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Haider S, Parker MM, Huang ES, Grant RW, Moffet HH, Laiteerapong N, Jain RK, Liu JY, Lipska KJ, Karter AJ. Willingness to take less medication for type 2 diabetes among older patients: The Diabetes & Aging Study. J Am Geriatr Soc 2024. [PMID: 38471959 DOI: 10.1111/jgs.18870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/01/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND To examine the willingness of older patients to take less diabetes medication (de-intensify) and to identify characteristics associated with willingness to de-intensify treatment. METHODS Survey conducted in 2019 in an age-stratified, random sample of older (65-100 years) adults with diabetes on glucose-lowering medications in the Kaiser Permanente Northern California Diabetes Registry. We classified survey responses to the question: "I would be willing to take less medication for my diabetes" as willing, neutral, or unwilling to de-intensify. Willingness to de-intensify treatment was examined by several clinical characteristics, including American Diabetes Association (ADA) health status categories used for individualizing glycemic targets. Analyses were weighted to account for over-sampling of older individuals. RESULTS A total of 1337 older adults on glucose-lowering medication(s) were included (age 74.2 ± 6.0 years, 44% female, 54.4% non-Hispanic white). The proportions of participants willing, neutral, or unwilling to take less medication were 51.2%, 27.3%, and 21.5%, respectively. Proportions of willing to take less medication varied by age (65-74 years: 54.2% vs. 85+ years: 38.5%) and duration of diabetes (0-4 years: 61.0% vs. 15+ years: 44.2%), both p < 0.001. Patients on 1-2 medications were more willing to take less medication(s) compared with patients on 10+ medications (62.1% vs. 46.6%, p = 0.03). Similar proportions of willingness to take less medications were seen across ADA health status, and HbA1c. Willingness to take less medication(s) was similar across survey responses to questions about patient-clinician relationships. CONCLUSIONS Clinical guidelines suggest considering treatment de-intensification in older patients with longer duration of diabetes, yet patients with these characteristics are less likely to be willing to take less medication(s).
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Affiliation(s)
- Shanzay Haider
- Section of Endocrinology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Endocrinology, KPC Health - Hemet Global Medical Center, Hemet, California, USA
| | - Melissa M Parker
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Elbert S Huang
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Richard W Grant
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Howard H Moffet
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Neda Laiteerapong
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Rajesh K Jain
- Department of Endocrinology, Diabetes, and Metabolism, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jennifer Y Liu
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Kasia J Lipska
- Section of Endocrinology, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente, Oakland, California, USA
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Kaplan J, Rado J, Laiteerapong N. Mandatory Documented Consent and Cost-Sharing Impede Access to Collaborative Care Psychiatry. J Gen Intern Med 2024; 39:500. [PMID: 38087180 PMCID: PMC10897096 DOI: 10.1007/s11606-023-08556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/01/2023] [Indexed: 02/28/2024]
Affiliation(s)
- Jonathan Kaplan
- Department of Internal Medicine, Rush University, Chicago, IL, USA.
- Department of Psychiatry and Behavioral Sciences, Rush University, Chicago, IL, USA.
| | | | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
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3
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Niu S, Alkhuzam KA, Guan D, Jiao T, Shi L, Fonseca V, Laiteerapong N, Ali MK, Schatz DA, Guo J, Shao H. 5-Year simulation of diabetes-related complications in people treated with tirzepatide or semaglutide versus insulin glargine. Diabetes Obes Metab 2024; 26:463-472. [PMID: 37867175 DOI: 10.1111/dom.15332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/24/2023]
Abstract
AIM This study compared the 5-year incidence rate of macrovascular and microvascular complications for tirzepatide, semaglutide and insulin glargine in individuals with type 2 diabetes, using the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes simulation model. RESEARCH DESIGN AND METHODS This study was a 5-year SURPASS-2 trial extrapolation, with an insulin glargine arm added as an additional comparator. The 1-year treatment effects of tirzepatide (5, 10 or 15 mg), semaglutide (1 mg) and insulin glargine on glycated haemoglobin, systolic blood pressure, low-density lipoprotein and body weights were obtained from the SUSTAIN-4 and SURPASS-2 trials. We used the BRAVO model to predict 5-year complications for each study arm under two scenarios: the 1-year treatment effects persisted (optimistic) or diminished to none in 5 years (conservative). RESULTS When compared with insulin glargine, we projected a 5-year risk reduction in cardiovascular adverse events [rate ratio (RR) 0.64, 95% confidence interval (CI) 0.61-0.67] and microvascular composite (RR 0.67, 95% CI 0.64-0.70) with 15 mg tirzepatide, and 5-year risk reduction in cardiovascular adverse events (RR 0.75, 95% CI 0.72-0.79) and microvascular composite (RR 0.79, 95% CI 0.76-0.82) with semaglutide (1 mg) under an optimistic scenario. Lower doses of tirzepatide also had similar, albeit smaller benefits. Treatment effects for tirzepatide and semaglutide were smaller but still significantly higher than insulin glargine under a conservative scenario. The 5-year risk reduction in diabetes-related complication events and mortality for the 15 mg tirzepatide compared with insulin glargine ranged from 49% to 10% under an optimistic scenario, which was reduced by 17%-33% when a conservative scenario was assumed. CONCLUSION With the use of the BRAVO diabetes model, tirzepatide and semaglutide exhibited potential to reduce the risk of macrovascular and microvascular complications among individuals with type 2 diabetes, compared with insulin glargine in a 5-year window. Based on the current modelling assumptions, tirzepatide (15 mg) may potentially outperform semaglutide (1 mg). While the BRAVO model offered insights, the long-term cardiovascular benefit of tirzepatide should be further validated in a prospective clinical trial.
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Affiliation(s)
- Shu Niu
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Khalid A Alkhuzam
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Dawei Guan
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Tianze Jiao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Lizheng Shi
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Vivian Fonseca
- Section of Endocrinology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Neda Laiteerapong
- Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Mohammed K Ali
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
| | - Desmond A Schatz
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Hui Shao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville, Florida, USA
- Hubert Department of Global Health, Emory University, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, Emory University, Atlanta, Georgia, USA
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4
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Zimmer D, Staab EM, Ridgway JP, Schmitt J, Franco M, Hunter SJ, Motley D, Laiteerapong N. Population-Level Portal-Based Anxiety and Depression Screening Perspectives in HIV Care Clinicians: Qualitative Study Using the Consolidated Framework for Implementation Research. JMIR Form Res 2024; 8:e48935. [PMID: 38206651 PMCID: PMC10811578 DOI: 10.2196/48935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/07/2023] [Accepted: 11/22/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Depression and anxiety are common among people with HIV and are associated with inadequate viral suppression, disease progression, and increased mortality. However, depression and anxiety are underdiagnosed and undertreated in people with HIV owing to inadequate visit time and personnel availability. Conducting population-level depression and anxiety screening via the patient portal is a promising intervention that has not been studied in HIV care settings. OBJECTIVE We aimed to explore facilitators of and barriers to implementing population-level portal-based depression and anxiety screening for people with HIV. METHODS We conducted semistructured hour-long qualitative interviews based on the Consolidated Framework for Implementation Research with clinicians at an HIV clinic. RESULTS A total of 10 clinicians participated in interviews. In total, 10 facilitators and 7 barriers were identified across 5 Consolidated Framework for Implementation Research domains. Facilitators included advantages of systematic screening outside clinic visits; the expectation that assessment frequency could be tailored to patient needs; evidence from the literature and previous experience in other settings; respect for patient privacy; empowering patients and facilitating communication about mental health; compatibility with clinic culture, workflows, and systems; staff beliefs about the importance of mental health screening and benefits for HIV care; engaging all clinic staff and leveraging their strengths; and clear planning and communication with staff. Barriers included difficulty in ensuring prompt response to suicidal ideation; patient access, experience, and comfort using the portal; limited availability of mental health services; variations in how providers use the electronic health record and communicate with patients; limited capacity to address mental health concerns during HIV visits; staff knowledge and self-efficacy regarding the management of mental health conditions; and the impersonal approach to a sensitive topic. CONCLUSIONS We proposed 13 strategies for implementing population-level portal-based screening for people with HIV. Before implementation, clinics can conduct local assessments of clinicians and clinic staff; engage clinicians and clinic staff with various roles and expertise to support the implementation; highlight advantages, relevance, and evidence for population-level portal-based mental health screening; make screening frequency adaptable based on patient history and symptoms; use user-centered design methods to refine results that are displayed and communicated in the electronic health record; make screening tools available for patients to use on demand in the portal; and create protocols for positive depression and anxiety screeners, including those indicating imminent risk. During implementation, clinics should communicate with clinicians and clinic staff and provide training on protocols; provide technical support and demonstrations for patients on how to use the portal; use multiple screening methods for broad reach; use patient-centered communication in portal messages; provide clinical decision support tools, training, and mentorship to help clinicians manage mental health concerns; and implement integrated behavioral health and increase mental health referral partnerships.
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Affiliation(s)
- Daniela Zimmer
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Erin M Staab
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Jessica P Ridgway
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Jessica Schmitt
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Melissa Franco
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Scott J Hunter
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
- Western Institutional Review Board- Copernicus Group, Princeton, NJ, United States
| | - Darnell Motley
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
| | - Neda Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, IL, United States
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5
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Kahn SE, Anderson CAM, Buse JB, Selvin E, Angell SY, Aroda VR, Cheng AYY, Danne T, Echouffo-Tcheugui JB, Fitzpatrick SL, Gadgil MD, Gastaldelli A, Gloyn AL, Green JB, Jastreboff AM, Kanaya AM, Kandula NR, Kovesdy CP, Laiteerapong N, Nadeau KJ, Pettus J, Pop-Busui R, Posey JE, Powe CE, Rebholz CM, Rickels MR, Sattar N, Shaw JE, Sims EK, Utzschneider KM, Vella A, Zhang C. Reflecting on a Year at the Helm of Diabetes Care. Diabetes Care 2024; 47:4-6. [PMID: 38117988 DOI: 10.2337/dci23-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Affiliation(s)
- Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle
| | - Cheryl A M Anderson
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA
| | - John B Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Sonia Y Angell
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Vanita R Aroda
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Alice Y Y Cheng
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Danne
- Diabetes Center and Clinical Research, Children's Hospital Auf der Bult, Hannover Medical School, Hannover, Germany
| | - Justin B Echouffo-Tcheugui
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Stephanie L Fitzpatrick
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Meghana D Gadgil
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Amalia Gastaldelli
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Anna L Gloyn
- Division of Endocrinology and Diabetes, Department of Pediatrics and Department of Genetics, Stanford University School of Medicine, Stanford, CA
| | - Jennifer B Green
- Division of Endocrinology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ania M Jastreboff
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Division of Pediatric Endocrinology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Alka M Kanaya
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Namratha R Kandula
- Division of General Internal Medicine, Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Kristen J Nadeau
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Jeremy Pettus
- Division of Endocrinology and Metabolism, Department of Medicine, University of California San Diego, La Jolla, CA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jennifer E Posey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Camille E Powe
- Diabetes Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Broad Institute, Cambridge, MA
| | - Casey M Rebholz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Emily K Sims
- Center for Diabetes and Metabolic Diseases, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Kristina M Utzschneider
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle
| | - Adrian Vella
- Division of Diabetes, Endocrinology and Metabolism, Mayo Clinic, Rochester, MN
| | - Cuilin Zhang
- Global Center for Asian Women's Health and Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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6
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Lipska KJ, Huang ES, Liu JY, Parker MM, Laiteerapong N, Grant RW, Moffet HH, Karter AJ. Glycemic control and diabetes complications across health status categories in older adults treated with insulin or insulin secretagogues: The Diabetes & Aging Study. J Am Geriatr Soc 2023; 71:3692-3700. [PMID: 37638777 PMCID: PMC10872822 DOI: 10.1111/jgs.18565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/08/2023] [Accepted: 07/16/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND For older adults with type 2 diabetes (T2D) treated with insulin or sulfonylureas, Endocrine Society guideline recommends HbA1c between 7% to <7.5% for those in good health, 7.5% to <8% for those in intermediate health, and 8% to <8.5% for those in poor health. Our aim was to examine associations between attained HbA1c below, within (reference), or above recommended target range and risk of complication or mortality. METHODS Retrospective cohort study of adults ≥65 years old with T2D treated with insulin or sulfonylureas from an integrated healthcare delivery system. Cox proportional hazards models of complications during 2019 were adjusted for sociodemographic and clinical variables. Primary outcome was a combined outcome of any microvascular or macrovascular event, severe hypoglycemia, or mortality during 12-month follow-up. RESULTS Among 63,429 patients (mean age: 74.2 years, 46.8% women), 8773 (13.8%) experienced a complication. Complication risk was significantly elevated for patients in good health (n = 16,895) whose HbA1c was above (HR 1.97, 95% CI 1.62-2.41) or below (HR 1.29, 95% CI 1.02-1.63) compared to within recommended range. Among those in intermediate health (n = 30,129), complication risk was increased for those whose HbA1c was above (HR 1.45, 95% CI 1.30-1.60) but not those below the recommended range (HR 0.99, 95% CI 0.89-1.09). Among those in poor health (n = 16,405), complication risk was not significantly different for those whose HbA1c was below (HR 0.98, 95% CI 0.89-1.09) or above (HR 0.96, 95% CI 0.88-1.06) recommended range. CONCLUSIONS For older adults with T2D in good health, HbA1c below or above the recommended range was associated with significantly elevated complication risk. However, for those in poor health, achieving specific HbA1c levels may not be helpful in reducing the risk of complications.
