Comparative analysis of hospitalization risk for incident heart failure in non-Hispanic Black versus non-Hispanic White individuals with type 2 diabetes on empagliflozin (Empa-AA): Insights from real-world data

AIM

There are limited data to evaluate hospitalization for heart failure (hHF) in non-Hispanic Black (hereafter Black) or non-Hispanic White (hereafter White) individuals without previous hHF. Our goal was to evaluate the risk of hHF among Black versus White patients with type 2 diabetes (T2DM) who were initially prescribed empagliflozin using real-world data.

METHODS

This multicentre retrospective cohort study included participants aged ≥18 years who had T2DM, were either Black or White, had no previous hHF, and were prescribed empagliflozin between August 2014 and December 2019. Our primary outcome was time to first hHF after the initial prescription of empagliflozin. A propensity-score (PS)-weighted analysis was performed to balance characteristics by race. The inverse probability treatment weighting method based on PS was used to make treatment comparisons. To compare Black with White, a PS-weighted Cox's cause-specific hazards model was used.

RESULTS

In total, 8789 participants were eligible for inclusion (Black = 3216 vs. White = 5573). The Black cohort was significantly younger, had a higher proportion of females, and had a higher prevalence of chronic kidney disease, hypertension and diabetic retinopathy, while the White cohort had a higher prevalence of coronary artery disease. After adjustment for confounding factors such as age, gender, coronary artery disease, hypertension and diabetic retinopathy, the hazard ratio for first-time hHF was not significantly different between the two racial groups [hazard ratio (95% confidence interval) = 1.09 (0.84-1.42), p = .52].

CONCLUSION

This study showed no significant difference in incident hHF among Black versus White individuals with T2DM following a prescription for empagliflozin.

Practice Facilitation and Peer Coaching for Uncontrolled Hypertension Among Black Individuals: A Randomized Clinical Trial

Importance

Rural Black participants need effective intervention to achieve better blood pressure (BP) control.

Objective

Among Black rural adults with persistently uncontrolled hypertension attending primary care clinics, to determine whether peer coaching (PC), practice facilitation (PF), or both (PCPF) are superior to enhanced usual care (EUC) in improving BP control.

Design, Setting, and Participants

A cluster randomized clinical trial was conducted in 69 rural primary care practices across Alabama and North Carolina between September 23, 2016, and September 26, 2019. The participating practices were randomized to 4 groups: PC plus EUC, PF plus EUC, PCPF plus EUC, and EUC alone. The baseline EUC approach included a laptop for each participating practice with hyperlinks to participant education on hypertension, a binder of practice tips, a poster showing an algorithm for stepped care to improve BP, and 25 home BP monitors. The trial was stopped on February 28, 2021, after final data collection. The study included Black participants with persistently uncontrolled hypertension. Data were analyzed from February 28, 2021, to December 13, 2022.

Interventions

Practice facilitators helped practices implement at least 4 quality improvement projects designed to improve BP control throughout 1 year. Peer coaches delivered a structured program via telephone on hypertension self-management throughout 1 year.

Main Outcomes and Measures

The primary outcome was the proportion of participants in each trial group with BP values of less than 140/90 mm Hg at 6 months and 12 months. The secondary outcome was a change in the systolic BP of participants at 6 months and 12 months.

Results

A total of 69 practices were randomized, and 1209 participants' data were included in the analysis. The mean (SD) age of participants was 58 (12) years, and 748 (62%) were women. In the intention-to-treat analyses, neither intervention alone nor in combination improved BP control or BP levels more than EUC (at 12 months, PF vs EUC odds ratio [OR], 0.94 [95% CI, 0.58-1.52]; PC vs EUC OR, 1.30 [95% CI, 0.83-2.04]; PCPF vs EUC OR, 1.02 [95% CI, 0.64-1.64]). In preplanned subgroup analyses, participants younger than 60 years in the PC and PCPF groups experienced a significant 5 mm Hg greater reduction in systolic BP than participants younger than 60 years in the EUC group at 12 months. Practicewide BP control estimates in PF groups suggested that BP control improved from 54% to 61%, a finding that was not observed in the trial's participants.

Conclusions and Relevance

The results of this cluster randomized clinical trial demonstrated that neither PC nor PF demonstrated a superior improvement in overall BP control compared with EUC. However, PC led to a significant reduction in systolic BP among younger adults.

Trial Registration

ClinicalTrials.gov Identifier: NCT02866669.

Neighborhood Disadvantage and Risk of Heart Failure: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Heart failure (HF) affects >6 million US adults, with recent increases in HF hospitalizations. We aimed to investigate the association between neighborhood disadvantage and incident HF events and potential differences by diabetes status.

METHODS

We included 23 645 participants from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), a prospective cohort of Black and White adults aged ≥45 years living in the continental United States (baseline 2005-2007). Neighborhood disadvantage was assessed using a Z score of 6 census tract variables (2000 US Census) and categorized as quartiles. Incident HF hospitalizations or HF-related deaths through 2017 were adjudicated. Multivariable-adjusted Cox regression was used to examine the association between neighborhood disadvantage and incident HF. Heterogeneity by diabetes was assessed using an interaction term.

RESULTS

The mean age was 64.4 years, 39.5% were Black adults, 54.9% females, and 18.8% had diabetes. During a median follow-up of 10.7 years, there were 1125 incident HF events with an incidence rate of 3.3 (quartile 1), 4.7 (quartile 2), 5.2 (quartile 3), and 6.0 (quartile 4) per 1000 person-years. Compared to adults living in the most advantaged neighborhoods (quartile 1), those living in neighborhoods in quartiles 2, 3, and 4 (most disadvantaged) had 1.30 (95% CI, 1.06-1.60), 1.36 (95% CI, 1.11-1.66), and 1.45 (95% CI, 1.18-1.79) times greater hazard of incident HF even after accounting for known confounders. This association did not significantly differ by diabetes status (interaction P=0.59). For adults with diabetes, the adjusted incident HF hazards comparing those in quartile 4 versus quartile 1 was 1.34 (95% CI, 0.92-1.96), and it was 1.50 (95% CI, 1.16-1.94) for adults without diabetes.

CONCLUSIONS

In this large contemporaneous prospective cohort, neighborhood disadvantage was associated with an increased risk of incident HF events. This increase in HF risk did not differ by diabetes status. Addressing social, economic, and structural factors at the neighborhood level may impact HF prevention.

Treatment Intensity, Prescribing Patterns, and Blood Pressure Control in Rural Black Patients with Uncontrolled Hypertension

BACKGROUND/OBJECTIVE

Because racial disparities in hypertension treatment persist, the objective of the present study was to examine patient vs. practice characteristics that influence antihypertensive selection and treatment intensity for non-Hispanic Black (hereafter "Black") patients with uncontrolled hypertension in the rural southeastern USA.

METHODS

We enrolled 25 Black patients from each of 69 rural practices in Alabama and North Carolina with uncontrolled hypertension (systolic blood pressure (BP) ≥ 140 mm Hg) in a 4-arm cluster randomized trial of BP control interventions. Patients' antihypertensive medications were abstracted from medical records and reconciled at the baseline visit. Treatment intensity was computed using the defined daily dose (DDD) method of the World Health Organization. Correlates of greater antihypertensive medication intensity were assessed by linear regression modeling, and antihypertensive medication classes were compared by baseline systolic BP (SBP) level.

RESULTS

A total of 1431 patients were enrolled and had complete baseline data. Antihypertensive treatment intensity averaged 3.7 ± 2.6 equivalent medications at usual dosages and was significantly related to higher baseline systolic BP, older age, male sex, insurance availability, higher BMI, and concurrent diabetes, but not to practice type or medication barriers in regression models. Renin-angiotensin system inhibitors were the most commonly used medications, followed by diuretics and calcium channel blockers.

CONCLUSION/RELEVANCE

Antihypertensive treatment intensity for Black patients in the rural southeastern USA with a history of uncontrolled hypertension averaged the equivalent of almost four medications at usual dosages and was significantly associated with baseline SBP levels and other patient characteristics, but not clinic type.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02866669.

