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Strombotne KL, Lum J, Pizer SD, Figueroa S, Frakt AB, Conlin PR. Clinical effectiveness and cost-impact after 2 years of a ketogenic diet and virtual coaching intervention for patients with diabetes. Diabetes Obes Metab 2024; 26:1016-1022. [PMID: 38082469 PMCID: PMC10987085 DOI: 10.1111/dom.15401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/06/2024]
Abstract
AIM We previously evaluated the impacts at 5 months of a digitally delivered coaching intervention in which participants are instructed to adhere to a very low carbohydrate, ketogenic diet. With extended follow-up (24 months), we assessed the longer-term effects of this intervention on changes in clinical outcomes, health care utilization and costs associated with outpatient, inpatient and emergency department use in the Veterans Health Administration. MATERIALS AND METHODS We employed a difference-in-differences model with a waiting list control group to estimate the 24-month change in glycated haemoglobin, body mass index, blood pressure, prescription medication use, health care utilization rates and associated costs. The analysis included 550 people with type 2 diabetes who were overweight or obese and enrolled in the Veterans Health Administration for health care. Data were obtained from electronic health records from 2018 to 2021. RESULTS The virtual coaching and ketogenic diet intervention was associated with significant reductions in body mass index [-1.56 (SE 0.390)] and total monthly diabetes medication usage [-0.35 (SE 0.054)]. No statistically significant differences in glycated haemoglobin, blood pressure, outpatient visits, inpatient visits, or emergency department visits were observed. The intervention was associated with reductions in per-patient, per-month outpatient spending [-USD286.80 (SE 97.175)] and prescription drug costs (-USD105.40 (SE 30.332)]. CONCLUSIONS A virtual coaching intervention with a ketogenic diet component offered modest effects on clinical and cost parameters in people with type 2 diabetes and with obesity or overweight. Health care systems should develop methods to assess participant progress and engagement over time if they adopt such interventions, to ensure continued patient engagement and goal achievement.
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Affiliation(s)
- Kiersten L. Strombotne
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA
- VA Boston Healthcare System, Boston, MA
| | | | - Steven D. Pizer
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA
- VA Boston Healthcare System, Boston, MA
| | - Stuart Figueroa
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA
- VA Boston Healthcare System, Boston, MA
| | - Austin B. Frakt
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, MA
- VA Boston Healthcare System, Boston, MA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Cambridge, MA
| | - Paul R. Conlin
- VA Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
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Castilla‐Ojo N, Turkson‐Ocran R, Conlin PR, Appel LJ, Miller ER, Juraschek SP. Effects of the DASH diet and losartan on serum urate among adults with hypertension: Results of a randomized trial. J Clin Hypertens (Greenwich) 2023; 25:915-922. [PMID: 37695134 PMCID: PMC10560966 DOI: 10.1111/jch.14721] [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: 06/20/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Abstract
Serum urate is a risk factor for hypertension and gout. The DASH diet and losartan independently lower blood pressure (BP); however, their effects on serum urate are understudied. We performed a post-hoc analysis of the DASH-losartan trial, which randomized participants with hypertension in parallel fashion to the DASH diet or a standard American diet (control) and in crossover fashion to 4-week losartan or placebo. Serum urate was measured at baseline and after each 4-week period. Diets were designed to maintain weight constant. We examined the effects of DASH (vs control) and/or losartan (vs placebo) on serum urate, overall and among those with baseline serum urate ≥6 mg/dL, using generalized estimating equations. Of 55 participants (mean age 52 years, 58% women, 64% Black), mean (±SD) baseline ambulatory SBP/DBP was 146±12/91±9 and mean (±SD) serum urate was 5.2±1.2 mg/dL. The DASH diet did not significantly reduce urate levels overall (mean difference -0.05 mg/dL; 95%CI: -0.39, 0.28), but did decrease levels among participants with baseline hyperuricemia (-0.33 mg/dL; 95%CI: -0.87, 0.21; P-interaction=0.007 across hyperuricemia groups). Losartan significantly decreased serum urate (-0.23 mg/dL; 95%CI: -0.40, -0.05) with greater effects on serum urate among adults <60 years old versus adults ≥60 years old (-0.33 mg/dL vs 0.16 mg/dL, P interaction = 0.003). In summary, the DASH diet significantly decreased serum urate among participants with higher urate at baseline, while losartan significantly reduced serum urate, especially among younger adults. Future research should examine the effects of these interventions in patients with hyperuricemia or gout.
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Affiliation(s)
- Noelle Castilla‐Ojo
- Harvard Medical SchoolBostonMassachusettsUSA
- Beth Israel Deaconess Medical Center/Harvard Medical SchoolDivision of General MedicineBostonMassachusettsUSA
| | | | - Paul R. Conlin
- Harvard Medical SchoolBostonMassachusettsUSA
- VA Boston Healthcare SystemWest RoxburyMassachusettsUSA
| | - Lawrence J. Appel
- Johns Hopkins UniversitySchool of MedicineDepartment of MedicineDivision of General Internal MedicineBaltimoreMarylandUSA
| | - Edgar R. Miller
- Johns Hopkins UniversitySchool of MedicineDepartment of MedicineDivision of General Internal MedicineBaltimoreMarylandUSA
| | - Stephen P. Juraschek
- Harvard Medical SchoolBostonMassachusettsUSA
- Beth Israel Deaconess Medical Center/Harvard Medical SchoolDivision of General MedicineBostonMassachusettsUSA
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Huang ES, Sinclair A, Conlin PR, Cukierman-Yaffe T, Hirsch IB, Huisingh-Scheetz M, Kahkoska AR, Laffel L, Lee AK, Lee S, Lipska K, Meneilly G, Pandya N, Peek ME, Peters A, Pratley RE, Sherifali D, Toschi E, Umpierrez G, Weinstock RS, Munshi M. The Growing Role of Technology in the Care of Older Adults With Diabetes. Diabetes Care 2023; 46:1455-1463. [PMID: 37471606 PMCID: PMC10369127 DOI: 10.2337/dci23-0021] [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: 03/03/2023] [Accepted: 05/24/2023] [Indexed: 07/22/2023]
Abstract
The integration of technologies such as continuous glucose monitors, insulin pumps, and smart pens into diabetes management has the potential to support the transformation of health care services that provide a higher quality of diabetes care, lower costs and administrative burdens, and greater empowerment for people with diabetes and their caregivers. Among people with diabetes, older adults are a distinct subpopulation in terms of their clinical heterogeneity, care priorities, and technology integration. The scientific evidence and clinical experience with these technologies among older adults are growing but are still modest. In this review, we describe the current knowledge regarding the impact of technology in older adults with diabetes, identify major barriers to the use of existing and emerging technologies, describe areas of care that could be optimized by technology, and identify areas for future research to fulfill the potential promise of evidence-based technology integrated into care for this important population.
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Affiliation(s)
| | | | - Paul R. Conlin
- Harvard Medical School, Boston, MA
- Veteran Affairs Boston Healthcare System, Boston, MA
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes, and Metabolism, Ramat Gan, Israel
- Sheba Medical Centre, Ramat Gan, Israel
- Epidemiology Department, Sackler Faculty of Medicine, Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel
| | | | | | | | | | | | - Sei Lee
- University of California San Francisco, San Francisco, CA
| | | | - Graydon Meneilly
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, FL
| | | | - Anne Peters
- University of Southern California, Los Angeles, CA
| | - Richard E. Pratley
- AdventHealth Diabetes Institute, AdventHealth Translational Research Institute, AdventHealth, Orlando, FL
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Conlin PR, Zhang L, Li D, Nelson RE, Prentice JC, Mohr DC. Association of hemoglobin A1c stability with mortality and diabetes complications in older adults with diabetes. BMJ Open Diabetes Res Care 2023; 11:11/2/e003211. [PMID: 37024152 PMCID: PMC10083809 DOI: 10.1136/bmjdrc-2022-003211] [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: 11/04/2022] [Accepted: 03/16/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION Hemoglobin A1c (A1c) treatment goals in older adults should be individualized to balance risks and benefits. It is unclear if A1c stability over time within unique target ranges also affects adverse outcomes. RESEARCH DESIGN AND METHODS We conducted a retrospective observational cohort study from 2004 to 2016 of veterans with diabetes and at least four A1c tests during a 3-year baseline. We generated four distinct categories based on the percentage of time that baseline A1c levels were within patient-specific target ranges: ≥60% time in range (TIR), ≥60% time below range (TBR), ≥60% time above range (TAR), and a mixed group with all times <60%. We assessed associations of these categories with mortality, macrovascular, and microvascular complications. RESULTS We studied 397 634 patients (mean age 76.9 years, SD 5.7) with an average of 5.5 years of follow-up. In comparison to ≥60% A1c TIR, mortality was increased with ≥60% TBR, ≥60% TAR, and the mixed group, with HRs of 1.12 (95% CI 1.11 to 1.14), 1.10 (95% CI 1.08 to 1.12), and 1.06 (95% CI 1.04 to 1.07), respectively. Macrovascular complications were increased with ≥60% TBR and ≥60% TAR, with estimates of 1.04 (95% CI 1.01 to 1.06) and 1.06 (95% CI 1.03 to 1.09). Microvascular complications were lower with ≥60% TBR (HR 0.97, 95% CI 0.95 to 1.00) and higher with ≥60% TAR (HR 1.11, 95% CI 1.08 to 1.14). Results were similar with higher TIR thresholds, shorter follow-up, and competing risk of mortality. CONCLUSIONS In older adults with diabetes, mortality and macrovascular complications are associated with increased time above and below individualized A1c target ranges. Higher A1c TIR may identify patients with lower risk of adverse outcomes.
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Affiliation(s)
- Paul R Conlin
- Medical Service (111), VA Boston Health Care System West Roxbury Campus, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Libin Zhang
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
| | - Donglin Li
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
| | - Richard E Nelson
- University of Utah Health, Salt Lake City, Utah, USA
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Julia C Prentice
- Boston University School of Medicine, Boston, Massachusetts, USA
- VA Boston Heatlhcare System, Boston, MA, USA
| | - David C Mohr
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
- Boston University School of Public Health, Boston, MA, USA
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Conlin PR, Boltri JM, Bullock A, Greenlee MC, Lopata AM, Powell C, Schillinger D, Tracer H, Herman WH. The National Clinical Care Commission Report to Congress: Summary and Next Steps. Diabetes Care 2023; 46:e60-e63. [PMID: 36701591 PMCID: PMC9887605 DOI: 10.2337/dc22-0622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 11/02/2022] [Indexed: 01/27/2023]
Abstract
The U.S. is experiencing an epidemic of type 2 diabetes. Socioeconomically disadvantaged and certain racial and ethnic groups experience a disproportionate burden from diabetes and are subject to disparities in treatment and outcomes. The National Clinical Care Commission (NCCC) was charged with making recommendations to leverage federal policies and programs to more effectively prevent and control diabetes and its complications. The NCCC determined that diabetes cannot be addressed simply as a medical problem but must also be addressed as a societal problem requiring social, clinical, and public health policy solutions. As a result, the NCCC's recommendations address policies and programs of both non-health-related and health-related federal agencies. The NCCC report, submitted to the U.S. Congress on 6 January 2022, makes 39 specific recommendations, including three foundational recommendations that non-health-related and health-related federal agencies coordinate their activities to better address diabetes, that all federal agencies and departments ensure that health equity is a guiding principle for their policies and programs that impact diabetes, and that all Americans have access to comprehensive and affordable health care. Specific recommendations are also made to improve general population-wide policies and programs that impact diabetes risk and control, to increase awareness and prevention efforts among those at high risk for type 2 diabetes, and to remove barriers to access to effective treatments for diabetes and its complications. Finally, the NCCC recommends that an Office of National Diabetes Policy be established to coordinate the activities of health-related and non-health-related federal agencies to address diabetes prevention and treatment. The NCCC urges Congress and the Secretary of Health and Human Services to implement these recommendations to protect the health and well-being of the more than 130 million Americans at risk for and living with diabetes.
