Economic Costs of Diabetes in the U.S. in 2022

OBJECTIVE

This study updates previous estimates of the economic burden of diagnosed diabetes, with calculation of the health resource use and indirect costs attributable to diabetes in 2022.

RESEARCH DESIGN AND METHODS

We combine the demographics of the U.S. population in 2022 with diabetes prevalence, from national survey data, epidemiological data, health care cost data, and economic data, into a Cost of Diabetes Economic Model to estimate the economic burden at the population and per capita levels. Health resource use and associated medical costs are analyzed by age, sex, race/ethnicity, comorbid condition, and health service category. Data sources include national surveys (2015-2020 or most recent available), Medicare standard analytic files (2020), and administrative claims data from 2018 to 2021 for a large commercially insured population in the U.S.

RESULTS

The total estimated cost of diagnosed diabetes in the U.S. in 2022 is $412.9 billion, including $306.6 billion in direct medical costs and $106.3 billion in indirect costs attributable to diabetes. For cost categories analyzed, care for people diagnosed with diabetes accounts for 1 in 4 health care dollars in the U.S., 61% of which are attributable to diabetes. On average people with diabetes incur annual medical expenditures of $19,736, of which approximately $12,022 is attributable to diabetes. People diagnosed with diabetes, on average, have medical expenditures 2.6 times higher than what would be expected without diabetes. Glucose-lowering medications and diabetes supplies account for ∼17% of the total direct medical costs attributable to diabetes. Major contributors to indirect costs are reduced employment due to disability ($28.3 billion), presenteeism ($35.8 billion), and lost productivity due to 338,526 premature deaths ($32.4 billion).

CONCLUSIONS

The inflation-adjusted direct medical costs of diabetes are estimated to rise 7% from 2017 and 35% from 2012 calculations (stated in 2022 dollars). Following decades of steadily increasing prevalence of diabetes, the overall estimated prevalence in 2022 remains relatively stable in comparison to 2017. However, the absolute number of people with diabetes has grown and contributes to increased health care expenditures, particularly per capita spending on inpatient hospital stays and prescription medications. The enormous economic toll of diabetes continues to burden society through direct medical and indirect costs.

Role of prices in driving the variation in spending across medical groups

OBJECTIVE

To understand the relative role of prices versus utilization in the variation in total spending per patient across medical groups.

DATA SOURCES

We conducted a cross-sectional analysis of medical claims for commercially insured adults from a large national insurer in 2018.

STUDY DESIGN

After assigning patients to a medical group based on primary care visits in 2018, we calculated total medical spending for each patient in that year. Total spending included care provided by clinicians within the medical group and care provided by other providers, including hospitals. It did not include drug spending. We estimated the case mix adjusted spending per patient for each medical group. Within each market, we categorized medical groups into quartiles based on the group's spending per patient. To decompose spending variation into price versus utilization, we compared spending differences between highest and lowest quartile medical groups under two scenarios: (1) using actual prices (2) using a standardized price (same price used for a given service across the nation).

PRINCIPAL FINDINGS

In total, 3,921,736 patients were assigned to 7284 medical groups. Per-patient spending in the highest quartile of spending medical groups was $1813 higher than per-patient spending in the lowest spending quartile of medical groups (50% higher relative spending). This overall difference was primarily driven by differences in inpatient care, imaging, and specialty care. In the scenario where we used standardized prices, the difference in spending between medical groups in the top and bottom quartiles decreased to $1425, implying that 79% of the $1813 difference in spending between the top and bottom quartile groups is explained by utilization and the remaining 21% by prices. The likely explanation for the modest impact of prices is that patients cared for by a given medical group receive care across a wide range of providers.

CONCLUSIONS

Prices explained a modest fraction of the differences in spending between medical groups.

Treatment modification after initiating second-line medication for type 2 diabetes

OBJECTIVES

To describe changes in antidiabetic medication (ADM) use and characteristics associated with changes in ADM use after initiation of noninsulin second-line therapy.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study analyzed private health plan claims for adults with type 2 diabetes who initiated 1 of 5 index ADM classes: sulfonylureas, dipeptidyl peptidase 4 inhibitors (DPP4is), sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or thiazolidinediones. Analyses evaluated 3 treatment modification outcomes-discontinuation, switching, and intensification-over 12-month follow-up.

RESULTS

Of 82,624 included adults, nearly two-thirds (63.6%) experienced any treatment modification. Discontinuation was the most common modification (38.6%), especially among patients prescribed GLP-1 RAs (50.3%). Switching occurred in 5.2% of patients and intensification in 19.8%. In adjusted analysis, compared with patients prescribed sulfonylureas, discontinuation risk was 7% higher (HR, 1.07; 95% CI, 1.04-1.10) among patients prescribed DPP4is and 28% higher (HR, 1.28; 95% CI, 1.23-1.33) among patients prescribed GLP-1 RAs. Compared with sulfonylureas, all other index ADM classes had higher risks of switching and lower risks of intensification. Younger age group and female sex were both associated with higher risks of all modifications. Compared with index ADM prescription by a family medicine or internal medicine physician, index prescription by an endocrinologist was associated with both lower discontinuation risk and higher intensification risk.

CONCLUSIONS

Most patients experienced a treatment modification within 1 year. Results highlight the need for new prescribing approaches and patient supports that can maximize medication adherence and reduce health system waste.

Costs for commercially insured adults prescribed second-line diabetes medications

OBJECTIVES

To examine differences in health care costs associated with choice of second-line antidiabetes medication (ADM) for commercially insured adults with type 2 diabetes.

STUDY DESIGN

Retrospective cohort study with multiple pretests and posttests.

METHODS

Included patients initiated second-line ADM therapy between 2011 and 2015, with variable follow-up through 2017. The 6 index medication classes were sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), basal insulin, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, and thiazolidinediones (TZDs). Multivariable regression models compared between-class changes in adjusted quarterly costs after second-line ADM initiation.

RESULTS

The study cohort included 34,963 adults. Most were prescribed a sulfonylurea (46.0%) or DPP-4 inhibitor (30.4%). Adjusted quarterly index medication costs were significantly higher for all patients receiving nonsulfonylurea medications, ranging from $108 (95% CI, $99-$118) for TZDs to $742 (95% CI, $720-$765) for GLP-1 RAs. Changes in quarterly total health care costs were significantly higher for all nonsulfonylurea classes. Conversely, changes in quarterly nonpharmacy medical costs were significantly lower for patients receiving DPP-4 inhibitors (-$67; 95% CI, -$92 to -$43), GLP-1 RAs (-$43; 95% CI, -$85 to -$1), and SGLT-2 inhibitors (-$46; 95% CI, -$87 to -$6); changes in all other quarterly costs besides the index medication were significantly lower for patients receiving DPP-4 inhibitors (-$60; 95% CI, -$94 to -$26) and SGLT-2 inhibitors (-$113; 95% CI, -$169 to -$57).

CONCLUSIONS

The higher cost of nonsulfonylurea medications was the main driver of relative increases in total costs. Relative decreases in nonpharmacy medical costs among patients receiving newer ADM classes reflect these medications' potential value.

Variation in spending associated with primary care practices

OBJECTIVES

To measure variation in spending and inpatient prices associated with the primary care physician (PCP) practice to which patients are attributed.

STUDY DESIGN

Cross-sectional analysis of claims data.

METHODS

We used random effect models to estimate case mix-adjusted spending across large PCP practices within 3-digit zip codes. We compare inpatient prices for patients in high-spending practices with those in low-spending practices.

RESULTS

The physician practice to which a patient was attributed is associated with significant differences in spending after controlling for patient comorbidities and geography. Patients attributed to practices in the top quartile of total medical expenses have about 30% higher spending than patients attributed to practices in the bottom quartile of adjusted spending in their 3-digit zip code. If patients attributed to practices in the top 2 quartiles had spending equivalent to those in the median practice, total spending would drop by 8%. Price variation accounts for a meaningful amount of the variation, with inpatient prices 17% higher in top-quartile vs bottom-quartile practices. We cannot disaggregate the large variation in utilization into practice patterns and unmeasured case mix (including unmeasured differences in patients' socioeconomic status) vs random health shocks, but correlation in spending patterns across years suggests that some persistent differences in spending patterns exist.

CONCLUSIONS

There are meaningful opportunities to reduce spending by changing patient PCP selection, encouraging patients to use lower-priced specialists and hospitals, and eliminating wasteful care. Attention must be paid to the best ways to reap these savings.

