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INTRODUCTION: Video telehealth can offer people convenient, real-time access to clinicians without arranging transportation or time off work. Among people with diabetes, this study examines the association between video telehealth access and changes in HbA1c. METHODS: This longitudinal cohort study (2016–2019) used linear regression with person-level fixed effects, stratified by baseline HbA1c (last value in 2015), to examine the association between video visit access and changes in HbA1c. HbA1c values were categorized into 3 periods of video visit exposure: (1) before any video visit, (2) video visit transition year (calendar year of the first video visit), and (3) after video visits. The model compared changes in HbA1c values collected before the patient had any video visits with those collected after the transition year. Analyses was conducted in September 2020. RESULTS: Among 204,301 people with diabetes, video visit access was associated with a statistically significant reduction of 0.15 (95% CI= −0.19, −0.11) percentage points in HbA1c, with greater reductions among patients with an elevated baseline HbA1c value (−0.22 percentage points, 95% CI= −0.32, −0.11) and with no baseline HbA1c measurement (−0.39 percentage points, 95% CI= −0.71, −0.07). CONCLUSIONS: Gaining access to video telehealth was associated with reductions in HbA1c among people with diabetes. Video telehealth offers people with chronic conditions a new, convenient way to access health care, is not associated with worsening HbA1c, and may support better disease management, particularly among patients with higher baseline HbA1c.

Background: Prediabetes disproportionally affects US Latino adolescents. However, it is unclear which characteristics or modifiable lifestyle behaviors captured in the electronic health record (EHR) are associated with prediabetes among Latino adolescents. Addressing this knowledge gap was the objective of this study. Methods: Cross-sectional data was used from 8,946 Latino adolescents ages 13-17 years in northern California with a well-child visit in 2016-20 and BMI ≥95th percentile. Characteristics and modifiable lifestyle behaviors of interest included age, gender, household language preference (English/Spanish) , neighborhood deprivation index (NDI, quartiles) , obesity class and 4 self-reported daily obesogenic behaviors captured during the visit: 1) consuming 2 hours of screen time. Prediabetes was ascertained within 1 year of the health visit and was classified as HbA1c 5.7-6.4%. Multivariate logistic regression was used to examine the association between the variables of interest and prediabetes. Results: Among 8,946 Latino adolescents with obesity, 15.4% had prediabetes. Having class 3 obesity (OR of 2.7; [95% CI: 2.3-3.1], living in a Spanish-speaking household (1.15; 1.0-1.3) and engaging in low exercise (OR 1.12; 0.99-1.3) were all independently associated with increased odds of prediabetes, though exercise was only marginally significant at a p-value Conclusion: Among Latino adolescents with obesity, 1 in 7 had prediabetes. Our findings suggest that strategies targeting obesity and promotion of physical activity, particularly among adolescents living in Spanish-speaking households, may have the most success in preventing diabetes among Latino adolescents with prediabetes. Disclosure A. Gopalan: None. M. Chandra: None. J.A. Darbinian: None. L. Greenspan: None. J.C. Lo: None. Funding The Permanente Medical Group (TPMG) Health Care Delivery and Policy Section Pilot Award. TPMG (Delivery Science Fellowship Program) . Kaiser Permanente Northern California Graduate Medical Education Research Community Benefit Program. National Institutes of Health (T32DK11668401) .

Individuals with anemias are often excluded from diabetes research when the population or outcome of interest is defined by HbA1c, as abnormal red blood cell turnover rates raise concern about the accuracy of measured HbA1c values. While racial/ethnic differences in the prevalence of certain anemias are well-known, the potential bias introduced by excluding individuals with anemias from research samples is less studied. We examined the prevalence of diagnosed anemias by race/ethnicity in a population of adults diagnosed with diabetes. Using data from a large healthcare system, we identified adults (≥21 years) diagnosed with type 2 diabetes from 2010-2016. We used ICD-9/codes to identify individuals diagnosed with anemia in the year prior to diabetes diagnosis and inherited hemoglobinopathies through follow-up. We used chi-square tests to compare the prevalence of these diagnoses by race/ethnicity. Among 78,2individuals, 5,434 (6.9%) had an anemia diagnosis in the 12 months prior to their diabetes diagnosis, with the most common being unspecified anemia (3.3%) and iron deficiency anemia (2.3%) . Black adults had the highest prevalence of any anemia (11% vs. Other race/ethnicity 8.8% vs. White 7% vs. Latino 6.1% vs. Asian 5.9%, p≤.0001) , unspecified anemia (5.4% vs. Other race/ethnicity 3.8% vs. White 3.5% vs. Latino 2.8% vs. Asian 2.4%, p≤.0001) , and iron deficiency anemia (3.6% vs. Other race/ethnicity 2.9% vs. White 2.2% vs. Latino 2.4% vs. Asian 1.9%, p≤.0001) . Black and Asian adults had the highest prevalence of inherited hemoglobinopathies (Asian 2.3% vs. Black 1.9% vs. Other race/ethnicity 1.3% vs. White 0.3% vs. Latino 0.3%, p≤.0001) . In conclusion, among adults diagnosed with diabetes, Black adults had the highest prevalence of diagnosed anemias (>1 in Black adults had a diagnosis) . Excluding individuals from diabetes research based on diagnosis of anemia may disproportionately impact the relevance of the findings to Black adults. Disclosure C.Board: None. A.Gopalan: None. A.J.Karter: Research Support; Dexcom, Inc. R.W.Grant: None. O.Sofrygin: None. Funding National Institutes of Health (1R21DK130018-01)