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Affiliation(s)
- Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Clydette Powell
- School of Medicine and Health Services, George Washington University, Washington, DC
| | - Dean Schillinger
- University of California San Francisco and San Francisco General Hospital, San Francisco, CA
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
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Greenlee MC, Bolen S, Chong W, Dokun A, Gonzalvo J, Hawkins M, Herman WH, Leake E, Linder B, Conlin PR. The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Improve Diabetes Treatment and Reduce Complications. Diabetes Care 2023; 46:e51-e59. [PMID: 36701593 PMCID: PMC9887628 DOI: 10.2337/dc22-0621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/08/2022] [Indexed: 01/27/2023]
Abstract
The Treatment and Complications subcommittee of the National Clinical Care Commission focused on factors likely to improve the delivery of high-quality care to all people with diabetes. The gap between available resources and the needs of people living with diabetes adversely impacts both treatment and outcomes. The Commission's recommendations are designed to bridge this gap. At the patient level, the Commission recommends reducing barriers and streamlining administrative processes to improve access to diabetes self-management training, diabetes devices, virtual care, and insulin. At the practice level, we recommend enhancing programs that support team-based care and developing capacity to support technology-enabled mentoring interventions. At the health system level, we recommend that the Department of Health and Human Services routinely assess the needs of the health care workforce and ensure funding of training programs directed to meet those needs. At the health policy level, we recommend establishing a process to identify and ensure pre-deductible insurance coverage for high-value diabetes treatments and services and developing a quality measure that reduces risk of hypoglycemia and enhances patient safety. We also identified several areas that need additional research, such as studying the barriers to uptake of diabetes self-management education and support, exploring methods to implement team-based care, and evaluating the importance of digital connectivity as a social determinant of health. The Commission strongly encourages Congress, the Department of Health and Human Services, and other federal departments and agencies to take swift action to implement these recommendations to improve health outcomes and quality of life among people living with diabetes.
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Affiliation(s)
| | - Shari Bolen
- Population Health Research Institute and Center for Health Care Research and Policy, Case Western Reserve at The MetroHealth System, Cleveland, OH
| | - William Chong
- Office of Generic Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Rockville, MD
| | - Ayotunde Dokun
- Division of Endocrinology and Metabolism, Carver School of Medicine, University of Iowa, Iowa City, IA
| | - Jasmine Gonzalvo
- Center for Health Equity and Innovation, Purdue University, Indianapolis, IN
| | - Meredith Hawkins
- Global Diabetes Institute, Albert Einstein College of Medicine, Bronx, NY
| | | | - Ellen Leake
- Juvenile Diabetes Research Foundation, Jackson, MS
| | - Barbara Linder
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
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Herman WH, Schillinger D, Bolen S, Boltri JM, Bullock A, Chong W, Conlin PR, Cook JW, Dokun A, Fukagawa N, Gonzalvo J, Greenlee MC, Hawkins M, Idzik S, Leake E, Linder B, Lopata AM, Schumacher P, Shell D, Strogatz D, Towne J, Tracer H, Wu S. The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes. Diabetes Care 2023; 46:255-261. [PMID: 36701592 PMCID: PMC9887614 DOI: 10.2337/dc22-1587] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.
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Affiliation(s)
| | - Dean Schillinger
- University of California San Francisco and San Francisco General Hospital, San Francisco, CA
| | - Shari Bolen
- Case Western Reserve at The MetroHealth System, Cleveland, OH
| | - John M. Boltri
- Northeast Ohio Medical University College of Medicine, Rootstown, OH
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Ayotunde Dokun
- Carver School of Medicine, University of Iowa, Iowa City, IA
| | - Naomi Fukagawa
- Beltsville Human Nutrition Research Center, U.S. Department of Agriculture Agricultural Research Service, Beltsville, MD
| | | | | | | | - Shannon Idzik
- School of Nursing, University of Maryland Baltimore, Baltimore, MD
| | - Ellen Leake
- International Board of Directors, Juvenile Diabetes Research Foundation, Jackson, MS
| | - Barbara Linder
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Pat Schumacher
- Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, GA
| | | | | | - Jana Towne
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | - Samuel Wu
- Office of Minority Health, Department of Health and Human Service, Rockville, MD
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Herman WH, Bullock A, Boltri JM, Conlin PR, Greenlee MC, Lopata AM, Powell C, Tracer H, Schillinger D. The National Clinical Care Commission Report to Congress: Background, Methods, and Foundational Recommendations. Diabetes Care 2023; 46:e14-e23. [PMID: 36701594 PMCID: PMC9887619 DOI: 10.2337/dc22-0611] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
Since the first Federal Commission on Diabetes issued its report in 1975, the diabetes epidemic in the U.S. has accelerated, and efforts to translate advances in diabetes treatment into routine clinical practice have stalled. In 2021, the National Clinical Care Commission (NCCC) delivered a report to Congress that provided recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. In the five articles in this series, we present the NCCC's evidence-based recommendations to 1) reduce diabetes-related risks, prevent type 2 diabetes, and avert diabetes complications through changes in federal policies and programs affecting the general population; 2) prevent type 2 diabetes in at-risk individuals through targeted lifestyle and medication interventions; and 3) improve the treatment of diabetes and its complications to improve the health outcomes of people with diabetes. In this first article, we review the successes and limitations of previous federal efforts to combat diabetes. We then describe the establishment of and charge to the NCCC. We discuss the development of a hybrid conceptual model that guided the NCCC's novel all-of-government approach to address diabetes as both a societal and medical problem. We then review the procedures used by the NCCC to gather information from federal agencies, stakeholders, key informants, and the public and to conduct literature reviews. Finally, we review the NCCC's three foundational recommendations: 1) improve the coordination of non-health-related and health-related federal agencies to address the social and environmental conditions that are accelerating the diabetes epidemic; 2) ensure that all Americans at risk for and with diabetes have health insurance and access to health care; and 3) ensure that all federal policies and programs promote health equity in diabetes.
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Affiliation(s)
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Clydette Powell
- School of Medicine and Health Services, George Washington University, Washington, DC
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | - Dean Schillinger
- University of California San Francisco School of Medicine and San Francisco General Hospital, San Francisco, CA
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Mohr DC, Zhang L, Prentice JC, Nelson RE, Li D, Pleasants E, Conlin PR. Association of hemoglobin A1c time in range with risk for diabetes complications. BMJ Open Diabetes Res Care 2022; 10:10/4/e002738. [PMID: 35820708 PMCID: PMC9277370 DOI: 10.1136/bmjdrc-2021-002738] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/07/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION We assessed the association between hemoglobin A1c time in range (A1c TIR), based on unique patient-level A1c target ranges, with risks of developing microvascular and macrovascular complications in older adults with diabetes. RESEARCH DESIGN AND METHODS We used a retrospective observational study design and identified patients with diabetes from the Department of Veterans Affairs (n=397 634). Patients were 65 years and older and enrolled in Medicare during the period 2004-2016. Patients were assigned to individualized A1c target ranges based on estimated life expectancy and the presence or absence of diabetes complications. We computed A1c TIR for patients with at least four A1c tests during a 3-year baseline period. The association between A1c TIR and time to incident microvascular and macrovascular complications was studied in models that included A1c mean and A1c SD. RESULTS We identified 74 016 patients to assess for incident microvascular complications and 89 625 patients to assess for macrovascular complications during an average follow-up of 5.5 years. Cox proportional hazards models showed lower A1c TIR was associated with higher risk of microvascular (A1c TIR 0% to <20%; HR=1.04; 95%) and macrovascular complications (A1c TIR 0% to <20%; HR=1.07; 95%). A1c mean was associated with increased risk of microvascular and macrovascular complications but A1c SD was not. The association of A1c TIR with incidence and progression of individual diabetes complications within the microvascular and macrovascular composites showed similar trends. CONCLUSIONS Maintaining stability of A1c levels in unique target ranges was associated with lower likelihood of developing microvascular and macrovascular complications in older adults with diabetes.
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Affiliation(s)
- David C Mohr
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System Jamaica Plain Campus, Boston, Massachusetts, USA
- Boston University School of Public Health, Health Law, Policy & Management, Boston, Massachusetts, USA
| | - Libin Zhang
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System Jamaica Plain Campus, Boston, Massachusetts, USA
| | - Julia C Prentice
- Betsy Lehman Center for Patient Safety, Commonwealth of Massachusetts, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Richard E Nelson
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Donglin Li
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System Jamaica Plain Campus, Boston, Massachusetts, USA
| | - Erin Pleasants
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System Jamaica Plain Campus, Boston, Massachusetts, USA
| | - Paul R Conlin
- Medical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Conlin PR, Greenlee C, Schillinger D, Lopata A, Boltri JM, Tracer H, Albright A, Bullock A, Herman WH. The National Clinical Care Commission Report: Improving Federal Programs That Impact Diabetes Prevention and Care. Ann Intern Med 2022; 175:594-597. [PMID: 35157491 PMCID: PMC9029008 DOI: 10.7326/m21-4175] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/22/2022] Open
Affiliation(s)
| | - Paul R Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | | | - Dean Schillinger
- University of California, San Francisco, School of Medicine, San Francisco General Hospital, San Francisco, California
| | - Aaron Lopata
- Maternal and Child Health Bureau, Office of the Associate Administrator, Health Resources and Services Administration, Department of Health and Human Services, Rockville, Maryland
| | - John M Boltri
- Department of Family and Community Medicine, Northeast Ohio Medical University College of Medicine, Rootstown, Ohio
| | - Howard Tracer
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, Maryland
| | - Ann Albright
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, Georgia
| | - Ann Bullock
- Indian Health Service, Department of Health and Human Services, Rockville, Maryland
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11
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Vaidya AU, Benavidez GA, Prentice JC, Mohr DC, Conlin PR, Griffith KN. A novel dataset of predictors of mortality for older Veterans living with type II diabetes. Data Brief 2022; 41:108005. [PMID: 35282179 PMCID: PMC8904241 DOI: 10.1016/j.dib.2022.108005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/19/2022] [Accepted: 02/24/2022] [Indexed: 11/25/2022] Open
Abstract
The dataset summarized in this article includes a nationwide prevalence sample of U.S. military Veterans who were aged 65 years or older, dually enrolled in the Veterans Health Administration and traditional Medicare and had a previous diagnosis of diabetes (diabetes mellitus) as of December 2005 (N = 275,190) [1]. Our data were originally used to develop and validate prognostic indices of 5- and 10-year mortality among older Veterans with diabetes. We include various potential predictors including demographics (e.g., sex, age, marital status, and VA priority group), healthcare utilization (e.g., # of outpatient visits, # days of inpatient stays), medication history, and major comorbidities. This novel dataset provides researchers with an opportunity to study the associations between a large variety of individual-level risk factors and longevity for patients living with diabetes.
