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Purpose There is clear evidence that prison can be detrimental to mental health and that wider society has tended to assume “out of sight, out of mind” for prisoners in mental distress. The lack of access to effective mental health care in prisons along with increasingly lower numbers of prison officers, or Operational Officers (OOs), has created a negative culture that requires the development of specialist services. With this comes a need to conduct evaluations, and investigations, into the roles of OOs and mental health-care staff. This study aims to report on a commissioned evaluation around the introduction and development of an HMP Mental Health Unit, named the integrated support unit (ISU), in the North of England. This study’s section of the wider evaluation focuses on the early team building, working practice and development of mental health registered nurses, other care staff and OOs within the ISU. Design/methodology/approach Three focus groups incorporating two professional groups took place on the ISU. The first of six Mental Health Workers (MHW) including Registered Mental Health Nurses and support workers; the second of two sets of two ISU dedicated OOs. The areas addressed within each of the groups concerned why staff wanted to work in the ISU, as well as how they would measure its potential success, and the necessary skills competencies and training they thought were required to prepare them to work in the area. Findings Overall, the participants expressed an interest or enthusiasm for their work having actively chosen to work in the ISU. There was a strong sense of a wish for the unit to succeed; in fact, success was a motivating drive for all. Both OOs and MHW emphasised the importance of teamworking, autonomy and freedom as well as information sharing. Analysis also revealed many areas of practice that were challenging. The findings are optimistic for the development of such special units as evaluated here. The drivers for different professions along with their measures of success in the field are discussed in detail. The relationship, expectations, hopes and needs of both MHW and prison officers working in a multidisciplinary unit provide useful information to support both policy and practice in the field. The authors make recommendations around training regimes and how they can effectively coordinate the different symbiotic professional roles. The ISU is a new initiative in offender management within prisons and is reviewed as a model of mental health practice in prison settings. Practical implications The value in recruiting to the ISU dedicated OOs, with committed interests in mental health. A continued emphasis on the ongoing development of team working, focussing on issues of risk, trust and treatment. The development (by nurses) of a formal/mandatory period of training for new OO’s prior to taking up a role on the ISU. For mental health nurses to embrace team leadership/educator roles in the areas of mental health awareness, team building and conflict resolution. To capture and formulate and develop the specific range of mental health interventions offered within the ISU. Originality/value The presented research explores and evaluates the introduction of a new mental health wing (ISU) for 11 patients in a Northern UK prison. It does this through the consideration of group discussions with both MHW and OOs on this wing. This work is part of a larger study.

Melioidosis is an infectious disease caused by the bacterium Burkholderia pseudomallei. Although this environmental organism is endemic in certain regions of Australia, it is not considered endemic in Southern Queensland, where the last case was reported 21 years ago. We report a climate change–associated outbreak of melioidosis occurring during two La Niña events in a region previously considered nonendemic for B. pseudomallei. During a 15-month period, 14 cases of locally acquired melioidosis were identified. Twelve patients were adults (> 50 years), with diabetes mellitus the most common risk factor in 6 of 12 patients (50%). Eleven patients (79%) had direct exposure to floodwaters or the flooded environment. This study suggests an association between climate change and an increased incidence of melioidosis. In addition, this is the first report of environmental sampling and whole-genome analysis to prove endemicity and local acquisition in this region.

BACKGROUND: Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence. OBJECTIVE: To assess an intervention to encourage MOP services to increase its use and medication adherence. DESIGN: Randomized encouragement trial. PATIENTS: 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months. INTERVENTION: Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. MEASUREMENTS: We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis. RESULTS: During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p

BACKGROUND: Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. OBJECTIVE: To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI. DESIGN: Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring. KEY RESULTS: Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21–1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87–0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02–1.05, p < .001; aRR 1.02; 95% CI 1.00–1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02–1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71–0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control. CONCLUSIONS: Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-019-05489-3) contains supplementary material, which is available to authorized users.

A pragmatic solution for the provision of care for prisoners with serious mental illness, who are often subject to delays in hospital transfer, is the creation of specialist prison units. This paper analyses the development of a prison unit in England for prisoners with ‘serious mental illness’. The unit was developed within over-lapping health and justice contexts, including expectations, pressures and priorities, which impacted on the outcomes expected and achieved. The methodology included attendance at Steering group meetings, analysis of a minimum dataset, and interviews with key stakeholders. A number of key sites of contestation are analyzed including: admission criteria; aims; activities; staffing; the physical environment; and discharge.

The use of quantitative methods within realist methodologies are fairly rare. This is perhaps because a realist understanding of the social word as complex and dynamic (messy but not chaotic) does not sit well with traditional variable-based causal analysis which test specific theoretical assumptions, yet cannot account for interaction, moderation and emergence. In this paper, we explore the ontological challenges and epistemological issues which underpin the development of our complex realist approach to quantitative data analysis. We provide an example of its application to a large case-based time-ordered dataset and the resultant discovery of the deep patterns that underlie what happened to similar and different mentally disordered offenders as a consequence of the implementation of a new policy of custody diversion.