Background Adults diagnosed with type 2 diabetes at a younger age are at increased risk for poor outcomes. Yet, little is known about the early experiences of these individuals, starting with communication of the diagnosis. Addressing this knowledge gap is important as this initial interaction may shape subsequent disease-related perceptions and self-management. Objective We examined diagnosis disclosure experiences and initial reactions among younger adults with newly diagnosed type 2 diabetes. Participants Purposive sample of adult members of Kaiser Permanente Northern California, an integrated healthcare delivery system, diagnosed with type 2 diabetes before age 45 years. Approach We conducted six focus groups between November 2017 and May 2018. Transcribed audio recordings were coded by two coders using thematic analysis. Key Results Participants (n = 41) were 38.4 (± 5.8) years of age; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified variation in diagnosis disclosure experiences, centered on four key domains: (1) participants’ sense of preparedness for diagnosis (ranging from expectant to surprised); (2) disclosure setting (including in-person, via phone, via secure message, or via review of results online); (3) perceived provider tone (from nonchalant, to overly fear-centered, to supportive); and (4) participants’ emotional reactions to receiving the diagnosis (including acceptance, denial, guilt, and/or fear, rooted in personal and family experience). Conclusions For younger adults, the experience of receiving a diabetes diagnosis varies greatly. Given the long-term consequences of inadequately managed diabetes and the need for early disease control, effective initial disclosure represents an opportunity to optimize initial care. Our results suggest several opportunities to improve the type 2 diabetes disclosure experience: (1) providing pre-test counseling, (2) identifying patient-preferred settings for receiving the news, and (3) developing initial care strategies that acknowledge and address the emotional distress triggered by this life-altering, chronic disease diagnosis. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-020-06481-y.

Non-alcoholic fatty liver disease (NAFLD) disproportionally affects US children of Latino descent, who also have a higher burden of obesity and type 2 diabetes. We previously found significant associations between diet and sedentary behaviors and weight status, but it is unclear if these measured behaviors are associated with suspected NAFLD among Latino adolescents with obesity, which was the objective of this study. We used cross-sectional data from 10,087 Latino adolescents ages 13-17 years in northern California with a well-child visit in 2016-2019, health behavior assessment, and BMI ≥95th percentile. Adolescents self-reported on 4 daily obesogenic behaviors at the visit: 1) consuming 2 hours of screen time. Suspected NAFLD was classified by serum alanine transaminase level ≥44 U/L (girls) and ≥52 U/L (boys). We used logistic regression to examine the associations of obesogenic behaviors with NAFLD, adjusting for age, gender, household language preference (English/Spanish), neighborhood deprivation index (quartiles), and Class 1, 2, and 3 obesity. Among 10,087 Latino adolescents with obesity, 88% (8,877) had ≥1 obesogenic behaviors and 10% (1012) had suspected NAFLD. None of the obesogenic behaviors were associated with NAFLD in unadjusted or adjusted models. Boys (vs girls) had higher odds of NAFLD (OR 2.2; 95% CI: 1.9-2.5), as did older adolescents (ages 16-17 vs 13-15, OR 1.7; 1.5-1.9) and those with more severe obesity (OR 2.2; 1.9-2.5, and OR 3.0; 2.5-3.6 for Class 2 and 3 (vs Class 1) obesity, respectively). In summary, older age, male gender and severe obesity were risk factors for suspected NAFLD while binary assessment of diet and sedentary behaviors were not, suggesting that more precise diet and exercise assessment tools are needed. The high burden of obesogenic behaviors and strong association of severe obesity with NAFLD point to important actionable targets for pediatric primary care.