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Affiliation(s)
| | | | - Jennifer Y Liu
- Kaiser Permanente Northern California, Oakland, California, USA
| | | | | | - Richard W Grant
- Kaiser Permanente of Northern California, Oakland, California, USA
| | - Howard H Moffet
- Kaiser Permanente Northern California, Oakland, California, USA
| | - Andrew J Karter
- Kaiser Permanente Northern California, Oakland, California, USA
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7
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Kaplan J, Rado J, Laiteerapong N. Mandatory Documented Consent and Cost-Sharing Impede Access to Collaborative Care Psychiatry. J Gen Intern Med 2023; 38:3616-3617. [PMID: 37698723 PMCID: PMC10713939 DOI: 10.1007/s11606-023-08394-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Affiliation(s)
- Jonathan Kaplan
- Department of Internal Medicine, Rush University, Chicago, IL, USA.
- Department of Psychiatry and Behavioral Sciences, Rush University, Chicago, IL, USA.
| | | | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
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8
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Ettleson MD, Ibarra S, Wan W, Peterson S, Laiteerapong N, Bianco AC. Demographic, Healthcare Access, and Dietary Factors Associated With Thyroid Hormone Treatments for Hypothyroidism. J Clin Endocrinol Metab 2023; 108:e1614-e1623. [PMID: 37327351 PMCID: PMC10655529 DOI: 10.1210/clinem/dgad331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT Clinical guidelines have recommended a trial of liothyronine (LT3) with levothyroxine (LT4) in select patients with hypothyroidism. However, little is known about the real-world use of LT3 and desiccated thyroid extract (DTE) and the characteristics of patients treated with LT3 and DTE. OBJECTIVES (1) Determine national trends of new LT4, LT3, and DTE prescriptions in the United States; (2) determine whether sociodemographic, healthcare access, and dietary factors are associated with different thyroid hormone (TH) therapies. METHODS Parallel cross-sectional studies were conducted using 2 datasets: (1) a national patient claims dataset (2010-2020) and (2) the National Health and Nutrition Examination Study (NHANES) dataset (1999-2016). Included participants had a diagnosis of primary or subclinical hypothyroidism. Study outcomes included the impact of demographics and healthcare access on differences in the proportion of TH therapies consisting of LT4, LT3, and DTE (patient claims) and differences in dietary behaviors between DTE-treated participants and LT4-treated matched controls (NHANES). RESULTS On an average annual basis, 47 711 adults received at least 1 new TH prescription, with 88.3% receiving LT4 monotherapy, 2.0% receiving LT3 therapy, and 9.4% receiving DTE therapy. The proportion receiving DTE therapy increased from 5.4% in 2010 to 10.2% in 2020. In the analysis between states, high primary care and endocrinology physician densities were associated with increased use of LT4 monotherapy (odds ratio 2.51, P < .001 and odds ratio 2.71, P < .001). DTE-treated NHANES participants (n = 73) consumed more dietary supplements compared to LT4-treated participants (n = 146) (4.7 vs 2.1, P < .001). CONCLUSIONS The proportion of new TH therapies containing DTE for hypothyroidism doubled since 2010 while LT3 therapies remained stable. DTE treatment was associated with decreased physician density and increased dietary supplement use.
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Affiliation(s)
- Matthew D Ettleson
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Sabrina Ibarra
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Wen Wan
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Sarah Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, IL 60612, USA
| | - Neda Laiteerapong
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Antonio C Bianco
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
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9
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Bernstein S, Gilson S, Zhu M, Nathan AG, Cui M, Press VG, Shah S, Zarei P, Laiteerapong N, Huang ES. Diabetes Life Expectancy Prediction Model Inputs and Results From Patient Surveys Compared With Electronic Health Record Abstraction: Survey Study. JMIR Aging 2023; 6:e44037. [PMID: 37962566 PMCID: PMC10662674 DOI: 10.2196/44037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 06/13/2023] [Accepted: 09/19/2023] [Indexed: 11/15/2023] Open
Abstract
Background Prediction models are being increasingly used in clinical practice, with some requiring patient-reported outcomes (PROs). The optimal approach to collecting the needed inputs is unknown. Objective Our objective was to compare mortality prediction model inputs and scores based on electronic health record (EHR) abstraction versus patient survey. Methods Older patients aged ≥65 years with type 2 diabetes at an urban primary care practice in Chicago were recruited to participate in a care management trial. All participants completed a survey via an electronic portal that included items on the presence of comorbid conditions and functional status, which are needed to complete a mortality prediction model. We compared the individual data inputs and the overall model performance based on the data gathered from the survey compared to the chart review. Results For individual data inputs, we found the largest differences in questions regarding functional status such as pushing/pulling, where 41.4% (31/75) of participants reported difficulties that were not captured in the chart with smaller differences for comorbid conditions. For the overall mortality score, we saw nonsignificant differences (P=.82) when comparing survey and chart-abstracted data. When allocating participants to life expectancy subgroups (<5 years, 5-10 years, >10 years), differences in survey and chart review data resulted in 20% having different subgroup assignments and, therefore, discordant glucose control recommendations. Conclusions In this small exploratory study, we found that, despite differences in data inputs regarding functional status, the overall performance of a mortality prediction model was similar when using survey and chart-abstracted data. Larger studies comparing patient survey and chart data are needed to assess whether these findings are reproduceable and clinically important.
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Affiliation(s)
- Sean Bernstein
- Rush University Medical Center, ChicagoIL, United States
| | - Sarah Gilson
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
| | - Mengqi Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
| | - Aviva G Nathan
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
| | - Michael Cui
- Rush University Medical Center, ChicagoIL, United States
| | - Valerie G Press
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
| | - Sachin Shah
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
| | - Parmida Zarei
- College of Medicine, University of Illinois Chicago, ChicagoIL, United States
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
| | - Elbert S Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, ChicagoIL, United States
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10
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Wang J, Knitter AC, Staab EM, Beckman N, Araújo FS, Vinci LM, Ari M, Yohanna D, Laiteerapong N. Association between wait time and behavioral health appointment attendance across patient characteristics. Psychol Serv 2023; 20:983-987. [PMID: 37141046 DOI: 10.1037/ser0000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Adequate access to behavioral health (BH) services is a critical issue. Many patients who are referred to BH care miss their appointments. One barrier to BH care is that longer wait times decrease the likelihood of appointment attendance. The present study examines the relationship between the wait time for BH services and appointment attendance, overall and by multiple patient characteristics. Logistic regression was performed to analyze the association between wait time and patient attendance for BH referrals made from March 1, 2016, to February 28, 2019, at an urban academic medical center. In total, 1,587 referrals were included. Most patients were female (72%) and of non-Hispanic/Latinx Black race (55%). Each additional week of waiting between the referral and scheduled appointment was associated with a 5% decrease in odds of attendance. In adjusted race/ethnicity-stratified analyses, Hispanic/Latinx patients had a 9% lower odds of attendance per week of waiting. Non-Hispanic/Latinx White and Black patients had a 5% lower odds of attendance per week of waiting. Patients with private insurance had a 7% lower odds of attendance per week of waiting, and patients with Medicare had a 6% lower odds of attendance per week of waiting. Limiting scheduling may improve BH care utilization by decreasing the rate of "no shows." (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Joanne Wang
- Department of Medicine, University of Chicago
| | | | | | - Nancy Beckman
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago
| | | | | | - Mim Ari
- Department of Medicine, University of Chicago
| | - Daniel Yohanna
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago
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11
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Moffet HH, Huang ES, Liu JY, Parker MM, Lipska KJ, Laiteerapong N, Grant RW, Lee AK, Karter AJ. Severe hypoglycemia and falls in older adults with diabetes: The Diabetes & Aging Study. Diabet Epidemiol Manag 2023; 12:100162. [PMID: 37920602 PMCID: PMC10621321 DOI: 10.1016/j.deman.2023.100162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Objective To estimate rates of severe hypoglycemia and falls among older adults with diabetes and evaluate their association. Research Design and Methods Survey in an age-stratified, random sample adults with diabetes age 65-100 years; respondents were asked about severe hypoglycemia (requiring assistance) and falls in the past 12 months. Prevalence ratios (adjusted for age, sex, race/ethnicity) estimated the increased risk of falls associated with severe hypoglycemia. Results Among 2,158 survey respondents, 79 (3.7%) reported severe hypoglycemia, of whom 68 (86.1%) had no ED visit or hospitalization for hypoglycemia. Falls were reported by 847 (39.2%), of whom 745 (88.0%) had no fall documented in outpatient or inpatient records. Severe hypoglycemia was associated with a 70% greater prevalence of falls (adjusted prevalence ratio = 1.7 (95% CI, 1.3-2.2)). Conclusion While clinical documentation of events likely reflects severity or care-seeking behavior, severe hypoglycemia and falls are common, under-reported life-threatening events.
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Affiliation(s)
- Howard H Moffet
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612
| | - Elbert S Huang
- University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637
| | - Jennifer Y Liu
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612
| | - Melissa M Parker
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612
| | - Kasia J Lipska
- Yale University School of Medicine, PO Box 208020, New Haven, CT 06520
| | | | - Richard W Grant
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612
| | - Alexandra K Lee
- Division of Geriatrics, University of California, 4150 Clement St, VA181G, San Francisco, CA 94121
| | - Andrew J Karter
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612
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12
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Roy R, Mayer MM, Dzekem BS, Laiteerapong N. Screening for Emotional Distress in Patients with Cardiovascular Disease. Curr Cardiol Rep 2023; 25:1165-1174. [PMID: 37610597 DOI: 10.1007/s11886-023-01936-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE OF REVIEW In this article, we discuss the relationship between emotional distress and common cardiovascular disease condition, including coronary artery disease, atrial fibrillation, congestive heart failure, mechanical circulatory support, and heart transplant. We review screening measures that have been studied and used in clinical practice for each condition, as well as priorities for future research. RECENT FINDINGS Studies consistently demonstrate failing to identify and treat emotional distress in patients with cardiovascular disease is associated with adverse outcomes. However, routine emotional distress screening is not formally recommended for all cardiovascular disease conditions and is limited to depression screening in select patient populations. Future research should focus on evaluating the validity and reliability of standardized screening measures across the scope of emotional distress in patients with or at risk for cardiovascular disease. Other areas of future research include implementation of evidence-based pharmaceutical treatments and integrated behavioral health approaches and interventions.
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Affiliation(s)
- Rukmini Roy
- Department of Medicine, University of Chicago, 5841 S Maryland Avenue, MC 3051, Chicago, IL 60637, USA
| | - Michael M Mayer
- Department of Medicine, University of Chicago, 5841 S Maryland Avenue, MC 3051, Chicago, IL 60637, USA
| | - Bonaventure S Dzekem
- Department of Medicine, University of Chicago, 5841 S Maryland Avenue, MC 3051, Chicago, IL 60637, USA
| | - Neda Laiteerapong
- Department of Medicine, University of Chicago, 5841 S Maryland Avenue, MC 3051, Chicago, IL 60637, USA.
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 5841 S Maryland Avenue, MC 3051, Chicago, IL 60637, USA.