In 2006, the National Health Service commenced with assuming responsibility for the delivery and commissioning of mental healthcare services in prisons within the UK. Previous research has indicated that some prison environments may present challenges to the delivery of mental healthcare for prison populations. The present study aimed to explore the experiences of staff working in NHS offender health teams to identify the sources of adversity that frontline staff may encounter when providing mental healthcare in prison settings. The present study also aimed to identify working conditions that may be conducive in facilitating the delivery of mental healthcare in prison settings. Mental healthcare professionals (n = 10) who worked in NHS offender health teams took part in 1:1 semi-structured interviews that were audio recorded and transcribed verbatim. The thematic analysis of the dataset indicated three themes that presented sources of adversity for NHS offender health teams in their delivery of mental health care in prisons; which were 1) location of mental healthcare delivery 2) communication links with stakeholders and 3) prison policies, procedures and legislation. The results of this study have illustrated some of the work-related factors that require attention in order to further support frontline staff in their delivery of mental healthcare in prison settings.

Effective management of diabetes during the coronavirus disease 2019 (COVID-19) pandemic is critical given that hyperglycemia is both a risk factor for infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has been associated with poorer outcomes for those infected (1). Unfortunately, inadequate diabetes self-management due to medication nonadherence is prevalent among patients with diabetes and is a major contributor to poor diabetes outcomes (2,3). Research suggests that mail order pharmacy (MOP) use can improve medication adherence (3). However, there is little data on how the COVID-19 pandemic is related to MOP use. Regrettably, racial/ethnic minority patients with diabetes have poorer medication adherence than White patients, and research shows marked disparities among racial/ethnic minorities in SARS-CoV-2 infection rates and outcomes, but little is known about racial/ethnic differences in MOP use during the COVID-19 pandemic (3,4). The objectives of our study were to 1 ) assess the association between the COVID-19 pandemic shelter-in-place order and MOP use and 2 ) examine these associations by patient race/ethnicity. We conducted a retrospective cohort study using a cohort from a randomized encouragement trial conducted in 2017–2018 at Kaiser Permanente Northern California (KPNC), the Encouraging Mail Order Pharmacy Use to Improve Outcomes and Reduce Disparities …

Key Points Question Among adults with type 2 diabetes receiving long-acting insulin with a glycated hemoglobin A1c level of 6.8% to 8.5%, is there a difference in cardiovascular events and mortality among individuals who do or do not initiate additional treatment with short-acting insulin? Findings In this cohort study of 57 278 adults, addition of short-acting insulin was associated with increased all-cause mortality compared with long-acting insulin alone and a decreased risk of acute myocardial infarction, with limited evidence of a difference in congestive heart failure. Meaning Given the lack of evidence demonstrating an increase in major cardiovascular events or cardiovascular mortality, the increased mortality with the combination of long- and short-acting insulin may be explained by noncardiovascular events or unmeasured confounding., This cohort study assesses the occurrence of overall mortality, cardiovascular mortality, acute myocardial infarction, stroke, and hospitalization for congestive heart failure among adults with type 2 diabetes receiving long-acting insulin alone vs long- plus short-acting insulin treatment., Importance Cardiovascular events and mortality are the principal causes of excess mortality and health care costs for people with type 2 diabetes. No large studies have specifically compared long-acting insulin alone with long-acting plus short-acting insulin with regard to cardiovascular outcomes. Objective To compare cardiovascular events and mortality in adults with type 2 diabetes receiving long-acting insulin who do or do not add short-acting insulin. Design, Setting, and Participants This retrospective cohort study emulated a randomized experiment in which adults with type 2 diabetes who experienced a qualifying glycated hemoglobin A1c (HbA1c) level of 6.8% to 8.5% with long-acting insulin were randomized to continuing treatment with long-acting insulin (LA group) or adding short-acting insulin within 1 year of the qualifying HbA1c level (LA plus SA group). Retrospective data in 4 integrated health care delivery systems from the Health Care Systems Research Network from January 1, 2005, to December 31, 2013, were used. Analysis used inverse probability weighting estimation with Super Learner for propensity score estimation. Analyses took place from April 1, 2018, to June 30, 2019. Exposures Long-acting insulin alone or with added short-acting insulin within 1 year from the qualifying HbA1c level. Main Outcomes and Measures Mortality, cardiovascular mortality, acute myocardial infarction, stroke, and hospitalization for heart failure. Results Among 57 278 individuals (39 279 with data on cardiovascular mortality) with a mean (SD) age of 60.6 (11.5) years, 53.6% men, 43.5% non-Hispanic White individuals, and 4 years of follow-up (median follow-up of 11 [interquartile range, 5-20] calendar quarters), the LA plus SA group was associated with increased all-cause mortality compared with the LA group (hazard ratio, 1.27; 95% CI, 1.05-1.49) and a decreased risk of acute myocardial infarction (hazard ratio, 0.89; 95% CI, 0.81-0.97). Treatment with long-acting plus short-acting insulin was not associated with increased risks of congestive heart failure, stroke, or cardiovascular mortality. Conclusions and Relevance Findings of this retrospective cohort study suggested an increased risk of all-cause mortality and a decreased risk of acute myocardial infarction for the LA plus SA group compared with the LA group. Given the lack of an increase in major cardiovascular events or cardiovascular mortality, the increased all-cause mortality with long-acting plus short-acting insulin may be explained by noncardiovascular events or unmeasured confounding.

