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Duffy RA, Jeffreys AS, Coffman CJ, Alexopoulos AS, Tarkington PE, Bosworth H, Edelman D, Crowley MJ. Evaluating Therapeutic Inertia in Two Telehealth Interventions for Type 2 Diabetes: Secondary Analyses of a Randomized Trial. Telemed J E Health 2024. [PMID: 38377570 DOI: 10.1089/tmj.2023.0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Introduction: Although therapeutic inertia is a known driver of suboptimal type 2 diabetes control, little is known about how to combat this phenomenon. We analyzed randomized trial data to determine whether a comprehensive telehealth intervention was more effective than a less structured telehealth approach (telemonitoring and care coordination) at promoting treatment intensification in poorly controlled diabetes. Methods: Patients with poorly controlled type 2 diabetes were randomized 1:1 to telemonitoring/care coordination or a comprehensive telehealth intervention, which included an active, study provider-guided medication management component. Prospectively collected medication lists were used to determine whether treatment intensification occurred for each patient during 3-month intervals throughout the study period. To examine between-arm differences in treatment intensification over time, we fit a generalized estimation equation model. In each arm, hemoglobin A1c levels at the beginning and end of each 3-month interval were used to distinguish between therapeutic inertia and potentially appropriate nonintensification of treatment. Results: The mean, model-estimated likelihood of treatment intensification during 3-month intervals was 61.3% in the comprehensive telehealth group versus 48.6% for telemonitoring/care coordination (odds ratio 1.7, 95% confidence interval 1.2-2.2; p = 0.0007), with no evidence that treatment effect varied over time (p = 0.54). Treatment intervals with observed therapeutic inertia were more common in the telemonitoring/care coordination arm than the comprehensive telehealth arm (116/300, 39% vs. 57/275, 21%). Conclusions: A comprehensive telehealth approach that integrated protocol-guided medication management increased treatment intensification and reduced therapeutic inertia compared with a less structured telehealth approach. The studied approaches may serve as examples of how systems might use telehealth to combat therapeutic inertia. Clinical Trial Registration: ClinicalTrials.gov NCT03520413.
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Affiliation(s)
- Ryan A Duffy
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Phillip E Tarkington
- Central Virginia VA Health Care System, Department of Veterans Affairs, Richmond, Virginia, USA
| | - Hayden Bosworth
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Edelman
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; USA
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Alexopoulos AS, Parish A, Olsen M, Batch BC, Moylan C, Crowley MJ. Prescribing of evidence-based diabetes pharmacotherapy in patients with metabolic dysfunction-associated steatohepatitis. BMJ Open Diabetes Res Care 2023; 11:e003763. [PMID: 38030391 PMCID: PMC10689360 DOI: 10.1136/bmjdrc-2023-003763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/01/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION Metabolic dysfunction-associated steatohepatitis (MASH) is highly prevalent in type 2 diabetes (T2D). Pioglitazone and glucagon-like peptide-1 receptor agonists (GLP-1RA) are medications used in T2D that can resolve MASH and should be considered in all patients with T2D and MASH. We assessed prescription rates of evidence-based T2D pharmacotherapy (EBP) in MASH, and ascertained racial/ethnic disparities in prescribing. RESEARCH DESIGN AND METHODS We conducted a cross-sectional study on patients in Duke University Health System with diagnosis codes for T2D and MASH between January 2019 and January 2021. Only patients with ≥1 primary care or endocrinology encounter were included. The primary outcome was EBP, defined as ≥1 prescription for pioglitazone and/or a GLP-1RA during the study period. A multivariable logistic regression model was used to examine the primary outcome. RESULTS A total of 847 patients with T2D and MASH were identified; mean age was 59.7 (SD 12) years, 61.9% (n=524) were female, and 11.9% (n=101) and 4.6% (n=39) were of Black race and Latino/a/x ethnicity, respectively. EBP was prescribed in 34.8% (n=295). No significant differences were noted in the rates of EBP use across racial/ethnic groups (Latino/a/x vs White patients: adjusted OR (aOR) 1.82, 95% CI 0.78 to 4.28; Black vs White patients: aOR 0.76, 95% CI 0.44 to 1.33, p=0.20). CONCLUSIONS EBP prescriptions, especially pioglitazone, are low in patients with T2D and MASH, regardless of race/ethnicity. These data underscore the need for interventions to close the gap between current and evidence-based care.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Department of Medicine, Division of Endocrinology, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discover and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Maren Olsen
- Center of Innovation to Accelerate Discover and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Duke University, Durham, North Carolina, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, North Carolina, USA
| | - Cynthia Moylan
- Department of Medicine, Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - Matthew J Crowley
- Department of Medicine, Division of Endocrinology, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discover and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, North Carolina, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, North Carolina, USA
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Alexopoulos AS, Crowley MJ, Kahkoska AR. Diabetes Medication Changes in Older Adults With Type 2 Diabetes: Insights Into Physician Factors and Questions Ahead. Diabetes Care 2023; 46:1137-1139. [PMID: 37220268 DOI: 10.2337/dci23-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Division of Endocrinology, Department of Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
| | - Matthew J Crowley
- Division of Endocrinology, Department of Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
| | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Division of Endocrinology and Metabolism, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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4
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Zupa MF, Alexopoulos AS, Esteve L, Rosland AM. Specialist Perspectives on Delivering High-Quality Telemedicine for Diabetes: A Mixed Methods Survey Study. J Endocr Soc 2023; 7:bvad039. [PMID: 37035500 PMCID: PMC10074391 DOI: 10.1210/jendso/bvad039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Indexed: 03/22/2023] Open
Abstract
Background Recent recommendations guiding appropriate use of telemedicine for endocrinology care have largely relied on expert opinion due to limited evidence on factors that increase quality of telemedicine care. In this study, we assessed the perspectives of front-line specialists on factors and strategies perceived to increase quality of diabetes care delivered via telemedicine after more than 2 years of widespread use. Methods Adult diabetes specialists in 2 academic health systems who recently used video-based telemedicine to provide diabetes care were invited to participate in an online survey study between March and April 2022. Likert-style questions, followed by related open-ended questions, assessed perspectives on availability of key resources, factors affecting quality, and anticipated benefits from telemedicine for diabetes. Results Response rate was 52% (56/111). More than half (54%) of participants reported better overall quality of diabetes care with face-to-face care vs telemedicine. Participants reported clinical data supporting high-quality care, such as home blood glucose readings and vital signs, were often not available with telemedicine. Patient factors, including comorbidities and communication barriers, reduced anticipated benefit from telemedicine, while geographic and mobility barriers increased expected benefit. Providers described multiple health care setting resources that could promote high-quality telemedicine diabetes care, including greater support for sharing patient-generated health data and coordinating multidisciplinary care. Conclusions After 2 years of sustained use, diabetes specialists identified telemedicine as an important way to enhance access to care. However, specialists identified additional supports needed to increase appropriate use and delivery of high-quality telemedicine care for patients with complex clinical needs.
