Military Health System, but reflective of a larger national problem, efforts should be made within the Military Health System to increase the screening for this common disorder. Identifying service members with prediabetes enables opportunities for targeted interventions to delay or prevent the progression to diabetes mellitus.

Extension for Community Healthcare Outcomes (ECHO) Telementoring in the Military: Where We Are Now, Opportunities and Challenges.

INTRODUCTION: In collaboration with the ECHO (Extension for Community Healthcare Outcomes) Institute since 2012, the Army, Navy, and Air Force have developed medical teleECHO programs to address various health and safety issues affecting military personnel. This article describes and compares the current state of military teleECHOs as well as the growth and change over time. MATERIALS AND METHODS: This study evaluated continuing education units (CEUs) offered, average session attendance, and number of spoke sites for current military teleECHO programs across the service branches. RESULTS: Between 2012 and 2019, the military teleECHO initiative grew from one program to seven different teleECHO programs, covering topics from pain to diabetes to amputee care. Military ECHOs now provide training to 10 countries and 27 states in the United States. Between October 2018 and September 2019, the military ECHO programs provided a total of 51,769 continuing medical education (CME) hours to a total of 3,575 attendees from 223 spoke sites. CONCLUSIONS: The military has successfully used the ECHO model to improve the health and safety of active-duty military, retirees, and dependents.

The Choice Should Be Yours: Diabetes-Related Distress by Insulin Delivery Method for People with Type 1 Diabetes.

Background: American Diabetes Association (ADA) recommends psychosocial assessment for people with diabetes, including diabetes-related distress. Elevated diabetes-related distress is associated with poor self-management, lower medication adherence, and poorer quality of life. Insulin delivery methods are multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Because people with type 1 diabetes mellitus (T1DM) require comprehensive insulin therapy to manage blood glucose, we explored the association of insulin delivery methods and diabetes distress in this group. Methods: The U.S. Air Force Diabetes Center of Excellence (DCOE), a specialty clinic for adults who are Military Health System beneficiaries, administers the validated 17-item Diabetes-related Distress Scale (DDS-17) as part of standard care. Patient data were analyzed from June 2015 to August 2016 using SPSS version 22. Patients were free to choose the method of insulin delivery with minimal or no additional cost. Results: There were 203 patients with T1DM who completed the DDS-17 as part of standard care during the time period. Patients were categorized as CSII (57.6%) or MDI (42.4%). Women were significantly more likely to choose MDI over CSII than men (P = 0.003). DDS-17 scores were low in both groups, and there were no significant differences in DDS-17 by insulin delivery method. Furthermore, no significant differences were found in hemoglobin A1c (HbA1c) between CSII (7.9% or 63 mmol/mol) and MDI (8.1% or 65 mmol/mol) users (P = 0.22) and no significant differences in body mass index (BMI) between patients using CSII (M = 28.33 kg/m2) and MDI (28.49 kg/m2) users (P = 0.15). Conclusions: Our study demonstrated that if patients are relatively free to choose the insulin delivery method (minimal or no financial constraints), there were no differences in diabetes distress scores, HbA1c, or BMI between CSII and MDI. Therefore, people with T1DM may benefit from choosing the method of insulin delivery that will enable them to achieve individual goals and manage diabetes-related distress.

Analysis of current thyroid function test ordering practices.

RATIONALE: Current guidelines recommend thyroid stimulating hormone (TSH) alone as the best test to detect and monitor thyroid dysfunction, yet free thyroxine (FT4) and free triiodothyronine (FT3) are commonly ordered when not clinically indicated. Excessive testing can lead to added economic burden in an era of rising healthcare costs, while rarely contributing to the evaluation or management of thyroid disease. OBJECTIVE: To evaluate our institution's practice in ordering thyroid function tests (TFTs) and to identify strategies to reduce inappropriate FT4 and FT3 testing. METHODS: A record of all TFTs obtained in the San Antonio Military Health System during a 3-month period was extracted from the electronic medical record. The TFTs of interest were TSH, FT4, thyroid panel (TSH + FT4), FT3, total thyroxine (T4), and total triiodothyronine (T3). These were categorized based on the presence or absence of hypothyroidism. RESULTS: Between August 1 and October 31, 2016, there were 38 214 individual TFTs ordered via 28 597 total laboratory requests; 11 486 of these requests were in patients with a history of hypothyroidism. The number (percent) of laboratory requests fell into these patterns: TSH alone 14 919 (52.14%), TSH + FT4 7641 (26.72%), FT3 alone 3039 (10.63%), FT4 alone 1219 (4.26%), TSH + FT4 + FT3 783 (2.74%), and others 996 (3.48%); 36.0% of TFTs ordered were free thyroid hormones. Projected out to a year, using Department of Defense laboratory costs, $317 429 worth of TFTs would be ordered, with free thyroid hormone testing accounting for $107 720. CONCLUSION: Inappropriate ordering of free thyroid hormone tests is common. In an era of rising healthcare costs, inappropriate thyroid function testing is an ideal target for efforts to reduce laboratory overutilization, which in our system, could save up to $120 000 per year. Further evaluation is needed to determine strategies that can reduce excessive thyroid hormone testing.