Background Preventing diabetes before pregnancy may be important to improve maternal and infant outcomes. Although the preconception period is a crucial time to focus on chronic disease prevention, little is known about preventive services for reproductive-aged women at risk of developing diabetes. Methods Using electronic health record data from patients at Kaiser Permanente Northern California, we identified 21,965 nonpregnant women aged 18 to 44 with incident prediabetes (PDM; fasting plasma glucose [FPG] = 100–125 or glycated hemoglobin A1c = 5.7%–6.4%) between 2007 and 2010. We looked for evidence of a “clinical response” to PDM in the 6 months after laboratory testing, defined as retesting of blood glucose levels, referral or attendance to health education, diagnosis of PDM, metformin initiation, or a clinical note of discussion of PDM. Multilevel models were used to examine the relationship between patient characteristics and clinical response, and to assess provider-level variation. Results Fewer than one-half of women had a documented clinical response to the PDM-range laboratory result. Women with higher FPG values and body mass indexes were more likely to have a PDM diagnosis (FPG 120–125 vs. 100–119: OR, 1.96; 95% CI, 1.78–2.17; body mass index, 30–34 kg/m 2 vs. 2 : OR, 1.30; 95% CI, 1.13–1.48) and have ‘PDM’ recorded in the notes (FPG 120–125 vs. 100–119: OR, 1.15; 95% CI, 1.06–1.26; body mass index: 30–34 kg/m 2 vs. 2 : OR, 1.58; 95% CI, 1.44–1.74). Provider-level variation was modest, except for metformin initiation (intraclass correlation coefficient, 0.8; p Conclusions Low clinical response to PDM among women of reproductive age suggests there are missed opportunities for diabetes prevention among this vulnerable population.

BACKGROUND:Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications. OBJECTIVE:To estimate diabetes screening prevalence among patients with SMI within an integrated health care system, and to assess characteristics associated with lack of screening. DESIGN:Retrospective cohort study. PARTICIPANTS:Antipsychotic-treated adults with SMI. We excluded participants with known diabetes. MAIN MEASURES:Primary outcome was screening via fasting glucose test or hemoglobin A1c during a 1-year period. KEY RESULTS:In 2014, 16,754 patients with SMI diagnoses were receiving antipsychotics. Seventy-four percent of these patients' providers ordered diabetes screening tests that year, but only 55% (9247/16,754) received screening. When the observation time frame was extended to 2years, 73% (12,250/16,754) were screened. Adjusting for sex and race/ethnicity, young adults (aged 18-29 years) were less likely to receive screening than older age groups [adjusted RR (aRR) 1.23-1.57, p&nbsp

In this paper we explore the enfolding spatialities of control and care within the penal estate through analysis of the creation of a unit for prisoners with serious mental illnesses (SMIs). Prisons have increasingly become the key institutions for mental health care provision, yet serious mental illness disrupts the self-government upon which contemporary prison regimes are based. Our analysis highlights the ‘trouble’ institutions face in making space for mental health care; in trying to fit different control-care regimes into existing carceral environments. We argue that the different actors that have made space for this control-care have been open to potentiality. Developments have been experimental, emergent and incomplete; often not officially challenging wider institutional processes, but eluding them. What emerges is an institution within an institution with a certain level of spatial autonomy but constrained in its transformative potential.

OBJECTIVE: As part of a multidisciplinary team managing patients with type-2 diabetes, pharmacists need a consistent approach of identifying and prioritizing patients at highest risk of adverse outcomes. Our objective was to identify which predictors of adverse outcomes among type-2 diabetes patients were significant and common across 7 outcomes and whether these predictors improved the performance of risk prediction models. Identifying such predictors would allow pharmacists and other health care providers to prioritize their patient panels. RESEARCH DESIGN AND METHODS: Our study population included 120,256 adults aged 65 years or older with type-2 diabetes from a large integrated health system. Through an observational retrospective cohort study design, we assessed which risk factors were associated with 7 adverse outcomes (hypoglycemia, hip fractures, syncope, emergency department visit or hospital admission, death, and 2 combined outcomes). We split (50:50) our study cohort into a test and training set. We used logistic regression to model outcomes in the test set and performed k-fold validation (k = 5) of the combined outcome (without death) within the validation set. RESULTS: The most significant predictors across the 7 outcomes was: age, number of medicines, prior history of outcome within the past 2 years, chronic kidney disease, depression, and retinopathy. Experiencing an adverse outcome within the prior 2 years was the strongest predictor of future adverse outcomes (odds ratio range: 4.15–7.42). The best performing models across all outcomes included: prior history of outcome, physiological characteristics, comorbidities and pharmacy-specific factors (c-statistic range: 0.71–0.80). CONCLUSIONS: Pharmacists and other health care providers can use models with prior history of adverse event, number of medicines, chronic kidney disease, depression and retinopathy to prioritize interventions for elderly patients with type-2 diabetes.

Medication non-adherence is a major contributor to poor diabetes outcomes. Observational studies show positive associations between mail order pharmacy (MOP) use and adherence, and suggest that mail order is cost-saving to patients. However, no prospective trials have examined the effect of encouraging MOP use on medication adherence. We conducted a randomized encouragement trial in 2017 in three health plans: Kaiser Permanente (KP) Northern California, KP Hawaii, and Harvard Pilgrim Health Care (HPHC). Patients were eligible if they had diabetes, poor adherence (Proportion of Days Covered Disclosure J. Schmittdiel: None. C.M. Trinacty: None. J. Wharam: None. O. Duru: Advisory Panel; Self; Healthwise. R. Neugebauer: None. S.D. Brown: None. D. Ross-Degnan: None. A.J. Karter: None. W.T. Dyer: None. B. Ramachandran: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases

Background Diabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined. Methods This retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures—glycemic testing, glycemic control, and medication adherence—among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use. Results In this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar. Conclusions Our findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.

IntroductionSmoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15-20years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high rates of smoking among people with SMI, tobacco cessation interventions have not been broadly offered to this population.MethodsWe conducted a retrospective cohort study using electronic health records from 2014 in a large integrated care delivery system to examine whether use of smoking cessation pharmacotherapy among smokers with type 2 diabetes varies by serious mental illness (SMI) diagnosis. We analyzed smoking cessation medication prescription fills among adult smokers with diabetes, comparing those with SMI (N=634) and without SMI (N=18,021). Risk ratios were adjusted for age, gender, race, urban area type, and medical facility.ResultsOf the SMI group, 19.09% filled at least one smoking cessation prescription compared to 9.73% of the non-SMI group (adjusted risk ratio 1.80 [95% CI 1.52-2.13]; p&nbsp

This cohort study examines the association of analogue compared with human insulin use with mortality and major cardiovascular events among adults with type 2 diabetes., Key Points Question Are there significant differences in cardiovascular outcomes in adults with type 2 diabetes who use human insulin compared with those who use analogue insulin? Findings In this cohort study of 127 600 adults with type 2 diabetes, no differences were found in overall mortality, cardiovascular mortality, myocardial infarction, stroke, and hospitalization for congestive heart failure. Meaning In this study, insulin-naive adults with type 2 diabetes treated with human vs analogue insulin had similar rates of major cardiovascular events, mortality due to cardiovascular disease, and overall mortality., Importance The comparative cardiovascular safety of analogue and human insulins in adults with type 2 diabetes who initiate insulin therapy in usual care settings has not been carefully evaluated using machine learning and other rigorous analytic methods. Objective To examine the association of analogue vs human insulin use with mortality and major cardiovascular events. Design, Setting, and Participants This retrospective cohort study included 127 600 adults aged 21 to 89 years with type 2 diabetes at 4 health care delivery systems who initiated insulin therapy from January 1, 2000, through December 31, 2013. Machine learning and rigorous inference methods with time-varying exposures were used to evaluate associations of continuous exposure to analogue vs human insulins with mortality and major cardiovascular events. Data were analyzed from September 1, 2017, through June 30, 2018. Exposures On the index date (first insulin dispensing), participants were classified as using analogue insulin with or without human insulin or human insulin only. Main Outcomes and Measures Overall mortality, mortality due to cardiovascular disease (CVD), myocardial infarction (MI), stroke or cerebrovascular accident (CVA), and hospitalization for congestive heart failure (CHF) were evaluated. Marginal structural modeling (MSM) with inverse probability weighting was used to compare event-free survival in separate per-protocol analyses. Adjusted and unadjusted hazard ratios and cumulative risk differences were based on logistic MSM parameterizations for counterfactual hazards. Propensity scores were estimated using a data-adaptive approach (machine learning) based on 3 nested covariate adjustment sets. Sensitivity analyses were conducted to address potential residual confounding from unmeasured differences in risk factors across delivery systems. Results The 127 600 participants (mean [SD] age, 59.4 [12.6] years; 68 588 men [53.8%]; mean [SD] body mass index, 32.3 [7.1]) had a median follow-up of 4 quarters (interquartile range, 3-9 quarters) and experienced 5464 deaths overall (4.3%), 1729 MIs (1.4%), 1301 CVAs (1.0%), and 3082 CHF hospitalizations (2.4%). There were no differences in adjusted hazard ratios for continuous analogue vs human insulin exposure during 10 quarters for overall mortality (1.15; 95% CI, 0.97-1.34), CVD mortality (1.26; 95% CI, 0.86-1.66), MI (1.11; 95% CI, 0.77-1.45), CVA (1.30; 95% CI, 0.81-1.78), or CHF hospitalization (0.93; 95% CI, 0.75-1.11). Conclusions and Relevance Insulin-naive adults with type 2 diabetes who initiate and continue treatment with human vs analogue insulins had similar observed rates of major cardiovascular events, CVD mortality, and overall mortality.

Background: This article critically explores the implementation and evaluation of a project designed, delivered and evaluated by frontline staff to improve prison responses to prisoner suicide and self-harm. We begin by evidencing the need for the project and detail its content, delivery and attempts at evaluation. We draw on the reflections of the three practitioners most closely involved in its development, delivery and review in order to explore lessons learned for future staff-led projects including those aimed at tackling prison suicide and self-harm.\ud \ud Results: Findings from staff reflections suggest that the development, implementation and evaluation of the project were influenced by a combination of issues around: project focus, communication and professional relationships, the institutional environment, funding and time, roll-out and evaluation, and the need for a ‘champion’ role.\ud \ud Conclusions: There is limited evidence that the project left a modest positive legacy in terms of impact. A more substantial legacy of the project is provided in terms of actionable learning points for future projects of this nature.

Aims To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy. Methods We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment. Results Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes. Conclusions Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy. Trial registration ClinicalTrials.gov (NCT02056431).