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Affiliation(s)
- Margaret F Zupa
- University of Pittsburgh School of Medicine, Division of Endocrinology and Metabolism, Pittsburgh, PA, USA
| | - Anastasia-Stefania Alexopoulos
- Duke University School of Medicine, Division of Endocrinology, Metabolism, and Nutrition, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Lucy Esteve
- Duke University School of Medicine, Division of Endocrinology, Metabolism, and Nutrition, Durham, NC, USA
| | - Ann-Marie Rosland
- University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA, USA
- VA Pittsburgh Center for Health Equity and Research Promotion, Pittsburgh, PA, USA
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5
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Alexopoulos AS, Soliman D, Lewinski AA, Strawbridge E, Steinhauser K, Edelman D, Crowley MJ. Simplifying therapy to assure glycemic control and engagement (STAGE) in poorly-controlled diabetes: A pilot study. J Diabetes Complications 2023; 37:108364. [PMID: 36525906 PMCID: PMC9839589 DOI: 10.1016/j.jdiacomp.2022.108364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/08/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
In this single-arm pilot study, we demonstrated feasibility and acceptability of an insulin simplification intervention in patients with persistent, poorly-controlled type 2 diabetes on complex insulin regimens. While not powered to assess clinical outcomes, we observed neither worsened glycemic control nor increased hypoglycemia.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; Department of Medicine, Division of Endocrinology, Duke University Medical Center, Rd, Durham, NC 27710, United States.
| | - Diana Soliman
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Rd, Durham, NC 27710, United States
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; School of Nursing, Duke University, Durham, NC 27710, United States
| | - Elizabeth Strawbridge
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States
| | - Karen Steinhauser
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; Department of Population Health Sciences, Duke University, Durham, NC 27710, United States
| | - David Edelman
- Department of Population Health Sciences, Duke University, Durham, NC 27710, United States; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710, United States
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC 27710, United States; Department of Medicine, Division of Endocrinology, Duke University Medical Center, Rd, Durham, NC 27710, United States
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Lewinski AA, Walsh C, Rushton S, Soliman D, Carlson SM, Luedke MW, Halpern DJ, Crowley MJ, Shaw RJ, Sharpe JA, Alexopoulos AS, Tabriz AA, Dietch JR, Uthappa DM, Hwang S, Ball Ricks KA, Cantrell S, Kosinski AS, Ear B, Gordon AM, Gierisch JM, Williams JW, Goldstein KM. Telehealth for the Longitudinal Management of Chronic Conditions: Systematic Review. J Med Internet Res 2022; 24:e37100. [PMID: 36018711 PMCID: PMC9463619 DOI: 10.2196/37100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Extensive literature support telehealth as a supplement or adjunct to in-person care for the management of chronic conditions such as congestive heart failure (CHF) and type 2 diabetes mellitus (T2DM). Evidence is needed to support the use of telehealth as an equivalent and equitable replacement for in-person care and to assess potential adverse effects. OBJECTIVE We conducted a systematic review to address the following question: among adults, what is the effect of synchronous telehealth (real-time response among individuals via phone or phone and video) compared with in-person care (or compared with phone, if synchronous video care) for chronic management of CHF, chronic obstructive pulmonary disease, and T2DM on key disease-specific clinical outcomes and health care use? METHODS We followed systematic review methodologies and searched two databases (MEDLINE and Embase). We included randomized or quasi-experimental studies that evaluated the effect of synchronously delivered telehealth for relevant chronic conditions that occurred over ≥2 encounters and in which some or all in-person care was supplanted by care delivered via phone or video. We assessed the bias using the Cochrane Effective Practice and Organization of Care risk of bias (ROB) tool and the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation. We described the findings narratively and did not conduct meta-analysis owing to the small number of studies and the conceptual heterogeneity of the identified interventions. RESULTS We identified 8662 studies, and 129 (1.49%) were reviewed at the full-text stage. In total, 3.9% (5/129) of the articles were retained for data extraction, all of which (5/5, 100%) were randomized controlled trials. The CHF study (1/5, 20%) was found to have high ROB and randomized patients (n=210) to receive quarterly automated asynchronous web-based review and follow-up of telemetry data versus synchronous personal follow-up (in-person vs phone-based) for 1 year. A 3-way comparison across study arms found no significant differences in clinical outcomes. Overall, 80% (4/5) of the studies (n=466) evaluated synchronous care for patients with T2DM (ROB was judged to be low for 2, 50% of studies and high for 2, 50% of studies). In total, 20% (1/5) of the studies were adequately powered to assess the difference in glycosylated hemoglobin level between groups; however, no significant difference was found. Intervention design varied greatly from remote monitoring of blood glucose combined with video versus in-person visits to an endocrinology clinic to a brief, 3-week remote intervention to stabilize uncontrolled diabetes. No articles were identified for chronic obstructive pulmonary disease. CONCLUSIONS This review found few studies with a variety of designs and interventions that used telehealth as a replacement for in-person care. Future research should consider including observational studies and studies on additional highly prevalent chronic diseases.
