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Objective: To examine the longitudinal effects of medication nonadherence (MNA) on key costs and estimate potential savings from increased adherence using a novel methodology that accounts for shared correlation among cost categories.Research Design and Methods: Veterans with type 2 diabetes (740,195) were followed from January 2002 until death, loss to follow-up, or December 2006. A novel multivariate, generalized, linear, mixed modeling approach was used to assess the differential effect of MNA, defined as medication possession ratio (MPR) ≥0.8 on healthcare costs. A sensitivity analysis was performed to assess potential cost savings at different MNA levels using the Consumer Price Index to adjust estimates to 2012 dollar value.Results: Mean MPR for the full sample over 5 years was 0.78, with a mean of 0.93 for the adherent group and 0.58 for the MNA group. In fully adjusted models, all annual cost categories increased ∼3% per year (P = 0.001) during the 5-year study time period. MNA was associated with a 37% lower pharmacy cost, 7% lower outpatient cost, and 41% higher inpatient cost. Based on sensitivity analyses, improving adherence in the MNA group would result in annual estimated cost savings ranging from ∼$661 million (MPR <0.6 vs. ≥0.6) to ∼$1.16 billion (MPR <1 vs. 1). Maximal incremental annual savings would occur by raising MPR from <0.8 to ≥0.8 ($204,530,778) among MNA subjects.Conclusions: Aggressive strategies and policies are needed to achieve optimal medication adherence in diabetes. Such approaches may further the so-called "triple aim" of achieving better health, better quality care, and lower cost. [ABSTRACT FROM AUTHOR]

Objective: This study assessed associations among health literacy, diabetes knowledge, self-care, and glycemic control in a low income, predominately minority population with type 2 diabetes.Methods: One hundred twenty-five adults with diabetes were recruited from a primary care clinic. Subjects completed validated surveys to measure health literacy, diabetes knowledge, and self-care (medication adherence, diet, exercise, blood sugar testing, and foot care). Hemoglobin A1c values were extracted from the medical record. Spearman's correlation and multiple linear regression were used to assess the relationship among health literacy, diabetes knowledge, self-care, and glycemic control controlling for covariates.Results: Cronbach's α was 0.95 for the Revised Rapid Estimate of Adult Literacy in Medicine. The majority of the sample was <65 years old (50.7%), female (72.5%), and African American (71.4%), had less than a high school education (68.2%) and a household income < $15,000 (64.2%), and reported their health status as worse than last year (73.9%). In adjusted models that examined the associations among health literacy, diabetes knowledge, medication adherence, and self-care, health literacy was only significantly associated with diabetes knowledge (β = 0.55; 95% confidence interval [CI] 0.29, 0.82). In the final adjusted model for independent factors associated with glycemic control, both diabetes knowledge (β = 0.12; 95% CI 0.01, 0.23) and perceived health status (β = 1.14; 95% CI 0.13, 2.16) were significantly associated with glycemic control, whereas health literacy was not associated with glycemic control (β = -0.03; 95% CI -0.19, 0.13).Conclusions: Diabetes knowledge and perceived health status are the most important factors associated with glycemic control in this population. Health literacy appears to exert its influence through diabetes knowledge and is not directly related to self-care or medication adherence. [ABSTRACT FROM AUTHOR]

Objective: Comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We applied the Information-Motivation-Behavioral Skills (IMB) model, a well-validated, comprehensive health behavior change framework, to diabetes self-care.Methods: Patients with diabetes were recruited from an outpatient clinic. Information gathered pertained to demographics, diabetes knowledge (information); diabetes fatalism (personal motivation); social support (social motivation); and diabetes self-care (behavior). Hemoglobin A1C values were extracted from the patient medical record. Structural equation models tested the IMB framework.Results: More diabetes knowledge (r=0.22 p<0.05), less fatalistic attitudes (r=-0.20, p<0.05), and more social support (r=0.27, p<0.01) were independent, direct predictors of diabetes self-care behavior; and through behavior, were related to glycemic control (r=-0.20, p<0.05).Conclusions: Consistent with the IMB model, having more information (more diabetes knowledge), personal motivation (less fatalistic attitudes), and social motivation (more social support) was associated with behavior; and behavior was the sole predictor of glycemic control.Practice Implications: The IMB model is an appropriate, comprehensive health behavior change framework for diabetes self-care. The findings indicate that in addition to knowledge, diabetes education programs should target personal and social motivation to effect behavior change. [ABSTRACT FROM AUTHOR]

Objective: To examine racial/ethnic differences in utilization of stroke-related rehabilitation. Methods: We searched Medline (from 1966-2007), CINAHL (from 1982-2007), PsycINFO (1966-2007), REHABDATA (1966-2007), the Cochrane Library, and reference lists of published articles. We identified 82 studies in our initial search, including randomized and quasirandomized controlled trials, working papers, technical reports, and conference presentations of stroke patients that reported utilization of rehabilitation services including physical therapy (PT), occupational therapy (OT), speech-language pathology (SLP), and at least two groups that differed by race/ethnicity. Because of limited information on outcomes and heterogeneity of the studies, a formal meta-analysis was not conducted. A qualitative aggregation of study findings was performed instead. Results: Ten studies involving 214,229 patients met the final criteria for review. Racial/ethnic minorities were more likely to receive rehabilitation and have longer lengths of stays in studies that reported use of rehabilitation services. In contrast, when studies reported discipline-specific (PT, OT, SLP) utilization of services, the results were mixed. Conclusions: Racial/ethnic differences in the utilization of rehabilitation services primarily reflected the manner in which service utilization was reported. Future studies should be designed to ensure an accurate comparison of service utilization by race/ethnicity. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Researchers have only just begun to investigate physician-related effects on medical outcomes. Such research is necessary for developing empirically informed practice guidelines and policy. The primary goal of this study was to investigate whether glucose management in type 2 diabetes varies by randomly assigned physicians over the course of a year in treatment. A second goal of the study was to investigate whether physician-related effects vary across differential patient characteristics. A tertiary goal was to investigate potential patient-level effects on glucose management. RESEARCH DESIGN AND METHODS: Hierarchical linear models were used to investigate A1C among 1,381 patients, nested within 42 randomly assigned primary care physicians at a Veterans Affairs medical center in the southeastern U.S. The primary outcome measure was change in A1C over the course of 1 year in treatment. On average, each study physician had 33 patients with diabetes. RESULTS: Overall, physician-related factors were associated with statistically significant but modest variability in A1C change (2%), whereas patient-level factors accounted for the majority of variation in A1C change (98%). Physician effects varied by patient characteristics, mattering more for black patients, patients aged 65 years, and patients whose glucose management improved over the treatment year. CONCLUSIONS: The results of this study indicate that differential physician effects have minimal impact on glycemic control. Results suggest that it is logical to support policies encouraging the development of patient-level behavioral interventions because that is the level that accounts for the majority of variance in glycemic control. [ABSTRACT FROM AUTHOR]

Objective: To determine the effectiveness of physician advice on hypertension-related lifestyle modification in individuals with diabetes.Research Design and Methods: Data on adults with one or more physician visit in the 1998 National Health Interview Survey (NHIS) were analyzed (diabetes, n = 1609; no diabetes, n = 19672). The proportion with hypertension who received physician advice to lose weight, increase physical activity, or take antihypertensive medications and the proportion who reported adhering to advice were compared by diabetes status. Logistic regression was used to identify factors associated with receipt of physician advice and adherence to advice by diabetes status controlling for covariates. Then, logistic regression was also used to determine the extent to which patient adherence among people with diabetes differed by age, sex, and race/ethnicity, controlling for other covariates. STATA statistical software was used for all analyses to account for the complex survey design of NHIS.Results: Controlling for covariates, individuals with diabetes were more likely to receive advice (odds ratio [OR] 1.94 for weight loss, 1.99 for exercise, and 2.16 for medications). Adherence was more likely in individuals with diabetes (OR 1.40 for losing weight and 2.16 for taking medications). Adherence in people with diabetes did not differ by sex or race/ethnicity. Subjects 18-44 years old were least likely to report losing weight (OR 0.15) or taking medications (0.31) compared with subjects >or=65 years old.Conclusions: Physician advice appears effective at changing hypertension-related lifestyles in people with diabetes regardless of sex or race/ethnicity. However, advice on increasing physical activity does not seem as effective. [ABSTRACT FROM AUTHOR]

