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Patel PR, Desai JR, Plescia M, Baggett J, Briss P. The Role of U.S. Public Health Agencies in Addressing Long COVID. Am J Prev Med 2024; 66:921-926. [PMID: 38218559 DOI: 10.1016/j.amepre.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/05/2024] [Accepted: 01/07/2024] [Indexed: 01/15/2024]
Affiliation(s)
- Priti R Patel
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia.
| | - Jay R Desai
- Minnesota Department of Health, Minneapolis, Minnesota
| | - Marcus Plescia
- Association of State and Territorial Health Officials, Arlington, Virginia
| | - Jessica Baggett
- Association of State and Territorial Health Officials, Arlington, Virginia
| | - Peter Briss
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Kayle M, Blewer AL, Pan W, Rothman JA, Polick CS, Rivenbark J, Fisher E, Reyes C, Strouse JJ, Weeks S, Desai JR, Snyder AB, Zhou M, Sutaria A, Valle J, Horiuchi SS, Sontag MK, Miller JI, Singh A, Dasgupta M, Janson IA, Galadanci N, Reeves SL, Latta K, Hurden I, Cromartie SJ, Plaxco AP, Mukhopadhyay A, Smeltzer MP, Hulihan M. Birth Prevalence of Sickle Cell Disease and County-Level Social Vulnerability - Sickle Cell Data Collection Program, 11 States, 2016-2020. MMWR Morb Mortal Wkly Rep 2024; 73:248-254. [PMID: 38547025 PMCID: PMC10986820 DOI: 10.15585/mmwr.mm7312a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Sickle cell disease (SCD) remains a public health priority in the United States because of its association with complex health needs, reduced life expectancy, lifelong disabilities, and high cost of care. A cross-sectional analysis was conducted to calculate the crude and race-specific birth prevalence for SCD using state newborn screening program records during 2016-2020 from 11 Sickle Cell Data Collection program states. The percentage distribution of birth mother residence within Social Vulnerability Index quartiles was derived. Among 3,305 newborns with confirmed SCD (including 57% with homozygous hemoglobin S or sickle β-null thalassemia across 11 states, 90% of whom were Black or African American [Black], and 4% of whom were Hispanic or Latino), the crude SCD birth prevalence was 4.83 per 10,000 (one in every 2,070) live births and 28.54 per 10,000 (one in every 350) non-Hispanic Black newborns. Approximately two thirds (67%) of mothers of newborns with SCD lived in counties with high or very high levels of social vulnerability; most mothers lived in counties with high or very high levels of vulnerability for racial and ethnic minority status (89%) and housing type and transportation (64%) themes. These findings can guide public health, health care systems, and community program planning and implementation that address social determinants of health for infants with SCD. Implementation of tailored interventions, including increasing access to transportation, improving housing, and advancing equity in high vulnerability areas, could facilitate care and improve health outcomes for children with SCD.
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Coughlin JW, Nauman E, Wellman R, Coley RY, McTigue KM, Coleman KJ, Jones DB, Lewis KH, Tobin JN, Wee CC, Fitzpatrick SL, Desai JR, Murali S, Morrow EH, Rogers AM, Wood GC, Schlundt DG, Apovian CM, Duke MC, McClay JC, Soans R, Nemr R, Williams N, Courcoulas A, Holmes JH, Anau J, Toh S, Sturtevant JL, Horgan CE, Cook AJ, Arterburn DE. Preoperative Depression Status and 5 Year Metabolic and Bariatric Surgery Outcomes in the PCORnet Bariatric Study Cohort. Ann Surg 2023; 277:637-646. [PMID: 35058404 PMCID: PMC9994793 DOI: 10.1097/sla.0000000000005364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine whether depression status before metabolic and bariatric surgery (MBS) influenced 5-year weight loss, diabetes, and safety/utilization outcomes in the PCORnet Bariatric Study. SUMMARY OF BACKGROUND DATA Research on the impact of depression on MBS outcomes is inconsistent with few large, long-term studies. METHODS Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005-2015. Patients with and without a depression diagnosis in the year before MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilization (reoperations, revisions, endoscopy, hospitalizations, mortality) at 1, 3, and 5 years after MBS. RESULTS 27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At 5 years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (between group difference = 0.42%TWL, P = 0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (between group difference = - 0.19, P = 0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG. CONCLUSIONS Patients with depression undergoing RYGB and SG had similar weight loss, diabetes, and safety/utilization outcomes to those without depression. The effects of depression were clinically small compared to the choice of operation.
