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Clinical guidelines recommend reevaluation of glucose-lowering medications and relaxation of HbA1c targets in patients with diabetes after a severe hypoglycemic event. We compared diabetes management before and after hypoglycemia requiring emergency department (ED) visit or hospital admission. Using data from OptumLabs® Data Warehouse, we identified privately insured and Medicare Advantage enrollees 18+ years with pharmacologically-treated type 2 diabetes and an ED visit or hospitalization for hypoglycemia between July 1, 2013 and June 30, 2014. We assessed the differences in the number of physician office visits, glucometer test strips filled, continuous glucose monitor (CGM) use, diabetes medication fills, and HbA1c levels (available for 1582 [27.7%]), within 6 months prior to and 6 months after hypoglycemia. Among 5721 patients with type 2 diabetes and severe hypoglycemia, mean age was 67.8 (SD 12.3), 51% women, 63% white, and 68% used insulin. Changes in management are summarized in Table 1. After an event, the proportion of patients filling insulin increased, but the proportion filling sulfonylureas declined. Less than one third of patients with a baseline HbA1c Few of the recommended changes in diabetes management occur after a severe hypoglycemic event. These findings suggest the need for better post-event care to improve the safety of glucose-lowering therapy. Disclosure P. Vijayakumar: None. S. Liu: None. P.A. Kahn: None. R.G. McCoy: None. A.J. Karter: None. K.J. Lipska: Consultant; Self; Health Services Advisory Group (HSAG). Research Support; Self; National Institute on Aging. Other Relationship; Self; Centers for Medicare and Medicaid Services. Funding National Institute of Diabetes and Digestive and Kidney Diseases (T35DK104689); National Institute on Aging; American Federation for Aging Research; National Institutes of Health (K23AG048359)

Background Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional “brick and mortar” pharmacies to refill prescriptions. Methods We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. Results A total of 28 diabetes patients participated. Participants’ average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of ‘Opportunity.’ Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions. Conclusions This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems. Electronic supplementary material The online version of this article (10.1186/s12913-019-4250-7) contains supplementary material, which is available to authorized users.

Background: Diabetic ketoacidosis (DKA) is a life-threatening complication common in type 1 diabetes (T1D). DKA is associated with short-term cognitive impairment in children and adolescents with T1D, but it is unknown if a lifetime history of DKA is associated with poorer cognition in older adults. Methods: We examined the association between self-reported frequency of lifetime DKA hospitalizations and cognition in 720 older adults with T1D from the Study of Longevity in Diabetes (SOLID). Cognitive tests assessed 4 cognitive domains identified via factor analysis (language, executive function, episodic memory, attention). We examined: 1) the association between DKA and cognitive domains using adjusted linear regression; and 2) frequency of cognitive impairment (1.5 SD below mean) by DKA exposure. Results: Overall, 28% of participants reported DKA resulting in hospitalization in their lifetime (18% had 1 hospitalization; 10% had 2+ hospitalizations). Compared to those with no DKA hospitalizations, those with 2+ had lower executive function scores and were more likely to have impaired executive function. Language, episodic memory and simple attention did not differ by DKA. Conclusions: In older adults with T1D, lifetime exposure to DKA is associated with long-term impairment in cognition, specifically through executive function. Disclosure M.E.L. Leigh: None. P. Gilsanz: None. M.S. Beeri: None. A.J. Karter: None. C. Quesenberry: None. R.A. Whitmer: None. Funding National Institutes of Health (R01AG047500, T32AG049663, R01DK103721, R01DK081796, P30DK092924); Patient-Centered Outcomes Research Institute (PPRN-1306-04709)

Introduction: Severe hypoglycemia is common among those with type 1 diabetes (T1D). Hypoglycemia unawareness (HU) in T1D increases the risk of severe hypoglycemia more than five-fold. Prior work has established an association between severe hypoglycemia and impaired cognition. However, it is unknown if HU is associated with impaired cognition. Hypothesis: We hypothesized that HU would be associated with impaired cognition in a large cohort of older adults with T1D. Methods: We examined the association between HU and cognitive function using baseline data collected on 544 older adults with T1D from the Study of Longevity in Diabetes (SOLID). Self-reported HU was assessed using the 8-item Clarke Hypoglycemia Awareness Questionnaire, which captures frequency of hypoglycemia and awareness of symptoms. Participants with responses indicating ‘reduced awareness’ on ≥4 of the 8 items were categorized as having reduced awareness. Cognitive tests assessed four cognitive domains identified via factor analysis (language, executive function, episodic memory, attention). All cognitive test scores were standardized. Using generalized linear regression, we examined the association between HU and cognition on each of the four cognitive domains and on global cognition (average of scores on the 4 domains) in models adjusted for age and age, sex, education, race/ethnicity, and diabetes duration. Results: Overall, 27% of participants (n=149) had reduced hypoglycemia awareness. In fully adjusted models, compared to those with normal awareness, those with reduced hypoglycemia awareness had significantly lower scores on measures of language and global cognition; however, executive function, episodic memory and simple attention did not differ by HU status. Conclusions: Our results suggest that, among older adults with type 1 diabetes, HU may be associated with poorer cognition, specifically through language-related processes.

Objectives To assess changes in medication use after a diagnosis of dementia in individuals with type 2 diabetes mellitus. Design Difference-in-differences analysis of changes in the number of dispensed chronic medications between individuals with and without newly diagnosed dementia. Setting Integrated healthcare delivery system, Kaiser Permanente Northern California. Participants Individuals aged 50 and older without prevalent dementia with type 2 diabetes mellitus enrolled in a baseline survey. During 5 years of follow-up, 193 individuals with a new diagnosis of dementia were identified, and risk-set sampling was used to randomly select five reference subjects per case matched on 5-year age categories and sex (965 matched participants), resulting in an analytical sample of 1,158. Measurements The exposure was new diagnosis of dementia. The primary outcome was change in number of current chronic medications (total, cardiovascular (blood pressure and lipid control), diabetes mellitus) at three times: 1 year before index date (preindex date), date of diagnosis of dementia or matched reference date (index date), and up to 1 year after index date or end of follow-up if censored before 1 year (postindex date). Results After adjustment, the number of chronic medications and the subset of cardiovascular medications declined after a dementia diagnosis in the overall cohort and in age-, sex-, and time-matched reference individuals, but the decline was significantly greater in the group with dementia (0.71 medications fewer than the reference group, P = .02). The number of diabetes mellitus medications declined in both groups, but the declines were not statistically different (0.18 medications fewer than the reference group, P = .008). Conclusions Use of cardiometabolic medications fell after a diagnosis of dementia, as recommended in national guidelines.