Context\ud \ud Research on predictors of clinical outcomes usually focuses on the impact of individual patient factors, despite known relationships between neighborhood environment and health.\ud \ud Objective\ud \ud To determine whether US census information on where a patient resides is associated with diabetes development among patients with prediabetes. \ud \ud Design\ud \ud Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes (fasting plasma glucose, 100 mg/dL-125 mg/dL, and/or glycated hemoglobin, 5.7%-6.4%). We assessed whether census data on education, income, and percentage of households receiving benefits through the US Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) was associated with diabetes development using logistic regression controlling for age, sex, race/ethnicity, blood glucose levels, and body mass index.\ud Main Outcome Measure: Progression to diabetes within 36 months.\ud \ud Results\ud \ud Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor’s degree or higher (odds ratio [OR] =1.22, 95% confidence interval [CI] = 1.09-1.36), where median annual income was below $79,999 (OR = 1.16 95% CI = 1.03-1.31), or where SNAP benefits were received by 10% or more of households (OR = 1.24, 95% CI = 1.1-1.4).\ud \ud Conclusion\ud \ud Area-level socioeconomic and food assistance data predict the development of diabetes, even after adjusting for traditional individual demographic and clinical factors. Clinical interventions should take these factors into account, and health care systems should consider addressing social needs and community resources as a path to improving health outcomes.

Background\ud Prisoners are at increased risk of self-harm and when either intent is expressed, or an act of self-harm carried out, prisoners in the UK are subject to self-harm/suicide monitoring (referred to as “open ACCT” monitoring). However, there is a paucity of validated instruments to identify risk of self-harm in prisoner populations. In response to the need to support prison staff to determine who is at increased risk of self-harm or repeat self-harm, the aim of this study was to determine whether any pre-existing, standardised instruments could usefully identify future self-harm events in prisoners undergoing ACCT monitoring.\ud \ud Methods\ud A multi-stage prospective cohort study was conducted, where the Prison Screening Questionnaire (PriSnQuest), a modified Borderline Symptom List-23 (BSL-23), Self-Harm Inventory (SHI), Patient Health Questionnaire-9 (PHQ-9) and Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) instruments were administered to prisoners aged 18 and above, who were judged to be at an increased risk of self-harm (on open ACCT monitoring) during the recruitment phase. A 6-month follow-up determined self-harm occurrence since baseline, and Area-Under-the-Curve (AUC) analysis examined the ability of the instruments to predict future self-harm.\ud \ud Results\ud Prison records established that 29.1% self-harmed during the follow up period, involving a total of 423 self-harm events reported from 126 individuals, followed up for 66,789 prisoner days (median 167 days; IQR 71–207.5 days). This translated to an ‘event incidence’ of 6.33 per 1000 prisoner days of those who had been placed upon an ACCT, or ‘prisoner incidence’ of 1.89 per 1000 days, with considerable variation for both gender and participating prisons. None of the summary scores derived from the selected instruments showed a meaningful ability to predict self-harm, however, exploratory logistic regression analysis of individual background and instrument items revealed gender-specific item sets which were statistically significant in predicting future self-harm.\ud \ud Conclusions\ud Prospective self-harm was not predicted by any of the pre-existing instruments that were under consideration. Exploratory logistic regression analysis did reveal gender-specific item sets, producing predictive algorithms which were statistically significant in predicting future self-harm; however, the operational functionality of these item sets may be limited.

The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics.To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata.We studied 54,480 patients with diabetes aged65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c8% defined good glycemic control. We also defined poor control as A1c9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables.The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c9% for patients aged80 years or with3 comorbidities.Among patients with diabetes aged65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted.This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association's 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.

This paper explores the implementation of Cleveland Police’s pilot Street Triage service. The service aimed to reduce the number of section 136 detentions under the Mental Health Act and improve referral pathways for those presenting with mental health issues. The initiative was funded by Tees, Esk and Wear Valleys NHS Foundation Trust. Dedicated Street Triage mental health nurses accompanied police officers to incidents where it was suspected that mental health issues were a presenting concern. Semi-structured interviews were conducted with sixteen strategic and operational stakeholders to review whether the project was successful. Analysis was supplemented with secondary data from the Street Triage Team. We conclude that there were significantly fewer section 136 detentions, and identify continuing challenges.

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

Background The Centers for Medicare and Medicaid Services (CMS) Medicare Star program provides incentives to health plans when their patients with diabetes meet adherence targets to angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs) and statins. While a link between adherence and cardiovascular risk factor control is established, most studies included young patients with few comorbidities. Whether the Star adherence target is associated with reduced blood pressure or low-density lipoprotein cholesterol (LDL-C) in complex older patients is not well understood. Objectives Determine correlates of adherence and examine the effect of meeting Star adherence targets on blood pressure and LDL-C in the Medicare-aged diabetes population. Design and Subjects Retrospective cohort study of 129,040 patients with diabetes aged 65 or older. Measures Adherence estimated using proportion of days covered target ≥ 0.8; blood pressure < 140/90 mg Hg; LDL-C < 100 mg/dl. Modified Poisson regression used to assess relationships. Results Adherence differed little across elderly age groups. Compared to no comorbidity, high comorbidity (≥ 4) was associated with lower ACEI/ARB (risk ratio [RR] 0.88 [95% confidence interval (CI) 0.87–0.89]) or statin (RR 0.91 [0.90–0.92]) adherence. ACEI/ARB adherence was not associated with blood pressure < 140/90 mm Hg in patients ≥ 85 years (RR 1.01 [0.96–1.07]) or with multiple comorbidities (e.g., 3: RR 1.04 [0.99–1.08]). Statin adherence and LDL-C < 100 mg/dl were associated in all elderly age groups (e.g., ≥ 85: RR 1.13 [1.09–1.16]) and comorbidity levels (e.g., ≥ 4: RR 1.13 [1.12–1.15]). Conclusions Adherence to ACEI/ARB is not linked with reduced blood pressure in patients with diabetes who are at least 85 years or with multiple comorbidities.