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Affiliation(s)
- Janelle W Coughlin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, MD
| | | | - Robert Wellman
- Kaiser Permanente Washington Health Research institute, Seattle, WA
| | - R Yates Coley
- Kaiser Permanente Washington Health Research institute, Seattle, WA
| | - Kathleen M McTigue
- Departments of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Karen J Coleman
- Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena, CA
| | - Daniel B Jones
- Department of Surgery, Beth israel Deaconess Medical Center and Harvard Medical School Boston, MA
| | - Kristina H Lewis
- Departments of Epidemiology & Prevention, and implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jonathan N Tobin
- Clinical Directors Network (CDN) and The Rockefeller University Center for Clinical and Translational Science, New York, NY
| | - Christina C Wee
- Department of Surgery, Beth israel Deaconess Medical Center and Harvard Medical School Boston, MA
| | | | | | - Sameer Murali
- Kaiser Permanente Southern California Medical Group, Oakland, CA
| | - Ellen H Morrow
- Department of Surgery, University of Utah, Salt Lake City, UT
| | - Ann M Rogers
- Penn State University College of Medicine, Penn State Health, Department of Surgery, Hershey, PA
| | - G Craig Wood
- Obesity Institute, Geisinger Medical Center, Danville, PA
| | | | | | | | | | - Rohit Soans
- Temple University Hospital, Philadelphia, PA
| | - Rabih Nemr
- Weill Cornell Medical College, New York, NY
| | | | | | - John H Holmes
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jane Anau
- Louisiana Public Health Institute, New Orleans, LA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Jessica L Sturtevant
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Casie E Horgan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Andrea J Cook
- Kaiser Permanente Washington Health Research institute, Seattle, WA
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Saman DM, Allen CI, Freitag LA, Harry ML, Sperl-Hillen JM, Ziegenfuss JY, Haapala JL, Crain AL, Desai JR, Ohnsorg KA, O’Connor PJ. Clinician perceptions of a clinical decision support system to reduce cardiovascular risk among prediabetes patients in a predominantly rural healthcare system. BMC Med Inform Decis Mak 2022; 22:301. [PMID: 36402988 PMCID: PMC9675125 DOI: 10.1186/s12911-022-02032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 10/27/2022] [Indexed: 11/20/2022] Open
Abstract
Background The early detection and management of uncontrolled cardiovascular risk factors among prediabetes patients can prevent cardiovascular disease (CVD). Prediabetes increases the risk of CVD, which is a leading cause of death in the United States. CVD clinical decision support (CDS) in primary care settings has the potential to reduce cardiovascular risk in patients with prediabetes while potentially saving clinicians time. The objective of this study is to understand primary care clinician (PCC) perceptions of a CDS system designed to reduce CVD risk in adults with prediabetes. Methods We administered pre-CDS implementation (6/30/2016 to 8/25/2016) (n = 183, 61% response rate) and post-CDS implementation (6/12/2019 to 8/7/2019) (n = 131, 44.5% response rate) independent cross-sectional electronic surveys to PCCs at 36 randomized primary care clinics participating in a federally funded study of a CVD risk reduction CDS tool. Surveys assessed PCC demographics, experiences in delivering prediabetes care, perceptions of CDS impact on shared decision making, perception of CDS impact on control of major CVD risk factors, and overall perceptions of the CDS tool when managing cardiovascular risk. Results We found few significant differences when comparing pre- and post-implementation responses across CDS intervention and usual care (UC) clinics. A majority of PCCs felt well-prepared to discuss CVD risk factor control with patients both pre- and post-implementation. About 73% of PCCs at CDS intervention clinics agreed that the CDS helped improve risk control, 68% reported the CDS added value to patient clinic visits, and 72% reported they would recommend use of this CDS system to colleagues. However, most PCCs disagreed that the CDS saves time talking about preventing diabetes or CVD, and most PCCs also did not find the clinical domains useful, nor did PCCs believe that the clinical domains were useful in getting patients to take action. Finally, only about 38% reported they were satisfied with the CDS. Conclusions These results improve our understanding of CDS user experience and can be used to guide iterative improvement of the CDS. While most PCCs agreed the CDS improves CVD and diabetes risk factor control, they were generally not satisfied with the CDS. Moreover, only 40–50% agreed that specific suggestions on clinical domains helped patients to take action. In spite of this, an overwhelming majority reported they would recommend the CDS to colleagues, pointing for the need to improve upon the current CDS. Trial registration: NCT02759055 03/05/2016.