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12
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Gallagher EJ, Rockey DC, Kontos CD, Vyas JM, Brass LF, Hu PJ, Isales CM, Ajijola OA, Rathmell WK, Conlin PR, Baiocchi RA, Kazmierczak BI, Akabas MH, Williams CS. Pearls of wisdom for aspiring physician-scientist residency applicants and program directors. JCI Insight 2022; 7:158467. [PMID: 35315364 PMCID: PMC8986063 DOI: 10.1172/jci.insight.158467] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Postgraduate physician-scientist training programs (PSTPs) enhance the experiences of physician-scientist trainees following medical school graduation. PSTPs usually span residency and fellowship training, but this varies widely by institution. Applicant competitiveness for these programs would be enhanced, and unnecessary trainee anxiety relieved, by a clear understanding of what factors define a successful PSTP matriculant. Such information would also be invaluable to PSTP directors and would allow benchmarking of their admissions processes with peer programs. We conducted a survey of PSTP directors across the US to understand the importance they placed on components of PSTP applications. Of 41 survey respondents, most were from internal medicine and pediatrics residency programs. Of all components in the application, two elements were considered very important by a majority of PSTP directors: (a) having one or more first-author publications and (b) the thesis advisor’s letter. Less weight was consistently placed on factors often considered more relevant for non-physician-scientist postgraduate applicants — such as US Medical Licensing Examination scores, awards, and leadership activities. The data presented here highlight important metrics for PSTP applicants and directors and suggest that indicators of scientific productivity and commitment to research outweigh traditional quantitative measures of medical school performance.
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Affiliation(s)
- Emily J Gallagher
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Tisch Cancer Institute at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Don C Rockey
- Division of Gastroenterology and Hepatology and Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christopher D Kontos
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jatin M Vyas
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence F Brass
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick J Hu
- Departments of Medicine and Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Carlos M Isales
- Departments of Medicine, Neuroscience and Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles City, California, USA
| | - W Kimryn Rathmell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Paul R Conlin
- VA Boston Healthcare System and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Baiocchi
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Barbara I Kazmierczak
- Department of Microbial Pathogenesis, Department of Medicine (Infectious Diseases), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Myles H Akabas
- Departments of Physiology and Biophysics, Neuroscience, and Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Christopher S Williams
- Department of Medicine, Division of Gastroenterology, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Veterans Affairs Tennessee Valley Health Care System, Nashville, Tennessee, USA; Vanderbilt Ingram Cancer Center, Nashville, Tennessee, USA
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13
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Strombotne KL, Lum J, Ndugga NJ, Utech AE, Pizer SD, Frakt AB, Conlin PR. Effectiveness of a ketogenic diet and virtual coaching intervention for patients with diabetes: A difference-in-differences analysis. Diabetes Obes Metab 2021; 23:2643-2650. [PMID: 34351035 PMCID: PMC8789005 DOI: 10.1111/dom.14515] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/13/2021] [Accepted: 07/28/2021] [Indexed: 01/07/2023]
Abstract
AIM To test the effectiveness of a ketogenic diet and virtual coaching intervention in controlling markers of diabetes care and healthcare utilization. MATERIALS AND METHODS Using a difference-in-differences analysis with a waiting list control group-a quasi-experimental methodology-we estimated the 5-month change in HbA1c, body mass index, blood pressure, prescription medication use and costs, as well as healthcare utilization. The analysis included 590 patients with diabetes who were also overweight or obese, and who regularly utilize the Veterans Health Administration (VA) for healthcare. We used data from VA electronic health records from 2018 to 2020. RESULTS The ketogenic diet and virtual coaching intervention was associated with significant reductions in HbA1c (-0.69 [95% CI -1.02, -0.36]), diabetes medication fills (-0.38, [-0.49, -0.26]), body mass index (-1.07, [-1.95, -0.19]), diastolic blood pressure levels (-1.43, [-2.72, -0.14]), outpatient visits (-0.36, [-0.70, -0.02]) and prescription drug costs (-34.54 [-48.56, -20.53]). We found no significant change in emergency department visits (-0.02 [-0.05, 0.01]) or inpatient admissions (-0.01 [-0.02, 0.01]). CONCLUSIONS This real-world assessment of a virtual coaching and diet programme shows that such an intervention offers short-term benefits on markers of diabetes care and healthcare utilization in patients with diabetes.
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Affiliation(s)
- Kiersten L. Strombotne
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jessica Lum
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Nambi J. Ndugga
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Anne E. Utech
- Veterans Health Administration, Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Steven D. Pizer
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Austin B. Frakt
- Department of Health Law, Policy and Management, Boston University of Public Health, Boston, Massachusetts, USA
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Cambridge, Massachusetts, USA
| | - Paul R. Conlin
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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14
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Prentice JC, Mohr DC, Zhang L, Li D, Legler A, Nelson RE, Conlin PR. Increased Hemoglobin A 1c Time in Range Reduces Adverse Health Outcomes in Older Adults With Diabetes. Diabetes Care 2021; 44:1750-1756. [PMID: 34127496 PMCID: PMC8385473 DOI: 10.2337/dc21-0292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 02/03/2021] [Accepted: 04/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Short- and long-term glycemic variability are risk factors for diabetes complications. However, there are no validated A1C target ranges or measures of A1C stability in older adults. We evaluated the association of a patient-specific A1C variability measure, A1C time in range (A1C TIR), on major adverse outcomes. RESEARCH DESIGN AND METHODS We conducted a retrospective observational study using administrative data from the Department of Veterans Affairs and Medicare from 2004 to 2016. Patients were ≥65 years old, had diabetes, and had at least four A1C tests during a 3-year baseline period. A1C TIR was the percentage of days during the baseline in which A1C was in an individualized target range (6.0-7.0% up to 8.0-9.0%) on the basis of clinical characteristics and predicted life expectancy. Increasing A1C TIR was divided into categories of 20% increments and linked to mortality and cardiovascular disease (CVD) (i.e., myocardial infarction, stroke). RESULTS The study included 402,043 veterans (mean [SD] age 76.9 [5.7] years, 98.8% male). During an average of 5.5 years of follow-up, A1C TIR had a graded relationship with mortality and CVD. Cox proportional hazards models showed that lower A1C TIR was associated with increased mortality (A1C TIR 0 to <20%: hazard ratio [HR] 1.22 [95% CI 1.20-1.25]) and CVD (A1C TIR 0 to <20%: HR 1.14 [95% CI 1.11-1.19]) compared with A1C TIR 80-100%. Competing risk models and shorter follow-up (e.g., 24 months) showed similar results. CONCLUSIONS In older adults with diabetes, maintaining A1C levels within individualized target ranges is associated with lower risk of mortality and CVD.
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Affiliation(s)
- Julia C Prentice
- VA Boston Healthcare System, Boston, MA .,Boston University School of Medicine, Boston, MA
| | - David C Mohr
- VA Boston Healthcare System, Boston, MA.,Boston University School of Public Health, Boston, MA
| | | | | | | | - Richard E Nelson
- VA Salt Lake City Healthcare System, Salt Lake City, UT.,University of Utah, Salt Lake City, UT
| | - Paul R Conlin
- VA Boston Healthcare System, Boston, MA.,Harvard Medical School, Boston, MA
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15
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Zhao MJY, Prentice JC, Mohr DC, Conlin PR. Association between hemoglobin A1c variability and hypoglycemia-related hospitalizations in veterans with diabetes mellitus. BMJ Open Diabetes Res Care 2021; 9:9/1/e001797. [PMID: 33431600 PMCID: PMC7802724 DOI: 10.1136/bmjdrc-2020-001797] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION To study the impact of hemoglobin A1c (A1c) variability on the risk of hypoglycemia-related hospitalization (HRH) in veterans with diabetes mellitus. RESEARCH DESIGN AND METHODS 342 059 veterans with diabetes aged 65 years or older were identified for a retrospective cohort study. All participants had a 3-year baseline period from January 1, 2005 to December 31, 2016, during which they had at least four A1c tests. A1c variability measures included coefficient of variation (A1c CV), A1c SD, and adjusted A1c SD. HRH was identified during a 2-year follow-up period from Medicare and the Veterans Health Administration through validated algorithms of International Classification of Diseases (ICD)-9 and ICD-10 codes. Logistic regression modeling was used to evaluate the relationship between A1c variability and HRH risk while controlling for relevant clinical covariates. RESULTS 2871 patients had one or more HRH in the 2-year follow-up period. HRH risk increased with greater A1c variability, and this was consistent across A1c CV, A1c SD, and adjusted A1c SD. Average A1c levels were also independently associated with HRH, with levels <7.0% (53 mmol/mol) having lower risk and >9% (75 mmol/mol) with greater risk. The relationships between A1c variability remained significant after controlling for average A1c levels and prior HRH during the baseline period. CONCLUSION Increasing A1c variability and elevated A1c levels are associated with a greater risk of HRH in older adults with diabetes. Clinicians should consider A1c variability when assessing patients for risk of severe hypoglycemia.
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Affiliation(s)
- Molly J Y Zhao
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Paul R Conlin
- Medical Service (111), VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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16
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Munshi MN, Meneilly GS, Rodríguez-Mañas L, Close KL, Conlin PR, Cukierman-Yaffe T, Forbes A, Ganda OP, Kahn CR, Huang E, Laffel LM, Lee CG, Lee S, Nathan DM, Pandya N, Pratley R, Gabbay R, Sinclair AJ. Diabetes in ageing: pathways for developing the evidence base for clinical guidance. Lancet Diabetes Endocrinol 2020; 8:855-867. [PMID: 32946822 PMCID: PMC8223534 DOI: 10.1016/s2213-8587(20)30230-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [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: 05/04/2020] [Revised: 06/12/2020] [Accepted: 06/19/2020] [Indexed: 02/07/2023]
Abstract
Older adults with diabetes are heterogeneous in their medical, functional, and cognitive status, and require careful individualisation of their treatment regimens. However, in the absence of detailed information from clinical trials involving older people with varying characteristics, there is little evidence-based guidance, which is a notable limitation of current approaches to care. It is important to recognise that older people with diabetes might vary in their profiles according to age category, functional health, presence of frailty, and comorbidity profiles. In addition, all older adults with diabetes require an individualised approach to care, ranging from robust individuals to those residing in care homes with a short life expectancy, those requiring palliative care, or those requiring end-of-life management. In this Review, our multidisciplinary team of experts describes the current evidence in several important areas in geriatric diabetes, and outlines key research gaps and research questions in each of these areas with the aim to develop evidence-based recommendations to improve the outcomes of interest in older adults.