Assessment of COPD-related outcomes in patients initiating a once daily or twice daily ICS/LABA

BACKGROUND

Use of inhaled corticosteroids and long acting beta agonist (ICS/LABA) combination therapy has been shown to decrease the frequency of exacerbations in patients with chronic obstructive pulmonary disease (COPD). In this population, adherence to treatment is associated with better disease control and lower risk of COPD-related exacerbations in the future. Using a treatment with a more convenient regimen or easier-to-use device could improve patient adherence, improve disease control, decrease the frequency of exacerbations and minimize the COPD-related economic burden. Real-world information on the impact on healthcare costs and exacerbation risk of initiating once-daily or twice daily ICS/LABA in this patient population is limited. The objective of this study was to assess COPD-related healthcare costs, adherence, and exacerbations in COPD patients initiating treatment with fluticasone furoate/vilanterol 100/25 (FF/VI) or budesonide/formoterol 160/4.5 (BUD/F) using a large managed care database in the US.

METHODS

This was a retrospective cohort study among COPD patients initiating FF/VI or BUD/F between January 01, 2014 and June 30, 2016. The analysis used the Optum Research Database (ORD) which contains patients from commercial and Medicare Advantage Prescription Drug (MAPD) plans. The study included new initiators of ICS/LABA as either FF/VI or BUD/F for COPD, ≥40 years of age at index, ≥15 months of continuous enrollment (12 months pre-index and ≥3 months post-index). New users of FF/VI or BUD/F were matched on baseline characteristics using propensity score matching (PSM) methods. Multivariate models including ordinary least squares regression, Lin's regression, logistic regression, and Cox proportional hazards were used to assess differences between the cohorts on outcomes of interest.

RESULTS

A total of 18,652 subjects met all inclusion and exclusion criteria with 5044 initiating FF/VI and 13,608 initiating BUD/F. Of these, 9026 subjects were matched at a 1:1 ratio (4513 patients in each cohort) and were included in the final analyses. Proportion of days covered (PDC), was significantly better for FF/VI (mean PDC [SD]: FF/VI: 0.46 [0.31], BUD/F: 0.41 [0.29], p < 0.001) while FF/VI was associated with a 9% lower risk (adj. hazard ratio (HR): 0.91, 95% CI: 0.85-0.96) of having a moderate or severe COPD-related exacerbation. However, COPD-related healthcare costs were not significantly different, $11,521 vs $10,986, p = 0.41 for FF/VI and BUD/F, respectively.

CONCLUSIONS

Patients initiating once-daily FF/VI were more adherent, and were associated with a lower risk of subsequent COPD-related exacerbations compared with twice-daily BUD/F, however this was not associated with a significant difference in costs. (GSK Study HO1617333/206702).

Comparison of healthcare resource utilization and costs in patients with type 2 diabetes initiating dapagliflozin versus sitagliptin

AIMS

To compare healthcare costs and utilization in patients with type 2 diabetes (T2D) who initiated dapagliflozin (DAPA) with costs and utilization in those who initiated sitagliptin (SITA) in a real-world setting.

MATERIALS AND METHODS

This was a retrospective study of health plan enrollees in two US commercial claims databases or Medicare Part D. The study population comprised adult patients with T2D who initiated DAPA or SITA between January 1, 2014 and April 30, 2015. DAPA and SITA initiators were propensity-score-matched, and healthcare utilization and costs during the 1-year follow-up period were compared. Analyses were conducted separately for patients with evidence of oral antidiabetic drug (OAD) monotherapy use at baseline.

RESULTS

A total of 2722 patients were included in each matched cohort. Follow-up unadjusted all-cause costs ($16 065 and $17 281; P = 0.135) and diabetes-related costs ($9697 and $9354; P = 0.539) were similar in the DAPA and SITA cohorts. Higher office and outpatient visit costs in the SITA group were offset by higher pharmacy costs in the DAPA group. In the subgroup of 1804 patients with OAD monotherapy use at baseline, patients in the SITA group had higher total all-cause costs compared with those in the DAPA group ($14 884 vs. $12 353; P = 0.026).

CONCLUSION

Patients who initiated DAPA or SITA had similar all-cause and diabetes-related healthcare costs over 1 year of follow-up. In the subgroup of patients treated with OAD monotherapy at baseline (84% metformin monotherapy), those who initiated DAPA as add-on therapy had lower costs than patients who added SITA.

Injury mechanism, epidemiology, and Hospital trends of scapula fractures: A 10-year retrospective study of the National Trauma Data Bank

BACKGROUND

This 10 year retrospective study of the NTDB is the first to describe trends in scapula fracture diagnosis frequency, epidemiology, injury mechanisms and the type of hospital where the condition is treated.

METHODS

Demographics, ISS scores, hospital data, mechanism of injury, complications, and hospital length of stay were recorded for patients with diagnosed scapula fractures (ICD-9, 811.0) recorded in the NTDB, v7.2 (2002-2012). Mean and standard deviation for continuous variables and proportions for binary variables are calculated.

RESULTS

The prevalence of scapula fractures in all patients submitted to the NTDB (2002-2012) was 1.74%. Between 2006-2007, the reported incidence doubled from 1% to 2.2%. There was a predominance of injury to white males (75% and 78% respectively). Forty-one percent were treated at a Level 1 trauma center and had a mean ISS of 20.1 (SD-11.8). Scapula fracture rates declined in patients 0-19 years and increased in the 60-79 and 80+ age groups. The increasing incidence of the aged population is also reflected in the increase of falls as the mechanism of injury in the elderly population.

CONCLUSION

This study is the first to describe a full decade of scapula fracture epidemiology on a national scale. The number of diagnosed scapula fractures increased substantially in the NTDB between 2002-2012. Scapula fractures diagnosed in the geriatric demographic and fractures resulting from falls are both on the rise, whereas the reported incidence is decreasing in the younger demographic. Additionally, fractures as a result of motor vehicle accidents also decreased precipitously during the reported decade.

Potentially Preventable Hospital and Emergency Department Events: Lessons from a Large Innovation Project

INTRODUCTION

There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative.

METHODS

Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events.

RESULTS

Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events.

CONCLUSION

Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

Burden of Illness Associated with Tenosynovial Giant Cell Tumors

PURPOSE

Little is known about the burden of illness in patients with tenosynovial giant cell tumors (TGCT), which are rare, typically benign, lesions of the synovial tissue including giant cell tumor of the tendon sheath (GCT-TS) and pigmented villonodular synovitis (PVNS). The objective of this study was to describe health care resource use and costs for patients with GCT-TS and PVNS, which are rare and typically benign TGCT.

METHODS

A retrospective cohort study design was used to analyze administrative claims for adult commercial and Medicare Advantage health plan enrollees with evidence of GCT-TS and PVNS from January 1, 2006 through March 31, 2015. Participants were continuously enrolled for 12 months before (pre-index period) and 12 months after (post-index period) the date of the first tenosynovial giant cell tumor (TGCT) claim (index date). Preindex and postindex measures were compared using the McNemar test and Wilcoxon signed-rank test. Results were stratified by TGCT type.

FINDINGS

The study identified 4664 patients with TGCT, 284 with GCT-TS, and 4380 with PVNS. Mean age (GCT-TS group: 50 years; PVNS group: 51 years) and sex distributions (GCT-TS group: 60.2% female; PVNS group: 59.5% female) were similar for each group. Most patients with GCT-TS (78.2%) had at least one postindex surgery, compared with 38.7% of patients with PVNS. Mean total health care costs increased from $8943 in the preindex period to $14,880 in the postindex period (P < 0.001) for GCT-TS and from $13,221 in the preindex period to $17,728 in the postindex period (P < 0.001) for PVNS. Preindex to postindex ambulatory costs increased nearly 120% for patients with GCT-TS ($4340 to $9570, P < 0.001) and 50% for patients with PVNS ($6782 to $10,278, P < 0.001), and physical therapy use increased significantly during the same period (GCT-TS: 18% to 40%, P < 0.001; PVNS: 38% to 60%, P < 0.001).

IMPLICATIONS

Costs increased substantially 1 year after the first TGCT claim, with more than half the costs covering ambulatory care. These results suggest a high health care burden once TGCT is identified.

Predicting Hypertension Among Children With Incident Elevated Blood Pressure

OBJECTIVE

To develop a model to predict hypertension risk among children with incident elevated blood pressure (BP); to test the external validity of the model.