PURPOSE: This study was conducted to explore the concept of fatalism in relation to diabetes self-management behavior in African Americans with type 2 diabetes. METHODS: Participants (n = 39) were recruited from a clinic sample of African Americans with type 2 diabetes. Seven focus groups were conducted; the sessions were recorded, transcribed, and analyzed to identify themes related to fatalism and diabetes self-management. The ISAS paradigm (individual, symbols, audience, situation), a social psychology theory, provided the theoretical framework for the study. RESULTS: Four dimensions of fatalism were identified: the meaning of diabetes, the illness experience, the individual's coping response, and the individual's religious and spiritual beliefs. For the participants in this study, fatalism seemed to characterize the nature of the interaction between the individual with diabetes and others, the meanings they attached to such interactions, and the decision to adopt an effective or ineffective diabetes self-management behavior. CONCLUSIONS: Fatalism was associated with diabetes self-management in African Americans with diabetes and was multidimensional in this population; the construct appeared to differ conceptually from the perspective of current measures. [ABSTRACT FROM AUTHOR]

PURPOSE: This qualitative study was conducted with African Americans with type 2 diabetes to explore beliefs and attitudes about depression. METHODS: Twenty-five adults participated in 4 focus groups. The sessions were recorded, transcribed, and analyzed. The Health Belief Model was used as a theoretical framework for the design and analysis of the focus group data. RESULTS: Five themes pertinent to depression management emerged: (1) There were misconceptions about the etiology of depression and individual vulnerability to depression. (2) Depression was perceived as severe. (3) Treatment was perceived as beneficial. (4) Stigma was a significant barrier to seeking treatment. (5) Cues to action did not appear to change beliefs. CONCLUSIONS: Despite awareness about the severity of depression and benefits of treatment, several barriers and erroneous beliefs may interfere with the ability of African Americans with type 2 diabetes to seek and adhere to treatment for depression. [ABSTRACT FROM AUTHOR]

PURPOSE: The purpose of this cross-sectional study was to determine the attitudes of internal medicine physicians toward treating diabetes in different patient ethnic groups and compared with treating common chronic medical conditions in primary care. METHODS: The survey instrument was administered to 55 internal medicine physicians. An e-mail message was sent to each physician with a hyperlink to a site where the survey could be completed. The instrument was a modified, quantitative 10-point scale designed to measure attitudes regarding the difficulty of treating diabetes. RESULTS: Diabetes was perceived to be more difficult to treat than hyperlipidemia and angina. African Americans with diabetes were perceived to be more difficult to treat than Caucasian patients. Difficulty in treating diabetes was comparable to that for hypertension, arthritis, and congestive heart failure. Physicians were confident about treatment efficacy for diabetes and changing diabetes outcomes, but not about the adequacy of time and resources for diabetes treatment. CONCLUSIONS: Diabetes was perceived as a difficult disease to treat, African American patients were more difficult to treat, and time and resources were inadequate for diabetes treatment. To improve diabetes care, there is a need to address these attitudes and concerns of internal medicine physicians. [ABSTRACT FROM AUTHOR]

Abstract Background With the current focus on personalized medicine, patient/subject level inference is often of key interest in translational research. As a result, random effects models (REM) are becoming popular for patient level inference. However, for very large data sets that are characterized by large sample size, it can be difficult to fit REM using commonly available statistical software such as SAS since they require inordinate amounts of computer time and memory allocations beyond what are available preventing model convergence. For example, in a retrospective cohort study of over 800,000 Veterans with type 2 diabetes with longitudinal data over 5 years, fitting REM via generalized linear mixed modeling using currently available standard procedures in SAS (e.g. PROC GLIMMIX) was very difficult and same problems exist in Stata’s gllamm or R’s lme packages. Thus, this study proposes and assesses the performance of a meta regression approach and makes comparison with methods based on sampling of the full data. Data We use both simulated and real data from a national cohort of Veterans with type 2 diabetes (n=890,394) which was created by linking multiple patient and administrative files resulting in a cohort with longitudinal data collected over 5 years. Methods and results The outcome of interest was mean annual HbA1c measured over a 5 years period. Using this outcome, we compared parameter estimates from the proposed random effects meta regression (REMR) with estimates based on simple random sampling and VISN (Veterans Integrated Service Networks) based stratified sampling of the full data. Our results indicate that REMR provides parameter estimates that are less likely to be biased with tighter confidence intervals when the VISN level estimates are homogenous. Conclusion When the interest is to fit REM in repeated measures data with very large sample size, REMR can be used as a good alternative. It leads to reasonable inference for both Gaussian and non-Gaussian responses if parameter estimates are homogeneous across VISNs.

Abstract Background In the United States, it is estimated that 40% of adults utilize complementary and alternative medicine (CAM) therapies. Recently, national surveys report that over 90 million adults have inadequate health literacy. To date, no study has assessed health literacy and its effect on CAM use. The primary objective of this study was to assess the relationship between health literacy and CAM use independent of educational attainment. Second objective was to evaluate the differential effect of health literacy on CAM use by race. Methods 351 patients were recruited from an outpatient primary care clinic. Validated surveys assessed CAM use (I-CAM-Q), health literacy (REALM-R), and demographic information. We compared demographics by health literacy (adequate vs. inadequate) and overall and individual CAM categories by health literacy using chi square statistics. We found a race by health literacy interaction and ran sequential logistic regression models stratified by race to test the association between health literacy and overall CAM use (Model 1), Model 1 + education (Model 2), and Model 2 + other demographic characteristics (Model 3). We reported the adjusted effect of health literacy on CAM use for both whites and African Americans separately. Results 75% of the participants had adequate literacy and 80% used CAM. CAM use differed by CAM category. Among whites, adequate health literacy was significantly associated with increased CAM use in both unadjusted (Model 1, OR 7.68; p = 0.001) and models adjusted for education (Model 2, OR 7.70; p = 0.002) and other sociodemographics (Model 3, OR 9.42; p = 0.01). Among African Americans, adequate health literacy was not associated with CAM use in any of the models. Conclusions We found a race by literacy interaction suggesting that the relationship between health literacy and CAM use differed significantly by race. Adequate health literacy among whites is associated with increased CAM use, but not associated with CAM use in African Americans.

