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Context: Diabetes or hyperglycemia at admission are established risk factors for adverse outcomes during hospitalization for COVID-19, but the impact of prior glycemic control is not clear. Objective: We aimed to examine the associations between admission variables, including glycemic gap, and adverse clinical outcomes in patients hospitalized with COVID-19 infection. Methods: We examined the relationship between clinical predictors, including acute and chronic glycemia, and clinical outcomes, including intensive care unit (ICU) admission, mechanical ventilation (MV), and mortality among 1786 individuals with diabetes or hyperglycemia (glucose>10 mmol/L twice in 24 hours) who were admitted from March 2020 through February 2021 with COVID-19 infection at 5 university hospitals in the eastern United States. Results: The cohort was 51.3% male, 53.3% White, 18.8% Black, 29.0% Hispanic, with age=65.6 ±14.4 years, BMI= 31.5±7.9 kg/m2, glucose=12.0±7.5 mmol/L [216± 135 mg/dL], and HbA1c =8.07%±2.25%. During hospitalization, 38.9% were admitted to the ICU, 22.9% received MV, and 10.6% died. Age (P<0.001) and admission glucose (P=0.014) but not HbA1c were associated with increased risk of mortality. Glycemic gap, defined as admission glucose minus estimated average glucose based on HbA1c, was a stronger predictor of mortality than either admission glucose or HbA1c alone (OR=1.040 [95% CI: 1.019, 1.061] per mmol/L, P<0.001). In an adjusted multivariable model, glycemic gap, age, BMI, and diabetic ketoacidosis on admission were associated with increased mortality, while higher estimated glomerular filtration rate (eGFR) and use of any diabetes medication were associated with lower mortality (P< 0.001). Conclusion: Relative hyperglycemia, as measured by the admission glycemic gap, is an important marker of mortality risk in COVID-19. [ABSTRACT FROM AUTHOR]

Objective: We examined predictors of early and late loss of glycemic control in individuals with youth-onset type 2 diabetes, as well as predictors of short-term deterioration in youth from the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study. Methods: Demographic, physical, and biochemical measures at baseline and 48 months, and change over time, were examined in 584 participants separated into those with loss of glycemic control (sustained HbA1c ≥ 8%) before 48 months or at 48 months or later, and those who remained in control until the end of the study (median 6.8 years). Univariate and multivariate models, and receiver operating characteristic curve analyses were performed. Results: Approximately 45% of youth remained in control at 48 months; of these, 30% subsequently lost glycemic control prior to the end of follow-up. Predictors of early loss of glycemic control included baseline HbA1c, C-peptide index, oral disposition index, proinsulin, and proinsulin to insulin ratio. Predictors of late loss included baseline measures of insulin secretion and change in HbA1c and insulin processing at 48 months. A baseline HbA1c cutoff of ≥ 6.2% was optimally predictive of loss of glycemic control at any time, while an absolute rise in HbA1c > 0.5% related to loss of glycemic control within 3 to 6 months. Conclusion: This analysis demonstrates that youth with type 2 diabetes at risk for loss of glycemic control, including impending rapid deterioration, can be identified using available clinical measures, allowing for closer monitoring of at-risk youth, and facilitating the design of research on better therapeutic options. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate feasibility of initiating continuous glucose monitoring (CGM) through telehealth as a means of expanding access. Adults with type 1 diabetes (N = 27) or type 2 diabetes using insulin (N = 7) and interest in starting CGM selected a CGM system (Dexcom G6 or Abbott FreeStyle Libre), which they received by mail. CGM was initiated with a certified diabetes care and education specialist providing instruction via videoconference or phone. The primary outcome was days per week of CGM use during the last 4 weeks. Hemoglobin A1c (HbA1c) was measured at baseline and 12 weeks. Participant self-reported outcome measures were also evaluated. All 34 participants (mean age, 46 ± 18 years; 53% female, 85% white) were using CGM at 12 weeks, with 94% using CGM at least 6 days per week during weeks 9 to 12. Mean HbA1c decreased from 8.3 ± 1.6 at baseline to 7.2 ± 1.3 at 12 weeks (P  < .001) and mean time in range (70-180 mg/dL, 3.9-10.0 mmol/L) increased from an estimated 48% ± 18% to 59% ± 20% (P  < .001), an increase of approximately 2.7 hours/day. Substantial benefits of CGM to quality of life were observed, with reduced diabetes distress, increased satisfaction with glucose monitoring, and fewer perceived technology barriers to management. Remote CGM initiation was successful in achieving sustained use and improving glycemic control after 12 weeks as well as improving quality-of-life indicators. If widely implemented, this telehealth approach could substantially increase the adoption of CGM and potentially improve glycemic control for people with diabetes using insulin. [ABSTRACT FROM AUTHOR]

