Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations.

RESULTS

At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence.

CONCLUSIONS

Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.

Patient-level factors associated with hemoglobin A1C testing in Alabama Medicaid beneficiaries with diabetes

AIM

We evaluated patient-level factors associated with receipt of hemoglobin A1c (HbA1c) testing among Alabama Medicaid beneficiaries with type 2 diabetes.

METHODS

We conducted a retrospective analysis of person-year observations from Medicaid claims data from 2011 to 2020. Adults aged 19-64 years with type 2 diabetes and continuous enrollment in Medicaid for study year and year prior were included. Primary outcomes were ≥ 1 and ≥ 2 HbA1c test(s) per year. We conducted multivariable Poisson regression stratified by Medicaid eligibility reason (disability, poverty) examining the association of study year, demographics, clinical factors, and healthcare utilization with HbA1c testing.

RESULTS

We analyzed 288,379 observations, 51% with disability-based, 49% poverty-based eligibility. Overall, 57% observations had ≥ 1 HbA1c, 35% had ≥ 2 HbA1c tests. More observations with disability-based than poverty-based eligibility had ≥ 1 (76% vs. 38%) and ≥ 2 HbA1c tests (49% vs. 20%). Patient-level factors were associated with a higher likelihood of having ≥ 1 HbA1c: Black race and older age (disability-based eligibility); year after 2011, female sex, and younger age (poverty-based eligibility); and rurality, insulin use, endocrinology care, diabetes complications, and ambulatory care visits (both groups).

CONCLUSIONS

Just over one-third of adult Alabama Medicaid beneficiaries with diabetes had ≥ 2 HbA1c tests per year; testing frequency differed by Medicaid eligibility.

Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019

INTRODUCTION

Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019.

METHODS

We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds.

RESULTS

We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model.

CONCLUSION

Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.

Measuring continuity of care for diabetes: which visits to include?

OBJECTIVES

Continuity of care measures are widely used to evaluate the quality of health care delivery, but which visits are included vary across studies. Our objective was to determine how the provider specialties included affect continuity values, year-to-year stability, and association with emergency department (ED) visits.

STUDY DESIGN

Retrospective study of Alabama Medicaid administrative data.

METHODS

We included beneficiaries with diabetes who had at least 3 outpatient visits in each of 2018 and 2019 (N = 9578). We defined 3 provider groupings: all providers, diabetes-broad (primary care, cardiology, neurology, endocrinology, ophthalmology, nephrology, and psychiatry), and diabetes-narrow (primary care and endocrinology). Continuity of care was calculated using the Continuity of Care Index (COCI) for each provider grouping. We compared correlation between measures and from year to year using Spearman correlations, and we used multivariable logistic regression to determine association with ED visits.

RESULTS

The mean COCI was 0.54 using visits with all providers, 0.64 with diabetes-broad providers, and 0.83 with diabetes-narrow providers. COCI with diabetes-narrow providers was moderately correlated with the broader sets of providers (Spearman ρ, 0.52-0.65). Comparing each participant's COCI in 2018 with that in 2019, the mean intraperson difference was similar (0.16-0.22), and correlation was moderate (Spearman ρ, 0.41-0.47) for each measure. COCI had similar weak association with ED visits using each provider grouping (odds ratio, 0.99; 95% CI, 0.98-0.99 for each 0.1-unit difference in COCI).

CONCLUSIONS

Continuity values differed substantially depending on which provider specialties were included. The importance of this variation is uncertain, as continuity was weakly associated with ED visits using each of the measures.