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13
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Karter AJ, Parker MM, Moffet HH, Lipska KJ, Laiteerapong N, Grant RW, Lee C, Huang ES. Development and Validation of the Life Expectancy Estimator for Older Adults with Diabetes (LEAD): the Diabetes and Aging Study. J Gen Intern Med 2023; 38:2860-2869. [PMID: 37254010 PMCID: PMC10228886 DOI: 10.1007/s11606-023-08219-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/21/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Estimated life expectancy for older patients with diabetes informs decisions about treatment goals, cancer screening, long-term and advanced care, and inclusion in clinical trials. Easily implementable, evidence-based, diabetes-specific approaches for identifying patients with limited life expectancy are needed. OBJECTIVE Develop and validate an electronic health record (EHR)-based tool to identify older adults with diabetes who have limited life expectancy. DESIGN Predictive modeling based on survival analysis using Cox-Gompertz models in a retrospective cohort. PARTICIPANTS Adults with diabetes aged ≥ 65 years from Kaiser Permanente Northern California: a 2015 cohort (N = 121,396) with follow-up through 12/31/2019, randomly split into training (N = 97,085) and test (N = 24,311) sets. Validation was conducted in the test set and two temporally distinct cohorts: a 2010 cohort (n = 89,563; 10-year follow-up through 2019) and a 2019 cohort (n = 152,357; 2-year follow-up through 2020). MAIN MEASURES Demographics, diagnoses, utilization and procedures, medications, behaviors and vital signs; mortality. KEY RESULTS In the training set (mean age 75 years; 49% women; 48% racial and ethnic minorities), 23% died during 5 years follow-up. A mortality prediction model was developed using 94 candidate variables, distilled into a life expectancy model with 11 input variables, and transformed into a risk-scoring tool, the Life Expectancy Estimator for Older Adults with Diabetes (LEAD). LEAD discriminated well in the test set (C-statistic = 0.78), 2010 cohort (C-statistic = 0.74), and 2019 cohort (C-statistic = 0.81); comparisons of observed and predicted survival curves indicated good calibration. CONCLUSIONS LEAD estimates life expectancy in older adults with diabetes based on only 11 patient characteristics widely available in most EHRs and claims data. LEAD is simple and has potential application for shared decision-making, clinical trial inclusion, and resource allocation.
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Affiliation(s)
- Andrew J. Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA
- Department of General Internal Medicine, University of California, San Francisco, CA USA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA USA
| | - Melissa M. Parker
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA
| | - Howard H. Moffet
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA
| | - Kasia J. Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL USA
| | - Richard W. Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA
| | - Elbert S. Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL USA
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14
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Jiang C, Wolf K, Kaakati R, Oh J, Yip AT, Jonklaas J, Bianco AC, Laiteerapong N, Ettleson MD. The Effects of Patient Characteristics on the Management of Subclinical Hypothyroidism: A Survey of Faculty and Trainees. Endocr Pract 2023; 29:787-793. [PMID: 37549880 PMCID: PMC10592164 DOI: 10.1016/j.eprac.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE There is no universal approach to the management of subclinical hypothyroidism (SCH). This study was designed to determine the impact of patient characteristics on management decisions in SCH amongst physician faculty members and trainees. METHODS An online survey was distributed to faculty members and medical trainees (ie, interns, residents, and fellows) at multiple academic medical centers. The survey included 9 clinical scenarios describing women with SCH with 5 management options sequenced from most "conservative" (no further treatment or monitoring) to most "aggressive" (treatment with levothyroxine). RESULTS Of the 194 survey respondents, 95 (49.0%) were faculty members and 99 (51.0%) were trainees. Faculty members were more likely to report being "confident" or "very confident" in making the diagnosis of SCH compared to trainees (95.8% vs 46.5%, P < .001). Faculty members were also more likely to consider patient preference for treatment (60.0% vs 32.3%, P < .001). Among all respondents, the clinical factors that resulted in the highest predicted probability of treatment were hypothyroid symptoms (predicted probability [PP] 68.8%, 95% CI [65.7%-71.9%]), thyroid stimulating hormone >10 mIU/L in a 31-year-old (PP 63.9%, 95% CI [60.3%-67.3%]), and the desire for fertility (PP 52.2%, 95% CI [48.6%-56.0%]). In general, faculty members favored more aggressive treatment across all clinical scenarios. CONCLUSION The presence of symptoms, thyroid stimulating hormone >10 mIU/L, and desire for fertility were most predictive of the decision to treat in SCH. In several clinical scenarios, both trainee and faculty decision-making demonstrated discordance with general SCH management principles.
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Affiliation(s)
- Cherry Jiang
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Katherine Wolf
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rayan Kaakati
- Division of Rheumatology, Allergy, and Immunology, Department of Pediatrics, Univeristy of North Carolina, Chapel Hill, North Carolina
| | - Jessica Oh
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allison T Yip
- Division of General Internal Medicine, University of California San Diego, San Diego, California
| | - Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University Medical Center, Washington, District of Columbia
| | - Antonio C Bianco
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois
| | - Matthew D Ettleson
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, Illinois.
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15
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Sawicki SM, Hernandez C, Laiteerapong N, Zahradnik EK. The Use of Dispensary-Obtained Tetrahydrocannabinol as a Treatment for Neuropsychiatric Symptoms of Dementia. J Clin Psychiatry 2023; 84:23m14791. [PMID: 37728481 DOI: 10.4088/jcp.23m14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Objective: Neuropsychiatric symptoms (NPS) of dementia represent a large driver of health care costs, caregiver burden, and institutionalization of people with dementia. Management options are limited, and antipsychotics are often used, although they carry a significant side effect profile. One novel option is tetrahydrocannabinol (THC); however, in the US, to obtain THC for patients with dementia, caregivers have to go to a commercial dispensary. We evaluated the effectiveness of dispensary-obtained THC for patients with dementia and NPS. Methods: Two independent reviewers reviewed charts of patients with diagnosed dementia (N = 50) seen in geriatric psychiatry between 2017 and 2021 for whom dispensary-obtained THC was recommended. The primary outcome was effectiveness in treating NPS; secondary outcomes were the proportion of caregivers who obtained and administered THC (uptake), post-THC antipsychotic use, and adverse reactions leading to treatment discontinuation. Results: Caregiver uptake of dispensary-obtained THC was high (38/50, 76%). The majority of patients (30/38, 79%) who took THC had an improvement in NPS according to their caregivers. THC was recommended most often for the NPS of agitation, aggression, irritability, lability, anxiety, and insomnia. Among the 20 patients who were taking antipsychotics at baseline and took THC, over half (12/20, 60%) were able to decrease or discontinue the antipsychotic. Adverse reactions to THC included dizziness, worsening of agitation, and worsening of paranoia; two caregivers of patients who took THC reported adverse reactions that led to treatment discontinuation. Conclusions: Our results suggest that dispensary-obtained THC can be effective in managing a subset of NPS in patients with dementia and may decrease the requirement for antipsychotics.
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Affiliation(s)
- Samantha M Sawicki
- University of Chicago Medical Center, Department of Medicine, Chicago, Illinois
| | - Cristian Hernandez
- University of Chicago Medical Center, Department of Medicine, Chicago, Illinois
| | - Neda Laiteerapong
- University of Chicago Medical Center, Department of Medicine, Chicago, Illinois
| | - Erin K Zahradnik
- University of Chicago Medical Center, Department of Medicine, Chicago, Illinois
- University of Chicago Medical Center, Department of Psychiatry and Behavioral Neuroscience, Chicago, Illinois
- Corresponding Author: Erin K. Zahradnik, MD, Department of Psychiatry and Behavioral Neuroscience, 5841 S Maryland Ave, Chicago, IL 60637 . Dr Sawicki and Mr Hernandez are co-first authors
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16
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Staab EM, Franco MI, Zhu M, Wan W, Gibbons RD, Vinci LM, Beckman N, Yohanna D, Laiteerapong N. Population Health Management Approach to Depression Symptom Monitoring in Primary Care via Patient Portal: A Randomized Controlled Trial. Am J Med Qual 2023; 38:188-195. [PMID: 37314235 DOI: 10.1097/jmq.0000000000000126] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Depression is undertreated in primary care. Using patient portals to administer regular symptom assessments could facilitate more timely care. At an urban academic medical center outpatient clinic, patients with active portal accounts and depression on their problem list or a positive screen in the past year were randomized to assessment during triage at visits (usual care) versus usual care plus assessment via portal (population health care). Portal invitations were sent regardless of whether patients had scheduled appointments. More patients completed assessments in the population health care arm than usual care: 59% versus 18%, P < 0.001. Depression symptoms were more common among patients who completed their initial assessment via the portal versus in the clinic. In the population health care arm, 57% (N = 80/140) of patients with moderate-to-severe symptoms completed at least 1 follow-up assessment versus 37% (N = 13/35) in usual care. A portal-based population health approach could improve depression monitoring in primary care.
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Affiliation(s)
- Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL
| | | | - Mengqi Zhu
- Department of Medicine, University of Chicago, Chicago, IL
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL
| | - Robert D Gibbons
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL
- Department of Public Health Sciences, University of Chicago, Chicago, IL
| | - Lisa M Vinci
- Department of Medicine, University of Chicago, Chicago, IL
| | - Nancy Beckman
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL
| | - Daniel Yohanna
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL
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17
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Huang ES, Liu JY, Lipska KJ, Grant RW, Laiteerapong N, Moffet HH, Schumm LP, Karter AJ. Data-driven classification of health status of older adults with diabetes: The diabetes and aging study. J Am Geriatr Soc 2023; 71:2120-2130. [PMID: 36883732 PMCID: PMC10363208 DOI: 10.1111/jgs.18310] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/20/2023] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND We set out to identify empirically-derived health status classes of older adults with diabetes based on clusters of comorbid conditions which are associated with future complications. METHODS We conducted a cohort study among 105,786 older (≥65 years of age) adults with type 2 diabetes enrolled in an integrated healthcare delivery system. We used latent class analysis of 19 baseline comorbidities to derive health status classes and then compared incident complication rates (events per 100 person-years) by health status class during 5 years of follow-up. Complications included infections, hyperglycemic events, hypoglycemic events, microvascular events, cardiovascular events, and all-cause mortality. RESULTS Three health status classes were identified: Class 1 (58% of the cohort) had the lowest prevalence of most baseline comorbidities, Class 2 (22%) had the highest prevalence of obesity, arthritis, and depression, and Class 3 (20%) had the highest prevalence of cardiovascular conditions. The risk for incident complications was highest for Class 3, intermediate for Class 2 and lowest for Class 1. For example, the age, sex and race-adjusted rates for cardiovascular events (per 100 person-years) for Class 3, Class 2 and Class 1 were 6.5, 2.3, and 1.6, respectively; 2.1, 1.2, 0.7 for hypoglycemia; and 8.0, 3.8, and 2.3 for mortality. CONCLUSIONS Three health status classes of older adults with diabetes were identified based on prevalent comorbidities and were associated with marked differences in risk of complications. These health status classes can inform population health management and guide the individualization of diabetes care.
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Affiliation(s)
- Elbert S. Huang
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Jennifer Y. Liu
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Kasia J. Lipska
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | - Richard W. Grant
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Howard H. Moffet
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - L. Philip Schumm
- Biostatistics Laboratory, University of Chicago, Chicago, IL, USA
| | - Andrew J. Karter
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
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18
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Laiteerapong N, Huang ES, Knitter AC, Chin MH. Response to Letter to the Editor by Drs Cook and Stange. Med Care 2023; 61:415. [PMID: 37067980 PMCID: PMC10286125 DOI: 10.1097/mlr.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Affiliation(s)
| | - Elbert S Huang
- Department of Medicine, Section of General Internal Medicine
- Department of Public Health Sciences, The University of Chicago, Chicago, IL
| | | | - Marshall H Chin
- Department of Medicine, Section of General Internal Medicine
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19
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Ettleson MD, Prieto WH, Russo PST, de Sa J, Wan W, Laiteerapong N, Maciel RMB, Bianco AC. Serum Thyrotropin and Triiodothyronine Levels in Levothyroxine-treated Patients. J Clin Endocrinol Metab 2023; 108:e258-e266. [PMID: 36515655 PMCID: PMC10413428 DOI: 10.1210/clinem/dgac725] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
CONTEXT Small adjustments in levothyroxine (LT4) dose do not appear to provide clinical benefit despite changes in thyrotropin (TSH) levels within the reference range. We hypothesize that the accompanying changes in serum total triiodothyronine (T3) levels do not reflect the magnitude of the changes in serum TSH. OBJECTIVE This work aims to characterize the relationships of serum free thyroxine (FT4) vs T3, FT4 vs TSH, and FT4 vs the T3/FT4 ratio. METHODS This cross-sectional, observational study comprised 9850 participants aged 18 years and older treated with LT4 from a large clinical database from January 1, 2009, to December 31, 2019. Patients had been treated with LT4, subdivided by serum FT4 level. Main outcome measures included model fitting of the relationships between serum FT4 vs TSH, FT4 vs T3, and FT4 vs T3/FT4. Mean and median values of TSH, T3, and T3/FT4 were calculated. RESULTS The relationships T3 vs FT4 and TSH vs FT4 were both complex and best represented by distinct, segmented regression models. Increasing FT4 levels were linearly associated with T3 levels until an inflection point at an FT4 level of 0.7 ng/dL, after which a flattening of the slope was observed following a convex quadratic curve. In contrast, increasing FT4 levels were associated with steep declines in TSH following 2 negative sigmoid curves. The FT4 vs T3/FT4 relationship was fit to an asymptotic regression curve supporting less T4 to T3 activation at higher FT4 levels. CONCLUSION In LT4-treated patients, the relationships between serum FT4 vs TSH and FT4 vs T3 across a range of FT4 levels are disproportionate. As a result, dose changes in LT4 that robustly modify serum FT4 and TSH values may only minimally affect serum T3 levels and result in no significant clinical benefit.