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Coleman KJ, Wellman R, Fitzpatrick SL, Conroy MB, Hlavin C, Lewis KH, Coley RY, McTigue KM, Tobin JN, McBride CL, Desai JR, Clark JM, Toh S, Sturtevant JL, Horgan CE, Duke MC, Williams N, Anau J, Horberg MA, Michalsky MP, Cook AJ, Arterburn DE, Apovian CM. Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort. JAMA Surg 2022; 157:897-906. [PMID: 36044239 PMCID: PMC9434478 DOI: 10.1001/jamasurg.2022.3714] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/02/2022] [Indexed: 11/14/2022]
Abstract
Importance Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups. Objective To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study. Design, Setting, and Participants This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022. Exposure RYGB or SG. Outcomes Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery. Results A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse. Conclusions and Relevance Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.
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Affiliation(s)
- Karen J. Coleman
- Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena
| | - Robert Wellman
- Kaiser Permanente Washington Health Research Institute, Seattle
| | | | | | - Callie Hlavin
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristina H. Lewis
- Departments of Epidemiology & Prevention, and Implementation Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - R. Yates Coley
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Kathleen M. McTigue
- Departments of Medicine and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan N. Tobin
- Clinical Directors Network and The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | | | - Jay R. Desai
- HealthPartners Institute, Minneapolis, Minnesota
| | - Jeanne M. Clark
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sengwee Toh
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jessica L. Sturtevant
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | - Casie E. Horgan
- Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jane Anau
- Kaiser Permanente Washington Health Research Institute, Seattle
| | | | | | - Andrea J. Cook
- Kaiser Permanente Washington Health Research Institute, Seattle
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Schroeder EB, Neugebauer R, Reynolds K, Schmittdiel JA, Loes L, Dyer W, Pimentel N, Desai JR, Vazquez-Benitez G, Ho PM, Anderson JP, O’Connor PJ. Association of Cardiovascular Outcomes and Mortality With Sustained Long-Acting Insulin Only vs Long-Acting Plus Short-Acting Insulin Treatment. JAMA Netw Open 2021; 4:e2126605. [PMID: 34559229 PMCID: PMC8463942 DOI: 10.1001/jamanetworkopen.2021.26605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Cardiovascular events and mortality are the principal causes of excess mortality and health care costs for people with type 2 diabetes. No large studies have specifically compared long-acting insulin alone with long-acting plus short-acting insulin with regard to cardiovascular outcomes. OBJECTIVE To compare cardiovascular events and mortality in adults with type 2 diabetes receiving long-acting insulin who do or do not add short-acting insulin. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study emulated a randomized experiment in which adults with type 2 diabetes who experienced a qualifying glycated hemoglobin A1c (HbA1c) level of 6.8% to 8.5% with long-acting insulin were randomized to continuing treatment with long-acting insulin (LA group) or adding short-acting insulin within 1 year of the qualifying HbA1c level (LA plus SA group). Retrospective data in 4 integrated health care delivery systems from the Health Care Systems Research Network from January 1, 2005, to December 31, 2013, were used. Analysis used inverse probability weighting estimation with Super Learner for propensity score estimation. Analyses took place from April 1, 2018, to June 30, 2019. EXPOSURES Long-acting insulin alone or with added short-acting insulin within 1 year from the qualifying HbA1c level. MAIN OUTCOMES AND MEASURES Mortality, cardiovascular mortality, acute myocardial infarction, stroke, and hospitalization for heart failure. RESULTS Among 57 278 individuals (39 279 with data on cardiovascular mortality) with a mean (SD) age of 60.6 (11.5) years, 53.6% men, 43.5% non-Hispanic White