Abstract Background An estimated 1 in 3 American adults will have diabetes by the year 2050. Nationally, South Carolina ranks 10th in cases of diagnosed diabetes compared to other states. In adults, type 2 diabetes (T2DM) accounts for approximately 90-95% of all diagnosed cases of diabetes. Clinically, provider and health system factors account for < 10% of the variance in major diabetes outcomes including hemoglobin A1c (HbA1c), lipid control, and resource use. Use of telemonitoring systems offer new opportunities to support patients with T2DM while waiting to be seen by their health care providers at actual office visits. A variety of interventions testing the efficacy of telemedicine interventions have been conducted, but the outcomes have yielded equivocal results, emphasizing the shortage of controlled, randomized trials in this area. This study provides a unique opportunity to address this gap in the literature by optimizing two strategies that have been shown to improve glycemic control, while simultaneously implementing clinical outcomes measures, using a sufficient sample size, and offering health care delivery to rural, underserved and low income communities with T2DM who are seen at Federally Qualified Health Centers (FQHCs) in coastal South Carolina. Methods We describe a four-year prospective, randomized clinical trial, which will test the effectiveness of technology-assisted case management in low income rural adults with T2DM. Two-hundred (200) male and female participants, 18 years of age or older and with an HbA1c ≥ 8%, will be randomized into one of two groups: (1) an intervention arm employing the innovative FORA system coupled with nurse case management or (2) a usual care group. Participants will be followed for 6-months to ascertain the effect of the interventions on glycemic control. Our primary hypothesis is that among indigent, rural adult patients with T2DM treated in FQHC's, participants randomized to the technology-assisted case management intervention will have significantly greater reduction in HbA1c at 6 months of follow-up compared to usual care. Discussion Results from this study will provide important insight into the effectiveness of technology-assisted case management intervention (TACM) for optimizing diabetes care in indigent, rural adult patients with T2DM treated in FQHC's. Trial Registration National Institutes of Health Clinical Trials Registry (http://ClinicalTrials.gov identifier# NCT01373489

Abstract Background Many studies have investigated racial/ethnic disparities in medication non-adherence in patients with type 2 diabetes using common measures such as medication possession ratio (MPR) or gaps between refills. All these measures including MPR are quasi-continuous and bounded and their distribution is usually skewed. Analysis of such measures using traditional regression methods that model mean changes in the dependent variable may fail to provide a full picture about differential patterns in non-adherence between groups. Methods A retrospective cohort of 11,272 veterans with type 2 diabetes was assembled from Veterans Administration datasets from April 1996 to May 2006. The main outcome measure was MPR with quantile cutoffs Q1-Q4 taking values of 0.4, 0.6, 0.8 and 0.9. Quantile-regression (QReg) was used to model the association between MPR and race/ethnicity after adjusting for covariates. Comparison was made with commonly used ordinary-least-squares (OLS) and generalized linear mixed models (GLMM). Results Quantile-regression showed that Non-Hispanic-Black (NHB) had statistically significantly lower MPR compared to Non-Hispanic-White (NHW) holding all other variables constant across all quantiles with estimates and p-values given as -3.4% (p = 0.11), -5.4% (p = 0.01), -3.1% (p = 0.001), and -2.00% (p = 0.001) for Q1 to Q4, respectively. Other racial/ethnic groups had lower adherence than NHW only in the lowest quantile (Q1) of about -6.3% (p = 0.003). In contrast, OLS and GLMM only showed differences in mean MPR between NHB and NHW while the mean MPR difference between other racial groups and NHW was not significant. Conclusion Quantile regression is recommended for analysis of data that are heterogeneous such that the tails and the central location of the conditional distributions vary differently with the covariates. QReg provides a comprehensive view of the relationships between independent and dependent variables (i.e. not just centrally but also in the tails of the conditional distribution of the dependent variable). Indeed, without performing QReg at different quantiles, an investigator would have no way of assessing whether a difference in these relationships might exist.

Abstract Background African Americans with Type 2 diabetes (T2DM) have higher prevalence of diabetes, poorer metabolic control, and greater risk for complications and death compared to American Whites. Poor outcomes in African Americans with T2DM can be attributed to patient, provider, and health systems level factors. Provider and health system factors account for Methods/Design We describe an ongoing four-year randomized clinical trial, using a 2 × 2 factorial design, which will test the efficacy of separate and combined telephone-delivered, diabetes knowledge/information and motivation/behavioral skills training interventions in high risk African Americans with poorly controlled T2DM (HbA1c ≥ 9%). Two-hundred thirty-two (232) male and female African-American participants, 18 years of age or older and with an HbA1c ≥ 9%, will be randomized into one of four groups for 12-weeks of phone interventions: (1) an education group, (2) a motivation/skills group, (3) a combined group or (4) a usual care/general health education group. Participants will be followed for 12-months to ascertain the effect of the interventions on glycemic control. Our primary hypothesis is that among African Americans with poorly controlled T2DM, patients randomized to the combined diabetes knowledge/information and motivation/behavioral skills training intervention will have significantly greater reduction in HbA1c at 12 months of follow-up compared to the usual care/general health education group. Discussion Results from this study will provide important insight into how best to deliver diabetes education and skills training in ethnic minorities and whether combined knowledge/information and motivation/behavioral skills training is superior to the usual method of delivering diabetes education for African Americans with poorly controlled T2DM. Trial registration National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00929838).

Abstract Background Older adults who live in rural areas experience significant disparities in health status and access to mental health care. "Telepsychology," (also referred to as "telepsychiatry," or "telemental health") represents a potential strategy towards addressing this longstanding problem. Older adults may benefit from telepsychology due to its: (1) utility to address existing problematic access to care for rural residents; (2) capacity to reduce stigma associated with traditional mental health care; and (3) utility to overcome significant age-related problems in ambulation and transportation. Moreover, preliminary evidence indicates that telepsychiatry programs are often less expensive for patients, and reduce travel time, travel costs, and time off from work. Thus, telepsychology may provide a cost-efficient solution to access-to-care problems in rural areas. Methods We describe an ongoing four-year prospective, randomized clinical trial comparing the effectiveness of an empirically supported treatment for major depressive disorder, Behavioral Activation, delivered either via in-home videoconferencing technology ("Telepsychology") or traditional face-to-face services ("Same-Room"). Our hypothesis is that in-homeTelepsychology service delivery will be equally effective as the traditional mode (Same-Room). Two-hundred twenty-four (224) male and female elderly participants will be administered protocol-driven individual Behavioral Activation therapy for depression over an 8-week period; and subjects will be followed for 12-months to ascertain longer-term effects of the treatment on three outcomes domains: (1) clinical outcomes (symptom severity, social functioning); (2) process variables (patient satisfaction, treatment credibility, attendance, adherence, dropout); and (3) economic outcomes (cost and resource use). Discussion Results from the proposed study will provide important insight into whether telepsychology service delivery is as effective as the traditional mode of service delivery, defined in terms of clinical, process, and economic outcomes, for elderly patients with depression residing in rural areas without adequate access to mental health services. Trial registration National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00324701).

Background: African Americans with Type 2 diabetes (T2DM) have higher prevalence of diabetes, poorer metabolic control, and greater risk for complications and death compared to American Whites. Poor outcomes in African Americans with T2DM can be attributed to patient, provider, and health systems level factors. Provider and health system factors account for <10% of variance in major diabetes outcomes including hemoglobin A1c (HbA1c), lipid control, and resource use. Key differences appear to be at the patient level. Of the patient level factors, consistent differences between African Americans and American Whites with T2DM have been found in diabetes knowledge, self-management skills, empowerment, and perceived control. A variety of interventions to improve diabetes self-management have been tested including: 1) knowledge interventions; 2) lifestyle interventions; 3) skills training interventions; and 4) patient activation and empowerment interventions. Most of these interventions have been tested individually, but rarely have they been tested in combination, especially among African Americans who have the greatest burden of diabetes related complications. This study provides a unique opportunity to address this gap in the literature.Methods/design: We describe an ongoing four-year randomized clinical trial, using a 2 x 2 factorial design, which will test the efficacy of separate and combined telephone-delivered, diabetes knowledge/information and motivation/behavioral skills training interventions in high risk African Americans with poorly controlled T2DM (HbA1c >or= 9%). Two-hundred thirty-two (232) male and female African-American participants, 18 years of age or older and with an HbA1c >or= 9%, will be randomized into one of four groups for 12-weeks of phone interventions: (1) an education group, (2) a motivation/skills group, (3) a combined group or (4) a usual care/general health education group. Participants will be followed for 12-months to ascertain the effect of the interventions on glycemic control. Our primary hypothesis is that among African Americans with poorly controlled T2DM, patients randomized to the combined diabetes knowledge/information and motivation/behavioral skills training intervention will have significantly greater reduction in HbA1c at 12 months of follow-up compared to the usual care/general health education group.Discussion: Results from this study will provide important insight into how best to deliver diabetes education and skills training in ethnic minorities and whether combined knowledge/information and motivation/behavioral skills training is superior to the usual method of delivering diabetes education for African Americans with poorly controlled T2DM.Trial Registration: National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00929838). [ABSTRACT FROM AUTHOR]