Introduction: Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Methods: Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco9s public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM). Results: Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients9 self-management. Health service providers leveraged these resources to address patients9 social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. Conclusion: The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

Adults diagnosed with type 2 diabetes (T2D) at a younger age are at increased risk for poor outcomes. We examined how family history of diabetes shaped the experiences and self-management perspectives of younger-onset individuals newly diagnosed with T2D. We conducted six focus groups between Nov 2017 and May 2018. Participants (n=41) were members of an integrated healthcare delivery system, had been diagnosed with T2D during the prior two years, and were 21-44 years old at the time of diagnosis. Each group met twice for 60-90 minutes, two weeks apart. Groups were led by an experienced facilitator, audio-recorded, transcribed verbatim, and coded by two reviewers using thematic analysis. The average age of participants was 38.4 years (±5.8 years); 20 were women, 10 self-identified as Latinx, 12 as Black, 12 as White and 7 as multiple or other races. Over 65% had a family history of T2D. Having a family member with T2D facilitated self-management in several ways. First, personal familiarity with T2D and related lifestyle changes, as well as advice from older relatives, led individuals to feel that they were capable of modifying behaviors and made adjusting to the diagnosis easier. In addition, family members with T2D served as both positive and negative role models that motivated individuals to adapt relatives’ health-promoting behaviors and take steps to avoid adverse outcomes. Conversely, for some, the perception that T2D diagnosis was inevitable was a barrier to initial self-care. Perceived lack of control over developing T2D due to family history of the disease led to feelings of self-blame and futility regarding self-management efforts. Our results highlight the importance of recognizing how familial experiences impact patients’ ability to navigate a new T2D diagnosis. Proactively addressing perceived barriers to and facilitators of self-management in the context of family T2D history may aid in efforts to educate and support high-risk, younger patients establish a trajectory towards improved health. Disclosure M. A. Blatchins: None. K. Xu: None. A. Altschuler: None. R. W. Grant: None. A. Gopalan: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK116968); Kaiser Permanente Northern California

The disclosure of a new type 2 diabetes (T2D) diagnosis shapes patients’ T2D-related experiences, with more supportive approaches linked with better self-care and lower diabetes distress. Given changes in patient-provider communication and greater use of telemedicine, we examined the setting of T2D disclosures among adults in a large, integrated healthcare delivery system. Physicians reviewed charts of a random sample of 200 adults diagnosed with T2D between 2014-2018 to determine the diagnosis disclosure setting. Identified settings were an in-person visit, telemedicine visit (telephone/video), secure message via the online patient portal, mailed letter, or voicemail. These settings were further categorized into 2-way synchronous communication (in-person/telemedicine), 2-way asynchronous communication (secure message), and 1-way asynchronous communication (letter/voicemail). We examined differences in disclosure setting by patient demographics. The disclosure setting was discernible for 197/200 individuals; 55.3% received the diagnosis via 2-way synchronous communication (25.4% in-person, 29.9% telemedicine), 23.9% via 2-way asynchronous communication, and 20.8% via 1-way asynchronous communication (18.8% letter, 2% voicemail). Disclosure setting did not differ by age, gender, or level of neighborhood deprivation. Latinx individuals were overrepresented among those receiving the diagnosis via 1-way asynchronous communication (42.5% vs. 17.1% 2-way synchronous vs. 8.7% 2-way asynchronous, p=0.001) and had lower online patient portal enrollment (59%). The heterogeneity in T2D diagnosis disclosure setting suggests a lack of standard practices for communicating a T2D diagnosis. The common use of asynchronous modalities is concerning given the gravity of the diagnosis, especially when established best practices for communicating bad news to patients exist. Disclosure K. Gu: None. C. Gong: None. M. A. Blatchins: None. P. Mishra: None. R. W. Grant: None. A. Gopalan: None. Funding Kaiser Permanente Northern California

Metformin is the first line treatment for type 2 diabetes (T2D). While earlier initiation is associated with achievement of glycemic targets and a delayed need for treatment escalation, metformin initiation and adherence remain suboptimal. We explored contributors to suboptimal metformin initiation and adherence during the year following a T2D diagnosis. From a population of adults diagnosed with T2D between 2014-2018, we randomly identified 100 individuals who were prescribed metformin during the year after diagnosis (starters) and 100 who were not (non-starters). Through physician review of electronic health record (EHR) notes from the year following diagnosis, we explored patient-provider discussions about metformin, reasons metformin was or was not ordered, and reasons for discontinuation. Metformin starters were younger (mean age 53.8 vs. 60.0 years, p In conclusion, among metformin starters, efforts to mitigate side effects, including titration strategies or long-acting formulations, may improve metformin adherence. For most non-starters, there was no documented discussion regarding metformin. Strategies that prompt providers to have this important discussion may increase early initiation of this critical medication. Disclosure C. Gong: None. K. Gu: None. M. A. Blatchins: None. P. Mishra: None. R. W. Grant: None. A. Gopalan: None. Funding Kaiser Permanente Northern California