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Affiliation(s)
- Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois 60637, USA
| | | | | | - Jose de Sa
- Fleury Group, Sao Paulo, SP 04344, Brazil
| | - Wen Wan
- Section of General Medicine, University of Chicago, Chicago, Illinois 60637, USA
| | - Neda Laiteerapong
- Section of General Medicine, University of Chicago, Chicago, Illinois 60637, USA
| | - Rui M B Maciel
- Fleury Group, Sao Paulo, SP 04344, Brazil
- Department of Medicine, Federal University of Sao Paulo, Sao Paulo SP 04039, Brazil
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois 60637, USA
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20
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Laiteerapong N, Alexander J, Philipson L, Winn AN, Huang ES. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists. Ann Intern Med 2023; 176:eL230007. [PMID: 37068291 DOI: 10.7326/l23-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Affiliation(s)
- Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jason Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Louis Philipson
- Sections of Adult and Pediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elbert S Huang
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois
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21
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Franco MI, Staab EM, Zhu M, Knitter A, Wan W, Gibbons R, Vinci L, Shah S, Yohanna D, Beckman N, Laiteerapong N. Pragmatic Clinical Trial of Population Health, Portal-Based Depression Screening: the PORTAL-Depression Study. J Gen Intern Med 2023; 38:857-864. [PMID: 36127535 PMCID: PMC9488885 DOI: 10.1007/s11606-022-07779-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression. OBJECTIVE To determine whether a population health approach to depression screening is more effective than screening during clinic appointments alone for identifying patients with depression. DESIGN A pragmatic clinical trial at an adult outpatient internal medicine clinic at an urban, academic, tertiary care center. PATIENTS Eligible patients (n = 2713) were adults due for depression screening with active portal accounts. Patients with documented depression or bipolar disorder and those who had been screened in the year prior to the study were excluded. INTERVENTION Patients were randomly assigned to usual (n = 1372) or population healthcare (n = 1341). For usual care, patients were screened by medical assistants during clinic appointments. Population healthcare patients were sent letters through the portal inviting them to fill out an online screener regardless of whether they had a scheduled appointment. The same screening tool, the Computerized Adaptive Test for Mental Health (CAT-MH™), was used for clinic- and portal-based screening. MAIN MEASURES The primary outcome was the depression screening rate. KEY RESULTS The depression screening rate in the population healthcare arm was higher than that in the usual care arm (43% (n = 578) vs. 33% (n = 459), p < 0.0001). The rate of positive screens was also higher in the population healthcare arm compared to that in the usual care (10% (n = 58) vs. 4% (n = 17), p < 0.001). CONCLUSION Findings suggest depression screening via a portal as part of a population health approach can increase screening and case identification, compared to usual care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03832283.
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Affiliation(s)
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Mengqi Zhu
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Robert Gibbons
- Department of Medicine, University of Chicago, Chicago, IL, USA
- Department of Public Health Sciences, University of Chicago, Chicago, IL, USA
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Lisa Vinci
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Sachin Shah
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Daniel Yohanna
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Nancy Beckman
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
| | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, IL, USA.
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA.
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22
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Gopalan A, Winn AN, Karter AJ, Laiteerapong N. Racial and Ethnic Differences in Medication Initiation Among Adults Newly Diagnosed with Type 2 Diabetes. J Gen Intern Med 2023; 38:994-1000. [PMID: 35927604 PMCID: PMC10039131 DOI: 10.1007/s11606-022-07746-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Given persistent racial/ethnic differences in type 2 diabetes outcomes and the lasting benefits conferred by early glycemic control, we examined racial/ethnic differences in diabetes medication initiation during the year following diagnosis. METHODS Among adults newly diagnosed with type 2 diabetes (2005-2016), we examined how glucose-lowering medication initiation differed by race/ethnicity during the year following diagnosis. We specified modified Poisson regression models to estimate the association between race/ethnicity and medication initiation in the entire cohort and within subpopulations defined by HbA1c, BMI, age at diagnosis, comorbidity, and neighborhood deprivation index (a census tract-level socioeconomic indicator). RESULTS Among the 77,199 newly diagnosed individuals, 47% started a diabetes medication within 12 months of diagnosis. The prevalence of medication initiation ranged from 32% among Chinese individuals to 58% among individuals of Other/Unknown races/ethnicities. Compared to White individuals, medication initiation was less likely among Chinese (relative risk: 0.78 (95% confidence interval 0.72, 0.84)) and Japanese (0.82 (0.75, 0.90)) individuals, but was more likely among Hispanic/Latinx (1.27 (1.24, 1.30)), African American (1.14 (1.11, 1.17)), other Asian (1.13 (1.08, 1.18)), South Asian (1.10 (1.04, 1.17)), Other/Unknown (1.31 (1.24, 1.39)), American Indian or Alaska Native (1.11 (1.04, 1.18)), and Native Hawaiian/Pacific Islander (1.28 (1.19, 1.37)) individuals. Racial/ethnic differences dissipated among individuals with higher HbA1c values. CONCLUSIONS Initiation of glucose-lowering treatment during the year following type 2 diabetes diagnosis differed markedly by race/ethnicity, particularly for those with lower HbA1c values. Future research should examine how patient preferences, provider implicit bias, and shared decision-making contribute to these early treatment differences.
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Affiliation(s)
- Anjali Gopalan
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew J Karter
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA, 94612, USA
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23
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Saunders M, Laiteerapong N. 2022 Clinical Practice Guideline Update for Diabetes Management of Chronic Kidney Disease: An Important First Step, More Work to Do. Ann Intern Med 2023; 176:417-418. [PMID: 36623285 DOI: 10.7326/m22-3635] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Milda Saunders
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois
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24
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Khunti K, Feldman EL, Laiteerapong N, Parker W, Routen A, Peek M. The Impact of the COVID-19 Pandemic on Ethnic Minority Groups With Diabetes. Diabetes Care 2023; 46:228-236. [PMID: 35944272 PMCID: PMC10090266 DOI: 10.2337/dc21-2495] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/10/2022] [Indexed: 02/03/2023]
Abstract
Major ethnic disparities in diabetes care, especially for intermediate outcomes and diabetes complications, were evident prior to the coronavirus disease 2019 (COVID-19) pandemic. Diabetes is a risk factor for severe COVID-19, and the combination of these ethnic disparities in diabetes care and outcomes may have contributed to the inequity in COVID-19 outcomes for people with diabetes. Overall, ethnic minority populations have suffered disproportionate rates of COVID-19 hospitalization and mortality. Results from the limited number of studies of COVID-19 in ethnic minority populations with diabetes are mixed, but there is some suggestion that rates of hospitalization and mortality are higher than those of White populations. Reasons for the higher incidence and severity of COVID-19-related outcomes in minority ethnic groups are complex and have been shown to be due to differences in comorbid conditions (e.g., diabetes), exposure risk (e.g., overcrowded living conditions or essential worker jobs), and access to treatment (e.g., health insurance status and access to tertiary care medical centers), which all relate to long-standing structural inequities that vary by ethnicity. While guidelines and approaches for diabetes self-management and outpatient and inpatient care during the pandemic have been published, few have recommended addressing wider structural issues. As we now plan for the recovery and improved surveillance and risk factor management, it is imperative that primary and specialist care services urgently address the disproportionate impact the pandemic has had on ethnic minority groups. This should include a focus on the larger structural barriers in society that put ethnic minorities with diabetes at potentially greater risk for poor COVID-19 outcomes.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Eva L. Feldman
- Department of Neurology, School of Medicine, University of Michigan, Ann Arbor, MI
| | | | - William Parker
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL
| | - Ash Routen
- Diabetes Research Centre, University of Leicester, Leicester, U.K
| | - Monica Peek
- Department of Medicine, University of Chicago, Chicago, IL
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25
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Centor RM, Laiteerapong N, Winn AN. Web Exclusive. Annals On Call - First-Line Drug Therapy for Type 2 Diabetes. Ann Intern Med 2023; 176:eA220004. [PMID: 36802895 DOI: 10.7326/a22-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Affiliation(s)
- Robert M Centor
- Huntsville Regional Medical Campus, University of Alabama Birmingham School of Medicine, Birmingham, Alabama (R.M.C.)
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (N.L.)
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
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26
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Slostad J, Jain S, McKinnon M, Chokkara S, Laiteerapong N. Evaluation of Faculty Parental Leave Policies at Medical Schools Ranked by US News & World Report in 2020. JAMA Netw Open 2023; 6:e2250954. [PMID: 36689228 PMCID: PMC9871796 DOI: 10.1001/jamanetworkopen.2022.50954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/15/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Physician parents, particularly women, are more likely to experience burnout, poor family-career balance, adverse maternal and fetal outcomes, and stigmatization compared with nonparent colleagues. Because many physicians delay child-rearing due to the rigorous demands of medical training, favorable parental leave policies for faculty physicians are crucial to prevent physician workforce attrition. Objective To evaluate paid and unpaid parental leave policies at medical schools ranked by US News & World Report in 2020 and identify factors associated with leave policies. Design, Setting, and Participants This cross-sectional national study was performed at US medical schools reviewed from December 1, 2019, through May 31, 2020, and February 1 through March 31, 2021, due to the COVID-19 pandemic. All medical schools ranked by US News & World Report in 2020 were included. Main Outcomes and Measures The primary outcome was the number of weeks of paid and unpaid leave for birth, nonbirth, adoption, and foster care physician parents. Institutional policies for the number of weeks of leave and requirements to use vacation, sick, or disability leave were characterized. Institutional factors were evaluated for association with the duration of paid parental leave using χ2 tests. Results Among the 90 ranked medical schools, 87 had available data. Sixty-three medical schools (72.4%) had some paid leave for birth mothers, but only 13 (14.9%) offered 12 weeks of fully paid leave. While 11 medical schools (12.6%) offered 12 weeks of full paid leave for nonbirth parents, 38 (43.7%) had no paid leave for nonbirth parents. Adoptive and foster parents had no paid leave in 35 (40.2%) and 65 (74.7%) medical schools, respectively. Median paid parental leave was 4 (IQR, 0-8) weeks for birth parents, 4 (IQR, 0-6) weeks for adoptive parents, 3 (IQR, 0-6) weeks for nonbirth parents, and 0 (IQR, 0-1) weeks for foster parents. About one-third of medical schools required birth mothers to use vacation (29 [33.3%]), sick leave (31 [35.6%]), or short-term disability (9 [10.3%]). Among institutional characteristics, higher ranking (top vs bottom quartile: 30.4% vs 4.0%; P = .03) and private designation (private vs public, 23.5% vs 9.4%; P < .001) was associated with a higher rate of 12 weeks of paid leave for birth mothers. Conclusions and Relevance In this cross-sectional national study of medical schools ranked by US News & World Report in 2020, many physician faculty receive no or very limited paid parental leave. The lack of paid parental leave was associated with higher rates of physician burnout and work-life integration dissatisfaction and may further perpetuate sex, racial and ethnic, and socioeconomic disparities in academic medicine.