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Affiliation(s)
- Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- School of Nursing, Duke University, Durham, NC, United States
| | - Conor Walsh
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Sharron Rushton
- School of Nursing, Duke University, Durham, NC, United States
| | - Diana Soliman
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Scott M Carlson
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Matthew W Luedke
- Department of Neurology, Duke University Medical Center, Durham, NC, United States
- Neurodiagnostic Center, Durham Veterans Affairs Medical Center, Durham, NC, United States
| | - David J Halpern
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Duke Primary Care, Duke University Medical Center, Durham, NC, United States
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Ryan J Shaw
- School of Nursing, Duke University, Durham, NC, United States
| | - Jason A Sharpe
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, United States
| | - Jessica R Dietch
- School of Psychological Science, Oregon State University, Corvallis, OR, United States
| | - Diya M Uthappa
- Doctor of Medicine Program, Duke University School of Medicine, Durham, NC, United States
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States
| | - Katharine A Ball Ricks
- Cecil G Sheps Center for Health Service Research, University of North Carolina, Chapel Hill, NC, United States
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, United States
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States
| | - Belinda Ear
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Adelaide M Gordon
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
| | - Jennifer M Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - John W Williams
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
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Sagalla N, Yancy WS, Edelman D, Jeffreys AS, Coffman CJ, Voils CI, Alexopoulos AS, Maciejewski ML, Dar M, Crowley MJ. Factors associated with non-adherence to insulin and non-insulin medications in patients with poorly controlled diabetes. Chronic Illn 2022; 18:398-409. [PMID: 33100020 PMCID: PMC8995079 DOI: 10.1177/1742395320968627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate differences in factors associated with self-reported medication non-adherence to insulin and non-insulin medications in patients with uncontrolled type 2 diabetes. METHODS In this secondary analysis of a randomized trial in patients with obesity and uncontrolled type 2 diabetes, multivariable logistic regression was used to evaluate associations between several clinical factors (measured with survey questionnaires at study baseline) and self-reported non-adherence to insulin and non-insulin medications. RESULTS Among 263 patients, reported non-adherence was 62% (52% for insulin, 55% for non-insulin medications). Reported non-adherence to non-insulin medications was less likely in white versus non-white patients (odds ratio (OR) = 0.42; 95%CI: 0.22,0.80) and with each additional medication taken (OR = 0.75; 95%CI: 0.61,0.93). Non-adherence to non-insulin medications was more likely with each point increase in a measure of diabetes medication intensity (OR = 1.43; 95%CI: 1.01,2.03), the Problem Areas in Diabetes (PAID) score (OR = 1.06; 95%CI: 1.02,1.12), and in men versus women (OR = 3.03; 95%CI: 1.06,8.65). For insulin, reporting non-adherence was more likely (OR = 1.02; 95%CI: 1.00,1.04) with each point increase in the PAID. DISCUSSION Despite similar overall rates of reported non-adherence to insulin and non-insulin medications, factors associated with reported non-adherence to each medication type differed. These findings may help tailor approaches to supporting adherence in patients using different types of diabetes medications.
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Affiliation(s)
- Nicole Sagalla
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, USA
| | - William S Yancy
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, USA.,Duke Diet and Fitness Center, Durham, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, USA
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, USA
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, USA.,Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| | - Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, USA
| | - Moahad Dar
- Division of Endocrinology and Metabolism, East Carolina University, Greenville, USA.,Greenville Veterans Affairs Health Care Center, Greenville, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, USA
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Alexopoulos AS, Yancy WS, Edelman D, Coffman CJ, Jeffreys AS, Maciejewski ML, Voils CI, Sagalla N, Barton Bradley A, Dar M, Mayer SB, Crowley MJ. Clinical associations of an updated medication effect score for measuring diabetes treatment intensity. Chronic Illn 2021; 17:451-462. [PMID: 31653175 PMCID: PMC7182482 DOI: 10.1177/1742395319884096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The medication effect score reflects overall intensity of a diabetes regimen by consolidating dosage and potency of agents used. Little is understood regarding how medication intensity relates to clinical factors. We updated the medication effect score to account for newer agents and explored associations between medication effect score and patient-level clinical factors. METHODS Cross-sectional analysis of baseline data from a randomized controlled trial involving 263 Veterans with type 2 diabetes and hemoglobin A1c levels ≥8.0% (≥7.5% if under age 50). Medication effect score was calculated for all patients at baseline, alongside additional measures including demographics, comorbid illnesses, hemoglobin A1c, and self-reported psychosocial factors. We used multivariable regression to explore associations between baseline medication effect score and patient-level clinical factors. RESULTS Our sample had a mean age of 60.7 (SD = 8.2) years, was 89.4% male, and 57.4% non-White. Older age and younger onset of diabetes were associated with a higher medication effect score, as was higher body mass index. Higher medication effect score was significantly associated with medication nonadherence, although not with hemoglobin A1c, self-reported hypoglycemia, diabetes-related distress, or depression. DISCUSSION We observed several expected associations between an updated medication effect score and patient-level clinical factors. These associations support the medication effect score as an appropriate measure of diabetes regimen intensity in clinical and research contexts.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - William S Yancy
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Diet and Fitness Center, Durham, NC, USA
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Amy S Jeffreys
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
| | - Matthew L Maciejewski
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Corrine I Voils
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA.,Department of Surgery, University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Nicole Sagalla
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - Anna Barton Bradley
- Richmond Diabetes and Endocrinology, Bon Secours Medical Group, Richmond, VA, USA
| | - Moahad Dar
- Division of Endocrinology and Metabolism, East Carolina University, Greenville NC, USA.,Greenville Veterans Affairs Health Care Center, Greenville, NC, USA
| | - Stéphanie B Mayer
- Hunter Holmes McGuire Veterans Affairs Medical Center, Division of Endocrinology and Metabolism, Richmond, VA, USA.,Virginia Commonwealth University, Division of Endocrinology and Metabolism, Richmond, VA, USA
| | - Matthew J Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA.,Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
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Alexopoulos AS, Duffy R, Kobe EA, German J, Moylan CA, Soliman D, Jeffreys AS, Coffman CJ, Crowley MJ. Underrecognition of Nonalcoholic Fatty Liver Disease in Poorly Controlled Diabetes: A Call to Action in Diabetes Care. J Endocr Soc 2021; 5:bvab155. [PMID: 34755002 PMCID: PMC8570418 DOI: 10.1210/jendso/bvab155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Indexed: 11/19/2022] Open
Abstract
Individuals with type 2 diabetes (T2DM) are at high risk for nonalcoholic fatty liver disease (NAFLD), and evidence suggests that poor glycemic control is linked to heightened risk of progressive NAFLD. We conducted an observational study based on data from a telehealth trial conducted in 2018-2020. Our objectives were to (1) characterize patterns of NAFLD testing/care in a cohort of individuals with poorly controlled T2DM; and (2) explore how laboratory based measures of NAFLD (eg, liver enzymes, fibrosis-4 [FIB-4]) vary by glycemic control. We included individuals with poorly controlled T2DM (n = 228), defined as hemoglobin A1c (HbA1c) ≥ 8.5% despite clinic-based care. Two groups of interest were (1) T2DM without known NAFLD; and (2) T2DM with known NAFLD. Demographics, medical history, medication use, glycemic control (HbA1c), and NAFLD testing/care patterns were obtained by chart review. Among those without known NAFLD (n = 213), most were male (78.4%) and self-identified as Black race (68.5%). Mean HbA1c was 9.8%. Most had liver enzymes (85.4%) and platelets (84.5%) ordered in the outpatient department over a 2-year period that would allow for FIB-4 calculation, yet only 2 individuals had FIB-4 documented in clinical notes. Approximately one-third had abnormal liver enzymes at least once over a 2-year period, yet only 7% had undergone liver ultrasound and 4.7% had referral to hepatology. Among those with known NAFLD (n = 15), mean HbA1c was 9.5%. Only 4 individuals had undergone transient elastography, half of whom had advanced fibrosis. NAFLD is underrecognized in poorly controlled T2DM, even though this is a high-risk group for NAFLD and its complications.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC 27705, USA.,Department of Medicine, Division of Endocrinology, Duke University, Durham NC 27710, USA