OBJECTIVE Appropriate glycemic control is fundamental to diabetes care, but aggressive glucose targets and intensive therapy may unintentionally increase episodes of hypoglycemia. We quantified the burden of severe hypoglycemia requiring medical intervention in a well-defined population of insured individuals with diabetes receiving care in integrated health care delivery systems across the U.S. RESEARCH DESIGN AND METHODS This observational cohort study included 917,440 adults with diabetes receiving care during 2005 to 2011 at participating SUrveillance, PREvention, and ManagEment of Diabetes Mellitus (SUPREME-DM) network sites. Severe hypoglycemia rates were based on any occurrence of hypoglycemia-related ICD-9 codes from emergency department or inpatient medical encounters and reported overall and by age, sex, comorbidity status, antecedent A1C level, and medication use. RESULTS Annual rates of severe hypoglycemia ranged from 1.4 to 1.6 events per 100 person-years. Rates of severe hypoglycemia were higher among those with older age, chronic kidney disease, congestive heart failure, cardiovascular disease, depression, and higher A1C levels, and in users of insulin, insulin secretagogues, or β-blockers (P < 0.001 for all). Changes in severe hypoglycemia occurrence over time were not clinically significant in the cohort as a whole but were observed in subgroups of individuals with chronic kidney disease, congestive heart failure, and cardiovascular disease. CONCLUSIONS Risk of severe hypoglycemia in clinical settings is considerably higher in identifiable patient subgroups than in randomized controlled trials. Strategies that reduce the risk of hypoglycemia in high-risk patients are needed.

The risk of future coronary heart disease (CHD) in subjects with diabetes and "metabolic dyslipidemia" (high triglyceride [TGs] and low high-density cholesterol levels) remains a matter of concern. Little is known regarding the risk of CHD for this phenotype with low-density lipoprotein cholesterol (LDL-C) levels

Data is lacking regarding contributions of risk factors for premature atherosclerotic cardiovascular disease (ASCVD), especially among women. This study sought to evaluate the impact of smoking on future risk of ASCVD in young men and women. We conducted an observational cohort study of young

We previously developed and validated a hypoglycemia risk stratification tool (1) and made available the computer source code for implementation (online-only supplemental eTable 2 [1]). This tool classifies 12-month risk of hypoglycemia-related utilization (HRU) of emergency department (ED) or in-patient services among type 2 diabetes (T2D) patients as high (>5%), intermediate (1–5%), or low (

ObjectiveTo examine the association between traumatic brain injury (TBI) and dementia risk among a cohort of middle-aged and elderly individuals with type 1 diabetes (T1D).MethodsWe evaluated 4,049 members of an integrated health care system with T1D ≥50 years old between January 1, 1996, and September 30, 2015. Dementia and TBI diagnoses throughout the study period were abstracted from medical records. Cox proportional hazards models estimated associations between time-dependent TBI and dementia adjusting for demographics, HbA1c, nephropathy, neuropathy, stroke, peripheral artery disease, depression, and dysglycemic events. Fine and Gray regression models evaluated the association between baseline TBI and dementia risk accounting for competing risk of death.ResultsA total of 178 individuals (4.4%) experienced a TBI and 212 (5.2%) developed dementia. In fully adjusted models, TBI was associated with 3.6 times the dementia risk (hazard ratio [HR] 3.64; 95% confidence interval [CI] 2.34, 5.68). When accounting for the competing risk of death, TBI was associated with almost 3 times the risk of dementia (HR 2.91; 95% CI 1.29, 5.68).ConclusionThis study demonstrates a marked increase in risk of dementia associated with TBI among middle-aged and elderly people with T1D. Given the complexity of self-care for individuals with T1D, and the comorbidities that predispose them to trauma and falls, future work is needed on interventions protecting brain health in this vulnerable population, which is now living to old age.

Language barriers in healthcare are associated with worse glycemic control among Latino patients with limited English proficiency and diabetes. We examined the association of patient-physician language concordance with lipid (low-density lipoprotein cholesterol [LDL-C]) and systolic blood pressure (SBP) control.Retrospective cohort study.Data were obtained from a survey and the electronic health records of Latino and white patients with diabetes receiving care within 1 integrated health plan with interpreter services available. Limited English proficiency and patient-physician language concordance were defined by patient report. Outcomes were poor lipid control (LDL-C100 mg/dL) and poor SBP control (SBP140 mm Hg).In total, 3463 Latino (2921 who spoke English and 542 who were limited English proficient [LEP]) and 3896 English-speaking white patients participated. One-third of the patients had poor lipid control and one-fifth had poor SBP control. English-speaking white patients were slightly less likely to have poor lipid control than English-speaking Latino patients, but the difference did not persist after adjustment for age and sex. Among Latinos, LEP patients were less likely to have poor lipid control than English-speaking patients (odds ratio, 0.71; 95% CI, 0.54-0.93), with no difference by LEP patient-physician language concordance. Poor SBP control did not differ by ethnicity, primary language, or patient-physician language concordance.We found no evidence that ethnicity or language barriers in healthcare were associated with poorer lipid or blood pressure control among Latino and white patients with diabetes receiving care in settings with professional interpreters.

Limited health literacy is a barrier to optimal healthcare delivery and outcomes. Current measures requiring patients to self-report limitations are time-consuming and may be considered intrusive by some. This makes widespread classification of patient health literacy challenging. The objective of this study was to develop and validate “literacy profiles” as automated indicators of patients’ health literacy to facilitate a non-intrusive, economic and more comprehensive characterization of health literacy among a health care delivery system’s membership. To this end, three literacy profiles were generated based on natural language processing (combining computational linguistics and machine learning) using a sample of 283,216 secure messages sent from 6,941 patients to their primary care physicians. All patients were participants in Kaiser Permanente Northern California’s DISTANCE Study. Performance of the three literacy profiles were compared against a gold standard of patient self-reported health literacy. Associations were analyzed between each literacy profile and patient demographics, health outcomes and healthcare utilization. T-tests were used for numeric data such as A1C, Charlson comorbidity index and healthcare utilization rates, and chi-square tests for categorical data such as sex, race, poor adherence and severe hypoglycemia. Literacy profiles varied in their test characteristics, with C-statistics ranging from 0.61–0.74. Relations between literacy profiles and health outcomes revealed patterns consistent with previous health literacy research: patients identified via literacy profiles indicative of limited health literacy: (a) were older and more likely of minority status; (b) had poorer medication adherence and glycemic control; and (c) exhibited higher rates of hypoglycemia, comorbidities and healthcare utilization. This represents the first successful attempt to employ natural language processing to estimate health literacy. Literacy profiles can offer an automated and economical way to identify patients with limited health literacy and greater vulnerability to poor health outcomes.