Racial and Ethnic Differences Among Active-Duty Service Members in Use of Mental Health Care and Perceived Mental Health Stigma: Results From the 2018 Health Related Behaviors Survey

INTRODUCTION

The prevalence of mental health disorders is rising among US service members; however, research is limited on their use of mental health care. The objective of our study was to determine whether racial and ethnic disparities exist in the use of mental health care and perceived mental health stigma among active-duty service members.

METHODS

We obtained data from a sample of 17,166 active-duty service members who participated in the 2018 Department of Defense Health Related Behavior Survey (HRBS). Racial and ethnic groups included Black, Hispanic, White, and other. Yes-no questions about use of mental health care and perceived mental health stigma were our outcome variables. We used multiple logistic regression to assess racial and ethnic differences in mental health care use and perceived mental health stigma by service members. Significance was set at P <.05.

RESULTS

In 2018, approximately 25.5% of service members self-reported using mental health services, and 34.2% self-reported perceived mental health stigma. Hispanic service members (AOR = 0.78) and service members in the "other" racial and ethnic group (AOR = 0.81) were less likely than their White counterparts to have used mental health care. Black (AOR = 0.68) and Hispanic (AOR = 0.86) service members were less likely than their White counterparts to self-report perceived mental health stigma.

CONCLUSION

The 2018 HRBS showed racial and ethnic differences in mental health care use and perceived stigma among US active-duty service members. Perceived stigma was a barrier to use of mental health care among service members with a mental health condition. Culture-sensitive programs customized for different racial and ethnic groups are needed to promote mental health care and reduce perceptions of stigma associated with its use.

Diabetes Self-management Education and Support Completion Before and During the COVID-19 Pandemic: Results From Local Health Departments in North Carolina

OBJECTIVE

To assess diabetes self-management education and support (DSMES) completion rate and explore the differences in DSMES completion by different delivery models.

METHODS

We conducted a retrospective analysis of 2017-2021 DSMES data at 2 local health departments (LHDs) in Eastern North Carolina. We evaluated DSMES completion by 2 delivery models.

RESULTS

From 2017 to 2021, the overall DSMES completion rate was 15.3%. The delivery model of two 4-hour sessions was associated with a higher completion rate than the delivery model of four 2-hour sessions ( P < .05). Patients with less than a high school education and without health insurance were less likely to have completed their DSMES training ( P < .05).

CONCLUSION

The DSMES completion rate at LHDs in North Carolina is very low. A delivery model consisting of 10 hours of education delivered in fewer sessions may contribute to a higher DSMES completion rate, but more research is needed. Targeted programs are needed to engage patients and improve DSMES completion.

Implementing practice facilitation in research: how facilitators spend their time guiding practices to improve blood pressure control

BACKGROUND

Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices' unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure.

METHODS

The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs.

RESULTS

In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members (n = 886 instances) or with practice managers alone (n = 670 instances) while relatively few on-site visits were conducted with primary care providers alone (n = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices' percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status.

CONCLUSIONS

PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services.

TRIAL REGISTRATION

NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691.

The design and rationale of a multicenter real-world trial: The southeastern collaboration to improve blood pressure control in the US Black Belt - Addressing the triple threat

BACKGROUND

Impoverished African Americans (AA) with hypertension face poor health outcomes.

PURPOSE

To conduct a cluster-randomized trial testing two interventions, alone and in combination, to improve blood pressure (BP) control in AA with persistently uncontrolled hypertension.

METHODS

We engaged primary care practices serving rural Alabama and North Carolina residents, and in each practice we recruited approximately 25 AA adults with persistently uncontrolled hypertension (mean systolic BP >140 mmHg over the year prior to enrollment plus enrollment day BP assessed by research assistants ≥140/90 mmHg). Practices were randomized to peer coaching (PC), practice facilitation (PF), both PC and PF (PC + PF), or enhanced usual care (EUC). Coaches met with participants from PC and PC + PF practices weekly for 8 weeks then monthly over one year, discussing lifestyle changes, medication adherence, home monitoring, and communication with the healthcare team. Facilitators met with PF and PC + PF practices monthly to implement ≥1 quality improvement intervention in each of four domains. Data were collected at 0, 6, and 12 months.

RESULTS

We recruited 69 practices and 1596 participants; 18 practices (408 participants) were randomized to EUC, 16 (384 participants) to PF, 19 (424 participants) to PC, and 16 (380 participants) to PC + PF. Participants had mean age 57 years, 61% were women, and 56% reported annual income <$20,000.

LIMITATIONS

The PF intervention acts at the practice level, possibly missing intervention effects in trial participants. Neither PC nor PF currently has established clinical reimbursement mechanisms.

CONCLUSIONS

This trial will fill evidence gaps regarding practice-level vs. patient-level interventions for rural impoverished AA with uncontrolled hypertension.

Disparate statin prescribing following hospital discharge for stroke or transient ischemic attack: Findings from COMPASS

BACKGROUND

Published guidelines recommend high-intensity statins following an ischemic stroke or transient ischemic attack (TIA). The authors examined the potential for disparate patterns of statin prescribing in a cluster randomized trial of transitional care following acute stroke or TIA.

METHODS

Medications taken before hospitalization and statins prescribed at discharge among stroke and TIA patients at 27 participating hospitals were examined. Any statin and intensive statin prescribed at discharge were compared by age (<65, 65-75, >75 years), racial category (White vs. Black), sex (male vs. female), and rurality (urban vs. non-urban) using logistic mixed models.

RESULTS

Among 3211 patients (mean age 67 years; 47% female; 29% Black), 90% and 55%, respectively, were prescribed any statin or intensive statin therapy at discharge. White (vs. Black) patients (0.71, 0.51-0.98) less commonly received any statin prescription, while stroke (vs. TIA) patients (1.90, 1.38-2.62) and those residing in urban areas (1.66, 1.07-2.55) more commonly received any statin prescription. Among those prescribed a statin, only 42% of White and 51% of Black patients >75 years. were prescribed an intensive statin; the OR for intensive statin prescribing was 0.44 for patients >75 years and was similar in a subgroup not on a statin previously.

CONCLUSION/RELEVANCE

Following stroke or TIA, statin prescribing remains lower in White patients, in those with TIA, and in those in non-urban areas. Intensive statin prescribing remains limited, particularly in patients >75 years. These data may inform efforts to improve guideline concordant prescribing for post-stroke patients.

Abstract WMP42: Differences In Antihypertensive Prescribing And Smoking Cessation Counseling After Acute Ischemic Stroke 2003-2016: The National Regards Cohort Study

Background: Limited population-based evidence is available about risk factor management following stroke. We examined age, race, sex, and regional (Stroke Belt vs. other) differences in discharge antihypertensive prescribing and smoking cessation counseling after ischemic stroke using population level data from a national cohort study.

Methods: Medical record data was abstracted from 1042 participants enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who had an adjudicated ischemic stroke between 2003-2016. Participants with a history of prior stroke, in-hospital death, hospice discharge, incomplete records, and non-smokers for smoking cessation analyses were excluded resulting in 798 cases for discharge antihypertensive prescribing and 117 cases for smoking cessation counseling in the final analyses. Differences were assessed using modified Poisson regression adjusting for patient and hospital level factors.

Results: Overall, 86% received discharge antihypertensives while 50% of current smokers received counseling at discharge. Participants who were older, female, had a greater number of CV risk factors, and higher BMIs were significantly more likely to receive discharge antihypertensives compared to younger participants, males, those with fewer risk factors and lower BMIs, respectively (age RR 1.05; 95% CI, 1.02-1.09; female sex RR 1.09; 95% CI, 1.03-1.16; total risk factors RR 1.07; 95% CI, 1.04-1.10; BMI RR 1.01; 95% CI, 1.00-1.01). There was an increasing trend in receipt of smoking cessation counseling over time (RR 1.12; 95% CI, 1.04-1.21).

Conclusions: Discharge antihypertensive prescribing varies modestly by patient-level variables. There were no differences in smoking cessation counseling by age, sex, race, or study region. Smoking cessation counseling has improved over time, yet only half of smokers received cessation counseling.

Recruitment and retention of primary care practices in the Southeastern Collaboration to Improve Blood Pressure Control

Background

Racial disparities related to hypertension prevalence and control persist, with Black persons continuing to have both high prevalence and suboptimal control. The Black Belt region of the US Southeast is characterized by multiple critical priority populations: rural, low-income, and minority (Black).