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Affiliation(s)
- Jessica Slostad
- Division of Hematology-Oncology, Rush University Medical Center, Chicago, Illinois
| | - Shikha Jain
- Division of Hematology-Oncology, University of Illinois, Chicago
| | - Marie McKinnon
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Sukarn Chokkara
- Department of Medicine, University of Chicago, Chicago, Illinois
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27
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Abstract
BACKGROUND Many patients do not receive guideline-recommended preventive, chronic disease, and acute care. One potential explanation is insufficient time for primary care providers (PCPs) to provide care. OBJECTIVE To quantify the time needed to provide 2020 preventive care, chronic disease care, and acute care for a nationally representative adult patient panel by a PCP alone, and by a PCP as part of a team-based care model. DESIGN Simulation study applying preventive and chronic disease care guidelines to hypothetical patient panels. PARTICIPANTS Hypothetical panels of 2500 patients, representative of the adult US population based on the 2017-2018 National Health and Nutrition Examination Survey. MAIN MEASURES The mean time required for a PCP to provide guideline-recommended preventive, chronic disease and acute care to the hypothetical patient panels. Estimates were also calculated for visit documentation time and electronic inbox management time. Times were re-estimated in the setting of team-based care. KEY RESULTS PCPs were estimated to require 26.7 h/day, comprising of 14.1 h/day for preventive care, 7.2 h/day for chronic disease care, 2.2 h/day for acute care, and 3.2 h/day for documentation and inbox management. With team-based care, PCPs were estimated to require 9.3 h per day (2.0 h/day for preventive care and 3.6 h/day for chronic disease care, 1.1 h/day for acute care, and 2.6 h/day for documentation and inbox management). CONCLUSIONS PCPs do not have enough time to provide the guideline-recommended primary care. With team-based care the time requirements would decrease by over half, but still be excessive.
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Affiliation(s)
- Justin Porter
- Department of Medicine, University of Chicago, Chicago, IL, USA.
| | - Cynthia Boyd
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M Reza Skandari
- Imperial College Business School, Centre for Health Economics & Policy Innovation, Imperial College London, London, UK
| | - Neda Laiteerapong
- Departments of Medicine & Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL, USA
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28
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Kahn SE, Anderson CAM, Buse JB, Selvin E, Angell SY, Aroda VR, Castle JR, Cheng AYY, Danne T, Echouffo-Tcheugui JB, Florez JC, Gadgil MD, Gastaldelli A, Green JB, Jastreboff AM, Kanaya AM, Kandula NR, Kovesdy CP, Laiteerapong N, Nadeau KJ, Pop-Busui R, Powe CE, Rebholz CM, Rickels MR, Sattar N, Shaw JE, Sims EK, Utzschneider KM, Vella A, Zhang C. "The Times They Are A-Changin'" at Diabetes Care. Diabetes Care 2023; 46:3-5. [PMID: 36548704 DOI: 10.2337/dci22-0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA
| | - Cheryl A M Anderson
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA
| | - John B Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Elizabeth Selvin
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Sonia Y Angell
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Vanita R Aroda
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jessica R Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland, OR
| | - Alice Y Y Cheng
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Danne
- Diabetes Center and Clinical Research, Children's Hospital Auf der Bult, Hannover Medical School, Hannover, Germany
| | - Justin B Echouffo-Tcheugui
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Jose C Florez
- Diabetes Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
| | - Meghana D Gadgil
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Amalia Gastaldelli
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Jennifer B Green
- Division of Endocrinology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ania M Jastreboff
- Division of Endocrinology and Metabolism, Department of Internal Medicine, and Division of Pediatric Endocrinology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Alka M Kanaya
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Namratha R Kandula
- Division of General Internal Medicine, Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL
| | - Kristen J Nadeau
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Camille E Powe
- Diabetes Unit, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Casey M Rebholz
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Michael R Rickels
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Emily K Sims
- Center for Diabetes and Metabolic Diseases, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Kristina M Utzschneider
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA
| | - Adrian Vella
- Division of Diabetes, Endocrinology and Metabolism, Mayo Clinic, Rochester, MN
| | - Cuilin Zhang
- Global Center for Asian Women's Health and Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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29
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Shao H, Guo J, Laiteerapong N, Tang S, Fonseca V, Shi L, Zhang P. Lowering hemoglobin A1c level to less than 6.0% in people with type 2 diabetes may reduce major adverse cardiovascular events: a Bayesian's narrative. Curr Med Res Opin 2022; 38:1883-1884. [PMID: 36164760 PMCID: PMC9737997 DOI: 10.1080/03007995.2022.2129234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/09/2022] [Accepted: 09/22/2022] [Indexed: 11/03/2022]
Abstract
Whether lowering the hemoglobin A1c to <6.0% in patients with type 2 diabetes can reduce the risk of cardiovascular disease (CVD) remains under debate. The ACCORDION and the VADT studies both found reductions in the primary CVD composite associated with intensive glycemic control, though the difference is not statistically significant. However, the lack of significance is often overinterpreted as non-effective: a p-value >.05 only implies that the study "failed to reject" the null hypothesis (i.e. lowering the A1c level to <6.0% results in no CVD benefit), which is different from concluding the null hypothesis being true. In this study, we used Bayesian analysis to reanalyze results from the ACCORDION and VADT-15 trials. Our results suggest achieving an A1c goal of <6.0% as compared to moderate control could result in a moderate risk reduction in MACE.
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Affiliation(s)
- Hui Shao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
| | | | - Shichao Tang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Vivian Fonseca
- Department of Medicine and Pharmacology, School of Medicine, Tulane University, New Orleans, LA, USA
| | - Lizheng Shi
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
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30
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Knitter AC, Murugesan M, Saulsberry L, Wan W, Nocon RS, Huang ES, Bolton J, Chin MH, Laiteerapong N. Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings. Med Care 2022; 60:813-820. [PMID: 36040020 PMCID: PMC9588553 DOI: 10.1097/mlr.0000000000001766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate indicators of diabetes quality of care for US nonelderly, adult Medicaid enrollees with type 2 diabetes and compare federally qualified health centers (FQHCs) versus non-FQHCs. RESEARCH DESIGN AND METHODS We analyzed diabetes process measures and acute health services utilization with 2012 US fee-for-service and managed care Medicaid claims in all 50 states and DC. We compared FQHC (N=121,977) to non-FQHC patients (N=700,401) using propensity scores to balance covariates and generalized estimating equation models. RESULTS Overall, laboratory-based process measures occurred more frequently (range, 65.7%-76.6%) than measures requiring specialty referrals (retinal examinations, 33.3%; diabetes education, 3.4%). Compared with non-FQHC patients, FQHC patients had about 3 percentage point lower rates of each process measure, except for higher rates of diabetes education [relative risk=1.09, 95% confidence interval (CI): 1.03-1.16]. FQHC patients had fewer overall [incident rate ratio (IRR)=0.87, 95% CI: 0.86-0.88] and diabetes-related hospitalizations (IRR=0.79, 95% CI: 0.77-0.81), but more overall (IRR=1.06, 95% CI: 1.05-1.07) and diabetes-related emergency department visits (IRR=1.10, 95% CI: 1.08-1.13). CONCLUSIONS This national analysis identified opportunities to improve diabetes management among Medicaid enrollees with type 2 diabetes, especially for retinal examinations or diabetes education. Overall, we found slightly lower rates of most diabetes care process measures for FQHC patients versus non-FQHC patients. Despite having higher rates of emergency department visits, FQHC patients were significantly less likely to be hospitalized than non-FQHC patients. These findings emphasize the need to identify innovative, effective approaches to improve diabetes care for Medicaid enrollees, especially in FQHC settings.
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Affiliation(s)
- Alexandra C. Knitter
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Manoradhan Murugesan
- Department of Public Health Sciences, The University of Chicago, Chicago, IL, USA
| | - Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Robert S. Nocon
- Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, CA, USA
| | - Elbert S. Huang
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Joshua Bolton
- U.S. Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD, USA
| | - Marshall H. Chin
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Neda Laiteerapong
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
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31
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Peterson L, Murugesan M, Nocon R, Hoang H, Bolton J, Laiteerapong N, Pollack H, Marsh J. Health care use and spending for Medicaid patients diagnosed with opioid use disorder receiving primary care in Federally Qualified Health Centers and other primary care settings. PLoS One 2022; 17:e0276066. [PMID: 36256662 PMCID: PMC9578596 DOI: 10.1371/journal.pone.0276066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/28/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This nationwide study builds on prior research, which suggests that Federally Qualified Health Centers (FQHCs) and other primary care providers are associated with increased access to opioid use disorder (OUD) treatment. We compare health care utilization, spending, and quality for Medicaid patients diagnosed with OUD who receive primary care at FQHCs and Medicaid patients who receive most primary care in other settings, such as physician offices (non-FQHCs). We hypothesized that the integrated care model of FQHCs would be associated with greater access to medication for opioid use disorder (MOUD) and/or behavioral health therapy and lower rates of potentially inappropriate co-prescribing. METHODS This cross-sectional study examined 2012 Medicaid Analytic eXtract files for patients diagnosed with OUD receiving most (>50%) primary care at FQHCs (N = 37,142) versus non-FQHCs (N = 196,712) in all 50 states and Washington DC. We used propensity score overlap weighting to adjust for measurable confounding between patients who received care at FQHCs versus non-FQHCs and increase generalizability of findings given variation in Medicaid programs and substance use policies across states. RESULTS FQHC patients displayed higher primary care utilization and fee-for-service spending, and similar or lower utilization and fee-for-service spending for other health service categories. Contrary to our hypotheses, non-FQHC patients were more likely to receive timely (≤90 days) MOUD (buprenorphine, methadone, naltrexone, or suboxone) (Relative Risk [RR] = 1.10, 95% CI: 1.07, 1.12) and more likely be retained in medication treatment (>180 days) (RR = 1.12, 95% CI: 1.09, 1.14). However, non-FQHC patients were less likely to receive behavioral health therapy (mental health or substance use therapy) (RR = 0.90, 95% CI: 0.88, 0.92) and less likely to remain in behavioral health treatment (RR = 0.92, 95% CI: 0.89, 0.94). Non-FQHC patients were more likely to fill potentially inappropriate prescriptions of benzodiazepines and opioids after OUD diagnosis (RR = 1.35, 95% CI: 1.30, 1.40). CONCLUSIONS Observed patterns suggest that Medicaid patients diagnosed with OUD who obtained primary care at FQHCs received more integrated care compared to non-FQHC patients. Greater care integration may be associated with increased access to behavioral health therapy and quality of care (lower potentially inappropriate co-prescribing) but not necessarily greater access to MOUD.
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Affiliation(s)
- Lauren Peterson
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois, United States of America
| | - Manoradhan Murugesan
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States of America
| | - Robert Nocon
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
| | - Hank Hoang
- Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
| | - Joshua Bolton
- Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
| | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Harold Pollack
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois, United States of America
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States of America
| | - Jeanne Marsh
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois, United States of America
- * E-mail:
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32
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Choi JG, Winn AN, Skandari MR, Franco MI, Staab EM, Alexander J, Wan W, Zhu M, Huang ES, Philipson L, Laiteerapong N. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists : A Cost-Effectiveness Study. Ann Intern Med 2022; 175:1392-1400. [PMID: 36191315 PMCID: PMC10155215 DOI: 10.7326/m21-2941] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs. OBJECTIVE To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists. DESIGN Individual-level Monte Carlo-based Markov model. DATA SOURCES Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey. TARGET POPULATION Drug-naive U.S. patients with type 2 diabetes. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION First-line SGLT2 inhibitors or GLP1 receptor agonists. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin. RESULTS OF SENSITIVITY ANALYSIS By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists. LIMITATION U.S. population and costs not generalizable internationally. CONCLUSION As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would improve type 2 diabetes outcomes, but their costs would need to fall by at least 70% to be cost-effective. PRIMARY FUNDING SOURCE American Diabetes Association.
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Affiliation(s)
- Jin G Choi
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - M Reza Skandari
- Centre for Health Economics & Policy Innovation, Imperial College Business School, Imperial College London, London, United Kingdom (M.R.S.)
| | - Melissa I Franco
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Erin M Staab
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Jason Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Wen Wan
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Mengqi Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Elbert S Huang
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Louis Philipson
- Sections of Adult and Pediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois (L.P.)