IMPORTANCE: Among older individuals with type 2 diabetes, those with poor health have greater risk and derive less benefit from tight glycemic control with insulin. OBJECTIVE: To examine whether insulin treatment is used less frequently and discontinued more often among older individuals with poor health compared with those in good health. DESIGN, SETTING, AND PARTICIPANTS: This longitudinal cohort study included 21 531 individuals with type 2 diabetes followed for up to 4 years starting at age 75 years. Electronic health record data from the Kaiser Permanente Northern California Diabetes Registry was collected to characterize insulin treatment and glycemic control over time. Data were collected from January 1, 2009, through December 31, 2017, and analyzed from February 2, 2018, through June 30, 2019. EXPOSURES: Health status was defined as good (2 comorbidities or 2 comorbidities and no self-reported weekly exercise), or poor (having end-stage pulmonary, cardiac, or renal disease; diagnosis of dementia; or metastatic cancer). MAIN OUTCOMES AND MEASURES: Insulin use prevalence at age 75 years and discontinuation among insulin users over the next 4 years (or 6 months prior to death if

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating – frequencies of eating meals with others, meals prepared at home, and meals outside the home – are associated with nutrient intake. Because diet improvement can reduce complications of diabetes mellitus, we surveyed a multi-ethnic cohort of persons with type 2 diabetes (n = 770) about social aspects of diet (based on 24-hour recalls). Sex-stratified multiple regression analyses adjusted for confounders assessed the relationship between frequency of eating with others and nutrient intake (total energy, energy from fat, energy from carbohydrates, Healthy Eating Index/HEI, Dietary Approaches to Stop Hypertension/DASH score). Although there was slight variation in men's versus women's propensity to share meals, after adjustment for confounders, there was no consistently significant association between meals with others and the 5 nutrient intake measures for either men or women. The directions of association between categories of eating with others and diet quality (HEI and DASH scores) – albeit not significant – were different for men (positive) and women (mostly negative), which warrants further investigation. The next analyses estimated nutrient intake associated with meals prepared at home, and meals consumed outside the home. Analyses indicated that greater meal frequency at home was associated with significantly better scores on diet quality indices for men (but not women), while meal frequency outside the home was associated with poorer diet quality and energy intake for women (but not men). Better measurement of social dimensions of eating may inform ways to improve nutrition, especially for persons with diabetes for whom diet improvement can result in better disease outcomes.

Purpose To assess the relation between diabetic retinopathy (DR) severity, duration of diabetes, insulin dependence, and preoperative hemoglobin A1c (HbA1c) with visual outcome after phacoemulsification for cataract in patients with type 2 diabetes. Setting Kaiser Permanente Northern California, USA. Design Retrospective case series. Methods Information was obtained from the electronic medical record for patients, June 1, 2010, through May 31, 2015. Confounding factors and clustering of eyes within patients were controlled for using linear mixed-effects regression models for continuous outcomes and general estimating equations for dichotomous outcomes. Results The study included 65 370 patients; 28% had type 2 diabetes without DR, 5% nonproliferative DR, and 1.2% proliferative DR. Patients with diabetes and no DR were as likely as those without diabetes to achieve a corrected distance visual acuity (CDVA) of 20/20 (odds ratio, 1.01; 95% confidence interval, 0.94-1.10). The odds of a postoperative CDVA of 20/25 or worse increased with the severity of retinopathy duration of diabetes and insulin dependence, but not with the preoperative HbA1c. Although the odds of a postoperative CDVA of 20/20 was lower in patients with DR, every DR group averaged 4 lines of CDVA improvement, the same as patients without diabetes. A longer duration of diabetes, insulin dependence, and elevated HbA1c were not associated with worse postoperative outcomes. Conclusion Patients with DR and cataracts were less likely to achieve a CDVA of 20/20 vision but gained as many lines of CDVA from phacoemulsification as patients without diabetes, showing no evidence that cataract surgery should be delayed in diabetic patients with elevated HbA1c.

Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between mail order pharmacy (MOP) and better medication adherence, but little is known about the barriers and facilitators to MOP use in diabetes patients. This qualitative study examined factors related to use of MOP vs. traditional pharmacies to obtain prescription medications. We conducted four 90-minute focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred pharmacy use and perceptions of barriers and facilitators of MOP use. One researcher independently coded each focus group transcript, with two transcripts double-coded by an additional researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. The average age of participants was 64.1; 57% were female; 21% were Asian; 21% were black/African-American; 7% were Hispanic/Latino, and 14% were Native Hawaiian/Pacific Islander. Analysis uncovered 26 themes related to the decision to use MOP for dispensing medications. Most themes (18 out of 26) fell into the COM-B category of ’Opportunity.’ Barriers to MOP use included unpredictability of medication delivery date, concerns about mail security, and difficulty of coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Receiving a MOP incentive of free one-month supply of prescriptions was a motivational facilitator to using MOP for delivering medications. These findings can be used to design interventions and quality improvement initiatives to increase MOP usage and improve medication adherence in diabetes patients across health care systems. Disclosure J. Schmittdiel: None. C. Marshall: None. D. Wiley: None. C.V. Chau: None. C.M. Trinacty: None. J.F. Wharam: None. O. Duru: None. A.J. Karter: None. K. Estacio: None. S. Brown: None.

In clinical trial populations, long-acting insulin analogs modestly reduce the risk of nocturnal hypoglycemia compared with neutral protamine Hagedorn (NPH) in type 2 diabetes, but cost 2-4 times more. In real-world clinical practice, insulin performance may vary due to greater heterogeneity of patient characteristics and behaviors. To compare rates of severe hypoglycemia and changes in glycemic control associated with insulin analogs vs. NPH, we conducted a propensity-score matched cohort analysis using data from Kaiser Permanente Northern California (20to 2015). We included patients with type 2 diabetes if they started a long-acting insulin analog or NPH, and we censored follow-up at death, loss of health plan coverage, change in type of insulin used, change in sulfonylurea treatment, or end of follow-up. Main outcomes were time to hypoglycemia-related utilization (emergency department visit or hospitalization with a primary or principal discharge diagnosis of hypoglycemia) and change in hemoglobin A1c within 1 year of insulin initiation. Among 1,928 patients with type 2 diabetes who started insulin analogs and 23,561 who started NPH, there were 31 and 319 hypoglycemic events, respectively. After propensity score matching, the hazard ratio for severe hypoglycemia associated with insulin analog use was 0.95 (95% CI, 0.57, 1.46) and did not change significantly after additional adjustment for prior severe hypoglycemia and time-dependent diabetes medication use (HR 0.97, 95% CI 0.58, 1.54). Hemoglobin A1c decreased from 9.4% to 8.1% after initiation of insulin analogs and from 9.4% to 7.9% after initiation of NPH (difference-in-difference -0.19% (95% CI, -0.06, -0.34)). In real-world clinical practice, the use of basal insulin analogs is not associated with a substantial reduction in hypoglycemia-related utilization or improvement in glycemic control compared with NPH insulin. Disclosure K.J. Lipska: Other Relationship; Self; Centers for Medicare and Medicaid Services. Research Support; Self; National Institutes of Health. M.M. Parker: Research Support; Self; Eli Lilly and Company. H.H. Moffet: Research Support; Self; Regeneron Pharmaceuticals, Inc., AstraZeneca. E. Huang: None. A.J. Karter: None.