METHODS

A retrospective cohort study was conducted in 3 organizations: Kaiser Permanente Colorado was the model derivation site; HealthPartners of Minnesota and Kaiser Permanente Northern California served as external validation sites. During study years 2006 through 2012, all children aged 3 through 17 years with incident elevated BP in an outpatient setting were identified. The predictor variables were demographic and clinical characteristics collected during routine care. Cox proportional hazards regression was used to predict subsequent hypertension, and diagnostic statistics were used to assess model performance.

RESULTS

Among 5598 subjects at the derivation site with incident elevated BP, 160 (2.9%) developed hypertension during the study period. Eight characteristics were used to predict hypertension risk: age, sex, race, BP preceding incident elevated BP, body mass index percentile, systolic BP percentile, diastolic BP percentile, and clinical setting of the incident elevated BP. At the derivation site, the model discriminated well between those at higher versus lower risk of hypertension (c-statistic = 0.77). At external validation sites, the observed risk of hypertension was higher than the predicted risk, and the model showed poor discrimination (c-statistic ranged from 0.64 to 0.67).

CONCLUSIONS

Among children with incident elevated BP, a risk model demonstrated good internal validity with respect to predicting subsequent hypertension. However, the risk model did not perform well at 2 external validation sites, which might limit transportability to other settings.

The financial impact of team-based care on primary care

OBJECTIVES

Although team-based care can improve coronary heart disease (CHD) risk factors and is considered cost-effective from a healthcare system perspective, little is known about the financial impact of team-based primary care for secondary prevention of CHD. The purpose of this study was to define the impact of team-based care for CHD on utilization, costs, and revenue of a private primary care practice.

STUDY DESIGN

Interrupted time series analysis.

METHODS

Between March 1, 2010, and March 31, 2013, we assisted a private medical practice, comprising 5 primary care clinic sites, to organize and deliver team-based care for patients with CHD. We used billing records and the registered nurse care manager's diary to calculate the cost of team-based care, differences in the average number of visits per patient, and revenue per patient before and after the implementation of team-based care.

RESULTS

The net cost of team-based primary care was $291 per patient over the 1-year period of observation.

CONCLUSIONS

The findings from this study are consistent with other economic analyses of team-based care and suggest that payment for care must be restructured if patients are expected to enjoy the benefits of team-based primary care.

Change in Weight Status and Development of Hypertension

OBJECTIVE

To examine the association of BMI percentile and change in BMI percentile to change in blood pressure (BP) percentile and development of hypertension (HTN).

METHODS

This retrospective cohort included 101 606 subjects age 3 to 17 years from 3 health systems across the United States. Height, weight, and BPs were extracted from electronic health records, and BMI and BP percentiles were computed with the appropriate age, gender, and height charts. Mixed linear regression estimated change in BP percentile, and proportional hazards regression was used to estimate risk of incident HTN associated with BMI percentile and change in BMI percentile.

RESULTS

The largest increases in BP percentile were observed among children and adolescents who became obese or maintained obesity. Over a median 3.1 years of follow-up, 0.3% of subjects developed HTN. Obese children ages 3 to 11 had twofold increased risk of developing HTN compared with healthy weight children. Obese children and adolescents had a twofold increased risk of developing HTN, and severely obese children had a more than fourfold increased risk. Compared with those who maintained a healthy weight, children and adolescents who became obese or maintained obesity had a more than threefold increased risk of incident HTN.

CONCLUSIONS

We observed a strong, statistically significant association between increasing BMI percentile and increases in BP percentile, with risk of incident HTN associated primarily with obesity. The adverse impact of weight gain and obesity in this cohort over a short period underscores the early need for effective strategies for prevention of overweight and obesity.

Using Principles of Complex Adaptive Systems to Implement Secondary Prevention of Coronary Heart Disease in Primary Care

CONTEXT

Primary care practice.

OBJECTIVE

To test whether the principles of complex adaptive systems are applicable to implementation of team-based primary care.

DESIGN

We used complex adaptive system principles to implement team-based care in a private, five-clinic primary care practice. We compared randomly selected samples of patients with coronary heart disease (CHD) and diabetes before system implementation (March 1, 2009, to February 28, 2010) and after system implementation (December 1, 2011, to March 31, 2013).

MAIN OUTCOME MEASURES

Rates of patients meeting the composite goals for CHD (blood pressure < 140/90 mmHg, low-density lipoprotein cholesterol level < 100 mg/dL, tobacco-free, and using aspirin unless contraindicated) and diabetes (CHD goal plus hemoglobin A1c concentration < 8%) before and after the intervention. We also measured provider and patient satisfaction with preventive services.

RESULTS

The proportion of patients with CHD who met the composite goal increased from 40.3% to 59.9% (p < 0.0001) because documented aspirin use increased (65.2%-97.5%, p < 0.0001) and attainment of the cholesterol goal increased (77.0%-83.9%, p = 0.0041). The proportion of diabetic patients meeting the composite goal rose from 24.5% to 45.4% (p < 0.0001) because aspirin use increased (58.6%-97.6%, p < 0.0001). Increased percentages of patients meeting the CHD and diabetes composite goals were not significantly different (p = 0.2319). Provider satisfaction with preventive services delivery increased significantly (p = 0.0017). Patient satisfaction improved but not significantly.

CONCLUSION

Principles of complex adaptive systems can be used to implement team-based care systems for patients with CHD and possibly diabetic patients.

Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature

Blood pressure (BP) is measured in percentiles that are adjusted for sex, age, and height percentile in children and adolescents. Standard tables for the conversion of BP percentiles do not present exact BP percentile cutoffs for extremes in stature, either short (<5th percentile) or tall (>95th percentile). An algorithm can be used to calculate exact BP percentiles across a range of height z scores. We compared values from standard BP tables with exact calculations of BP percentiles to see which were better at identifying hypertension in more than 5,000 children with either short or tall stature. Study subjects were 3-17-year-old patients within HealthPartners Medical Group, an integrated health care delivery system in Minnesota, at any time between 2007 and 2012. Approximately half of the subjects who met the criteria for hypertension using exact calculation would be misclassified as normal using available thresholds in the published BP tables instead of the recommended algorithm, which was not included in the tables.

A qualitative study of processes used to implement evidence-based care in a primary care practice

BACKGROUND

Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients.

OBJECTIVE

To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients.

METHODS

We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice.

RESULTS

Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys.

CONCLUSIONS

Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.

Comparing US paediatric and adult weight classification at the transition from late teenage to young adulthood

BACKGROUND

Although paediatric growth charts are recommended for weight assessment prior to age 20, many teenagers transition earlier to adult care where absolute body mass index (BMI) is used. This study examines concordance of weight classification in older teenagers using paediatric percentiles and adult thresholds.

METHODS

BMI from 23 640 US teens ages 18-19 years were classified using paediatric BMI percentile criteria for underweight (< 5th), normal (5th to < 85th), overweight (85th to < 95th), obesity (≥ 95th) and severe obesity (≥ 120% × 95th percentile) and adult BMI (kg m(-2) ) criteria for underweight (< 18.5), normal (18.5-24.9), overweight (25-29.9) and obesity: class I (30-34.9), class II (35-39.9) and class III (≥ 40). Concordance was examined using the kappa (κ) statistic. Blood pressure (BP) from the same visit was classified hypertensive for BP ≥ 140/90.

RESULTS

The majority of visits (72.8%) occurred in adult primary care. Using paediatric/adult criteria, 3.4%/5.2% were underweight, 66.6%/58.8% normal weight, 15.7%/21.7% overweight, 14.3%/14.3% obese and 4.9%/6.0% severely/class II-III obese, respectively. Paediatric and adult classification for underweight, normal, overweight and obesity were concordant for 90.3% (weighted κ 0.87 [95% confidence interval, 0.87-0.88]). For severe obesity, BMI ≥ 120% × 95th percentile showed high agreement with BMI ≥ 35 kg m(-2) (κ 0.89 [0.88-0.91]). Normal-weight males and moderately obese females by paediatric BMI percentile criteria who were discordantly classified into higher adult weight strata had a greater proportion with hypertensive BP compared with concordantly classified counterparts.

CONCLUSIONS

Strong agreement exists between US paediatric BMI percentile and adult BMI classification for older teenagers. Adult BMI classification may optimize BMI tracking and risk stratification during transition from paediatric to adult care.