Question:How do people rate the effects of depression on their overall health status in comparison to angina, arthritis, asthma and diabetes?Population:245 404 inhabitants of 60 countries.Setting:Global study representing people from 60 countries (26 from the European region, 15 from the African region, six from the Americas, four from the eastern Mediterranean region, five from the southeast Asia region and four from the western Pacific region); time period not stated.Assessment:Face-to-face interviews were conducted with the majority of participants in their home countries using the standardised WHO World Health Survey (WHO WHS) that collected demographic information and used 16 health-related questions assessing eight health domains (including vision, mobility, cognition, pain, etc) to derive an overall health score. The overall health score ranged from 0 (worst health) to 100 (best health). The WHO WHS also incorporated a series of questions about symptoms which were used to diagnose each condition. Sensitivity and specificity of using symptom questions to diagnose chronic diseases was determined in a separate sub-study. Symptom questions for depression were based on the Composite International Diagnostic Interview, and for angina on the Rose questionnaire. The answers to the best combination of symptom questions (based on ROC analysis) were used to diagnose asthma and arthritis. Diagnoses of diabetes were based on self-report.Outcomes:Prevalence of chronic physical diseases (angina, arthritis, asthma and diabetes); prevalence of depression; prevalence of comorbid disease; health status. Results were determined for country and global levels; only global results were published.METHODSDesign: Cross-sectional study.MAIN RESULTSOverall the study found that compared with chronic diseases (diabetes, asthma, arthritis or angina), depression resulted in the lowest health scores. Comorbid depression was associated with lower health scores than depression alone, any of chronic conditions alone as well as any combination of the chronic diseases without depression. See online table for prevalence results and associated health scores. Depression was more common in people with chronic diseases than in those without (p<0.0001). When authors controlled for all factors associated with lower health scores (income, marital status, age, education, employment), people with depression still had the lowest health scores.CONCLUSIONSWorldwide, depression affects the overall state of health more negatively than four other chronic diseases. [ABSTRACT FROM AUTHOR]

Objectives: To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims.Methods: Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework.Results: Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects.Conclusions: Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East. [ABSTRACT FROM AUTHOR]

Importance: Historic redlining, the practice by the Home Owners' Loan Corporation (HOLC) of systematically denying credit to borrowers in neighborhoods that were inhabited by primarily African American individuals, has been associated with poor community outcomes, but the association with individual risk of death is not clear., Objective: To examine if exposure to residential redlining practices by HOLC in 1940 is associated with increased risk of death later in life., Design, Setting, and Participants: The study linked individuals who resided within HOLC-graded neighborhoods (defined as Census Enumeration Districts) in 1940 with administrative death records data. The study estimated hazard ratios as well as age-specific life expectancy gaps (at age 55, 65, and 75 years) for HOLC grading exposure. This was done using methods that adapted standard parametric survival analysis to data with limited mortality coverage windows and incomplete observations of survivors. The analysis sample consisted of 961 719 individual-level observations across 13 912 enumeration districts within 30 of the largest US cities (based on 1940 population counts) across 23 states. Data were analyzed between December 1, 2023, and September 4, 2024., Main Outcome and Measures: The exposure was HOLC grade based on historic HOLC maps, with A representing "best" or creditworthy areas; B, "still desirable"; C, "definitely declining"; and D, "hazardous" areas not worthy of credit (ie, redlined), and the main outcome was age at death from the Social Security Numident file., Results: The 961 719-person individual sample had a mean (SD) age of 19.26 (9.26) years in 1940 and a mean (SD) age at death of 76.83 (9.22) years. In a model adjusted for sex (52.48% female; 47.52% male), race and ethnicity (7.36% African American; 92.64% White), and latent place effects, a 1-unit lower HOLC grade was associated with an 8% (hazard ratio, 1.08 [95% CI, 1.07-1.09]) increased risk of death. At age 65 years, these hazard differentials translated into an estimated life expectancy gap of -0.49 (95% CI, -0.56 to -0.43) years for each 1-unit decrease of the HOLC grade., Conclusion: This study found that individuals who resided within redlined neighborhoods in 1940 had lower life expectancy later in life than individuals who resided within other HOLC-graded areas.

Objective: To evaluate the evidence on the relationship between delay discounting and clinical diabetes outcomes, identify current measures, and recommend areas for future work., Methods: A reproducible search using OVID Medline, PsycINFO, PubMed, Science Direct, and Scopus was conducted. Articles published from database creation up to March 2024 were searched. Medical Subject Heading (MeSH) terms and keywords representing delay discounting and diabetes were used. Outcomes included hemoglobin A1c (HbA1c), LDL, body mass index (BMI), blood pressure, quality of life (QOL), psychosocial factors, self-care behaviors, and diabetes complications., Results: A total of 15 articles met the inclusion criteria and were included for final synthesis. Overall, 14 studies included in this review found a significant relationship between delay discounting and diabetes-related outcomes, such that higher delay discounting is significantly related to worse diabetes outcomes for HbA1c, self-care behaviors, BMI, stress, and quality of life across self-reported measures of delay discounting and delay discounting tasks., Conclusions: Evidence supports the relationship between delay discounting and diabetes-related outcomes and self-care behaviors across measures of delay discounting and type of diabetes. To understand delay discounting as a mechanism driving diabetes outcomes and to develop targeted interventions, additional work using a multidisciplinary approach is needed to validate the construct, identify pathways, and refine intervention approaches that can be tested to improve population health., Competing Interests: Declarations: Conflict of Interest: The authors declare that they do not have a conflict of interest., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objective: Health literacy is an important social determinant of health, with limited health literacy associated with worse health outcomes. This study examined the associations between limited health literacy with patient-reported outcomes and disease activity/damage among 267 Black women with active systemic lupus erythematosus (SLE) enrolled in the Peer Approaches to Lupus Self-Management (PALS) program., Methods: The three-item Chew Health Literacy Screening was used to dichotomize those reporting in the "limited" range on any item with outcomes compared via generalized linear models. Baseline surveys and assessments obtained at study entry as part of the PALS study were used. Primary outcomes included disease activity and lupus damage; other secondary outcomes included patient activation, self-efficacy, physician/patient communication, and quality of life., Results: The study included 267 Black women with SLE. In covariate-adjusted analyses, participants with limited health literacy (88 [33%]) were more likely to have lower patient activation (Patient Activation Measure P < 0.0001), lower self-efficacy (Lupus Self-Efficacy P < 0.0001), higher lupus damage (self-administered Brief Index of Lupus Damage P = .016), higher disease activity (Systemic Lupus Activity Questionnaire symptom severity P = 0.006), and worse physician/patient communication (patient-centered care P < 0.0001) compared to those with adequate health literacy. Those with limited health literacy also reported worse lupus quality of life (P = 0.0004) and greater levels of stress (Perceived Stress Scale-4 P < 0.0001) and were 2.4 times more likely to have probable major depression (Patient Health Questionnaire Depression Scale-8 of ≥10 P = 0.004) and probable anxiety disorder (General Anxiety Disorder-7 of ≥10 P = 0.007) compared to those with adequate health literacy., Conclusion: Black women with SLE and limited health literacy have worse clinical outcomes and represent a particularly vulnerable population with significantly disparate health outcomes. These findings suggest health literacy and complexities of managing SLE may impair clinical care in multiple domains, ultimately contributing to higher disease activity and death/damage, and are important to address in clinical care and future interventions in patients with SLE., (© 2024 The Author(s). ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Diabetes is a significant public health concern with significant implications for health equity. Functional disability undermines disease control and may be associated with the relationship between criminal legal involvement and poor chronic disease outcomes, but this relationship has not been studied. This study examined the association between recent criminal legal involvement and functional disability among a nationally representative sample of US adults with diabetes. Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported a diagnosis of diabetes were included in this analysis examining the association between three forms of recent criminal legal involvement (past year arrest, or supervision on probation or parole) and functional disability, as measured by the World Health Organization Disability Assessment Score 2.0. In multivariate linear regression analyses adjusted for relevant socio-demographic and clinical confounders, the functional disability score increased by 2.7 (95% CI, 1.6-3.9) for those with past year arrest compared to no past year arrest; 1.2 (95% CI, -0.1, 2.6) for those with past year probation compared to no past year probation; and 0.4 (95% CI, -1.1, 1.8) for those with past year parole compared to no past year parole. Recent criminal legal involvement, specifically past year arrest, is associated with greater functional disability, which may serve as an important mediator for poor health outcomes in patients with diabetes. Future research should examine this pathway and prioritize interventions to improve both functional disability and glycemic control among individuals with diabetes and recent criminal legal involvement., (© 2024. The New York Academy of Medicine.)