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Affiliation(s)
- Medha N Munshi
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | | | | - Kelly L Close
- The diaTribe Foundation San Francisco, CA, USA; Close Concerns, San Francisco, CA, USA
| | - Paul R Conlin
- Harvard Medical School, Boston, MA, USA; Veteran Affairs Boston Healthcare System, Boston, MA, USA
| | - Tali Cukierman-Yaffe
- Division of Endocrinology, Diabetes and Metabolism, Gertner Institute, Ramat Gan, Israel; Sheba Medical Centre, Ramat Gan, Israel; Epidemiology Department, Sackler School of Medicine, Herczeg Institute on Aging, Tel Aviv University, Tel Aviv, Israel
| | | | - Om P Ganda
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - C Ronald Kahn
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - Elbert Huang
- Center for Chronic Disease Research and Policy, Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
| | - Lori M Laffel
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - Christine G Lee
- Division of Diabetes, Endocrinology and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sei Lee
- University of California San Francisco, San Francisco, CA, USA; Geriatrics and Extended Care, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - David M Nathan
- Harvard Medical School, Boston, MA, USA; Diabetes Research Center and Clinical Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Naushira Pandya
- Department of Geriatrics, Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Aventura Hospital, Aventura, FL, USA
| | - Richard Pratley
- AdventHealth, AdventHealth Diabetes Institute, AdventHealth Translational Research Institute, Orlando, FL, USA
| | - Robert Gabbay
- Harvard Medical School, Boston, MA, USA; Joslin Diabetes Center, Boston, MA, USA
| | - Alan J Sinclair
- King's College London, London, UK; Diabetes Frail, London, UK
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17
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Griffith KN, Prentice JC, Mohr DC, Conlin PR. Predicting 5- and 10-Year Mortality Risk in Older Adults With Diabetes. Diabetes Care 2020; 43:1724-1731. [PMID: 32669409 PMCID: PMC7372062 DOI: 10.2337/dc19-1870] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 05/08/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Several diabetes clinical practice guidelines suggest that treatment goals may be modified in older adults on the basis of comorbidities, complications, and life expectancy. The long-term benefits of treatment intensification may not outweigh short-term risks for patients with limited life expectancy. Because of the uncertainty of determining life expectancy for individual patients, we sought to develop and validate prognostic indices for mortality in older adults with diabetes. RESEARCH DESIGN AND METHODS We used a prevalence sample of veterans with diabetes who were aged ≥65 years on 1 January 2006 (N = 275,190). Administrative data were queried for potential predictors that included patient demographics, comorbidities, procedure codes, laboratory values and anthropomorphic measurements, medication history, and previous health service utilization. Logistic least absolute shrinkage and selection operator regressions were used to identify variables independently associated with mortality. The resulting odds ratios were then weighted to create prognostic indices of mortality over 5 and 10 years. RESULTS Thirty-seven predictors of mortality were identified: 4 demographic variables, prescriptions for insulin or sulfonylureas or blood pressure medications, 6 biomarkers, previous outpatient and inpatient utilization, and 22 comorbidities/procedures. The prognostic indices showed good discrimination, with C-statistics of 0.74 and 0.76 for 5- and 10-year mortality, respectively. The indices also demonstrated excellent agreement between observed outcome and predictions, with calibration slopes of 1.01 for both 5- and 10-year mortality. CONCLUSIONS Prognostic indices obtained from administrative data can predict 5- and 10-year mortality in older adults with diabetes. Such a tool may enable clinicians and patients to develop individualized treatment goals that balance risks and benefits of treatment intensification.
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Affiliation(s)
- Kevin N Griffith
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, MA
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
| | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
- Department of Psychiatry, Boston University School of Medicine, Boston, MA
| | - David C Mohr
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Paul R Conlin
- VA Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
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18
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Rosenzweig JL, Conlin PR, Gonzalvo JD, Kutler SB, Maruthur NM, Solis P, Vijan S, Wallia A, Wright RF. 2019 Endocrine Society Measures Set for Older Adults With Type 2 Diabetes Who Are at Risk for Hypoglycemia. J Clin Endocrinol Metab 2020; 105:5673461. [PMID: 31825487 PMCID: PMC7753052 DOI: 10.1210/clinem/dgz250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 12/10/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Hypoglycemia in the outpatient setting has a significant financial impact on the health care system and negative impact on a person's quality of life. Primary care physicians must address a multitude of issues in a visit with a person with type 2 diabetes mellitus (T2DM), often leaving little time to ask about hypoglycemia. OBJECTIVE To develop quality measures that focus on outpatient hypoglycemia episodes for patients 65 and older with T2DM, which facilitate a clinician's ability to identify opportunities to improve the quality of care and reduce hypoglycemic episodes. PARTICIPANTS AND PROCESS A technical expert panel established by the Endocrine Society in March 2019, which includes endocrinologists, primary care physicians, a diabetes care and education specialist/pharmacist, and a patient, developed 3 outpatient hypoglycemia quality measures. The measure set is intended to improve quality of care for patients with T2DM who are at greatest risk for hypoglycemia. The measures were available for public comment in July 2019. A fourth measure on shared decision-making was removed from the final measure set based on public feedback. CONCLUSION A lack of outpatient hypoglycemia measures focusing on older adults with T2DM is a barrier to improving care of people with diabetes and reducing hypoglycemic episodes. This paper provides measure specifications for 3 measures that may be used to focus quality improvement efforts on patients at greatest risk for hypoglycemia.
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Affiliation(s)
- James L Rosenzweig
- Hebrew SeniorLife, Roslindale, MA
- Correspondence: James Lawrence Rosenzweig, MD,Hebrew Rehabilitation Hospital, 1200 Centre Street, Roslindale, Massachusetts 02131. E-mail:
| | - Paul R Conlin
- Medical Service, VA Boston Healthcare System, West Roxbury, Massachusetts
| | | | | | - Nisa M Maruthur
- General Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Sandeep Vijan
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Amisha Wallia
- Center for Diabetes and Metabolism, Northwestern University, Chicago, Illinois
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Maris SA, Williams JS, Sun B, Brown S, Mitchell GF, Conlin PR. Interactions of the DASH Diet with the Renin-Angiotensin-Aldosterone System. Curr Dev Nutr 2019; 3:nzz091. [PMID: 31528838 PMCID: PMC6735835 DOI: 10.1093/cdn/nzz091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/01/2019] [Accepted: 07/26/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Dietary Approaches to Stop Hypertension (DASH) diet is widely recommended to lower blood pressure, but its mechanisms of action are unclear. Lines of evidence suggest an interaction with the renin-angiotensin-aldosterone system (RAAS). OBJECTIVE We conducted a randomized, controlled, cross-over feeding trial to test RAAS-related mechanisms underlying the DASH diet in patients with isolated systolic hypertension. METHODS Participants entered a 1-wk run-in period on a control (CON) diet and then consumed the DASH or CON diets for 4 wk each in randomized sequence. Calorie content was controlled to maintain weight, and sodium intake was set at 3 g daily. After each diet, participants had hormonal and hemodynamic assessments obtained at baseline, in response to RAAS inhibition with captopril (CAP) 25 mg, and to graded angiotensin II (AngII) infusions (1 ng/kg and 3 ng/kg × 45 min). Primary outcomes were mean arterial pressure (MAP) and renal blood flow (RBF), and secondary outcomes were diastolic function, pulse wave velocity (PWV), plasma renin activity (PRA), and aldosterone (ALDO) responses by diet. RESULTS In total, 44 (19 female) participants completed the study. DASH + CAP significantly lowered MAP compared with CON + CAP (83 ± 11 mmHg compared with 88 ± 14 mmHg, P <0.01). RBF was increased with DASH + CAP compared with CON + CAP (486 ± 149 cc/min compared with 451 ± 171 cc/min, P <0.001). Study diet did not change PWV but CAP reduced diastolic function on the DASH diet (P <0.05). DASH + CAP significantly increased PRA compared with CON + CAP (1.52 ± 1.78 ng/mL/min compared with 0.89 ± 1.17 ng/mL/min; P <0.001). ALDO sensitivity to AngII infusion was greater with DASH when compared to CON (17.4 ± 7.7 ng/mL compared with 13.8 ± 6.2 ng/dL, P <0.05) as was DASH + CAP compared with CON + CAP (15.1 ± 5.3 ng/dL compared with 13.1 ± 5.9 ng/mL, P <0.05). CONCLUSIONS The DASH diet interacts with the RAAS resulting in vascular and hormonal responses similar to a natriuretic effect, which appears to augment the hypotensive effect of angiotensin-converting enzyme (ACE) inhibition in individuals with isolated systolic hypertension. This trial was registered at clinicaltrials.gov as NCT00123006.
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Affiliation(s)
- Stephen A Maris
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Jonathan S Williams
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Bei Sun
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Stacey Brown
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Gary F Mitchell
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
- Cardiovascular Engineering, Inc., Norwood, MA
| | - Paul R Conlin
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA
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20
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Aron DC, Conlin PR, Pogach L. Brief Commentary: The Glycemic Target Guideline Controversy: Same Evidence, Different Perspectives, and a Proposal for Common Ground. Ann Intern Med 2018; 169:248-249. [PMID: 29946698 DOI: 10.7326/m18-1342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 11/22/2022] Open
Affiliation(s)
- David C Aron
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio (D.C.A.)
| | - Paul R Conlin
- VA Boston Healthcare System, West Roxbury, Massachusetts (P.R.C.)