Objective: to examine the effects of the Informatics for Diabetes Education and Telemedicine (IDEATel) telemedicine intervention and pedometer use on physical activity (PA) and impairment in older adults with diabetes.Design: randomised clinical trial.Subjects ethnically diverse medically underserved Medicare beneficiaries with diabetes (n= 1,650).Methods: participants received home videovisits with a diabetes educator every 4–6 weeks or usual care. All received a pedometer. Annual measurements included hemoglobin A1c, Comprehensive Assessment and Referral Evaluation Activities of Daily Living, Diabetes Self-Care Activities, Charlson Comorbidity Index, Luben Social Support and pedometer use. Mixed model analyses were performed using random effects to adjust for clustering within primary care physicians.Results: in the telemedicine group compared with the usual care group, the rate of decline in PA (P= 0.0128) and physical impairment (PI) (P= 0.0370) was significantly less over time. Significant mean endpoint differences were observed for PA (P= 0.003). Pedometer use was significantly associated with PA (P= 0.0006) and PI (P< 0.0001). Baseline characteristics associated with greater PA included having fewer comorbid conditions (P= 0.0054), less depression (P< 0.0001), more social networking (P< 0.0001), lower BMI (P< 0.0001), male gender (P< 0.0001) and lower hemoglobin A1c level (P= 0.0045). Similar predictors were observed for PI, except duration of diabetes also predicted increased impairment (P< 0.0001). Significant indirect effects were observed through use of the pedometer on reduced decline in PA (P= 0.0024, 0.0013) and PI (P= 0.0024, P< 0.0001).Conclusions: this telemedicine intervention reduced rates of decline in PA and impairment in older adults with diabetes. Pedometers may be a helpful inexpensive adjunct to diabetes initiatives delivered remotely with emerging technologies.ClinicalTrials.gov identifier NCT 00271739. [ABSTRACT FROM AUTHOR]

Objective To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention. Design We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State. Measurements We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000-February 27, 2006). Results Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant! month. Conclusion Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used. [ABSTRACT FROM AUTHOR]

CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care. OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older, ethnically diverse, medically underserved patients with diabetes. DESIGN, Setting, and Patients A randomized controlled trial was conducted, comparing telemedicine case management to usual care, with blinded outcome evaluation, in 1,665 Medicare recipients with diabetes, aged >/= 55 years, residing in federally designated medically underserved areas of New York State. Interventions Home telemedicine unit with nurse case management versus usual care. Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c (HgbA1c), low density lipoprotein (LDL) cholesterol, and blood pressure levels. RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints (HgbA1c, p = 0.001; LDL, p < 0.001; systolic and diastolic blood pressure, p = 0.024; p < 0.001). Estimated differences (95% CI) in year 5 were 0.29 (0.12, 0.46)% for HgbA1c, 3.84 (-0.08, 7.77) mg/dL for LDL cholesterol, and 4.32 (1.93, 6.72) mm Hg for systolic and 2.64 (1.53, 3.74) mm Hg for diastolic blood pressure. There were 176 deaths in the intervention group and 169 in the usual care group (hazard ratio 1.01 [0.82, 1.24]). CONCLUSIONS Telemedicine case management resulted in net improvements in HgbA1c, LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries. Mortality was not different between the groups, although power was limited. Trial Registration http://clinicaltrials.gov Identifier: NCT00271739. [ABSTRACT FROM AUTHOR]

Background: with increasing prevalence of diabetes in older people, it is important to understand factors that affect their outcomes. The Informatics for Diabetes Education and Telemedicine (IDEATe1) project is a demonstration project to evaluate the feasibility and effectiveness of telemedicine with kiiverse, medically underserved, older diabetes patients. Subjects were randomised to telemedicine case management or usua! care. This intervention has been shown to result in improved medical outcomes and self-efficacy. Self-efficacy refers to one!s belief that (s)he can successfully engage in a behaviour. Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle -aged individuals, but not studied in older individuals. Objectives: to assess whether (a) diabetes self-efficacy relates to the primary medical outcome o glycaemic control, and to secondary outcomes (blood pressure and cholesterol), and (b) whether, after an intervention, change in diabetes self-efficacy relates to change in these medical outcomes in a group of older, ethnically diverse individuals. Methods: three waves of longitudinal data from participants in IDEATe1 were analysed. Results: diabetes self-efficacy at baseline correlated with glycaemic control, blood pressure and cholesterol. An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control (P < 0.0001), but not in blood pressure and lipid levels. The intervention was significantly related to improved self-efficacy over time (P < 0.0001)., and, both directly (P= 0.022) and indirectly through self-efficacy (P < 0.001) to improved glycaemic control. The mediation effect of self-efficacy was also significant (P< 0.004). Conclusions: diabetes self-efficacy is a relevant construct for older diabetes patients. Thus, interventions that target enhanced self-efficacy may also result in improved glycaemic control. [ABSTRACT FROM AUTHOR]

