Social and Psychosocial Determinants of Health Associated With Uncontrolled Diabetes in a Federally Qualified Health Center Population.

PURPOSE: Many people with diabetes have difficulty achieving glycemic targets, and social and psychosocial determinants of health may influence their ability to obtain glycemic goals. The objective of this study was to identify characteristics independently associated with A1C >9% or untested A1C compared to those with A1C ≤9% at a federally qualified health center. METHODS: This retrospective cohort study included people with a diagnosis of diabetes, who were 18-89 years of age and had a medical evaluation from a primary care provider between 1 September 2016 and 31 August 2017. The primary outcome was to identify characteristics associated with an A1C >9% or untested A1C compared to those with an A1C ≤9%. RESULTS: Of 6,185 patients meeting inclusion criteria, 2,965 (48%) had uncontrolled A1C. In the uncontrolled A1C group, 1,549 patients (52%) were female, 1,296 (44%) preferred care in a language other than English (1,273 [43%] in Spanish), and 535 (18%) had a concurrent mental health diagnosis. Multivariable logistic regression of 4,774 patients with complete data revealed that poor appointment adherence (odds ratio [OR] 3.24, 95% CI 2.30-4.57) and/or a positive Patient Health Questionnaire-2 depression screen (OR 1.35, 95% CI 1.12-1.62) had an increased risk of being in the uncontrolled A1C group. Patients with a prescription for antidepressant medication were more likely to be in the controlled group. CONCLUSION: Poor adherence to appointments and presence of depressive symptoms were associated with high A1C values. Interventions can be developed targeting these determinants to improve blood glucose levels.

Impact of multidisciplinary chart reviews on opioid dose reduction and monitoring practices.

INTRODUCTION: The Veterans Affairs (VA) Eastern Colorado Health Care System implemented an Opioid Safety Initiative (OSI); this included multidisciplinary chart reviews of patients with chronic, non-malignant pain on high-dose opioid therapy to provide safety recommendations to prescribers through the electronic medical record. Our study objective was to evaluate the impact of these documented recommendations. Outcomes included change in total daily opioid dose, concurrent prescribing of opioids and benzodiazepines, adherence to local VA/Veterans Integrated Service Network (VISN) policy, and monitoring practices. METHODS: This retrospective chart review of patients prescribed ≥200 mg of morphine equivalent daily dose (MEDD) collected data from OSI chart reviews conducted between January 1, 2015 and March 31, 2015. Outcomes were assessed during the 12 months following initial review. Primary outcomes included: opioid dose reduction, discontinuation of concurrent benzodiazepines, and adherence to VA/VISN policy, including documentation of signed informed Consent for Long-Term Opioid Therapy for Pain, biannual urine drug screens (UDS), and follow-up every six months with primary opioid prescriber. RESULTS: Of 147 patients meeting inclusion criteria, 50 patients (34%) reduced opioid dose with the baseline median MEDD decreasing from 315 mg to 278 mg. Of the 48 patients prescribed benzodiazepines and opioids, 10 patients discontinued benzodiazepines (21%). Completion of informed consents increased from 31% to 48%, biannual UDS increased from 44% to 61%, and follow-up with opioid prescriber was unchanged. CONCLUSION: After completion of OSI chart reviews, reduction in opioid dose and concurrent prescribing of benzodiazepines was observed. VA/VISN policy and monitoring adherence also showed improvement.