The purpose of this study was to examine the relationship between the presence of clinical depression and persistence to drug therapy treatment for depression with early nonpersistence to antihypertensive therapies in a large, diverse cohort of newly treated hypertension patients. Using a hypertension registry at Kaiser Permanente Northern California, the authors conducted a retrospective cohort study of 44,167 adults (18 years and older) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between the presence of clinical depression and early nonpersistence (defined as failing to refill the first prescription within 90 days after the end of the first fill days' supply) to antihypertensive therapies, controlling for sociodemographic and clinical risk factors. Within the group of 1484 patients who had evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, the authors examined the relationship between drug therapy treatment for depression and 6-month persistence with antidepressant therapy with early nonpersistence with antihypertensive therapies. No association was found between the presence of clinical depression and early nonpersistence to antihypertensive therapies after adjustment for individual demographic and clinical characteristics and neighborhood-level socioeconomic status. However, among the subset of 1484 patients with documented evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, being prescribed and persistence with antidepressant therapy was strongly associated with lower odds of early nonpersistence to antihypertensive medications (odds ratio, 0.64; confidence interval, 0.42-0.96). In an integrated delivery system, the authors found that treatment for depression was associated with higher levels of antihypertensive persistence. Improving quality of depression care in patients with comorbid hypertension may be an important strategy in decreasing cardiovascular disease risk in these patients.

People with severe mental illnesses (SMI) such as schizophrenia and bipolar disorder have an increased risk for diabetes (1), in part due to treatment with both first- and second-generation antipsychotics (2). A large systematic review estimated that 15% of people with SMI have type 2 diabetes, a prevalence double that of age-matched samples from the general population during the same time period (1). Preliminary evidence suggests that racial/ethnic minorities with SMI may be at especially high risk for diabetes compared with whites; unfortunately, similar data regarding prevalence of prediabetes is more limited (2). Understanding of the prevalence of prediabetes and diabetes in a large, racially and ethnically diverse and representative sample is an important first step in reducing diabetes prevalence and related adverse outcomes in this particularly vulnerable population. In this study, we estimate diabetes and prediabetes prevalence among antipsychotic-treated patients within an integrated health care system and determine whether racial/ethnic differences exist. In this retrospective cohort study of adults with SMI in Kaiser Permanente Northern California (KPNC), our primary outcome was evidence of diabetes. The cohort used for this study has been previously described (3). To estimate diabetes prevalence, the primary outcome measure was inclusion in the KPNC diabetes registry at any time before 31 December 2014 (4). To estimate our secondary outcome, prediabetes prevalence, we first excluded people who were in the …

Background: Challenges to effective pharmacologic management of symptomatic diabetic peripheral neuropathy include the limited effectiveness of available medicines, frequent side effects, and the need for ongoing symptom assessment and treatment titration for maximal effectiveness. We present here the rationale and implementation challenges of the Diabetes Telephone Study, a randomized trial designed to improve medication treatment, titration, and quality of life among patients with symptomatic diabetic peripheral neuropathy. Methods: We implemented a pragmatic cluster randomized controlled trial to test the effectiveness of an automated interactive voice response tool designed to provide physicians with real-time patient-reported data about responses to newly prescribed diabetic peripheral neuropathy medicines. A total of 1834 primary care physicians treating patients in the diabetes registry at Kaiser Permanente Northern California were randomized into the intervention or control arm. In September 2014, we began identification and recruitment of patients assigned to physicians in the intervention group who receive three brief interactive calls every 2 months after a medication is prescribed to alleviate diabetic peripheral neuropathy symptoms. These calls provide patients with the opportunity to report on symptoms, side effects, self-titration of medication dose and overall satisfaction with treatment. We plan to compare changes in self-reported quality of life between the intervention group and patients in the control group who receive three non-interactive automated educational phone calls. Results: Successful implementation of this clinical trial required robust stakeholder engagement to help tailor the intervention and to address pragmatic concerns such as provider time constraints. As of 27 October 2015, we had screened 2078 patients, 1447 of whom were eligible for participation. We consented and enrolled 1206 or 83% of those eligible. Among those enrolled, 53% are women and the mean age is 67 (standard deviation = 12) years. The racial ethnic make-up is 56% White, 8% Asian, 13% Black or African American, and 19% Hispanic or Latino. Conclusion: Innovative strategies are needed to guide improvements in healthcare delivery for patients with symptomatic diabetic peripheral neuropathy. This trial aims to assess whether real-time collection and clinical feedback of patient treatment experiences can reduce patient symptom burden. Implementation of a clinical trial closely involving clinical care required researchers to partner with clinicians. If successful, this intervention provides a critical information feedback loop that would optimize diabetic peripheral neuropathy medication titration through widely available interactive voice response technology.

Diversion services for adult mentally disordered offenders are back in the limelight twenty years after their original development. This article argues there are a number of important lessons to be learnt. Services of this kind ‘process’ different people in different ways with different outcomes. Current developments therefore need to provide an holistic, patient-centred approach across the whole offender pathway, which meets the needs of different groups of people. What works for some might not work for others, but patterns can be mapped and good and bad pathways identified and used to inform good practice and service improvement.