Methods

In a cluster-randomized, controlled, pragmatic implementation trial, the Southeastern Collaboration to Improve Blood Pressure Control evaluated two multi-component, multi-level functional interventions - peer coaching (PC) and practice facilitation (PF) (separately and combined) - as adjuncts to usual care to improve blood pressure control in the Black Belt. The overall goal was to randomize 80 primary care practices (later reduced to 69 practices) in Alabama and North Carolina to one of four interventions: 1) enhanced usual care (EUC); 2) EUC plus PC; 3) EUC plus PF; or 4) EUC plus both PC and PF. Several measures to facilitate recruitment and retention of practices were employed, including practice readiness assessment.

Results

Contact was initiated with 248 practices during the study enrollment period. Of these, 99 declined participation, 39 were ineligible, and 41 were being evaluated for inclusion when the target number of practices was reached. The remaining 69 practices eventually were enrolled, with 18 practices randomized to EUC, 19 to PC, 16 to PF, and 16 to PC plus PF. Only two practices (2.9%) were withdrawn during the study. Several facilitators of and barriers to practice recruitment and retention were identified.

Conclusion

Our findings underscore the importance of a structured approach to recruiting primary care practices in a pragmatic implementation trial.ClinicalTrials.gov registration number NCT02866669.

Persistence of Depressive Symptoms and Risk of Incident Cardiovascular Disease With and Without Diabetes: Results from the REGARDS Study

BACKGROUND

Baseline depressive symptoms are associated with subsequent adverse cardiovascular (CV) events in subjects with and without diabetes but the impact of persistent symptoms vs. improvement remains controversial.

OBJECTIVE

Examine long-term changes in depressive symptoms in individuals with and without diabetes and the associated risk for adverse CV events.

DESIGN

REGARDS is a prospective cohort study of CV risk factors in 30,000 participants aged 45 years and older.

PARTICIPANTS

N = 16,368 (16.5% with diabetes mellitus) who remained in the cohort an average of 11.1 years later and who had complete data.

MAIN MEASURES

Depressive symptoms were measured using the 4-item Centers for Epidemiologic Study of Depression (CES-D) questionnaire at baseline and again at a mean follow-up of 5.07 (SD = 1.66) years. Adjudicated incident stroke, coronary heart disease (CHD), CV mortality, and a composite outcome were assessed in a subsequent follow-up period of 6.1 (SD = 2.6) years.

METHODS

The association of changes in depressive symptoms (CES-D scores) across 5 years with incident CV events was assessed using Cox proportional hazards modeling.

KEY RESULTS

Compared to participants with no depressive symptoms at either time point, participants without diabetes but with persistently elevated depressive symptoms at both baseline and follow-up demonstrated a significantly increased risk of incident stroke (HR (95% CI) = 1.84 (1.03, 3.30)), a pattern which was substantially more prevalent in blacks (HR (95% CI) = 2.64 (1.48, 4.72)) compared to whites (HR (95% CI) = 1.06 (0.50, 2.25)) and in those not taking anti-depressants (HR (95% CI) = 2.01 (1.21, 3.35)) in fully adjusted models.

CONCLUSIONS

The persistence of depressive symptoms across 5 years of follow-up in participants without diabetes identifies individuals at increased risk for incident stroke. This was particularly evident in black participants and among those not taking anti-depressants.

LBSUN162 Cumulative Probability Of Heart Failure Hospitalization Among Non-Hispanic Black Compared To Non-Hispanic White Individuals With Type 2 Diabetes On Empagliflozin (EMPA-AA): Real-world Data

The results from the SGLT-2 inhibitors cardiovascular outcome trials were generalized to all, despite that non-Hispanic Black (hereafter, "Black") participants were underrepresented. Our goal was to evaluate, among patients with type 2 diabetes, the risk of heart failure hospitalizations among black vs non-Hispanic White (hereafter "White") patients initially prescribed empagliflozin. | We performed a multicenter retrospective study using clinical data derived from Electronic Medical Records (EMR's) from adults with type 2 diabetes cared for at 4 healthcare systems (UNC Health, Duke Health, MUSC, and ECU Health) who were prescribed empagliflozin between August 2014 and December 2019. Our primary outcome was time to first heart failure hospitalization. We wanted to understand if the outcomes were different in Black vs White patients with previous hospitalizations for heart failure that occurred prior to an empagliflozin prescription. Cumulative probability of heart failure hospitalization by race was estimated using the cumulative incidence function. The association of race with risk of heart failure hospitalization was evaluated using multivariable Cox hazards models. Hazard ratio (HR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively. | A total of 704 patients with previous heart failure hospitalizations were eligible. Mean age by race category (Black/White) was 60.2 vs 64.3 years (p &lt; 0. 0001); 42.8% vs 61. 0% were males (p &lt; 0. 0001) and 81.2% vs 73.2% had a history of hypertension respectively. Black patients were significantly younger and predominantly female. Cumulative probability of heart failure hospitalization at 2-years post-initiation of empagliflozin was 71.7% (95% CI = 61.6%, 79.6%) vs. 70.9% (95% CI = 64. 0%, 76.7%) for Black vs White, respectively. When adjusting for age, gender, and baseline comorbidities, there was no statistically significant difference in the risk of hospitalizations for heart failure between Black vs White patients (HR = 1. 03; 95% CI = 0.85, 1.25, p = 0.79). | In patients with type 2 diabetes with a documented previous hospitalization for heart failure prior to a prescription for empagliflozin, we found no significant difference in the cumulative probability of heart failure hospitalization in Black vs White patients.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

The Key Driver Implementation Scale (KDIS) for practice facilitators: Psychometric testing in the “Southeastern collaboration to improve blood pressure control” trial

Background

Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the “Key Driver Implementation Scale” (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale’s psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial.

Methods

The KDIS items assess a practice’s progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options.

Results

PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care.

Conclusions

The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one.

Cardiovascular benefits of GLP-1RA and SGLT-2i in women with type 2 diabetes

Given the CV benefit noted in the CVOTs, GLP-1RAs and SGLT-2is are given preference in T2DM guidelines. While guidelines do not report potential gender difference, those differences exist. On restricting the CVOTs results to women with increased CV risk or established ASCVD, GLP-1RAs significantly reduced MACE while SGLT-2is resulted in a non-significant reduction.

Musculoskeletal Injections Performed by Family Medicine Residents Participating in a Clinical Sports Medicine Track

Background and Objectives: Primary care physicians (PCPs) are front line providers of musculoskeletal (MSK) care and MSK injections. Little is known about the volume of common MSK injections performed by FM residents (FMRs) and those residents participating in a longitudinal clinical sports medicine (SM) track. This study outlines an SM track and demonstrates the MSK procedural experience of SM track residents (SMRs) and traditional FMRs (non-SMRs). Methods: We utilized a retrospective study design. We compared billing codes and provider information for common MSK injections for the second (PGY-2) and third (PGY-3) postgraduate years for non-SMRs (n=39) and SMRs (n=7) graduating between 2018-2021. We used the average number of patient encounters for each comparison group (non-SMRs vs SMRs) to determine the percentage of patients receiving an MSK injection in each cohort by PGY status. Results: Of patients receiving MSK injections across both groups, the most common was the landmark-guided large joint injection (64.23%), and the most frequent site was the knee (47.00%). SMRs performed significantly more MSK injections per patient evaluated compared to non-SMRs while in the SM clinic (PGY-2: 2.706% vs 0.913%, P&lt;.001; PGY-3: 4.276% vs 0.862%, P&lt;.001). No significant differences existed between PGY-2 groups when the influence of the SM clinic was removed, but PGY-3 SMRs performed significantly more injections than PGY-3 non-SMRs (1.225% vs 0.862%, P&lt;.011). Conclusions: An SM track in the FM residency is associated with an increased volume of MSK injections among SMRs compared to their graduate year-matched non-SMRs.

