Increased cardiovascular disease, resource use, and costs before the clinical diagnosis of diabetes in veterans in the southeastern U.S

Cholecystectomy for Biliary Gallstone Pancreatitis Is Often Not Performed During Index Hospitalization and Is Associated With Worse Outcomes

Guidelines recommend that patients with mild gallstone pancreatitis (GSP) without necrosis or infection should undergo cholecystectomy during the index hospitalization before discharge.^1,2 However, in routine clinical practice, cholecystectomy is often performed several weeks after hospital discharge, or not performed at all.³.

Healthcare system encounters before COPD diagnosis: a registry-based longitudinal cohort study

BACKGROUND

There is high interest in strategies for improving early detection of chronic obstructive pulmonary disease (COPD). These strategies often rely on opportunistic encounters between patients with undiagnosed COPD and the healthcare system; however, the frequency of these encounters is currently unknown.

METHODS

We used administrative health data for the province of British Columbia, Canada, from 1996 to 2015. We identified patients with COPD using a validated case definition, and assessed their visits to pharmacists, primary care and specialist physicians in the 5 years prior to the initial diagnosis of COPD. We used generalised linear models to compare the rate of outpatient visits between COPD and non-COPD comparator subjects matched on age, sex and socioeconomic status.

RESULTS

We assessed 112 635 COPD and non-COPD pairs (mean 68.6 years, 51.0% male). Patients with COPD interacted with pharmacists most frequently in the 5 years before diagnosis (mean 14.09, IQR 4-17 visits/year), followed by primary care (10.29, IQR 4-13 visits/year) and specialist (8.11, IQR 2-11 visits/year) physicians. In the 2 years prior to diagnosis, 72.1% of patients with COPD had a respiratory-related primary care visit that did not result in a COPD diagnosis. Compared with non-COPD subjects, patients with COPD had higher rates of primary care (rate ratio (RR) 1.40, 95% CI 1.39 to 1.41), specialist (RR 1.35, 95% CI 1.34 to 1.37) and pharmacist (RR 1.62, 95% CI 1.60 to 1.63) encounters.

CONCLUSIONS

Patients with COPD used higher rates of outpatient services before diagnosis than non-COPD subjects. Case detection technologies implemented in pharmacy or primary care settings have opportunities to diagnose COPD earlier.

Trajectory of Excess Medical Expenditures 10 Years Before and After Diabetes Diagnosis Among U.S. Adults Aged 25-64 Years, 2001-2013

OBJECTIVE

We assessed the excess medical expenditures for adults newly diagnosed with diabetes, for up to 10 years before and after diabetes diagnosis.

RESEARCH DESIGN AND METHODS

Using the 2001-2013 MarketScan data, we identified people with newly diagnosed diabetes among adults aged 25-64 years (diabetes cohort) and matched them with people who did not have diagnosed diabetes (control cohort) using 1:1 propensity score matching. We followed these two cohorts up to ±10 years from the index date, with annual matched cohort sizes ranging from 3,922 to 39,726 individuals. We estimated the yearly and cumulative excess medical expenditures of the diabetes cohorts before and after the diagnosis of diabetes.

RESULTS

The per capita annual total excess medical expenditure for the diabetes cohort was higher for the entire 10 years prior to their index date, ranging between $1,043 in year -10 and $4,492 in year -1. Excess expenditure spiked in year 1 ($8,109), declined in year 2, and then increased steadily, ranging from $4,261 to $6,162 in years 2-10. The cumulative excess expenditure for the diabetes cohort during the entire 20 years of follow-up was $69,177 ($18,732 before and $50,445 after diagnosis).

CONCLUSIONS

People diagnosed with diabetes had higher medical expenditures compared with their counterparts, not only after diagnosis but also up to 10 years prior to diagnosis. Managing risk factors for type 2 diabetes and cardiovascular disease before diagnosis, and for diabetes-related complications after diagnosis, could alleviate medical expenditure in people with diabetes.

Weight Trends in Veterans With and Without Diabetes, 2000 to 2014

OBJECTIVE

The aim of this study was to assess weight trends and diabetes prevalence among US veterans.

METHODS

Information from the Veterans Affairs Informatics and Computing Infrastructure Corporate Data Warehouse was used to construct data sets that included demographic data, diabetes status, and weight observations for males and females. Secular and longitudinal trends in mean weight were analyzed.