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21
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Maris SA, Brown S, Conlin PR, Williams JS. The DASH Diet Produces a Natriuretic Effect and Interacts with the Renin‐Angiotensin‐Aldosterone System. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.763.7] [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] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Stephen A. Maris
- Endocrinology, Hypertension, and DiabetesBrigham & Women's Hospital and Harvard Medical SchoolBostonMA
| | - Stacey Brown
- Endocrinology, Hypertension, and DiabetesBrigham & Women's Hospital and Harvard Medical SchoolBostonMA
| | - Paul R. Conlin
- Endocrinology, Hypertension, and DiabetesBrigham & Women's Hospital and Harvard Medical SchoolBostonMA
- Veterans Affairs Boston Healthcare SystemBostonMA
| | - Jonathan S. Williams
- Endocrinology, Hypertension, and DiabetesBrigham & Women's Hospital and Harvard Medical SchoolBostonMA
- Veterans Affairs Boston Healthcare SystemBostonMA
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Conlin PR, Colburn J, Aron D, Pries RM, Tschanz MP, Pogach L. Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus. Ann Intern Med 2017; 167:655-663. [PMID: 29059687 DOI: 10.7326/m17-1362] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [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
DESCRIPTION In April 2017, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes mellitus. METHODS The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development effort that included a multidisciplinary panel of practicing clinician stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions in collaboration with the ECRI Institute, which systematically searched and evaluated the literature through June 2016, developed an algorithm, and rated recommendations by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. RECOMMENDATIONS This synopsis summarizes key features of the guideline in 7 areas: patient-centered care and shared decision making, glycemic biomarkers, hemoglobin A1c target ranges, individualized treatment plans, outpatient pharmacologic treatment, glucose targets for critically ill patients, and treatment of hospitalized patients.
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Affiliation(s)
- Paul R Conlin
- From VA Boston Healthcare System, West Roxbury, Massachusetts; San Antonio Military Medical Center, Fort Sam Houston, Texas; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; VHA National Center for Health Promotion and Disease Prevention, Durham, North Carolina; San Diego Internal Medicine, San Diego, California; and Veterans Affairs Central Office, Office of Specialty Care Services, Washington, DC
| | - Jeffrey Colburn
- From VA Boston Healthcare System, West Roxbury, Massachusetts; San Antonio Military Medical Center, Fort Sam Houston, Texas; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; VHA National Center for Health Promotion and Disease Prevention, Durham, North Carolina; San Diego Internal Medicine, San Diego, California; and Veterans Affairs Central Office, Office of Specialty Care Services, Washington, DC
| | - David Aron
- From VA Boston Healthcare System, West Roxbury, Massachusetts; San Antonio Military Medical Center, Fort Sam Houston, Texas; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; VHA National Center for Health Promotion and Disease Prevention, Durham, North Carolina; San Diego Internal Medicine, San Diego, California; and Veterans Affairs Central Office, Office of Specialty Care Services, Washington, DC
| | - Rose Mary Pries
- From VA Boston Healthcare System, West Roxbury, Massachusetts; San Antonio Military Medical Center, Fort Sam Houston, Texas; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; VHA National Center for Health Promotion and Disease Prevention, Durham, North Carolina; San Diego Internal Medicine, San Diego, California; and Veterans Affairs Central Office, Office of Specialty Care Services, Washington, DC
| | - Mark P Tschanz
- From VA Boston Healthcare System, West Roxbury, Massachusetts; San Antonio Military Medical Center, Fort Sam Houston, Texas; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; VHA National Center for Health Promotion and Disease Prevention, Durham, North Carolina; San Diego Internal Medicine, San Diego, California; and Veterans Affairs Central Office, Office of Specialty Care Services, Washington, DC
| | - Leonard Pogach
- From VA Boston Healthcare System, West Roxbury, Massachusetts; San Antonio Military Medical Center, Fort Sam Houston, Texas; Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio; VHA National Center for Health Promotion and Disease Prevention, Durham, North Carolina; San Diego Internal Medicine, San Diego, California; and Veterans Affairs Central Office, Office of Specialty Care Services, Washington, DC
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Tschanz MP, Watts SA, Colburn JA, Conlin PR, Pogach LM. Overview and Discussion of the 2017 VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care. Fed Pract 2017; 34:S14-S19. [PMID: 30766312 PMCID: PMC6375527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The 2017 diabetes mellitus guidelines emphasize shared decision making, dietary changes, and HbA1c target range for optimal control of diabetes mellitus.
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Affiliation(s)
- Mark P Tschanz
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Sharon A Watts
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Jeffrey A Colburn
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Paul R Conlin
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
| | - Leonard M Pogach
- is an associate program director at Naval Medical Center San Diego in California. is the VHA Office of Nursing Services metabolic syndrome & diabetes advisor at Louis Stokes Cleveland VA Medical Center in Ohio. is a staff endocrinologist at San Antonio Military Medical Center in Texas. is chief of the medical service for the VA Boston Healthcare System in Massachusetts. is the national director of medicine for the VHA Office of Specialty Care Services
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Kerfoot BP, Gagnon DR, McMahon GT, Orlander JD, Kurgansky KE, Conlin PR. A Team-Based Online Game Improves Blood Glucose Control in Veterans With Type 2 Diabetes: A Randomized Controlled Trial. Diabetes Care 2017; 40:1218-1225. [PMID: 28790131 DOI: 10.2337/dc17-0310] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [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] [Received: 02/09/2017] [Accepted: 06/14/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Rigorous evidence is lacking whether online games can improve patients' longer-term health outcomes. We investigated whether an online team-based game delivering diabetes self-management education (DSME) to patients via e-mail or mobile application (app) can generate longer-term improvements in hemoglobin A1c (HbA1c). RESEARCH DESIGN AND METHODS Patients (n = 456) on oral diabetes medications with HbA1c ≥58 mmol/mol were randomly assigned between a DSME game (with a civics booklet) and a civics game (with a DSME booklet). The 6-month games sent two questions twice weekly via e-mail or mobile app. Participants accrued points based on performance, with scores posted on leaderboards. Winning teams and individuals received modest financial rewards. Our primary outcome measure was HbA1c change over 12 months. RESULTS DSME game patients had significantly greater HbA1c reductions over 12 months than civics game patients (-8 mmol/mol [95% CI -10 to -7] and -5 mmol/mol [95% CI -7 to -3], respectively; P = 0.048). HbA1c reductions were greater among patients with baseline HbA1c >75 mmol/mol: -16 mmol/mol [95% CI -21 to -12] and -9 mmol/mol [95% CI -14 to -5] for DSME and civics game patients, respectively; P = 0.031. CONCLUSIONS Patients with diabetes who were randomized to an online game delivering DSME demonstrated sustained and meaningful HbA1c improvements. Among patients with poorly controlled diabetes, the DSME game reduced HbA1c by a magnitude comparable to starting a new diabetes medication. Online games may be a scalable approach to improve outcomes among geographically dispersed patients with diabetes and other chronic diseases.
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Affiliation(s)
- B Price Kerfoot
- Veterans Affairs Boston Healthcare System, Boston, MA .,Harvard Medical School, Boston, MA
| | - David R Gagnon
- Veterans Affairs Boston Healthcare System, Boston, MA.,Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Graham T McMahon
- Accreditation Council for Continuing Medical Education and Northwestern University, Chicago, IL
| | - Jay D Orlander
- Veterans Affairs Boston Healthcare System, Boston, MA.,Evans Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Katherine E Kurgansky
- Veterans Affairs Boston Healthcare System, Boston, MA.,Massachusetts Veterans Epidemiology Research and Information Center, Boston, MA
| | - Paul R Conlin
- Veterans Affairs Boston Healthcare System, Boston, MA.,Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
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Vimalananda VG, DeSotto K, Chen T, Mullakary J, Schlosser J, Archambeault C, Peck J, Cassidy H, Conlin PR, Evans S, McConnell M, Shirley E. A Quality Improvement Program to Reduce Potential Overtreatment of Diabetes Among Veterans at High Risk of Hypoglycemia. Diabetes Spectr 2017; 30:211-216. [PMID: 28848316 PMCID: PMC5556587 DOI: 10.2337/ds16-0006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background.. Intensive glycemic control confers increased risk of hypoglycemia and little benefit among older individuals with diabetes. The aim of this quality improvement project was to reduce the number of patients treated to A1C levels that might confer greater risk than benefit (i.e., potential overtreatment) in the VA New England Healthcare System. Methods.. A provider report and clinical reminder were created to identify potentially overtreated patients and prompt clinicians to consider treatment de-intensification. Potentially overtreated patients were defined as those on insulin or a sulfonylurea whose most recent A1C was <7.0% and who were >74 years of age or diagnosed with dementia or cognitive impairment. The numbers of patients screened and whose treatment was de-intensified using the clinical reminder were counted from January to December 2014. The number of high-risk veterans at baseline was compared with that 6 and 18 months after implementation using t tests. Results.. A total of 2,830 patients were screened using the clinical reminder; 9.6% had their glycemic treatment de-intensified. Among the 261 patients reporting hypoglycemia, 37% had their treatment de-intensified. Higher percentages of patients had treatment de-intensified when reported symptoms were more severe. The monthly average in the high-risk cohort declined from baseline by 18% at 6 months and by 22% at 18 months (both P <0.005). Conclusions.. A clinical reminder helps clinicians identify and reduce the number of potentially overtreated patients. The large number of screened patients whose treatment was not de-intensified suggests that a clinical reminder should be combined with provider education, national guidelines, and performance measures aligned in the interest of reducing potential overtreatment.
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Prentice JC, Pizer SD, Conlin PR. Identifying the independent effect of HbA 1c variability on adverse health outcomes in patients with Type 2 diabetes. Diabet Med 2016; 33:1640-1648. [PMID: 27279250 PMCID: PMC8321425 DOI: 10.1111/dme.13166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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] [Accepted: 06/07/2016] [Indexed: 12/13/2022]
Abstract
AIMS To characterize the relationship between HbA1c variability and adverse health outcomes among US military veterans with Type 2 diabetes. METHODS This retrospective cohort study used Veterans Affairs and Medicare claims for veterans with Type 2 diabetes taking metformin who initiated a second diabetes medication (n = 50 861). The main exposure of interest was HbA1c variability during a 3-year baseline period. HbA1c variability, categorized into quartiles, was defined as standard deviation, coefficient of variation and adjusted standard deviation, which accounted for the number and mean number of days between HbA1c tests. Cox proportional hazard models predicted mortality, hospitalization for ambulatory care-sensitive conditions, and myocardial infarction or stroke and were controlled for mean HbA1c levels and the direction of change in HbA1c levels during the baseline period. RESULTS Over a mean 3.3 years of follow-up, all HbA1c variability measures significantly predicted each outcome. Using the adjusted standard deviation measure for HbA1c variability, the hazard ratios for the third and fourth quartile predicting mortality were 1.14 (95% CI 1.04, 1.25) and 1.42 (95% CI 1.28, 1.58), for myocardial infarction and stroke they were 1.25 (95% CI 1.10, 1.41) and 1.23 (95% CI 1.07, 1.42) and for ambulatory-care sensitive condition hospitalization they were 1.10 (95% CI 1.03, 1.18) and 1.11 (95% CI 1.03, 1.20). Higher baseline HbA1c levels independently predicted the likelihood of each outcome. CONCLUSIONS In veterans with Type 2 diabetes, greater HbA1c variability was associated with an increased risk of adverse long-term outcomes, independently of HbA1c levels and direction of change. Limiting HbA1c fluctuations over time may reduce complications.