Importance: As the global population ages, the proportion of individuals living with functional disability is increasing. Evidence suggests that functional disability is associated with worse health outcomes and is concentrated in populations with high rates of concurrent social risk factors such as criminal legal involvement (CLI), making it an increasingly important issue for advocates of health equity., Objective: To determine whether age is associated with functional disability in a nationally representative sample of United States adults with lifetime exposure to the criminal legal system., Design: Cross-sectional survey data from the National Survey of Drug Use and Health, 2015-2019., Setting: Nationally representative survey data., Participants: US adults who reported lifetime history of arrest (N = 37,279)., Exposure: Respondents were categorized into age groups: younger adults (age 18-49); middle-aged adults (age 50-64); and older adults (age ≥ 65)., Main Outcome Measure: Functional disability as measure by the World Health Organization Disability Assessment Score 2.0 (WHO-DAS 2.0). A higher score indicates a greater degree of functional disability., Results: The sample included 37,279 US adults with lifetime CLI of whom 60.0 % were younger adults, 28.5 % were middle-aged adults, and 11.5 % were older adults. The mean, unadjusted functional disability score for younger adults was 5.0 (95 % CI, 4.9, 5.1); for middle-aged adults it was 4.2 (95 % CI, 4.0, 4.4); and for older adults it was 3.2 (95 % CI, 2.9, 3.5). In models adjusted for sociodemographic and clinical confounders, differences were attenuated but remained statistically significant, indicating increased functional disability in the younger age groups., Conclusion and Relevance: Our findings suggest that among adults with CLI, functional disability is distributed by age in a pattern distinct from the general population. A large number of young adults have CLI, and the findings suggest that prevalence of functional disability is exceedingly high in this marginalized group. Future studies should examine if substance use and mental health conditions contribute to these findings, and policy makers should examine if flexible interventions tailored to the needs of those with disability improve reentry outcomes for young adults with CLI., Competing Interests: Declaration of competing interest All authors confirm they have no competing interests., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background : This study aimed to investigate the relationship between food insecurity and physical- and mental-health-related quality of life in adults with diabetes. Methods : Using two years of national Medical Expenditure Panel Survey data (2016-2017), we investigated the relationship between food insecurity and physical-health-related (PCS) and mental-health-related (MCS) quality of life in adults with diabetes. PCS and MCS were measured with the Short-Form 12 health survey and food insecurity was measured with the USDA 10-item adult scale. Analyses were weighted to represent the US adult population. Adjusted linear regression models, including covariates of age, gender, education, race/ethnicity, marital status, region, poverty level, employment status, health insurance, and comorbidities were used. Results : After adjustment, food-insecure adults with diabetes maintained significantly lower quality of life compared to food-secure adults with diabetes (PCS: -3.44, 95%CI -4.63, -2.25; MCS: -5.37, 95%CI -6.68, -4.06). This drop in PCS was larger than the drop for chronic conditions, including arthritis (-3.77, 95%CI -5.02, -2.52), emphysema (-2.82, 95%CI -5.12, -0.53), stroke (-2.63, 95%CI -4.11, -1.15), cancer (-2.59, 95%CI -4.00, -1.17), and heart attack (2.58, 95%CI 4.68, 0.48). Similarly, the drop for MCS was larger than for chronic pain (-2.37, 95%CI -3.24, -1.50) and arthritis (-1.31, 95%CI -2.28, -0.33). Conclusions : Food insecurity was associated with a significant reduction in both physical- and mental-health-related quality of life in adults with diabetes, with a magnitude of effect greater than adjusted estimates for the drop in quality of life for key chronic conditions. Addressing food insecurity through integration of social and medical care may lead to improvements in quality of life for adults with diabetes.

Background: Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults., Methods: Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015-2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates., Results: For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06-1.31) but not older adults (IRR 0.99, 95% CI 0.85-1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08-1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57)., Conclusion: Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization., (© 2024. The Author(s).)

Background: Approximately 11.3% of the US population has diabetes. The burden of diabetes is higher in older adults and African Americans (AAs), such that 40% of adults aged 50 years and older have diabetes; African Americans are 60% more likely to be diagnosed with diabetes compared to non-Hispanic Whites (NHWs). Structural racism has resulted in fewer economic and educational opportunities for AAs, higher social risks, and unmet basic needs, which result in financial instability, housing instability, food insecurity, and a lack of transportation compared to NHWs. The presence of these unmet basic needs is a driver of poor adherence to diabetes self-management in older AAs., Aim: To test the preliminary efficacy of a nurse case-manager, telephone-delivered intervention that provides foundational diabetes self-management education and skills training, while also addressing and resolving the unmet social needs of older AAs with poorly controlled type 2 diabetes mellitus (T2DM). The primary hypothesis is that older AAs with T2DM randomized to the DM Social Needs intervention will have significantly lower hemoglobin A1C (HbA1C), blood pressure, and LDL levels compared to the usual care arm at 6 months post randomization., Methods: This is a three-year prospective, randomized clinical trial that will enroll 100 AAs aged 50 and older with type 2 diabetes (T2DM) and HbA1C ≥ 8% into one of the following two groups: (1) a nurse case-manager, telephone-delivered intervention that provides foundational diabetes self-management education and skills training, but also addresses and resolves unmet social needs; or (2) an enhanced usual care group that will receive mailed diabetes education materials. Participants will be followed for 6 months to determine the effect of the intervention on HbA1C, blood pressure, and low-density lipoprotein (LDL) cholesterol levels., Results: Baseline characteristics will be presented by study group, and within- and between-group changes in primary outcomes from baseline to 6 months will be reported., Conclusion: The results from this study will provide insights into the efficacy of a combined diabetes education and skills training and social needs resolution intervention for older African Americans with poorly controlled type 2 diabetes and will inform strategies to improve diabetes outcomes for this vulnerable population.