| | - Ryan Duffy
- Department of Medicine, Duke University Medical Center, Durham NC 27710, USA
| | - Elizabeth A Kobe
- Department of Medicine, Duke University Medical Center, Durham NC 27710, USA
| | - Jashalynn German
- Department of Medicine, Division of Endocrinology, Duke University, Durham NC 27710, USA
| | - Cynthia A Moylan
- Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, NC 27710, USA.,Department of Medicine, Division of Gastroenterology, Duke University, Durham NC 27710, USA
| | - Diana Soliman
- Department of Medicine, Division of Endocrinology, Duke University, Durham NC 27710, USA
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC 27705, USA
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC 27705, USA.,Department of Biostatistics and Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC 27705, USA.,Department of Medicine, Division of Endocrinology, Duke University, Durham NC 27710, USA
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Alexopoulos AS, Kahkoska AR, Pate V, Bradley MC, Niznik J, Thorpe C, Stürmer T, Buse J. Deintensification of Treatment With Sulfonylurea and Insulin After Severe Hypoglycemia Among Older Adults With Diabetes. JAMA Netw Open 2021; 4:e2132215. [PMID: 34726745 PMCID: PMC8564578 DOI: 10.1001/jamanetworkopen.2021.32215] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Practice guidelines recommend deintensification of hypoglycemic agents among older adults with diabetes who are at high risk of hypoglycemia, yet real-world treatment deintensification practices are not well characterized. OBJECTIVE To examine the incidence of sulfonylurea and insulin deintensification after a hypoglycemia-associated emergency department (ED) visit or hospitalization among older adults with diabetes and to identify factors associated with deintensification of treatment. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included a random sample of 20% of nationwide fee-for-service US Medicare beneficiaries aged 65 years and older with concurrent Medicare parts A, B, and D coverage between January 1, 2007, and December 31, 2017. Individuals with diabetes who had at least 1 hypoglycemia-associated ED visit or hospitalization were included. Data were analyzed from August 1, 2020, to August 1, 2021. EXPOSURES Baseline medication for the treatment of diabetes (sulfonylurea, insulin, or both). MAIN OUTCOMES AND MEASURES Incidence of treatment deintensification (yes or no) in the 100 days after a severe hypoglycemic episode requiring an ED visit or hospitalization, with treatment deintensification defined as (1) a decrease in sulfonylurea dose, (2) a change from long-acting to short-acting sulfonylurea (glipizide), (3) discontinuation of sulfonylurea, or (4) discontinuation of insulin based on pharmacy dispensing claims. RESULTS Among 76 278 distinct Medicare beneficiaries who had a hypoglycemia-associated ED visit or hospitalization, the mean (SD) age was 76.6 (7.6) years. Of 106 293 total hypoglycemic episodes requiring hospital attention, 69 084 (65.0%) occurred among women, 26 056 (24.5%) among Black individuals; 4761 (4.5%) among Hispanic individuals; 69 704 (65.6%) among White individuals; and 5772 (5.4%) among individuals of other races and ethnicities (comprising Asian, North American Native, unknown race or ethnicity, and unspecified race or ethnicity). A total of 32 074 episodes (30.2%) occurred among those receiving sulfonylurea only, 60 350 (56.8%) occurred among those receiving insulin only, and 13 869 (13.0%) occurred among those receiving both sulfonylurea and insulin. Treatment deintensification rates were highest among individuals receiving both sulfonylurea and insulin therapies at the time of their hypoglycemic episode (6677 episodes [48.1%]), followed by individuals receiving sulfonylurea only (14 192 episodes [44.2%]) and insulin only (14 495 episodes [24.0%]). Treatment deintensification rates increased between 2007 and 2017 (sulfonylurea only: from 41.4% to 49.7%; P < .001 for trend; insulin only: from 21.3% to 25.9%; P < .001 for trend; sulfonylurea and insulin: from 45.9% to 49.6%; P = .005 for trend). Lower socioeconomic status (as indicated by the receipt of low-income subsidies) was associated with lower odds of deintensification, regardless of baseline hypoglycemic regimen (sulfonylurea only: adjusted odds ratio [AOR], 0.74 [95% CI, 0.70-0.78]; insulin only: AOR, 0.71 [95% CI, 0.68-0.75]; sulfonylurea and insulin: AOR, 0.72 [95% CI, 0.66-0.78]). A number of patient factors were associated with higher odds of treatment deintensification: higher frailty (eg, ≥40% probability of needing assistance with activities of daily living among those receiving sulfonylurea and insulin: AOR, 1.50; 95% CI, 1.32-1.71), chronic kidney disease (eg, sulfonylurea and insulin: AOR, 1.29; 95% CI, 1.19-1.40), a history of falls (eg, sulfonylurea and insulin: AOR, 1.20; 95% CI, 1.09-1.33), and depression (eg, sulfonylurea and insulin: AOR, 1.11; 95% CI, 1.02-1.20). CONCLUSIONS AND RELEVANCE In this cohort study, deintensification of sulfonylurea and/or insulin therapy within 100 days after a hypoglycemia-associated ED visit or hospitalization occurred in fewer than 50% of older adults with diabetes; however, these deintensification rates may be increasing over time, and deintensification of insulin was likely underestimated because of challenges in capturing changes to insulin dosing using administrative claims data. These results suggest that greater efforts are needed to identify individuals at high risk of hypoglycemia to encourage appropriate treatment deintensification in accordance with current evidence.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Department of Medicine, Division of Endocrinology, Duke University, Durham, North Carolina
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina
| | - Anna R. Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Marie C. Bradley
- Division of Epidemiology, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Joshua Niznik
- Department of Medicine, Division of Geriatrics and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
- Center of Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Carolyn Thorpe
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill
- Center of Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - John Buse
- Department of Medicine, Division of Endocrinology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
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11
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Yang JY, Moon AM, Kim H, Pate V, Barritt AS, Crowley MJ, Buse JB, Stürmer T, Alexopoulos AS. Newer second-line glucose-lowering drugs versus thiazolidinediones on cirrhosis risk among older US adult patients with type 2 diabetes. J Diabetes Complications 2020; 34:107706. [PMID: 32843283 PMCID: PMC7657660 DOI: 10.1016/j.jdiacomp.2020.107706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022]
Abstract
AIMS Type 2 diabetes (T2D) accelerates progression of chronic liver disease to cirrhosis, yet the effects of most glucose-lowering drugs (GLDs) on cirrhosis risk in T2D are unknown. To address this gap, we compared cirrhosis risk following initiation of newer second-line GLDs vs. thiazolidinediones (TZDs), which improve histology in non-alcoholic fatty liver disease. MATERIALS AND METHODS Using the US Medicare Fee-for-Service database (2007-2015) and an active comparator, new-user design, we estimated crude incidence rates (IRs) and propensity-score adjusted hazard ratios (aHR) for incident cirrhosis, comparing newer GLDs (dipeptidyl peptidase-4 inhibitors (DPP4i), glucagon-like peptide-1 receptor agonists (GLP1RA), and sodium-glucose co-transporter 2 inhibitors (SGLT2i)) vs. TZDs. RESULTS Among 239,549 total initiators, we observed 318, 151, and < 30 cirrhosis events when comparing DPP4i vs. TZD, GLP1RA vs. TZD, and SGLT2i vs. TZD, respectively. IRs ranged from 1.7 [95% CI, 0.8-3.6] to 3.6 [2.5-5.2] events per 1000 person-years. Point aHR estimates for cirrhosis were elevated among newer GLD initiators vs. TZD (DPP4i: 1.15 [0.89-1.50]; GLP1RA: 1.34 [0.82-2.20]; SGLT2i: 1.16, [0.44-3.08]), although estimates were imprecise due to short durations of drug exposure. CONCLUSIONS We observed mildly elevated cirrhosis risk with newer GLDs vs. TZD; however, uncertainty remains due to imprecise and statistically non-significant effect estimates.
