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OBJECTIVE Although diabetic retinopathy is a leading cause of blindness worldwide, diabetes-related blindness can be prevented through effective screening, detection, and treatment of disease. The study goal was to develop risk stratification algorithms for the onset of retinal complications of diabetes, including proliferative diabetic retinopathy, referable retinopathy, and macular edema. RESEARCH DESIGN AND METHODS Retrospective cohort analysis of patients from the Kaiser Permanente Northern California Diabetes Registry who had no evidence of diabetic retinopathy at a baseline diabetic retinopathy screening during 2008–2020 was performed. Machine learning and logistic regression prediction models for onset of proliferative diabetic retinopathy, diabetic macular edema, and referable retinopathy detected through routine screening were trained and internally validated. Model performance was assessed using area under the curve (AUC) metrics. RESULTS The study cohort (N = 276,794) was 51.9% male and 42.1% White. Mean (±SD) age at baseline was 60.0 (±13.1) years. A machine learning XGBoost algorithm was effective in identifying patients who developed proliferative diabetic retinopathy (AUC 0.86; 95% CI, 0.86–0.87), diabetic macular edema (AUC 0.76; 95% CI, 0.75–0.77), and referable retinopathy (AUC 0.78; 95% CI, 0.78–0.79). Similar results were found using a simpler nine-covariate logistic regression model: proliferative diabetic retinopathy (AUC 0.82; 95% CI, 0.80–0.83), diabetic macular edema (AUC 0.73; 95% CI, 0.72–0.74), and referable retinopathy (AUC 0.75; 95% CI, 0.75–0.76). CONCLUSIONS Relatively simple logistic regression models using nine readily available clinical variables can be used to rank order patients for onset of diabetic eye disease and thereby more efficiently prioritize and target screening for at risk patients.

Continuous glucose monitoring (CGM) is indicated in poorly controlled insulin-treated patients with type 2 diabetes (T2D) to improve glycemic control and reduce the risk of hypoglycemia, but the benefits of CGM for lower risk patients have not been well studied. Among 17,422 insulin-treated patients with T2D with hemoglobin A1c (HbA1c)

This cohort study uses data from continuous glucose monitoring to validate a hypoglycemia risk stratification tool.

The relationship between achieved low-density lipoprotein cholesterol (LDL-C) levels and risk of incident atherosclerotic cardiovascular disease events among patients with diabetes and metabolic dyslipidemia has not been well described.We conducted an observational cohort study of statin-treated adults (ages 21-90 years) with type 2 diabetes without established atherosclerotic cardiovascular disease (as of January 1, 2006) who had metabolic dyslipidemia (elevated triglycerides ≥150 mg/dL and low high-density lipoprotein cholesterol,50 mg/dL [women] and40 mg/dL [men]). All subjects were members of Kaiser Permanente Northern California, an integrated health care delivery system. Adjusted multivariable Cox models were specified to estimate hazard ratios (HRs) for incident atherosclerotic cardiovascular disease events by achieved LDL-C levels (50, 50-70, 70-100, and ≥100 mg/dL). Incident atherosclerotic cardiovascular disease events were defined as a composite of nonfatal myocardial infarction, ischemic stroke, or coronary heart disease death through December 31, 2013.A total of 19,095 individuals met the selection criteria. Mean age was 63.4 years, 53.5% were women, and the mean follow-up was 5.9 years. Unadjusted rates of atherosclerotic cardiovascular disease events were not significantly different across specified LDL-C categories. In models adjusted for demographics and clinical characteristics, the risk was significantly lower with decreasing achieved LDL-C levels (P0.0001 for trend). Relative to achieved LDL-C ≥100 mg/dL, LDL-C50 mg/dL had an hazard ratio of 0.66 (95% confidence interval [CI] 0.52-0.82).In a large, contemporary cohort of statin-treated patients with type 2 diabetes and metabolic dyslipidemia without established atherosclerotic cardiovascular disease, lower achieved LDL-C levels were associated with a monotonically lower risk of incident atherosclerotic cardiovascular disease events. The benefits of achieving very-low LDL-C (50 mg/dL) in this population requires further evaluation in prospective interventional studies.