The prevalence of type 2 diabetes (T2D) is increasing among individuals younger than 45 years, who are at an increased risk of T2D-related complications, making the lasting benefits conferred by early glycemic control particularly critical. The ability to proactively identify these younger-onset individuals at increased risk of inadequate early glycemic control could support more targeted and tailored initial care. The study sample was randomly split into training (70%) and validation (30%) sets to develop and test the model. We used logistic LASSO (Least Absolute Shrinkage and Selection Operator) regression to identify predictors of inadequate glycemic control (HbA1c ≥8%) at 1-year following diagnosis among adults ages 21-44. Potential predictors were assessed at diagnosis. We used terciles of predicted risk to stratify our cohort into low (LR), intermediate (IR) and high-risk (HR) groups and compared characteristics between them using chi-square and ANOVA tests. Of the 10,897 individuals with new T2D, the mean age was 37.9 ± 5.3 years and 33% were Latinx. The LASSO model selected 46 out of 97 candidate variables. The resulting model yielded a c-statistic of 0.73 and had good calibration. We observed differences in socioeconomic, clinical, and care utilization characteristics between the risk groups. Those in high-risk group were more likely to be Latinx (45% HR vs. 30% IR vs. 27% LR, p Disclosure P. Mishra: None. S. Alexeeff: None. R. W. Grant: None. A. Gopalan: None.

Video telemedicine can offer patients direct real-time convenient access to clinicians without arranging transportation or work time-off, improving access to diabetes care and self-management support. We examined the association between video visit use and hemoglobin A1c (HbA1c) among patients with diabetes. In a longitudinal study, within a large integrated delivery system where patients were first able to self-schedule real-time physician video visits in 2016, we used the clinical registry to identify patients with diabetes (2015), and followed their video visit use and subsequent HbA1c values over time (2016-2019). Using linear regression with patient-level fixed effects (within-patient changes), adjusting for calendar year and month and time-changing patient mobile portal access, we measured the association between use of video visits as a time-changing variable and the patient’s yearly HbA1c values (in subsequent calendar years after video visit use). We then stratified analyses by baseline HbA1c value: Among 204,301 patients with diabetes, 50% were 65 years or older, 48% were women, and 45% were of white race/ethnicity. Overall, 95% of patients had a baseline HbA1c value, 24% had HbA1c values ≥8%. Patient use of video visits was associated with an overall statistically significant reduction in HbA1c value by 0.15% (95% CI: 0.11%-0.19%). Among those with baseline HbA1c values ≥8%, using video visits was associated with a HbA1c value reduction of 0.22% (95% CI: 0.12%-0.32%), and among patients with lower baseline engagement (i.e., no baseline HbA1c measurement), using video visits was associated with a HbA1c reduction of 0.39% (95% CI: 0.07%-0.71%). Use of video visit was associated with improved glycemic control among patients with diabetes, with greater improvements found among patients with worse baseline control and lower engagement. Video visits may offer convenient health care access to improve diabetes management. Disclosure M. Reed: None. A. Gopalan: None. I. Graetz: None. L. Hsueh: None. J. Huang: None. E. Muelly: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK085070)

Introduction The primary care visit is an important opportunity to discuss and modify diabetes management. Objective To gain insight into doctor-patient communication during primary care visits among English and Spanish speaking patients with type 2 diabetes and suboptimal glycemic control (HbA1c > 7%). Methods We conducted a quantitative content analysis of audiotaped primary care visits in 2 patient cohorts. In Study 1 (31 English-speaking patients), we examined factors associated with management changes, and in Study 2 (20 Spanish-speaking patients and their Spanish-speaking providers), we examined the association of question asking with HbA1c control. This study was conducted between November 2017 and January 2020 across 8 primary care practices within Kaiser Permanente Northern California. Results In Study 1, the only factor significantly associated with a diabetes management change was patient identification of diabetes as a priority prior to the visit (91.7% had a management change vs 52.6% of patients who did not identify diabetes as a priority; p = 0.02). In Study 2, patients with poorer glycemic control (HbA1c ≥ 10.0) asked significantly fewer questions (3.4 ± 1.8 vs 10.7 ± 6.9 questions per 15 minutes; p = 0.004). Overall, despite receiving primary care from language-concordant providers, Spanish-speaking Study 2 patients asked fewer questions than English-speaking Study 1 patients (4.5 ± 2.9 vs 7.5 ± 3.7 questions per 15 minutes, respectively; p = 0.004). Conclusion Our results highlight 2 potential strategies (preparing patients for their visits through identifying priorities and learning how to ask more questions during visits) for improving diabetes primary care.