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Affiliation(s)
- Jeff Y Yang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America.
| | - Andrew M Moon
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Hannah Kim
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - A Sidney Barritt
- Department of Medicine, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Matthew J Crowley
- Department of Medicine, Division of Endocrinology, Duke University, Durham, NC, United States of America; Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC, United States of America
| | - John B Buse
- Department of Medicine, Division of Endocrinology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Anastasia-Stefania Alexopoulos
- Department of Medicine, Division of Endocrinology, Duke University, Durham, NC, United States of America; Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC, United States of America
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12
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Crowley MJ, McGuire DK, Alexopoulos AS, Jensen TJ, Rasmussen S, Saevereid HA, Verma S, Buse JB. Effects of Liraglutide on Cardiovascular Outcomes in Type 2 Diabetes Patients With and Without Baseline Metformin Use: Post Hoc Analyses of the LEADER Trial. Diabetes Care 2020; 43:e108-e110. [PMID: 32647053 PMCID: PMC7440910 DOI: 10.2337/dc20-0437] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/13/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Matthew J Crowley
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, NC .,Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anastasia-Stefania Alexopoulos
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, NC.,Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC
| | | | | | | | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - John B Buse
- Division of Endocrinology and Metabolism, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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13
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Lunyera J, Mohottige D, Alexopoulos AS, Campbell H, Cameron CB, Sagalla N, Amrhein TJ, Crowley MJ, Dietch JR, Gordon AM, Kosinski AS, Cantrell S, Williams JW, Gierisch JM, Ear B, Goldstein KM. Risk for Nephrogenic Systemic Fibrosis After Exposure to Newer Gadolinium Agents: A Systematic Review. Ann Intern Med 2020; 173:110-119. [PMID: 32568573 PMCID: PMC7847719 DOI: 10.7326/m20-0299] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The risk for nephrogenic systemic fibrosis (NSF) after exposure to newer versus older gadolinium-based contrast agents (GBCAs) remains unclear. PURPOSE To synthesize evidence about NSF risk with newer versus older GBCAs across the spectrum of kidney function. DATA SOURCES MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science for English-language references from inception to 5 March 2020. STUDY SELECTION Randomized controlled trials, cohort studies, and case-control studies that assessed NSF occurrence after GBCA exposure. DATA EXTRACTION Data were abstracted by 1 investigator and verified by a second. Investigator pairs assessed risk of bias by using validated tools. DATA SYNTHESIS Of 32 included studies, 20 allowed for assessment of NSF risk after exposure to newer GBCAs and 12 (11 cohort studies and 1 case-control study) allowed for comparison of NSF risk between newer and older GBCAs. Among 83 291 patients exposed to newer GBCAs, no NSF cases developed (exact 95% CI, 0.0001 to 0.0258 case). Among the 12 studies (n = 118 844) that allowed risk comparison between newer and older GBCAs, 37 NSF cases developed after exposure to older GBCAs (exact CI, 0.0001 to 0.0523 case) and 4 occurred (3 confounded) after exposure to newer GBCAs (exact CI, 0.0018 to 0.0204 case). Data were scant for patients with acute kidney injury or those at risk for chronic kidney disease. LIMITATIONS Study heterogeneity prevented meta-analysis. Risk of bias was high in most studies because of inadequate exposure and outcome ascertainment. CONCLUSION Although NSF occurrence after exposure to newer GBCAs is very rare, the relatively scarce data among patients with acute kidney injury and those with risk factors for chronic kidney disease limit conclusions about safety in these populations. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO: CRD42019135783).
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Affiliation(s)
- Joseph Lunyera
- Duke University School of Medicine, Durham, North Carolina (J.L., C.B.C.)
| | - Dinushika Mohottige
- Duke University School of Medicine and Duke University Medical Center, Durham, North Carolina (D.M.)
| | - Anastasia-Stefania Alexopoulos
- Duke University Medical Center and Durham Veterans Affairs Health Care System, Durham, North Carolina (A.A., T.J.A., M.J.C.)
| | - Hilary Campbell
- Margolis Center for Health Policy at Duke University, Durham, North Carolina (H.C.)
| | - C Blake Cameron
- Duke University School of Medicine, Durham, North Carolina (J.L., C.B.C.)
| | - Nicole Sagalla
- Durham Veterans Affairs Health Care System and Duke University School of Medicine, Durham, North Carolina (N.S.)
| | - Timothy J Amrhein
- Duke University Medical Center and Durham Veterans Affairs Health Care System, Durham, North Carolina (A.A., T.J.A., M.J.C.)
| | - Matthew J Crowley
- Duke University Medical Center and Durham Veterans Affairs Health Care System, Durham, North Carolina (A.A., T.J.A., M.J.C.)
| | - Jessica R Dietch
- Stanford University and Veterans Affairs Palo Alto Health Care System, Palo Alto, California (J.R.D.)
| | - Adelaide M Gordon
- Durham Veterans Affairs Health Care System, Durham, North Carolina (A.M.G., B.E.)
| | - Andrzej S Kosinski
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina (A.S.K.)
| | - Sarah Cantrell
- Duke University School of Medicine and Duke University Medical Center Library and Archives, Durham, North Carolina (S.C.)
| | - John W Williams
- Duke University School of Medicine and Durham Veterans Affairs Health Care System, Durham, North Carolina (J.W.W., K.M.G.)
| | - Jennifer M Gierisch
- Duke University School of Medicine, Durham Veterans Affairs Health Care System, and Duke University, Durham, North Carolina (J.M.G.)
| | - Belinda Ear
- Durham Veterans Affairs Health Care System, Durham, North Carolina (A.M.G., B.E.)
| | - Karen M Goldstein
- Duke University School of Medicine and Durham Veterans Affairs Health Care System, Durham, North Carolina (J.W.W., K.M.G.)