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
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Staab EM, Wan W, Campbell A, Gedeon S, Schaefer C, Quinn MT, Laiteerapong N. Elements of Integrated Behavioral Health Associated with Primary Care Provider Confidence in Managing Depression at Community Health Centers. J Gen Intern Med 2022; 37:2931-2940. [PMID: 34981360 PMCID: PMC9485335 DOI: 10.1007/s11606-021-07294-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Depression is most often treated by primary care providers (PCPs), but low self-efficacy in caring for depression may impede adequate management. We aimed to identify which elements of integrated behavioral health (BH) were associated with greater confidence among PCPs in identifying and managing depression. DESIGN Mailed cross-sectional surveys in 2016. PARTICIPANTS BH leaders and PCPs caring for adult patients at community health centers (CHCs) in 10 midwestern states. MAIN MEASURES Survey items asked about depression screening, systems to support care, availability and integration of BH, and PCP attitudes and experiences. PCPs rated their confidence in diagnosing, assessing severity, providing counseling, and prescribing medication for depression on a 5-point scale. An overall confidence score was calculated (range 4 (low) to 20 (high)). Multilevel linear mixed models were used to identify factors associated with confidence. KEY RESULTS Response rates were 60% (N=77/128) and 52% (N=538/1039) for BH leaders and PCPs, respectively. Mean overall confidence score was 15.25±2.36. Confidence was higher among PCPs who were satisfied with the accuracy of depression screening (0.38, p=0.01), worked at CHCs with depression tracking systems (0.48, p=0.045), had access to patients' BH treatment plans (1.59, p=0.002), and cared for more patients with depression (0.29, p=0.003). PCPs who reported their CHC had a sufficient number of psychiatrists were more confident diagnosing depression (0.20, p=0.02) and assessing severity (0.24, p=0.03). Confidence in prescribing was lower at CHCs with more patients living below poverty (-0.66, p<0.001). Confidence in diagnosing was lower at CHCs with more Black/African American patients (-0.20, p=0.03). CONCLUSIONS PCPs who had access to BH treatment plans, a system for tracking patients with depression, screening protocols, and a sufficient number of psychiatrists were more confident identifying and managing depression. Efforts are needed to address disparities and support PCPs caring for vulnerable patients with depression.
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Affiliation(s)
| | - Wen Wan
- University of Chicago, Chicago, IL, USA
| | | | - Stacey Gedeon
- Mid-Michigan Community Health Services, Houghton Lake, MI, USA
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Abstract
IMPORTANCE Time-based billing options for physicians have expanded, enabling many physicians to bill according to time spent instead of medical decision-making (MDM) level for fee-for-service outpatient visits. However, no study to date has estimated the revenue changes associated with time-based billing. OBJECTIVE To compare evaluation and management (E/M) reimbursement for physicians using time-based billing vs MDM-based billing for outpatient visits of varying lengths. DESIGN, SETTING, AND PARTICIPANTS This economic evaluation used 2019 billing data for outpatient E/M codes and 2021 reimbursement rates from the Centers for Medicare & Medicaid Services. Modeling of generic clinic templates was performed to estimate expected yearly E/M revenues for a single full-time physician working in an outpatient clinic using fee-for-service billing. MAIN OUTCOMES AND MEASURES Yearly E/M revenues for different patient visit templates were modeled. The standardized length of return patient visits was 10 to 45 minutes, and new patient visits were twice as long in duration. RESULTS Under MDM-based billing, increased visit length was associated with decreased E/M revenue ($564 188 for 30-minute new patient visit/15-minute return patient visit vs $423 137 for 40-minute new patient visit/20-minute return patient visit). Under time-based billing, yearly E/M revenue remained similar across increasing visit lengths ($400 432 for 30-minute new patient visit/15-minute return patient visit vs $458 718 for 40-minute new patient visit/20-minute return patient visit). Compared with time-based billing, MDM-based billing was associated with higher E/M revenue for 10- to 15-minute return patient visits ($400 432 vs $564 188). Time-based billing was associated with higher E/M revenue for return patient visits lasting 20 minutes or longer. The highest modeled E/M revenue of $846 273 occurred for 10-minute return patient visits under MDM-based billing. CONCLUSIONS AND RELEVANCE Results of this study showed that the relative economic benefits of MDM-based billing and time-based billing differed and were associated with the length of patient visits. Physicians with longer patient visits were more likely to experience revenue increases from using time-based billing than physicians with shorter patient visits.
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Affiliation(s)
- Tyler J. Miksanek
- Biological Sciences Division, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Samuel T. Edwards
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland
- Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - George Weyer
- Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Biological Sciences Division, Department of Medicine, University of Chicago, Chicago, Illinois
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Kagarmanova A, Sparkman H, Laiteerapong N, Thompson K, Rosul L, Lazar D, Staab E, Wan W, Kass A, Ari M. Improving the management of chronic pain, opioid use, and opioid use disorder in older adults: study protocol for I-COPE study. Trials 2022; 23:602. [PMID: 35897111 PMCID: PMC9327217 DOI: 10.1186/s13063-022-06537-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background Older adults with chronic pain, opioid use, and opioid use disorder (OUD) present complex management decisions in primary care. Clinical tools are needed to improve care delivery. This study protocol describes the planned implementation and evaluation of I-COPE (Improving Chicago Older Adult Opioid and Pain Management through Patient-centered Clinical Decision Support and Project ECHO®) to improve care for this population. Methods This study uses a pragmatic, expanding cohort stepped-wedge design to assess the outcomes. The study will be implemented in 35 clinical sites across metropolitan Chicago for patients aged ≥ 65 with chronic pain, opioid use, or OUD who receive primary care at one of the clinics. I-COPE includes the integration of patient-reported data on symptoms and preferences, clinical decision support tools, and a shared decision-making tool into routine primary care for more effective management of chronic pain, opioid prescribing, and OUD in older adults. Primary care providers will be trained through web-based videos and an optional Project ECHO® course, entitled “Pain Management and OUD in Older Adults.” The RE-AIM framework will be used to assess the I-COPE implementation. Effectiveness outcomes will include an increased variety of recommended pain treatments, decreased prescriptions of higher-risk pain treatments, and decreased patient pain scores. All outcomes will be evaluated 6 and 12 months after implementation. PCPs participating in Project ECHO® will be evaluated on changes in knowledge, attitudes, and self-efficacy using pre- and post-course surveys. Discussion This study will provide evidence about the effectiveness of collecting patient-reported data on symptoms and treatment preferences and providing clinical decision support and shared decision-making tools to improve management for older adults with chronic pain, opioid use, and OUD. Trial registration
ClinicalTrials.gov NCT04878562. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06537-w.
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Affiliation(s)
- Ainur Kagarmanova
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA
| | | | - Neda Laiteerapong
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA
| | - Katherine Thompson
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA
| | - Linda Rosul
- Access Community Health Network, Chicago, IL, USA
| | | | - Erin Staab
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA
| | - Amanda Kass
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA
| | - Mim Ari
- Department of Medicine, University of Chicago, 5841 S. Maryland Ave., Rm. B200, MC 2007B, Chicago, IL, 60637, USA.
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Abstract
CONTEXT Many patients with hypothyroidism receive suboptimal treatment that may affect hospital outcomes. OBJECTIVE This work aimed to identify differences in hospital outcomes between patients with and without hypothyroidism. METHODS A retrospective cohort study, using the propensity score-based fine stratification method to balance covariates, was conducted using a large, US-based, commercial claims database from January 1, 2008 to December 31, 2015. Participants included patients aged 64 years and younger who had a thyrotropin (TSH) level collected before a hospital admission. Covariates included age, sex, US region, type of admission, year of admission, and comorbidities. Exposure included clinical hypothyroidism, which was divided into 4 subgroups based on prehospitalization TSH level: low (TSH < 0.40 mIU/L), normal (TSH 0.40-4.50 mIU/L), intermediate (TSH 4.51-10.00 mIU/L), and high (TSH > 10.00 mIU/L). MAIN OUTCOME MEASURES INCLUDED length of stay (LOS), in-hospital mortality, and readmission outcomes. RESULTS A total of 43 478 patients were included in the final study population, of whom 8873 had a diagnosis of hypothyroidism. Those with a high prehospitalization TSH level had an LOS that was 1.2 days longer (95% CI, 1.1-1.3; P = .003), a 49% higher risk of 30-day readmission (relative risk [RR] 1.49; 95% CI, 1.20-1.85; P < .001), and a 43% higher rate of 90-day readmission (RR 1.43; 95% CI, 1.21-1.67; P < .001) compared to balanced controls. Patients with normal TSH levels exhibited decreased risk of in-hospital mortality (RR 0.46; 95% CI, 0.27-0.79; P = .004) and 90-day readmission (RR 0.92; 95% CI, 0.85-0.99; P = .02). CONCLUSION The results suggest suboptimal treatment of hypothyroidism is associated with worse hospital outcomes, including longer LOS and higher rate of readmission.
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Affiliation(s)
- Matthew D Ettleson
- Correspondence: Matthew D. Ettleson, MD, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S Maryland Ave, MC1027, Chicago, IL 60637, USA.
| | - Antonio C Bianco
- Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, Illinois 60637, USA
| | - Wen Wan
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois 60637, USA
| | - Neda Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, Illinois 60637, USA
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Staab EM, Wan W, Li M, Quinn MT, Campbell A, Gedeon S, Schaefer CT, Laiteerapong N. Integration of primary care and behavioral health services in midwestern community health centers: A mixed methods study. Fam Syst Health 2022; 40:182-209. [PMID: 34928653 PMCID: PMC9743793 DOI: 10.1037/fsh0000660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Integrating behavioral health (BH) and primary care is an important strategy to improve health behaviors, mental health, and substance misuse, particularly at community health centers (CHCs) where disease burden is high and access to mental health services is low. Components of different integrated BH models are often combined in practice. It is unknown which components distinguish developing versus established integrated BH programs. METHOD A survey was mailed to 128 CHCs in 10 Midwestern states in 2016. Generalized estimating equation models were used to assess associations between program characteristics and stage of integration implementation (precontemplation, contemplation, preparation, action, or maintenance). Content analysis of open-ended responses identified integration barriers. RESULTS Response rate was 60% (N = 77). Most CHCs had colocated BH and primary care services, warm hand-offs from primary care to BH clinicians, shared scheduling and electronic health record (EHR) systems, and depression and substance use disorder screening. Thirty-two CHCs (42%) indicated they had completed integration and were focused on quality improvement (maintenance). Being in the maintenance stage was associated with having a psychologist on staff (odds ratio [OR] = 7.16, 95% confidence interval [CI] [2.76, 18.55]), a system for tracking referrals (OR = 3.42, 95% CI [1.03, 11.36]), a registry (OR = 2.71, 95% CI [1.86, 3.94]), PCMH designation (OR = 2.82, 95% CI [1.48, 5.37]), and a lower proportion of Black/African American patients (OR = .82, 95% CI [.75, .89]). The most common barriers to integration were difficulty recruiting and retaining BH clinicians and inadequate reimbursement. DISCUSSION CHCs have implemented many foundational components of integrated BH. Future work should address barriers to integration and racial disparities in access to integrated BH. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Ettleson MD, Raine A, Batistuzzo A, Batista SP, McAninch E, Teixeira MCT, Jonklaas J, Laiteerapong N, Ribeiro MO, Bianco AC. Brain Fog in Hypothyroidism: Understanding the Patient's Perspective. Endocr Pract 2022; 28:257-264. [PMID: 34890786 PMCID: PMC8901556 DOI: 10.1016/j.eprac.2021.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/20/2021] [Accepted: 12/02/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Patient-centered studies have shown that several patients on thyroid hormone replacement therapy for hypothyroidism exhibit persistent symptoms, including "brain fog." Here, we aimed to determine which of these specific symptoms are associated with brain fog, identify patient-reported factors that modify these symptoms, and identify patient concerns related to brain fog not included in thyroid-specific questionnaires. METHODS A survey on brain fog symptoms adapted from thyroid-specific patient-reported outcome was distributed online. Textual data analysis was performed to identify common areas of concern from open-ended survey responses. RESULTS A total of 5170 participants reporting brain fog while being treated for hypothyroidism were included in the analysis. Of these, 2409 (46.6%) participants reported symptom onset prior to the diagnosis of hypothyroidism, and 4096 (79.2%) participants experienced brain fog symptoms frequently. Of the symptoms listed, participants associated fatigue and forgetfulness most frequently with brain fog. More rest was the most common factor provided for improving symptoms. The textual data analysis identified areas of concern that are not often included in thyroid-specific quality of life questionnaires, including a focus on the diagnosis of hypothyroidism, the types and doses of medications, and the patient-doctor relationship. CONCLUSION Brain fog in patients treated for hypothyroidism was associated most frequently with fatigue and cognitive symptoms. Several additional areas of patient concern were found to be associated with brain fog, which are not typically addressed in thyroid-specific questionnaires.
