Program Factors Affecting Weight Loss and Mobility in Older Adults: Evidence From the Mobility and Vitality Lifestyle Program (MOVE UP)

Background. The Mobility and Vitality Lifestyle Program (MOVE UP) is a behavioral weight-management intervention for improving mobility among community-dwelling older adults. We examined program factors that affect implementation outcomes and participant-level health outcomes. Methods. The MOVE UP program was implemented in the greater Pittsburgh area from January 2015 to June 2019 to improve lower extremity performance in community-dwelling older adults who were overweight or obese. Thirty-two sessions were delivered over 13 months. All sessions were designed to be 1-hour in length, on-site, group-based, and led by trained and supported community health workers (CHWs). Participants completed weekly Lifestyle Logs for self-monitoring of body weight, diet, and physical activity. We evaluated the MOVE UP program using the RE-AIM framework, and collected quantitative data at baseline, 5-, 9-, and 13-months. Multilevel linear regression models assessed the impacts of program factors (site, CHW, and participant characteristics) on implementation outcomes and participant-level health outcomes. Results. Twenty-two CHWs delivered MOVE UP program to 303 participants in 26 cohorts. Participants were similar to the target source population in weight but differed in some demographic characteristics. The program was effective for weight loss and lower extremity function in both intervention and maintenance periods (ps < .01), with an independent effect for Lifestyle Logs submission but not session attendance. Discussion. CHWs were able to deliver a multi-component weight loss intervention effectively in community settings. CHW and site characteristics had independent impacts on participants' adherence. Lifestyle Log submission may be a more potent measure of adherence in weight loss interventions than attendance.

Longitudinal blood glucose level and increased silent myocardial infarction: a pooled analysis of four cohort studies

BACKGROUND

Fasting glucose (FG) demonstrates dynamic fluctuations over time and is associated with cardiovascular outcomes, yet current research is limited by small sample sizes and relies solely on baseline glycemic levels. Our research aims to investigate the longitudinal association between FG and silent myocardial infarction (SMI) and also delves into the nuanced aspect of dose response in a large pooled dataset of four cohort studies.

METHODS

We analyzed data from 24,732 individuals from four prospective cohort studies who were free of myocardial infarction history at baseline. We calculated average FG and intra-individual FG variability (coefficient of variation), while SMI cases were identified using 12-lead ECG exams with the Minnesota codes and medical history. FG was measured for each subject during the study's follow-up period. We applied a Cox regression model with time-dependent variables to assess the association between FG and SMI with adjustment for age, gender, race, Study, smoking, longitudinal BMI, low-density lipoprotein level, blood pressure, and serum creatinine.

RESULTS

The average mean age of the study population was 60.5 (sd: 10.3) years with median fasting glucose of 97.3 mg/dL at baseline. During an average of 9 years of follow-up, 357 SMI events were observed (incidence rate, 1.3 per 1000 person-years). The association between FG and SMI was linear and each 25 mg/dL increment in FG was associated with a 15% increase in the risk of SMI. This association remained significant after adjusting for the use of lipid-lowering medication, antihypertensive medication, antidiabetic medication, and insulin treatment (HR 1.08, 95% CI 1.01-1.16). Higher average FG (HR per 25 mg/dL increase: 1.17, 95% CI 1.08-1.26) and variability of FG (HR per 1 sd increase: 1.23, 95% CI 1.12-1.34) over visits were also correlated with increased SMI risk.

CONCLUSIONS

Higher longitudinal FG and larger intra-individual variability in FG over time were associated in a dose-response manner with a higher SMI risk. These findings support the significance of routine cardiac screening for subjects with elevated FG, with and without diabetes.

Abuse and Neglect in Nursing Homes: The Role of Serious Mental Illness

BACKGROUND AND OBJECTIVES

Nursing homes (NH) are serving a large number of residents with serious mental illness (SMI). We analyze the highest ("High-SMI") quartile of NHs based on the proportion of residents with SMI and compare NHs on health deficiencies and the incidence of deficiencies given for resident abuse, neglect, and involuntary seclusion.

RESEARCH DESIGN AND METHODS

We used national Certification and Survey Provider Enhanced Reports (CASPER) data for all freestanding certified NHs in the continental United States from 2014 to 2017 (14,698 NHs; 41,717 recertification inspections; 246,528 deficiencies). Differences in the number of deficiencies, a weighted deficiency score, the deficiency grade, and the facility characteristics associated with deficiencies for abuse, neglect, and involuntary seclusion were examined in High-SMI. Incidence rate ratios (IRR) and odds ratios (OR) were reported with 95% confidence intervals.

RESULTS

High-SMI NHs did not receive more deficiencies or a greater weighted deficiency score per recertification inspection. Deficiencies given to High-SMI NHs were associated with a wider scope, especially Pattern (IRR:1.03;[1.00, 1.07]) and Widespread (IRR:1.07;[1.02, 1.11]). High-SMI NHs were more likely to be cited for resident abuse and neglect (OR:1.49;[1.23, 1.81]) and the policies to prohibit and monitor for abuse and neglect (OR:1.18;[1.08, 1.30]) in comparison to all other NHs.

DISCUSSION AND IMPLICATIONS

Although resident abuse, neglect, and involuntary seclusion are rarely cited, these deficiencies are disproportionately found in High-SMI NHs. Further work is needed to disentangle the antecedents to potential resident abuse and neglect in those with mental healthcare needs.

Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study

BACKGROUND

Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults.

METHODS

The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk.

RESULTS

Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use.

CONCLUSIONS

Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.

Weight Loss through Lifestyle Intervention Improves Mobility in Older Adults

BACKGROUND AND OBJECTIVES

The high prevalence of overweight or obesity in older adults is a public health concern because obesity affects health, including risk of mobility disability.

RESEARCH DESIGN AND METHODS

The Mobility and Vitality Lifestyle Program (MOVE UP), delivered by community health workers (CHW), enrolled 303 community-dwelling adults to assess the impact of a 32-session behavioral weight management intervention. Participants completed the program at 26 sites led by 22 CHWs. Participation was limited to people aged 60-75 who had a BMI 27-45 kg/m 2. The primary outcome was performance on the Short Physical Performance Battery (SPPB) over 12 months.

RESULTS

Participants were age (sd) 67.7 (4.1) and mostly female (87%); 22.7% were racial minorities. The mean (sd) BMI at baseline was 34.7 (4.7). Participants attended a median of 24 of 32 sessions; 240 (80.3%) completed the 9- or 13-month outcome assessment. Median weight loss in the sample was 5% of baseline body weight. SPPB total scores improved by +0.31 units (p < .006), gait speed by +0.04 m/sec (p < .0001), and time to complete chair stands by -0.95 sec (p < .0001). Weight loss ≥ 5% was associated with a gain of +0.73 in SPPB score. Increases in activity (by self-report or device) were not independently associated with SPPB outcomes but did reduce the effect of weight loss.

DISCUSSION AND IMPLICATIONS

Promoting weight management in a community group setting may be an effective strategy for reducing risk of disability in older adults.

Systematic review of Integrated Disease Surveillance and Response (IDSR) implementation in the African region

Background

The WHO African region frequently experiences outbreaks and epidemics of infectious diseases often exacerbated by weak health systems and infrastructure, late detection, and ineffective outbreak response. To address this, the WHO Regional Office for Africa developed and began implementing the Integrated Disease Surveillance and Response strategy in 1998.

Objectives

This systematic review aims to document the identified successes and challenges surrounding the implementation of IDSR in the region available in published literature to highlight areas for prioritization, further research, and to inform further strengthening of IDSR implementation.

Methods

A systematic review of peer-reviewed literature published in English and French from 1 July 2012 to 13 November 2019 was conducted using PubMed and Web of Science. Included articles focused on the WHO African region and discussed the use of IDSR strategies and implementation, assessment of IDSR strategies, or surveillance of diseases covered in the IDSR framework. Data were analyzed descriptively using Microsoft Excel and Tableau Desktop 2019.

Results

The number of peer-reviewed articles discussing IDSR remained low, with 47 included articles focused on 17 countries and regional level systems. Most commonly discussed topics were data reporting (n = 39) and challenges with IDSR implementation (n = 38). Barriers to effective implementation were identified across all IDSR core and support functions assessed in this review: priority disease detection; data reporting, management, and analysis; information dissemination; laboratory functionality; and staff training. Successful implementation was noted where existing surveillance systems and infrastructure were utilized and streamlined with efforts to increase access to healthcare.

Conclusions and implications of findings

These findings highlighted areas where IDSR is performing well and where implementation remains weak. While challenges related to IDSR implementation since the first edition of the technical guidelines were released are not novel, adequately addressing them requires sustained investments in stronger national public health capabilities, infrastructure, and surveillance processes.