Objective Cardiovascular disease (CVD) continues to be a leading cause of morbidity in the U.S. Managing CVD risk factors, such as diabetes or hypertension, can be challenging for many individuals. We investigated the barriers experienced by patients who persistently struggled to reach their CVD risk factor control goals. Methods This qualitative study examined patient, clinician, and researcher observations of individuals’ experiences in a chronic disease management program. All participants (n = 332) were enrolled in a clinical trial testing a skills-based group intervention seeking to improve healthcare engagement. Data were analyzed through a general inductive approach and resulting themes were structured along the Capability-Opportunity-Motivation-Behavior framework. Results Analyses identified care engagement barriers related to participants’ communication skills and activation, care team relationship processes, and emotional factors. Although most participants reported benefitting from skills training, persistent barriers included distrust of their providers, shame about health challenges, and dissatisfaction with care team interactions that were described as impersonal or unresponsive. Conclusions and practice implications Efforts to support engagement in CVD risk factor management programs should address whether patients and their care team have the necessary skills, opportunities and confidence to proactively communicate health needs and engage in non-judgmental interactions for goal-setting, rapport-building, and shared decision-making.

The aim of this study is to examine the association between patient characteristics and primary care telemedicine choice among integrated delivery system patients self-scheduling visits during the COVID-19 pandemic. We used multivariate logistic regression to examine the association between the choice of video versus telephone and patient sociodemographic characteristics and technology access among patient-initiated primary care telemedicine visits scheduled online from March to October 2020. Among 978 272 patient-scheduled primary care telemedicine visits, 39% were video visits. Patients of Black or Hispanic race/ethnicity, or living in low socioeconomic status or low internet access neighborhoods were less likely to schedule video visits. Patients 65 years or older, with prior video visit experience or mobile portal access, or visiting their own personal provider were more likely to schedule video visits. While video adoption was substantial in all patient groups examined, differences in telemedicine choice suggest the persistence of a digital divide, emphasizing the importance of maintaining a telephone telemedicine option.

OBJECTIVE The prevalence of type 2 diabetes is increasing among adults under age 45. Onset of type 2 diabetes at a younger age increases an individual’s risk for diabetes-related complications. Given the lasting benefits conferred by early glycemic control, we compared glycemic control and initial care between adults with younger onset (21–44 years) and mid-age onset (45–64 years) of type 2 diabetes. RESEARCH DESIGN AND METHODS Using data from a large, integrated health care system, we identified 32,137 adults (aged 21–64 years) with incident diabetes (first HbA1c ≥6.5% [≥48 mmol/mol]). We excluded anyone with evidence of prior type 2 diabetes, gestational diabetes mellitus, or type 1 diabetes. We used generalized linear mixed models, adjusting for demographic and clinical variables, to examine differences in glycemic control and care at 1 year. RESULTS Of identified individuals, 26.4% had younger-onset and 73.6% had mid-age–onset type 2 diabetes. Adults with younger onset had higher initial mean HbA1c values (8.9% [74 mmol/mol]) than adults with onset in mid-age (8.4% [68 mmol/mol]) (P < 0.0001) and lower odds of achieving an HbA1c CONCLUSIONS Adults with onset of type 2 diabetes at a younger age were less likely to achieve glycemic control at 1 year following diagnosis, suggesting the need for tailored care approaches to improve outcomes for this high-risk patient population.

This cross-sectional study assesses whether having limited English proficiency was associated with lower video use compared with telephone use, especially among patients without prior video visit experience, during the COVID-19 pandemic.

