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Diabetes self-management education and support enhance self-efficacy and promote self-management behaviors essential for diabetes management. We investigated the mediating effect of self-efficacy on the association between diabetes education or care coordination and self-care activities. We surveyed a population-based sample of adults with type 2 diabetes (19-64 years of age) covered by Alabama Medicaid. We examined whether receipt of diabetes education or care coordination were associated with improvements in diabetes self-care activities. We then examined if improvements were mediated by self-efficacy. Models were adjusted for age, gender, race, education, insulin use, diabetes duration, and depressive symptoms. Results: A total of 1,318 participants were included in the study (mean age = 52.9 years, SD = 9.6; 72.5% female, 56.4% Black, 3.1% Hispanic). Diabetes education was associated with increases in self-care activity scores related to general diet, physical activity, glucose self-monitoring, and foot care; care coordination was associated with glucose self-monitoring. In addition, mediation analysis models confirmed that improvements in self-efficacy led to improved self-care activities scores, mediating the association of diabetes education and self-care activities. Conclusions: Diabetes education and self-efficacy were associated with better self-care. Receiving diabetes education led to a higher likelihood of engaging in self-care activities, driven in part by increases in self-efficacy. Future interventions that aim to improve diabetes self-management behaviors can benefit from targeting self-efficacy constructs and from the integration of diabetes education in the care coordination structure.