How the use of vaccines outside the cold chain or in controlled temperature chain contributes to improving immunization coverage in low- and middle-income countries (LMICs): A scoping review of the literature

Background

Most vaccines are recommended for storage at temperatures of +2°C to +8°C to maintain potency. Immunization supply chain bottlenecks constraints reaching populations with life-saving vaccines. The World Health Organization permits the use of vaccines outside the cold chain as "controlled temperature chain (CTC)" upon meeting certain conditions and has set targets to license more vaccines CTC by 2020.

Objectives

This scoping review aims to explore and synthesize the evidence in the literature on how the use of vaccines outside the cold chain or in a controlled temperature chain increases immunization coverage in low and middle-income countries (LMICs), with a focus on the timelines of the Global Vaccine Action Plan (2011-2020).

Methods

A systematic search of three online databases (PubMed, Embase, and Web of Science) due to their broad coverage of global health sciences retrieved 173 original peer-reviewed articles, of which 13 were included in the review having met our inclusion criteria.

Results

The majority of the studies were conducted in Africa (n = 9), followed by Asia (n = 3), and the least in the Pacific (n = 1). The different study designs captured included four non-randomized trials, three randomized trials, two simulation models, two cross-sectional studies, and one cohort study. Reported benefits included increased coverage, logistical ease, cost savings while vaccines remain potent.

Conclusion

Currently, only two vaccines have been licensed to be stored CTC. More needs to be done to get additional vaccines licensed for CTC and disseminate operational guidance to operationalize its use in low- and middle-income countries.

MULTIPLE MEDICATION USE AND RISK OF TREATED FALL INJURY: THE HEALTH ABC STUDY

Multiple medication use within one year is associated with increased fall injury risk in older adults. However, chronically using multiple medications and treated fall injury have rarely been explored, particularly in cohort studies linked with claims data. We examined using >5 medications in 2 or more consecutive years (chronic medication use) as a risk factor for treated fall injury in 1,898 community-dwelling adults (age 73.6±2.9 years; 53% women; 37% black) with linked Medicare Fee-For-Service (FFS) claims from the Health, Aging and Body Composition Study since 1997/98 clinic visit. Incident fall injury (N=546) was the first claim from 1998/99 clinic visit to 12/31/08 with an ICD-9 fall code and non-fracture injury code, or fracture code with/without a fall code. Stepwise Cox models with a time-varying predictor of chronic medication use before fall injury or censoring (N=414) vs. not using >5 medications at the same time (N=1008) were adjusted for baseline demographics, lifestyle factors, fall history, quadriceps strength, cardiovascular disease (CVD), diabetes, sensory nerve impairment, and kidney function. Fall injury risk increased for chronic medication users (37%) vs. non-users (29%) (HR=1.25[1.00-1.57]), though was attenuated after adjustment for CVD and diabetes (HR=1.18[0.93-1.51]). Sensitivity analyses excluding fall-risk-increasing drugs (FRIDs) from medication counts (HR=1.32[0.54-3.20]), or including those using >5 medications non-chronically (N=365) in referent groups (HR=1.22[0.96-1.55]) had consistent findings. Unmeasured comorbidity differences may confound associations of chronic medication use and treated fall injury risk in older adults with Medicare FFS. Considering both chronic diseases and medication use in fall risk assessments is needed.

Mobility and Vitality Lifestyle Program (MOVE UP): A Community Health Worker Intervention for Older Adults With Obesity to Improve Weight, Health, and Physical Function

BACKGROUND AND OBJECTIVES

Obesity rates in adults ≥65 years have increased more than other age groups in the last decade, elevating risk for chronic disease and poor physical function, particularly in underserved racial and ethnic minorities. Effective, sustainable lifestyle interventions are needed to help community-based older adults prevent or delay mobility disability. Design, baseline recruitment, and implementation features of the Mobility and Vitality Lifestyle Program (MOVE UP) study are reported.

RESEARCH DESIGN AND METHODS

MOVE UP aimed to recruit 26 intervention sites in underserved areas around Allegheny County, Pennsylvania and train a similar number of community health workers to deliver a manualized intervention to groups of approximately 12 participants in each location. We adapted a 13-month healthy aging/weight management intervention aligned with several evidence-based lifestyle modification programs. A nonrandomized, pre-post design was used to measure intervention impact on physical function performance, the primary study endpoint. Secondary outcomes included weight, self-reported physical activity and dietary changes, exercise self-efficacy, health status, health-related quality of life, and accelerometry in a subsample.

RESULTS

Of 58 community-based organizations approached, nearly half engaged with MOVE UP. Facilities included neighborhood community centers (25%), YMCAs (25%), senior service centers (20%), libraries (18%), senior living residences (6%), and churches (6%). Of 24 site-based cohorts with baseline data completed through November 2017, 21 community health workers were recruited and trained to implement the standardized intervention, and 287 participants were enrolled (mean age 68 years, 89% female, 33% African American, other, or more than one race).

DISCUSSION AND IMPLICATIONS

The MOVE UP translational recruitment, training, and intervention approach is feasible and could be generalizable to diverse aging individuals with obesity and a variety of baseline medical conditions. Additional data regarding strategies for program sustainability considering program cost, organizational capacity, and other adaptations will inform public health dissemination efforts.

Integration and Utilization of Peer Leaders for Diabetes Self-Management Support: Results From Project SEED (Support, Education, and Evaluation in Diabetes)

Purpose The purpose of the study was to evaluate the effectiveness of a peer leader-led (PL) diabetes self-management support (DSMS) group in achieving and maintaining improvements in A1C, self-monitoring of blood glucose (SMBG), and diabetes distress in individuals with diabetes. Diabetes self-management support is critical; however, effective, sustainable support models are scarce. Methods The study was a cluster randomized controlled trial of 221 people with diabetes from 6 primary care practices. Practices and eligible participants (mean age: 63.0 years, 63.8% female, 96.8% white, 28.5% at or below poverty level, 32.5% using insulin, A1C ≥7%: 54.2%) were randomized to diabetes self-management education (DSME) + PL DSMS (n = 119) or to enhanced usual care (EUC) (DSME + traditional DSMS with no PL; n = 102). Data were collected at baseline, after DSME (6 weeks), after DSMS (6 months), and after telephonic DSMS (12 months). Results Decreases in A1C occurred between baseline and post-DSME in both groups. Both groups sustained improvements during DSMS, but A1C levels increased during telephonic DSMS. Improvements in self-monitoring of blood glucose were observed in both groups following DSME and were sustained throughout. At study end, the intervention group was 4.3 times less likely to have diabetes regimen-related distress compared to EUC. Conclusions PL DSMS is as effective as traditional DSMS in helping participants to maintain glycemic control and self-monitoring of blood glucose (SMBG) and more effective at improving distress. With increasing diabetes prevalence and shortage of diabetes educators, it is important to integrate and use low-cost interventions in high-risk communities that build on available resources.

Economic Burden Associated with Receiving Inhaled Corticosteroids with Leukotriene Receptor Antagonists or Long-Acting Beta Agonists as Combination Therapy in Older Adults

BACKGROUND

There is a paucity of literature on the health care expenditures associated with different pharmacologic treatments in older adults with asthma that is not well controlled on inhaled corticosteroids (ICS).

OBJECTIVE

To compare asthma-related and all-cause health care expenditures associated with leukotriene receptor antagonists (LTRA) versus long-acting beta agonists (LABA) when added to ICS in older adults with asthma.

METHODS

A retrospective cohort was constructed using 2009-2010 Medicare fee-for-service medical and pharmacy claims from a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009. The sample comprised patients who were aged 65 years and older, diagnosed with asthma, and treated exclusively with ICS + LABA or ICS + LTRA. Outcomes assessed were asthma-related expenditures (medical, pharmacy, and total) and all-cause health care expenditures (medical, pharmacy, and total). Outcomes were measured from the date of the first prescription for the add-on treatment (LABA or LTRA in combination with ICS) after having at least a 4-month "wash-in" period in which patients were receiving no controller, ICS alone, or ICS plus the add-on treatment of the follow-up period. Patients were followed until death, switching to or adding the other add-on treatment, or the end of the study (December 31, 2010). Multivariable regression models with nonparametric bootstrapped standard errors were used to compare all-cause and asthma-related expenditures per patient per month (PPPM) between ICS + LABA and ICS + LTRA users. All models were adjusted for demographics, comorbidities, and county-level health care access variables.

RESULTS

The primary analysis included 14,702 patients, of whom 12,940 were treated with ICS + LABA and 1,762 were treated with ICS + LTRA. The mean (SD) follow-up periods were 12.3 (± 5.7) months for the ICS + LABA group and 15.3 (± 5.1) months for the ICS + LTRA group. Adjusted asthma-related expenditures PPPM were $400 for the ICS + LTRA group compared with $286 for the ICS + LABA group (P < 0.001). However, adjusted total all-cause expenditure PPPM was significantly lower for patients treated with ICS + LTRA ($6,087 for ICS + LTRA compared with $6,975 for ICS + LABA, P = 0.029).