individuals, and 4 years of follow-up (median follow-up of 11 [interquartile range, 5-20] calendar quarters), the LA plus SA group was associated with increased all-cause mortality compared with the LA group (hazard ratio, 1.27; 95% CI, 1.05-1.49) and a decreased risk of acute myocardial infarction (hazard ratio, 0.89; 95% CI, 0.81-0.97). Treatment with long-acting plus short-acting insulin was not associated with increased risks of congestive heart failure, stroke, or cardiovascular mortality. CONCLUSIONS AND RELEVANCE Findings of this retrospective cohort study suggested an increased risk of all-cause mortality and a decreased risk of acute myocardial infarction for the LA plus SA group compared with the LA group. Given the lack of an increase in major cardiovascular events or cardiovascular mortality, the increased all-cause mortality with long-acting plus short-acting insulin may be explained by noncardiovascular events or unmeasured confounding.
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Affiliation(s)
- Emily B. Schroeder
- Kaiser Permanente Colorado Institute for Health Research, Aurora
- Parkview Health, Fort Wayne, Indiana
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Linda Loes
- HealthPartners Institute, Minneapolis, Minnesota
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jay R. Desai
- HealthPartners Institute, Minneapolis, Minnesota
- Minnesota Department of Health, St Paul
| | | | - P. Michael Ho
- Rocky Mountain Regional Veterans Affairs and University of Colorado (Anschutz) Medical Center, Denver
| | | | - Patrick J. O’Connor
- HealthPartners Institute, Minneapolis, Minnesota
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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Desai JR, Vazquez-Benitez G, Taylor G, Johnson S, Anderson J, Garrett JE, Gilmer T, Vue-Her H, Rinn S, Engel K, Schiff J, O'Connor PJ. The effects of financial incentives on diabetes prevention program attendance and weight loss among low-income patients: the We Can Prevent Diabetes cluster-randomized controlled trial. BMC Public Health 2020; 20:1587. [PMID: 33087083 PMCID: PMC7580006 DOI: 10.1186/s12889-020-09683-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 10/13/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Penetration and participation of real life implementation of lifestyle change programs to prevent type 2 diabetes has been challenging. This is particularly so among low income individuals in the United States. The purpose of this study is to examine the effectiveness of financial incentives on attendance and weight loss among Medicaid beneficiaries participating in the 12-month Diabetes Prevention Program (DPP). METHODS This is a cluster-randomized controlled trial with two financial incentive study arms and an attention control study arm. Medicaid beneficiaries with prediabetes from 13 primary care clinics were randomly assigned to individually earned incentives (IND; 33 groups; n = 309), a hybrid of individual- and group-earned incentives (GRP; 30 groups; n = 259), and an attention control (AC; 30 groups; n = 279). Up to $520 in incentives could be earned for attaining attendance and weight loss goals over 12 months. Outcomes are percent weight loss from baseline, achieving 5% weight loss from baseline, and attending 75% of core and 75% of maintenance DPP sessions. Linear mixed models were used to examine weight change and attendance rates over the 16 weeks and 12 months. RESULTS The percent weight change at 16 weeks for the IND, GRP, and AC participants were similar, at - 2.6, - 3.1%, and - 3.4%, respectively. However, participants achieving 5% weight loss in the IND, GRP, and AC groups was 21.5, 24.0% (GRP vs AC, P < 0.05), and 15.2%. Attendance at 75% of the DPP core sessions was significantly higher among IND (60.8%, P < 0.001) and GRP (64.0%, P < 0.001) participants than among AC (38.6%) participants. Despite substantial attrition over time, attendance at 75% of the DPP maintenance sessions was also significantly higher among IND (23.0%, P < 0.001) and GRP (26.1%, P < 0.001) participants than among AC (11.0%) participants. CONCLUSIONS Financial incentives can improve the proportion of Medicaid beneficiaries attending the 12-month DPP and achieving at least 5% weight loss. TRIAL REGISTRATION ClinicalTrials.gov NCT02422420 ; retrospectively registered April 21, 2015.