Background: Ambulatory 24-h pulse pressure predicts progression of albuminuria in people with diabetes mellitus. It is not known whether the ambulatory arterial stiffness index (AASI) may add to that prediction. Methods: We compared the multivariate-adjusted association of AASI and 24-h pulse pressure with progression of urine albumin excretion during follow-up in a multiethnic cohort of older people with type-2 diabetes mellitus. The baseline evaluation included office and 24-h ambulatory blood pressure (BP) measurements, and a spot urine measurement of albumin-to-creatinine ratio (ACR). The ACR measurements were repeated annually during 3 years. Results: The AASI was ≥0.55 units in 47% of those exhibiting progression of albuminuria, and in 37% of those without progression (P = .004), whereas 24-h pulse pressure was ≥65 mm Hg in 50% and 38% of those with and without progression, respectively (P = .001). In repeated measures mixed linear model (n = 1043), after adjustment for several covariates including office pulse pressure, AASI in the fourth quartile was independently associated with higher follow-up ACR (P = .024). However, that association did not persist after adjusting for 24-h pulse pressure, which was an independent predictor (P < .001). Cox proportional hazards models examined progression of albuminuria in 957 participants without macroalbuminuria at baseline. The hazard ratio (95% CI) for AASI ≥0.55 units was 1.37 (1.02–1.83) after multivariable adjustment, including office pulse pressure. But AASI was not an independent predictor after adjustment for ambulatory pulse pressure, which was again an independent predictor (P = .033). Conclusions: Ambulatory 24-h pulse pressure outperformed AASI in predicting progression of albuminuria in elderly people with type 2 diabetes. [Copyright &y& Elsevier]

Objectives: To describe the development and validation of low literacy English and Spanish versions of the 26-item Telemedicine Satisfaction and Usefulness Questionnaire (TSUQ), report telemedicine satisfaction and usefulness ratings of urban and rural participants in the Informatics for Diabetes Education and Telemedicine (IDEATel) project, and explore relationships between utilization and perceptions of satisfaction and usefulness.Methods: Data sources included TSUQ, utilization data from IDEATel log files, and sociodemographic data from the annual IDEATel interview. Psychometric analyses were conducted to examine the reliability and validity of TSUQ. Data were analyzed using descriptive, correlational techniques.Results: The principal components factor analysis extracted two factors (Video Visits, alpha=.96, and Use and Impact, alpha=.92) that explained 63.6% of the variance in TSUQ satisfaction scores. All satisfaction and usefulness items had mean scores of greater than 4 on a 5-point scale. Those from urban areas reported significantly higher ratings on both factors than rural participants as did those who did not know how to use a computer at baseline. Mean frequency of utilization of IDEATel components was highest for blood sugar testing followed by web site for reviewing results, blood pressure testing, video visits, and ADA educational Web pages. Associations between utilization and perceptions of satisfaction and usefulness varied among IDEATel components.Conclusion: Psychometric analyses support the construct validity and internal consistency reliability of TSUQ, which is available in both English and Spanish at a readability level of 8th grade. Both rural and urban participants reported high levels of satisfaction and found all IDEATel components useful. Further work is needed to examine the relationships between utilization and perceptions of satisfaction and usefulness and to explore the effects of location (urban versus rural) and ethnicity on satisfaction with telemedicine services. [ABSTRACT FROM AUTHOR]

Background: Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness. Methods: The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels. Results: In the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c ≥7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18%(p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c ≥7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York. Conclusion: Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up. [ABSTRACT FROM AUTHOR]