CONCLUSIONS

Older adults with asthma often experience economic burden from asthma and other chronic illnesses. Compared with ICS + LTRA, ICS + LABA was associated with lower asthma-related expenditures but with higher all-cause expenditures in older adults.

DISCLOSURES

Support for this study was provided by the University of Pittsburgh School of Pharmacy and the Pittsburgh Claude D. Pepper Older Americans Independence Center (NIA P30 AGAG024827). C. Thorpe reports grants from the National Institute of Aging during the conduct of this study. The other authors have nothing to disclose.

The effect of insulin on bone mineral density among women with type 2 diabetes: a SWAN Pharmacoepidemiology study

This was a longitudinal study examining the effects of insulin use on bone mineral density loss. Insulin use was found to be associated with greater bone mineral density loss at the femoral neck among women with diabetes mellitus.

INTRODUCTION

Women with diabetes mellitus (DM) have higher bone mineral density (BMD) and experience slower BMD loss but have an increased risk of fracture. The data regarding the effect of insulin treatment on BMD remains conflicted. We examined the impact of insulin initiation on BMD.

METHODS

We investigated the annual changes in BMD associated with the new use of insulin among women with DM in the Study of Women's Health Across the Nation (SWAN). Propensity score (PS) matching, which is a statistical method that helps balance the baseline characteristics of women who did and did not initiate insulin, was used. Covariates with a potential impact on bone health were included in all models. Mixed model regression was used to test the change in BMD between the two groups. Median follow-up time was 5.4 years.

RESULTS

The cohort consisted of 110 women, mean age, 53.6 years; 49% white and 51% black. Women using insulin (n = 55) were similar on most relevant characteristics to the 55 not using insulin. Median diabetes duration for the user group was 10 vs. 5.0 years for the non-user group. There was a greater loss of BMD at the femoral neck among insulin users (- 1.1%) vs non-users (- 0.77%) (p = 0.04). There were no differences in BMD loss at the spine - 0.30% vs - 0.32% (p = 0.85) or at the total hip - 0.31% vs - 0.25 (p = 0.71), respectively.

CONCLUSIONS

Women with T2DM who initiated insulin experienced a more rapid BMD loss at the femoral neck as compared to women who did use insulin.

Community-Based Healthy Aging Interventions for Older Adults with Arthritis and Multimorbidity

Examine the impact of programs led by community health workers on health and function in older adults with arthritis and other health conditions. We conducted a cluster-randomized trial of the Arthritis Foundation Exercise Program (AFEP) enhanced with the "10 Keys"™ to Healthy Aging compared with the AFEP program at 54 sites in 462 participants (mean age 73 years, 88 % women, 80 % white). Trained Community health workers delivered the 10-week programs. Outcomes assessed after 6 months included physical performance [Short Physical Performance Battery (SPPB)], Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, and preventive health behaviors. Both groups experienced improvements. Performance improved by 0.3 SPPB points in the AFEP/"10 Keys"™ group and 0.5 in AFEP alone; WOMAC scores declined by 3.0 and 3.9 points respectively. More participants had controlled hypertension at 6 months in both groups (60.1 % baseline to 76.7 % in AFEP/10 Keys and from 76.5 to 84.9 % in AFEP alone) and greater diabetes control (from 15.0 to 34.9 and 15.5 to 34.1 %, respectively). These community-based programs showed similar improvements in preventive health, mobility and arthritis outcomes.

Should we screen for type 2 diabetes among asymptomatic individuals? Yes

RCTs of whether screening asymptomatic individuals for undiagnosed diabetes results in reduced mortality or has other benefits have been suggestive, but inconclusive. In this issue of Diabetologia, two additional controlled studies (DOIs: 10.1007/s00125-017-4323-2 and 10.1007/s00125-017-4299-y ) that investigated whether screening for type 2 diabetes in asymptomatic individuals is associated with a reduction in mortality are presented. Treating diabetes early, and identifying and treating impaired glucose tolerance, are of benefit, and economic modelling indicates such screening is cost-effective. Now that such screening is already underway in many countries, new data, along with the existing evidence, suggests opportunistic screening is the best way forward. More research is needed, however, on how best to screen and how to improve risk-factor control once dysglycaemia is detected.

Abstract 3297: Survival predictors of Burkitt's lymphoma in children, adults and elderly in the United States during 2000-2013

Background. Burkitt’s Lymphoma (BL) has three peaks of occurrence, in children, adults and elderly, at 10, 40 and 70 years respectively. To the best of our knowledge, no study has been conducted to assess predictors of survival in the three age groups. We hypothesized that the predictors of survival may differ by age group. We, therefore, sought to determine the predictors of survival for BL in these three groups: children (&lt;15 years of age), adults (40-70 years of age) and elderly (&gt;70 years of age).

Methods. Using the Surveillance, Epidemiology, and End Results (SEER) database covering the years 2000-2013, we identified 797 children, 1,994 adults and 757 elderly patients newly diagnosed with BL. We used Cox proportional hazards regression models to determine prognostic factors for survival for each age group.

Results. Five-year relative survival in BL for children, adults and elderly were 90.4%, 47.8%, and 28.9%, respectively. Having at least stage II disease and multiple primaries were associated with higher mortality in the elderly group. In adults, multiple primaries, stage III or IV disease, African American race and bone marrow primary were associated with increased mortality whereas stage IV disease and multiple primaries were associated with worse outcome in children.

Conclusion. These findings demonstrate commonalities and differences in predictors of survival that may have implications for management of BL patients.

Financial Support: This work was supported by the US National Institutes of Health/National Cancer Institute 1P20CA210300-01 (PI: Shu XO, Tran T/Sub-contract-PI: Luu HN) and the University of South Florida start-up grant (PI: Luu HN).

Note: This abstract was not presented at the meeting.

Citation Format: Fahad Mukhtar, Paolo Boffetta, Harvey A. Risch, Jong Y. Park, Omonigho M. Bubu, Lindsay Womack, Thuan V. Tran, Janice C. Zgibor, Hung N. Luu. Survival predictors of Burkitt's lymphoma in children, adults and elderly in the United States during 2000-2013 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3297. doi:10.1158/1538-7445.AM2017-3297

Survival predictors of Burkitt's lymphoma in children, adults and elderly in the United States during 2000-2013

Burkitt's Lymphoma (BL) has three peaks of occurrence, in children, adults and elderly, at 10, 40 and 70 years respectively. To the best of our knowledge, no study has been conducted to assess predictors of survival in the three age groups. We hypothesized that survival predictors may differ by age group. We, therefore, sought to determine survival predictors for BL in these three groups: children (<15 years of age), adults (40-70 years of age) and elderly (>70 years of age). Using the Surveillance, Epidemiology, and End Results (SEER) database covering the years 2000-2013, we identified 797 children, 1,994 adults and 757 elderly patients newly diagnosed with BL. We used adjusted Cox proportional hazards regression models to determine prognostic factors for survival for each age group. Five-year relative survival in BL for children, adults and elderly were 90.4, 47.8 and 28.9%, respectively. Having at least Stage II disease and multiple primaries were associated with higher mortality in the elderly group. In adults, multiple primaries, Stage III or IV disease, African American race and bone marrow primary were associated with increased mortality whereas Stage IV disease and multiple primaries were associated with worse outcome in children. These findings demonstrate commonalities and differences in predictors of survival that may have implications for management of BL patients.

Implementing the Chronic Care Model for Improvements in Diabetes Care and Education in a Rural Primary Care Practice

Purpose

The purpose of this pilot study was to determine the impact of implementing elements of the chronic care model (CCM; decision support, self-management, and delivery system redesign) on providers' diabetes care practices and patient outcomes in a rural practice setting.

Methods

In this pilot study, 104 patients with type 2 diabetes and 6 providers in a rural primary care practice were involved in an intervention that included a certified diabetes educator (CDE) who educated and supported providers on diabetes management and adherence to the American Diabetes Association (ADA) Standards of Care over the year of the project. The CDE also provided diabetes self-management education (DSME) at the office site for 29 of the 104 patients who received their care in the practice. The following variables were evaluated: provider perceived barriers to care and adherence to ADA standards of care and patient A1C, blood pressure, cholesterol, knowledge, and empowerment levels.

Results

Provider adherence to ADA Standards of Care increased significantly across all process measures. Patients who received DSME at point of service in the primary care practice setting gained improvements in knowledge, empowerment, A1C, and high-density lipoprotein cholesterol levels.

Conclusions

Implementing systems to support decision support, selfmanagement education, and delivery system redesign has a positive influence on practices and patient outcomes in outlying rural communities.