Objective In the National Library of Medicine funded ECLIPPSE Project (Employing Computational Linguistics to Improve Patient-Provider Secure Emails exchange), we attempted to create novel, valid, and scalable measures of both patients’ health literacy (HL) and physicians’ linguistic complexity by employing natural language processing (NLP) techniques and machine learning (ML). We applied these techniques to > 400,000 patients’ and physicians’ secure messages (SMs) exchanged via an electronic patient portal, developing and validating an automated patient literacy profile (LP) and physician complexity profile (CP). Herein, we describe the challenges faced and the solutions implemented during this innovative endeavor. Materials and methods To describe challenges and solutions, we used two data sources: study documents and interviews with study investigators. Over the five years of the project, the team tracked their research process using a combination of Google Docs tools and an online team organization, tracking, and management tool (Asana). In year 5, the team convened a number of times to discuss, categorize, and code primary challenges and solutions. Results We identified 23 challenges and associated approaches that emerged from three overarching process domains: (1) Data Mining related to the SM corpus; (2) Analyses using NLP indices on the SM corpus; and (3) Interdisciplinary Collaboration. With respect to Data Mining, problems included cleaning SMs to enable analyses, removing hidden caregiver proxies (e.g., other family members) and Spanish language SMs, and culling SMs to ensure that only patients’ primary care physicians were included. With respect to Analyses, critical decisions needed to be made as to which computational linguistic indices and ML approaches should be selected; how to enable the NLP-based linguistic indices tools to run smoothly and to extract meaningful data from a large corpus of medical text; and how to best assess content and predictive validities of both the LP and the CP. With respect to the Interdisciplinary Collaboration, because the research required engagement between clinicians, health services researchers, biomedical informaticians, linguists, and cognitive scientists, continual effort was needed to identify and reconcile differences in scientific terminologies and resolve confusion; arrive at common understanding of tasks that needed to be completed and priorities therein; reach compromises regarding what represents “meaningful findings” in health services vs. cognitive science research; and address constraints regarding potential transportability of the final LP and CP to different health care settings. Discussion Our study represents a process evaluation of an innovative research initiative to harness “big linguistic data” to estimate patient HL and physician linguistic complexity. Any of the challenges we identified, if left unaddressed, would have either rendered impossible the effort to generate LPs and CPs, or invalidated analytic results related to the LPs and CPs. Investigators undertaking similar research in HL or using computational linguistic methods to assess patient-clinician exchange will face similar challenges and may find our solutions helpful when designing and executing their health communications research.

Introduction: Studies evaluating the relationship of severe hypoglycemia (SH) with the risk of atherosclerotic cardiovascular disease (ASCVD) events are limited by size, confounding and inconsistent outcome definitions. The aim of this study was to assess the association of SH, as defined by hypoglycemia-related hospital utilization, with risk of ASCVD. Methods: We conducted an observational cohort study of adults with diabetes with or without established ASCVD (as of 1/1/2014). All subjects were members of Kaiser Permanente Northern California, an integrated health care delivery system. Baseline was determined by the date of the first hypoglycemia-related utilization (primary diagnosis of hypoglycemia in the emergency department or principal diagnosis in the hospital) during 1/1/2013 - 12/31/2013. Baseline for those without SH, was a randomly assigned date in 2013. Multivariate Cox proportional hazard models were specified to estimate hazard ratios (HRs) for SH in adjusted models of time to incident ASCVD events. This outcome was defined as a composite of nonfatal myocardial infarction, ischemic stroke, or coronary heart disease death through 12/31/2017. Results: Among 233,696 eligible individuals, mean age was 63.6 years, 47.6% were women, and mean follow-up was 3.8 years. There were 2,179 episodes of SH. Age-sex-race adjusted risk of ASCVD among those with SH versus those without was HR 2.59 (95% CI 2.3-2.9). When additionally adjusted for prior ASCVD, the HR was still more than double, HR 2.32 (95% CI 2.1-2.6). In a fully saturated model with additional adjustments for diabetes type, diabetes duration, HbA1c, GFR, Charlson score, insulin use, sulfonylureas, and quartiles of neighborhood deprivation, SH was associated with a 30% increased risk (HR 1.31, 95% CI 1.16-1.5). The substantial attenuation in risk after more comprehensive adjustment suggests that patients at higher risk of SH are likely at higher risk of ASCVD. Conclusions: In a large, diverse and contemporary cohort of patients with diabetes, SH as defined by hypoglycemia-related hospital utilization is associated with greater risk of ASCVD. Increased awareness in recognizing this risk and vigilance in care for this higher risk population is warranted.