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14
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Li D, Silvester JA, Crowley MJ, Yang JY, Alexopoulos AS, Xu Y, Zhan S, Wang T. Assessing the association between dipeptidyl peptidase-4 inhibitors use and celiac disease through drug adverse event reporting. Ther Adv Chronic Dis 2020; 11:2040622320904301. [PMID: 32071711 PMCID: PMC6997957 DOI: 10.1177/2040622320904301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/06/2020] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jocelyn Anne Silvester
- Harvard Celiac Disease Research Program, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Matthew J Crowley
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jeff Y Yang
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | | | - Yang Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Tiansheng Wang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 2101 McGavran-Greenberg Hall, Campus Box 7453, 27599 Chapel Hill, NC 27515, USA
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15
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Wolf RA, Haw JS, Paul S, Spezia Faulkner M, Cha E, Findley MK, Khan F, Markley Webster S, Alexopoulos AS, Mehta K, Alfa DA, Ali MK. Hospital admissions for hyperglycemic emergencies in young adults at an inner-city hospital. Diabetes Res Clin Pract 2019; 157:107869. [PMID: 31560962 PMCID: PMC6914263 DOI: 10.1016/j.diabres.2019.107869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/18/2019] [Accepted: 09/23/2019] [Indexed: 12/16/2022]
Abstract
AIMS There is limited information characterizing young adults (18-35 years) (YA) with diabetes, especially those admitted for hyperglycemic emergencies. The study aims were to examine associations of patient-level characteristics with hyperglycemic emergency hospitalization and to identify variations based on diabetes type and glycemic control. METHODS We conducted retrospective analysis of 273 YA admitted to an inner-city hospital with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic nonketotic syndrome (HHS). T-tests, Chi-Square tests, and ANOVA identified differences in demographics, diabetes history, clinical indicators, complications/comorbidities, and hospital admission stratified separately by diabetes type (1 vs 2) and admission HbA1c < 9% (75 mmol/mol), ≥9% to 12% (108 mmol/mol), ≥12%). RESULTS Mean admission HbA1c was 12.4% (112 mmol/ml). HbA1c was ≥9.0% for 90.5%. The main DKA/HHS trigger was medication nonadherence (57.9%), with 35.6% presenting with new-onset type 2 diabetes. Only 3.7% utilized outpatient diabetes clinics, 38.8% were re-hospitalized within the year, and 69% lacked insurance. Diabetes complications (44.7%) and psychiatric co-morbidities (35.5%) were common. Significantly more YA with type 1 diabetes had insurance, whereas YA with type 2 diabetes had higher admission HbA1c. YA with HbA1c ≥12% were more likely to be Black and lack insurance. CONCLUSIONS YA hospitalized for DKA/HHS in an inner-city hospital tended to have severely uncontrolled diabetes. Many already had comorbidities and diabetes complications, high use of acute care services and low use of diabetes specialty services. YA characteristics varied by diabetes type and HbA1c. Overall, a substantial percentage lacked insurance, potentially impacting healthcare utilization patterns and medication adherence, and leading to DKA/HHS admissions.
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Affiliation(s)
- Rachel A Wolf
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States.
| | - J Sonya Haw
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Sudeshna Paul
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Melissa Spezia Faulkner
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; School of Nursing, Georgia State University, Atlanta, GA, United States
| | - EunSeok Cha
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Chungnam National University, College of Nursing, Daejeon, South Korea
| | - M K Findley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States
| | - Farah Khan
- School of Medicine, Emory University, Atlanta, GA, United States; Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, United States
| | | | | | - Komal Mehta
- School of Medicine, Emory University, Atlanta, GA, United States
| | - David A Alfa
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Mohammed K Ali
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States; Rollins School of Public Health, Emory University, Atlanta, GA, United States
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16
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Woo V, Kvist K, Buse JB, Hachmann-Nielsen E, Alexopoulos AS. 117 - Diabetes Duration Did Not Moderate Severe Hypoglycemia Seen With Glargine U100 vs Degludec in DEVOTE. Can J Diabetes 2019. [DOI: 10.1016/j.jcjd.2019.07.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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17
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Alexopoulos AS, Buse JB. Initial injectable therapy in type 2 diabetes: Key considerations when choosing between glucagon-like peptide 1 receptor agonists and insulin. Metabolism 2019; 98:104-111. [PMID: 31255662 PMCID: PMC6690751 DOI: 10.1016/j.metabol.2019.06.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/17/2019] [Accepted: 06/24/2019] [Indexed: 12/24/2022]
Abstract
Managing type 2 diabetes is complex and necessitates careful consideration of patient factors such as engagement in self-care, comorbidities and costs. Since type 2 diabetes is a progressive disease, many patients will require injectable agents, usually insulin. Recent ADA-EASD guidelines recommend glucagon-like peptide 1 receptor agonists (GLP-1 RAs) as first injectable therapy in most cases. The basis for this recommendation is the similar glycemic efficacy of GLP-1 RAs and insulin, but with GLP-1 RAs promoting weight loss instead of weight gain, at lower hypoglycemia risk, and with cardiovascular benefits in patients with pre-existing cardiovascular disease. GLP-1 RAs also reduce burden of glucose self-monitoring. However, tolerability and costs are important considerations, and notably, rates of drug discontinuation are often higher for GLP-1 RAs than basal insulin. To minimize risk of gastrointestinal symptoms patients should be started on lowest doses of GLP-1 RAs and up-titrated slowly. Overall healthcare costs may be lower with GLP-1 RAs compared to insulin. Though patient-level costs may still be prohibitive, GLP-1 RAs can replace 50-80 units of insulin daily and reduce costs associated with glucose self-monitoring. Decisions regarding initiating injectable therapy should be individualized. This review provides a framework to guide decision-making in the real-world setting.