Factors Associated With Adherence to Blood Pressure Measurement Recommendations at Pediatric Primary Care Visits, Minnesota and Colorado, 2007-2010

Introduction

Elevated blood pressure in childhood may predict increased cardiovascular risk in young adulthood. The Task Force on the Diagnosis, Evaluation and Treatment of High Blood pressure in Children and Adolescents recommends that blood pressure be measured in children aged 3 years or older at all health care visits. Guidelines from both Bright Futures and the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommend annual blood pressure screening. Adherence to these guidelines is unknown.

Methods

We conducted a cross-sectional study to assess compliance with blood pressure screening recommendations in 2 integrated health care delivery systems. We analyzed electronic health records of 103,693 subjects aged 3 to 17 years. Probability of blood pressure measurement documented in the electronic health record was modeled as a function of visit type (well-child vs nonwell-child); patient age, sex, race/ethnicity, and body mass index; health care use; insurance type; and type of office practice or clinic department (family practice or pediatrics).

Results

Blood pressure was measured at 95% of well-child visits and 69% of nonwell-child outpatient visits. After adjusting for potential confounders, the percentage of nonwell-child visits with measurements increased linearly with patient age (P < .001). Overall, the proportion of children with annual blood pressure measurements was high and increased with age. Family practice clinics were more likely to adhere to blood pressure measurement guidelines compared with pediatric clinics (P < .001).

Conclusion

These results show good compliance with recommendations for routine blood pressure measurement in children and adolescents. Findings can inform the development of EHR-based clinical decision support tools to augment blood pressure screening and recognition of prehypertension and hypertension in pediatric patients.

Initiation of oral contraceptives and changes in blood pressure and body mass index in healthy adolescents

OBJECTIVES

To describe changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI) associated with initiation and continued use of combined oral contraceptives (COCs) in healthy adolescents.

STUDY DESIGN

This observational, matched cohort study was conducted in 2 large health systems. Utilizing claims and electronic medical records, we identified adolescents 14-17.9 years of age initiating medium-dose COCs (containing 30 or 35 (μg of ethinyl estradiol or equivalent and a progestin) between July 1, 2007 and December 31, 2009 with a baseline and at least 1 follow-up blood pressure (BP) and BMI. COC-users were matched 1:2 by age, race/ethnicity, and site to controls (COC-nonusers). All BPs and BMIs recorded during outpatient visits starting 1 month prior to COC initiation (index date for controls), through December 31, 2010 were collected. Mixed model linear regression with random intercepts and slopes were then used to estimate changes in SBP, DBP, and BMI over time.

RESULTS

The 510 adolescent COC-users and 912 controls did not differ significantly by age, race/ethnicity, insurance, and baseline SBP, DBP, or BMI. After adjusting for baseline values, over a median of 18 months follow-up, COC-users had an decrease in SBP of 0.07 mm Hg/mo, and controls had an increase of 0.02 mm Hg/mo (P = .65). Similarly, DBP decreased by 0.007 mm Hg/mo in COC-users vs 0.006 mm Hg/mo in controls (P = .99). BMI increased by 0.04 (kg/m(2))/mo in COC-users vs 0.025 (kg/m(2))/mo in controls (P = .09).

CONCLUSIONS

These data should provide reassurance to patients and providers regarding the lack of significant associations between COC-use and BMI or BP changes in adolescents.

Lipid screening in children and adolescents in community practice: 2007 to 2010

BACKGROUND

Integrated guidelines on cardiovascular health and risk reduction in children issued in 2011 newly recommended universal screening for dyslipidemia in children at 9 to 11 years and 17 to 21 years.

METHODS AND RESULTS

We determined the frequency and results of lipid testing in 301 080 children and adolescents aged 3 to 19 enrolled in 3 large US health systems in 2007 to 2010 before the 2011 guidelines were issued. Overall, 9.8% of the study population was tested for lipids. The proportion tested varied by body mass index percentile (5.9% of normal weight, 10.8% of overweight, and 26.9% of obese children) and age (8.9% of 9- to 11-year olds and 24.3% of 17- to 19-year olds). In normal weight individuals, 2.8% of 9- to 11-year olds and 22.0% of 17- to 19-year olds were tested. In multivariable models, age and body mass index category remained strongly associated with lipid testing. Sex, race, ethnicity, and blood pressure were weakly associated with testing. Abnormal lipid levels were found in 8.6% for total cholesterol, 22.5% for high-density lipoprotein-cholesterol, 12.0% for non-high-density lipoprotein-cholesterol, 8.0% for low-density lipoprotein-cholesterol, and 21% for triglycerides (age, 10-19 years). There was a strong and graded association of abnormal lipid levels with body mass index, particularly for high-density lipoprotein-cholesterol and triglycerides (2- to 6-fold higher odds ratio in obese when compared with that in normal weight children).

CONCLUSIONS

Lipid screening was uncommon in 9- to 11-year olds and was performed in a minority of 17- to 19-year olds during 2007 to 2010. These data serve as a benchmark for assessing change in practice patterns after the new recommendations for pediatric lipid screening and management.

Impact of hypertension on healthcare costs among children

OBJECTIVES

Despite the significant prevalence of elevated blood pressure (BP) and body mass index (BMI) in children, few studies have assessed their combined impact on healthcare costs. This study estimates healthcare costs related to BP and BMI in children and adolescents.

STUDY DESIGN

Prospective dynamic cohort study of 71,617 children aged 3 to 17 years with 208,800 child years of enrollment in integrated health systems in Colorado or Minnesota between January 1, 2007, and December 31, 2011.

METHODS

Generalized linear models were used to calculate standardized annual estimates of total, inpatient, outpatient, and pharmacy costs, outpatient utilization, and receipt of diagnostic and evaluation tests associated with BP status and BMI status. Results: Total annual costs were significantly lower in children with normal BP ($736, SE = $15) and prehypertension ($945, SE = $10) than children with hypertension ($1972, SE = $74) (P <.001, each comparison), adjusting for BMI. Total annual cost for children below the 85th percentile of BMI ($822, SE = $8) was significantly lower than for children between the 85th and 95th percentiles ($954, SE = $45) and for children at or above the 95th percentile ($937, SE = $13) (P <.001, each), adjusting for HT.

CONCLUSIONS

This study shows strong associations of prehypertension and hypertension, independent of BMI, with healthcare costs in children. Although BMI status was also statistically significantly associated with costs, the major influence on cost in this large cohort of children and adolescents was BP status. Costs related to elevated BMI may be systematically overestimated in studies that do not adjust for BP status.

Influenza and pertussis vaccination coverage among privately insured women of reproductive age

An increasing number of vaccines are now designated as maternal vaccines, recommended prior to, during, or immediately following pregnancy. The influenza and pertussis (Tdap) vaccines have the potential to improve the health of women and their offspring. Among privately insured women of reproductive age, goals of this study were to describe influenza and Tdap vaccination coverage and to explore variation in coverage by age and race/ethnicity. This cross-sectional, observational study included women 18-44 years of age with continuous enrollment from 1 January 2007-31 March 2011 in a single, Midwestern health insurance plan and at least one visit to a plan affiliated practice. Data on vaccine coverage came from insurance claims, supplemented by electronic medical record data. Primary outcomes were: receipt of Tdap ever, receipt of Tdap or Tetanus vaccination (Td) in the past 10 years, and receipt of influenza vaccination during the 2010-2011 influenza season. Coverage was compared by race/ethnicity. Among 12,657 women with continuous private insurance, 45.5 % had received Tdap ever, 82.5 % had received Td or Tdap in the past 10 years, and 39.8 % received the influenza vaccine in the 2010-2011 season. Marked disparities in influenza vaccination coverage by race/ethnicity were observed, only 30.0 % of African American women received influenza vaccine compared to 40.7 % of white, non-Hispanic women (p < .0001). Among insured women of reproductive age, there is a need for interventions to increase Tdap and influenza vaccination uptake. Further research is needed to understand and address disparities in influenza vaccination coverage in this population.

Prevalence of obesity and extreme obesity in children aged 3-5 years

BACKGROUND

Early childhood adiposity may have significant later health effects. This study examines the prevalence and recognition of obesity and severe obesity among preschool-aged children.

METHODS

The electronic medical record was used to examine body mass index (BMI), height, sex and race/ethnicity in 42,559 children aged 3-5 years between 2007 and 2010. Normal or underweight (BMI < 85th percentile); overweight (BMI 85th-94th percentile); obesity (BMI ≥ 95th percentile); and severe obesity (BMI ≥ 1.2 × 95th percentile) were classified using the 2000 Centers for Disease Control and Prevention growth charts. Provider recognition of elevated BMI was examined for obese children aged 5 years.