Importance: Growing evidence suggests that social determinants of health are associated with low uptake of preventive care services., Objective: To examine the independent associations of social risk factor domains with preventive care services among US adults., Design, Setting, and Participants: This cross-sectional study used National Health Interview Survey data on 82 432 unweighted individuals (239 055 950 weighted) from 2016 to 2018. Subpopulations were created for each of the primary outcomes: routine mammography (women aged 40-74 years), Papanicolaou test (women aged 21-65 years), colonoscopy (adults aged 45-75 years), influenza vaccine (adults aged ≥18 years), and pneumococcal vaccine (adults aged ≥65 years). Statistical analysis was performed from July to December 2023., Exposures: Six social risk domains (economic instability, lack of community, education deficit, food insecurity, social isolation, and lack of access to care) and a count of domains., Main Outcomes and Measures: Logistic regression models were used to examine the independent association between each primary outcome (mammography, Papanicolaou test, colonoscopy, influenza vaccine, and pneumococcal vaccine) and social risk factor domains, while controlling for covariates (age, sex, race and ethnicity, health insurance, and comorbidities)., Results: A total of 82 432 unweighted US individuals (239 055 950 weighted individuals) were analyzed. A total of 54.3% were younger than 50 years, and 51.7% were female. All 5 screening outcomes were associated with educational deficit (mammography: odds ratio [OR], 0.73 [95% CI, 0.67-0.80]; Papanicolaou test: OR, 0.78 [95% CI, 0.72-0.85]; influenza vaccine: OR, 0.71 [95% CI, 0.67-0.74]; pneumococcal vaccine: OR, 0.68 [95% CI, 0.63-0.75]; colonoscopy: OR, 0.82 [95% CI, 0.77-0.87]) and a lack of access to care (mammography: OR, 0.32 [95% CI, 0.27-0.38]; Papanicolaou test: OR, 0.49 [95% CI, 0.44-0.54]; influenza vaccine: OR, 0.44 [95% CI, 0.41-0.47]; pneumococcal vaccine: OR, 0.30 [95% CI, 0.25-0.38]; colonoscopy: OR, 0.35 [95% CI, 0.30-0.41]). Fully adjusted models showed that every unit increase in social risk count was significantly associated with decreased odds of receiving a mammography (OR, 0.74 [95% CI, 0.71-0.77]), Papanicolaou test (OR, 0.84 [95% CI, 0.81-0.87]), influenza vaccine (OR, 0.81 [95% CI, 0.80-0.83]), pneumococcal vaccine (OR, 0.80 [95% CI, 0.77-0.83]), and colonoscopy (OR, 0.88 [95% CI, 0.86-0.90])., Conclusions and Relevance: This cross-sectional study of US adults suggests that social risk factor domains were associated with decreased odds of receiving preventive services; this association was cumulative. There is a need to address social risk factors to optimize receipt of recommended preventive services.

Background: Limited data exists on trends in prevalence of adverse childhood experiences (ACE) at the national level and sociodemographic correlates of having ACEs. This study examined trends in ACE prevalence and sociodemographic correlates in US adults over 14 years using nationally representative data., Methods: Data on 447,162 adults from the Behavioral Risk Factor Surveillance System (BRFSS) across four timepoints (2009-2010; 2011-2012; 2019-2020; 2021-2022) was analyzed and weighted for population estimates. The primary outcome was ACEs with 3 groups used (0 vs. 1 + ACEs; <4 vs. 4 + ACEs; 0 vs. 1 vs. 2 vs. 3 vs. 4 + ACEs). Sociodemographic factors included age, sex, race/ethnicity, employment, education, marital status, income and insurance status. Prevalence trends were examined by estimating prevalence of ACE groupings (0/1+; <4/4+; 0,1,2,3,4+) across the four timepoints and trend analysis was performed to determine if the differences over time were statistically significant. Unadjusted and adjusted prevalence ratios were estimated using log-binomial regression models with ACE groupings as the outcome and timepoints as the primary independent variable with sociodemographic factors as covariates., Results: Across the four time points, prevalence of ACEs was higher across groupings of ACEs by time. For ACEs 1+, prevalence was 62.2% (2009-2010); 62.2% (2011-2012); 64.5% (2019-2020); and 67.2% (2021-2022). For ACEs 4+, prevalence was 17.4% (2009-2010); 18.1% (2011-2012); 20.4% (2019-2020); and 22.6% (2021-2022). Prevalence of ACE 1 + was higher for older adults, Non-Hispanic Black adults, Non-Hispanic Other adults, and those with higher education. Prevalence of 4 + ACEs was higher for females, and lower for those with higher education and those with higher annual incomes., Conclusion: This study shows an increased prevalence of having ACEs over a 14-year period and identified independent sociodemographic correlates of having ACEs in a nationally representative study. Targeted interventions are needed to reduce burden of ACEs using population-based approaches., (© 2024. The Author(s).)

Purpose: Adverse childhood experiences (ACEs) confer significant risk for diabetes in adulthood. The purpose of this study was to explore perceptions about risk, potential pathways leading to diabetes, and solutions based on the lived experience., Methods: Three focus groups were conducted. A semi-structured interview guide was used to explore prevalence and causes of ACEs, pathways to diabetes, and possible solutions. Grounded theory was used for analysis. Constant comparisons resulted in emergent themes that were indexed and compared with the rest of the data to establish analytical categories. Analytical categories were further refined as additional data was collected until groups of key themes or categories were identified and used to construct a theoretical framework., Results: Participants totaled 23 across 3 groups. All participants were African American. Average age was 49, average number of years living with diabetes was 13 years. Participants included both men and women. Participants experienced one or more occasions of sexual abuse, physical and verbal abuse, and neglect. The major themes can be classified as A. Cause, B. Pathway, and C. Treatment/solution., Limitations: Findings may not generalize to the overall population with ACEs and diabetes., Conclusions: Three major themes were identified: family instability and financial hardship as risks for ACEs, maladaptive coping leading to diabetes, and social structure as a potential solution. Future research is needed to examine quantitatively, pathways to inform prevention at the primary, secondary, and tertiary levels of care for both the prevention of ACEs, mitigating risk for diabetes, and improving overall health., Competing Interests: Declaration of competing interest All authors declare they have no conflict of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Determine whether patient-level or provider-level factors have greater influence on patient satisfaction scores in an academic general internal medicine clinic., Methods: Two years of data (2017-2019) from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) surveys from ambulatory internal medicine clinic visits in an academic health center located in the Midwest United States were used. Patient satisfaction was measured using the overall provider satisfaction score (0-10), dichotomized with 9-10 defined as satisfactory and 0-8 as unsatisfactory. Provider-level independent variables included age, sex, race/ethnicity, provider type, service type, clinical effort, academic rank, and years since graduation. Patient-level factors included age, sex, race/ethnicity, education, and Epic Risk Score. Generalized mixed-effects logistic regression models were used to investigate associations between top-box satisfaction score and patient- and provider-level factors, accounting for the nesting of patients within providers., Results: Thirty-three providers and 4597 patients were included in the analysis. Male providers (OR, 1.57; 95% CI, 1.00, 2.47), minority group 2 (OR, 3.54; 95% CI, 1.24, 10.07) and minority group 3 (OR, 6.04; 95% CI, 1.45, 25.12), faculty (OR, 3.83; 95% CI, 1.56, 9.36), and primary care providers (OR, 5.60; 95% CI, 1.62, 19.34) had increased odds of having a top-box rating compared with females, minority group 1, advanced practice providers, and perioperative providers respectively. Age was the only patient independent correlate of top-box rating with a 3% increased odds of top-box rating for every year increase in age (OR, 1.03; 95% CI 1.02, 1.03)., Conclusions: In this academic general internal medicine clinic, top-box satisfaction scores were more strongly associated with provider-level factors, including provider race/ethnicity, provider type, and service type, as opposed to patient-level factors. Further research is needed to confirm these findings and identify potential system-level interventions., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: The prevalence of cardiovascular disease is burgeoning in low- and middle-income countries (LMICs). In sub-Saharan Africa, the prevalence of cardiovascular risk factors is increasing, though rates of CVD diagnosis and management remain low. Awareness of the influence of social determinants of health (SDOH) on cardiovascular outcomes is growing, however, most work focuses on high-income countries. Material needs security is a measure of SDOH that may be particularly relevant for LMICs. This study investigated the relationship between material needs security and cardiovascular risk in older adults living in South Africa., Methods: The analysis included 5059 respondents age ≥ 40 in the Health and Aging in Africa survey, an observational cohort study administered in 2014 in Mpumalanga Province, South Africa. Linear regression models tested the association between material needs and eight cardiovascular risk factors (waist-to-hip ratio, body mass index, blood pressure, glucose, cholesterol, LDL, and triglycerides). Adjusted linear regression models controlled for sociodemographic confounders., Results: There were significant adjusted associations found between increased material needs security and four cardiovascular risk factors, including waist-to-hip ratio (β = 0.001; 95% CI [0.00002,0.002]), BMI (β = 0.19; 95%CI=[0.14,0.24]), glucose (β = 0.46; 95%CI=[0.02,0.90]), and triglycerides (β = 0.26; 95%CI=[0.02,0.49])., Conclusion: Increased material needs security was associated with significantly increased cardiovascular risk in older adults in rural South Africa. These findings can inform the approach to treatment and management of cardiovascular disease in South Africa and similar LMICs. Future investigations should evaluate the implementation and efficacy of interventions that recognize the role of material needs security in cardiovascular risk., (© 2024. The Author(s).)