As the U.S. population ages, more older adults will be newly diagnosed with type 2 diabetes (T2D). These individuals have a greater prevalence of comorbidities placing them at increased risk for T2D-related adverse drug events. We identified adults ≥ 65 within an integrated care system with newly diagnosed T2D, defined by a first elevated A1c (≥6.5%) with no evidence of T2D prior 18 months. We examined treatment initiation (metformin, sulfonylurea [SFU], insulin) during the 5 years following diagnosis among patients with 3 treatment-sensitive comorbid conditions (chronic kidney disease [CKD], dementia, frailty) at time of diagnosis. We compared A1c levels between treatment initiators vs. non-initiators and identified independent predictors of treatment initiation using multivariate logistic models. The 4,011 older adults with new T2D had mean age 72.2 ± 6.4 years, 53% were women, 50% were non-Hispanic white. Among those with advanced CKD (≥ stage 3b, 4% of cohort), nearly one-quarter (23%) were initiated on metformin (mean A1C 8.3 ± 2.7 vs. untreated 7.3 ± 1.4 p Disclosure P. Mishra: None. A. Gopalan: None. R.W. Grant: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

The prevalence of newly diagnosed type 2 diabetes (T2D) among American adults under age 45 is increasing. Given the lasting benefits conferred by early glycemic control, we examined initial diabetes care and subsequent glycemic control at one year following diagnosis, comparing adults with early onset (21- Using data from a large, integrated care delivery system, we identified adults who had a first diabetes-defining Hemoglobin A1c value (≥6.5% “index A1c”) between Jan. 2010 and Dec. 2016, followed by clinical diagnosis of T2D (visit with T2D ICD code or T2D on problem list) within 3 months of the index A1c. We excluded anyone with evidence of prior T2D, gestational diabetes or T1D. We compared baseline characteristics by onset age using t- or chi-2 tests. Adjusting for index A1c and other patient characteristics, we used logistic regression to examine initial management and GEE models to examine glycemic control (goal A1c We identified 32,137 adults with new T2D, including 8,496 with early onset (26.4%, age 37.6 ± 5.3 years) and 23,641 with usual onset (73.6%, age 54.4 ± 5.5 years). Adults with early onset had a higher index A1c (A1c 8.9% vs. 8.4% for usual onset, p In conclusion, individuals with early onset T2D were less likely to achieve goal A1c ( Disclosure M.A. Blatchins: None. P. Mishra: None. R.W. Grant: None. A. Gopalan: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

AIMS: To examine the prevalence and person-level predictors of undiagnosed Type 2 diabetes among adults with elevated HbA(1c) values. METHODS: We identified adults without diabetes who had a first elevated HbA(1c) (index HbA(1c) ≥ 48 mmol/mol; ≥ 6.5%) between January 2014 and December 2015, and classified them by Type 2 diabetes diagnosis status at 1 year following this result. Multilevel modelling techniques were used to examine the association of individual demographic, clinical and utilization characteristics with remaining undiagnosed. We quantified differences in early Type 2 diabetes care between diagnosed and undiagnosed individuals. RESULTS: Of the 18 356 adults with a first elevated index HbA(1c), 30.2% remained undiagnosed with Type 2 diabetes 1 year later. Individuals with lower index HbA(1c) values [adjusted odds ratio (aOR) 5.95, 95% confidence interval (CI) 5.21–6.78 for 48 to < 53 mmol/mol (6.5% to 7.0%); referent 53 to < 64 mmol/mol (7.0% to

Social comparison feedback is an increasingly popular strategy that uses performance report cards to modify physician behavior. Our objective was to test the effect of such feedback on the ordering of routine laboratory tests for hospitalized patients, a practice considered overused.This was a single-blinded randomized controlled trial. Between January and June 2016, physicians on six general medicine teams at the Hospital of the University of Pennsylvania were cluster randomized with equal allocation to two arms: (1) those e-mailed a summary of their routine laboratory test ordering vs. the service average for the prior week, linked to a continuously updated personalized dashboard containing patient-level details, and snapshot of the dashboard and (2) those who did not receive the intervention. The primary outcome was the count of routine laboratory test orders placed by a physician per patient-day. We modeled the count of orders by each physician per patient-day after the intervention as a function of trial arm and the physician's order count before the intervention. The count outcome was modeled using negative binomial models with adjustment for clustering within teams.One hundred and fourteen interns and residents participated. We did not observe a statistically significant difference in adjusted reduction in routine laboratory ordering between the intervention and control physicians (physicians in the intervention group ordered 0.14 fewer tests per patient-day than physicians in the control group, 95% CI - 0.56 to 0.27, p = 0.50). Physicians whose absolute ordering rate deviated from the peer rate by more than 1.0 laboratory test per patient-day reduced their laboratory ordering by 0.80 orders per patient-day (95% CI - 1.58 to - 0.02, p = 0.04).Personalized social comparison feedback on routine laboratory ordering did not change targeted behavior among physicians, although there was a significant decrease in orders among participants who deviated more from the peer rate.Clinicaltrials.gov registration: #NCT02330289.