Background: Diabetes is a chronic illness that requires significant behavior change through adherence to, and maintenance of, a complex health care regimen. Social support has been found to be a factor that influences adherence. Purpose: This article reports a cross-sectional and prospective assessment of the relationship between marital quality (i.e., intimacy and adjustment) and self reported adherence to the diabetes care regimen. Methods: Seventy-eight insulin-treated adults with diabetes were assessed at Time I (TI) when they completed two marital quality measures and a measure of adherence to the diabetes care regimen. Sixty participants were contacted 2 years later (Time 2; T2), and the self-care measure was readministered. Blood glucose (sugar) control was assessed by hemoglobin AIc. Demographic data (age, gender, type and duration of diabetes, years married, other medical problems, family history of diabetes, years of education) were gathered from charts and questionnaires. Linear regression analyses were used to assess the ability of the two marital measures at T1 to predict adherence in self-care at T2, controlling for confounding baseline variables. Results: Results showed that both of the marital quality measures predicted many aspects of self-care at T1. Dietary self-care related to marital intimacy and adjustment, as did adherence to exercise and to doctor's recommendations. Neither adherence to blood glucose testing nor blood glucose control was related to marital quality. Prospective analyses showed that neither marital quality measure at T1 was a prospective predictor of aspects of adherence to self-care at T2. Conclusions: Future efforts to improve self-care should explore the value of interventions that target the spouse and/or the couple's relationship. [ABSTRACT FROM AUTHOR]

Background: diabetes is a significant disease of elderly people, an age group whose numbers will double over the next 20-30 years. Yet studies which assess diabetes-related quality of life have rarely included elderly participants. Objectives: to compare and contrast the health-related quality of life of elderly (≥ 65 years) and younger individuals with diabetes using reliable and valid assessment tools. Methods: 191 adults (≥ 30 years) with diabetes currently on an insulin regimen were recruited. Medical and demographic data were gathered from the medical chart. Participants completed a generic quality of life measure (SF-36) and 3 diabetes-specific measures. Statistical analyses compared adults (30-64 years) to elderly adults (≥ 65 years). Results: on the generic SF-36, physical and mental summary scores did not differ. However, elderly participants reported greater role limitations due to physical problems, and better social function. On diabetes-specific measures, elderly participants reported higher satisfaction with diabetes-related aspects of their lives, less diabetes-related emotional distress, and better ability to cope with their diabetes. Conclusions: the differences that did emerge between the two groups suggest that, though experiencing more limitations in their ability to function in their roles, elderly individuals with diabetes may still feel that they can cope with these limitations and thus manage the distress and lifestyle demands of the diabetes. The value of subscale analysis of the SF-36 and use of diabetes-specific health-related quality of life measures is also affirmed. [ABSTRACT FROM AUTHOR]

The Columbia University Informatics for Diabetes Education and Telemedicine (IDEATel) Project is a four-year demonstration project funded by the Centers for Medicare and Medicaid Services with the overall goals of evaluating the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine in the management of older patients with diabetes. The study is designed as a randomized controlled trial and is being conducted by a state-wide consortium in New York. Eligibility requires that participants have diabetes, are Medicare beneficiaries, and reside in federally designated medically underserved areas. A total of 1,500 participants will be randomized, half in New York City and half in other areas of the state. Intervention participants receive a home telemedicine unit that provides synchronous videoconferencing with a project-based nurse, electronic transmission of home fingerstick glucose and blood pressure data, and Web access to a project Web site. End points include glycosylated hemoglobin, blood pressure, and lipid levels; patient satisfaction; health care service utilization; and costs. The project is intended to provide data to help inform regulatory and reimbursement policies for electronically delivered health care services. [ABSTRACT FROM AUTHOR]

The Columbia University Informatics for Diabetes Education and Telemedicine IDEATel) project is a four-year demonstration project funded by the Centers for Medicare and Medicaid Services with the overall goal of evaluating the feasibility, acceptability, effectiveness, and cost-effectiveness of telemedicine. The focal point of the intervention is the home telemedicine unit (HTU), which provides four functions: synchronous videoconferencing over standard telephone lines, electronic transmission for fingerstick glucose and blood pressure readings, secure Web-based messaging and clinical data review, and access to Web-based educational materials. The HTU must be usable by elderly patients with no prior computer experience. Providing these functions through the HTU requires tight integration of six components: the HTU itself, case management software, a clinical information system, Web-based educational material, data security, and networking and telecommunications. These six components were integrated through a variety of interfaces, providing a system that works well for patients and providers. With more than 400 HTUs installed, IDEATel has demonstrated the feasibility of large-scale home telemedicine. [ABSTRACT FROM PUBLISHER]