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Affiliation(s)
- J C Prentice
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - S D Pizer
- VA Boston Healthcare System, Boston, MA, USA
- Northeastern University, Boston, MA, USA
| | - P R Conlin
- VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Conlin PR, Asefzadeh B, Pasquale LR, Selvin G, Lamkin R, Cavallerano AA. Accuracy of a technology-assisted eye exam in evaluation of referable diabetic retinopathy and concomitant ocular diseases. Br J Ophthalmol 2015; 99:1622-7. [DOI: 10.1136/bjophthalmol-2014-306536] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 05/07/2015] [Indexed: 11/04/2022]
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Kerfoot BP, Turchin A, Breydo E, Gagnon D, Conlin PR. An online spaced-education game among clinicians improves their patients' time to blood pressure control: a randomized controlled trial. Circ Cardiovasc Qual Outcomes 2015; 7:468-74. [PMID: 24847084 DOI: 10.1161/circoutcomes.113.000814] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many patients with high blood pressure (BP) do not have antihypertensive medications appropriately intensified at clinician visits. We investigated whether an online spaced-education (SE) game among primary care clinicians can decrease time to BP target among their hypertensive patients. METHODS AND RESULTS A 2-arm randomized trial was conducted over 52 weeks among primary care clinicians at 8 hospitals. Educational content consisted of 32 validated multiple-choice questions with explanations on hypertension management. Providers were randomized into 2 groups: SE clinicians were enrolled in the game, whereas control clinicians received identical educational content in an online posting. SE game clinicians were e-mailed 1 question every 3 days. Adaptive game mechanics resent questions in 12 or 24 days if answered incorrectly or correctly, respectively. Clinicians retired questions by answering each correctly twice consecutively. Posting of relative performance among peers fostered competition. Primary outcome measure was time to BP target (<140/90 mm Hg). One hundred eleven clinicians enrolled. The SE game was completed by 87% of clinicians (48/55), whereas 84% of control clinicians (47/56) read the online posting. In multivariable analysis of 17 866 hypertensive periods among 14 336 patients, the hazard ratio for time to BP target in the SE game cohort was 1.043 (95% confidence interval, 1.007-1.081; P=0.018). The number of hypertensive episodes needed to treat to normalize one additional patient's BP was 67.8. The number of clinicians needed to teach to achieve this was 0.43. CONCLUSIONS An online SE game among clinicians generated a modest but significant reduction in the time to BP target among their hypertensive patients. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00904007.
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Affiliation(s)
- B Price Kerfoot
- From the Veterans Affairs Boston Healthcare System, Boston, MA (B.P.K., D.G., P.R.C.); Harvard Medical School, Boston, MA (B.P.K., A.T., P.R.C.); Brigham and Women's Hospital, Boston, MA (A.T., E.B., P.R.C.); Partners HealthCare, Boston, MA (A.T.); Pharmacoepidemiology Research Group Massachusetts Veterans Epidemiology Research and Information Center, Boston (D.G.); and Boston University School of Public Health, MA (D.G.).
| | - Alexander Turchin
- From the Veterans Affairs Boston Healthcare System, Boston, MA (B.P.K., D.G., P.R.C.); Harvard Medical School, Boston, MA (B.P.K., A.T., P.R.C.); Brigham and Women's Hospital, Boston, MA (A.T., E.B., P.R.C.); Partners HealthCare, Boston, MA (A.T.); Pharmacoepidemiology Research Group Massachusetts Veterans Epidemiology Research and Information Center, Boston (D.G.); and Boston University School of Public Health, MA (D.G.)
| | - Eugene Breydo
- From the Veterans Affairs Boston Healthcare System, Boston, MA (B.P.K., D.G., P.R.C.); Harvard Medical School, Boston, MA (B.P.K., A.T., P.R.C.); Brigham and Women's Hospital, Boston, MA (A.T., E.B., P.R.C.); Partners HealthCare, Boston, MA (A.T.); Pharmacoepidemiology Research Group Massachusetts Veterans Epidemiology Research and Information Center, Boston (D.G.); and Boston University School of Public Health, MA (D.G.)
| | - David Gagnon
- From the Veterans Affairs Boston Healthcare System, Boston, MA (B.P.K., D.G., P.R.C.); Harvard Medical School, Boston, MA (B.P.K., A.T., P.R.C.); Brigham and Women's Hospital, Boston, MA (A.T., E.B., P.R.C.); Partners HealthCare, Boston, MA (A.T.); Pharmacoepidemiology Research Group Massachusetts Veterans Epidemiology Research and Information Center, Boston (D.G.); and Boston University School of Public Health, MA (D.G.)
| | - Paul R Conlin
- From the Veterans Affairs Boston Healthcare System, Boston, MA (B.P.K., D.G., P.R.C.); Harvard Medical School, Boston, MA (B.P.K., A.T., P.R.C.); Brigham and Women's Hospital, Boston, MA (A.T., E.B., P.R.C.); Partners HealthCare, Boston, MA (A.T.); Pharmacoepidemiology Research Group Massachusetts Veterans Epidemiology Research and Information Center, Boston (D.G.); and Boston University School of Public Health, MA (D.G.)
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Prentice JC, Conlin PR, Gellad WF, Edelman D, Lee TA, Pizer SD. Long-term outcomes of analogue insulin compared with NPH for patients with type 2 diabetes mellitus. Am J Manag Care 2015; 21:e235-e243. [PMID: 26014311] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Long-acting insulin analogues (eg, insulin glargine and insulin detemir) are an alternative to neutral protamine Hagedorn (NPH) insulin for maintaining glycemic control in patients with diabetes. Clinical trials comparing analogue insulin and NPH have neither been adequately powered nor had sufficient follow-up to examine long-term health outcomes. OBJECTIVES To compare the effects of NPH and long-acting insulin analogues on long-term outcomes. STUDY DESIGN This retrospective observational study relied on administrative data from the Veterans Health Administration and Medicare from 2000 to 2010. Local variations in analogue insulin prescribing rates were used in instrumental variable models to control for confounding. Outcomes were assessed using survival models. METHODS The study population included US veterans dually enrolled in Medicare who received at least 1 prescription for oral diabetes medication and then initiated long-acting insulin between 2001 and 2009. Outcomes included ambulatory care-sensitive condition (ACSC) hospitalizations and mortality. RESULTS There was no significant relationship between type of insulin and ACSC hospitalization or mortality. The hazard ratio for mortality of individuals starting a long-acting analogue insulin was 0.97 (95% CI, 0.85-1.11), and was 1.05 (95% CI, 0.95-1.16) for ACSC hospitalization. Differences in risk remained insignificant when predicting diabetes-specific ACSC hospitalizations, but starting on long-acting analogue insulin significantly increased the risk of a cardiovascular-specific ACSC hospitalization. CONCLUSIONS We found no consistent difference in long-term health outcomes when comparing use of long-acting insulin analogues and NPH insulin. The higher cost of analogue insulin without demonstrable clinical benefit raises questions of its cost-effectiveness in the treatment of patients with diabetes.
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Affiliation(s)
- Julia C Prentice
- Health Care Financing and Economics, VA Boston Healthcare System, 150 So Hunting-ton Ave (152H), Boston, MA 02130. E-mail:
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Prentice JC, Conlin PR, Gellad WF, Edelman D, Lee TA, Pizer SD. Capitalizing on prescribing pattern variation to compare medications for type 2 diabetes. Value Health 2014; 17:854-862. [PMID: 25498781 DOI: 10.1016/j.jval.2014.08.2674] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [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] [Received: 02/21/2014] [Revised: 08/19/2014] [Accepted: 08/20/2014] [Indexed: 06/04/2023]
Abstract
BACKGROUND Clinical trials often compare hypoglycemic medications on the basis of glycemic control but do not examine long-term outcomes (e.g., mortality). This study demonstrates an alternative approach to lengthening clinical trials to assess these long-term outcomes. OBJECTIVE To use observational quasi-experimental methods using instrumental variables (IVs) to compare the effect of two hypoglycemic medications, sulfonylureas (SUs) and thiazolidinediones (TZDs), on long-term outcomes. METHODS This study used administrative data from the Veterans Health Administration and Medicare from 2000 to 2010. The study population included US veterans dually enrolled in Medicare who received a prescription for metformin and then initiated SUs or TZDs. Patients could either continue on or discontinue metformin after the initiation of the second agent. Treatment was defined as starting either a SU or a TZD. Local variations in SU prescribing rates were used as instruments in IV models to control for selection bias. Survival models predicted all-cause mortality, ambulatory care sensitive condition hospitalizations, and stroke or heart attack (acute myocardial infarction). RESULTS Starting on SUs compared to TZDs significantly increased the likelihood of experiencing mortality and ACSC hospitalization. The estimated hazard ratio for the effect of starting on SUs compared to TZDs was 1.50 (95% confidence interval [CI] 1.09-2.09) for all-cause mortality, 1.68 (95% CI 1.31-2.15) for ambulatory care sensitive condition hospitalization, and 1.15 (95% CI 0.80-1.66) for acute myocardial infarction or stroke. CONCLUSIONS Our findings suggest increased risk of major adverse events associated with SUs as a second-line agent. Quasi-experimental IV methods may be an important alternative to lengthening clinical trials to assess long-term outcomes.
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Affiliation(s)
- Julia C Prentice
- VA Boston Healthcare System, Boston, MA; Boston University School of Medicine, Boston, MA.
| | - Paul R Conlin
- VA Boston Healthcare System, Boston, MA; Harvard Medical School, Harvard University, Boston, MA
| | - Walid F Gellad
- VA Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh, Pittsburgh, PA
| | - David Edelman
- Durham VA Medical Center, Durham, NC; Duke University School of Medicine, Duke University, Durham, NC
| | - Todd A Lee
- University of Illinois at Chicago, Chicago, IL
| | - Steven D Pizer
- VA Boston Healthcare System, Boston, MA; Northeastern University, Boston, MA
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McMahon GT, Fonda SJ, Gomes HE, Alexis G, Conlin PR. A randomized comparison of online- and telephone-based care management with internet training alone in adult patients with poorly controlled type 2 diabetes. Diabetes Technol Ther 2012; 14:1060-7. [PMID: 22953754 PMCID: PMC3482842 DOI: 10.1089/dia.2012.0137] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [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: 10/27/2022]
Abstract
AIMS Care management may improve the quality of diabetes care by enhancing contact between high-risk patients and their providers. This prospective, longitudinal, randomized trial sought to investigate whether telephone or online care management improves diabetes-related outcomes over time compared with usual care supplemented with Internet access and training. SUBJECTS AND METHODS One hundred fifty-one adult subjects with type 2 diabetes mellitus and an elevated hemoglobin A1c (A1c) level (≥8.5%) were randomly assigned to online care management (n=51), telephone-based care management (n=51), or Web training (n=49) groups. Online and telephone participants interacted with a care manager through a diabetes education and care management Web site and by telephone, respectively. The Web training group was provided with online diabetes self-management resources but no care management support. The primary outcome measure was A1c measured every 3 months for a year. RESULTS A1c declined significantly and substantially in all groups over 12 months. A1c declined linearly at a rate of 0.32% (P<0.0001) per quarter for the online group, 0.36% (P<0.0001) for the telephone group, and 0.41% for the Web training group (P<0.0001). The rate of change over time did not differ significantly among groups. The groups converged at 12 months with average absolute A1c difference of -1.5%. The number of interactions with care providers was not significantly associated with the change in A1c. Blood pressure, weight, lipid levels, and diabetes distress did not differ among groups over time. CONCLUSIONS Online, telephone-based care management, and Web training for diabetes patients with elevated A1c were each associated with a substantial improvement in A1c over a 1-year period. Internet access and training alone may be as effective as care management in patients with poorly controlled diabetes.