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Affiliation(s)
| | - John B Buse
- University of North Carolina, Chapel Hill, NC, United States
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18
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Abstract
IMPORTANCE The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes. OBSERVATIONS Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated. CONCLUSIONS AND RELEVANCE Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.
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Affiliation(s)
| | - Rachel Blair
- Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Anne L. Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
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Alexopoulos AS, Jackson GL, Edelman D, Smith VA, Berkowitz TSZ, Woolson SL, Bosworth HB, Crowley MJ. Clinical factors associated with persistently poor diabetes control in the Veterans Health Administration: A nationwide cohort study. PLoS One 2019; 14:e0214679. [PMID: 30925177 PMCID: PMC6440639 DOI: 10.1371/journal.pone.0214679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/18/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Patients with persistent poorly-controlled diabetes mellitus (PPDM) despite engagement in clinic-based care are at particularly high risk for diabetes complications and costs. Understanding this population's demographics, comorbidities and care utilization could guide strategies to address PPDM. We characterized factors associated with PPDM in a large sample of Veterans with type 2 diabetes. METHODS We identified a cohort of Veterans with medically treated type 2 diabetes, who received Veterans Health Administration primary care during fiscal years 2012 and 2013. PPDM was defined by hemoglobin A1c levels uniformly >8.5% during fiscal year (FY) 2012, despite engagement with care during this period. We used FY 2012 demographic, comorbidity and medication data to describe PPDM in relation to better-controlled diabetes patients and created multivariable models to examine associations between clinical factors and PPDM. We also constructed multivariable models to explore the association between PPDM and FY 2013 care utilization. RESULTS In our cohort of diabetes patients (n = 435,820), 12% met criteria for PPDM. Patients with PPDM were younger than better-controlled patients, less often married, and more often Black/African-American and Hispanic or Latino/Latina. Of included comorbidities, only retinopathy (OR 1.68, 95% confidence interval (CI): 1.63,1.73) and nephropathy (OR 1.26, 95% CI: 1.19,1.34) demonstrated clinically significant associations with PPDM. Complex insulin regimens such as premixed (OR 10.80, 95% CI: 10.11,11.54) and prandial-containing regimens (OR 18.74, 95% CI: 17.73,19.81) were strongly associated with PPDM. Patients with PPDM had higher care utilization, particularly endocrinology care (RR 3.56, 95% CI: 3.47,3.66); although only 26.4% of patients saw endocrinology overall. CONCLUSION PPDM is strongly associated with complex diabetes regimens, although heterogeneity in care utilization exists. While there is evidence of underutilization, inadequacy of available care may also contribute to PPDM. Our findings should inform tailored approaches to meet the needs of PPDM, who are among the highest-risk, highest-cost patients with diabetes.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of Endocrinology, Duke University, Durham, NC, United States of America
| | - George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - David Edelman
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - Valerie A. Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
| | - Theodore S. Z. Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Sandra L. Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
| | - Hayden B. Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Department of Population Health Sciences, Duke University, Durham NC, United States of America
- Division of General Internal Medicine, Duke University, Durham NC, United States of America
- Department of Psychiatry & Behavioral Sciences, Duke University, Durham NC, United States of America
| | - Matthew J. Crowley
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC, United States of America
- Division of Endocrinology, Duke University, Durham, NC, United States of America
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Abstract
PURPOSE OF REVIEW Moderate hypertriglyceridemia is exceedingly common in diabetes, and there is growing evidence that it contributes to residual cardiovascular risk in statin-optimized patients. Major fibrate trials yielded inconclusive results regarding the cardiovascular benefit of lowering triglycerides, although there was a signal for improvement among patients with high triglycerides and low high-density lipoprotein (HDL)-the "diabetic dyslipidemia" phenotype. Until recently, no trials have examined a priori the impact of triglyceride lowering in patients with diabetic dyslipidemia, who are likely among the highest cardiovascular-risk patients. RECENT FINDINGS In the recent REDUCE IT trial, omega-3 fatty acid icosapent ethyl demonstrated efficacy in lowering cardiovascular events in patients with high triglycerides, low HDL, and statin-optimized low-density lipoprotein (LDL). The ongoing PROMINENT trial is examining the impact of pemafibrate in a similar patient population. Emerging evidence suggests that lowering triglycerides may reduce residual cardiovascular risk, especially in high-risk patients with diabetic dyslipidemia.
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Affiliation(s)
- Anastasia-Stefania Alexopoulos
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA.
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, NC, USA.
| | - Ali Qamar
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, NC, USA
| | - Kathryn Hutchins
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, NC, USA
| | - Matthew J Crowley
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, NC, USA
| | - Bryan C Batch
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
- Department of Medicine, Division of Endocrinology, Durham VA Medical Center, Durham, NC, USA
| | - John R Guyton
- Department of Medicine, Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
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Fayfman M, Vellanki P, Alexopoulos AS, Buehler L, Zhao L, Smiley D, Haw S, Weaver J, Pasquel FJ, Umpierrez GE. Report on Racial Disparities in Hospitalized Patients with Hyperglycemia and Diabetes. J Clin Endocrinol Metab 2016; 101:1144-50. [PMID: 26735258 PMCID: PMC4803176 DOI: 10.1210/jc.2015-3220] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/30/2015] [Indexed: 11/19/2022]
Abstract
CONTEXT A higher prevalence of diabetes-related complications is reported in minority populations; however, it is not known if there are racial disparities in diabetes care and outcomes in hospitalized patients. OBJECTIVE Our objective was to determine the association between hyperglycemia, in patients with and without diabetes mellitus (non-DM), and complications among different racial groups. DESIGN This observational study compared the frequency of hyperglycemia (blood glucose ≥ 180 mg/dL; 10 mmol/L) and DM and hospital complications between Black and White patients hospitalized patients between January 2012 and December 2013. SETTING AND PARTICIPANTS Adults admitted to medical and surgery services in two academic hospitals were included in this study. RESULTS Among 35 866 patients, there were 14 387 Black (40.1%) and 21 479 White patients (59.9%). Blacks had a higher prevalence of hyperglycemia (42.3% vs 36.7%, P < .0001) and DM (34.5% vs 22.8%, P < .0001) and a higher admission rate and mean daily blood glucose (P < .001). Blacks also had higher rates of complications (22.2% vs 19.2%, P < .0001), both in patients with DM (24.7 vs 22.9%, P = .0413) and non-DM with hyperglycemia (41.2% vs 37.2%, P = .0019). Using sequential modelling adjusted for age, gender, body mass index, comorbidities, and insurance coverage, non-DM Blacks with normoglycemia (odds ratio, 1.22; 95% confidence interval, 1.10-1.35) and non-DM Blacks with hyperglycemia (odds ratio, 1.18; 95% confidence interval, 1.04-1.33) had higher number of complications compared to Whites. CONCLUSIONS Black patients have higher rates of hyperglycemia and diabetes, worse inpatient glycemic control, and greater frequency of hospital complications compared to Whites. Non-DM Blacks with hyperglycemia are a particularly vulnerable group. Further investigation is needed to better understand factors contributing the racial disparities in the hospital.