Is There a Relationship Between Perceived Neighborhood Contentedness and Physical Activity in Young Men and Women

The relationship between perceived neighborhood contentedness and physical activity was evaluated in the Add Health study population. Wave I includes 20,745 respondents (collected between 1994 and 1995) and wave II includes 14,738 (71 %) of these same students (collected in 1996). Multinomial logistic regression was used to evaluate this relationship in both wave I and wave II of the sample. Higher levels of Perceived Neighborhood Contentedness were associated with higher reports of physical activity in both males and females and in both waves. For every one-point increment in PNS, males were 1.3 times as likely to report being highly physically active than low (95 % CI 1.23-1.37) in wave 1 and 1.25 times as likely in wave 2 (95 % CI 1.17-1.33). Females were 1.17 (95 % CI 1.12-1.22) times as likely to report being highly active than low and 1.22 times as likely in wave 2 (95 % CI 1.17-1.27) with every one-point increment. PNC appears to be significantly associated with physical activity in adolescents. Involving the community in the development of intervention programs could help to raise the contentedness of adolescents in these communities.

Antileukotriene Agents Versus Long-Acting Beta-Agonists in Older Adults with Persistent Asthma: A Comparison of Add-On Therapies

OBJECTIVES

To compare the effectiveness and cardiovascular safety of long-acting beta-agonists (LABAs) with those of leukotriene receptor antagonists (LTRAs) as add-on treatments in older adults with asthma already taking inhaled corticosteroids (ICSs).

DESIGN

Retrospective cohort study.

SETTING

Medicare fee-for-service (FFS) claims (2009-10) for a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009.

PARTICIPANTS

Medicare beneficiaries aged 66 and older continuously enrolled in FFS Medicare with Part D coverage with a diagnosis of asthma before 2009 treated exclusively with ICSs plus LABAs or ICSs plus LTRAs (N = 14,702).

MEASUREMENTS

The augmented inverse propensity-weighted estimator was used to compare the effect of LABA add-on therapy with that of LTRA add-on therapy on asthma exacerbations requiring inpatient, emergency, or outpatient care and on cardiovascular (CV) events, adjusting for demographic characteristics, comorbidities, and county-level healthcare-access variables.

RESULTS

The primary analysis showed that LTRA add-on treatment was associated with greater odds of asthma-related hospitalizations or emergency department visits (odds ratio (OR) = 1.4, P < .001), as well as outpatient exacerbations requiring oral corticosteroids or antibiotics (OR = 1.41, P < .001) than LABA treatment. LTRA add-on therapy was also less effective in controlling acute symptoms, as indicated by greater use of short-acting beta agonists (rate ratio = 1.58, P < .001). LTRA add-on treatment was associated with lower odds of experiencing a CV event than LABA treatment (OR = 0.86, P = .006).

CONCLUSION

This study provides new evidence specific to older adults to help healthcare providers weigh the risks and benefits of these add-on treatments. Further subgroup analysis is needed to personalize asthma treatments in this high-risk population.

Partnership Building and Implementation of an Integrated Healthy-Aging Program

BACKGROUND

Evidence-based interventions exist for prevention of chronic disease in older adults. Partnering with community organizations may provide a mechanism for disseminating these interventions.

OBJECTIVE

To describe the partnership and program implementation by the Arthritis Foundation (AF) and the University of Pittsburgh.

METHODS

The AF Exercise Program (AFEP; an existing evidence-based program) was enhanced with the "10 Keys"™ to Healthy Aging (a prevention-focused program bundling the most common risk factors for chronic disease and disability in older adults and applies behavior change strategies to enhance prevention). The program was delivered in 20 sessions over 10 weeks by community health workers in a cluster-randomized trial.

LESSONS LEARNED

Partnering with an organization having an existing infrastructure supports program delivery at the community level. This partnership provided programming in 54 sites across Pittsburgh and surrounding communities.

CONCLUSIONS

This collaborative partnership created a productive synergy maximizing strengths in both research and program delivery.

Influence of Patient-Centered Decision Making on Sustained Weight Loss and Risk Reduction Following Lifestyle Intervention Efforts in Rural Pennsylvania

Purpose

The purpose of this study was to determine whether weight loss and cardiovascular disease risk factor reduction was maintained following a lifestyle intervention.

Methods

Five hundred fifty-five individuals without diabetes from 8 rural communities were screened for BMI ≥25 kg/m2 and abdominal obesity (86.1% female, 95.1% white, 55.8% obese). Communities and eligible participants (n = 493; mean age, 51 years, 87.6% female, 94.1% Caucasian) were assigned to 4 study groups: face-to-face, DVD, Internet, and self-selection (SS) (n = 101). Self-selection participants chose the intervention modality (60% face-to-face, 40% Internet, 0% DVD). Outcomes included weight change and risk factor reduction at 18 months.

Results

All groups achieved maintenance of 5% weight loss in over half of participants. Self-selection participants had the largest proportion maintain (89.5%). Similarly, nearly 75% of participants sustained risk factor reduction. After multivariate adjustment, participants in SS were 2.3 times more likely to maintain 5% weight loss compared to the other groups, but not risk factor reduction.

Conclusion

Despite the modality, lifestyle intervention was effective at maintaining weight loss and risk reduction. However, SS participants were twice as likely to sustain improvements compared to other groups. The importance of patient-centered decision making in health care is paramount.

The preventive services use self-efficacy (PRESS) scale in older women: development and psychometric properties

Background

Preventive services offered to older Americans are currently under-utilized despite considerable evidence regarding their health and economic benefits. Individuals with low self-efficacy in accessing these services need to be identified and provided self-efficacy enhancing interventions. Scales measuring self-efficacy in the management of chronic diseases exist, but do not cover the broad spectrum of preventive services and behaviors that can improve the health of older adults, particularly older women who are vulnerable to poorer health and lesser utilization of preventive services. This study aimed to evaluate the psychometric properties of a new preventive services use self-efficacy scale, by measuring its internal consistency reliability, assessing internal construct validity by exploring factor structure, and examining differences in self-efficacy scores according to participant characteristics.

Methods

The Preventive Services Use Self-Efficacy (PRESS) Scale was developed by an expert panel at the University of Pittsburgh Center for Aging and Population Health - Prevention Research Center. It was administered to 242 women participating in an ongoing trial and the data were analyzed to assess its psychometric properties. An exploratory factor analysis with a principal axis factoring approach and orthogonal varimax rotation was used to explore the underlying structure of the items in the scale. The internal consistency of the subscales was assessed using Cronbach’s alpha coefficient.

Results

The exploratory factor analysis defined five self-efficacy factors (self-efficacy for exercise, communication with physicians, self-management of chronic disease, obtaining screening tests, and getting vaccinations regularly) formed by 16 items from the scale. The internal consistency of the subscales ranged from .81 to .94. Participants who accessed a preventive service had higher self-efficacy scores in the corresponding sub-scale than those who did not.

Conclusions

The 16-item PRESS scale demonstrates preliminary validity and reliability in measuring self-efficacy in the use of preventive services among older women. It can potentially be used to evaluate the impact of interventions designed to improve self-efficacy in the use of preventive services in community-dwelling older women.

Pilot Enhancement of the Arthritis Foundation Exercise Program with a Healthy Aging Program

Older adults with arthritis or joint pain were targeted for a pilot program enhancing the Arthritis Foundation Exercise Program with the 10 Keys™ to Healthy Aging Program. Using a one-group, pre-post design, feasibility was examined and improvements in preventive behaviors, arthritis outcomes, and cardiometabolic outcomes were explored. A 10-week program was developed, instructors were recruited and trained, and four sites and 51 participants were recruited. Measures included attendance, adherence, satisfaction, preventive behaviors, Western Ontario and McMaster Universities Osteoarthritis Index (pain and stiffness), glucose, and cholesterol. Three fourths of participants attended >50% of the sessions. At 6 and 12 months, more than one half performed the exercises 1 to 2 days per week, whereas 28% and 14% exercised 3 to 7 days per week, respectively. Participants (92%) rated the program as excellent/very good. Nonsignificant changes were observed in expected directions. Effect sizes were small for arthritis and cardiometabolic outcomes. This program engaged community partners, demonstrated feasibility, and showed improvements in some preventive behaviors and health risk profiles. [Res Gerontol Nurs. 2016; 9(3):123-132.].

Clinically Relevant Cognitive Impairment in Middle-Aged Adults With Childhood-Onset Type 1 Diabetes

OBJECTIVE

The aim of this study was to investigate the presence and correlates of clinically relevant cognitive impairment in middle-aged adults with childhood-onset type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

During 2010-2013, 97 adults diagnosed with T1D and aged <18 years (age and duration 49 ± 7 and 41 ± 6 years, respectively; 51% female) and 138 similarly aged adults without T1D (age 49 ± 7 years; 55% female) completed extensive neuropsychological testing. Biomedical data on participants with T1D were collected periodically since 1986-1988. Cognitive impairment status was based on the number of test scores ≥1.5 SD worse than demographically appropriate published norms: none, mild (only one test), or clinically relevant (two or more tests).