Disparities in Postdischarge Ambulatory Care Follow-Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure

Background Ambulatory follow-up for all patients with heart failure (HF) is recommended within 7 to 14 days after hospital discharge to improve HF outcomes. We examined postdischarge ambulatory follow-up of patients with comorbid diabetes and HF from a low-income population in primary and specialty care. Methods and Results Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010 to 2019, were included and the claims analyzed for ambulatory care use (any, primary care, cardiology, or endocrinology) within 60 days after discharge using restricted mean survival time regression and negative binomial regression. Among 9859 Medicaid-covered adults with diabetes and first hospitalization for HF (mean age, 53.7 years; SD, 9.2 years; 47.3% Black; 41.8% non-Hispanic White; 10.9% Hispanic/Other [Other included non-White Hispanic, American Indian, Pacific Islander and Asian adults]; 65.4% women, 34.6% men), 26.7% had an ambulatory visit within 0 to 7 days, 15.2% within 8 to 14 days, 31.3% within 15 to 60 days, and 26.8% had no visit; 71% saw a primary care physician and 12% a cardiology physician. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory visit (P<0.0001) or the visit was delayed (by 1.8 days, P=0.0006 and by 2.8 days, P=0.0016, respectively) and were less likely to see a primary care physician than non-Hispanic White adults (adjusted incidence rate ratio, 0.96 [95% CI, 0.91-1.00] and 0.91 [95% CI, 0.89-0.98]; respectively). Conclusions More than half of Medicaid-covered adults with diabetes and HF in Alabama did not receive guideline-concordant postdischarge care. Black and Hispanic/Other adults were less likely to receive recommended postdischarge care for comorbid diabetes and HF.

Diabetes distress and self-reported health in a sample of Alabama Medicaid-covered adults before and during the COVID-19 pandemic

Temporary closures of outpatient health facilities and transitions to virtual care during the COVID-19 pandemic interrupted the care of millions of patients with diabetes contributing to worsening psychosocial factors and enhanced difficulty in managing type 2 diabetes mellitus. We explored associations between COVID time period and self-reported diabetes distress on self-reported health among a sample of Alabama Medicaid-covered adults with diabetes pre-COVID (2017-2019) and during-COVID (2020-2021).

Method

In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by the Alabama Medicaid Agency. Participants were dichotomized into pre-COVID (March 2017 to October 2019) vs during-COVID (October 2020 to May 2021) groups. Participants with missing data were removed from analyses. We assessed diabetes related stress by the Diabetes Distress Scale. We measured self-reported health using a single item with a 5-point Likert scale. We ran logistic regressions modeling COVID time period on self-reported poor health controlling for demographics, severity of diabetes, and diabetes distress.

Results

In this sample of 1822 individuals, median age was 54, 74.5% were female and 59.4% were Black. Compared to pre-COVID participants, participants surveyed during COVID were younger, more likely to be Black (64.1% VS 58.2%, p=0.01) and female (81.8% VS 72.5%, p<0.001). This group also had fewer individuals from rural areas (29.2% VS 38.4%, p<0.001), and shorter diabetes duration (7 years VS 9 years, p<0.001). During COVID individuals reported modestly lower levels of diabetes distress (1.2 VS 1.4, p<0.001) when compared to the pre-COVID group. After adjusting for demographic differences, diabetes severity, and diabetes distress, participants responding during COVID had increased odds of reporting poor health (Odds ratio [OR] 1.41, 95% Confidence Interval [CI] 1.11-1.80).

Discussion

We found respondents were more likely to report poorer health during COVID compared to pre-COVID. These results suggest that increased outreach may be needed to address diabetes management for vulnerable groups, many of whom were already at high risk for poor outcomes prior to the pandemic.

Primary care visits and ambulatory care sensitive diabetes hospitalizations among adult Alabama Medicaid beneficiaries

PURPOSE

To describe patterns of care use for Alabama Medicaid adult beneficiaries with diabetes and the association between primary care utilization and ambulatory care sensitive (ACS) diabetes hospitalizations.

METHODS

This retrospective cohort study analyzes Alabama Medicaid claims data from January 2010 to April 2018 for 52,549 covered adults ages 19-64 with diabetes. Individuals were characterized by demographics, comorbidities, and health care use including primary, specialty, mental health and hospital care. Characteristics of those with and without any ACS diabetes hospitalization are reported. A set of 118,758 observations was created, pairing information on primary care use in one year with ACS hospitalizations in the following year. Logistic regression analysis was used to assess the impact of primary care use on the occurrence of an ACS hospitalization.