CMS recently added medication adherence to antihypertensives, antihyperlipidemics, and oral antihyperglycemics to its Medicare Star quality measures. These CMS metrics exclude patients with2 medication fills (ie, "early nonadherence") and patients concurrently taking insulin. This study examined the proportion of patients with diabetes prescribed cardiovascular disease (CVD) medications excluded from Star adherence metrics and assessed the relationship of both Star-defined adherence and exclusion from Star metrics with CVD risk factor control.Cross-sectional, population-based analysis of 129,040 patients with diabetes aged ≥65 years in 2010 from 3 Kaiser Permanente regions.We estimated adjusted risk ratios to assess the relationship between achieving Star adherence and being excluded from Star adherence metrics, with CVD risk factor control (glycated hemoglobin [A1C]8.0%, low-density lipoprotein cholesterol [LDL-C]100 mg/dL, and systolic blood pressure [SBP]130 mm Hg) in patients with diabetes.Star metrics excluded 27% of patients with diabetes prescribed oral medications. Star-defined nonadherence was negatively associated with CVD risk factor control (risk ratio [RR], 0.95, 0.84, 0.96 for A1C, LDL-C, and SBP control, respectively; P.001). Exclusion from Star metrics due to early nonadherence was also strongly associated with poor control (RR, 0.83, 0.56, 0.87 for A1C, LDL-C, and SBP control, respectively; P.001). Exclusion for insulin use was negatively associated with A1C control (RR, 0.78; P.0001).Medicare Star adherence measures underestimate the prevalence of medication nonadherence in diabetes and exclude patients at high risk for poor CVD outcomes. Up to 3 million elderly patients with diabetes may be excluded from these measures nationally. Quality measures designed to encourage effective medication use should focus on all patients treated for CVD risk.

OVERVIEW LPNs may be able to help fill some of the gaps caused by the nursing shortage, but little research has been conducted on the demographic characteristics of LPNs, their education and scope of practice, and the demand for their services, all of which vary from state to state. In 2002 and 2003, the authors conducted a comprehensive national study, Supply, Demand, and Use of Licensed Practical Nurses, and have summarized that study's findings in this article. They found that RNs and LPNs are similar in age and tend to have similar numbers of children, but that racial and ethnic minorities, particularly African Americans, and those who are single, widowed, divorced, or separated are better represented among LPNs. Expanding LPN educational programs might draw more people into nursing. Some LPNs would like to become RNs, so expanding LPN-to-RN "ladder" programs could also be beneficial. LPNs can't replace RNs entirely, but they could perform much of the work now performed by RNs. While long-term care facilities already depend heavily on LPNs, hospitals could benefit from employing more LPNs. The authors make several specific policy recommendations to improve the education and employment of LPNs.

Custody diversion teams were introduced in England in order to divert mentally disordered offenders away from the criminal justice system and custody because of concerns about the growing prevalence of psychiatric disorder in prison populations. This research explored the impact of one such team on the psychiatric and criminal careers of people referred to it. Time ordered cluster analysis was used to identify and map the different institutional careers experienced by people referred to the team and the different paths their careers took as a consequence of the team's actions. Five different types of career were identified. Careers One and Two describe experiences of offenders – violent offenders with no psychiatric history who were referred, assessed and diagnosed but had no health or social care needs identified and were not referred again. Careers Three and Four describe experiences of mentally disordered offenders – violent offenders with a psychiatric history half of whom (Career Three) were referred...

OBJECTIVE Medication nonadherence is a major obstacle to better control of glucose, blood pressure (BP), and LDL cholesterol in adults with diabetes. Inexpensive effective strategies to increase medication adherence are needed. RESEARCH DESIGN AND METHODS In a pragmatic randomized trial, we randomly assigned 2,378 adults with diabetes mellitus who had recently been prescribed a new class of medication for treating elevated levels of glycated hemoglobin (A1C) ≥8% (64 mmol/mol), BP ≥140/90 mmHg, or LDL cholesterol ≥100 mg/dL, to receive 1) one scripted telephone call from a diabetes educator or clinical pharmacist to identify and address nonadherence to the new medication or 2) usual care. Hierarchical linear and logistic regression models were used to assess the impact on 1) the first medication fill within 60 days of the prescription; 2) two or more medication fills within 180 days of the prescription; and 3) clinically significant improvement in levels of A1C, BP, or LDL cholesterol. RESULTS Of the 2,378 subjects, 89.3% in the intervention group and 87.4% in the usual-care group had sufficient data to analyze study outcomes. In intent-to-treat analyses, intervention was not associated with significant improvement in primary adherence, medication persistence, or intermediate outcomes of care. Results were similar across subgroups of patients defined by age, sex, race/ethnicity, and study site, and when limiting the analysis to those who completed the intended intervention. CONCLUSIONS This low-intensity intervention did not significantly improve medication adherence or control of glucose, BP, or LDL cholesterol. Wide use of this strategy does not appear to be warranted; alternative approaches to identify and improve medication adherence and persistence are needed.