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Affiliation(s)
- Matthew D. Ettleson
- University of Chicago, Section of Endocrinology, Diabetes, and Metabolism, Chicago, Illinois,Address correspondence to Dr Matthew D. Ettleson, University of Chicago, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, 5841 S. Maryland Ave. MC1027, Chicago, IL 60637. (M.D. Ettleson)
| | - Ava Raine
- Carleton College, Northfield, Minnesota
| | - Alice Batistuzzo
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Samuel P. Batista
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Elizabeth McAninch
- Stanford University Medical Center, Division of Endocrinolgoy, Gerontology, and Metabolism, Stanford Hospital, Stanford, California
| | - Maria Cristina T.V. Teixeira
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Jacqueline Jonklaas
- Georgetown University Medical Center, Division of Endocrinology, Washington, DC
| | - Neda Laiteerapong
- University of Chicago, Section of General Internal Medicine, Chicago, Illinois
| | - Miriam O. Ribeiro
- Developmental Disorders Program, Center for Biological Sciences and Health, Mackenzie Presbyterian University, Sao Paulo SP, Brazil
| | - Antonio C. Bianco
- University of Chicago, Section of Endocrinology, Diabetes, and Metabolism, Chicago, Illinois
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. Longer-term Benefits and Risks of Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes: a Systematic Review and Meta-analysis. J Gen Intern Med 2022; 37:439-448. [PMID: 34850334 PMCID: PMC8811049 DOI: 10.1007/s11606-021-07227-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 10/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) are a recent class of medication approved for the treatment of type 2 diabetes (T2D). Previous meta-analyses have quantified the benefits and harms of SGLT2Is; however, these analyses have been limited to specific outcomes and comparisons and included trials of short duration. We comprehensively reviewed the longer-term benefits and harms of SGLT2Is compared to placebo or other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov from inception to July 2019 for randomized controlled trials of minimum 52 weeks' duration that enrolled adults with T2D, compared an SGLT2I to either placebo or other anti-hyperglycemic medications, and reported at least one outcome of interest including cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events. We conducted random effects meta-analyses to provide summary estimates using weighted mean differences (MD) and pooled relative risks (RR). The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Fifty articles describing 39 trials (vs. placebo, n = 28; vs. other anti-hyperglycemic medication, n = 12; vs. both, n = 1) and 112,128 patients were included in our analyses. Compared to placebo, SGLT2Is reduced cardiovascular risk factors (e.g., hemoglobin A1c, MD - 0.55%, 95% CI - 0.62, - 0.49), macrovascular outcomes (e.g., hospitalization for heart failure, RR 0.70, 95% CI 0.62, 0.78), and mortality (RR 0.87, 95% CI 0.80, 0.94). Compared to other anti-hyperglycemic medications, SGLT2Is reduced cardiovascular risk factors, but insufficient data existed for other outcomes. About a fourfold increased risk of genital yeast infections for both genders was observed for comparisons vs. placebo and other anti-hyperglycemic medications. DISCUSSION We found that SGLT2Is led to durable reductions in cardiovascular risk factors compared to both placebo and other anti-hyperglycemic medications. Reductions in macrovascular complications and mortality were only observed in comparisons with placebo, although trials comparing SGLT2Is vs. other anti-hyperglycemic medications were not designed to assess longer-term outcomes.
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Affiliation(s)
- Jason T Alexander
- Department of Medicine, University of Chicago, Chicago, IL, USA.
- , Chicago, USA.
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Melissa Franco
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, UK
| | - Shari Bolen
- Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Nisa M Maruthur
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elbert S Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kathryn Gunter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Brittany Bindon
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sanjay Jumani
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Alexander JT, Staab EM, Wan W, Franco M, Knitter A, Skandari MR, Bolen S, Maruthur NM, Huang ES, Philipson LH, Winn AN, Thomas CC, Zeytinoglu M, Press VG, Tung EL, Gunter K, Bindon B, Jumani S, Laiteerapong N. The Longer-Term Benefits and Harms of Glucagon-Like Peptide-1 Receptor Agonists: a Systematic Review and Meta-Analysis. J Gen Intern Med 2022; 37:415-438. [PMID: 34508290 PMCID: PMC8810987 DOI: 10.1007/s11606-021-07105-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/19/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous meta-analyses of the benefits and harms of glucagon-like peptide-1 receptor agonists (GLP1RAs) have been limited to specific outcomes and comparisons and often included short-term results. We aimed to estimate the longer-term effects of GLP1RAs on cardiovascular risk factors, microvascular and macrovascular complications, mortality, and adverse events in patients with type 2 diabetes, compared to placebo and other anti-hyperglycemic medications. METHODS We searched PubMed, Scopus, and clinicaltrials.gov (inception-July 2019) for randomized controlled trials ≥ 52 weeks' duration that compared a GLP1RA to placebo or other anti-hyperglycemic medication and included at least one outcome of interest. Outcomes included cardiovascular risk factors, microvascular and macrovascular complications, all-cause mortality, and treatment-related adverse events. We performed random effects meta-analyses to give summary estimates using weighted mean differences (MD) and pooled relative risks (RR). Risk of bias was assessed using the Cochrane Collaboration risk of bias in randomized trials tool. Quality of evidence was summarized using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The study was registered a priori with PROSPERO (CRD42018090506). RESULTS Forty-five trials with a mean duration of 1.7 years comprising 71,517 patients were included. Compared to placebo, GLP1RAs reduced cardiovascular risk factors, microvascular complications (including renal events, RR 0.85, 0.80-0.90), macrovascular complications (including stroke, RR 0.86, 0.78-0.95), and mortality (RR 0.89, 0.84-0.94). Compared to other anti-hyperglycemic medications, GLP1RAs only reduced cardiovascular risk factors. Increased gastrointestinal events causing treatment discontinuation were observed in both comparisons. DISCUSSION GLP1RAs reduced cardiovascular risk factors and increased gastrointestinal events compared to placebo and other anti-hyperglycemic medications. GLP1RAs also reduced MACE, stroke, renal events, and mortality in comparisons with placebo; however, analyses were inconclusive for comparisons with other anti-hyperglycemic medications. Given the high costs of GLP1RAs, the lack of long-term evidence comparing GLP1RAs to other anti-hyperglycemic medications has significant policy and clinical practice implications.
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Affiliation(s)
| | - Erin M Staab
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Wen Wan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Melissa Franco
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - M Reza Skandari
- Centre for Health Economics and Policy Innovation, Imperial College Business School, London, UK
| | - Shari Bolen
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Nisa M Maruthur
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elbert S Huang
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Aaron N Winn
- Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kathryn Gunter
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Brittany Bindon
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Sanjay Jumani
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Gorman DC, Ham SA, Staab EM, Vinci LM, Laiteerapong N. Medical Assistant Protocol Improves Disparities in Depression Screening Rates. Am J Prev Med 2021; 61:692-700. [PMID: 34284914 PMCID: PMC8627913 DOI: 10.1016/j.amepre.2021.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/16/2021] [Accepted: 05/05/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Depression is a prevalent condition for which screening rates remain low and disparities in screening exist. This study examines the impacts of a medical assistant screening protocol on the rates of depression screening, overall and by sociodemographic groups, in a primary care setting. METHODS Between September 2016 and August 2018, a quasi-experimental study of adult primary care visits was conducted at an urban academic clinic to ascertain the change in the rates of completion of the Patient Health Questionnaire-2 after the implementation of a medical assistant protocol (intervention) versus that of physician-only screening (control arm). Analyses were conducted between April 2019 and April 2020 and used interrupted time-series models with generalized estimating equations. RESULTS A total of 45,157 visits by 21,377 unique patients were included. Overall, screening increased from 18% (physician-only screening) to 57% (medical assistant protocol) (p<0.0001). Screening increased for all measured demographics. With physician screening, depression screening was less likely to occur at visits by women (than at visits by men; OR=0.91, 95% CI=0.85, 0.98) and at visits by Black/African American patients (than at visits by White; OR=0.91, 95% CI=0.84, 0.99). However, with the medical assistant protocol, depression screening was more likely to occur at visits by women (than at visits by men; OR=1.07, 95% CI=1.0002, 1.14) and at visits by Black/African American patients (than at visits by White; OR=1.11, 95% CI=1.02, 1.20). In addition, age-related disparities were mitigated for visits by patients aged 40-64 and ≥65 years (e.g., age ≥65 years: physician, OR=0.66, 95% CI=0.59, 0.73; medical assistant protocol, OR=0.78, 95% CI=0.71, 0.85), compared with visits by patients aged 18-39 years. CONCLUSIONS Implementation of a medical assistant protocol in a primary care setting may significantly increase depression screening rates while mitigating or removing sociodemographic disparities.
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Affiliation(s)
- Deirdre C Gorman
- Pritzker School of Medicine, The University of Chicago, Chicago, Illinois
| | - Sandra A Ham
- Center for Health and The Social Sciences, The University of Chicago, Chicago, Illinois
| | - Erin M Staab
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Lisa M Vinci
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Neda Laiteerapong
- Department of Medicine, The University of Chicago, Chicago, Illinois.
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Han X, Spicer A, Carey KA, Gilbert ER, Laiteerapong N, Shah NS, Winslow C, Afshar M, Kashiouris MG, Churpek MM. Identifying High-Risk Subphenotypes and Associated Harms From Delayed Antibiotic Orders and Delivery. Crit Care Med 2021; 49:1694-1705. [PMID: 33938715 PMCID: PMC8448901 DOI: 10.1097/ccm.0000000000005054] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Early antibiotic administration is a central component of sepsis guidelines, and delays may increase mortality. However, prior studies have examined the delay to first antibiotic administration as a single time period even though it contains two distinct processes: antibiotic ordering and antibiotic delivery, which can each be targeted for improvement through different interventions. The objective of this study was to characterize and compare patients who experienced order or delivery delays, investigate the association of each delay type with mortality, and identify novel patient subphenotypes with elevated risk of harm from delays. DESIGN Retrospective analysis of multicenter inpatient data. SETTING Two tertiary care medical centers (2008-2018, 2006-2017) and four community-based hospitals (2008-2017). PATIENTS All patients admitted through the emergency department who met clinical criteria for infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient demographics, vitals, laboratory values, medication order and administration times, and in-hospital survival data were obtained from the electronic health record. Order and delivery delays were calculated for each admission. Adjusted logistic regression models were used to examine the relationship between each delay and in-hospital mortality. Causal forests, a machine learning method, was used to identify a high-risk subgroup. A total of 60,817 admissions were included, and delays occurred in 58% of patients. Each additional hour of order delay (odds ratio, 1.04; 95% CI, 1.03-1.05) and delivery delay (odds ratio, 1.05; 95% CI, 1.02-1.08) was associated with increased mortality. A patient subgroup identified by causal forests with higher comorbidity burden, greater organ dysfunction, and abnormal initial lactate measurements had a higher risk of death associated with delays (odds ratio, 1.07; 95% CI, 1.06-1.09 vs odds ratio, 1.02; 95% CI, 1.01-1.03). CONCLUSIONS Delays in antibiotic ordering and drug delivery are both associated with a similar increase in mortality. A distinct subgroup of high-risk patients exist who could be targeted for more timely therapy.
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Affiliation(s)
- Xuan Han
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Alexandra Spicer
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Kyle A Carey
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Emily R Gilbert
- Department of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Neda Laiteerapong
- Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Nirav S Shah
- Department of Medicine, The University of Chicago, Chicago, Illinois
- Department of Medicine, NorthShore University Healthcare, Evanston, Illinois
| | - Christopher Winslow
- Department of Medicine, NorthShore University Healthcare, Evanston, Illinois
| | - Majid Afshar
- Department of Medicine, University of Wisconsin, Madison, Wisconsin
| | - Markos G Kashiouris
- Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
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Abstract
In this narrative review, we summarise the evidence for and against the glycaemic legacy effect from the long-term follow-up of major diabetes trials and observational cohort studies. We provide a summary of the pathophysiological basis for the legacy effect and discuss some translational research. Results from trials of early diabetes and observational cohort studies suggest that a long-term effect of early glycaemic control exists; however, long-term follow-up from trials in participants with established diabetes is not supportive. Additionally, findings for the legacy effect are more conclusive for microvascular complications than macrovascular events. Overall, these results suggest that the glycaemic legacy effect is a long-term benefit (or risk) conferred to individuals in the early stages of diabetes and which is muted over time as individuals' vasculature changes and they develop complications from diabetes.