RESULTS

Among 42,559 children, 12.4% of boys and 10.0% of girls had BMI ≥ 95th percentile. The prevalence was highest among Hispanics (18.2% boys, 15.2% girls), followed by blacks (12.4% boys, 12.7% girls). A positive trend existed between increasing BMI category and median height percentile, with obesity rates highest in the highest height quintile. The prevalence of severe obesity was 1.6% overall and somewhat higher for boys compared with girls (1.9 vs. 1.4%, P < 0.01). By race/ethnicity, the highest prevalence of severe obesity was seen in Hispanic boys (3.3%). Among those aged 5 years, 77.9% of obese children had provider diagnosis of obesity or elevated BMI, increasing to 89.0% for the subset with severe obesity.

CONCLUSIONS

Obesity and severe obesity are evident as early as age 3-5 years, with race/ethnic trends similar to older children. This study underscores the need for continued recognition and contextualization of early childhood obesity in order to develop effective strategies for early weight management.

Severe obesity in children: prevalence, persistence and relation to hypertension

Background

Newer approaches for classifying gradations of pediatric obesity by level of body mass index (BMI) percentage above the 95^th percentile have recently been recommended in the management and tracking of obese children. Examining the prevalence and persistence of severe obesity using such methods along with the associations with other cardiovascular risk factors such as hypertension is important for characterizing the clinical significance of severe obesity classification methods.

Methods

This retrospective study was conducted in an integrated healthcare delivery system to characterize obesity and obesity severity in children and adolescents by level of body mass index (BMI) percentage above the 95^th BMI percentile, to examine tracking of obesity status over 2–3 years, and to examine associations with blood pressure. Moderate obesity was defined by BMI 100-119% of the 95^th percentile and severe obesity by BMI ≥120% × 95^th percentile. Hypertension was defined by 3 consecutive blood pressures ≥95^th percentile (for age, sex and height) on separate days and was examined in association with obesity severity.

Results

Among 117,618 children aged 6–17 years with measured blood pressure and BMI at a well-child visit during 2007–2010, the prevalence of obesity was 17.9% overall and was highest among Hispanics (28.9%) and blacks (20.5%) for boys, and blacks (23.3%) and Hispanics (21.5%) for girls. Severe obesity prevalence was 5.6% overall and was highest in 12–17 year old Hispanic boys (10.6%) and black girls (9.5%). Subsequent BMI obtained 2–3 years later also demonstrated strong tracking of severe obesity. Stratification of BMI by percentage above the 95^th BMI percentile was associated with a graded increase in the risk of hypertension, with severe obesity contributing to a 2.7-fold greater odds of hypertension compared to moderate obesity.

Conclusion

Severe obesity was found in 5.6% of this community-based pediatric population, varied by gender and race/ethnicity (highest among Hispanics and blacks) and showed strong evidence for persistence over several years. Increasing gradation of obesity was associated with higher risk for hypertension, with a nearly three-fold increased risk when comparing severe to moderate obesity, underscoring the heightened health risk associated with severe obesity in children and adolescents.

Safety of the yellow Fever vaccine: a retrospective study

BACKGROUND

Yellow fever (YF) vaccine is considered safe; however, severe illness and death following vaccination have been reported.

METHODS

Vaccine Safety Datalink (VSD) and US Department of Defense (DoD) data were used to identify adverse reactions following YF vaccination. Within the VSD, YF-vaccine-exposed subjects were compared to age-, site-, and gender-matched unexposed subjects. YF-vaccine-exposed DoD subjects were studied using a risk-interval design. For both cohorts, ICD-9 codes were analyzed for allergic and local reactions, mild systemic reactions, and possible visceral and neurologic adverse events (AEs).

RESULTS

The VSD cohort received 47,159 doses from 1991 through 2006. The DoD cohort received 1.12 million doses from 1999 through 2007. Most subjects received other vaccines simultaneously. In the VSD cohort, rates of allergic, local, and mild systemic reactions were not statistically different between YF-vaccine-exposed and -unexposed subjects. In the DoD, there was an increased risk for outpatient allergic events in the period following vaccination with YF and other vaccines rate ratios [RR 3.85, 95% confidence interval (CI) 3.35-4.41] but with no increased risk for inpatient allergic reactions. In both cohorts, inpatient ICD-9 codes for visceral events were significantly less common following vaccination; inpatient codes for neurologic events were less common in the VSD YF-vaccine-exposed adult cohort, but did not differ between exposed and unexposed periods in the DoD. In the DoD, one fatal case of YF-vaccine-associated viscerotropic disease (YF-vaccine-AVD) was detected. The estimated death rate was 0.89 for 1,000,000 YF vaccine doses (95% CI 0.12-6.31/1,000,000 doses). No YF vaccine-associated deaths occurred in the VSD.

CONCLUSIONS

In these closed cohorts we did not detect increased risk for visceral or neurologic events following YF vaccination. The death rate following YF vaccine was consistent with previous reports. These data support current recommendations for use of YF vaccine in young healthy individuals. These data are inadequate to judge safety of YF vaccines in elderly patients.

Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors?

Immunizations are crucial to the prevention of disease, thus, having an accurate measure of vaccination status for a population is an important guide in targeting prevention efforts. In order to comprehensively assess the validity of self-reported adult vaccination status for the eight most common adult vaccines we conducted a survey of vaccination receipt and compared it to the electronic medical record (EMR), which was used as the criterion standard, in a population of community-dwelling patients in a large healthcare system. In addition, we assessed whether validity varied by demographic factors. The vaccines included: pneumococcal (PPSV), influenza (Flu), tetanus diphtheria (Td), tetanus diphtheria pertussis (Tdap), Human Papilloma Virus (HPV), hepatitis A (HepA), hepatitis B (HepB) and herpes zoster (shingles). Telephone surveys were conducted with 11,760 individuals, ≥18, half with documented receipt of vaccination and half without. We measured sensitivity, specificity, positive and negative predictive value, net bias and over- and under-reporting of vaccination. Variation was found across vaccines, however, sensitivity and specificity did not vary substantially by either age or race/ethnicity. Sensitivity ranged between 63% for HepA to over 90% (tetanus, HPV, shingles and Flu). Hispanics were 2.7 times more likely to claim receipt of vaccination compared to whites. For PPSV and Flu those 65+ had low specificity compared to patients of younger ages while those in the youngest age group had lowest specificity for HepA and HepB. In addition to racial/ethnic differences, over-reporting was more frequent in those retired and those with household income less than $75,000. Accurate information for vaccination surveillance is important to estimate progress toward vaccination coverage goals and ensure appropriate policy decisions and allocation of resources for public health. It was clear from our findings that EMR and self-report do not always agree. Finding approaches to improve both EMR data capture and patient awareness would be beneficial.

Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors?

Immunizations are crucial to the prevention of disease, thus, having an accurate measure of vaccination status for a population is an important guide in targeting prevention efforts. In order to comprehensively assess the validity of self-reported adult vaccination status for the eight most common adult vaccines we conducted a survey of vaccination receipt and compared it to the electronic medical record (EMR), which was used as the criterion standard, in a population of community-dwelling patients in a large healthcare system. In addition, we assessed whether validity varied by demographic factors. The vaccines included: pneumococcal (PPSV), influenza (Flu), tetanus diphtheria (Td), tetanus diphtheria pertussis (Tdap), Human Papilloma Virus (HPV), hepatitis A (HepA), hepatitis B (HepB) and herpes zoster (shingles). Telephone surveys were conducted with 11,760 individuals, ≥18, half with documented receipt of vaccination and half without. We measured sensitivity, specificity, positive and negative predictive value, net bias and over- and under-reporting of vaccination. Variation was found across vaccines, however, sensitivity and specificity did not vary substantially by either age or race/ethnicity. Sensitivity ranged between 63% for HepA to over 90% (tetanus, HPV, shingles and Flu). Hispanics were 2.7 times more likely to claim receipt of vaccination compared to whites. For PPSV and Flu those 65+ had low specificity compared to patients of younger ages while those in the youngest age group had lowest specificity for HepA and HepB. In addition to racial/ethnic differences, over-reporting was more frequent in those retired and those with household income less than $75,000. Accurate information for vaccination surveillance is important to estimate progress toward vaccination coverage goals and ensure appropriate policy decisions and allocation of resources for public health. It was clear from our findings that EMR and self-report do not always agree. Finding approaches to improve both EMR data capture and patient awareness would be beneficial.