RESULTS

The prevalence of clinically relevant cognitive impairment was five times higher among participants with than without T1D (28% vs. 5%; P < 0.0001), independent of education, age, or blood pressure. Effect sizes were large (Cohen d 0.6-0.9; P < 0.0001) for psychomotor speed and visuoconstruction tasks and were modest (d 0.3-0.6; P < 0.05) for measures of executive function. Among participants with T1D, prevalent cognitive impairment was related to 14-year average A1c >7.5% (58 mmol/mol) (odds ratio [OR] 3.0; P = 0.009), proliferative retinopathy (OR 2.8; P = 0.01), and distal symmetric polyneuropathy (OR 2.6; P = 0.03) measured 5 years earlier; higher BMI (OR 1.1; P = 0.03); and ankle-brachial index ≥1.3 (OR 4.2; P = 0.01) measured 20 years earlier, independent of education.

CONCLUSIONS

Clinically relevant cognitive impairment is highly prevalent among these middle-aged adults with childhood-onset T1D. In this aging cohort, chronic hyperglycemia and prevalent microvascular disease were associated with cognitive impairment, relationships shown previously in younger populations with T1D. Two additional potentially modifiable risk factors for T1D-related cognitive impairment, vascular health and BMI, deserve further study.

Assessing Physical Performance in Free-Living Older Adults with a Wearable Computer

This study investigates the use of a chest-worn wearable computer, the eButton, to assess physical performance of older adults. The Short Physical Performance Battery (SPPB), a standard cliniucal test, is first conducted on older human subjects. Then, a triaxial accelerometer and a triaxial gyroscope within the eButton are utilized to record acceleration and angular velocity of body motion on the same subjects for one week. The sensor data corresponding to walking episodes are segmented and features in the time and frequency domains are extracted. Comparison between these features and the total SPPB scores shows that the sensor data acquired in free-living conditions can be used as indicators of the subjects physical performance.

White matter hyperintensities in middle-aged adults with childhood-onset type 1 diabetes

OBJECTIVE

Although microvascular complications are common in type 1 diabetes mellitus (T1DM), few studies have quantified the severity, risk factors, and implications of cerebral microvascular damage in these patients. As life expectancy in patients with T1DM increases, patients are exposed to age- and disease-related factors that may contribute to cerebral microvascular disease.

METHODS

Severity and volume of white matter hyperintensities (WMH) and infarcts were quantified in 97 middle-aged patients with childhood-onset T1DM (mean age and duration: 50 and 41 years, respectively) and 81 non-T1DM adults (mean age: 48 years), concurrent with cognitive and health-related measures.

RESULTS

Compared with non-T1DM participants, patients had more severe WMH (Fazekas scores 2 and 3 compared with Fazekas score 1, p < 0.0001) and slower information processing (digit symbol substitution, number correct: 65.7 ± 10.9 and 54.9 ± 13.6; pegboard, seconds: 66.0 ± 9.9 and 88.5 ± 34.2; both p < 0.0001) independent of age, education, or other factors. WMH were associated with slower information processing; adjusting for WMH attenuated the group differences in processing speed (13% for digit symbol, 11% for pegboard, both p ≤ 0.05). Among patients, prevalent neuropathies and smoking tripled the odds of high WMH burden, independent of age or disease duration. Associations between measures of blood pressure or hyperglycemia and WMH were not significant.

CONCLUSIONS

Clinically relevant WMH are evident earlier among middle-aged patients with childhood-onset T1DM and are related to the slower information processing frequently observed in T1DM. Brain imaging in patients with T1DM who have cognitive difficulties, especially those with neuropathies, may help uncover cerebral microvascular damage. Longitudinal studies are warranted to fully characterize WMH development, risk factors, and long-term effects on cognition.

Statin use and decline in gait speed in community-dwelling older adults

OBJECTIVES

To examine the association between statin use and objectively assessed decline in gait speed in community-dwelling older adults.

DESIGN

Longitudinal cohort study.

SETTING

Health, Aging and Body Composition (Health ABC) Study.

PARTICIPANTS

Two thousand five participants aged 70-79 at baseline with medication and gait speed data at 1998-99, 1999-2000, 2001-02, and 2002-03.

MEASUREMENTS

The independent variables were any statin use and their standardized daily doses (low, moderate, high) and lipophilicity. The primary outcome measure was decline in gait speed of 0.1 m/s or more in the following year of statin use. Multivariable generalized estimating equations were used, adjusting for demographic characteristics, health-related behaviors, health status, and access to health care.

RESULTS

Statin use increased from 16.2% in 1998-99 to 25.6% in 2002-03. The overall proportions of those with decline in gait speed of 0.1 m/s or more increased from 22.2% in 1998 to 23.9% in 2003. Statin use was not associated with decline in gait speed of 0.1 m/s or more (adjusted odds ratio (AOR) = 0.90, 95% confidence interval (CI) = 0.77-1.06). Similar nonsignificant trends were also seen with the use of hydrophilic or lipophilic statins. Users of low-dose statins were found to have a 22% lower risk of decline in gait speed than nonusers (AOR = 0.78, 95% CI = 0.61-0.99), which was mainly driven by the results from 1999-2000 follow-up.

CONCLUSION

These results suggest that statin use did not increase decline in gait speed in community-dwelling older adults.

Hostility modifies the association between TV viewing and cardiometabolic risk

BACKGROUND

It was hypothesized that television viewing is predictive of cardiometabolic risk. Moreover, people with hostile personality type may be more susceptible to TV-induced negative emotions and harmful health habits which increase occurrence of cardiometabolic risk.

PURPOSE

The prospective association of TV viewing on cardiometabolic risk was examined along with whether hostile personality trait was a modifier.

METHODS

A total of 3,269 Black and White participants in the coronary artery risk development in young adults (CARDIA) study were assessed from age 23 to age 35. A cross-lagged panel model at exam years 5, 10, 15, and 20, covering 15 years, was used to test whether hours of daily TV viewing predicted cardiometabolic risk, controlling confounding variables. Multiple group analysis of additional cross-lagged panel models stratified by high and low levels of hostility was used to evaluate whether the association was modified by the hostile personality trait.

RESULTS

The cross-lagged association of TV viewing at years 5 and 15 on clustered cardiometabolic risk score at years 10 and 20 was significant (B = 0.058 and 0.051), but not at 10 to 15 years. This association was significant for those with high hostility (B = 0.068 for exam years 5 to 10 and 0.057 for exam years 15 to 20) but not low hostility.

CONCLUSION

These findings indicate that TV viewing is positively associated with cardiometabolic risk. Further, they indicate that hostility might be a modifier for the association between TV viewing and cardiometabolic risk.

Changes in cholesterol-lowering medications use over a decade in community-dwelling older adults

BACKGROUND

The impact of evidence-based guidelines and controlled trial data on use of cholesterol-lowering medications in older adults is unclear.

OBJECTIVE

To examine whether utilization patterns of cholesterol-lowering medications in community-dwelling older adults changed following the release of the National Cholesterol Education Program Adult Treatment Panel III guidelines and results from the Prospective Study of Pravastatin in the Elderly at Risk in 2002.

METHODS

Community-dwelling elderly individuals who were enrolled in the Health, Aging and Body Composition Study in 1997-1998 were followed for up to 11 years. An interrupted time series analysis with multivariable generalized estimating equations (GEEs) was used to examine changes in level and trend in cholesterol-lowering medication use before and after 2002, adjusting for sociodemographics, health-related behaviors, and health status.

RESULTS

Cholesterol-lowering medication use increased nearly 3-fold from 14.9% in 1997-1998 to 42.6% in 2007-2008, with statins representing the most common class used (87-94%). Multivariable GEE results revealed no significant difference in the level of cholesterol-lowering medication use after 2002 (adjusted OR 0.95; 95% CI 0.89-1.02). Multivariable GEE results revealed that trend changes in the rate of increase in cholesterol-lowering medication declined after 2002 (adjusted ratio of ORs 0.92; 95% CI 0.89-0.95).

CONCLUSIONS

The use of cholesterol-lowering medication increased substantially over a decade in community-dwelling elderly individuals but was not related to a change in level or trend following the release of the guidelines and evidence-based data.

Comparative effectiveness of lifestyle intervention efforts in the community: results of the Rethinking Eating and ACTivity (REACT) study

OBJECTIVE

To determine the comparative effectiveness of three lifestyle intervention modalities in decreasing risk for diabetes.