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Affiliation(s)
- Graham T McMahon
- Medical Service, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.
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Abstract
OBJECTIVE Several studies have suggested that HbA(1c) levels may predict incident diabetes. With new recommendations for use of HbA(1c) in diagnosing diabetes, many patients with HbA(1c) results below the diagnostic threshold will be identified. Clinicians will need to categorize risk for a subsequent diabetic diagnosis in such patients. The objective of this study was to determine the ability of HbA(1c) to predict the incidence of a diabetic diagnosis. RESEARCH DESIGN AND METHODS We performed a historical cohort study using electronic medical record data from two Department of Veterans Affairs Medical Centers. Patients (n = 12,589) were identified with a baseline HbA(1c) <6.5% between January 2000 and December 2001 and without a diagnosis of diabetes. Patients (12,375) had at least one subsequent follow-up visit. These patients were tracked for 8 years for a subsequent diagnosis of diabetes. RESULTS During an average follow-up of 4.4 years, 3,329 (26.9%) developed diabetes. HbA(1c) ≥ 5.0% carried a significant risk for developing diabetes during follow-up. When compared with the reference group (HbA(1c) <4.5%), HbA(1c) increments of 0.5% between 5.0 and 6.4% had adjusted odds ratios of 1.70 (5.0-5.4%), 4.87 (5.5-5.9%), and 16.06 (6.0-6.4%) (P < 0.0001). Estimates of hazard ratios similarly showed significant increases for HbA(1c) ≥ 5.0%. A risk model for incident diabetes within 5 years was developed and validated using HbA(1c), age, BMI, and systolic blood pressure. CONCLUSIONS The incidence of diabetes progressively and significantly increased among patients with an HbA(1c) ≥ 5.0%, with substantially expanded risk for those with HbA(1c) 6.0-6.4%.
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Affiliation(s)
- Peiyao Cheng
- Department of Veterans Affairs Medical Center, Tampa, Florida, USA
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Kerfoot BP, Lawler EV, Sokolovskaya G, Gagnon D, Conlin PR. Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial. Am J Prev Med 2010; 39:472-8. [PMID: 20965387 PMCID: PMC2994103 DOI: 10.1016/j.amepre.2010.07.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [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] [Received: 03/03/2010] [Revised: 07/09/2010] [Accepted: 07/26/2010] [Indexed: 01/22/2023]
Abstract
CONTEXT Prostate cancer screening with prostate-specific antigen (PSA) is frequently performed, counter to clinical practice guidelines. BACKGROUND It was hypothesized that an e-mail-based intervention termed "spaced education" could reduce clinicians' inappropriate screening for prostate cancer. DESIGN The study was conducted as an RCT. SETTING/PARTICIPANTS The study involved 95 primary care clinicians in eight Veterans Affairs medical centers from January 2007 to February 2009. INTERVENTION Participants were randomized into two cohorts: spaced education clinicians received four isomorphic cycles of nine e-mails over 36 weeks (zero to two e-mails per week), whereas control clinicians received no intervention. Each e-mail presented a clinical scenario and asked whether it was appropriate to obtain a PSA test. Participants received immediate feedback after submitting their answers. MAIN OUTCOME MEASURES The primary outcome was the number and percentage of inappropriate PSA screening tests ordered. Inappropriate testing was defined as use of PSA for prostate cancer screening in patients aged >76 or <40 years. Appropriateness of screening was dichotomized based on patient age at time of screening. Patients with PSA testing for non-screening reasons were excluded using a validated protocol. Logistic regression with adjustment for patient clustering by clinician was performed. Analyses were conducted in 2009. RESULTS During the intervention period (Weeks 1-36), clinicians receiving spaced education e-mails ordered significantly fewer inappropriate PSA screening tests than control clinicians (10.5% vs 14.2%, p=0.041). Over the 72-week period following the intervention (Weeks 37-108), spaced education clinicians continued to order fewer inappropriate tests compared to controls (7.8% vs 13.1%, respectively, p=0.011), representing a 40% relative reduction in inappropriate screening. CONCLUSIONS Spaced education durably improves the prostate cancer screening behaviors of clinicians and represents a promising new methodology to improve patient care across healthcare systems.
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Affiliation(s)
- B Price Kerfoot
- Veterans Affairs Boston Healthcare System, Massachusetts 02130, USA.
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Sun B, Williams JS, Svetkey LP, Kolatkar NS, Conlin PR. Beta2-adrenergic receptor genotype affects the renin-angiotensin-aldosterone system response to the Dietary Approaches to Stop Hypertension (DASH) dietary pattern. Am J Clin Nutr 2010; 92:444-9. [PMID: 20519561 PMCID: PMC2904038 DOI: 10.3945/ajcn.2009.28924] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Beta(2)-adrenergic receptor (beta2-AR) is a susceptibility locus for hypertension, and polymorphisms at this site relate to salt sensitivity and low plasma renin activity (PRA). The Dietary Approaches to Stop Hypertension (DASH) dietary pattern lowers blood pressure and appears to interact with the renin-angiotensin-aldosterone system (RAAS). OBJECTIVE We hypothesized that the DASH diet associates with increased RAAS activity, and genotype status at beta2-AR G46A modifies this response. DESIGN We genotyped participants in the DASH-Sodium study (n = 372) at beta2-AR G46A to determine the association with blood pressure, RAAS components, and consumption of the DASH diet. We used 2-way mixed linear regression and an additive model for all primary analyses. RESULTS Mean (+/-SEM) PRA was significantly higher in participants in the DASH group than in participants in the control group (0.68 +/- 0.03 compared with 0.54 +/- 0.03 ng x mL(-1) x h(-1), P = 0.002). Serum aldosterone, urinary aldosterone, and urinary potassium concentrations were also significantly higher in the DASH group (P < 0.01 for all). We observed significant gene-diet interactions for changes in systolic blood pressure (SBP) and concentrations of aldosterone and urinary potassium (P for interaction = 0.048, 0.017, and 0.001 for SBP and aldosterone and urinary potassium concentrations, respectively). There was an association between the A allele of beta2-AR G46A and greater blood pressure reduction and blunted aldosterone and PRA responses to the DASH diet. CONCLUSIONS Our results indicate that the DASH diet lowers blood pressure and increases PRA and aldosterone concentrations. There is an association between the G46A polymorphism of beta2-AR and blood pressure and RAAS responses to the DASH diet, which suggests that beta2-AR may be a genetic modifier of DASH-diet responsiveness. This trial was registered at clinicaltrials.gov as NCT00000608.
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Affiliation(s)
- Bei Sun
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Abstract
The relationship between encounter frequency (average number of provider-patient encounters over a period of time) and blood pressure for hypertensive patients is unknown. We tested the hypothesis that shorter encounter intervals are associated with faster blood pressure normalization. We performed a retrospective cohort study of 5042 hypertensive patients with diabetes mellitus treated at primary care practices affiliated with 2 academic hospitals between 2000 and 2005. Distinct periods of continuously elevated blood pressure (>or=130/85 mm Hg) were studied. We evaluated the association of the average encounter interval with time to blood pressure normalization and rate of blood pressure decrease. Blood pressure of the patients with the average interval between encounters <or=1 month normalized after a median of 1.5 months at the rate of 28.7 mm Hg/month compared with 12.2 months at 2.6 mm Hg/month for the encounter interval >1 month (P<0.0001 for all). Median time to blood pressure normalization was 0.7 versus 1.9 months for the average encounter interval <or=2 weeks versus between 2 weeks and 1 month, respectively (P<0.0001). In proportional hazards analysis adjusted for patient demographics, initial blood pressure, and treatment intensification rate, a 1 month increase in the average encounter interval was associated with a hazard ratio of 0.764 for blood pressure normalization (P<0.0001). Shorter encounter intervals are associated with faster decrease in blood pressure and earlier blood pressure normalization. Greatest benefits were observed at encounter intervals (<or=2 weeks) shorter than what is currently recommended.
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Affiliation(s)
- Alexander Turchin
- Division of Endocrinology, Brigham and Women's Hospital, 221 Longwood Ave, Boston, MA 02115, USA.
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Kerfoot BP, Lawler EV, Sokolovskaya G, Gagnon D, Conlin PR. INTERACTIVE SPACED EDUCATION IMPROVES CLINICIANS' SCREENING FOR PROSTATE CANCER: A MULTI-INSTITUTIONAL RANDOMIZED CONTROLLED TRIAL. J Urol 2009. [DOI: 10.1016/s0022-5347(09)60548-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Affiliation(s)
- Jonathan S. Williams
- Medical Service, VA Boston Healthcare System, Boston, MA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital
- Harvard Medical School
| | - Stacey Brown,
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital
| | - Paul R. Conlin
- Medical Service, VA Boston Healthcare System, Boston, MA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital
- Harvard Medical School
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Jacobs DR, Gross MD, Steffen L, Steffes MW, Yu X, Svetkey LP, Appel LJ, Vollmer WM, Bray GA, Moore T, Conlin PR, Sacks F. The effects of dietary patterns on urinary albumin excretion: results of the Dietary Approaches to Stop Hypertension (DASH) Trial. Am J Kidney Dis 2009; 53:638-46. [PMID: 19167797 DOI: 10.1053/j.ajkd.2008.10.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 10/23/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Dietary studies designed to decrease the urinary albumin excretion rate (AER) typically reduce protein by increasing lower protein plant foods and decreasing higher protein animal products. STUDY DESIGN We evaluated AER while increasing protein intake in the Dietary Approaches to Stop Hypertension (DASH) Trial (randomized, parallel group, 8 week controlled feeding). SETTING & PARTICIPANTS 378 individuals without diabetes with prehypertension or stage I hypertension. INTERVENTION The DASH diet, 18% energy from protein, emphasizes, among other features, low-fat dairy products; and the fruit/vegetable (FV) and control diets, each with 15% energy from protein. OUTCOME AER. MEASUREMENTS We measured AER by using immunoassay and covariates at baseline and after 8 weeks. RESULTS Baseline AER had a geometric mean value of 4.0 +/- 0.2 (SE) mg/24 h. In 285 participants with baseline AER less than 7 mg/24 h, AER was unchanged by diet treatment (geometric mean, 2.5 +/- 0.2 mg/24 h in the control diet, 3.0 +/- 0.2 mg/24 h in the FV diet, and 2.8 +/- 0.2 mg/24 h in the DASH diet). Conversely, in 93 participants with baseline AER of 7 mg/24 h or greater, end-of-feeding AER was lower in the FV diet (6.6 +/- 1.0 mg/24 h) than in the control (11.4 +/- 1.8 mg/24 h; P = 0.01) or DASH diets (11.7 +/- 1.6 mg/24 h; P = 0.005). The DASH and control diets were not different (P = 0.9). LIMITATIONS Long-term AER change not studied. CONCLUSIONS The decrease in AER after 8 weeks occurred in only those with high-normal baseline AER in the FV diet, in a pattern distinct from the blood pressure decrease. The DASH diet did not increase AER despite a 3% increase in energy from protein.