Towards better reporting of the Proportion of Days Covered method in cardiovascular medication adherence: A scoping review and new tool TEN-SPIDERS

Although medication adherence is commonly measured in electronic datasets using the proportion of days covered (PDC), no standardized approach is used to calculate and report this measure. We conducted a scoping review to understand the approaches taken to calculate and report the PDC for cardiovascular medicines to develop improved guidance for researchers using this measure. After prespecifying methods in a registered protocol, we searched Ovid Medline, Embase, Scopus, CINAHL Plus and grey literature (1 July 2012 to 14 December 2020) for articles containing the terms “proportion of days covered” and “cardiovascular medicine”, or synonyms and subject headings. Of the 523 articles identified, 316 were reviewed in full and 76 were included (93% observational studies; 47% from the USA; 2 grey literature articles). In 45 articles (59%), the PDC was measured from the first dispensing/claim date. Good adherence was defined as 80% PDC in 61 articles, 56% of which contained a rationale for selecting this threshold. The following parameters, important for deriving the PDC, were often not reported/unclear: switching (53%), early refills (45%), in‐hospital supplies (45%), presupply (28%) and survival (7%). Of the 46 articles where dosing information was unavailable, 59% reported how doses were imputed. To improve the transparent and systematic reporting of the PDC, we propose the TEN‐SPIDERS tool, covering the following PDC parameters: Threshold, Eligibility criteria, Numerator and denominator, Survival, Presupply, In‐hospital supplies, Dosing, Early Refills, and Switching. Use of this tool will standardize reporting of the PDC to facilitate reliable comparisons of medication adherence estimates between studies.

The benefit of GLP-1RA in different age groups in the cardiovascular outcome trials

There may be hesitancy in prescribing GLP-1RA in older adults. On pooling results from the CVOTs comparing GLP-1RA to placebo, there was a significantly lower incidence of MACE favoring GLP-1RA in both younger and older adults. GLP-1RA should be considered in high risk patients regardless of age.

Abstract MP50: Neighborhood Social And Economic Environment And Heart Failure Risk Among Adults With & Without Diabetes: The Reasons For Geographic And Racial Differences In Stroke (regards) Study

Background: Heart failure (HF) mortality rates have been increasing since 2011. Individual-level education and occupation have been inversely associated with HF mortality among those with diabetes mellitus (DM) but not among those without DM. However, less is known about the association between neighborhood social and economic environment (NSEE) and HF risk and whether this association varies by DM status.

Methods: This study included 21,244 Black and White adults age >=45 years at baseline (2003-07) from the REGARDS Study. NSEE quartiles were created using z-scores based on 6 census tract variables from year 2000 (% <high school education, % unemployed, % household with <$30,000, % living in poverty, % on public assistance, % without car). Incident HF events (fatal or non-fatal) were adjudicated based on hospitalization with HF signs and symptoms, supportive imaging or biomarkers. Diabetes was defined as fasting glucose >=126 mg/dL or random glucose >=200 mg/dL or use of diabetes medications. Cox proportional hazards regression was used to obtain hazard ratios (95% CI) with HF follow-up through 2016.

Results: Mean age was 65 years, 54% were women, 61% were White and 18% had prevalent DM at baseline. During a median 10.1 years, 829 incident HF events occurred. Among adults with DM, neighborhood disadvantage was associated with an increased HF risk , but this association was not statistically significant (Table). Among adults without DM, the risk of HF was higher for participants living in any neighborhood that was not the most advantaged, and the magnitude of association was smiliar across NSEE quartiles.

Conclusion: Adults living in disadvantaged neighborhoods had a higher risk of HF, particularly among those without DM. Addressing neighborhood social and economic conditions may be important for HF prevention.

Does the Association Between Hemoglobin A1c and Risk of Cardiovascular Events Vary by Residential Segregation? The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

OBJECTIVE

To examine if the association between higher A1C and risk of cardiovascular disease (CVD) among adults with and without diabetes is modified by racial residential segregation.

RESEARCH DESIGN AND METHODS

The study used a case-cohort design, which included a random sample of 2,136 participants at baseline and 1,248 participants with incident CVD (i.e., stroke, coronary heart disease [CHD], and fatal CHD during 7-year follow-up) selected from 30,239 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants originally assessed between 2003 and 2007. The relationship of A1C with incident CVD, stratified by baseline diabetes status, was assessed using Cox proportional hazards models adjusting for demographics, CVD risk factors, and socioeconomic status. Effect modification by census tract-level residential segregation indices (dissimilarity, interaction, and isolation) was assessed using interaction terms.

RESULTS

The mean age of participants in the random sample was 64.2 years, with 44% African American, 59% female, and 19% with diabetes. In multivariable models, A1C was not associated with CVD risk among those without diabetes (hazard ratio [HR] per 1% [11 mmol/mol] increase, 0.94 [95% CI 0.76-1.16]). However, A1C was associated with an increased risk of CVD (HR per 1% increase, 1.23 [95% CI 1.08-1.40]) among those with diabetes. This A1C-CVD association was modified by the dissimilarity (P < 0.001) and interaction (P = 0.001) indices. The risk of CVD was increased at A1C levels between 7 and 9% (53-75 mmol/mol) for those in areas with higher residential segregation (i.e., lower interaction index). In race-stratified analyses, there was a more pronounced modifying effect of residential segregation among African American participants with diabetes.

CONCLUSIONS

Higher A1C was associated with increased CVD risk among individuals with diabetes, and this relationship was more pronounced at higher levels of residential segregation among African American adults. Additional research on how structural determinants like segregation may modify health effects is needed.

Sodium-glucose co-transporter-2 inhibitors and atrial fibrillation in the cardiovascular and renal outcome trials

Dapagliflozin is a sodium-glucose co-transporter-2 (SGLT2) inhibitor that has recently been shown to reduce the incidence of reported episodes of atrial fibrillation (AF)/atrial flutter in the DECLARE-TIMI 58 trial. This raises the question regarding whether SGLT2 inhibitors can reduce the incidence of AF in a high-risk population. We searched for trials comparing SGLT2 inhibitors to placebo in high-risk individuals with or without diabetes (ie, cardiovascular and renal outcome trials) and that reported the incidence of AF as a serious adverse event. The EMPA-REG OUTCOME trial, CANVAS, CANVAS-R, the DECLARE-TIMI 58 trial, CREDENCE, DAPA-HF, VERTIS-CV and DAPA-CKD were included. The incidence of AF, reported as a serious adverse event, was 0.9% in individuals who received an SGLT2 inhibitor compared to 1.1% in those who received placebo. Pooled results showed a significantly lower incidence of AF in individuals with and without diabetes (relative risk 0.79, 95% confidence interval 0.67,0.93). This review suggests that there is a significantly lower risk of incident AF for individuals on SGLT2 inhibitors versus placebo. While there was a statistically significant lower incidence of AF, reported as a serious adverse event, more research is needed to evaluate its clinical significance.

Elevated depressive symptoms and risk of all-cause and cardiovascular mortality among adults with and without diabetes: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study

AIMS

To examine the association of elevated depressive symptoms with all-cause and cardiovascular disease (CVD) mortality and determine whether these associations differ for those with and without diabetes.

METHODS

We included 22,807 black and white men and women aged 45-98 years at baseline (2003-2007) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Elevated depressive symptoms were defined as a score ≥ 4 on the 4-item Centers for Epidemiologic Studies of Depression Scale. Participants were classified as having diabetes, prediabetes, or no prediabetes/diabetes based on glucose levels and diabetes medication use. All-cause mortality events were available through 2018 and adjudicated CVD mortality events were available through 2015.

RESULTS

During follow-up, there were 5383 all-cause deaths, of which 1585 were adjudicated CVD deaths. The mean survival time was lower for participants with elevated depressive symptoms than those without elevated depressive symptoms for those with diabetes, prediabetes, and no prediabetes/diabetes. In multivariable adjusted models, elevated depressive symptoms increased the risk of all-cause mortality for those with diabetes (HR = 1.15; 95% CI = 1.00-1.32), prediabetes (HR = 1.56; 95% CI = 1.28-1.91), and neither prediabetes/diabetes (HR = 1.34; 95% CI = 1.19-1.50) (p for interaction = 0.0342). Findings were similar for CVD mortality.

CONCLUSION

Elevated depressive symptoms increased the risk of all-cause and CVD mortality among individuals with and without diabetes, with a stronger magnitude of association observed among those with prediabetes. This underscores the need for assessing depressive symptoms across the glycemic spectrum, including those with prediabetes.