Introduction Studies have demonstrated the benefit of weight loss and physical activity for diabetes prevention among those with prediabetes. Despite this evidence, only about half of people with prediabetes report engaging in these behaviors. One presumed barrier is low patient awareness of prediabetes. The purpose of this study is to examine the impact of prediabetes awareness on the odds of engagement in diabetes risk–reduction behaviors. Methods A pooled cross-sectional analysis of adults from two cycles (2007–2008, 2009–2010) of the National Health and Nutrition Examination Survey was conducted. Those with prediabetes were identified by excluding people with self-reported diabetes and then screening for hemoglobin A1c values between 5.7% and 6.4%. This group was then divided based on self-reported prediabetes. Multivariate logistic regression was used to estimate the effect of prediabetes awareness on the odds of engagement in physical activity, weight management, and the combination of physical activity and weight management. Results Of those meeting the defined criteria for prediabetes ( n =2,694), only 11.8% ( n =288) were aware of their status. Prediabetes-aware individuals had higher odds of engagement in the combination of moderate physical activity plus BMI-appropriate weight management (AOR=1.5, 95% CI=1.1, 2.0), and the combination of at least 150 minutes/week of moderate activity and 7% weight loss in the past year (AOR=2.4, 95% CI=1.1, 5.6). Conclusions Prediabetes-aware adults have increased odds of engagement in physical activity and weight management. Increasing patients' awareness of prediabetes could result in increased performance of exercise and weight management behaviors and, most importantly, decreased risk of future diabetes.

Purpose of review Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment. Recent findings Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.

Previous work has indicated that for patients with diabetes, there is value in understanding glycemic control. Despite these findings, patient understanding of the hemoglobin A1C value (A1C) is notably poor. In this study, we test the effect of two alternative communication formats of the A1C on improving glycemic control among patients with poorly controlled diabetes. 177 patients with poorly controlled diabetes were randomized to one of three study arms that varied in the information they received: (1) a “diabetes report card” containing individualized information about glycemic control for each participant with letter grades ranging from A to F; (2) a “report card” containing a face whose emotion reflected current glycemic control; or (3) a “report card” with glycemic control expressed with the A1C value (standard arm). The primary study outcome was change in A1C at 6 months. Secondary outcomes included changes in participant perceptions of their glycemic control. The average A1C for enrolled participants was 9.9 % (S.D. 1.7) and did not differ significantly among study arms. We noted no significant differences in change in A1C at 6 months between the standard and experimental arms. Using multiple imputation to account for missing A1C values, the changes in A1C for the letter grade, face, and standard arms were -0.55 % (-1.15, 0.05), -0.89 % (-1.49, -0.29), and -0.74 % (-1.51, 0.029), respectively (p = 0.67 for control vs. grade, p = 0.76 for control vs. face). Feedback to patients with poorly controlled diabetes in the form of letter grades and faces did not differentially impact glycemic control at 6 months or participant perceptions of current control. These efforts to improve communication and patient understanding of disease management targets need further refinement to significantly impact diabetes outcomes. NCT01143870

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

Background: Studies suggest that patients do not understand the hemoglobin A1c value (A1c). However, clinicians may communicate information about glycemic control in other ways. Given this, this study evaluates patients’ understanding of current diabetes control, independent of the A1c, and the factors affecting this understanding. Method: Cross-sectional survey of patients with poorly controlled diabetes seen in urban clinics in fall of 2010. Results: 177 people completed the survey. 73.5% were women, 83.0% were African-American and the average age was 56.5 years. 80.2% of respondents reported having had diabetes for at least five years. 39% reported past participation in a diabetes education course. Average A1c was 9.9(S.D. 1.7)%; no differences were noted based on income, education, disease duration, or complication history. 23.7% described their disease control as “good” or “excellent” in spite of an average A1c of 9.5% (1.2). Notably, most of this group reported diabetes for over five years and did not differ in history of diabetes-related complications or educational attainment compared to those with more accurate perceptions of control. Conclusion: The high proportion of participants who reported “good” or “excellent” control in spite of mean A1c greater than 9.5% raises serious questions about the effectiveness of current communication methods for patients with poorly controlled diabetes.