RESEARCH DESIGN AND METHODS

Five hundred and fifty-five individuals (86.1% female, 95.1% white, and 55.8% obese) from eight rural communities were screened for BMI ≥25 kg/m(2) and waist circumference >40 inches in men and >35 inches in women. Communities with their eligible participants (n = 493; mean age 51 years, 87.6% female, 94.1% Caucasian) were assigned to four Group Lifestyle Balance (GLB) intervention groups: face to face (FF) (n = 119), DVD (n = 113), internet (INT) (n = 101), and self-selection (SS) (n = 101). SS participants chose the GLB modality. GLB is a comprehensive lifestyle behavior-change program.

RESULTS

A marked decline was observed in weight after the intervention in all groups (FF -12.5 lbs, P = 0.01; DVD -12.2 lbs, P < 0.0001; INT -13.7 lbs, P < 0.0001; and SS -14 lbs, P < 0.0001). Participants in SS experienced the largest average weight loss. Weight loss was sustained in >90% of participants in each group at 6 months (FF 90.7%, DVD 90.9%, INT 92.1%, and SS 100%). All groups experienced improvements in the proportion of participants with CVD risk factors. The proportion of individuals with CVD risk factors remained steady between 3 and 6 months in all groups and never returned back to baseline. All associations remained after multivariate adjustment.

CONCLUSIONS

Despite the modality, the GLB intervention was effective at decreasing weight and improving CVD risk factor control. SS and FF participants experienced greater improvements in outcomes compared with other groups, establishing the importance of patient-centered decision making and a support network for successful behavior change.

Two-year results of translating the diabetes prevention program into an urban, underserved community

PURPOSE

The purpose of the study was to examine the long-term effect of a Group Lifestyle Balance (GLB) program on weight, impaired fasting glucose, hypertension, and hyperlipidemia in an urban, medically underserved community.

METHODS

This study was a single-arm prospective intervention study that was designed to test the effectiveness of a community-based GLB intervention. In sum, 638 residents from 11 targeted neighborhoods were screened for body mass index ≥ 25 kg/m(2) and metabolic syndrome. Eligible individuals took part in a 12-week GLB intervention (n = 105) that addressed weight loss and physical activity. Subjects were followed for 24 months.

RESULTS

The probability of being at risk for diabetes and cardiovascular disease was significantly reduced by 25.7% over the long-term follow-up. Of the participants who lost at least 5% of their body weight following the intervention, 52.6% maintained the 5% weight loss at their last follow-up time, weighing about 20 lb less than they did at baseline.

CONCLUSION

Risk reduction and weight loss maintenance are possible following a GLB intervention and have substantial potential for future public health impact.

Identifying type 1 and type 2 diabetic cases using administrative data: a tree-structured model

BACKGROUND

To date, few administrative diabetes mellitus (DM) registries have distinguished type 1 diabetes mellitus (T1DM) from type 2 diabetes mellitus (T2DM).

OBJECTIVE

Using a classification tree model, a prediction rule was developed to distinguish T1DM from T2DM in a large administrative database.

METHODS

The Medical Archival Retrieval System at the University of Pittsburgh Medical Center included administrative and clinical data from January 1, 2000, through September 30, 2009, for 209,647 DM patients aged ≥18 years. Probable cases (8,173 T1DM and 125,111 T2DM) were identified by applying clinical criteria to administrative data. Nonparametric classification tree models were fit using TIBCO Spotfire S+ 8.1 (TIBCO Software), with model size based on 10-fold cross validation. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of T1DM were estimated.

RESULTS

The main predictors that distinguished T1DM from T2DM are age <40 years; International Classification of Disease, 9th revision, codes of T1DM or T2DM diagnosis; inpatient oral hypoglycemic agent use; inpatient insulin use; and episode(s) of diabetic ketoacidosis diagnosis. Compared with a complex clinical algorithm, the tree-structured model to predict T1DM had 92.8% sensitivity, 99.3% specificity, 89.5% PPV, and 99.5% NPV.

CONCLUSION

The preliminary predictive rule appears to be promising. Being able to distinguish between DM subtypes in administrative databases will allow large-scale subtype-specific analyses of medical care costs, morbidity, and mortality.

The association between driving distance and glycemic control in rural areas

BACKGROUND

In order to optimize care and improve outcomes in people with diabetes, adequate access to health care facilities and resources for self-management is required.

METHODS

Data on 3369 individuals with type 2 diabetes who received education at 7 diabetes centers were collected prospectively between June 2005 and January 2007. The driving distances of subjects who were in good control [hemoglobin A1c (A1C) ≤7.0%] were compared with the driving distances of those who were not (A1C >7.0%). The association between A1C and improvement in A1C with travel burden was tested.

RESULTS

The mean distance subjects traveled to visit their center was 13.3 miles. The results indicated that residing more than 10 miles from the diabetes management center [odds ratio (OR) = 1.91, p < .0001], being younger (OR = 0.99, p = .00015), and having a longer duration of diabetes (OR = 1.03, p = .0007) were significant contributors to a A1C >7% adjusted for individual- and community-level factors. In addition, those who lived within 10 miles of their center were 2.5 times more likely to have improved their A1C values between their first and last office visits.

CONCLUSION

Health care providers should be aware of travel burden as a potential barrier to glycemic control. In the future, it may be useful to minimize driving distance for individuals with diabetes, perhaps by improved public transportation, more diabetes center locations in rural areas, telemedicine, or home visits.

Cost-effectiveness of implementing the chronic care model for diabetes care in a military population

BACKGROUND

Applying the chronic care model (CCM) for diabetes management helps improve health outcomes and patient care. The CCM was implemented at U.S. Air Force Wilford Hall Medical Center through the Diabetes Outreach Clinic (DOC) in 2006, but its cost-effectiveness in this setting is unknown.

METHODS

We constructed a Markov decision model to estimate DOC cost-effectiveness compared with usual care (UC) over a 20-year period. Based on empirical, post-intervention demographic and clinical data, we applied United Kingdom Prospective Diabetes Study risk equations to predict long-term probabilities of developing microvascular or macrovascular complications. Health care system and societal perspectives were considered, discounting costs and benefits at 3% annually. Intervention costs and outcomes were obtained from military data, while other costs, disease progression data, and utilities were drawn from published literature.

RESULTS

From a health care system perspective, the DOC cost $45,495 per quality-adjusted life-year (QALY) compared with UC; from a societal perspective, the DOC compared with UC cost $42,051/QALY (when the model started with the uncomplicated diabetes cohort), $61,243/QALY (when starting with the DOC cohort), or $61,813/QALY (when starting with the UC cohort). In one-way sensitivity analyses, results were most sensitive to yearly costs for specialty care visits. In probabilistic sensitivity analysis, the DOC was favored in 51% of model iterations using an acceptability threshold of $50,000/QALY and in 72% at a threshold of $100,000/QALY.

CONCLUSIONS

The DOC strategy for diabetes care, performed with the CCM methodology in a military population, appears to be economically reasonable compared with UC.

Effects of depression and antidepressant use on goal setting and barrier identification among patients with type 2 diabetes

PURPOSE

The purpose of this study was to examine the effects of depression and antidepressant use on goal setting and barrier identification in patients with type 2 diabetes.

METHODS

In a large diabetes education network, 778 patients with type 2 diabetes were enrolled in the American Association of Diabetes Educators (AADE) Outcomes System as part of their routine diabetes education between 2005 and 2008. Self-reported depression, 7 self-identified behavior change goals, and 13 barriers to diabetes self-care were collected from the Diabetes Self-Management Assessment Report Tool (D-SMART(®)); antidepressant use was documented from the Diabetes Educator Tool (D-ET(®)). Multiple linear regression was used to evaluate the effects of depression or antidepressant use on the number of goals or the number of barriers while controlling for relevant covariates.

RESULTS

Among 778 patients (507 nondepressed, 181 depressed with antidepressant use, 90 depressed without antidepressant use), median age was 58, 60.9% were female, and 85.9% were Caucasian. Patients with and without depression had a similar number of self-identified behavior change goals, whereas patients with depression had 1 additional barrier to diabetes self-care compared with those without depression. In the depressed subgroup, antidepressant use had no association with the number of goals that the subjects set or the number of barriers they identified.

CONCLUSIONS

Among patients with type 2 diabetes, depression was associated with a slightly greater number of barriers, which may support the importance of depression screening and depression treatment in patients with diabetes.

Impact of patient level factors on the improvement of the ABCs of diabetes

OBJECTIVE

To determine which patient factors contribute to improvements in the ABCs of diabetes following a multi-faceted diabetes care intervention.

METHODS

A multi-level, cluster design, randomized controlled trial examined the effectiveness of a Chronic Care Model (CCM) intervention in an underserved community (n=119).