Risk factor control among Black and White adults with diabetes onset in older adulthood: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

The objective of this study was to determine whether attainment of clinical and lifestyle targets varied by race and sex among adults with diabetes onset in older adulthood. This study included 1420 black and white adults from the REGARDS study without diabetes at baseline (2003-07) but with diabetes onset at the follow-up exam (2013-16). Attainment of clinical targets (A1c <8%; blood pressure < 140/90 mmHg; and statin use) and lifestyle targets (not smoking; physical activity≥ 4 times/week; and moderate/no alcohol use) was assessed at the follow-up exam. Modified Poisson regression was used to obtain prevalence ratios (PR) for meeting clinical and lifestyle targets stratified by race and sex, separately. The mean age was 71.5 years, 53.6% were female, and 46.1% were black. The majority were aware of their diabetes status (85.7%) and used oral or injectable hypoglycemic medications (64.8%). Overall, 39.4% met all 3 clinical targets and 18.8% met all 3 lifestyle targets. Meeting A1c and blood pressure targets were similar by race and sex. Statin use was more prevalent for men than women among white adults (PR = 1.13; 95% CI = 0.99-1.29) and black adults (PR = 1.23; 95% CI = 1.06-1.43). For lifestyle factors, the non-smoking prevalence was similar by race and sex, while white men were more likely than white women to be physically active. Although the attainment of each clinical and lifestyle target separately was generally high among adults with diabetes onset in older adulthood, race and sex differences were apparent. Comprehensive management of clinical and lifestyle factors in people with diabetes remains suboptimal.

Randomized Pragmatic Trial of Stroke Transitional Care: The COMPASS Study

Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.

Do GLP-1RAs and SGLT-2is reduce cardiovascular events in women with type 2 diabetes? A systematic review and meta-analysis

AIMS

The risk of cardiovascular disease is often underestimated in women. This leads to a delay in controlling the risk factors for cardiovascular disease and even delays in prescribing medications with cardiovascular benefit. Our aim was to explore if glucagon-like peptide-1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter-2 inhibitor (SGLT-2i) medications would reduce cardiovascular events in women with type 2 diabetes when atherosclerotic cardiovascular disease (ASCVD) predominates.

MATERIALS AND METHODS

We searched for randomized trials comparing GLP-1RA or SGLT-2i to placebo in people with type 2 diabetes and had a primary outcome exploring major adverse cardiovascular events (MACE). Data concerning women were then extracted. A sensitivity and subgroup analyses were performed according to the class of diabetes medication.

RESULTS

A total of 9 trials (GLP-1RA in 6 trials and SGLT-2i in 3) were included. Of the 84,258 participants enrolled, 30,784 (37%) participants were women. Pooled results showed a statistically significant lower incidence of MACE favouring diabetes medications (GLP-1RA or SGLT-2i) compared to placebo (RR [95%CI]=0.87 [0.80, 0.94]). On restricting the analysis to GLP-1RA then to SGLT-2i, results remained significant with GLP-1RA but not SGLT-2i.

CONCLUSIONS

In women with type 2 diabetes who either have increased cardiovascular risk or established cardiovascular disease and ASCVD predominates, GLP-1RA significantly reduce the incidence of MACE while SGLT-2i result in a non-significant reduction. SGLT-2i may have comparable effect when examined in more studies. GLP-1RA and SGLT-2i should be considered without delay in women with type 2 diabetes and increased risk for cardiovascular disease.

Should Baseline Hemoglobin A1c or Dose of SGLT-2i Guide Treatment With SGLT-2i Versus DPP-4i in People With Type 2 Diabetes? A Meta-Analysis and Systematic Review

Our aim was to explore whether the baseline hemoglobin A_1c or the dose of sodium glucose cotransporter-2 inhibitor (SGLT-2i) chosen better predicted the efficacy of SGLT-2i versus dipeptidyl peptidase-4 inhibitor (DPP-4i) in type 2 diabetes. We searched for randomized trials that compared SGLT-2i with DPP-4i in type 2 diabetes and reported a change in hemoglobin A_1c over time. We created 2 separate analyses (one based on baseline hemoglobin A_1c and the other according to US Food and Drug Administration [FDA]-approved SGLT-2i dose). Thirteen trials were included. In the analysis according to baseline hemoglobin A_1c , there was a significantly greater reduction in hemoglobin A_1c when baseline hemoglobin A_1c was ≥8.5%, favoring SGLT-2i over DPP-4i but not when baseline hemoglobin A_1c was <8.5% (mean difference [95%CI], -0.36% [-0.53% to -0.18%] and 0.04% [-0.09% to 0.17%], respectively). On restricting the analysis to trials stratifying hemoglobin A_1c to <8.0% or ≥8.0%, results did not change. In the analysis based on FDA-approved SGLT-2i doses, higher SGLT-2i doses caused a significantly greater hemoglobin A_1c reduction at ≤26 and ≥52 weeks compared with the highest DPP-4i doses (mean difference [95%CI], -0.11% [-0.18% to -0.04%] and -0.24% [-0.34% to -0.15%], respectively). Lower SGLT-2i doses caused a significantly greater hemoglobin A_1c reduction at ≥52 weeks but not at ≤26 weeks compared with the highest DPP-4i doses (mean difference [95%CI], -0.12% [-0.23% to -0.02%] and 0.01% [-0.05% to 0.07%], respectively). In people with type 2 diabetes and a baseline hemoglobin A_1c ≥ 8.0%, SGLT-2i produced significantly greater reductions in hemoglobin A_1c compared with DPP-4i and may be preferred. SGLT-2i dose titration to a higher FDA-approved dose is recommended in suitable patients.

Abstract WP337: Age and Race Disparities in Statin Prescribing Persist Following Discharge for Stroke or Transient Ischemic Attack

Introduction: Prescribing of high intensity statins (atorvastatin 40-80mg/d, rosuvastatin 20-40mg/d) following acute stroke and anti-coagulants in the subgroup with atrial fibrillation (AF) result in reduced risk for a second stroke. Recent data suggests that high intensity statins are less often prescribed for older patients and real-world data are limited for direct-acting oral anti-coagulants (DOAC). The present study examines discharge prescribing patterns for these medications by age and race from a prospective trial in 41 hospitals in North Carolina.

Methods: Data are from the Comprehensive Post-Acute Stroke Services Study, a cluster-randomized trial of transitional care for adult stroke or TIA patients discharged directly home after hospital discharge. Analyses included 3787 patients [mean age 66 yrs., 47% female; 30% non-white] linked to the Get-with-the-Guidelines (GWTG) database. Prescribing of intensive statin therapy as well as rivaroxaban or apixaban vs. warfarin in those with a history of AF was abstracted, and was compared by age (< 65 vs. ≥ 65yr.), race (white vs. non-white) and gender. Odds ratios were obtained from logistic mixed models with a random intercept for hospital.

Results: Among 3096 patients prescribed statin therapy at discharge, 61% were prescribed intensive statin therapy. Patients who were ≥ 65yr. had significantly lower odds of intensive statin therapy prescription than younger patients (OR=0.54, 95% CI 0.45-0.65); results were similar across all sex-race subgroups. Among 366 patients with a history of AF who were prescribed an anti-coagulant at discharge, 72% were prescribed rivaroxaban or apixaban. Among 254 patients ≥ 65yr., 26 of 39 non-white patients (67%) vs. 156 of 215 white patients (73%) were prescribed rivaroxaban or apixaban [p=0.29].

Conclusion: Intensive statin therapy following mild stroke or TIA is significantly less common in older patients compared with those under age 65. Among patients ≥65yr. with a history of AF and acute stroke, there was minimal difference by race in rivaroxaban or apixaban prescribing. Prescription fills/refills and adherence should be further explored in these patients.

Do GLP-1RAs and SGLT-2is reduce cardiovascular events in black patients with type 2 diabetes? A systematic review and meta-analysis

AIMS

While recent cardiovascular safety trials (CVST) concerning newer diabetes medications included mostly white participants, results are being generalized to all races in recent guidelines. This raises a controversial question regarding the appropriateness of applying CVST data to black patients with type 2 diabetes.

MATERIALS AND METHODS

We searched for randomized trials comparing diabetes medications to placebo in type 2 diabetes and investigated three- or four-point major adverse cardiovascular events (MACE). Data concerning black patients were then extracted. As the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) updated their recommendations for patients with established cardiovascular risk based on the CVST showing cardiovascular benefit, we performed a sensitivity analysis by including those trials only.

