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Objective The aim of this study was to design and assess the formative usability of a novel patient portal intervention designed to empower patients with diabetes to initiate orders for diabetes-related monitoring and preventive services. Materials and Methods We used a user-centered Design Sprint methodology to create our intervention prototype and assess its usability with 3 rounds of iterative testing. Participants (5/round) were presented with the prototype and asked to perform common, standardized tasks using think-aloud procedures. A facilitator rated task performance using a scale: (1) completed with ease, (2) completed with difficulty, and (3) failed. Participants completed the System Usability Scale (SUS) scored 0—worst to 100—best. All testing occurred remotely via Zoom. Results We identified 3 main categories of usability issues: distrust about the automated system, content concerns, and layout difficulties. Changes included improving clarity about the ordering process and simplifying language; however, design constraints inherent to the electronic health record system limited our ability to respond to all usability issues (eg, could not modify fixed elements in layout). Percent of tasks completed with ease across each round were 67%, 60%, and 80%, respectively. Average SUS scores were 87, 74, and 93, respectively. Across rounds, participants found the intervention valuable and appreciated the concept of patient-initiated ordering. Conclusions Through iterative user-centered design and testing, we improved the usability of the patient portal intervention. A tool that empowers patients to initiate orders for disease-specific services as part of their existing patient portal account has potential to enhance the completion of recommended health services and improve clinical outcomes.

Background: To test the hypothesis that patients treated with sodium-glucose cotransporter 2 (SGLT2) inhibitors or glucagon-like peptide 1 receptor agonists (GLP1RA) was associated with lower risk of cardiovascular endpoints vs dipeptidyl peptidase 4 inhibitors (DPP4). Methods: A retrospective cohort combined Veterans Administration, Medicare, and National Death Index databases. Patients using metformin, sulfonylurea or insulin alone or in combination were followed until a new fill of one of the following classes: SGLT2; GLP1RA; or DPP4. The index date and start of follow-up was the new prescription fill date. The composite outcome was major adverse cardiovascular event (MACE) or heart failure (HF) hospitalization: acute myocardial infarction (AMI), stroke, acute HF or cardiovascular (CV) death. Cox Proportional Hazards models compared MACE and HF for the comparison groups of interest, separately, in propensity score (PS) weighted cohorts adjusted for clinical covariates, laboratory data, ejection fraction (EF), smoking, and selected medications. Results: After PS weighting the cohorts included 46018 GLP1RA vs 45814 DPP4 and 36646 SGLT2 vs 36261 DPP4 participants. Median age was 69 years and diabetes duration of 9.0 (5.2, 13.4) years for GLP1RA vs DPP4 and 9.3 (5.7, 13.8) years for SGLT2 vs DPP4 users. Most new agents were added as third drug to either metformin + sulfonylurea or metformin + insulin regimen. GLP1RA was associated with lower hazard of MACE/HF vs DPP4 (0.73 [0.68, 0.78]) (panel A) yielding an adjusted risk difference (aRD) of 10.5 events [8.5, 12.4]); results were consistent for all outcome components. SGLT2 was associated with a lower hazard of MACE and HF (0.76 [0.69, 0.85]) (panel B) (aRD 8.1 [5.2, 10.7]); primarily due to reduction in CV death (0.71 [0.56, 0.90]) and HF hospitalization with reduced EF (0.40 [0.26, 0.62]). Conclusions: Use of GLP1RA or SGLT2 for diabetes treatment was associated with reduced risk of MACE and HF hospitalization vs DPP4.

Objective: Compare the risk of lactic acidosis hospitalization between patients treated with metformin versus sulfonylurea following development of reduced kidney function. Research Design and Methods: This retrospective cohort combined data from National Veterans Health Administration, Medicare, Medicaid and National Death Index. New users of metformin or sulfonylurea were followed from development of reduced kidney function (estimated Glomerular Filtration Rate [eGFR] >1.4 [female] or 1.5 [male] mg/dL) through hospitalization for lactic acidosis, death, lost to follow-up or study end. Lactic acidosis hospitalization was defined as a composite of primary discharge diagnosis or laboratory-confirmed lactic acidosis (lactic acid >2.5 mmol/L and either arterial blood pH <19 mmol/L within 24 hours of admission). We report the cause specific hazard of lactic acidosis hospitalization between metformin and sulfonylurea from a propensity score matched weighted cohort, and conduct additional competing risks analysis to account for treatment change and death. Results: The weighted cohort included 24,542 metformin and 24,662 sulfonylurea users who developed reduced kidney function (median age 70 years, median eGFR 55.8 ml/min/1.73m2). There were 4.18 [3.63, 4.81] versus 3.69 [3.19, 4.27] lactic acidosis hospitalizations per 1,000 person-years among metformin and sulfonylurea users, respectively (adjusted hazard ratio (aHR) 1.21 [0.99, 1.50]). Results were consistent for both primary discharge diagnosis (aHR 1.11 [0.87, 1.44]) and laboratory-confirmed lactic acidosis (aHR 1.25 [0.92,1.70]). Conclusions: Among veterans with diabetes who developed reduced kidney function, occurrence of lactic acidosis hospitalization was uncommon and not statistically different between patients who continued metformin and sulfonylurea.

The growth of Internet applications has substantially broadened the potential for its use in global telehealth. This pilot project used the virtual reality world of Second Life for diabetic patients to meet with their nurse practitioners for their maintenance visits. Using avatars and the online patient portal, these scheduled visits were designed to meet the needs of the patients as determined by the results from a questionnaire completed by patients prior to the visit. The virtual visits took place in the replicated building where patients typically receive their care, the Eskind Diabetes Clinic. Orientation sessions to Second Life were made available prior to the actual visit, and additional online resources were made available after the visit was over. Although only seven pilot patients have currently completed visits, data illustrate the positive potential use of this treatment modality for future study.

Animal studies have shown that the peroxime proliferator-activated receptor delta (PPARD) gene regulates glucose metabolism and insulin sensitivity. Genetic variation in the PPARD gene might affect physical endurance and has been associated with obesity. We investigated the independent and modifying effect of variants in the PPARD gene with exercise participation and body mass index (BMI) on type 2 diabetes (T2D), using data from a genome-wide association study (GWAS) of middle-aged women living in Shanghai, China, with 1019 T2D cases and 1709 controls. The genotyping was performed using the Affymetrix Genome-Wide Human SNP Array 6.0 platform. Imputation was used to determine missing genotypes. Participation in exercise was assessed by a questionnaire. Anthropometric variables were measured by trained interviewers. The association between polymorphisms and T2D was assessed by logistic regression analyses. The combined effects of polymorphisms in the PPARD gene with exercise participation and BMI on T2D risk was assessed by conducting stratified analysis with exercise participation and BMI categories. No significant associations between PPARD and T2D were found in either genotyped or imputed SNPs and no effect modification between exercise participation and PPARD genetic variation was found, suggesting that PPARD is not a risk factor for T2D in this population.