OBJECTIVE To examine for a legacy effect of early glycemic control on diabetic complications and death. RESEARCH DESIGN AND METHODS This cohort study of managed care patients with newly diagnosed type 2 diabetes and 10 years of survival (1997–2013, average follow-up 13.0 years, N = 34,737) examined associations between HbA1c RESULTS Compared with HbA1c CONCLUSIONS Among patients with newly diagnosed diabetes and 10 years of survival, HbA1c levels ≥6.5% (≥48 mmol/mol) for the 1st year after diagnosis were associated with worse outcomes. Immediate, intensive treatment for newly diagnosed patients may be necessary to avoid irremediable long-term risk for diabetic complications and mortality.

Background: The American Heart Association (AHA) introduced the concept of cardiovascular health (CVH) and defined “ideal,” “intermediate,” and “poor” CVH categories for adults based on cardiovascular disease risk factors and health behaviors. We sought to examine the association between these levels of CVH and incident atherosclerotic cardiovascular disease (ASCVD) events in a large diverse population. Methods: In a large integrated healthcare delivery system in Northern California , we gathered 6 AHA metrics (smoking status, physical activity, body mass index, blood pressure, total cholesterol, and blood glucose) during 2013-2014, graded on a scale of 0 to 2, with 2 indicating "ideal" status, 1 "intermediate" status, and 0 "poor" status. Points were summed to define three categories of Poor (0-6), Intermediate (7-9) and Ideal (10-12) CVH. ASCVD was defined as non-fatal myocardial infarction (MI), fatal coronary heart disease (CHD) and fatal and non-fatal stroke from electronic medical records and state death certificates during 2015. Incident ASCVD rates per 100,000 person-years were calculated. Results: Among 1,103,583 adult members (55.5% female) receiving outpatient care with all 6 metrics, there were 194,957 (17.7%) age 18-39, 585,449 (53.0%) age 40-64, and 323,177 (29.3%) age >65 years. There were 74,737 (6.8%) Blacks, 171,058 (15.5%) Hispanics and 225,303 (20.4%) Asian/Pacific Islanders. Poor CVH was present in 240,831 (21.8%), Intermediate in 584,013 (52.9%) and Ideal CVH in 278,739 (25.3%). During 2015, incidence of overall ASCVD, CHD (non-fatal MI and fatal CHD) and stroke (fatal and non-fatal stoke) was lower with better CVH metrics (p < 0.0001 for trend) (Figure). Conclusions: In a diverse “real world” population, a significantly lower incident of ASCVD was noted among individuals with Ideal CVH. This indicates continued need for large scale efforts to track and improve cardiovascular risk factors and behaviors.

We appreciate the opportunity to discuss our work (1) further in response to Hulman et al. (2). While we understand and appreciate their four concerns, we respectfully disagree with their interpretation of our work and stand by our analytic approach and conclusions. One major concern was that the results were biased because we conditioned study inclusion on survival of 10 years. While we agree that conditioning on survival would be a concern if we were generalizing results to all patients with diabetes, we clearly specified that our results only apply to patients who survive a minimum of 10 years. It was necessary to condition the study population on some minimum years of survival because one must …

Background— Examining trends in cardiovascular events and mortality in US health systems can guide the design of targeted clinical and public health strategies to reduce cardiovascular events and mortality rates. Methods and Results— We conducted an observational cohort study from 2005 to 2011 among 1.25 million diabetic subjects and 1.25 million nondiabetic subjects from 11 health systems that participate in the Surveillance, Prevention and Management of Diabetes Mellitus (SUPREME-DM) DataLink. Annual rates (per 1000 person-years) of myocardial infarction/acute coronary syndrome ( International Classification of Diseases-Ninth Revision , 410.0–410.91, 411.1–411.8), stroke ( International Classification of Diseases-Ninth Revision , 430–432.9, 433–434.9), heart failure ( International Classification of Diseases-Ninth Revision , 428–428.9), and all-cause mortality were monitored by diabetes mellitus (DM) status, age, sex, race/ethnicity, and a prior cardiovascular history. We observed significant declines in cardiovascular events and mortality rates in subjects with and without DM. However, there was substantial variation by age, sex, race/ethnicity, and prior cardiovascular history. Mortality declined from 44.7 to 27.1 ( P P =0.03) for those with DM only, and from 18.9 to 13.0 ( P P =0.10) and stroke rates (1.6–1.6; P =0.77) did not decline and heart failure rates increased (0.9–1.15; P =0.0005). Conclusions— To sustain improvements in myocardial infarction, stroke, heart failure, and mortality, health systems that have successfully focused on care improvement in high-risk adults with DM or CVD must broaden their improvement strategies to target lower risk adults who have not yet developed DM or CVD.

Objective To examine self-reported financial strain in relation to pharmacy utilization adherence data. Data sources/study setting Survey, administrative, and electronic medical data from Kaiser Permanente Northern California. Study design Retrospective cohort design (2006, n = 7,773). Data collection/extraction methods We compared survey self-reports of general and medication-specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models. Principal findings Eight percent and 9 percent reported general and medication-specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04-1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07-1.66); and medication-specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09-1.84). Conclusions Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.

© 2015, Academy of Managed Care Pharmacy. BACKGROUND: With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. OBJECTIVE: To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes. METHODS: We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a nonprofit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English- , Cantonese- , or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). For validity, we examined unadjusted associations of suboptimal adherence (CMG > 20%) with suboptimal cardiometabolic control. RESULTS: 429 members (63%) had calculable CMG. Compared with members without CMG, members with CMG were younger, more likely employed, and had poorer glycemic control but had better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, P = 0.02). CONCLUSIONS: CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable with its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG.

The Center for Medicare and Medicaid Services (CMS) uses its Medicare STAR program to monitor and reward the quality of care in health plans with Medicare Advantage enrollees, and provides substantial incentives to health plans that perform well on its Medicare STAR metrics.1 In 2012, CMS introduced 3 new Medicare STAR metrics to measure medication adherence for cardiovascular disease (CVD) risk factor medications: angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ACEI/ARBs) to control hypertension; statins to control LDL-cholesterol; and oral antihyperglycemics to control glycosylated hemoglobin (HbA1c). The implementation of these new measures emphasizes the responsibility of health plans to monitor and improve medication adherence in their Medicare populations.2,3 Overall performance on these Medicare STAR measures is highly dependent on the adherence of patients with diabetes, who account for almost all oral antihyperglycemic use and much antihypertensive and statin use.4–6 Most research on medication adherence to these CVD risk factor medications has focused on younger populations,7–11 and there is limited information on the correlates of adherence in diabetes patients aged 65 and older.10 Medication adherence research traditionally focuses on patient-level characteristics such as age and sex,7–12 despite the fact that patient characteristics have limited ability to predict adherence.13 In contrast, interventions focused on health care system-level characteristics may hold the most hope for improving appropriate CVD risk factor medication use at the population level,2,14–16 as these characteristics are modifiable through health care benefit and policy changes. Despite the potential for system-level interventions to improve adherence in high-risk patients, the system-level correlates of adherence to CVD risk factor medications in Medicare-aged diabetes patients, and their combined effect on adherence levels, are largely unknown. The purpose of this study is to examine the relationship between Medicare STAR medication adherence metrics and modifiable health system-level characteristics in a cohort of Medicare-aged diabetes patients.