RESULTS

A total of 11 trials were included, investigating a glucagon-like peptide-1 receptor agonist (GLP-1RA) in five, a sodium-glucose co-transporter-2 inhibitor (SGLT-2i) in two and dipeptidyl peptidase-4 inhibitors (DPP-4i) in four. Of the 102 416 participants enrolled in the included trials, only 4601 were black (4.5%). Pooled results showed no significant difference in the incidence of MACE among diabetes medications (GLP-1RA, SGLT-2i or DPP-4i) and placebo in black patients with type 2 diabetes (relative risk [RR] [95% CI], 0.94 [0.77,1.16]). Restricting the analysis to different classes of diabetes medication, the results remained non-significant. Restricting the analysis to CVST with significant outcomes, the results remained non-significant (RR [95% CI], 0.97 [0.68,1.39]).

CONCLUSIONS

Given that black patients with type 2 diabetes were not well represented in CVSTs and such trials were underpowered to evaluate racial differences, it remains unclear whether GLP-1RAs or SGLT-2is would reduce cardiovascular risk in such patients, and additional studies targeting black patients are urgently needed.

Trends and Racial/Ethnic Disparities in Diabetic Retinopathy Among Adults with Diagnosed Diabetes in North Carolina, 2000-2015

BACKGROUND There is limited information available in North Carolina on the current burden of, and racial disparities in, diabetic retinopathy (DR), a major complication associated with diabetes mellitus (DM). This study aims to describe the overall trend of, and racial/ethnic disparities in, DR among adults with DM in North Carolina.METHODS Data were from 13 waves (2000, 2002-2010, 2012, 2013, and 2015) of the Behavioral Risk Factor Surveillance System. The study sample included 16,976 adults aged ≥ 40 years with DM in North Carolina. DR was identified by self-report by the question, "Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?" The overall prevalence of DR was assessed during the time period, and was compared between whites and blacks. All analyses were conducted using Stata 13.0.RESULTS The prevalence of self-reported DR in North Carolina decreased from 27.2% in 2000 to 18.3% in 2015, a reduction of 33% (Trend P = .003). The age-adjusted DR prevalence in whites decreased from 21.7% to 17.6% (Trend P = .04), and in blacks from 39.4% to 20.2% (Trend P = .002). The declining rates in DR were not statistically different between whites and blacks (P = .06). Blacks were more likely to report DR (adjusted odds ratio = 1.20, 95% confidence interval, 1.03-1.40) during 2000-2015.CONCLUSION The prevalence of self-reported DR in adults with DM declined significantly in North Carolina in the past 15 years. While racial differences in some years appeared to be decreasing, the black-white disparity in DR prevalence during the entire period persisted. Focused efforts on reducing the gap are needed.

Randomized Trial of a Tailored Cognitive Behavioral Intervention in Type 2 Diabetes With Comorbid Depressive and/or Regimen-Related Distress Symptoms: 12-Month Outcomes From COMRADE

OBJECTIVE

This study evaluated the effect of cognitive behavioral therapy (CBT) plus lifestyle counseling in primary care on hemoglobin A_1c (HbA_1c) in rural adult patients with type 2 diabetes (T2D) and comorbid depressive or regimen-related distress (RRD) symptoms.

RESEARCH DESIGN AND METHODS

This study was a randomized controlled trial of a 16-session severity-tailored CBT plus lifestyle counseling intervention compared with usual care. Outcomes included changes in HbA_1c, RRD, depressive symptoms, self-care behaviors, and medication adherence across 12 months.

RESULTS

Patients included 139 diverse, rural adults (mean age 52.6 ± 9.5 years; 72% black; BMI 37.0 ± 9.0 kg/m²) with T2D (mean HbA_1c 9.6% [81 mmol/mol] ± 2.0%) and comorbid depressive or distress symptoms. Using intent-to-treat analyses, patients in the intervention experienced marginally significant improvements in HbA_1c (-0.92 ± 1.81 vs. -0.31 ± 2.04; P = 0.06) compared with usual care. However, intervention patients experienced significantly greater improvements in RRD (-1.12 ± 1.05 vs. -0.31 ± 1.22; P = 0.001), depressive symptoms (-3.39 ± 5.00 vs. -0.90 ± 6.17; P = 0.01), self-care behaviors (1.10 ± 1.30 vs. 0.58 ± 1.45; P = 0.03), and medication adherence (1.00 ± 2.0 vs. 0.17 ± 1.0; P = 0.02) versus usual care. Improvement in HbA_1c correlated with improvement in RRD (r = 0.3; P = 0.0001) and adherence (r = -0.23; P = 0.007).

CONCLUSIONS

Tailored CBT with lifestyle counseling improves behavioral outcomes and may improve HbA_1c in rural patients with T2D and comorbid depressive and/or RRD symptoms.

Ideal cardiovascular health, glycaemic status and incident type 2 diabetes mellitus: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study

AIMS/HYPOTHESIS

Ideal cardiovascular health (CVH) is associated with lower diabetes risk. However, it is unclear whether this association is similar across glycaemic levels (normal [<5.6 mmol/l] vs impaired fasting glucose [IFG] [5.6-6.9 mmol/l]).

METHODS

A secondary data analysis was performed in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Incident diabetes was assessed among 7758 participants without diabetes at baseline (2003-2007) followed over 9.5 years. Baseline cholesterol, blood pressure, diet, smoking, physical activity and BMI were used to categorise participants based on the number (0-1, 2-3 and ≥4) of ideal CVH components. Risk ratios (RRs) were calculated using modified Poisson regression, adjusting for cardiovascular risk factors.

RESULTS

Among participants (mean age 63.0 [SD 8.4] years, 56% female, 73% white, 27% African-American), there were 891 incident diabetes cases. Participants with ≥4 vs 0-1 ideal CVH components with normal fasting glucose (n = 6004) had 80% lower risk (RR 0.20; 95% CI 0.10, 0.37), while participants with baseline IFG (n = 1754) had 13% lower risk (RR 0.87; 95% CI 0.58, 1.30) (p for interaction by baseline glucose status <0.0001). Additionally, the magnitude of the association of ideal CVH components with lower diabetes risk was stronger among white than African-American participants (p for interaction = 0.0338).

CONCLUSIONS/INTERPRETATION

A higher number of ideal CVH components was associated with a dose-dependent lower risk of diabetes for participants with normal fasting glucose but not IFG. Tailored efforts that take into account observed differences by race and glycaemic level are needed for the primordial prevention of diabetes.

Race-Specific Patterns of Treatment Intensification Among Hypertensive Patients Using Home Blood Pressure Monitoring: Analysis Using Defined Daily Doses in the Heart Healthy Lenoir Study

BACKGROUND

Racial disparities in blood pressure (BP) control persist, but whether differences by race in antihypertensive medication intensification (AMI) contribute is unknown.

OBJECTIVE

To compare AMI by race for patients with elevated home BP readings.

METHODS

This prospective cohort study followed adult patients from 6 rural primary care practices who used home BP monitoring (HBPM) and recorded/reported values. For providers, AMI was encouraged when mean HBPM systolic blood pressure (SBP) values were ⩾135 mm Hg; patients received phone-based coaching on HBPM technique and sharing HBPM findings. AMI was assessed between baseline and 12 months using defined daily dose (DDD) and summed to create a total antihypertensive DDD value.

RESULTS

A total of 217 patients (mean age = 61.4 ± 10.2 years; 66% female; 57% black) provided usable HBPM data. Among 90 (41%) intensification-eligible hypertensive patients (ie, mean HBPM SBP values for 6-months ⩾135 mm Hg), mean total antihypertensive DDD was increased in 61% at 12 months. Blacks had significantly higher mean DDD at baseline and 12 months, but intensification (+0.72 vs +0.65; P = 0.83) was similar by race. However, intensification was greater in males than females (+1.1 vs +0.39; P = 0.031). Reduction in mean SBP following intensification was greater in white versus black patients (-8.2 vs -3.9 mm Hg; P = 0.14). Conclusion/Relevance: Treatment intensification in HBPM users was similar by race, differed significantly by gender, and may produce a greater response in white patients. Differential AMI in HBPM users does not appear to contribute to persistent racial disparities in BP control.