RESULTS

One third of the cohort had at least one ACS diabetes hospitalization over their observed periods; hospital users tended to have multiple ACS hospitalizations. Hospital users had more comorbidities and pharmaceutical and other types of care use than those with no ACS hospitalizations. Controlling for other types of care use, comorbidities and demographics, having a primary care visit in one year was significantly associated with a reduced likelihood of ACS hospitalization in the following year (odds ratio comparing 1-2 visits versus none 0.79, 95% confidence interval 0.73-0.85).

CONCLUSIONS

Program and population health interventions that increase access to primary care can have a beneficial effect of reducing excess inpatient hospital use for Medicaid covered adults with diabetes.

The Mediating Role of Self-Efficacy in the Association Between Diabetes Education and Support and Self-Care Management

RESULTS

A total of 1,318 participants were included in the study (mean age = 52.9 years, SD = 9.6; 72.5% female, 56.4% Black, 3.1% Hispanic). Diabetes education was associated with increases in self-care activity scores related to general diet, physical activity, glucose self-monitoring, and foot care; care coordination was associated with glucose self-monitoring. In addition, mediation analysis models confirmed that improvements in self-efficacy led to improved self-care activities scores, mediating the association of diabetes education and self-care activities.

CONCLUSIONS

Diabetes education and self-efficacy were associated with better self-care. Receiving diabetes education led to a higher likelihood of engaging in self-care activities, driven in part by increases in self-efficacy. Future interventions that aim to improve diabetes self-management behaviors can benefit from targeting self-efficacy constructs and from the integration of diabetes education in the care coordination structure.

Social support and diabetes distress among adults with type 2 diabetes covered by Alabama Medicaid

AIMS

Diabetes distress affects approximately 36% of adults with diabetes and is associated with worse diabetes self-management and poor glycaemic control. We characterized participants' diabetes distress and studied the relationship between social support and diabetes distress.

METHODS

In this cross-sectional study, we surveyed a population-based sample of adults with type 2 diabetes covered by Alabama Medicaid. We used the Diabetes Distress Scale assessing emotional burden, physician-related, regimen-related and interpersonal distress. We assessed participants' level of diabetes-specific social support and satisfaction with this support, categorized as low or moderate-high. We performed multivariable logistic regression of diabetes distress by level of and satisfaction with social support, adjusting for demographics, disease severity, self-efficacy and depressive symptoms.

RESULTS

In all, 1147 individuals participated; 73% were women, 41% White, 58% Black and 3% Hispanic. Low level of or satisfaction with social support was reported by 11% of participants; 7% of participants had severe diabetes distress. Participants with low satisfaction with social support were statistically significantly more likely to have severe diabetes distress than those with moderate-high satisfaction, adjusted odds ratio 2.43 (95% CI 1.30, 4.54).

CONCLUSIONS

Interventions addressing diabetes distress in adults with type 2 diabetes may benefit from a focus on improving diabetes-specific social support.

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS)

PURPOSE

High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation.

METHODS

We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders.

RESULTS

In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36).

CONCLUSIONS

An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.

Factors associated with antidepressant use among low-income racially and ethnically diverse patients with type 2 diabetes

OBJECTIVE

Depression is common in patients with type 2 diabetes and associated with poor diabetes-related outcomes. We evaluated the factors associated with antidepressant use in a low-income, racially and ethnically diverse sample of patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed a cross-sectional study of baseline data from participants in a cluster randomized trial evaluating a health literacy intervention for diabetes care in safety net clinics. Depressive symptoms were measured by the Center for Epidemiological Studies Depression Scale (CES-D); antidepressant use was abstracted from medication lists. Multivariable mixed effects logistic regression was used to evaluate the relationship between antidepressant use and race/ethnicity adjusting for depressive symptoms, age, gender, income, and health literacy.

RESULTS

Of 403 participants, 58% were non-Hispanic White, 18% were non-Hispanic Black, and 24% were Hispanic. Median age was 51 years old; 60% were female, 52% of participants had a positive screen for depression, and 18% were on antidepressants. Black and Hispanic participants were significantly less likely to be on an antidepressant compared with white participants, adjusted odds ratios 0.31(95% CI: 0.12 to 0.80) and 0.26 (95% CI: 0.10 to 0.74), respectively.