Leadership Training in Endocrinology Fellowship? A Survey of Program Directors and Recent Graduates.

CONTEXT: There is growing recognition that more physician leaders are needed to navigate the next era of medicine. OBJECTIVE: To determine current opinions about leadership training in endocrinology fellowship programs. DESIGN/PARTICIPANTS: Twenty-seven-question survey addressing various aspects of leadership training to current nationwide fellowship program directors (PDs) and fellowship graduates since 2010. INTERVENTION: In partnership with the Endocrine Society, the electronic survey was advertised primarily via direct e-mail. It was open from March through July 2016. MAIN OUTCOME MEASURES: The survey addressed leadership traits, importance of leadership training, preferred timing, and content of leadership training. RESULTS: Forty-six of 138 PDs (33.3%) and 147 of 1769 graduates (8.3%) completed the survey. Among PDs and graduates, there was strong agreement (>95%) about important leadership characteristics, including job knowledge, character traits, team-builder focus, and professional skills. PDs (64.5%) and graduates (60.8%) favored teaching leadership skills during fellowship, with PDs favoring mentoring/coaching (75.0%), direct observation of staff clinicians (72.5%), and seminars (72.5%). Graduates favored a variety of approaches. Regarding topics to include in a leadership curriculum, PDs responded that communication skills (97.5%), team building (95.0%), professional skills (90.0%), clinic management (87.5%), strategies to impact the delivery of endocrinology care (85.0%), and personality skills (82.5%) were most important. Graduates responded similarly, with >80% agreement for each topic. Finally, most PDs (89%) expressed a desire to incorporate more leadership training into their programs. CONCLUSIONS: Our survey suggests a need for leadership training in endocrinology fellowships. More work is needed to determine how best to meet this need.

Elevations in growth hormone and glucagon-like peptide-2 levels on admission are associated with increased mortality in trauma patients.

BACKGROUND: Burn and trauma patients present a clinical challenge due to metabolic derangements and hypermetabolism that result in a prolonged catabolic state with impaired healing and secondary complications, including ventilator dependence. Previous work has shown that circulating levels of growth hormone (GH) are predictive of mortality in critically ill adults, but few studies have examined the prognostic potential of GH levels in adult trauma patients. METHODS: To investigate the utility of GH and other endocrine responses in the prediction of outcomes, we conducted a prospective, observational study of adult burn and trauma patients. We evaluated the serum concentration of GH, insulin-like growth factor 1 (IGF-1), IGF binding protein 3 (IGFBP-3), and glucagon-like peptide-2 (GLP-2) weekly for up to 6 weeks in 36 adult burn and trauma patients admitted between 2010 and 2013. RESULTS: Non-survivors had significantly higher levels of GH and GLP-2 on admission than survivors. DISCUSSION: This study demonstrates that GH has potential as a predictor of mortality in critically ill trauma and burn patients. Future studies will focus on not only the role of GH, but also GLP-2, which was shown to correlate with mortality in this study with a goal of offering early, targeted therapeutic interventions aimed at decreasing mortality in the critically injured. CONCLUSIONS: GH and GLP-2 may have clinical utility for outcome prediction in adult trauma patients.

EVALUATION OF TOTAL DAILY DOSE AND GLYCEMIC CONTROL FOR PATIENTS TAKING U-500 REGULAR INSULIN ADMITTED TO THE HOSPITAL.

OBJECTIVE: Patients using U-500 regular insulin are severely insulin resistant, requiring high doses of insulin. It has been observed that a patient's insulin requirements may dramatically decrease during hospitalization. This study sought to systematically investigate this phenomenon. METHODS: We performed a retrospective chart review of patients with U-500 insulin outpatient regimens who were admitted to the San Antonio Military Medical Center over a 5-year period. Each patient's outpatient total daily dose (TDD) of insulin was compared to the average inpatient TDD. The outpatient estimated average glucose (eAG) was calculated from the glycated hemoglobin (HbA1c) and compared to the average inpatient glucose. RESULTS: There were 27 patients with a total of 62 separate admissions. The average age was 64.4 years, with a mean body mass index of 38.9 kg/m2 and eAG of 203 mg/dL (HbA1c, 8.7%, 71.6 mmol/mol). All patients were converted from U-500 to U-100 upon admission. The average inpatient TDD of insulin was 91 units, versus 337 units as outpatients (P<.001). Overall, 89% of patients received ≤50% of their outpatient TDD. The average inpatient glucose was slightly higher than the outpatient eAG, 234 mg/dL versus 203 mg/dL (P = .003). CONCLUSION: U-500 insulin is prone to errors in the hospital setting, so conversion to U-100 insulin is a preferred option. Despite a significant reduction in insulin TDD, these patients had clinically similar glucose levels. Therefore, patients taking U-500 insulin as an outpatient can be converted to a U-100 basal-bolus regimen with at least a 50% reduction of their outpatient TDD. ABBREVIATIONS: BG = blood glucose eAG = estimated average glucose HbA1c = glycated hemoglobin NPO = nil per os SPSS = Statistical Package for the Social Sciences TDD = total daily dose.