Validation of a combined health literacy and numeracy instrument for patients with type 2 diabetes

OBJECTIVES

This study aimed to validate a new consolidated measure of health literacy and numeracy (health literacy scale [HLS] plus the subjective numeracy scale [SNS]) in patients with type 2 diabetes (T2DM).

METHODS

A convenience sample (N = 102) of patients with T2DM was recruited from an academic family medicine center in the southeastern US between September-December 2017. Participants completed a questionnaire that included the composite HLS/SNS (22 questions) and a commonly used objective measure of health literacy-S-TOFHLA (40 questions). Internal reliability of the HLS/SNS was assessed using Cronbach's alpha. Criterion and construct validity was assessed against the S-TOFHLA.

RESULTS

The composite HLS/SNS had good internal reliability (Cronbach's alpha = 0.83). A confirmatory factor analysis revealed there were four factors in the new instrument. Model fit indices showed good model-data fit (RMSEA = 0.08). The Spearman's rank order correlation coefficient between the HLS/SNS and the S-TOFHLA was 0.45 (p < 0.01).

CONCLUSIONS

Our study suggests that the composite HLS/SNS is a reliable, valid instrument.

Applicability of Precision Medicine Approaches to Managing Hypertension in Rural Populations

As part of the Heart Healthy Lenoir Project, we developed a practice level intervention to improve blood pressure control. The goal of this study was: (i) to determine if single nucleotide polymorphisms (SNPs) that associate with blood pressure variation, identified in large studies, are applicable to blood pressure control in subjects from a rural population; (ii) to measure the association of these SNPs with subjects' responsiveness to the hypertension intervention; and (iii) to identify other SNPs that may help understand patient-specific responses to an intervention. We used a combination of candidate SNPs and genome-wide analyses to test associations with either baseline systolic blood pressure (SBP) or change in systolic blood pressure one year after the intervention in two genetically defined ancestral groups: African Americans (AA) and Caucasian Americans (CAU). Of the 48 candidate SNPs, 13 SNPs associated with baseline SBP in our study; however, one candidate SNP, rs592582, also associated with a change in SBP after one year. Using our study data, we identified 4 and 15 additional loci that associated with a change in SBP in the AA and CAU groups, respectively. Our analysis of gene-age interactions identified genotypes associated with SBP improvement within different age groups of our populations. Moreover, our integrative analysis identified AQP4-AS1 and PADI2 as genes whose expression levels may contribute to the pleiotropy of complex traits involved in cardiovascular health and blood pressure regulation in response to an intervention targeting hypertension. In conclusion, the identification of SNPs associated with the success of a hypertension treatment intervention suggests that genetic factors in combination with age may contribute to an individual's success in lowering SBP. If these findings prove to be applicable to other populations, the use of this genetic variation in making patient-specific interventions may help providers with making decisions to improve patient outcomes. Further investigation is required to determine the role of this genetic variance with respect to the management of hypertension such that more precise treatment recommendations may be made in the future as part of personalized medicine.

COMRADE: A randomized trial of an individually tailored integrated care intervention for uncontrolled type 2 diabetes with depression and/or distress in the rural southeastern US

BACKGROUND

Emerging evidence suggests that people living with Type 2 diabetes mellitus (T2D) are also at greater risk for depression and distress. If left untreated, these comorbid mental health concerns can have long-lasting impacts on medical and physical health outcomes.

DESIGN

This prospective trial randomized rural men and women with uncontrolled T2D (HbA1c ≥ 7.0) who screened positive for co-morbid depressive (PHQ-2 > 3) or distress (DDS-2 > 3) symptoms in a primary medical care setting to receive either: 1) 16 sessions of cognitive and/or behavioral intervention tailored to symptom severity across 12 months along with routine medical care, or 2) usual primary care. Outcomes included change from baseline to 12-months in HbA1c, diabetes related distress, depressive symptoms, and diabetes self-care activities.

BASELINE RESULTS

139 patients (Mean age = 52.6 ± 9.6 years) with T2D from impoverished rural communities were enrolled (almost half reporting annual income of <$10,000 per year). Baseline data indicated that patients were experiencing profoundly uncontrolled T2D of a long duration (Mean HbA1c = 9.61 ± 2.0; Mean BMI = 37.0 ± 9.1; Mean duration = 11.2 ± 8.9 years) along with high levels of distress (Mean DDS-17 Scale Score = 2.5 ± 1.0) and/or depressive symptoms (Mean PHQ-9 Scale Score = 9.3 ± 6.1).

CONCLUSION

Patients with uncontrolled T2D of long duration manifest complex co-morbidities including associated obesity, depressive symptoms and/or diabetes related distress. A behavioral intervention for T2D that concurrently targets symptoms of depression and distress may lead to more effective outcomes in this high-risk population.

CLINICAL TRIAL REGISTRATION

NCT02863523.

Endocrinologists' Opinions of Diabetology as a Primary Care Subspecialty

IN BRIEF This study was conducted to ascertain the opinions of endocrinologists about diabetes care as it relates to the health care provider workforce. A survey was administered to endocrinologists in the Planning Research in Inpatient Diabetes and Planning Research in Outpatient Diabetes (PRIDE/PROUD) group and given to attendees of the American Diabetes Association (ADA) Scientific Sessions special interest group whose focus was primary care. The majority of respondents agreed that there is a need for more providers to be trained to take care of patients with diabetes and that more trained providers are needed, and almost half agreed that primary care providers (PCPs) with advanced training in diabetes should be part of the workforce for managing the diabetes pandemic. Expanding diabetes fellowship programs for PCPs remains an important potential solution for addressing workforce development needs in diabetes care.

The effect of a practice-based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

Low adherence to anti-hypertensive medications contributes to worse outcomes. The authors conducted a secondary data analysis to examine the effects of a health-coaching intervention on medication adherence and blood pressure (BP), and to explore whether changes in medication adherence over time were associated with changes in BP longitudinally in 477 patients with hypertension. Data regarding medication adherence and BP were collected at baseline, 6, 12, 18, and 24 months. The intervention resulted in increases in medication adherence (5.75→5.94, P = .04) and decreases in diastolic BP (81.6→76.1 mm Hg, P < .001) over time. The changes in medication adherence were associated with reductions in diastolic BP longitudinally (P = .047). Patients with low medication adherence at baseline had significantly greater improvement in medication adherence and BP over time than those with high medication adherence. The intervention demonstrated improvements in medication adherence and diastolic BP and offers promise as a clinically applicable intervention in rural primary care.

A Person-Centered Approach to Poststroke Care: The COMprehensive Post-Acute Stroke Services Model

Many individuals who have had a stroke leave the hospital without postacute care services in place. Despite high risks of complications and readmission, there is no standard in the United States for postacute stroke care after discharge home. We describe the rationale and methods for the development of the COMprehensive Post-Acute Stroke Services (COMPASS) care model and the structure and quality metrics used for implementation. COMPASS, an innovative, comprehensive extension of the TRAnsition Coaching for Stroke (TRACS) program, is a clinician-led quality improvement model providing early supported discharge and transitional care for individuals who have had a stroke and have been discharged home. The effectiveness of the COMPASS model is being assessed in a cluster-randomized pragmatic trial in 41 sites across North Carolina, with a recruitment goal of 6,000 participants. The COMPASS model is evidence based, person centered, and stakeholder driven. It involves identification and education of eligible individuals in the hospital; telephone follow-up 2, 30, and 60 days after discharge; and a clinic visit within 14 days conducted by a nurse and advanced practice provider. Patient and caregiver self-reported assessments of functional and social determinants of health are captured during the clinic visit using a web-based application. Embedded algorithms immediately construct an individualized care plan. The COMPASS model's pragmatic design and quality metrics may support measurable best practices for postacute stroke care.

Abstract WMP110: Building Successful Hospital-Community Networks for Stroke Survivors and Their Family Caregivers

Introduction: Stroke patients, caregivers and providers are often frustrated by a lack of knowledge about community resources to optimize post-acute stroke care and recovery. To address this gap, an innovative model of care is being tested in the COMprehensive Post-Acute Stroke Services (COMPASS) Study, a PCORI-funded cluster-randomized pragmatic trial in North Carolina (NC). Hospital-based post-acute nurse care coordinators (PAC) and advanced practice providers partnered with community organizations to build 20 community resource networks (CRNs) providing transitional care to stroke survivors and caregivers. Community organizations include Area Agencies on Aging, Community Care of NC Community Pharmacy Enhanced Services Network, and NC Department of Health and Human Services.