OBJECTIVE The objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking. RESEARCH DESIGN AND METHODS Study subjects included 859,617 adults with diabetes enrolled for more than 6 months during 2005–2011 in a network of 11 U.S. integrated health care organizations. Inadequate risk factor control was classified as LDL-C ≥100 mg/dL, A1C ≥7% (53 mmol/mol), BP ≥140/90 mm Hg, or smoking. Major CV events were based on primary hospital discharge diagnoses for myocardial infarction (MI) and acute coronary syndrome (ACS), stroke, or heart failure (HF). Five-year incidence rates, rate ratios, and average attributable fractions were estimated using multivariable Poisson regression models. RESULTS Mean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD. CONCLUSIONS Additional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.

CONTEXT: Prediabetes is prevalent and significantly increases lifetime risk of progression to type 2 diabetes. This review summarizes the evidence surrounding metformin use for type 2 diabetes prevention. EVIDENCE ACQUISITION: Articles published between 1998 and 2017 examining metformin use for the primary indication of diabetes prevention available on MEDLINE. EVIDENCE SYNTHESIS: Forty articles met inclusion criteria and were summarized into four general categories: (1) RCTs of metformin use for diabetes prevention (n=7 and n=2 follow-up analyses), (2) observational analyses examining metformin use in heterogeneous subgroups of patients with prediabetes (n=9 from the Diabetes Prevention Program, n=1 from the biguanides and the prevention of the risk of obesity [BIGPRO] trial), (3) observational analyses examining cost effectiveness of metformin use for diabetes prevention (n=11 from the Diabetes Prevention Program, n=1 from the Indian Diabetes Prevention Program), and (4) real-world assessments of metformin eligibility or use for diabetes prevention (n=9). Metformin was associated with reduced relative risk of incident diabetes, with the strongest evidence for use in those at highest risk (i.e., aged

Optimal cardiovascular risk factors control among individuals with diabetes remains a challenge. We evaluated changes in glucose, lipid, and blood pressure control among diabetes patients after implementation of a large-scale population management program, known as Preventing Heart Attacks and Strokes Everyday, at Kaiser Permanente Northern California (KPNC), during 2004-2013.We used National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set cut points to identify prevalence of poor glycemic (hemoglobin A1c 9%) control, good lipid control (low-density lipoprotein cholesterol 100 mg/dL), and good blood pressure control (blood pressure 140/90 mm Hg) in each year (N range = 98,345 to 122,177 over the entire period). We assessed trends in risk factor control based on Joinpoint regression and average annual percentage change (AAPC) compared with published National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set commercial rates.We found that the prevalence of poor glycemic control (hemoglobin A1c 9%) declined in both KPNC and nationally, but was statistically significant only in KPNC (AAPC = -4.8; P .05). The prevalence of good lipid control (low-density lipoprotein cholesterol 100 mg/dL) increased significantly in KPNC (47% to 71%; AAPC = +4.3; P .05), but there was no significant improvement nationally (40% to 44%; AAPC = +1.4; P = .2). The prevalence of blood pressure control (140/90 mm Hg) was higher in KPNC (77% to 82%; AAPC = +1.1; P .05) versus nationally (57% to 62%; AAPC = +1.9; P .05) during the reported years 2007-2013.Relative to national benchmarks, a substantially greater improvement in risk factor control among adults with diabetes was observed after implementation of a comprehensive population management program.

Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable.To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D.Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D.Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records.Hypoglycemia-related ED or hospital use during 12 months of follow-up.The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (5%), intermediate (1%-5%), or low (1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79).This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.

Amy M Bauer,1 Melissa M Parker,2 Howard H Moffet,2 Dean Schillinger,3,4 Nancy E Adler,5 Alyce S Adams,2 Julie A Schmittdiel,2 Wayne J Katon,1,† Andrew J Karter2 1Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, 2Kaiser Permanente Northern California, Oakland, 3Division of General Internal Medicine, University of California, San Francisco, 4Center for Vulnerable Populations, San Francisco General Hospital and Trauma Center, 5Department of Psychiatry and Pediatrics, Center for Health and Community, University of California, San Francisco, CA, USA †Dr Wayne J Katon passed away on March 1, 2015 Objective: Among adults with diabetes, depression is associated with poorer adherence to cardiometabolic medications in ongoing users; however, it is unknown whether this extends to early adherence among patients newly prescribed these medications. This study examined whether depressive symptoms among adults with diabetes newly prescribed cardiometabolic medications are associated with early and long-term nonadherence. Patients and methods: An observational follow-up of 4,018 adults with type 2 diabetes who completed a survey in 2006 and were newly prescribed oral antihyperglycemic, antihypertensive, or lipid-lowering agents within the following year at Kaiser Permanente Northern California was conducted. Depressive symptoms were examined based on Patient Health Questionnaire-8 scores. Pharmacy utilization data were used to identify nonadherence by using validated methods: early nonadherence (medication never dispensed or dispensed once and never refilled) and long-term nonadherence (new prescription medication gap [NPMG]: percentage of time without medication supply). These analyses were conducted in 2016. Results: Patients with moderate-to-severe depressive symptoms had poorer adherence than nondepressed patients (8.3% more patients with early nonadherence, P=0.01; 4.9% patients with longer NPMG, P=0.002; 7.8% more patients with overall nonadherence [medication gap >20%], P=0.03). After adjustment for confounders, the models remained statistically significant for new NPMG (3.7% difference, P=0.02). There was a graded association between greater depression severity and nonadherence for all the models (test of trend, P

Enrollment in high-deductible health plans is increasing out-of-pocket spending. But innovative plans that pair deductibles with value-based insurance designs can help preserve low-cost access to high-value treatments for patients by aligning coverage with clinical value. Among adults in high-deductible health plans who were prescribed medications for chronic conditions, we examined what impact a value-based pharmacy benefit that offered free chronic disease medications had on medication adherence. Overall, we found that the value-based plan offset reductions in medication adherence associated with switching to a deductible plan. The value-based plan appeared particularly beneficial for patients who started with low levels of medication adherence. Patients with additional clinical complexity or vulnerable populations living in neighborhoods with lower socioeconomic status, however, did not show adherence improvements and might not be taking advantage of value-based insurance design provisions. Additional efforts may be needed to educate patients about their nuanced benefit plans to help overcome initial confusion about these complex plans.