Introduction/Objectives: Comprehensive eye exams are recommended at least every 2 years for people with diabetes for early identification and treatment of diabetic eye disease, but screening rates remain suboptimal. Our objective was to qualitatively assess barriers and facilitators to completing recommended eye exam screening for patients with diabetes among providers and practice staff. Methods: As part of a larger initiative, we conducted discussion groups with healthcare providers and practice staff to evaluate factors related to referral and screening for diabetic eye disease at 2 sites, a safety-net healthcare system and a specialty clinic. Discussions were audio-recorded and transcribed. Combined inductive, deductive thematic content analysis was conducted, applying the Practical Robust Implementation and Sustainability Model to organize themes and subthemes. Results: Two discussion groups with 28 participants were conducted in August 2023. Themes included existing processes for referrals, scheduling, and tracking; patient-level determinants including transportation and financial barriers and other competing demands to receiving recommended eye screening; clinic or system-related factors, and considerations for process improvement for eye exam referrals and appointments. Conclusions: These findings can be applied to determine the most effective strategies to improve the rates of recommended eye exam referral and screening rates in people with diabetes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We evaluated whether adding basal insulin to metformin in adults with early type 2 diabetes mellitus (T2DM) would increase emotional distress relative to other treatments. RESEARCH DESIGN AND METHODS: The Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE) of adults with T2DM of <10 years' duration, HbA1c 6.8–8.5%, and taking metformin monotherapy randomly assigned participants to add insulin glargine U-100, sulfonylurea glimepiride, the glucagon-like peptide-1 receptor agonist liraglutide, or the dipeptidyl peptidase 4 inhibitor sitagliptin. The Emotional Distress Substudy enrolled 1,739 GRADE participants (mean [SD] age 58.0 [10.2] years, 32% female, 56% non-Hispanic White, 18% non-Hispanic Black, 17% Hispanic) and assessed diabetes distress and depressive symptoms every 6 months. Analyses examined differences at 1 year and over the 3-year follow-up. RESULTS: Across treatments, diabetes distress (−0.24, P < 0.0001) and depressive symptoms (−0.67, P < 0.0001) decreased over 1 year. Diabetes distress was lower at 1 year for the glargine group than for the other groups combined (−0.10, P = 0.002). Diabetes distress was also lower for liraglutide than for glimepiride or sitagliptin (−0.10, P = 0.008). Over the 3-year follow-up, there were no significant group differences in total diabetes distress; interpersonal diabetes distress remained lower for those assigned to liraglutide. No significant differences were observed for depressive symptoms. CONCLUSIONS: Contrary to expectations, this randomized trial found no evidence for a deleterious effect of basal insulin on emotional distress. Glargine lowered diabetes distress modestly at 1 year rather than increasing it. Liraglutide also reduced diabetes distress at 1 year. Results can inform treatment decisions for adults with early T2DM. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations. RESULTS: At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%–15.5%) of the longitudinal link between emotional distress and adherence. CONCLUSIONS: Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To evaluate whether baseline levels of depressive symptoms and diabetes-specific distress are associated with glycemic control in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing the metabolic effects of four common glucose-lowering medications when combined with metformin in individuals with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS: The primary and secondary outcomes were defined as an HbA1c value ≥7%, subsequently confirmed, and an HbA1c value >7.5%, subsequently confirmed, respectively. Separate Cox proportional hazards models assessed the association between baseline levels of each exposure of interest (depressive symptoms measured with the eight-item Patient Health Questionnaire and diabetes distress measured with the Diabetes Distress Scale) and the subsequent risk of metabolic outcomes. RESULTS: This substudy included 1,739 participants (56% of whom were non-Hispanic White, 18% non-Hispanic Black, 17% Hispanic, and 68% male; mean [SD] age 58.0 [10.2] years, diabetes duration 4.2 [2.8] years, and HbA1c 7.5% [0.48%]). A total of 1,157 participants reached the primary outcome, with time to event of 2.1 years on average, while 738 participants reached the secondary outcome at 3 years on average. With adjustment for sex, race/ethnicity, treatment group, baseline age, duration of T2DM, BMI, and HbA1c, there were no significant associations between the depressive symptoms or diabetes distress and the subsequent risk of the primary or secondary outcomes. CONCLUSIONS: The current findings suggest that, at least for individuals with diabetes of relatively short duration, baseline levels of emotional distress are not associated with glycemic control over time. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Continuity of care measures are widely used to evaluate the quality of health care delivery, but which visits are included vary across studies. Our objective was to determine how the provider specialties included affect continuity values, year-to-year stability, and association with emergency department (ED) visits. STUDY DESIGN: Retrospective study of Alabama Medicaid administrative data. METHODS: We included beneficiaries with diabetes who had at least 3 outpatient visits in each of 2018 and 2019 (N = 9578). We defined 3 provider groupings: all providers, diabetes-broad (primary care, cardiology, neurology, endocrinology, ophthalmology, nephrology, and psychiatry), and diabetes-narrow (primary care and endocrinology). Continuity of care was calculated using the Continuity of Care Index (COCI) for each provider grouping. We compared correlation between measures and from year to year using Spearman correlations, and we used multivariable logistic regression to determine association with ED visits. RESULTS: The mean COCI was 0.54 using visits with all providers, 0.64 with diabetes-broad providers, and 0.83 with diabetes-narrow providers. COCI with diabetes-narrow providers was moderately correlated with the broader sets of providers (Spearman ρ, 0.52-0.65). Comparing each participant's COCI in 2018 with that in 2019, the mean intraperson difference was similar (0.16-0.22), and correlation was moderate (Spearman ρ, 0.41-0.47) for each measure. COCI had similar weak association with ED visits using each provider grouping (odds ratio, 0.99; 95% CI, 0.98-0.99 for each 0.1-unit difference in COCI). CONCLUSIONS: Continuity values differed substantially depending on which provider specialties were included. The importance of this variation is uncertain, as continuity was weakly associated with ED visits using each of the measures. [ABSTRACT FROM AUTHOR]

Aims: Diabetes distress affects approximately 36% of adults with diabetes and is associated with worse diabetes self‐management and poor glycaemic control. We characterized participants' diabetes distress and studied the relationship between social support and diabetes distress. Methods: In this cross‐sectional study, we surveyed a population‐based sample of adults with type 2 diabetes covered by Alabama Medicaid. We used the Diabetes Distress Scale assessing emotional burden, physician‐related, regimen‐related and interpersonal distress. We assessed participants' level of diabetes‐specific social support and satisfaction with this support, categorized as low or moderate–high. We performed multivariable logistic regression of diabetes distress by level of and satisfaction with social support, adjusting for demographics, disease severity, self‐efficacy and depressive symptoms. Results: In all, 1147 individuals participated; 73% were women, 41% White, 58% Black and 3% Hispanic. Low level of or satisfaction with social support was reported by 11% of participants; 7% of participants had severe diabetes distress. Participants with low satisfaction with social support were statistically significantly more likely to have severe diabetes distress than those with moderate–high satisfaction, adjusted odds ratio 2.43 (95% CI 1.30, 4.54). Conclusions: Interventions addressing diabetes distress in adults with type 2 diabetes may benefit from a focus on improving diabetes‐specific social support. [ABSTRACT FROM AUTHOR]