CONCLUSIONS

In this vulnerable population with type 2 diabetes, we found a high prevalence of depressive symptoms, and a small proportion of participants were on an antidepressant. Black and Hispanic participants were significantly less likely to be treated with an antidepressant. Our findings suggest depression may be inadequately treated in low-income, uninsured patients with type 2 diabetes, especially racial and ethnic minorities.

Evaluation of Frailty as an Unmeasured Confounder in Observational Studies of Antidiabetic Medications

BACKGROUND

It is unknown whether observational studies evaluating the association between antidiabetic medications and mortality adequately account for frailty. Our objectives were to evaluate if frailty was a potential confounder in the relationship between antidiabetic medication regimen and mortality and how well administrative and clinical electronic health record (EHR) data account for frailty.

METHODS

We conducted a retrospective cohort study in a single Veterans Health Administration (VHA) healthcare system of 500 hospitalizations-the majority due to heart failure-of Veterans who received regular VHA care and initiated type 2 diabetes treatment from 2001 to 2008. We measured frailty using a modified frailty index (FI, >0.21 frail). We obtained antidiabetic medication regimen and time-to-death from administrative sources. We compared FI among patients on different antidiabetic regimens. Stepwise Cox proportional hazards regression estimated time-to-death by demographic, administrative, clinical EHR, and FI data.

RESULTS

Median FI was 0.22 (interquartile range 0.18, 0.27). Frailty differed across antidiabetic regimens (p < .001). An FI increase of 0.05 was associated with an increased risk of death (hazard ratio 1.45, 95% confidence interval 1.32, 1.60). Cox proportional hazards model for time-to-death including demographic, administrative, and clinical EHR data had a c-statistic of 0.70; adding FI showed marginal improvement (c-statistic 0.72).

CONCLUSIONS

Frailty was associated with antidiabetic regimen and death, and may confound that relationship. Demographic, administrative, and clinical EHR data, commonly used to balance differences among exposure groups, performed moderately well in assessing risk of death, with minimal gain from adding frailty. Study design and analytic techniques can help minimize potential confounding by frailty in observational studies.

Accuracy of a composite event definition for hypoglycemia

PURPOSE

To evaluate the accuracy of a composite definition for the identification of hypoglycemia events that used both administrative claims and laboratory data in a cohort of patients.

METHODS

We reviewed medical records in a sample of presumed hypoglycemia events among patients who received care at the Veterans Health Administration Tennessee Valley Healthcare System in 2001 to 2012. A hypoglycemia event was defined as a hospitalization or emergency department visit judged by the treating clinician to be due to hypoglycemia, or an outpatient laboratory or point-of-care blood glucose measurement <60 mg/dL. Based on medical record review, each event was classified as true positive (severe, documented symptomatic, documented asymptomatic) or false positive (probable symptomatic, not hypoglycemia). The positive predictive values (PPV) of the individual event types (hospitalization, emergency department, and outpatient) were estimated.

RESULTS

Of 2250 events identified through the composite definition, 321 events (15 hospitalizations, 103 emergency department visits, and 203 outpatient events) were reviewed. The PPVs were 80% for hospitalization events, 48% for emergency department events, and 96% for outpatient events. The emergency department definition included a nonspecific diagnosis code for diabetic complications which captured many false positive events. Excluding this code from the definition improved the PPV for emergency department events to 70% and missed one true event.

CONCLUSIONS

Our composite definition for hypoglycemia performed moderately well in a cohort of Veterans. Further evaluation of the emergency department events may be needed.

An environmental scan of medication history technician programs within the Veterans Health Administration

PURPOSE

Results of a study to identify medication history technician (MHT) programs within the Veterans Health Administration (VHA) and to evaluate the personnel, structure, and scope of such programs are reported.

METHODS

Specially trained pharmacy technicians can take accurate patient medication histories and contribute to the medication reconciliation process. An environmental scan of MHT programs within VHA was conducted via an email query of pharmacy personnel. Semistructured interviews of personnel at each responding site (an MHT, a pharmacist, or both) were conducted.