Methods: In May 2017, 337 members from 19 CRNs were surveyed to assess the utility of the CRNs and their impact on connecting survivors to community-based services. COMPASS team members, including PACs from all intervention hospitals and 36 community representatives from 17 CRNs responded (N=85, 25% response rate).

Results: 80% of the PACs had contacted CRN members for help connecting patients to community-based services; 65% found the CRN very useful or useful. By working together hospital and community members felt their CRN was able to respond to stroke / TIA patients’ needs and problems: 30% to a great extent, 41% mostly, 9% sometimes, 11% a little, 10% not at all. In open-ended comments, streamlined referrals and partnerships with community pharmacists were identified as beneficial. Lack of transportation services in rural areas was a barrier. Some community service providers reported not being contacted again after the initial convening with the hospital.

Conclusion: PACs were able to build local CRNs to integrate medical services with community-based services as a strategy for addressing functional and social determinants of health. The majority reported that working with their CRN helped them optimize patients’ recovery after stroke. Future analyses will assess patient utilization of recommended community services. A quality metric assessing hospital-community partnerships may help solidify significance of this important and often overlooked part of care.

Abstract TP169: Knowledge of Hypertension as a Stroke Risk Factor and Use of Home Blood Pressure Monitoring. A Preliminary Report From Comprehensive Post-Acute Stroke Services (COMPASS) Study

Background: Self-monitoring blood pressure (BP) among persons with hypertension is associated with lower BP. The prevalence of BP self-monitoring and factors that may predict this behavior in the early post-acute stroke setting are unknown. Our aim was to identify whether knowledge of high BP as a stroke risk factor, social support, or primary care visits would be independently associated with BP self-monitoring 30 days after discharge in stroke patients.

Methods: We utilized data from consenting intervention participants in the Comprehensive Post-Acute Stroke Services (COMPASS) Study, who attended the post-discharge clinic visit, and had a 30-day follow-up call (N=528). The primary outcome was self-reported BP monitoring assessed at the 30-day call. The clinic visit included assessment of risk factor knowledge, social support and other clinical and neurological factors. Odds ratios were obtained using logistic mixed models that adjusted for confounders classified as demographic characteristics and clinical factors.

Results: Among 528 patients (mean age 67 (SD=14), 50.9% female, 80.1% white), 435 (82%) reported self-monitored BP at 30 days. Fifty-seven percent of those who noted high BP as a stroke risk factor monitored BP vs 43% of those who did not acknowledge this risk factor. Knowledge of BP as risk factor was significantly associated with monitoring after adjustment for demographic, but not after adjustment for clinical factors (Table). Those with social support and recent PCP visits also had higher odds of self-monitoring than those without support or PCP visits, respectively, though estimates were highly imprecise.

Conclusions: Among participants, acknowledging high BP is a stroke risk factor may lead to greater use of self-home BP monitoring at 30 days, although the magnitude of this effect is diminished when adjusted for having a history of hypertension. The COMPASS Study will determine whether BP self-monitoring leads to improved BP control at 90 days.

The Time Is Now: Diabetes Fellowships in the United States

PURPOSE OF REVIEW

Diabetes is a complex and costly chronic disease that is growing at an alarming rate. In the USA, we have a shortage of physicians who are experts in the care of patients with diabetes, traditionally endocrinologists. Therefore, the majority of patients with diabetes are managed by primary care physicians. With the rapid evolution in new diabetes medications and technologies, primary care physicians would benefit from additional focused and intensive training to manage the many aspects of this disease. Diabetes fellowships designed specifically for primary care physicians is one solution to rapidly expand a well-trained workforce in the management of patients with diabetes.

RECENT FINDINGS

There are currently two successful diabetes fellowship programs that meet this need for creating more expert diabetes clinicians and researchers outside of traditional endocrinology fellowships. We review the structure of these programs including funding and curriculum as well as the outcomes of the graduates. The growth of the diabetes epidemic has outpaced current resources for readily accessible expert diabetes clinical care. Diabetes fellowships aimed for primary care physicians are a successful strategy to train diabetes-focused physicians. Expansion of these programs should be encouraged and support to grow the cadre of clinicians with expertise in diabetes care and improve patient access and outcomes.

A Community Health Worker-Delivered Intervention in African American Women with Type 2 Diabetes: A 12-Month Randomized Trial

OBJECTIVE

To evaluate the effectiveness of a community health worker (CHW)-delivered lifestyle intervention for African American women with type 2 diabetes.

METHODS

Participants were randomized to either 16 phone-based lifestyle intervention sessions aimed at making small changes in their diet and activity or 16 educational mailings sent across 12 months. Main outcomes included glycosylated hemoglobin (HbA1c), blood pressure (BP), and weight (kg) changes.

RESULTS

Two hundred middle-aged (mean = 53 ± 10.24 years), rural, African American women with moderate obesity (mean BMI = 37.7 ± 8.02) and type 2 diabetes (mean HbA1c = 9.1 ± 1.83) were enrolled. At 12 months, the intervention group exhibited no significant differences in HbA1c (-0.29 ± 1.84 vs. + 0.005 ± 1.61; P = 0.789) or BP (-1.01 ± 20.46/+0.66 ± 13.24 vs. + 0.22 ± 25.33/-2.87 ± 1.52; P = 0.100) but did exhibit greater weight loss (-1.35 ± 6.22  vs. -0.39 ± 4.57 kg, respectively; P = 0.046) compared with controls. Exploratory post hoc analyses revealed that participants not using insulin had significantly greater reductions in HbA1c (-0.70 ± 1.86 vs. + 0.07 ± 2.01; P = 0.000), diastolic BP (-5.17 ± 14.16 vs. -3.40 ± 14.72 mmHg; P = 0.035), and weight (-2.36 ± 6.59 vs. -1.64 ± 4.36 kg; P = 0.003) compared to controls not on insulin.

CONCLUSIONS

A phone-based CHW intervention resulted in no significant improvements in HbA1c or BP but did demonstrate modest improvements in weight. Women not using insulin showed significant improvements in all primary outcomes.

The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

Background

Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes.

Methods

Forty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care Plan™ integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model.

Discussion

Given the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful.

Trial registration

Clinicaltrials.gov: NCT02588664; October 23, 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0907-1) contains supplementary material, which is available to authorized users.

Impact of Distress Reduction on Behavioral Correlates and A1C in African American Women with Uncontrolled Type 2 Diabetes: Results from EMPOWER

OBJECTIVE

Symptoms of emotional distress related to diabetes have been associated with inadequate self-care behaviors, medication non-adherence, and poor glycemic control that may predispose patients to premature death. African American women, in whom diabetes is more common and social support is often insufficient, may be at particularly high risk. The objective of this study was to examine the impact of lowering diabetes-related emotional distress on glycemic control and associated behavioral correlates in rural African American women with uncontrolled type 2 diabetes (T2D).

DESIGN

Post-hoc analysis of prospective, randomized, controlled trial.

SETTING

Rural communities in the southeastern United States.

PATIENTS

129 rural middle-aged African American women with uncontrolled type 2 diabetes (T2D)(A1C ≥ 7.0).

PRIMARY INDEPENDENT VARIABLE

Diabetes-related distress.

MAIN OUTCOME MEASURES

Changes from baseline to 12-month follow-up in diabetes-related distress, and associated changes in medication adherence, self-care activities, self-efficacy, and glycemic control (A1C).

RESULTS

Patients with a reduction in diabetes-related distress (n=79) had significantly greater improvement in A1C, medication adherence, self-care activities, and self-efficacy compared with those in whom diabetes distress worsened or was unchanged (n=50). Changes in distress were also significantly and inversely correlated with improvements in medication adherence, self-care activities, and self-efficacy.

CONCLUSIONS

Among rural African American women, reductions in diabetes-related distress may be associated with lower A1C and improvements in self-efficacy, self-care behaviors, and medication adherence.