Purpose High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation. Methods We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders. Results In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45–0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08–1.36). Conclusions An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals. [ABSTRACT FROM AUTHOR]

Background: It is unknown whether observational studies evaluating the association between antidiabetic medications and mortality adequately account for frailty. Our objectives were to evaluate if frailty was a potential confounder in the relationship between antidiabetic medication regimen and mortality and how well administrative and clinical electronic health record (EHR) data account for frailty.Methods: We conducted a retrospective cohort study in a single Veterans Health Administration (VHA) healthcare system of 500 hospitalizations-the majority due to heart failure-of Veterans who received regular VHA care and initiated type 2 diabetes treatment from 2001 to 2008. We measured frailty using a modified frailty index (FI, >0.21 frail). We obtained antidiabetic medication regimen and time-to-death from administrative sources. We compared FI among patients on different antidiabetic regimens. Stepwise Cox proportional hazards regression estimated time-to-death by demographic, administrative, clinical EHR, and FI data.Results: Median FI was 0.22 (interquartile range 0.18, 0.27). Frailty differed across antidiabetic regimens (p < .001). An FI increase of 0.05 was associated with an increased risk of death (hazard ratio 1.45, 95% confidence interval 1.32, 1.60). Cox proportional hazards model for time-to-death including demographic, administrative, and clinical EHR data had a c-statistic of 0.70; adding FI showed marginal improvement (c-statistic 0.72).Conclusions: Frailty was associated with antidiabetic regimen and death, and may confound that relationship. Demographic, administrative, and clinical EHR data, commonly used to balance differences among exposure groups, performed moderately well in assessing risk of death, with minimal gain from adding frailty. Study design and analytic techniques can help minimize potential confounding by frailty in observational studies. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the accuracy of a composite definition for the identification of hypoglycemia events that used both administrative claims and laboratory data in a cohort of patients. Methods: We reviewed medical records in a sample of presumed hypoglycemia events among patients who received care at the Veterans Health Administration Tennessee Valley Healthcare System in 2001 to 2012. A hypoglycemia event was defined as a hospitalization or emergency department visit judged by the treating clinician to be due to hypoglycemia, or an outpatient laboratory or point‐of‐care blood glucose measurement <60 mg/dL. Based on medical record review, each event was classified as true positive (severe, documented symptomatic, documented asymptomatic) or false positive (probable symptomatic, not hypoglycemia). The positive predictive values (PPV) of the individual event types (hospitalization, emergency department, and outpatient) were estimated. Results: Of 2250 events identified through the composite definition, 321 events (15 hospitalizations, 103 emergency department visits, and 203 outpatient events) were reviewed. The PPVs were 80% for hospitalization events, 48% for emergency department events, and 96% for outpatient events. The emergency department definition included a nonspecific diagnosis code for diabetic complications which captured many false positive events. Excluding this code from the definition improved the PPV for emergency department events to 70% and missed one true event. Conclusions: Our composite definition for hypoglycemia performed moderately well in a cohort of Veterans. Further evaluation of the emergency department events may be needed. [ABSTRACT FROM AUTHOR]