RESULTS

Ten VHA sites had existing MHT programs; the earliest was initiated in 2010. Sites employed from 1 to 4 MHTs, who most commonly worked in the inpatient setting (7 sites). At most sites (9), MHTs obtained a "best possible medication history" through systematic collection of medication information using 2 reliable sources, such as patients, caregivers, and medical records. Survey respondents at all sites reported benefits of MHT programs, including dedicated time to obtain medication histories, allowing for more effective use of pharmacists' time. Six sites were eager to increase the reach of their programs. MHT training, oversight, and quality assurance varied across the sites. The survey results indicated that there are opportunities nationally-within and outside VHA-to develop standardized training, competency assessments, and quality assurance measures for MHT programs.

CONCLUSION

Ten VHA sites with MHT programs were identified. MHTs most commonly worked in inpatient settings as part of admission medication reconciliation processes.

Validation of an algorithm to identify heart failure hospitalisations in patients with diabetes within the veterans health administration

OBJECTIVES

We aimed to validate an algorithm using both primary discharge diagnosis (International Classification of Diseases Ninth Revision (ICD-9)) and diagnosis-related group (DRG) codes to identify hospitalisations due to decompensated heart failure (HF) in a population of patients with diabetes within the Veterans Health Administration (VHA) system.

DESIGN

Validation study.

SETTING

Veterans Health Administration-Tennessee Valley Healthcare System PARTICIPANTS: We identified and reviewed a stratified, random sample of hospitalisations between 2001 and 2012 within a single VHA healthcare system of adults who received regular VHA care and were initiated on an antidiabetic medication between 2001 and 2008. We sampled 500 hospitalisations; 400 hospitalisations that fulfilled algorithm criteria, 100 that did not. Of these, 497 had adequate information for inclusion. The mean patient age was 66.1 years (SD 11.4). Majority of patients were male (98.8%); 75% were white and 20% were black.

PRIMARY AND SECONDARY OUTCOME MEASURES

To determine if a hospitalisation was due to HF, we performed chart abstraction using Framingham criteria as the referent standard. We calculated the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity for the overall algorithm and each component (primary diagnosis code (ICD-9), DRG code or both).

RESULTS

The algorithm had a PPV of 89.7% (95% CI 86.8 to 92.7), NPV of 93.9% (89.1 to 98.6), sensitivity of 45.1% (25.1 to 65.1) and specificity of 99.4% (99.2 to 99.6). The PPV was highest for hospitalisations that fulfilled both the ICD-9 and DRG algorithm criteria (92.1% (89.1 to 95.1)) and lowest for hospitalisations that fulfilled only DRG algorithm criteria (62.5% (28.4 to 96.6)).

CONCLUSIONS

Our algorithm, which included primary discharge diagnosis and DRG codes, demonstrated excellent PPV for identification of hospitalisations due to decompensated HF among patients with diabetes in the VHA system.

Perceptions of Provider Communication Among Vulnerable Patients With Diabetes: Influences of Medical Mistrust and Health Literacy

Patient-provider communication is modifiable and is linked to diabetes outcomes. The association of communication quality with medical mistrust is unknown. We examined these factors within the context of a low-literacy/numeracy-focused intervention to improve diabetes care, using baseline data from diverse patients enrolled in a randomized trial of a health communication intervention. Demographics, measures of health communication (Communication Assessment Tool [CAT], Interpersonal Processes of Care survey [IPC-18]), health literacy (Short Test of Functional Health Literacy in Adults), depression, medical mistrust, and glycemic control were ascertained. Adjusted proportional odds models were used to test the association of mistrust with patient-reported communication quality. The interaction effect of health literacy on mistrust and communication quality was also assessed. A total of 410 patients were analyzed. High levels of mistrust were observed. In multivariable modeling, patients with higher mistrust had lower adjusted odds of reporting a higher CAT score (adjusted odds ratio [AOR] = 0.67, 95% confidence interval [CI] [0.52, 0.86], p = .003) and higher scores on the Communication (AOR = 0.69, 95% CI [0.55, 0.88], p = .008), Decided Together (AOR = 0.74, 95% CI [0.59, 0.93], p = .02), and Interpersonal Style (AOR = 0.69, 95% CI [0.53, 0.90], p = .015) subscales of the IPC-18. We observed evidence of an interaction effect of health literacy for the association between mistrust and the Decided Together subscale of the IPC-18 such that patients with higher mistrust and lower literacy perceived worse communication relative to mistrustful patients with higher literacy. In conclusion, medical mistrust was associated with poorer communication with providers in this public health setting. Patients' health literacy level may vary the effect of mistrust on interactional aspects of communication. Providers should consider the impact of mistrust on communication with vulnerable diabetes populations and focus efforts on mitigating its influence.