Importance: No clear process exists for categorizing social risks in a way that informs effective social risk screening and intervention development., Objective: To investigate social risk profiles and associations of those profiles with clinical outcomes in adults with diabetes using latent profile analysis., Design, Setting, and Participants: For this cross-sectional study, a latent profile analysis was conducted using data for adults with type 2 diabetes collected at 2 primary care clinics in the Southeastern US from 2013 to 2014. Data were analyzed from November to December 2023., Main Outcomes and Measures: Participants completed validated questionnaires for 26 social risk factors within 5 domains of social determinants of health: socioeconomic, neighborhood, education, food, and social and community context. In addition, participants completed questions that assessed psychological risk and behavioral risk. A 3-step latent profile analysis was used to identify different subgroups within the sample. Profiles were then regressed on outcomes of hemoglobin A1c (HbA1c), blood pressure, and quality of life., Results: A total of 615 participants (mean [SD] age, 61.3 [10.9] years; 379 men [61.6%]) were included. Five latent class profiles were identified. The lowest risk group had significantly higher mental health-related quality of life compared with a group with higher neighborhood risk (β, 1.11; 95% CI, 0.67 to 1.55). The second group had low economic risk but high neighborhood risk and served as the reference group. The third group had high economic and neighborhood risk and had significantly higher blood pressure (β, 8.08; 95% CI, 2.16 to 14.01) compared with the reference. The fourth group had high psychological and behavioral risks but low socioeconomic and neighborhood risks. This group had significantly higher HbA1c (β, 0.47; 95% CI, 0.01 to 0.92) and lower mental health-related quality of life (β, -1.83; 95% CI, -2.41 to -1.24) compared with the reference. The highest risk group indicated high risk in all domains, had significantly higher HbA1c (β, 1.07; 95% CI, 0.50 to 1.63), and had lower mental health-related quality of life (β, -2.15; 95% CI, -2.87 to -1.42) compared with the reference., Conclusions and Relevance: These findings suggest that social risk profiles can be identified according to social, psychological, and behavioral risk domains and the health outcome of concern among adults with diabetes. Future work should consider the use of social risk profiles in intervention development and testing.

Violent behaviour perpetrated against women has long-lasting negative physical and mental health consequences for women, their children, their families, and their communities. Intimate partner violence (IPV) is associated with many adverse physical, psychological, and emotional consequences. Structural racism and historical trauma affect women's trust and further hinder the ability of Indigenous and Black women to seek help after experiencing IPV. The availability of IPV support services, which can include shelter, food, group therapy, legal assistance, and advocacy, can be inaccessible to women due to the inability to access often limited resources in urban environments and reasons compounded by potential geographic distance if living in rural areas or living in community. Understanding the unique reasons why Indigenous and Black women do not seek help, and the barriers they experience when seeking help after IPV, is critical. Pandemics have the potential to create further complexities on how IPV is experienced. Black and Indigenous women experiencing IPV were therefore at even greater risk for IPV-related harm because of state and local "stay at home" measures put in place to minimise the spread COVID-19. The purpose of this manuscript is to explicate the methods for a large R01 study in the Upper Midwest., (© 2024 John Wiley & Sons Australia, Ltd.)

Objective: The aim of this analysis was to create a parsimonious tool to screen for high social risk using item response theory to discriminate across social risk factors in adults with type 2 diabetes., Methods: Cross-sectional data of 615 adults with diabetes recruited from two primary care clinics were used. Participants completed assessments including validated scales on economic instability (financial hardship), neighborhood and built environment (crime, violence, neighborhood rating), education (highest education, health literacy), food environment (food insecurity), social and community context (social isolation), and psychological risk factors (perceived stress, depression, serious psychological distress, diabetes distress). Item response theory (IRT) models were used to understand the association between a participant's underlying level of a particular social risk factor and the probability of that response. A two-parameter logistic IRT model was used with each of the 12 social determinant factors being added as a separate parameter in the model. Higher values in item discrimination indicate better ability of a specific social risk factor in differentiating participants from each other., Results: Rate of crime reported in a neighborhood (discrimination 3.13, SE 0.50; item difficulty - 0.68, SE 0.07) and neighborhood rating (discrimination 4.02, SE 0.87; item difficulty - 1.04, SE 0.08) had the highest discrimination., Conclusions: Based on these findings, crime and neighborhood rating discriminate best between individuals with type 2 diabetes who have high social risk and those with low social risk. These two questions can be used as a parsimonious social risk screening tool to identify high social risk., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Objective: We investigated direct and indirect relationships between historic redlining and prevalence of diabetes in a U.S. national sample., Research Design and Methods: Using a previously validated conceptual model, we hypothesized pathways between structural racism and prevalence of diabetes via discrimination, incarceration, poverty, substance use, housing, education, unemployment, and food access. We combined census tract-level data, including diabetes prevalence from the Centers for Disease Control and Prevention PLACES 2019 database, redlining using historic Home Owners' Loan Corporation (HOLC) maps from the Mapping Inequality project, and census data from the Opportunity Insights database. HOLC grade (a score between 1 [best] and 4 [redlined]) for each census tract was based on overlap with historically HOLC-graded areas. The final analytic sample consisted of 11,375 U.S. census tracts. Structural equation modeling was used to investigate direct and indirect relationships adjusting for the 2010 population., Results: Redlining was directly associated with higher crude prevalence of diabetes within a census tract (r = 0.01; P = 0.008) after adjusting for the 2010 population (χ2(54) = 69,900.95; P < 0.001; root mean square error of approximation = 0; comparative fit index = 1). Redlining was indirectly associated with diabetes prevalence via incarceration (r = 0.06; P < 0.001), poverty (r = -0.10; P < 0.001), discrimination (r = 0.14; P < 0.001); substance use (measured by binge drinking: r = -0.65, P < 0.001; and smoking: r = 0.35, P < 0.001), housing (r = 0.06; P < 0.001), education (r = -0.17; P < 0.001), unemployment (r = -0.17; P < 0.001), and food access (r = 0.14; P < 0.001) after adjusting for the 2010 population., Conclusions: Redlining has significant direct and indirect relationships with diabetes prevalence. Incarceration, poverty, discrimination, substance use, housing, education, unemployment, and food access may be possible targets for interventions aiming to mitigate the impact of structural racism on diabetes., (© 2024 by the American Diabetes Association.)