Purpose. Results of a study to identify medication history technician (MHT) programs within the Veterans Health Administration (VHA) and to evaluate the personnel, structure, and scope of such programs are reported. Methods. Specially trained pharmacy technicians can take accurate patient medication histories and contribute to the medication reconciliation process. An environmental scan of MHT programs within VHA was conducted via an email query of pharmacy personnel. Semistructured interviews of personnel at each responding site (an MHT, a pharmacist, or both) were conducted. Results. Ten VHA sites had existing MHT programs; the earliest was initiated in 2010. Sites employed from 1 to 4 MHTs, who most commonly worked in the inpatient setting (7 sites). At most sites (9), MHTs obtained a "best possible medication history" through systematic collection of medication information using 2 reliable sources, such as patients, caregivers, and medical records. Survey respondents at all sites reported benefits of MHT programs, including dedicated time to obtain medication histories, allowing for more effective use of pharmacists' time. Six sites were eager to increase the reach of their programs. MHT training, oversight, and quality assurance varied across the sites. The survey results indicated that there are opportunities nationally--within and outside VHA--to develop standardized training, competency assessments, and quality assurance measures for MHT programs. Conclusion. Ten VHA sites with MHT programs were identified. MHTs most commonly worked in inpatient settings as part of admission medication reconciliation processes. [ABSTRACT FROM AUTHOR]

Objectives We aimed to validate an algorithm using both primary discharge diagnosis (International Classification of Diseases Ninth Revision (ICD-9)) and diagnosis-related group (DRG) codes to identify hospitalisations due to decompensated heart failure (HF) in a population of patients with diabetes within the Veterans Health Administration (VHA) system. Design Validation study. Setting Veterans Health Administration--Tennessee Valley Healthcare System. Participants We identified and reviewed a stratified, random sample of hospitalisations between 2001 and 2012 within a single VHA healthcare system of adults who received regular VHA care and were initiated on an antidiabetic medication between 2001 and 2008. We sampled 500 hospitalisations; 400 hospitalisations that fulfilled algorithm criteria, 100 that did not. Of these, 497 had adequate information for inclusion. The mean patient age was 66.1 years (SD 11.4). Majority of patients were male (98.8%); 75% were white and 20% were black. Primary and secondary outcome measures To determine if a hospitalisation was due to HF, we performed chart abstraction using Framingham criteria as the referent standard. We calculated the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity for the overall algorithm and each component (primary diagnosis code (ICD-9), DRG code or both). Results The algorithm had a PPV of 89.7% (95% CI 86.8 to 92.7), NPV of 93.9% (89.1 to 98.6), sensitivity of 45.1% (25.1 to 65.1) and specificity of 99.4% (99.2 to 99.6). The PPV was highest for hospitalisations that fulfilled both the ICD-9 and DRG algorithm criteria (92.1% (89.1 to 95.1)) and lowest for hospitalisations that fulfilled only DRG algorithm criteria (62.5% (28.4 to 96.6)). Conclusions Our algorithm, which included primary discharge diagnosis and DRG codes, demonstrated excellent PPV for identification of hospitalisations due to decompensated HF among patients with diabetes in the VHA system. [ABSTRACT FROM AUTHOR]

Patient–provider communication is modifiable and is linked to diabetes outcomes. The association of communication quality with medical mistrust is unknown. We examined these factors within the context of a low-literacy/numeracy-focused intervention to improve diabetes care, using baseline data from diverse patients enrolled in a randomized trial of a health communication intervention. Demographics, measures of health communication (Communication Assessment Tool [CAT], Interpersonal Processes of Care survey [IPC-18]), health literacy (Short Test of Functional Health Literacy in Adults), depression, medical mistrust, and glycemic control were ascertained. Adjusted proportional odds models were used to test the association of mistrust with patient-reported communication quality. The interaction effect of health literacy on mistrust and communication quality was also assessed. A total of 410 patients were analyzed. High levels of mistrust were observed. In multivariable modeling, patients with higher mistrust had lower adjusted odds of reporting a higher CAT score (adjusted odds ratio [AOR] = 0.67, 95% confidence interval [CI] [0.52, 0.86],p = .003) and higher scores on the Communication (AOR = 0.69, 95% CI [0.55, 0.88],p = .008), Decided Together (AOR = 0.74, 95% CI [0.59, 0.93],p = .02), and Interpersonal Style (AOR = 0.69, 95% CI [0.53, 0.90],p = .015) subscales of the IPC-18. We observed evidence of an interaction effect of health literacy for the association between mistrust and the Decided Together subscale of the IPC-18 such that patients with higher mistrust and lower literacy perceived worse communication relative to mistrustful patients with higher literacy. In conclusion, medical mistrust was associated with poorer communication with providers in this public health setting. Patients’ health literacy level may vary the effect of mistrust on interactional aspects of communication. Providers should consider the impact of mistrust on communication with vulnerable diabetes populations and focus efforts on mitigating its influence. [ABSTRACT FROM PUBLISHER]