Misperceptions of the norms for the frequency of alcohol and other drug use on college campuses

Data from surveys of students representing 100 diverse college campuses were used to investigate the difference between the self-reported frequency of a drug's use and students' perceptions of the frequency of use. Students were asked about the frequency of their own use of 11 drugs (alcohol, tobacco, marijuana, cocaine, amphetamines, sedatives, hallucinogens, opiates, inhalants, designer drugs, and steroids) and how often they thought "the average student" on their campus used these drugs. Respondents typically misperceived their peer norms (designated as the median of self-reported use) by substantially overestimating how often the average student used each drug, both in campus samples where abstinence or infrequent use were the median of self-reports and in samples where the median of self-reports revealed more frequent use. To the extent that they may promote or reinforce students' actual use, these misperceptions should be considered in designing college drug prevention programs.

Alcohol use and related consequences among students with varying levels of involvement in college athletics

Alcohol use, binge drinking, and substance abuse-related consequences among students with varying levels of participation in intercollegiate athletics were examined. Between October 1994 and May 1996, 51,483 students at 125 institutions answered questions about their involvement in athletics, ranging from noninvolvement to participant to leadership positions, on the long form of the Core Alcohol and Drug Survey. In comparisons with nonathletes, both male and female athletes consumed significantly more alcohol per week, engaged in binge drinking more often, and suffered more adverse consequences from their substance use. No support was found for the hypothesis that athletic leaders were more responsible than other team participants in using alcohol. Male team leaders appeared to be at significantly greater risk than female team leaders; they also consumed more alcohol, binged more often, and suffered more consequences than other team members.

Alcohol use in the Greek system: follow the leader?

OBJECTIVE

This study was designed to identify drinking patterns, consequences of use, and belief systems about alcohol among college students according to their level of involvement in campus fraternity and sorority life.

METHOD

This study of 25,411 (15,100 female) students who completed the Core Alcohol and Drug Survey, from 61 institutions, compared alcohol consumption, binge drinking, consequences of use and beliefs about drinking according to students' level of involvement in fraternities and sororities, ranging from no involvement to that of attending functions only, to active involvement, to leadership positions within Greek organizations.

RESULTS

Analyses indicated that students in the Greek system averaged significantly more drinks per week, engaged in heavy drinking more often and, with minor exceptions, suffered more negative consequences than non-Greeks. The leaders of fraternities and sororities consumed alcohol, engaged in heavy drinking and experienced negative consequences at levels at least as high and in some cases higher than that of other Greek members. In terms of their views about alcohol, fraternity and sorority members believed that alcohol was a vehicle for friendship, social activity and sexuality to a greater extent than non-Greeks. The beliefs of the leaders did not stand out compared to other members.

CONCLUSIONS

In addition to corroborating earlier reports that show that fraternity and sorority members use more alcohol than nonmembers, this study indicates that the leadership of Greek organizations are participating in setting heavy-drinking norms. Suggestions are made concerning targeting prevention programming efforts toward this group.

Understanding the three national databases on collegiate alcohol and drug use

An overview of the three major databases used to examine alcohol and other drug use habits of American college students is provided. The databases are compared in terms of purpose, study population, subject selection, method of administration, focus, utility for institutional use, and trend analyses. The authors conclude that no one source of data is "best." Rather, the studies represent three different sources of data. Although information from these databases overlaps to some extent, each database makes a unique contribution to the field.