Objective: Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women., Study Design: Cross-sectional data ( n  = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors., Results: Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (β0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (β -1.26, 95%CI: -2.08, -0.44), multifetal gestation (β -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (β -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia., Conclusion: Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors., Key Points: · We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Globally, the prevalence of diabetes is increasing, especially in low- and middle-income countries (LMICs), including those in the sub-Saharan African region. However, the independent socioeconomic correlates of glycemic control as measured by hemoglobin A1C have yet to be identified. Therefore, the aim of this analysis was to understand the independent correlates of glycemic control in South Africa., Methods: Data from the 2016 South Africa Demographic and Health Survey on adults with diabetes were used for this analysis. The dependent variable, glycemic control, was defined using hemoglobin A1c (HbA1c). Independent variables included: age, gender, ethnicity, marital status, region, urban/rural residence, ability to read, education, insurance, wealth, occupation, and employment in the last year. Analysis of variance was used to test for differences in mean HbA1c for each category of all independent variables, and a fully adjusted linear regression model was used to identify independent correlates of glycemic control (HbA1c)., Results: Among the 772 people included in this analysis, there were significant differences in mean HbA1c by age ( p < 0.001), ethnicity ( p < 0.001), place of residence ( p = 0.024), wealth index ( p = 0.001), and employment in the last year ( p = 0.008). Independent correlates of HbA1c included age, ethnicity, and wealth index., Conclusions: This study used data from a large diverse population with a high prevalence of diabetes in sub-Saharan Africa and provides new evidence on the correlates of glycemic control and potential targets for interventions designed to lower HbA1c and improve diabetes-related health outcomes of adults in South Africa.

Background: Stroke is the fifth leading cause of death and disability in the United States. Social risk factors contribute to recovery from stroke, however the relationship between social risk factors and functional limitation among stroke survivors remains unknown., Methods: Data on 2,888 adults with stroke from the National Health Interview Survey from 2016-2018 was analyzed. The primary independent variables included six social risk factors: economic instability, lack of community, educational deficit, food insecurity, social isolation, and inadequate access to care. The outcome measure was functional limitation count. Negative binomial regression models were run to test the relationship between the independent and dependent variables adjusting for covariates., Results: Overall, 56% of the study participants were aged 65+, 70% were Non-Hispanic White, and 95% had at least one comorbidity. The mean functional limitation count was 1.8. In the unadjusted model, each social risk factor was significantly associated with functional limitation. In the fully adjusted model, significant association with functional limitation was found in individuals reporting economic instability (Incidence rate ratio [IRR] 1.65, 95% CI 1.33, 2.06), food insecurity (IRR 1.28, 95% CI 1.15, 1.42), and social isolation (IRR 1.64, 95% CI 1.48, 1.82)., Conclusions: Social risk factors such as economic instability, food insecurity and social isolation are significantly associated with functional limitation in adults with stroke. Interventions designed to address both social and medical needs have the potential to improve physical functioning and other clinical outcomes in stroke survivors., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Chargemaster prices are the list prices that providers and health systems assign to each of their medical services in the US. These charges are often several factors of magnitude higher than those extended to individuals with either private or public insurance, however, these list prices are billed in full to uninsured patients, putting them at increased risk of catastrophic health expenditures (CHE). The objective of this study was to examine the risk of CHE across insurance status, diabetes diagnosis and to examine disparity gaps across race/ethnicity., Methods: We perform a retrospective observational study on a nationally representative cohort of adult patients from the Medical Expenditure Panel Survey for the years 2002-2017. Using logistic regression models we estimate the risk of CHE across insurance status, diabetes diagnosis and explore disparity gaps across race/ethnicity., Results: Our fully adjusted results show that the relative odds of having CHE if uninsured is 5.9 (p < 0.01) compared to if insured, and 1.1 (p < 0.01) for patients with a diabetes diagnosis (compared to those without one). We note significant interactions between insurance status and diabetes diagnosis, with uninsured patients with a diabetes diagnosis being 9.5 times (p < 0.01) more likely to experience CHE than insured patients without a diabetes diagnosis. In terms of racial/ethnic disparities, we find that among the uninsured, non-Hispanic blacks are 13% (p < 0.05), and Hispanics 14.2% (p < 0.05), more likely to experience CHE than non-Hispanic whites. Among uninsured patients with diabetes, we further find that Hispanic patients are 39.3% (p < 0.05) more likely to have CHE than non-Hispanic white patients., Conclusions: Our findings indicate that uninsured patients with diabetes are at significantly elevated risks for CHE. These risks are further found to be disproportionately higher among uninsured racial/ethnic minorities, suggesting that CHE may present a channel through which structural economic and health disparities are perpetuated., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: Individuals involved with the criminal legal system have higher rates of mental illness, addiction, and health care utilization. The authors examined whether substance use disorders and mental illness alone or in combination drive health care utilization among those with recent criminal legal involvement., Methods: This cross-sectional analysis used nationally representative data from U.S. adults with past-year criminal legal involvement (N=9,039) recorded in the National Survey on Drug Use and Health (2015-2019). Using adjusted negative binomial regression models, the authors estimated relative risks for health care utilization. Primary independent variable categories included neither substance use disorder nor mental illness, substance use disorder only, mental illness only, and both conditions. Health care utilization included emergency department (ED) visits and nights spent in inpatient care., Results: Relative to neither mental illness nor substance use disorder, mental illness alone was associated with significantly increased acute health care services use: for ED visits, incidence risk ratio (IRR)=1.43 (95% CI=1.18-1.75) and for inpatient stays, IRR=2.14 (95% CI=1.47-3.11). Having both conditions was associated with increased ED visits (IRR=1.62, 95% CI=1.38-1.91) and inpatient stays (IRR=4.16, 95% CI=2.98-5.82). Substance use disorder alone was associated only with higher risk for ED visits compared with neither condition (IRR=1.23, 95% CI=1.01-1.50)., Conclusions: Mental illness with or without co-occurring substance use disorder is a strong driver of acute health care utilization after interaction with the criminal legal system. Interventions tailored to the unique needs of individuals with mental illness or substance use disorder are needed for those with recent criminal legal involvement., Competing Interests: The authors report no financial relationships with commercial interests.

Purpose: Delay discounting and aversion are important areas for diabetes management; however, little has been done to understand the relationship with psychosocial outcomes among adults with type 2 diabetes., Methods: This study used data from 365 adults with type 2 diabetes to evaluate relationships between delay discounting and aversion and psychosocial outcomes. Delay discounting and aversion were measured with the validated Quick Delay Questionnaire. Psychosocial outcomes included depression, measured by the PHQ, anxiety by the GAD scale, perceived stress by the PSS, and social support by the Duke Social Support and Stress Scale. Multiple linear regression was used to assess the relationship between delay discounting and aversion on psychological health and social support controlling for relevant covariates., Results: Mean age of the sample was 61.8 years, 54.5 % were NHB, 41.8 % NHW, and 3.7 % Hispanic/Other. After adjusting for covariates, delay aversion was significantly associated with depression (beta = 0.35; p < 0.001), anxiety (beta = 0.52; p < 0.001), perceived stress (beta = 0.22; p < 0.001), and lower family support (beta = -0.62; p < 0.05). Delay discounting was significantly associated with depression (beta = 0.32; p < 0.001), anxiety (beta = 0.46; p < 0.001), and perceived stress (beta = 0.26; p < 0.001)., Limitations: This data is cross-sectional, future work should examine the longitudinal relationship while also including additional psychosocial outcomes., Conclusions: Delay discounting and aversion are significantly associated with poor psychosocial outcomes, including lower social support. As the body of evidence grows, additional research is needed to better understand the construct, mechanisms, and the impact of choice settings to better inform intervention development., Competing Interests: Declaration of competing interest All authors declare they have no conflict of interest., (Copyright © 2023 Elsevier B.V. All rights reserved.)