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Affiliation(s)
- Maya Fayfman
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Priyathama Vellanki
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Anastasia-Stefania Alexopoulos
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Lauren Buehler
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Liping Zhao
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Dawn Smiley
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Sonya Haw
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Jeff Weaver
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Francisco J Pasquel
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
| | - Guillermo E Umpierrez
- Division of Endocrinology (M.F., P.V., A.-S.A., L.B. D.S., S.H., F.J.P., G.E.U.), Department of Medicine, Department of Biostatistics and Bioinformatics (L.Z.), Rollins School of Public Health, Research & Woodruff Health Sciences IT (J.W.), Data Management Group, Emory University, Atlanta, Georgia 30322
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Alexopoulos AS, Fayfman M, Zhao L, Weaver J, Buehler L, Smiley D, Pasquel FJ, Vellanki P, Haw JS, Umpierrez GE. Impact of obesity on hospital complications and mortality in hospitalized patients with hyperglycemia and diabetes. BMJ Open Diabetes Res Care 2016; 4:e000200. [PMID: 27486518 PMCID: PMC4947725 DOI: 10.1136/bmjdrc-2016-000200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 06/03/2016] [Accepted: 06/09/2016] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Obesity is associated with increased risk of diabetes, hypertension and cardiovascular mortality. Several studies have reported increased length of hospital stay and complications; however, there are also reports of obesity having a protective effect on health, a phenomenon coined the 'obesity paradox'. We aimed to investigate the impact of overweight and obesity on complications and mortality in hospitalized patients with hyperglycemia and diabetes. RESEARCH DESIGN AND METHODS This retrospective analysis was conducted on 29 623 patients admitted to two academic hospitals in Atlanta, Georgia, between January 2012 and December 2013. Patients were subdivided by body mass index into underweight (body mass index <18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)) and obese (>30 kg/m(2)). Hyperglycemia was defined as a blood glucose >10 mmol/L during hospitalization. Hospital complications included a composite of pneumonia, acute myocardial infarction, respiratory failure, acute kidney injury, bacteremia and death. RESULTS A total of 4.2% were underweight, 29.6% had normal weight, 30.2% were overweight, and 36% were obese. 27.2% of patients had diabetes and 72.8% did not have diabetes (of which 75% had hyperglycemia and 25% had normoglycemia during hospitalization). A J-shaped curve with higher rates of complications was observed in underweight patients in all glycemic groups; however, there was no significant difference in the rate of complications among normal weight, overweight, or obese patients, with and without diabetes or hyperglycemia. CONCLUSIONS Underweight is an independent predictor for hospital complications. In contrast, increasing body mass index was not associated with higher morbidity or mortality, regardless of glycemic status. There was no evidence of an obesity paradox among inpatients with diabetes and hyperglycemia.
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Affiliation(s)
| | - Maya Fayfman
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Liping Zhao
- Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jeff Weaver
- Information Technology, Data Management Group, Emory University, Atlanta, Georgia, USA
| | - Lauren Buehler
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dawn Smiley
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Francisco J Pasquel
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Priyathama Vellanki
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - J Sonya Haw
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Buehler L, Fayfman M, Alexopoulos AS, Zhao L, Farrokhi F, Weaver J, Smiley-Byrd D, Pasquel FJ, Vellanki P, Umpierrez GE. The impact of hyperglycemia and obesity on hospitalization costs and clinical outcome in general surgery patients. J Diabetes Complications 2015; 29:1177-82. [PMID: 26355027 DOI: 10.1016/j.jdiacomp.2015.07.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/31/2015] [Accepted: 07/31/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The impact of obesity on clinical outcomes and hospitalization costs in general surgery patients with and without diabetes (DM) is unknown. MATERIALS AND METHODS We reviewed medical records of 2451 patients who underwent gastrointestinal surgery at two university hospitals. Hyperglycemia was defined as BG ≥140 mg/dl. Overweight was defined by body mass index (BMI) between 25-29.9 kg/m(2) and obesity as a BMI ≥30 kg/m(2). Hospital cost was calculated using cost-charge ratios from Centers for Medicare and Medicaid Services. Hospital complications included a composite of major cardiovascular events, pneumonia, bacteremia, acute kidney injury (AKI), respiratory failure, and death. RESULTS Hyperglycemia was present in 1575 patients (74.8%). Compared to patients with normoglycemia, those with DM and non-DM with hyperglycemia had higher number of complications (8.9% vs. 35.8% vs. 30.0%, p<0.0001), longer hospital stay (5 days vs. 9 days vs. 9 days, p<0.0001), more readmissions within 30 days (9.3% vs. 18.8% vs. 17.2%, p<0.0001), and higher hospitalization costs ($20,273 vs. $79,545 vs. $72,675, p<0.0001). In contrast, compared to normal-weight subjects, overweight and obesity were not associated with increased hospitalization costs ($58,313 vs. $58,173 vs. $66,633, p=0.74) or risk of complications, except for AKI (11.9% vs. 14.8% vs. 20.5%, p<0.0001). Multivariate analysis revealed that DM (OR=4.4, 95% CI=2.8,7.0) or perioperative hyperglycemia (OR=4.1, 95% CI=2.7-6.2) were independently associated with increased risk of complications. CONCLUSION Hyperglycemia but not increasing BMI, in patients with and without diabetes undergoing gastrointestinal surgery was associated with a higher number of complications and hospitalization costs.
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Affiliation(s)
- Lauren Buehler
- Emory University Department of Medicine, Atlanta, GA, USA
| | - Maya Fayfman
- Emory University Department of Medicine, Atlanta, GA, USA
| | | | - Liping Zhao
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | | | - Jeff Weaver
- Information Technology, Emory University, Atlanta, GA, USA
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Shariq O, Odedra A, Alexopoulos AS, Gould S, Soobrah R. Synchronous occurrence of gastrointestinal stromal tumour and ovarian neoplasm in a patient presenting with acute cholecystitis. J Gastrointest Cancer 2011; 43:113-6. [PMID: 21360271 DOI: 10.1007/s12029-011-9265-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Omair Shariq
- Imperial College London, South Kensington Campus, Eastcote, Middlesex HA5 1PP, UK.
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