ImportanceMedication adherence is essential to diabetes care. Patient-physician language barriers may affect medication adherence among Latino individuals.ObjectiveTo determine the association of patient race/ethnicity, preferred language, and physician language concordance with patient adherence to newly prescribed diabetes medications.Design, setting, and participantsThis observational study was conducted from January 1, 2006, to December 31, 2012, at a large integrated health care delivery system with professional interpreter services. Insured patients with type 2 diabetes, including English-speaking white, English-speaking Latino, or limited English proficiency (LEP) Latino patients with newly prescribed diabetes medication.ExposuresPatient race/ethnicity, preferred language, and physician self-reported Spanish-language fluency.Main outcomes and measuresPrimary nonadherence (never dispensed), early-stage nonpersistence (dispensed only once), late-stage nonpersistence (received ≥2 dispensings, but discontinued within 24 months), and inadequate overall medication adherence (>20% time without sufficient medication supply during 24 months after initial prescription).ResultsParticipants included 21 878 white patients, 5755 English-speaking Latino patients, and 3205 LEP Latino patients with a total of 46 131 prescriptions for new diabetes medications. Among LEP Latino patients, 50.2% (n = 1610) had a primary care physician reporting high Spanish fluency. For oral medications, early adherence varied substantially: 1032 LEP Latino patients (32.2%), 1565 English-speaking Latino patients (27.2%), and 4004 white patients (18.3%) were either primary nonadherent or early nonpersistent. Inadequate overall adherence was observed in 1929 LEP Latino patients (60.2%), 2975 English-speaking Latino patients (51.7%), and 8204 white patients (37.5%). For insulin, early-stage nonpersistence was 42.8% among LEP Latino patients (n = 1372), 34.4% among English-speaking Latino patients (n = 1980), and 28.5% among white patients (n = 6235). After adjustment for patient and physician characteristics, LEP Latino patients were more likely to be nonadherent to oral medications and insulin than English-speaking Latino patients (relative risks from 1.11 [95% CI, 1.06-1.15] to 1.17 [95% CI, 1.02-1.34]; P .28).Conclusions and relevanceNonadherence to newly prescribed diabetes medications is substantially greater among Latino than white patients, even among English-speaking Latino patients. Limited English proficiency Latino patients are more likely to be nonadherent than English-speaking Latino patients independent of the Spanish-language fluency of their physicians. Interventions beyond access to interpreters or patient-physician language concordance will be required to improve medication adherence among Latino patients with diabetes.

In a comment (1) on our article in Diabetes Care (2), Dr. Philip Home posits that the association of severe hypoglycemic events with other medical conditions and the use of diagnoses from hospitalized patients could explain the high event rate noted in our study compared with other reports based in the …

OBJECTIVE To estimate the incidence of remission in adults with type 2 diabetes not treated with bariatric surgery and to identify variables associated with remission. RESEARCH DESIGN AND METHODS We quantified the incidence of diabetes remission and examined its correlates among 122,781 adults with type 2 diabetes in an integrated healthcare delivery system. Remission required the absence of ongoing drug therapy and was defined as follows: 1) partial: at least 1 year of subdiabetic hyperglycemia (hemoglobin A1c [HbA1c] level 5.7–6.4% [39–46 mmol/mol]); 2) complete: at least 1 year of normoglycemia (HbA1c level RESULTS The incidence density (remissions per 1,000 person-years; 95% CI) of partial, complete, or prolonged remission was 2.8 (2.6–2.9), 0.24 (0.20–0.28), and 0.04 (0.01–0.06), respectively. The 7-year cumulative incidence of partial, complete, or prolonged remission was 1.47% (1.40–1.54%), 0.14% (0.12–0.16%), and 0.007% (0.003–0.020%), respectively. The 7-year cumulative incidence of achieving any remission was 1.60% in the whole cohort (1.53–1.68%) and 4.6% in the subgroup with new-onset diabetes (65 years, African American race, CONCLUSIONS In community settings, remission of type 2 diabetes does occur without bariatric surgery, but it is very rare.

Mail order pharmacies (MOPs) dispense medications by mail to the patient's home, offering convenience and eliminating access barriers (e.g., time, mobility, transportation), the benefits of which may be compounded for patients using multiple medications (Choudhry et al. 2011). Currently, one-third of all chronic disease prescriptions in the United States are dispensed by mail (Wroblewski et al. 2005). We have previously demonstrated better adherence (Duru et al. 2010), better LDL-C control (Schmittdiel et al. 2011), and no substantive safety concerns (Schmittdiel et al. 2013) among diabetic patients using MOPs. Better adherence among those using MOPs has been reported in other studies as well (Devine, Vlahiotis, and Sundar 2010; Zhang et al. 2011; Visaria, Frazee, and Devine 2012). Compared to walk-in pharmacies, MOPs can also be cost-saving for the health plan, depending on differential wastage rates between the two delivery modes, the cost of increased drug utilization, and the size of any MOP incentives (Carroll et al. 2005; Carroll 2006; Valluri et al. 2007; Devine, Vlahiotis, and Sundar 2010). The World Health Organization recommends seeking effective and low-cost, structural (system-level) approaches to improving adherence as an alternative to the frequently expensive, individual-level interventions (Sabate 2003). Financial incentives for MOPs may represent such a system-level approach if they increase the use of MOPs and secondarily improve adherence and health outcomes. However, structural changes can simultaneously improve population-level quality metrics, while also increasing social inequalities in health access and outcomes. We have previously reported lower use of MOPs among minorities and those living in deprived neighborhoods (Duru et al. 2010). While MOP use has been increasing steadily over the past two decades (Carroll et al. 2005), underuse in vulnerable groups has been observed at Kaiser Permanente Northern California (KPNC) since MOPs were introduced in 1999 (unpublished data). For example, in 2000, the prevalence of MOP use was 11 percent in Latinos, 12 percent in African Americans and Filipinos, 20 percent in Asians, and 24 percent in Caucasians. A decade later, in 2010, MOP use grew considerably, but it still lagged substantially in minorities: 37 percent in Latinos and African Americans, 46 percent in Filipinos, 63 percent in Asians, and 65 percent in Caucasians. It remains unknown whether and how financial incentives might impact disparities in MOP use (Trinacty et al. 2009). We studied a natural experiment which included a pharmacy benefit change that increased cost sharing but promoted the use of MOPs by discounting medications (i.e., reducing the increase in out-of-pocket costs) if patients prepaid two copayments and refilled using MOPs. We evaluated the following: (1) the overall effect of rolling out the benefit change on subsequent uptake of MOPs for dispensing of cardiometabolic medications among patients with diabetes, and (2) whether the rollout's effect on MOP uptake was uniform across social strata (defined by ethnicity, educational attainment, household income, English proficiency, or health literacy).