RESULTS

A total of 4,527,865 patients born from 1915 to 1984 with weight data during 2000 to 2014 were included; 36.8% had diabetes. Mean weight at baseline was higher in men and women with diabetes (97 kg and 88 kg, respectively) than in men and women without diabetes (86 kg and 76 kg, respectively). Mean weight increased from 2000 to 2014 (P < 0.001) at rates of 0.36 kg/y in women without diabetes, 0.28 kg/y in men with diabetes, 0.25 kg/y in men without diabetes, and 0.22 kg/y in women with diabetes. Weight decreased in those born before 1940, was stable in those born between 1940 and 1949, and increased in those born since 1950.

CONCLUSIONS

Among contemporary veterans, women without diabetes are gaining weight more rapidly than women with diabetes or men. Younger veterans are gaining weight more rapidly than older veterans. Further efforts are needed to prevent weight gain in veterans, especially among women.

Inpatient Glucose Values: Determining the Nondiabetic Range and Use in Identifying Patients at High Risk for Diabetes

BACKGROUND

Many individuals with diabetes remain undiagnosed, leading to delays in treatment and higher risk for subsequent diabetes complications. Despite recommendations for diabetes screening in high-risk groups, the optimal approach is not known. We evaluated the utility of inpatient glucose levels as an opportunistic screening tool for identifying patients at high risk for diabetes.

METHODS

We retrospectively examined 462,421 patients in the US Department of Veterans Affairs healthcare system, hospitalized on medical/surgical services in 2000-2010, for ≥3 days, with ≥2 inpatient random plasma glucose (RPG) measurements. All had continuity of care: ≥1 primary care visit and ≥1 glucose measurement within 2 years before hospitalization and yearly for ≥3 years after discharge. Glucose levels during hospitalization and incidence of diabetes within 3 years after discharge in patients without diabetes were evaluated.

RESULTS

Patients had a mean age of 65.0 years, body mass index of 29.9 kg/m², and were 96% male, 71% white, and 18% black. Pre-existing diabetes was present in 39.4%, 1.3% were diagnosed during hospitalization, 8.1% were diagnosed 5 years after discharge, and 51.3% were never diagnosed (NonDM). The NonDM group had the lowest mean hospital RPG value (112 mg/dL [6.2 mmol/L]). Having at least 2 RPG values >140 mg/dL (>7.8 mmol/L), the 95th percentile of NonDM hospital glucose, provided 81% specificity for identifying incident diabetes within 3 years after discharge.

CONCLUSIONS

Screening for diabetes could be considered in patients with at least 2 hospital glucose values at/above the 95th percentile of the nondiabetic range (141 mg/dL [7.8 mmol/L]).

Glucose challenge test screening for prediabetes and early diabetes

AIMS

To test the hypothesis that a 50-g oral glucose challenge test with 1-h glucose measurement would have superior performance compared with other opportunistic screening methods.

METHODS

In this prospective study in a Veterans Health Administration primary care clinic, the following test performances, measured by area under receiver-operating characteristic curves, were compared: 50-g oral glucose challenge test; random glucose; and HbA1c level, using a 75-g oral glucose tolerance test as the 'gold standard'.

RESULTS

The study population was comprised of 1535 people (mean age 56 years, BMI 30.3 kg/m2 , 94% men, 74% black). By oral glucose tolerance test criteria, diabetes was present in 10% and high-risk prediabetes was present in 22% of participants. The plasma glucose challenge test provided area under receiver-operating characteristic curves of 0.85 (95% CI 0.78-0.91) to detect diabetes and 0.76 (95% CI 0.72-0.80) to detect high-risk dysglycaemia (diabetes or high-risk prediabetes), while area under receiver-operating characteristic curves for the capillary glucose challenge test were 0.82 (95% CI 0.75-0.89) and 0.73 (95% CI 0.69-0.77) for diabetes and high-risk dysglycaemia, respectively. Random glucose performed less well [plasma: 0.76 (95% CI 0.69-0.82) and 0.66 (95% CI 0.62-0.71), respectively; capillary: 0.72 (95% CI 0.65-0.80) and 0.64 (95% CI 0.59-0.68), respectively], and HbA1c performed even less well [0.67 (95% CI 0.57-0.76) and 0.63 (95% CI 0.58-0.68), respectively]. The cost of identifying one case of high-risk dysglycaemia with a plasma glucose challenge test would be $42 from a Veterans Health Administration perspective, and $55 from a US Medicare perspective.

CONCLUSIONS

Glucose challenge test screening, followed, if abnormal, by an oral glucose tolerance test, would be convenient and more accurate than other opportunistic tests. Use of glucose challenge test screening could improve management by permitting earlier therapy.