Meta-analyses and reviews of observational cohorts have reported a relationship between severe hypoglycemia (SH) and atherosclerotic cardiovascular disease (ASCVD) events, but estimates of effect vary widely and many studies are limited by size and diversity, ability to adjust for confounders, and inconsistent definitions of exposures and outcomes (1–4). We studied the association of SH events and risk of ASCVD in a large, diverse cohort of patients. This study was approved by the Kaiser Permanente Northern California (KPNC) Institutional Review Board. This observational cohort study included adults (age ≥18 years) with diabetes who were members of KPNC, an integrated health care delivery system, with continuous membership during the 2 years prior to baseline. The outcomes of interest were ASCVD events, defined as a composite of nonfatal myocardial infarction, fatal or nonfatal ischemic stroke, or death due to coronary heart disease. The exposure of interest …

Objective: We examined how diabetes medication initiation after first diagnosis varied by race/ethnicity. Method: We conducted a retrospective cohort study of 66,939 patients with newly diagnosed diabetes using data from a large integrated healthcare system. We classified patients into 12 race/ethnicity groups (see Table) and assessed their associations with diabetes medication initiation within 1, 12 and 18 months after diagnosis. We used a modified Poisson regression to estimate risk ratios adjusted for pre-diagnosis demographics and clinical characteristics. Results: Medications were started in 30%, 43% and 48% of patients within 1, 12 and 18 months, respectively. Within 1 month of diagnosis, Chinese, Filipino, and Native Hawaiian/Pacific islander were less likely to initiate a medication compared to whites. Results were consistent at 12 and 18 months, except that Japanese and blacks/African Americans were less likely to initiate compared to whites and that there was no difference between Native Hawaiian/Pacific islanders and whites at 18 months. Conclusions: We observed persistent racial differences between patients receiving any medication following initial diabetes diagnosis, with the largest differences for several Asian populations. Disclosure A.N. Winn: None. A.J. Karter: Research Support; Self; Dexcom, Inc. E.M. Staab: None. J. Liu: None. W. Wan: None. R. Skandari: None. A.C. Knitter: None. H.H. Moffet: None. D.R. Miller: None. M.E. Peek: Research Support; Self; Merck Foundation. E. Huang: None. N. Laiteerapong: None.

Importance Continuous glucose monitoring (CGM) is recommended for patients with type 1 diabetes; observational evidence for CGM in patients with insulin-treated type 2 diabetes is lacking. Objective To estimate clinical outcomes of real-time CGM initiation. Design, Setting, and Participants Exploratory retrospective cohort study of changes in outcomes associated with real-time CGM initiation, estimated using a difference-in-differences analysis. A total of 41 753 participants with insulin-treated diabetes (5673 type 1; 36 080 type 2) receiving care from a Northern California integrated health care delivery system (2014-2019), being treated with insulin, self-monitoring their blood glucose levels, and having no prior CGM use were included. Exposures Initiation vs noninitiation of real-time CGM (reference group). Main Outcomes and Measures Ten end points measured during the 12 months before and 12 months after baseline: hemoglobin A1c(HbA1c); hypoglycemia (emergency department or hospital utilization); hyperglycemia (emergency department or hospital utilization); HbA1clevels lower than 7%, lower than 8%, and higher than 9%; 1 emergency department encounter or more for any reason; 1 hospitalization or more for any reason; and number of outpatient visits and telephone visits. Results The real-time CGM initiators included 3806 patients (mean age, 42.4 years [SD, 19.9 years]; 51% female; 91% type 1, 9% type 2); the noninitiators included 37 947 patients (mean age, 63.4 years [SD, 13.4 years]; 49% female; 6% type 1, 94% type 2). The prebaseline mean HbA1cwas lower among real-time CGM initiators than among noninitiators, but real-time CGM initiators had higher prebaseline rates of hypoglycemia and hyperglycemia. Mean HbA1cdeclined among real-time CGM initiators from 8.17% to 7.76% and from 8.28% to 8.19% among noninitiators (adjusted difference-in-differences estimate, −0.40%; 95% CI, −0.48% to −0.32%;P Conclusions and Relevance In this retrospective cohort study, insulin-treated patients with diabetes selected by physicians for real-time continuous glucose monitoring compared with noninitiators had significant improvements in hemoglobin A1cand reductions in emergency department visits and hospitalizations for hypoglycemia, but no significant change in emergency department visits or hospitalizations for hyperglycemia or for any reason. Because of the observational study design, findings may have been susceptible to selection bias.