BackgroundSelf-harm is common among prisoners, particularly female prisoners. In 2007, concerned about the rising incidence, the prison service introduced a care-planning system called Assessment, Care in Custody, and Teamwork (ACCT). To date, it does not incorporate a standardised diagnostic test to estimate the risk of future self-harm.ObjectiveTo identify potential screening instruments, or items from those instruments, to predict the risk of self-harm among prisoners.ParticipantsPrisoners who had been assigned to an ACCT during the recruitment period.DesignA multistage prospective cohort study. Following a pilot study, instruments were administered to prisoners by interview at baseline, and followed up for 6 months (or until point of release if this was sooner) to ascertain self-harm status. Instruments were assessed for unidimensionality, scalability (Mokken) and quantitative structure (Rasch). Area under the curve (AUC) analysis was used to examine the ability of instruments and/or their items to predict future self-harm. Cox proportional hazards regression models were used to examine the multivariate predictive ability of the scales and various sociodemographic and sentencing factors.SettingThree prisons (including one women’s prison) in northern England.Main outcome measuresA set of standardised questionnaires, including the Prison Screening Questionnaire (PriSnQuest), Revised Borderline Symptom List-23 (frequency-based responses) (BSL-23-F), Self-Harm Inventory (SHI), Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), together with sociodemographic and sentencing data.ResultsIn total, 450 prisoners consented to participate in the study, of whom 26% were female. The mean age of participants was 31.2 years. Over half of male prisoners recruited were on remand, compared with just over one-fifth (22.6%) of female prisoners. The average tariff of those sentenced was 41 months, of which 14.7 months, on average, had been served. Just over one-third of ACCTs had been initiated because of a known self-harm event, and over one-quarter (27.8%) of participants self-harmed during the follow-up period. Thus, almost half (46.7%) of those entered into the study were reported to have self-harmed, either from their index ACCT, or subsequently, or both. Cutting was the most frequent behaviour (51%). All screening instruments showed some evidence of unidimensionality, and four out of five showed scaling criteria consistent with ordinal scaling, so verifying the validity of the cut points. However, many showed gender bias and failure to fit the Rasch measurement model. While a resolution was made in most cases, both ordinal raw scores and latent interval scale estimates failed to show predictive value when applied within AUC analysis (0.491–0.566) or adjusted Cox proportional hazards models. However, good predictive values were shown for gender-specific sets of items, thus providing easily applied screening indexes.ConclusionsWhile four out of five potential screening instruments were found to have acceptable psychometric properties within this setting, their predictive validity of all instruments was poor under AUC analysis. Gender-specific item sets were put together to form two screening indexes with formative indicators which gave reasonable AUC values, particularly so for females. The indexes provide identification of low–medium–high risk of self-harm, and so may help to inform potential care pathways and decisions to sign prisoners off from the ACCT. Future work should concentrate on refining a set of predictive screening items among different offender populations and investigating the time point at which this set of items should be administered. Future work may also look at the different magnitudes of risk as indicators for care pathways.FundingThe National Institute for Health Research Health Technology Assessment programme.

Objective To compare cardiovascular disease risk factor testing rates and intermediate outcomes of care between American Indian/Alaska Native (AI/AN) patients with diabetes and non-Hispanic Caucasians enrolled in nine commercial integrated delivery systems in the USA. Research design and methods We used modified Poisson regression models to compare the annual testing rates and risk factor control levels for glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP); number of unique diabetes drug classes; insulin use; and oral diabetes drug medication adherence between insured AI/AN and non-Hispanic white adults with diabetes aged ≥18 in 2011. Results 5831 AI/AN patients (1.8% of the cohort) met inclusion criteria. After adjusting for age, gender, comorbidities, insulin use, and geocoded socioeconomic status, AI/AN patients had similar rates of annual HbA1c, LDL-C, and SBP testing, and LDL-C and SBP control, compared with non-Hispanic Caucasians. However, AI/AN patients were significantly more likely to have HbA1c >9% (>74.9 mmol/mol; RR=1.47, 95% CI 1.38 to 1.58), and significantly less likely to adhere to their oral diabetes medications (RR=0.90, 95% CI 0.88 to 0.93) compared with non-Hispanic Caucasians. Conclusions AI/AN patients in commercial integrated delivery systems have similar blood pressure and cholesterol testing and control, but significantly lower rates of HbA1c control and diabetes medication adherence, compared with non-Hispanic Caucasians. As more AI/ANs move to urban and suburban settings, clinicians and health plans should focus on addressing disparities in diabetes care and outcomes in this population.

Objective To understand the burden of medication use for patients with newly diagnosed diabetes both before and after diabetes diagnosis and to identify subpopulations of patients with newly diagnosed diabetes who face a relatively high drug burden. Design Retrospective cohort study. Setting 11 integrated health systems in the United States. Participants 196,654 insured adults 20 years of age or older newly diagnosed with type 1 or type 2 diabetes from January 2005 through December 2009. Main outcome measures Number of unique therapeutic classes of drugs dispensed in the 12 months before and 12 months after diagnosis of diabetes in five categories: overall, antihypertensive agents, antihyperlipidemic agents, mental health agents, and antihyperglycemic agents (in the postdiagnosis period only). Results The mean number of drug classes used by newly diagnosed patients with diabetes is high before diagnosis (5.0) and increases significantly afterward (6.6). Of this increase, 81% is due to antihyperglycemic initiation and increased use of medications to control hypertension and lipid levels. Multivariate analyses showed that overall drug burden after diabetes diagnosis was higher in women, older, white, and obese patients, as well as among those with higher glycosylated hemoglobin concentrations and comorbidity levels (significant for all comparisons). The overall number of drug classes used by newly diagnosed patients with diabetes after diagnosis decreased slightly but significantly between 2005 and 2009. Conclusion Patients newly diagnosed with diabetes face a substantially increased burden of medications used to control diabetes and other comorbidities. This study shows an increased focus on cardiovascular disease risk factor control after diagnosis of diabetes. However, total drug burden may be slightly decreasing over time.

BACKGROUND Mail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related to improved CVD risk factor outcomes.