Objective: Depression is common in patients with type 2 diabetes and associated with poor diabetes-related outcomes. We evaluated the factors associated with antidepressant use in a low-income, racially and ethnically diverse sample of patients with type 2 diabetes.Research Design and Methods: We performed a cross-sectional study of baseline data from participants in a cluster randomized trial evaluating a health literacy intervention for diabetes care in safety net clinics. Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D); antidepressant use was abstracted from medication lists. Multivariable mixed effects logistic regression was used to evaluate the relationship between antidepressant use and race/ethnicity adjusting for depressive symptoms, age, gender, income, and health literacy.Results: Of 403 participants, 58% were non-Hispanic White, 18% were non-Hispanic Black, and 24% were Hispanic. Median age was 51 years old; 60% were female, 52% of participants had a positive screen for depression, and 18% were on antidepressants. Black and Hispanic participants were significantly less likely to be on an antidepressant compared with white participants, adjusted odds ratios 0.31(95% CI: 0.12 to 0.80) and 0.26 (95% CI: 0.10 to 0.74), respectively.Conclusions: In this vulnerable population with type 2 diabetes, we found a high prevalence of depressive symptoms, and a small proportion of participants were on an antidepressant. Black and Hispanic participants were significantly less likely to be treated with an antidepressant. Our findings suggest depression may be inadequately treated in low-income, uninsured patients with type 2 diabetes, especially racial and ethnic minorities. [ABSTRACT FROM AUTHOR]

Background: Diabetes distress affects up to 45% of adults with diabetes and is associated with reduced treatment adherence and poor glycemic control. We evaluated diabetes distress and the relationship between social support and diabetes distress in adults with Medicaid. Methods: We surveyed a population-based sample of adults, aged 19 to 64 years old, covered by Alabama Medicaid, and diagnosed with type 2 diabetes. Diabetes distress was measured with the 17-item Diabetes Distress Scale (DDS) assessing emotional burden, physician-related distress, regimen-related distress, and interpersonal distress. A score of <2 indicates little/no distress, 2-2.9 moderate distress, and ≥3 high distress. Social support was assessed by the question "How much support do you get for dealing with your diabetes?" and responses were categorized as low, moderate, or high social support. We performed multivariate logistic regression of diabetes distress by social support, adjusting for demographics, disease severity, self-efficacy, and depressive symptoms. Results: In total, 541 individuals participated; 72% were female, 40% white, 58% black, and 3% Hispanic. Mean diabetes distress score was 1.7 (SD 0.88); 72.8% of participants had little/no diabetes distress, 16.8% moderate distress, and 10.4% high distress. Most participants (56.9%) reported high social support, but 13.5% reported low and 29.6% moderate social support. Participants who reported low and moderate social support were significantly more likely to have high diabetes distress (≥3) than those who reported high social support, adjusted odds ratio 14.3 (95% CI 5.2, 39.1) and 4.2 (95% CI 1.6, 10.7), respectively. This relationship was present for each diabetes distress domain, with particularly strong relationships between low social support and high interpersonal and regimen-related distress. Conclusions: Interventions seeking to reduce diabetes distress in adults with type 2 diabetes may benefit from a focus on improving social support. Disclosure: C.A. Presley: None. F.L. Mondesir: None. A.A. Agne: None. K.R. Riggs: None. M. Pisu: None. E.B. Levitan: Consultant; Self; Novartis Pharmaceuticals Corporation. Research Support; Self; Amgen Inc. J.M. Bronstein: None. A. Cherrington: None. Funding: National Institute of Diabetes and Digestive and Kidney Diseases [ABSTRACT FROM AUTHOR]