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Affiliation(s)
- Rachel Folz
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Murphy SM, Laiteerapong N, Pho MT, Ryan D, Montoya I, Shireman TI, Huang E, McCollister KE. Health economic analyses of the justice community opioid innovation network (JCOIN). J Subst Abuse Treat 2021; 128:108262. [PMID: 33419602 PMCID: PMC8255321 DOI: 10.1016/j.jsat.2020.108262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 12/01/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023]
Abstract
The Justice Community Opioid Innovation Network (JCOIN) will generate real-world evidence to address the unique needs of people with opioid use disorder (OUD) in justice settings. Evidence regarding the economic value of OUD interventions in justice populations is limited. Moreover, the variation in economic study designs is a barrier to defining specific interventions as broadly cost-effective. The JCOIN Health Economics Analytic Team (HEAT) has worked closely with the Measures Committee to incorporate common economic measures and instruments across JCOIN studies, which will: a) ensure rigorous economic evaluations within each trial; b) enhance comparability of findings across studies; and c) allow for cross-study analyses of trials with similar designs/settings (e.g., pre-reentry MOUD), to assess questions beyond the scope of a single study, while controlling for and evaluating the effect of intervention-, organizational-, and population-level characteristics. We describe shared trial characteristics relevant to the economic evaluations, and discuss potential cross-study economic analyses.
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Affiliation(s)
- Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA.
| | | | - Mai T Pho
- University of Chicago, Chicago, IL, USA
| | - Danielle Ryan
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Iván Montoya
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Theresa I Shireman
- Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | | | - Kathryn E McCollister
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Gooptu A, Taitel M, Laiteerapong N, Press VG. Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications. Healthcare (Basel) 2021; 9:healthcare9080976. [PMID: 34442113 PMCID: PMC8394266 DOI: 10.3390/healthcare9080976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Importance: Medication non-adherence is highly costly and leads to worse disease control and outcomes. However, knowledge about medication adherence is often disconnected from prescribing decisions, and this disconnect may lead to inappropriate increases in medications and higher risks of adverse events. Objectives: To evaluate the association between medication non-adherence and the likelihood of increases in the intensity of medication regimens for two chronic conditions, hypertension and type 2 diabetes. Design: Cohort Study. Setting and Participants: This study used US national pharmacy claims data for Medicare Part D (ages ≥ 65) and commercial (ages 50-64) plans to evaluate medication adherence and its association with the likelihood of receiving an increase in medication intensity for patients with hypertension and/or oral diabetes medication fills. Patients had an index fill for hypertension (N = 2,536,638) and/or oral diabetes (N = 701,376) medications in January 2015. Medication fills in the follow-up period from August 2015 to December 2016 were assessed for increases in medication regimen intensity. Main Outcome(s) and Measure(s): The proportion of days covered (PDC) over 181 days was used as a measure for patient's medication adherence before a medication addition, medication increase, or dosage increase. Differences in the likelihood of experiencing an escalation in medication intensity was considered between patients with a PDC < 80% vs. PDC ≥ 80%. Results: Among Medicare Part D and commercial plan patients filling hypertension and/or oral diabetes medications, non-adherent patients were significantly more likely to experience an intensification of their medication regimens (p < 0.001). Conclusions and Relevance: This study found a significant association between non-adherence to medications and a higher likelihood of patients experiencing potentially inappropriate increases in treatment intensity. Sharing of objective patient refill data between retail pharmacies and prescribers can enable prescribers to have more targeted discussions with patients about their adherence and overall treatment plan. Additionally, it can increase safe medication prescribing and plausibly reduce adverse drug events and healthcare costs while improving patient health outcomes.
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Affiliation(s)
- Angshuman Gooptu
- IMPAQ International LLC, 10420 Little Patuxent Parkway, Suite 300, Columbia, MD 21044, USA
- Correspondence: ; Tel.: +1-312-515-3898
| | - Michael Taitel
- Walgreen Co., 102 Wilmot, 5th Floor MS#125D, Deerfield, IL 60015, USA;
| | - Neda Laiteerapong
- University of Chicago Medicine, University of Chicago, 5841 Maryland Avenue, Chicago, IL 60637, USA; (N.L.); (V.G.P.)
| | - Valerie G. Press
- University of Chicago Medicine, University of Chicago, 5841 Maryland Avenue, Chicago, IL 60637, USA; (N.L.); (V.G.P.)
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Piersa AP, Laiteerapong N, Ham SA, Del Castillo FF, Shah S, Burnet DL, Lee WW. Impact of a medical scribe on clinical efficiency and quality in an academic general internal medicine practice. BMC Health Serv Res 2021; 21:686. [PMID: 34247600 PMCID: PMC8272908 DOI: 10.1186/s12913-021-06710-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/28/2021] [Indexed: 11/15/2022] Open
Abstract
Background Scribes have been proposed as an intervention to decrease physician electronic health record (EHR) workload and improve clinical quality. We aimed to assess the impact of a scribe on clinical efficiency and quality in an academic internal medicine practice. Methods Six faculty physicians worked with one scribe at an urban academic general internal medicine clinic April through June 2017. Patient visits during the 3 months prior to intervention (baseline, n = 789), unscribed visits during the intervention (concurrent control, n = 605), and scribed visits (n = 579) were included in the study. Clinical efficiency outcomes included time to close encounter, patient time in clinic, and number of visits per clinic session. Quality outcomes included EHR note quality, rates of medication and immunization review, population of patient instructions, reconciliation of outside information, and completion of preventative health recommendations. Results Median time to close encounter (IQR) was lower for scribed visits [0.4 (4.8) days] compared to baseline and unscribed visits [1.2 (5.9) and 2.9 (5.4) days, both p < 0.001]. Scribed notes were more likely to have a clear history of present illness (HPI) [OR = 7.30 (2.35–22.7), p = 0.001] and sufficient HPI information [OR = 2.21 (1.13–4.35), p = 0.02] compared to unscribed notes. Physicians were more likely to review the medication list during scribed vs. baseline visits [OR = 1.70 (1.22–2.35), p = 0.002]. No differences were found in the number of visits per clinic session, patient time in clinic, completion of preventative health recommendations, or other outcomes. Conclusions Working with a scribe in an academic internal medicine practice was associated with more timely documentation. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06710-y.
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Affiliation(s)
| | | | - Sandra A Ham
- University of Chicago Center for Health and the Social Sciences, Chicago, USA
| | | | - Sachin Shah
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Wei Wei Lee
- Department of Medicine, University of Chicago, Chicago, IL, USA.
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Kacew AJ, Strohbehn GW, Saulsberry L, Laiteerapong N, Cipriani NA, Kather JN, Pearson AT. Artificial Intelligence Can Cut Costs While Maintaining Accuracy in Colorectal Cancer Genotyping. Front Oncol 2021; 11:630953. [PMID: 34168975 PMCID: PMC8217761 DOI: 10.3389/fonc.2021.630953] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 05/13/2021] [Indexed: 12/22/2022] Open
Abstract
Rising cancer care costs impose financial burdens on health systems. Applying artificial intelligence to diagnostic algorithms may reduce testing costs and avoid wasteful therapy-related expenditures. To evaluate the financial and clinical impact of incorporating artificial intelligence-based determination of mismatch repair/microsatellite instability status into the first-line metastatic colorectal carcinoma setting, we developed a deterministic model to compare eight testing strategies: A) next-generation sequencing alone, B) high-sensitivity polymerase chain reaction or immunohistochemistry panel alone, C) high-specificity panel alone, D) high-specificity artificial intelligence alone, E) high-sensitivity artificial intelligence followed by next generation sequencing, F) high-specificity artificial intelligence followed by next-generation sequencing, G) high-sensitivity artificial intelligence and high-sensitivity panel, and H) high-sensitivity artificial intelligence and high-specificity panel. We used a hypothetical, nationally representative, population-based sample of individuals receiving first-line treatment for de novo metastatic colorectal cancer (N = 32,549) in the United States. Model inputs were derived from secondary research (peer-reviewed literature and Medicare data). We estimated the population-level diagnostic costs and clinical implications for each testing strategy. The testing strategy that resulted in the greatest project cost savings (including testing and first-line drug cost) compared to next-generation sequencing alone in newly-diagnosed metastatic colorectal cancer was using high-sensitivity artificial intelligence followed by confirmatory high-specificity polymerase chain reaction or immunohistochemistry panel for patients testing negative by artificial intelligence ($400 million, 12.9%). The high-specificity artificial intelligence-only strategy resulted in the most favorable clinical impact, with 97% diagnostic accuracy in guiding genotype-directed treatment and average time to treatment initiation of less than one day. Artificial intelligence has the potential to reduce both time to treatment initiation and costs in the metastatic colorectal cancer setting without meaningfully sacrificing diagnostic accuracy. We expect the artificial intelligence value proposition to improve in coming years, with increasing diagnostic accuracy and decreasing costs of processing power. To extract maximal value from the technology, health systems should evaluate integrating diagnostic histopathologic artificial intelligence into institutional protocols, perhaps in place of other genotyping methodologies.
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Affiliation(s)
- Alec J Kacew
- Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Garth W Strohbehn
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Loren Saulsberry
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States
| | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Nicole A Cipriani
- Department of Pathology, University of Chicago, Chicago, IL, United States
| | - Jakob N Kather
- Department of Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen, Aachen, Germany
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Santos EE, Korah J, Subramanian S, Murugappan V, Huang ES, Laiteerapong N, Cinar A. Analyzing Medical Guideline Dissemination Behaviors Using Culturally Infused Agent Based Modeling Framework. IEEE J Biomed Health Inform 2021; 25:2137-2149. [PMID: 33465031 DOI: 10.1109/jbhi.2021.3052809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinical practice guidelines are a critical medium for the standardization of practices within the overall medical community. However, several studies have shown that, in general, there is a significant delay in the adoption of recommendations in such guidelines. Surveys have identified multiple barriers, including clinical inertia, organizational culture/incentives, access to information and peer influence on guideline dissemination and adoption. Although modeling techniques, especially agent-based models, have shown promise, a rigorous computational model for guideline dissemination that incorporates the intricacies of medical decision making and interactions of healthcare workers, and can identify more effective dissemination strategies, is needed. Similar modeling and simulation issues are also prevalent in many other domains such as opinion diffusion, innovation, and technology adoption. In this paper, we introduce a novel overarching computational modeling and simulation framework called the Culturally Infused Agent Based Modeling (CI-ABM) Framework. CI-ABM is a generalizable framework that provides the capability to model a wide range of real-world complex scenarios. To validate the framework, we focus on modeling and analyzing the dissemination of a Type 2 diabetes guideline that recommends individualizing glycemic (A1C) goals. Using existing cross-sectional surveys from physicians across the US, we demonstrate how our methodology for incorporating various socio-cultural and other related factors in agent based models lead to better posterior probability-based analysis and prediction of guideline dissemination behaviors.
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Yin I, Staab EM, Beckman N, Vinci LM, Ari M, Araújo FS, Yohanna D, Laiteerapong N. Improving Primary Care Behavioral Health Integration in an Academic Internal Medicine Practice: 2-Year Follow-Up. Am J Med Qual 2021; 36:379-386. [PMID: 33967190 DOI: 10.1097/01.jmq.0000735472.47097.a1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This report details ongoing efforts to improve integration in the 2 years following implementation of the Primary Care Behavioral Health model at a general internal medicine clinic of an urban academic medical center. Efforts were informed by a modified version of the validated Level of Integration Measure, sent to all faculty and staff annually. At baseline, results indicated that the domains of systems integration, training, and integrated clinical practices had the greatest need for improvement. Over the 2 years, the authors increased availability of behavioral medicine appointments, improved depression screening processes, offered behavioral health training for providers, disseminated clinical decision support tools, and provided updates about integration progress during clinic meetings. Follow-up survey results demonstrated that physicians and staff perceived improvements in integration overall and in targeted domains. However, the main ongoing barrier to integration was insufficient behavioral health staff to meet patient demand for behavioral health services.
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Affiliation(s)
- Isabel Yin
- Pritzker School of Medicine, University of Chicago, Chicago, IL Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, IL Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, IL
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