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Affiliation(s)
- David R Jacobs
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA.
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Fonda SJ, McMahon GT, Gomes HE, Hickson S, Conlin PR. Changes in diabetes distress related to participation in an internet-based diabetes care management program and glycemic control. J Diabetes Sci Technol 2009; 3:117-24. [PMID: 20046656 PMCID: PMC2769854 DOI: 10.1177/193229680900300113] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND This article investigated how changes in diabetes distress relate to receiving care management through an Internet-based care management (IBCM) program for diabetes and level of participation in this program. Further, it examined the relationship between diabetes distress and changes in glycemic control. METHODS We enrolled patients of the Veterans Affairs Boston Healthcare System with diabetes who had hemoglobin A1c (HbA1c) levels of ≥9.0%. Subjects were randomized to usual care (n=52) or IBCM (n=52) for 1 year. We measured diabetes distress at baseline and quarterly thereafter using the Problem Areas in Diabetes (PAID) questionnaire. Glycemic control was determined by baseline and quarterly HbA1c. For subjects randomized to IBCM, we measured participation by observing frequency and consistency of their usage of the IBCM patient portal over 12 months. Linear mixed models were used to analyze THE data. RESULTS PAID scores declined over time for both treatment groups. Among subjects randomized to IBCM, the decline in PAID scores over time was significant for sustained users of the IBCM patient portal but not for nonusers. Moreover, subjects whose usage of the patient portal was sustained throughout the study had lower PAID scores at baseline. With respect to changes in glycemic control, HbA1c reduced individual differences in PAID scores by 44%; a lower baseline HbA1c was associated with lower baseline PAID scores, and over time, the decrease in HbA1c was associated with further decreases in the PAID score. CONCLUSIONS Participation in IBCM varies by initial diabetes distress, with people with less distress participating more. For people who participate, IBCM further mitigates diabetes distress. There is also a relationship between achievements in glycemic control and subsequent lowering of diabetes distress. Future research should identify how to maximize fit between patient needs and the provisions of IBCM, with the aim of increasing patient engagement in the active management of their health using this care modality. A key to maximizing fit might be first addressing metabolic control aggressively and then using IBCM for sustainment of health.
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Mitchell GF, Conlin PR, Dunlap ME, Lacourcière Y, Arnold JMO, Ogilvie RI, Neutel J, Izzo JL, Pfeffer MA. Response to Wave Reflection in Systolic Hypertension: Smaller Stature, Shorter Aorta: Higher Pulse Pressure? and Questions Regarding the Aortic Measurements of Mitchell et al. Hypertension 2008. [DOI: 10.1161/hypertensionaha.108.111781] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | - Joel Neutel
- Orange County Research Center, Tustin, Calif
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Pasquale LR, Asefzadeh B, Dunphy RW, Fisch BM, Conlin PR. Detection of glaucoma-like optic discs in a diabetes teleretinal program. ACTA ACUST UNITED AC 2008; 78:657-63. [PMID: 18054136 DOI: 10.1016/j.optm.2007.04.101] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Revised: 03/30/2007] [Accepted: 04/16/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND Glaucoma is typically an insidious-onset disease with serious visual consequences that has been positively linked to diabetes mellitus (DM) in several studies. We assessed the sensitivity and specificity of a diabetes teleretinal program to identify the glaucoma-suspicious optic disc. METHODS Outpatients with DM (N = 1,644) presenting to Veterans Affairs ambulatory clinics participated in a nonmydriatic digital retinal imaging (NMDRI) program. Technicians transmitted digital retinal images electronically to readers for grading and eye care recommendations. Patients were referred for ophthalmic care based on the level of diabetic retinopathy and other ocular findings, including optic nerve changes suspicious for glaucoma. We retrospectively reviewed the electronic medical records of patients labeled as glaucoma suspects (N = 175) and compared them with those of patients from the same imaging pool who were not regarded as glaucoma suspects (N = 175). Ophthalmic data obtained from a comprehensive eye examination after digital retinal imaging was used to determine which patients met predefined criteria for the optic disc suggestive of glaucoma. RESULTS Assessment of clinical data obtained after NMDRI found that 103 of 175 (59%) glaucoma suspects had glaucoma-suspicious optic discs. In the comparison group, only 7 of 175 (4%) had glaucoma-suspicious optic discs. CONCLUSIONS Although specificity was high (96%), modifications in diabetes teleretinal imaging programs are needed to improve the sensitivity of detecting the optic disc that is suspicious for glaucoma.
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Affiliation(s)
- Louis R Pasquale
- Ocular Telehealth Center, VA Boston Healthcare System-Jamaica Plain Campus, Jamaica Plain, Massachusetts 02130, USA.
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Mitchell GF, Conlin PR, Dunlap ME, Lacourcière Y, Arnold JMO, Ogilvie RI, Neutel J, Izzo JL, Pfeffer MA. Aortic Diameter, Wall Stiffness, and Wave Reflection in Systolic Hypertension. Hypertension 2008; 51:105-11. [DOI: 10.1161/hypertensionaha.107.099721] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gary F. Mitchell
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Paul R. Conlin
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Mark E. Dunlap
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Yves Lacourcière
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - J. Malcolm O. Arnold
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Richard I. Ogilvie
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Joel Neutel
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Joseph L. Izzo
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Marc A. Pfeffer
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
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Abstract
Diabetes is the leading cause of adult vision loss in the United States and other industrialized countries. While the goal of preserving vision in patients with diabetes appears to be attainable, the process of achieving this goal poses a formidable challenge to health care systems. The large increase in the prevalence of diabetes presents practical and logistical challenges to providing quality care to all patients with diabetes. Given this challenge, the Veterans Health Administration (VHA) is increasingly using information technology as a means of improving the efficiency of its clinicians. The VHA has taken advantage of a mature computerized patient medical record system by integrating a program of digital retinal imaging with remote image interpretation (teleretinal imaging) to assist in providing eye care to the nearly 20% of VHA patients with diabetes. We describe this clinical pathway for accessing patients with diabetes in ambulatory care settings, evaluating their retinas for level of diabetic retinopathy with a teleretinal imaging system, and prioritizing their access into an eye and health care program in a timely and appropriate manner.
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Affiliation(s)
| | - Paul R. Conlin
- Endocrinology Section, VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Dunphy RW, Wentzolf JN, Subramanian M, Conlin PR, Pasquale LR. Structural Features Anterior to the Retina Represented in Panoramic Scanning Laser Fundus Images. Ophthalmic Surg Lasers Imaging Retina 2008; 39:160-3. [DOI: 10.3928/15428877-20080301-07] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Conlin PR, Fisch BM, Orcutt JC, Hetrick BJ, Darkins AW. Framework for a national teleretinal imaging program to screen for diabetic retinopathy in Veterans Health Administration patients. ACTA ACUST UNITED AC 2007; 43:741-8. [PMID: 17310423 DOI: 10.1682/jrrd.2005.08.0146] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Digital retinal imaging with remote image interpretation (teleretinal imaging) is an emerging healthcare technology for screening patients for diabetic retinopathy (DR). The Veterans Health Administration (VHA) convened an expert panel in 2001 to determine and resolve the requisite clinical, quality and training, information technology, and healthcare infrastructure issues associated with deploying a teleretinal imaging system. The panel formulated consensus recommendations based on available literature and identified areas of uncertainty that merited further clarification or research. Subsequent VHA experience with teleretinal imaging and accumulated scientific evidence support nationwide regionalized deployment of teleretinal imaging to screen for DR. The goal is to screen approximately 75,000 patients in the first year of the program, which commenced in 2006. This program will increase patients' access to screening for DR, provide outcomes data, and offer a unique platform for systematically evaluating the role of this technology in the care of diabetic eye disease and routine eye-care practice.
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Affiliation(s)
- Paul R Conlin
- Endocrinology Section, Department of Veterans Affairs (VA) Boston Healthcare System, Boston, MA 02130, USA.
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Kerfoot BP, Conlin PR, Travison T, McMahon GT. Patient safety knowledge and its determinants in medical trainees. J Gen Intern Med 2007; 22:1150-4. [PMID: 17551796 PMCID: PMC2305739 DOI: 10.1007/s11606-007-0247-8] [Citation(s) in RCA: 34] [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: 12/11/2006] [Revised: 05/08/2007] [Accepted: 05/16/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patient safety is a core educational topic for medical trainees. OBJECTIVES To determine the current level and determinants of patient safety knowledge in medical trainees. DESIGN Multi-institutional cross-sectional assessment of patient safety knowledge. PARTICIPANTS Residents and medical students from seven Harvard-affiliated residencies and two Harvard Medical School courses. MEASUREMENTS Participants were administered a 14-item validated test instrument developed based on the patient safety curriculum of the Risk Management Foundation (Cambridge, MA). The primary outcome measure was the amount of patient safety knowledge demonstrated by trainees on the validated test instrument. The secondary outcome measure was their subjective perceptions as to their baseline knowledge level in this domain. RESULTS Ninety-two percent (640/693) of residents and medical students completed the patient safety test. Participants correctly answered a mean 58.4% of test items (SD 15.5%). Univariate analyses show that patient safety knowledge levels varied significantly by year of training (p = 0.001), degree program (p < 0.001), specialty (p < 0.001), country of medical school (p = 0.006), age (p < 0.001), and gender (p = 0.050); all but the latter two determinants remained statistically significant in multivariate models. In addition, trainees were unable to assess their own knowledge deficiencies in this domain. CONCLUSIONS Patient safety knowledge is limited among medical trainees across a broad range of training levels, degrees, and specialties. Effective educational interventions that target deficiencies in patient safety knowledge are greatly needed.
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Affiliation(s)
- B Price Kerfoot
- Veterans Affairs Boston Healthcare System, 150 South Huntington Avenue, 151DIA, Jamaica Plain, Boston, MA 02130, USA.
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