Objective: To describe patterns of care use for adult Medicaid beneficiaries with diabetes and the association between primary care utilization and Ambulatory Care Sensitive (ACS) diabetes hospitalizations. Methods: This retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19 to 64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health, pharmaceutical, laboratory and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use in one year on the occurrence of an ACS hospitalization in the following year. Results: One third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (adjusted odds ratio comparing 1-2 primary care visits versus none 0.79, 95% confidence interval 0.73-0.85). Conclusions: Program and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes. Disclosure: J.M. Bronstein: None. L. Huang: None. A.A. Agne: None. F.L. Mondesir: None. C.A. Presley: None. K.R. Riggs: None. M. Pisu: None. E.B. Levitan: Consultant; Self; Novartis Pharmaceuticals Corporation. Research Support; Self; Amgen Inc. A. Cherrington: None. Funding: National Institute of Diabetes and Digestive and Kidney Diseases [ABSTRACT FROM AUTHOR]

Background Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7 to 14 days after hospital discharge to improve HF outcomes. We examined postdischarge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care. Methods and Results Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010 to 2019, were included and the claims analyzed for ambulatory care use (any, primary care, cardiology, or endocrinology) within 60 days after discharge using restricted mean survival time regression and negative binomial regression. Among 9859 Medicaid-covered adults with diabetes and first hospitalization for HF (mean age, 53.7 years; SD, 9.2 years; 47.3% Black; 41.8% non-Hispanic White; 10.9% Hispanic/Other [Other included non-White Hispanic, American Indian, Pacific Islander and Asian adults]; 65.4% women, 34.6% men), 26.7% had an ambulatory visit within 0 to 7 days, 15.2% within 8 to 14 days, 31.3% within 15 to 60 days, and 26.8% had no visit; 71% saw a primary care physician and 12% a cardiology physician. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory visit ( P <0.0001) or the visit was delayed (by 1.8 days, P =0.0006 and by 2.8 days, P =0.0016, respectively) and were less likely to see a primary care physician than non-Hispanic White adults (adjusted incidence rate ratio, 0.96 [95% CI, 0.91-1.00] and 0.91 [95% CI, 0.89-0.98]; respectively). Conclusions More than half of Medicaid-covered adults with diabetes and HF in Alabama did not receive guideline-concordant postdischarge care. Black and Hispanic/Other adults were less likely to receive recommended postdischarge care for comorbid diabetes and HF.

Temporary closures of outpatient health facilities and transitions to virtual care during the COVID-19 pandemic interrupted the care of millions of patients with diabetes contributing to worsening psychosocial factors and enhanced difficulty in managing type 2 diabetes mellitus. We explored associations between COVID time period and self-reported diabetes distress on self-reported health among a sample of Alabama Medicaid-covered adults with diabetes pre-COVID (2017-2019) and during-COVID (2020-2021)., Method: In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by the Alabama Medicaid Agency. Participants were dichotomized into pre-COVID (March 2017 to October 2019) vs during-COVID (October 2020 to May 2021) groups. Participants with missing data were removed from analyses. We assessed diabetes related stress by the Diabetes Distress Scale. We measured self-reported health using a single item with a 5-point Likert scale. We ran logistic regressions modeling COVID time period on self-reported poor health controlling for demographics, severity of diabetes, and diabetes distress., Results: In this sample of 1822 individuals, median age was 54, 74.5% were female and 59.4% were Black. Compared to pre-COVID participants, participants surveyed during COVID were younger, more likely to be Black (64.1% VS 58.2%, p=0.01) and female (81.8% VS 72.5%, p<0.001). This group also had fewer individuals from rural areas (29.2% VS 38.4%, p<0.001), and shorter diabetes duration (7 years VS 9 years, p<0.001). During COVID individuals reported modestly lower levels of diabetes distress (1.2 VS 1.4, p<0.001) when compared to the pre-COVID group. After adjusting for demographic differences, diabetes severity, and diabetes distress, participants responding during COVID had increased odds of reporting poor health (Odds ratio [OR] 1.41, 95% Confidence Interval [CI] 1.11-1.80)., Discussion: We found respondents were more likely to report poorer health during COVID compared to pre-COVID. These results suggest that increased outreach may be needed to address diabetes management for vulnerable groups, many of whom were already at high risk for poor outcomes prior to the pandemic., Competing Interests: 5Conflict of Interest The research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.