RESULTS

Improvements in glycemic control were experienced among older subjects (p=0.02), those with higher scores on the WHO-10 Quality of Well-Being Subscale 1 (p=0.05), and those in the CCM group (p=0.04). Insulin use was associated with greater improvements in SBP and DBP. Those taking insulin (p=0.07), and those more satisfied with their diabetes care and ready to make a behavior change (p=0.08) experienced larger improvements in Non-HDLc. Medication treatment intensification (TI) did not significantly impact the ABCs.

CONCLUSION

Psychosocial and sociodemographic factors explained more of the variation in the ABCs than TI, and are important contributors to clinical improvement.

PRACTICE IMPLICATIONS

Providers may be able to identify and intervene on patients who are at risk for developing diabetes complications and improve the consistency, quality, and effectiveness of patient care.

Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, 2005-2007

INTRODUCTION

We assessed the cost-effectiveness of a community-based, modified Diabetes Prevention Program (DPP) designed to reduce risk factors for type 2 diabetes and cardiovascular disease.

METHODS

We developed a Markov decision model to compare costs and effectiveness of a modified DPP intervention with usual care during a 3-year period. Input parameters included costs and outcomes from 2 projects that implemented a community-based modified DPP for participants with metabolic syndrome, and from other sources. The model discounted future costs and benefits by 3% annually.

RESULTS

At 12 months, usual care reduced relative risk of metabolic syndrome by 12.1%. A modified DPP intervention reduced relative risk by 16.2% and yielded life expectancy gains of 0.01 quality-adjusted life-years (3.67 days) at an incremental cost of $34.50 ($3,420 per quality-adjusted life-year gained). In 1-way sensitivity analyses, results were sensitive to probabilities that risk factors would be reduced with or without a modified DPP and that patients would enroll in an intervention, undergo testing, and acquire diabetes with or without an intervention if they were risk-factor-positive. Results were also sensitive to utilities for risk-factor-positive patients. In probabilistic sensitivity analysis, the intervention cost less than $20,000 per quality-adjusted life-year gained in approximately 78% of model iterations.

CONCLUSION

We consider the modified DPP delivered in community and primary care settings a sound investment.

Development of a coronary heart disease risk prediction model for type 1 diabetes: the Pittsburgh CHD in Type 1 Diabetes Risk Model

AIM

To create a coronary heart disease (CHD) risk prediction model specific to type 1 diabetes.

METHODS

Development of the model used data from the Pittsburgh Epidemiology of Diabetes Complications Study (EDC). EDC subjects had type 1 diabetes diagnosed between 1950 and 1980, received their first study exam between 1986 and 1988, and have been followed biennially since. The final cohort for model development consisted of 603 subjects and 46 incident events. Hard CHD was defined as CHD death, fatal/non-fatal MI or Q-waves. Baseline CHD risk factors were tested bivariately and introduced into a Weibull model. The prediction model was externally validated in the EURODIAB Prospective Complications Study.

RESULTS

In males, predictors were higher white blood cell count, micro- or macroalbuminuira, lower HDLc and longer diabetes duration. In females, larger waist/hip ratio, higher non-HDLc, higher systolic blood pressure, use of blood pressure medication, and longer diabetes duration were included. Models were robust to internal and external validation procedures.

CONCLUSIONS

CHD risk prediction models for hard CHD in those with type 1 diabetes should include risk factors not considered by existing models. Using models specifically developed for predicting CHD in type 1 diabetes may allow for more targeted prevention strategies.

3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial

PURPOSE

The purpose of this study was to determine if improvements observed in clinical, behavioral, and psychosocial outcomes measured at 12 months following a multifaceted diabetes care intervention were sustained at 3-year follow-up.

METHODS

This study was a multilevel, nonblinded, cluster design, randomized controlled trial that took place in an underserved suburb of Pittsburgh, Pennsylvania, between 1999 and 2005. Eleven primary care practices, and their patients, were randomly assigned to 3 groups: chronic care model (CCM) intervention (n = 30), provider education only (PROV) (n = 38), and usual care (UC) (n = 51). Subjects were followed for 3 years.

RESULTS

Improvements observed at 12-month follow-up in glycemic (-0.5%) and blood pressure control (-4.8 mm Hg), and the proportion of participants who self-monitor their blood glucose (86.7%-100%), were sustained at 3-year follow-up in the CCM group. Additional improvements occurred in non-HDLc levels in all study groups and quality of well-being scores in the CCM intervention group. All associations remained after controlling for medication treatment intensification.

CONCLUSIONS

We have demonstrated that improvements in outcomes can be sustained over time following a multifaceted diabetes care intervention. Future research in this area is necessary to understand if improvements in outcomes can be sustained following diabetes self-management education (DSME) and what type of patient fares the best from multifaceted diabetes care interventions.

Translating the Diabetes Prevention Program into an urban medically underserved community: a nonrandomized prospective intervention study

OBJECTIVE

The objective of this study was to determine if a community-based modified Diabetes Prevention Program Group Lifestyle Balance (GLB) intervention, for individuals with metabolic syndrome, was effective in decreasing risk for type 2 diabetes and cardiovascular disease (CVD) in an urban medically underserved community, and subsequently to determine if improvements in clinical outcomes could be sustained in the short term.

RESEARCH DESIGN AND METHODS

This nonrandomized prospective intervention study used a one-group design to test the effectiveness of a community-based GLB intervention. Residents from 11 targeted neighborhoods were screened for metabolic syndrome (n = 573) and took part in a 12-week GLB intervention (n = 88) that addressed safe weight loss and physical activity.

RESULTS

A marked decline in weight (46.4% lost > or = 5% and 26.1% lost or = 7%) was observed in individuals after completion of the intervention. Of these subjects, 87.5% (n = 28) and 66.7% (n = 12) sustained the 5% and 7% reduction, respectively, at the 6-month reassessment. Over one-third of the population (43.5%, n = 30) experienced improvements in one or more component of metabolic syndrome, and 73.3% (n = 22) sustained this improvement at the 6-month reassessment. Additional improvements occurred in waist circumference (P < 0.009) and blood pressure levels (P = 0.04) after adjustment for age, sex, race, mean number of GLB classes attended, and time.

CONCLUSIONS

Adults in an urban medically underserved community can decrease their risk for type 2 diabetes and CVD through participation in a GLB intervention, and short-term sustainability is feasible. Future research will include long-term follow-up of these subjects.

Using the American Association of Diabetes Educators Outcomes System to identify patient behavior change goals and diabetes educator responses

PURPOSE

The purpose of this article is to ascertain patients' self-identified and mutually identified or agreed on (working with diabetes educators) behavior change goals and examine the diabetes educators' response to these goals during the provision of diabetes self-management education.

METHODS

The American Association of Diabetes Educators Outcome System was integrated into Web-based, touch-screen, and telephonic systems within 8 sites within the Pittsburgh Regional Initiative for Diabetes Education network. Data from patients and their diabetes educators were obtained from the Diabetes Self-management Assessment Report Tool (D-SMART) and Diabetes Educator Tool (D-ET).

RESULTS

Nine hundred fifty-four individuals with diabetes (type 1 and type 2) using the D-SMART self-identified healthy eating (74%) and being active (54%) as the most common behavior change goals. From that sample, 527 patients identified goals that were mutually identified or agreed on with their diabetes educator: healthy eating (94%), being active (59%), monitoring (49%), taking medication (26%), reducing risks (19%), problem solving (18%), and healthy coping (18%).

CONCLUSION

The most common behavior change goals identified by patients (self-identified or mutually identified with their diabetes educator) were healthy eating and being active. The behavior change goal least addressed by patients and educators alike was healthy coping. Mutually identified goals among educators and patients may improve targeted appropriate educational strategies to support patients in meeting their goals.

The Diabetes Self-management Assessment Report Tool (D-SMART): process evaluation and patient satisfaction

PURPOSE

The purpose of this article is to present the results of the process evaluation and patient experience in completing the Diabetes Self-management Assessment Report Tool (D-SMART), an instrument within the AADE Outcome System to assist diabetes educators to assess, facilitate, and track behavior change in the provision of diabetes self-management education (DSME).

METHODS

The D-SMART was integrated into computer and telephonic systems at 5 sites within the Pittsburgh Regional Initiative for Diabetes Education (PRIDE) network. Data were obtained from 290 patients with diabetes using the system at these programs via paper-and-pencil questionnaires following baseline D-SMART assessments and electronic system measurement of system performance. Process evaluation included time of completion, understanding content, usability of technology, and satisfaction with the system. Patients were 58% female and 85% Caucasian and had a mean age of 58 years. Fifty-six percent of patients had no more than a high school education, and 78% had Internet access at home.

RESULTS

Most patients reported completing the D-SMART at home (78%), in 1 attempt (86%) via the Internet (55%), and in less than 30 minutes. Seventy-six percent believed the questions were easy to understand, and 80% did not need assistance. Age was negatively associated with ease of use. Moreover, 76% of patients believed the D-SMART helped them think about their diabetes, with 67% indicating that it gave the diabetes educator good information about themselves and their diabetes. Most (94%) were satisfied with the D-SMART. Level of satisfaction was independent of the system being used.