Abstract 44: Lipid Screening In Children And Adolescents In Community Practice 2007-2010

Background: A 2011 guideline on cardiovascular risk reduction in children recommended universal screening for dyslipidemia in children at age 9-11 and again at age 17-21.

Objectives: To ascertain frequency of lipid testing before the guideline was issued in children and adolescents, in predefined age, gender, BMI and race strata.

Methods: Study subjects included 294,369 individuals age 3-19 years enrolled at HealthPartners (Minnesota), Kaiser Permanente Colorado or Kaiser Permanente Northern California in 2007-2010 and with at least one measurement of blood pressure and a height measurement within 90 days. We excluded children with medical conditions (other than obesity) or medications that could have prompted lipid testing. Subjects’ electronic medical records were examined for date and results of the first recorded measurement of total cholesterol and HDL cholesterol (HDL-C). We report descriptive statistics on the proportion of children who received lipid testing and abnormal test results by age, gender, BMI and race/ethnicity group.

Results: The study population was 49.9% female, 12.3% Black, 21.0% Hispanic, 11.4% Asian; 15.3% were overweight (BMI percentile 85-<95) and 14.5% were obese (BMI percentile > 95). Across the 3 sites during the period of observation, 9.7% of youth had at least one lipid screen; rates varied by BMI (5.8% of normal weight, 10.8% of overweight and 27.3% of obese youth). The proportion tested increased steadily with age, ranging from 1.0% of 3-5 year olds, to 8.7% of 9-11 years olds, and to 25.2% of 17-19 year olds. There was relatively little variation in testing by sex and race/ethnicity after adjusting for age and BMI. Among those tested, total cholesterol was elevated ( > 200 mg/dL) in 8.7%, HDL-Cl was low (<40 mg/dL) in 27.5% of boys and in 18.0% of girls, and non-HDL-C was elevated ( > 145 mg/d/L) in 12.0%. The proportion with elevated levels of non-HDL-C was 6.9% in normal weight, 11.5% in overweight and 16.9% of obese children, and was 14.4% in 9-11 year olds and 12.4% in 17-19 year olds.

Conclusion: Before the 2011 guideline, lipid testing was uncommon in 9-11 year old children, but was performed in one quarter of 17-19 year old adolescents. The high proportion of youth with abnormally low HDL-C likely reflects targeted testing of overweight and obese individuals. The proportion of youth with elevated non-HDL-C is closer to that observed in population-based surveillance studies during the same time period. These data serve as a benchmark for assessing change in practice patterns as the new guideline is implemented for pediatric lipid screening and management. They suggest that health care systems will need to assess their capacity to deliver lifestyle interventions in the substantial proportion of youth for whom such services are recommended.

The association of whole grain consumption with incident type 2 diabetes: the Women's Health Initiative Observational Study

PURPOSE

Whole grains may offer protection from diabetes by decreasing energy intake, preventing weight gain, and direct effects on insulin resistance. This study examined associations of whole and refined grains with incident type 2 diabetes (T2D) ascertained by self-reported medication use in a cohort of postmenopausal women.

METHODS

We included 72,215 women free of diabetes at baseline from the Women's Health Initiative Observational Study. Whole grain consumption was categorized as 0, less than 0.5, 0.5 to 1.0, 1.0 to less than 1.5, 1.5 to less than 2.0, and 2.0 or more servings per day. Proportional hazards regression was performed to estimate hazard ratios (HR) and 95% confidence intervals adjusting for potential confounders.

RESULTS

There were 3465 cases of incident T2D over median follow-up of 7.9 years. Adjusted for age and energy intake per day, successively increasing categories of whole grain consumption were associated with statistically significant reduced risk of incident T2D (HRs, 1.00, 0.83, 0.73, 0.69, 0.61, and 0.57; P for trend < 0.0001). Results were attenuated after adjustment for confounders and other dietary components. The reduction in risk of T2D was greater among nonsmokers and those who maintained their weight within 5 pounds with higher consumption of whole grains than smokers and women who gained more weight.

CONCLUSIONS

This large, prospective study found an inverse dose-response relationship between whole grain consumption and incident T2D in postmenopausal women.

The relationship of area-level sociodemographic characteristics, household composition and individual-level socioeconomic status on walking behavior among adults

Understanding the contextual factors associated with why adults walk is important for those interested in increasing walking as a mode of transportation and leisure. This paper investigates the relationships between neighborhood-level sociodemographic context, individual level sociodemographic characteristics and walking for leisure and transport. Data from two community-based studies of adults (n=550) were used to determine the association between the area-sociodemographic environment (ASDE), calculated from U.S. Census variables, and individual-level SES as potential correlates of walking behavior. Descriptive statistics, mean comparisons and Pearson's correlations coefficients were used to assess bivariate relationships. Generalized estimating equations were used to model the relationship between ASDE, as quartiles, and walking behavior. Adjusted models suggest adults engage in more minutes of walking for transportation and less walking for leisure in the most disadvantaged compared to the least disadvantaged neighborhoods but adding individual level demographics and SES eliminated the significant results. However, when models were stratified for free or reduced cost lunch, of those with children who qualified for free or reduced lunch, those who lived in the wealthiest neighborhoods engaged in 10.7 minutes less of total walking per day compared to those living in the most challenged neighborhoods (p<0.001). Strategies to increase walking for transportation or leisure need to take account of individual level socioeconomic factors in addition to area-level measures.

Comparative effectiveness of 2 β-blockers in hypertensive patients

BACKGROUND

Randomized controlled trials have demonstrated the efficacy of selected β-blockers for preventing cardiovascular (CV) events in patients following myocardial infarction (MI) or with heart failure (HF). However, the effectiveness of β-blockers for preventing CV events in patients with hypertension has been questioned recently, but it is unclear whether this is a class effect.

METHODS

Using electronic medical record and health plan data from the Cardiovascular Research Network Hypertension Registry, we compared incident MI, HF, and stroke in patients who were new β-blocker users between 2000 and 2009. Patients had no history of CV disease and had not previously filled a prescription for a β-blocker. Cox proportional hazards regression was used to examine the associations of atenolol and metoprolol tartrate with incident CV events using both standard covariate adjustment (n = 120,978) and propensity score-matching methods (n = 22,352).

RESULTS

During follow-up (median, 5.2 years), there were 3517 incident MI, 3272 incident HF, and 3664 incident stroke events. Hazard ratios for MI, HF, and stroke in metoprolol tartrate users were 0.99 (95% CI, 0.97-1.02), 0.99 (95% CI, 0.96-1.01), and 0.99 (95% CI, 0.97-1.02), respectively. An alternative approach using propensity score matching yielded similar results in 11,176 new metoprolol tartrate users, who were similar to 11,176 new atenolol users with regard to demographic and clinical characteristics.

CONCLUSIONS

There were no statistically significant differences in incident CV events between atenolol and metoprolol tartrate users with hypertension. Large registries similar to the one used in this analysis may be useful for addressing comparative effectiveness questions that are unlikely to be resolved by randomized trials.

Prehypertension and hypertension in community-based pediatric practice

OBJECTIVE

To examine the prevalence of prehypertension and hypertension among children receiving well-child care in community-based practices.

METHODS

Children aged 3 to 17 years with measurements of height, weight, and blood pressure (BP) obtained at an initial (index) well-child visit between July 2007 and December 2009 were included in this retrospective cohort study across 3 large, integrated health care delivery systems. Index BP classification was based on the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents: normal BP, <90th percentile; prehypertension, 90th to 94th percentile; hypertension, 3 BP measurements ≥95th percentile (index and 2 subsequent consecutive visits).

RESULTS

The cohort included 199 513 children (24.3% aged 3-5 years, 34.5% aged 6-11 years, and 41.2% aged 12-17 years) with substantial racial/ethnic diversity (35.9% white, 7.8% black, 17.6% Hispanic, 11.7% Asian/Pacific Islander, and 27.0% other/unknown race). At the index visit, 81.9% of participants were normotensive, 12.7% had prehypertension, and 5.4% had a BP in the hypertension range (≥95th percentile). Of the 10 848 children with an index hypertensive BP level, 3.8% of those with a follow-up BP measurement had confirmed hypertension (estimated 0.3% prevalence). Increasing age and BMI were significantly associated with prehypertension and confirmed hypertension (P < .001 for trend). Among racial/ethnic groups, blacks and Asians had the highest prevalence of hypertension.

CONCLUSIONS

The prevalence of hypertension in this community-based study is lower than previously reported from school-based studies. With the size and diversity of this cohort, these results suggest the prevalence of hypertension in children may actually be lower than previously reported.