To estimate the rate, characteristics, and dispositions of hypoglycemia events among persons who received care from Alameda County, California, Emergency Medical Services (EMS).This study was based on data for 601,077 Alameda County EMS encounters during 2013-15. Subjects were defined as having hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (60 mg/dl or "unspecified low"). The outcome of interest was patient transport or non-transport to an emergency department or other care setting; we excluded 33,177 (6%) encounters which lacked clear disposition outcomes.Among 567,900 eligible encounters, 8,332 (1.47%) were attributed to hypoglycemia, of which 1,125 (13.5%) were not transported. Non-transport was more likely among males, adult patients age60, initial blood glucose60 mg/dl or EMS arrival time 18:00-6:00.Without an understanding of EMS encounters and non-transport rates, surveillance based solely on emergency department and hospital data will significantly underestimate rates of severe hypoglycemia. Additionally, given that hypoglycemia is often safely and effectively treated by non-physicians, EMS protocols should provide guidance for non-transport of hypoglycemic patients whose blood glucose levels have normalized.

Objective To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. Data Sources/Setting Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006–2012. Study Design Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. Data Collection Adherence and OOP costs were based on pharmacy dispensing records and benefits. Principal Findings Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1–$10, and 3 percent when the medication was free of charge (p

Seven-year surveillance study (2005-2011) to evaluate race/ethnic differences in the trends in rates of severe hypoglycemia (SH) in a population of insured, at-risk adults with diabetes.SH events were identified via any primary or principal diagnosis from emergency department or inpatient encounters among African American, Asian, Latino and White adult diabetes patients treated with insulin or secretagogues (Sulfonylureas or Meglitinides), receiving care from integrated healthcare delivery systems across the United States. We calculated age- and sex-standardized annual SH rates and average annual percent change (AAPC) in SH rates.Annual SH rates ranged from 1.8% to 2.1% during this 7-year observation period (2,200,471 person-years). African Americans had consistently higher SH rates compared with Whites, while Latinos and Asians had consistently lower rates compared with Whites in each of the 7 years (all p0.01). The trend increased significantly only among African Americans (AAPC = +4.3%; 95% CI: +2.1, +6.5%); in the other groups, the AAPC was not significantly different from zero.Surveillance efforts should monitor the racial/ethnic-specific rates. The factors underlying substantially higher rates of hypoglycemia in African Americans should be evaluated. Clinically and culturally-appropriate strategies to reduce the risk of SH need to be developed and tested.