Purpose To determine the survival of infants and young children with non-metastatic medulloblastoma using intensive myeloablative chemotherapy and autologous hematopoietic progenitor cell rescue (AuHCR). Methods Twenty-one children less than 3 years old at diagnosis with non-metastatic medulloblastoma were enrolled on two identical serial studies, “Head Start” I and “Head Start” II. After surgery, patients received five cycles of induction chemotherapy consisting of vincristine, cisplatin, cyclophosphamide and etoposide. Following induction, all patients underwent myeloablative chemotherapy using carboplatin, thiotepa and etoposide with AuHCR. Irradiation was used only at relapse. Results The 5-year event-free (EFS) and overall survival (OS) rates (±SE) for all patients, patients with gross total resection, and patients with residual tumor were 52 ± 11% and 70 ± 10%, 64 ± 13% and 79 ± 11%, and 29 ± 17% and 57 ± 19%, respectively. The 5-year EFS and OS ( ± SE) for patients with desmoplastic and classical medulloblastoma were 67 ± 16% and 78 ± 14%, and 42 ± 14 and 67 ± 14%, respectively. There were four treatment related deaths. The majority of survivors (71%) avoided irradiation completely. Mean intellectual functioning and quality of life (QoL) for children surviving without irradiation was within average range for a majority of survivors tested. Conclusion This strategy of brief intensive chemotherapy for young children with non-metastatic medulloblastoma eliminated the need for craniospinal irradiation 52% of the patients, and may preserve QoL and intellectual functioning. The excellent survival rates are somewhat dampened by high toxic mortality. Pediatr Blood Cancer 2008;50:1169–1175. © 2008 Wiley-Liss, Inc.

Background: More than 35% of American adults are obese. For African American and Hispanic adults, as well as individuals residing in poorer or more racially segregated urban neighborhoods, the likelihood of obesity is even higher. Information and communication technologies (ICTs) may substitute for or complement community-based resources for weight management. However, little is currently known about health-specific ICT use among urban-dwelling people with obesity. Objective: We describe health-specific ICT use and its relationship to measured obesity among adults in high-poverty urban communities. Methods: Using data collected between November 2012 and July 2013 from a population-based probability sample of urban-dwelling African American and Hispanic adults residing on the South Side of Chicago, we described patterns of ICT use in relation to measured obesity defined by a body mass index (BMI) of ≥30 kg/m2. Among those with BMI≥30 kg/m2, we also assessed the association between health-specific ICT use and diagnosed versus undiagnosed obesity as well as differences in health-specific ICT use by self-reported comorbidities, including diabetes and hypertension. Results: The survey response rate was 44.6% (267 completed surveys/598.4 eligible or likely eligible individuals); 53.2% were African American and 34.6% were Hispanic. More than 35% of the population reported an annual income of less than US $25,000. The population prevalence of measured obesity was 50.2%. People with measured obesity (BMI≥30 kg/m2) were more likely to report both general (81.5% vs 67.0%, P=.04) and health-specific (61.1% vs 41.2%, P=.01) ICT use. In contrast, among those with measured obesity, being told of this diagnosis by a physician was not associated with increased health-specific ICT use. People with measured obesity alone had higher rates of health-specific use than those with comorbid hypertension and/or diabetes diagnoses (77.1% vs 60.7% vs 47.4%, P=.04). Conclusions: In conclusion, ICT-based health resources may be particularly useful for people in high-poverty urban communities with isolated measured obesity, a population that is at high risk for poor health outcomes. [J Med Internet Res 2016;18(6):e182]

The arbuscular mycorrhizal (AM) symbiosis is responsible for huge fluxes of photosynthetically fixed carbon from plants to the soil. Lipid, which is the dominant form of stored carbon in the fungal partner and which fuels spore germination, is made by the fungus within the root and is exported to the extraradical mycelium. We tested the hypothesis that the glyoxylate cycle is central to the flow of carbon in the AM symbiosis. The results of 13C labeling of germinating spores and extraradical mycelium with13C2-acetate and13C2-glycerol and analysis by nuclear magnetic resonance spectroscopy indicate that there are very substantial fluxes through the glyoxylate cycle in the fungal partner. Full-length sequences obtained by polymerase chain reaction from a cDNA library from germinating spores of the AM fungus Glomus intraradices showed strong homology to gene sequences for isocitrate lyase and malate synthase from plants and other fungal species. Quantitative real-time polymerase chain reaction measurements show that these genes are expressed at significant levels during the symbiosis. Glyoxysome-like bodies were observed by electron microscopy in fungal structures where the glyoxylate cycle is expected to be active, which is consistent with the presence in both enzyme sequences of motifs associated with glyoxysomal targeting. We also identified among several hundred expressed sequence tags several enzymes of primary metabolism whose expression during spore germination is consistent with previous labeling studies and with fluxes into and out of the glyoxylate cycle.