Benefits of early hypertension control on cardiovascular outcomes in patients with diabetes

OBJECTIVE

To assess the impact of early hypertension (HT) control on occurrence of subsequent major cardiovascular events in those with diabetes and recent-onset HT.

RESEARCH DESIGN AND METHODS

Study subjects were 15,665 adults with diabetes but no diagnosed coronary or cerebrovascular disease at baseline who met standard criteria for new-onset HT. Poisson regression models assessed whether adequate blood pressure control within 1 year of HT onset predicts subsequent occurrence of major cardiovascular events with and without adjustment for baseline Framingham Risk Score (FRS) and other covariates.

RESULTS

Mean age was 51.5 years, and mean blood pressure at HT onset was 136.8/80.8 mmHg. In the year after HT onset, mean blood pressure decreased to 131.4/78.0 mmHg and was <130/80 mmHg in 32.9% of subjects and <140/90 mmHg in 80.2%. Over a mean follow-up of 3.2 years, age-adjusted rates of major cardiovascular events in those with mean 1-year blood pressure measurements of <130/80, 130-139/80-89, and ≥140/90 mmHg were 5.10, 4.27, and 6.94 events/1,000 person-years, respectively (P = 0.004). In FRS-adjusted models, rates of major cardiovascular events were significantly higher in those with mean blood pressure ≥140/90 mmHg in the first year after HT onset (rate ratio 1.30 [95% CI 1.01-1.169]; P = 0.04).

CONCLUSIONS

Failure to adequately control BP within 1 year of HT onset significantly increased the likelihood of major cardiovascular events within 3 years. Prompt control of new-onset HT in patients with diabetes may provide important short-term clinical benefits.

Accuracy of heart disease prevalence estimated from claims data compared with an electronic health record

Introduction

We developed a decision support tool that can guide the development of heart disease prevention programs to focus on the interventions that have the most potential to benefit populations. To use it, however, users need to know the prevalence of heart disease in the population that they wish to help. We sought to determine the accuracy with which the prevalence of heart disease can be estimated from health care claims data.

Methods

We compared estimates of disease prevalence based on insurance claims to estimates derived from manual health records in a stratified random sample of 480 patients aged 30 years or older who were enrolled at any time from August 1, 2007, through July 31, 2008 (N = 474,089) in HealthPartners insurance and had a HealthPartners Medical Group electronic record. We compared randomly selected development and validation samples to a subsample that was also enrolled on August 1, 2005 (n = 272,348). We also compared the records of patients who had a gap in enrollment of more than 31 days with those who did not, and compared patients who had no visits, only 1 visit, or 2 or more visits more than 31 days apart for heart disease.

Results

Agreement between claims data and manual review was best in both the development and the validation samples (Cohen’s κ, 0.92, 95% confidence interval [CI], 0.87–0.97; and Cohen’s κ, 0.94, 95% CI, 0.89–0.98, respectively) when patients with only 1 visit were considered to have heart disease.

Conclusion

In this population, prevalence of heart disease can be estimated from claims data with acceptable accuracy.

Obesogenic family types identified through latent profile analysis

BACKGROUND

Obesity may cluster in families due to shared physical and social environments.

PURPOSE

This study aims to identify family typologies of obesity risk based on family environments.

METHODS

Using 2007-2008 data from 706 parent/youth dyads in Minnesota, we applied latent profile analysis and general linear models to evaluate associations between family typologies and body mass index (BMI) of youth and parents.

RESULTS

Three typologies described most families with 18.8% "Unenriched/Obesogenic," 16.9% "Risky Consumer," and 64.3% "Healthy Consumer/Salutogenic." After adjustment for demographic and socioeconomic factors, parent BMI and youth BMI Z-scores were higher in unenriched/obesogenic families (BMI difference = 2.7, p < 0.01 and BMI Z-score difference = 0.51, p < 0.01, respectively) relative to the healthy consumer/salutogenic typology. In contrast, parent BMI and youth BMI Z-scores were similar in the risky consumer families relative to those in healthy consumer/salutogenic type.

CONCLUSIONS

We can identify family types differing in obesity risks with implications for public health interventions.

Adolescent primary care visit patterns

PURPOSE

Many clinical preventive care services are recommended for adolescents. Little is known about whether most adolescents have a sufficient number of preventive care services visits over time to receive those services. We wanted to measure how frequently adolescents who are insured either through private insurance or government programs have preventive vs nonpreventive care visits.

METHODS

We conducted a retrospective descriptive analysis based on claims data from a large health plan in Minnesota with about 700,000 members. All study patients were aged 11 to 18 years between January 1, 1998, and December 31, 2007. Our outcome measure was rates of preventive and nonpreventive care visits.

RESULTS

One-third of adolescents with 4 or more years of continuous enrollment had no preventive care visits from age 13 through 17 years, and another 40% had only a single such visit. Nonpreventive care visits were more frequent in all age-groups, averaging about 1 per year at age 11 years, climbing to about 1.5 per year at age 17 years. Differences in rates between government insurance and commercial insurance were small. In older adolescence, girls had more preventive care visits and more nonpreventive care visits than did boys.

CONCLUSIONS

Most adolescents come in infrequently for preventive care visits but more often for nonpreventive care visits. We recommend using the same approach in adolescence for preventive care that is being used in adults: the no-missed-opportunities paradigm. All visits by adolescents should be viewed as an opportunity to provide preventive care services, and systems should be set up to make that possible, even in busy practices with short encounters with a clinician.

Oral health-related quality of life among rural-dwelling indigenous Australians

BACKGROUND

There is limited information on the impact of poor oral health on Indigenous Australian quality of life. This study aimed to determine the prevalence, extent and severity of, and to calculate risk indicators for, poor oral health-related quality of life among a convenience sample of rural-dwelling Indigenous Australians.

METHODS

Participants (n = 468) completed a questionnaire that included socio-demographic, lifestyle, dental service utilization, dental self-care and oral health-related quality of life (OHIP-14) factors.

RESULTS

The prevalence of having experienced one or more of OHIP-14 items 'fairly often' or 'very often' was 34.8%. The extent of OHIP-14 scores was 1.88, while the severity was 15.0. Risk indicators for having experienced one or more of OHIP-14 items 'fairly often' or 'very often' included problem-based dental attendance, avoiding dental care because of cost, difficulty paying a $100 dental bill and non-ownership of a toothbrush. An additional risk indicator for OHIP-14 extent was healthcare card ownership, while additional indicators for OHIP-14 severity were healthcare card ownership and having had 5+ teeth extracted.

CONCLUSIONS

Risk indicators for poor oral health-related quality of life among this marginalized population included socio-economic factors, dentate status factors, dental service utilization patterns, financial factors and dental self-care factors.

Food security and metabolic syndrome in U.S. adults and adolescents: findings from the National Health and Nutrition Examination Survey, 1999-2006

PURPOSE

We sought to examine the association of food security and metabolic syndrome in a representative sample of U.S. adults and adolescents. We hypothesized that compared with those in food-secure households, adolescents and adults living in food-insecure households would have increased odds of (MetS).

METHODS

Data from the National Health and Nutrition Examination Surveys from 1999 to 2006 were combined and analyzed cross-sectionally. Logistic regression was used to compute odds ratios and 95% confidence intervals (95% CI) in the association of household food security (fully food secure, marginal, low, and very low food security) and MetS.

RESULTS

Compared with those who were food secure, adults in households with marginal food security had 1.80-fold increased odds of MetS (95% CI, 1.30-2.49), and those with very low food security had a 1.65-fold increased odds of MetS (95% CI 1.12-2.42). There was no association with low food security. The association of marginal household food security and MetS was not significant in adolescents. In adults and adolescents, very low was food security not associated with increased odds of MetS compared with those who were food secure.

CONCLUSIONS

Members of households with marginal and very low food security are at increased risk of MetS. A mechanism may be that foods that are inexpensive and easily accessible tend to be energy dense and nutrient poor.

A surveillance source of tobacco use differences among immigrant populations

INTRODUCTION

Tobacco use disproportionately affects some ethnic minority populations. Important gains in understanding the relationship between acculturation and tobacco use have been hindered by the lack of available data, large samples of specific immigrant groups. This study is among the first to use electronic medical record (EMR) data to examine differences in tobacco use associated with acculturation among various population groups.

METHODS

Relevant variables for all medical group patients aged 18 years and older with clinician visits were extracted from the EMR of one large medical group from March 2006 to February 2007. Preferred language and country of origin data from the EMR were used to create distinct cultural groupings. Adjusted prevalences were computed.