Aims To classify trajectories of long term HbA1c values in patients after diagnosis of type 2 diabetes and examine each trajectory's associations with subsequent microvascular and macrovascular events and mortality. Methods A longitudinal follow-up of 28,016 patients newly diagnosed with type 2 diabetes was conducted. Latent growth mixture modeling was used to identify ten-year HbA1c trajectories. Cox proportional hazards models were used to assess how HbA1c trajectories were associated with events (microvascular and macrovascular) and mortality. Results We identified 5 HbA1c trajectories: “low stable” (82.5%), “moderate increasing late” (5.1%), “high decreasing early” (4.9%), “moderate peaking late” (4.1%) and “moderate peaking early” (3.3%). After adjusting for average HbA1c, compared to the low stable trajectory, all non-stable trajectories were associated with higher incidences of microvascular events (hazard ratio (HR) range, 1.28 (95% CI, 1.08–1.53) (high decreasing early) to 1.45 (95% CI, 1.20–1.75) (moderate peaking early)). The high decreasing early trajectory was associated with an increased mortality risk (HR, 1.27 (95% CI, 1.03–1.58)). Trajectories were not associated with macrovascular events. Conclusions Non-stable HbA1c trajectories were associated with greater risk of microvascular events and mortality. These findings suggest a potential benefit of early diabetes detection, prioritizing good glycemic control, and maintaining control over time.

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

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

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

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

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

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

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

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

The relevance of low-density lipoprotein cholesterol (LDL-C) or non-high-density lipoprotein cholesterol (non-HDL-C) goals for primary prevention of atherosclerotic cardiovascular disease (ASCVD) among patients with diabetes was assessed. This retrospective cohort study included patients with type 2 diabetes, age 21 to 90years, taking statins, with no history of ASCVD as of January 1, 2006, in Kaiser Permanente Northern California, an integrated healthcare delivery system. Multivariate cox models were utilized to estimate hazard ratios (HRs) for incident ASCVD events by achieved LDL-C and non-HDL-C levels with adjustment for potential confounders. Incident ASCVD events were defined as a composite of myocardial infarction, ischemic stroke, or coronary heart disease death. A cohort of 62,428 patients, with mean age of 64.1years, 46.9% women, and mean follow-up of 6.0 years, was identified. After adjustment, the risk of incident ASCVD for these statin-treated patients was monotonically lower with decreasing achieved LDL-C levels (p0.0001 for trend) and non-HDL-C levels (p0.0001 for trend). Relative to achieved LDL-C ≥130 mg/dl, LDL-C50 mg/dl had HR = 0.58 (95% confidence interval 0.49 to 0.69). Relative to achieved non-HDL-C ≥160mg/dl, non-HDL-C80 mg/dl had HR = 0.59 (95% confidence interval 0.51 to 0.68). In a large cohort of statin-treated diabetic patients without ASCVD, a monotonically lower risk of incident ASCVD events was associated with lower achieved lipid levels. These findings support the use of LDL-C ornon-HDL-C treatment goals for ASCVD primary prevention in diabetic patients.

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

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

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

We estimated associations between neighborhood supermarket gain or loss and glycemic control (assessed by glycated hemoglobin (HbA1c) values) in patients from the Kaiser Permanente Northern California Diabetes Registry (n=434,806 person-years; 2007-2010). Annual clinical measures were linked to metrics from a geographic information system for each patient's address of longest residence. We estimated the association between change in supermarket presence (gain, loss, or no change) and change in HbA1c value, adjusting for individual- and area-level attributes and according to baseline glycemic control (near normal

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

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

Providing culturally competent care to the growing number of limited-English proficiency (LEP) Latinos with diabetes in the United States is challenging.To evaluate changes in risk factor control among LEP Latinos with diabetes who switched from language-discordant (English-only) primary care physicians (PCPs) to language-concordant (Spanish-speaking) PCPs or vice versa.This pre-post, difference-in-differences study selected 1605 adult patients with diabetes who self-identified as Latino, whose preferred language was Spanish, and who switched PCPs between January 1, 2007, and December 31, 2013. Study participants were members of the Kaiser Permanente Northern California health care system (an integrated health care delivery system with access to bilingual PCPs and/or professional interpreter services). Spanish-speaking and English-only PCPs were identified by self-report or utilization data.Change in patient-PCP language concordance after switching PCPs.Glycemic control (glycated hemoglobin [HbA1c] 8%), poor glycemic control (HbA1c 9%), low-density-lipoprotein (LDL) control (LDL 100 mg/dL), and systolic blood pressure (SBP) control (SBP 140 mm Hg).Overall, 1605 LEP Latino adults with diabetes (mean [SD] age, 60.5 [13.1] years) were included in this study, and there was a significant net improvement in glycemic and LDL control among patients who switched from language-discordant PCPs to concordant PCPs relative to those who switched from one discordant PCP to another discordant PCP. After adjustment and accounting for secular trends, the prevalence of glycemic control increased by 10% (95% CI, 2% to 17%; P = .01), poor glycemic control decreased by 4% (95% CI, -10% to 2%; P = .16) and LDL control increased by 9% (95% CI, 1% to 17%; P = .03). No significant changes were observed in SBP control. Prevalence of LDL control increased 15% (95% CI, 7% to 24%; P .001) among LEP Latinos who switched from concordant to discordant PCPs. Risk factor control did not worsen following a PCP switch in any group.We observed significant improvements in glycemic control among LEP Latino patients with diabetes who switched from language-discordant to concordant PCPs. Facilitating language-concordant care may be a strategy for diabetes management among LEP Latinos.