CONCLUSIONS

The D-SMART was easily completed at home in 1 attempt, content was understandable, and patients were generally satisfied with the wording of questions and selection of answers. The D-SMART is easy to use and enhanced communication between the patient and clinician; however, elderly patients may need more assistance. Computer-based and telephonic D-SMARTs appear to be feasible and useful assessment methods for diabetes educators.

Cardiovascular disease risk prediction in type 1 diabetes: accounting for the differences

Present analyses used data from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective study of subjects with childhood type 1 diabetes (T1D), diagnosed between 1950 and 1980. Baseline exams took place 1986-1988 with biennial exams since. The Framingham risk equation was applied to generate the probability of risk for coronary heart disease (CHD) (MI, CHD death, or Q-waves) in 552 CHD free subjects who experienced 42 events over the 10-year follow-up period. Probabilities were split in to deciles. Expected and observed events were compared and demonstrated poor prediction. Risk factors previously found to be associated with CHD in T1D other than those in the Framingham risk function (age, smoking, cholesterol/HDLc, systolic blood pressure) were compared within the highest risk deciles. In men, elevated fibrinogen (p=0.007), white blood cell count (WBC) (p=0.037), albumin excretion rate (AER) (p=0.0001), and lower HDLc (p=0.048) were predictive. In females, higher Beck Depression Inventory (p=0.008), HbA1 (p=0.008), AER (p=0.01), LDLc (p=0.007), fibrinogen (p=0.006), WBC (p=0.005), non-HDLc (p=0.0005), WHR (p=0.003), and estimated glucose disposal rate (p=0.002) were associated. Risk factors not considered by the Framingham risk equation may account for the lack of fit and should be examined further.

Novel approaches to diabetes care: a population perspective

PURPOSE OF REVIEW

The purpose of this review is to outline the current state of diabetes in the United States and to explore novel, population-based approaches that involve the patient, provider and community, in the context of the health system, to improve diabetes care.

RECENT FINDINGS

Currently, there is sub-optimal delivery of diabetes processes and outcomes in the United States. The US healthcare system remains rooted in acute and episodic care, resulting in consistently low-quality healthcare, and is not equipped to handle the diabetes epidemic. Evidence demonstrates that models of chronic care are needed in order for system changes to occur. Recent studies that have implemented such models are beginning to demonstrate improvements in both process measures and clinical outcomes following interventions which incorporate a comprehensive approach to chronic illness care.

SUMMARY

Research over the past 5+ years demonstrates that a more comprehensive approach to diabetes care is needed. Only recently have studies been able to validate this concept, however. Applied research that strives to translate available knowledge and operationalize it in clinical and public health practice is needed in order for diabetes care to improve.

Developing and validating a diabetes database in a large health system

BACKGROUND

One component of clinical information systems is a registry of patients. Registries allow providers to identify gaps in care at the population level. Registries also allow for rapid cycle continuous quality improvement, targeted practice change and improved outcomes. Most registries are built based on membership with an insurer or other selection criteria. Little, if any data exist on registries representing demographically heterogeneous populations.

METHODS

Administrative and clinical data for the period 1/1/2000-12/30/03 were examined. In total, 46,082,941 lab reports, 233,292,544 medical records, and 9,351,415 medical record abstracts, representing approximately 2 million unique patients were searched. The diabetes source population was identified by presence of any one of the following criteria: ICD-9 code 250 (diabetes) for inpatient, emergency room or outpatient visits; any hemoglobin A1c result; blood glucose >200mg/dl; or diabetes medication. A diagnosis of diabetes was verified by trained chart reviewers on a sample of patients. Single indicators and combinations were examined to determine optimal identification of these cases.

RESULTS

In two separate validation studies, using two or more indicators or outpatient diagnosis maximized positive predictive value (PPV) (96 and 97%) and sensitivity (99 and 100%) and identified 55,807 individuals. When all patients with a single indicator of outpatient diagnosis (which had the highest single PPV of 94 and 95%) were included together with those having >or=2 indicators, the final sample size was 65,725.

CONCLUSION

Two or more indicators or an out-patient-diagnosis identifies a sizeable and unselective diabetes database which can be used to track processes and outcomes.

Antioxidants and coronary artery disease among individuals with type 1 diabetes: Findings from the Pittsburgh Epidemiology of Diabetes Complications Study

OBJECTIVE

Oxidative stress has been implicated in the development of diabetes and cardiovascular disease. We evaluated the effect of serum antioxidants and total antioxidant reserve (TAR) on coronary artery disease (CAD) incidence in type 1 diabetes.

METHODS

Subjects were identified from the Pittsburgh Epidemiology of Diabetes Complications Study (EDC) cohort, a 10-year prospective study of childhood-onset type 1 diabetes. Mean age at baseline was 28 and diabetes duration 19 years. Coronary artery disease was defined as physician-diagnosed angina, confirmed MI, stenosis >or=50%, ischemic electrocardiogram (ECG), or revascularization. Controls were gender, age, and diabetes duration (+/-3 years) matched with cases. Samples and risk factors used in analyses were identified from the earliest exam prior to incidence in cases (54 cases, 67 controls).

RESULTS

None of the antioxidant measures (alpha-tocopherol, gamma-tocopherol, retinol, TAR) showed protection against incident CAD overall. However, a protective effect of alpha-tocopherol against CAD was observed among antioxidant supplement users (HR=0.22, 95% CI=0.10-0.49) and in renal disease (HR=0.46, 95% CI=0.23-0.91). Despite similar alpha-tocopherol concentration, there was no protective effect among nonusers of antioxidant supplements.

CONCLUSIONS

High alpha-tocopherol levels among patients with renal disease and in those using vitamin supplements were associated with lower CAD risk in type 1 diabetes. The specificity of these effects merits further investigation.

Influences on screening for chronic diabetes complications in type 1 diabetes

Screening for the long-term complications of diabetes is a critical component of diabetes management; however, evidence demonstrates that screening rates in diabetes populations are suboptimal. Our objective was to determine the use and predictors of optimal screening behavior, defined as receiving a fasting lipid test, dilated eye exam, spot urine test, foot examination, blood pressure reading, and hemoglobin A1c (HbA1c) in the previous year in a representative cohort of subjects with type 1 diabetes. Data are from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective cohort study of subjects with childhood onset type 1 diabetes. Data from 325 participants who responded to a survey during 1999-2001 were included in analyses. Reported screening rates were as follows: 87.9% had at least one HbA1c measurement in the past year, 63% had a foot exam, 73.3% had a spot urine test, 81.9% had a dilated eye exam, 93.5% had a blood pressure reading and 68.7% received a fasting lipid profile. Within this group, 37.7% of subjects reported undergoing all five tests (optimal screening). Independent correlates of optimal screening were receiving care from a specialist provider (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.4-4.1) and blood glucose monitoring at least weekly (OR = 2.6; 95% CI: 1.1-6.2). These findings indicate that a large proportion of persons with type 1 diabetes are not being screened at the optimal level. Our data indicate that efforts to rectify this should focus on men and those who do not monitor blood glucose, and should involve primary care practitioners.

Deficiencies of cardiovascular risk prediction models for type 1 diabetes

OBJECTIVE

Cardiovascular risk prediction models are available for the general population (Framingham) and for type 2 diabetes (U.K. Prospective Diabetes Study [UKPDS] Risk Engine) but may not be appropriate in type 1 diabetes, as risk factors including younger age at diabetes onset and presence of diabetes complications are not considered. Therefore, our objective was to examine the accuracy of Framingham and UKPDS models for predicting coronary heart disease (CHD) in a type 1 diabetic cohort.

RESEARCH DESIGN AND METHODS

Ten-year follow-up data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, a prospective cohort study of 658 subjects with childhood-onset type 1 diabetes diagnosed between 1950 and 1980 first seen in 1986-1988, were analyzed. EDC study data were used to calculate the 10-year probability of CHD (fatal CHD, nonfatal myocardial infarction, or Q-waves) applying to the Framingham and UKPDS equations.

RESULTS

Mean age at CHD onset was 39 years. When fatal/nonfatal myocardial infarction and CHD death were modeled, both the UKPDS and Framingham models showed significant lack of calibration (P < 0.0001) but moderate discrimination (0.76 UKPDS, 0.77 Framingham men, and 0.88 Framingham women). Both the UKPDS and Framingham models underestimated probability of events in highest risk deciles.

CONCLUSIONS

Currently available CHD models poorly predict events in type 1 diabetes. Future research should focus on determining the risk factors accounting for the lack of fit and developing prediction models specific to this high-risk group.