RESULTS

One hundred thousand [corrected] three hundred [corrected] twenty nine patients reported [corrected] languages as English, Hmong, Vietnamese, Oromo, Amharic, Somali, and Spanish and were categorized as U.S. born or non-U.S. born. After adjusting for age, utilization, and insurance status, more acculturated Mexican and Hmong women were more likely to be tobacco users compared with less acculturated women. Among non-English speaking, current tobacco use was more prevalent among men compared with women.

DISCUSSION

Interpreted language and country of origin data collected in a clinical setting were useful for describing tobacco use differences between and within cultural groups. Using preferred language and country of origin as a proxy for acculturation status may help understand some of the within and between cultural differences in tobacco use. These novel data sources have potential usefulness for tobacco surveillance of relatively small cultural groups.

Disparities in tobacco cessation medication orders and fills among special populations

BACKGROUND

There is considerable interest in measuring and eliminating health care disparities among various special populations, but there is limited understanding of their extent, causes, or potential remedies. To improve this for tobacco cessation, we measured differences in the frequency of receiving and filling cessation medication prescriptions by race, ethnicity, age, language preference, health insurance, and pregnancy.

METHODS

The relevant variables for all patients of a Minnesota medical group aged 18 years and older with clinician visits were extracted from the electronic medical records of 1 large medical group from March 2006 to February 2007. This was combined with claims data from 1 insurance plan that covered most of these individuals. Order and fill rates for cessation medications were then adjusted for each of the other variables.

RESULTS

There were 32,733 current users of tobacco, 18,047 of whom had both health insurance and pharmacy claims data available. After adjustment, 15.4% overall had received an order for cessation medications during this year, but only 78% had filled it. Groups receiving fewer orders than their comparison groups were aged 18-34 years or older than 65 years, men, pregnant women, Asians and Hispanics, and those with non-English-language preference, on Medicaid, or with fewer visits. The same groups were less likely to fill that prescription, except patients with non-English preference or Medicaid.

DISCUSSION

There are disparities in both the receipt of cessation medication orders and the likelihood of filling them for some special populations. The causes are likely to be complex, but this information provides a starting point for learning to improve this problem.

Diabetes care quality: insurance, health plan, and physician group contributions

OBJECTIVE

To study the relative contributions of insurance product (commercial, Medicaid, Medicare), health plan, and physician group to quality of diabetes care.

STUDY DESIGN

Cross-sectional observational study using data reported by Minnesota Community Measurement (MNCM) on care provided in 2005.

METHODS

Individual performance rates for glycosylated hemoglobin (A1C) level <7%, lowdensity lipoprotein cholesterol (LDL-C) level <100 mg/dL, blood pressure <30/80 mm Hg, documented tobacco-free status, and aspirin use, as well as an all-or-none composite measure (Optimal Diabetes Care), were obtained from MNCM for 57 physician groups. Results included 7169 patients connected with 1 of 8 health plans and 1 of 3 types of insurance product.

RESULTS

All factors studied had a relationship to quality results. Of the factors, insurance product has the strongest relationship to A1C, LDL-C, and Optimal Diabetes Care. Health plan had the strongest relationship to tobacco-free status and daily aspirin, and physician group had the strongest relationship to blood pressure control. Physician group results varied more than those for health plan or insurance product on most measures.

CONCLUSIONS

All factors studied contribute to diabetes quality results. Reporting both physician group performance and health plan performance may offer a greater opportunity to improve care than reporting only health plan or only physician group results.

Association of hip circumference with incident diabetes and coronary heart disease: the Atherosclerosis Risk in Communities study

When waist circumference is taken into account, larger hip circumference is associated with reduced risk factors for diabetes and cardiovascular disease. The authors investigated the prospective association of hip circumference with type 2 diabetes and coronary heart disease (CHD) incidence in a biracial cohort of men and women in 4 US communities. A total of 10,767 participants from the Atherosclerosis Risk in Communities (ARIC) study were followed from 1987 to 1998. Hip and waist circumferences and body mass index (BMI) were modeled separately and mutually in association with incident diabetes and CHD by using proportional hazards regression. After adjustment for age, race, sex, and clinical center, hip circumference was positively associated with incident diabetes. However, after further controlling for waist circumference, BMI, and confounding variables, successive quintiles of hip circumference were associated with a statistically significant reduced hazard of incident diabetes (hazard ratios = 1.00, 0.79, 0.60, 0.44, 0.41). Similarly, successive quintiles of hip circumference were associated with a statistically significant reduced hazard of CHD after controlling for waist circumference, BMI, and confounding variables (hazard ratios = 1.00, 0.92, 0.75, 0.63, 0.50). Although excess adiposity is a general risk factor for diabetes and CHD, for a given BMI and waist circumference, greater hip circumference appears to lessen the risk of diabetes and CHD.

The association of hip circumference with incident hip fracture in a cohort of postmenopausal women: the Iowa Women's Health Study

PURPOSE

As the mean age of the U.S. population increases, the public health burden of osteoporotic fractures is expected to increase. This study prospectively examined the independent association of hip circumference with hip fracture.

METHODS

The prospective association of hip circumference and hip fracture was examined in a cohort of 30,652 postmenopausal women.

RESULTS

Compared with the lowest quintile, successive quintiles of hip circumference were associated with a reduced hazard (i.e., hazard ratio [HR]) of hip fracture over 18 years of follow-up (HRs = 1.00, 0.78, 0.74, 0.76, 0.69, p for trend = 0.0015) after adjusting for age. Controlling for waist, this association persisted (HRs = 1.00, 0.78, 0.73, 0.72, 0.54, p for trend = 0.0006). When additionally controlling for body mass index (BMI), we found that the association of hip fracture with hip circumference was attenuated to the null whereas the association with successive quintiles of BMI remained significant and inverse (HRs = 1.00, 0.55, 0.45, 0.40, 0.35, p for trend <0.0001).

CONCLUSIONS

Although hip circumference has a strong inverse association with risk of hip fracture, this association was not independent of BMI. These results suggest that, in the prediction of hip fracture risk, overall body size may be more important than body composition of the femoral-gluteal region.

Degree of concordance with DASH diet guidelines and incidence of hypertension and fatal cardiovascular disease

BACKGROUND

Guidelines to prevent and treat hypertension advocate the Dietary Approaches to Stop Hypertension (DASH) diet.

METHODS

We studied whether a greater concordance with the DASH diet is associated with reduced incidence of hypertension (self-reported) and mortality from cardiovascular disease in 20,993 women initially aged 55 to 69 years. We created a DASH diet concordance score using food frequency data in 1986 and followed the women for events through 2002.

RESULTS

No woman had perfect concordance with the DASH diet. Adjusted for age and energy intake, incidence of hypertension was inversely associated with the degree of concordance with the DASH diet, with hazard ratios across quintiles of 1.0, 0.91, 0.95, 0.99, and 0.87 (P trend = .02). There also were inverse, but not monotonic, associations between better DASH diet concordance and mortality from coronary heart disease, stroke, and all cardiovascular disease (CVD). However, after adjustment for other risk factors, there was little evidence that any end point was associated with the DASH diet score.

CONCLUSIONS

Our results suggest that greater concordance with DASH guidelines did not have an independent long-term association with hypertension or cardiovascular mortality in this cohort. This implies that very high concordance, as achieved in the DASH trials, may be necessary to achieve any benefits of the DASH diet.

Physical activity in young adults and incident hypertension over 15 years of follow-up: the CARDIA study

OBJECTIVE

We sought to examine the relation between physical activity and incident hypertension in young adults over 15 years of follow-up in the Coronary Artery Risk Development in Young Adults study.

METHODS

A total of 3993 Black and White men and women aged 18 to 30 years were examined at baseline, and 2, 5, 7, 10, and 15 years later. Blood pressure and physical activity were measured at each exam. Hypertension was defined as systolic 140 mm Hg or higher, diastolic 90 mm Hg or higher, or antihypertensive medication use. Average physical activity and incident hypertension over 15 years of follow-up were analyzed.

RESULTS

There were 634 cases of incident hypertension over 15 years of follow-up. Those who were more versus less physically active experienced a reduced risk (hazard rate ratio = 0.83; 95% confidence interval = 0.73, 0.93) for incident hypertension, after adjustment for race, sex, age, education, and family history of high blood pressure.

CONCLUSIONS

Physical activity merits attention in the prevention of incident hypertension among young adults, particularly as they move into middle age.