Objectives To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus. Design A survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥65) and younger (18-65) adults. Setting Managed care. Participants Persons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341). Measurements The primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire. Results After controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant. Conclusion This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

© 2014, The Society of Behavioral Medicine (outside the USA). Purpose: Examine social support’s association with seven individual chronic illness self-management behaviors: two healthy “lifestyle” behaviors (physical activity, diet) and five more highly skilled and diabetes-specific (medical) behaviors (checking feet, oral medication adherence, insulin adherence, self-monitored blood glucose, primary care appointment attendance).Background: In chronic illness self-care, social support may influence some health behaviors more than others.Methods: Using cross-sectional administrative and survey data from 13,366 patients with type 2 diabetes, Poisson regression models estimated the adjusted relative risks (ARR) of practicing each behavior at higher vs lower levels of social support.Results: Higher emotional support and social network scores were significantly associated with increased ARR of both lifestyle behaviors. Both social support measures were also associated with increased ARR for checking feet. Neither measure was significantly associated with other medical behaviors.Conclusions: Findings suggest that social support diminished in importance as self-care progresses from lifestyle to more skilled “medical” behaviors.

BackgroundDepression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence.ObjectiveTo determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence.DesignObservational new prescription cohort study.SettingKaiser Permanente Northern California.PatientsOne thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010.MeasurementsExposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription).ResultsAfter adjusting for potential confounders, patients' perceived lack of shared decision-making was significantly associated with primary non-adherence (RR = 2.42, p

OBJECTIVE Although patients with type 2 diabetes have double the risk of dementia, potential racial/ethnic differences in dementia risk have not been explored in this population. We evaluated racial/ethnic differences in dementia and potential explanatory factors among older diabetic patients. RESEARCH DESIGN AND METHODS We identified 22,171 diabetic patients without preexisting dementia aged ≥60 years (14,546 non-Hispanic whites, 2,484 African Americans, 2,363 Latinos, 2,262 Asians, 516 Native Americans) from the Kaiser Permanente Northern California Diabetes Registry. We abstracted prevalent medical history (1 January 1996 to 31 December 1997) and dementia incidence (1 January 1998 to 31 December 2007) from medical records and calculated age-adjusted incidence densities. We fit Cox proportional hazards models adjusted for age, sex, education, diabetes duration, and markers of clinical control. RESULTS Dementia was diagnosed in 3,796 (17.1%) patients. Age-adjusted dementia incidence densities were highest among Native Americans (34/1,000 person-years) and African Americans (27/1,000 person-years) and lowest among Asians (19/1,000 person-years). In the fully adjusted model, hazard ratios (95% CIs) (relative to Asians) were 1.64 (1.30–2.06) for Native Americans, 1.44 (1.24–1.67) for African Americans, 1.30 (1.15–1.47) for non-Hispanic whites, and 1.19 (1.02–1.40) for Latinos. Adjustment for diabetes-related complications and neighborhood deprivation index did not change the results. CONCLUSIONS Among type 2 diabetic patients followed for 10 years, African Americans and Native Americans had a 40–60% greater risk of dementia compared with Asians, and risk was intermediate for non-Hispanic whites and Latinos. Adjustment for sociodemographics, diabetes-related complications, and markers of clinical control did not explain observed differences. Future studies should investigate why these differences exist and ways to reduce them.

Secondary prevention after an acute coronary syndrome (ACS) hospitalization is critical to prevent additional morbidity and mortality. While poor adherence to prescribed cardio-protective medications is a known problem,1,2 it is unknown whether an ACS event might motivate patients to achieve better adherence. In a large integrated health care population, we examined initiation and adherence to newly prescribed cardio-protective medications among post-ACS event patients compared to patients who were prescribed these same medications in usual care.

BackgroundAlthough many studies have shown that diabetes increases the risk for urinary incontinence, it is unclear whether poor glycemic control in women with diabetes is associated with incontinence. This study aims to determine the relationship between the hemoglobin A1c (HbA1c) level and urinary incontinence in a large, diverse cohort of older women.MethodsWe examined 6026 older women who responded to a survey (62% response rate) and were enrolled in the Diabetes and Aging Study, an ethnically stratified random sample of patients with diabetes enrolled in Kaiser Permanente Northern California. Our primary independent variable was the mean of all HbA1c measurements in the year preceding the survey. Outcomes included the presence/absence of incontinence and limitations in daily activities due to incontinence. We used modified Poisson regression and ordinal logistic regression models to account for age, race, body mass index, parity, diabetes treatment, duration of diabetes, and comorbidity.ResultsSixty-five percent of women reported incontinence (mean age 59±10 years). After adjustment, HbA1c levels were not associated with the presence or absence of incontinence. However, among women reporting incontinence, HbA1c ≥9% was associated with more limitations due to incontinence than HbA1c

OBJECTIVE We examined the association between HbA1c level and self-reported severe hypoglycemia in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Type 2 diabetic patients in a large, integrated healthcare system, who were 30–77 years of age and treated with glucose-lowering therapy, were asked about severe hypoglycemia requiring assistance in the year prior to the Diabetes Study of Northern California survey conducted in 2005–2006 (62% response rate). The main exposure of interest was the last HbA1c level collected in the year preceding the observation period. Poisson regression models adjusted for selected demographic and clinical variables were specified to evaluate the relative risk (RR) of severe hypoglycemia across HbA1c levels. We also tested whether the HbA1c-hypoglycemia association differed across potential effect modifiers (age, diabetes duration, and category of diabetes medication). RESULTS Among 9,094 eligible survey respondents (mean age 59.5 ± 9.8 years, mean HbA1c 7.5 ± 1.5%), 985 (10.8%) reported experiencing severe hypoglycemia. Across HbA1c levels, rates of hypoglycemia were 9.3–13.8%. Compared with those with HbA1c of 7–7.9%, the RR of hypoglycemia was 1.25 (95% CI 0.99–1.57), 1.01 (0.87–1.18), 0.99 (0.82–1.20), and 1.16 (0.97–1.38) among those with HbA1c CONCLUSIONS Severe hypoglycemia was common among patients with type 2 diabetes across all levels of glycemic control. Risk tended to be higher in patients with either near-normal glycemia or very poor glycemic control.

Although chronic kidney disease (CKD) is a highly prevalent condition among older adults with diabetes, the associations between health-related quality of life (HRQoL) and severity of CKD in this population are not well understood. The objective of this study was to assess HRQoL and depressive symptoms across estimated glomerular filtration rate (eGFR) stages.Cross-sectional.5,805 members of Kaiser Permanente Northern California, 60 years or older with diabetes, from the 2005-2006 Diabetes Study of Northern California (DISTANCE) survey.eGFR categories were defined as ≥90 (referent category), 75-89, 60-74, 45-59, 30-44, or ≤29 mL/min/1.73 m(2).HRQoL was measured using the modified Short Form-8 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Depressive symptoms were measured using the Patient Health Questionnaire-8.In unadjusted linear regression analyses, physical (PCS) and mental (MCS) HRQoL scores were significantly lower with worsening eGFR level. However, after adjustment for sociodemographics, diabetes duration, obesity, and cardiovascular comorbid conditions and taking into account interactions with proteinuria, none of the eGFR categories was significantly or substantively associated with PCS or MCS score. In both unadjusted and adjusted analyses, higher risk of depressive symptoms was observed in respondents with eGFR ≤29 mL/min/1.73 m(2) (relative risk, 2.02; 95% CI, 1.10-3.71; P0.05) compared with the referent group. However, this eGFR-depression relationship was no longer significant after adjusting for hemoglobin level.Participants are part of a single health care delivery system.Our findings suggest the need for greater attention to and potential interventions for depression in patients with reduced eGFR.