Weapon carrying and substance abuse among college students

Results from administering the Core Alcohol and Drug Survey on 61 US campuses during the 1994/95 academic year were analyzed to assess weapon carrying among college students. Seven percent of the 26,225 students (11.1% of the men and 4.3% of the women) responded that they had carried weapons (gun, knife, etc) during the last 30 days. A comparison with a matched sample of nonweapon carriers revealed that a greater percentage of the armed than the unarmed students had experienced harassment, violence, and threats of violence, and that they felt less safe on their campuses. The weapon-carrying men consumed significantly more alcohol than their unarmed counterparts, and a higher percentage reported binge drinking, use of other drugs, and adverse consequences from substance abuse. Differences between armed and unarmed female students were not as clearly consistent in terms of substance abuse and consequences.

Average weekly alcohol consumption: drinking percentiles for American college students

Data obtained from 44,433 students who reported the average number of drinks they consumed per week in response to the Core Alcohol and Drug Survey at 105 college campuses between October 1994 and June 1996 are discussed. The majority of the students indicated that, on an average weekly basis, they consumed little or no alcohol. Forty-eight percent of the students at 2-year schools and 38% of the students at 4-year schools reported consuming no alcoholic drinks per week. When responses from these students were combined with those of students who consumed only one drink per week, the total included 50% of the students at 2-year and 51% of students at 4-year colleges. Approximately 10% of the students reported they consumed 15 or more drinks on an average weekly basis. The authors provide a detailed table showing the cumulative percentages of student drinking at various levels and offer suggestions for clinical and programmatic intervention.

Beyond performance enhancement: polypharmacy among collegiate users of steroids

The extremely low prevalence of steroid use among college students makes it virtually impossible to conduct analyses on any single college campus. By studying a cohort of 58,625 college students from 78 institutions that administered the Core Alcohol and Drug Survey in 1990 and 1991, a critical mass of 175 users on which it was possible to conduct statistical analyses was identified. Compared with a randomly selected group of nonusers, the steroid users reported consuming dramatically more alcohol and demonstrated higher rates of binge drinking. In addition, a significantly higher percentage of steroid users reported using tobacco, marijuana, cocaine, amphetamines, sedatives, hallucinogens, opiates, inhalants, and designer drugs. A higher percentage of steroid users than nonusers also reported experiencing negative consequences as a result of substance abuse, and a greater percentage of the steroid users reported family histories of abuse of alcohol and other drugs. Implications from the standpoint of student development are discussed.

An instrument to assess adolescent alcohol involvement

This study was the beginning of a validation process for the Presley Adolescent Alcohol Scale (PAAS). The instrument is intended for youth of ages 11 to 24 and involves six subscales: Quantity and Frequency of Use, School Functioning, Family Functioning, Social Functioning, Driving and Legal Functioning, Physical and Psychological Functioning. Items identify Use, Misuse, Problematic Use, and Dependency. Three groups of students in Southern Illinois were used (N = 216): high school students in grades 7 to 12 (N = 51), undergraduate students at Southern Illinois University (N = 129), and patients at an adolescent alcohol inpatient treatment center (N = 36). ANOVA showed a significant difference between these three groups (p < .0001). In general, results from the study supported initial validity and reliability for the PAAS.

Development of the Core Alcohol and Drug Survey: initial findings and future directions

To assist universities in obtaining accurate information about the effectiveness of their efforts to prevent substance abuse, a committee of grantees of the US Department of Education's Fund for the Improvement of Postsecondary Education (FIPSE) developed an assessment tool known as the Core Alcohol and Drug Survey. This self-report instrument is designed to examine the nature, scope, and consequences of the use of alcohol and other drugs among college students. To date, the survey has been administered to nearly half a million students on 800 campuses, and the findings have been aggregated to create what is presently the largest national database on substance use in the higher education setting. The Core survey has often been used by campus health service personnel in assessment and programming efforts. This article describes the development and administration of the Core Alcohol and Drug Survey and provides a sampling of findings from the 1989-1991 FIPSE drug prevention group. This cohort included 58,625 students who completed the survey. Findings regarding consumption patterns, consequences of use, underage drinking, and regional differences are delineated, along with information regarding the future direction of Core survey projects.