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

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

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

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

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

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

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

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

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

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

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

OBJECTIVE We estimated the prevalence and incidence of diabetes among specific subgroups of Asians and Pacific Islanders (APIs) in a multiethnic U.S. population with uniform access to care. RESEARCH DESIGN AND METHODS This prospective cohort analysis included 2,123,548 adult members of Kaiser Permanente Northern California, including 1,704,363 with known race/ethnicity (white, 56.9%; Latino, 14.9%; African American, 8.0%; Filipino, 4.9%; Chinese, 4.0%; multiracial, 2.8%; Japanese, 0.9%; Native American, 0.6%; Pacific Islander, 0.5%; South Asian, 0.4%; and Southeast Asian, Korean, and Vietnamese, 0.1% each). We calculated age-standardized (to the 2010 U.S. population) and sex-adjusted diabetes prevalence at baseline and incidence (during the 2010 calendar year). Poisson models were used to estimate relative risks. RESULTS There were 210,632 subjects with prevalent diabetes as of 1 January 2010 and 15,357 incident cases of diabetes identified during 2010. The crude diabetes prevalence was 9.9% and the incidence was 8.0 cases per 1,000 person-years and, after standardizing by age and sex to the 2010 U.S. Census, 8.9% and 7.7 cases per 1,000 person-years. There was considerable variation among the seven largest API subgroups. Pacific Islanders, South Asians, and Filipinos had the highest prevalence (18.3, 15.9, and 16.1%, respectively) and the highest incidence (19.9, 17.2, and 14.7 cases per 1,000 person-years, respectively) of diabetes among all racial/ethnic groups, including minorities traditionally considered high risk (e.g., African Americans, Latinos, and Native Americans). CONCLUSIONS High rates of diabetes among Pacific Islanders, South Asians, and Filipinos are obscured by much lower rates among the large population of Chinese and several smaller Asian subgroups.

While stress has been linked to poor health outcomes, little is known about the impact of objective measures of neighborhood crime on stress in patients with chronic disease. Using the Kaiser Permanente Diabetes Study of Northern California (DISTANCE), we examined associations between police-recorded crime (2005-2007) and stress (Perceived Stress Scale-4) in four large Northern California cities (Oakland, Sacramento, San Francisco, and San Jose). We performed stratified analysis by gender and race/ethnicity using generalized linear regression models. In our study sample (n = 3188, mean age 59, range 30-77), 10% reported high stress. In adjusted analyses, higher neighborhood all crimes rate was associated with modest increase in high stress for African-American (OR = 1.10; 95% CI 1.02-1.22) and Latina women (OR = 1.36; 95% CI 1.10-1.67) and property crime showed similar associations with stress for these groups of women. Visible crime was associated with stress only for Latina women (OR = 1.43; 95% CI 1.14-1.78). We found no association between crime and stress among men or other racial/ethnic groups of women. High crime levels may disproportionately impact health among certain subpopulations. Studies using additional measures of stress are necessary to differentiate the health impact of crime-related stress from other forms of stressors among individuals living with diabetes.

The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one's doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one's doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.