OBJECTIVE It is unknown whether any association between neighborhood food environment and obesity varies according to individual income and/or race/ethnicity. The objectives of this study were to test whether there was an association between food environments and obesity among adults with diabetes and whether this relationship differed according to individual income or race/ethnicity. RESEARCH DESIGN AND METHODS Subjects (n = 16,057) were participants in the Diabetes Study of Northern California survey. Kernel density estimation was used to create a food environment score for each individual’s residence address that reflected the mix of healthful and unhealthful food vendors nearby. Logistic regression models estimated the association between the modeled food environment and obesity, controlling for confounders, and testing for interactions between food environment and race/ethnicity and income. RESULTS The authors found that more healthful food environments were associated with lower obesity in the highest income groups (incomes 301–600% and >600% of U.S. poverty line) among whites, Latinos, and Asians. The association was negative, but smaller and not statistically significant, among high-income blacks. On the contrary, a more healthful food environment was associated with higher obesity among participants in the lowest-income group ( CONCLUSIONS These findings suggest that the availability of healthful food environments may have different health implications when financial resources are severely constrained.

Objectives: To explore racial and ethnic (ethnic hereafter) differences in health-related quality of life (HRQL) in older adults with diabetes mellitus in an integrated delivery system. Design: Observational cross-sectional study. Setting: Kaiser Permanente Northern California. Participants: Ethnic-stratified, random sample of 6,096 adults with diabetes mellitus aged 60 to 75 who completed a HRQL questionnaire. Measurements: Physical and mental HRQL were measured based on the Medical Outcomes Study 8-item Short Form Survey (range 0�100, mean 50). Age- and sex-adjusted weighted linear regression models estimated associations between ethnicity and HRQL and evaluated potential mediators (socioeconomic status, acculturation, health behaviors, diabetes mellitus�related conditions). Differences in ethnic-specific, adjusted mean HRQL scores were tested (reference whites). Results: Physical HRQL was better for Filipinos (48.3, 95% confidence interval (CI) = 47.0�49.6, P < .001), Asians (48.1, 95% CI = 46.8�49.3, P < .001), Hispanics (45.1, 95% CI = 44.2�46.0, P < .001), and blacks (44.2, 95% CI = 43.3�45.1, P = .04) than whites (42.9, 95% CI = 42.6�43.2). Adjusting for potential mediators did not change these relationships. Mental HRQL was better only for Asians (52.7, 95% CI = 51.6�53.7, P = .01) than for whites (51.0, 95% CI = 50.7�51.3), but this difference was small and became nonsignificant after adjustment for socioeconomic status, acculturation, health behaviors, and diabetes mellitus�related conditions. Conclusion: In older adults with diabetes mellitus in a well-established integrated healthcare delivery system, ethnic minorities had better physical HRQL than whites. Equal access to care in an integrated delivery system may hold promise for reducing health disparities in diabetes mellitus-related patient-reported outcomes.

OBJECTIVE To compare associations between neighborhood deprivation and measures of BMI change among adults with type 2 diabetes. RESEARCH DESIGN AND METHODS Using data from the Kaiser Permanente Diabetes Study of Northern California (DISTANCE) survey, we estimated the association between neighborhood deprivation and two measures of BMI change over 3 years: 1) a continuous measure and 2) a categorical measure of clinically substantive BMI loss or gain (≥7% of baseline BMI) versus stable BMI. The sample included 13,609 adults. RESULTS On average, there was little change in BMI (−0.12, SD 3.07); 17.0 and 16.1% had clinically substantive BMI loss or gain, respectively, at follow-up. There was a positive association between neighborhood deprivation and BMI change for adults in the most versus least-deprived quartile of neighborhood deprivation (β = 0.22, P = 0.02) in adjusted models. In addition, relative to the least-deprived quartile (Q1), adults in more-deprived quartiles of neighborhood deprivation were more likely to experience either substantive BMI loss (Q2 relative risk ratio 1.19, 95% CI 1.00–1.41; Q3 1.20, 1.02–1.42; Q4 1.30, 1.08–1.55) or gain (Q2 1.25, 1.04–1.49; Q3 1.24, 1.04–1.49; Q4 1.45, 1.20–1.75). CONCLUSIONS Greater neighborhood deprivation was positively associated with BMI change among adults with diabetes as well as with clinically substantive BMI loss or gain. Findings stress the importance of allowing for simultaneous associations with both gain and loss in future longitudinal studies of neighborhood deprivation and weight change, which may be particularly true for studies of patients with diabetes for whom both weight loss and gain have health implications.

Cardiovascular risk is increased in individuals with impaired glucose tolerance (IGT) and impaired fasting glucose (IFG); however, those with IGT appear to be at greater risk. Lipoprotein abnormalities occur also in the prediabetic state.The authors examined lipoprotein composition in IGT and IFG.Cross-sectional analysis of a large epidemiological study was done.The Insulin Resistance Atherosclerosis Study had a total of 1107 participants.Lipoproteins and apolipoproteins were measured by conventional methods and lipoprotein composition by nuclear magnetic resonance spectroscopy.Compared with normal glucose tolerance, apolipoprotein B (105.2 vs 99.8 mg/dL, P.05) was high in isolated IFG, triglyceride (1.48 vs 1.16 mmol/L, P.001) was high in isolated IGT, and high-density lipoprotein cholesterol was low in combined IFG/IGT (1.12 vs 1.26 mmol/L, P.001). Nuclear magnetic resonance spectroscopy revealed additional changes: increased total low-density lipoprotein (LDL) particles (1190 vs 1096 nmol/L, P.01) in isolated IFG; increased large very-low-density lipoprotein (3.61 vs 2.47 nmol/L, P.01) and small LDL subclass particles (665 vs 541 nmol/L, P.05) and decreased large LDL subclass particles (447 vs 513 nmol/L, P.01) in isolated IGT; and decreased large high-density lipoprotein subclass particles in combined IFG/IGT (4.24 vs 5.39 μmol/L, P.001).Isolated IFG is characterized by increased apolipoprotein B and total LDL particles, whereas isolated IGT is associated with increased triglycerides, large very-low-density lipoprotein subclass particles, and structural remodeling of LDL particles. These results may help to explain differences in cardiovascular disease risk in the prediabetic state.