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Affiliation(s)
- Jay R Desai
- HealthPartners Institute, Bloomington, MN, USA. .,Minnesota Department of Health, 85 East 7th Place, P.O. Box 64882, St. Paul, MN, 55164, USA.
| | | | - Gretchen Taylor
- Minnesota Department of Health, 85 East 7th Place, P.O. Box 64882, St. Paul, MN, 55164, USA
| | - Sara Johnson
- Minnesota Department of Health, 85 East 7th Place, P.O. Box 64882, St. Paul, MN, 55164, USA
| | - Julie Anderson
- Minnesota Department of Health, 85 East 7th Place, P.O. Box 64882, St. Paul, MN, 55164, USA
| | | | - Todd Gilmer
- University of California, La Jolla, San Diego, CA, USA
| | - Houa Vue-Her
- Minnesota Department of Health, 85 East 7th Place, P.O. Box 64882, St. Paul, MN, 55164, USA
| | - Sarah Rinn
- Minnesota Department of Human Services, St. Paul, MN, USA
| | | | - Jeff Schiff
- Minnesota Department of Human Services, St. Paul, MN, USA
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Neugebauer R, Schroeder EB, Reynolds K, Schmittdiel JA, Loes L, Dyer W, Desai JR, Vazquez-Benitez G, Ho PM, Anderson JP, Pimentel N, O’Connor PJ. Comparison of Mortality and Major Cardiovascular Events Among Adults With Type 2 Diabetes Using Human vs Analogue Insulins. JAMA Netw Open 2020; 3:e1918554. [PMID: 31977057 PMCID: PMC6991251 DOI: 10.1001/jamanetworkopen.2019.18554] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 10/15/2019] [Indexed: 12/25/2022] Open
Abstract
Importance The comparative cardiovascular safety of analogue and human insulins in adults with type 2 diabetes who initiate insulin therapy in usual care settings has not been carefully evaluated using machine learning and other rigorous analytic methods. Objective To examine the association of analogue vs human insulin use with mortality and major cardiovascular events. Design, Setting, and Participants This retrospective cohort study included 127 600 adults aged 21 to 89 years with type 2 diabetes at 4 health care delivery systems who initiated insulin therapy from January 1, 2000, through December 31, 2013. Machine learning and rigorous inference methods with time-varying exposures were used to evaluate associations of continuous exposure to analogue vs human insulins with mortality and major cardiovascular events. Data were analyzed from September 1, 2017, through June 30, 2018. Exposures On the index date (first insulin dispensing), participants were classified as using analogue insulin with or without human insulin or human insulin only. Main Outcomes and Measures Overall mortality, mortality due to cardiovascular disease (CVD), myocardial infarction (MI), stroke or cerebrovascular accident (CVA), and hospitalization for congestive heart failure (CHF) were evaluated. Marginal structural modeling (MSM) with inverse probability weighting was used to compare event-free survival in separate per-protocol analyses. Adjusted and unadjusted hazard ratios and cumulative risk differences were based on logistic MSM parameterizations for counterfactual hazards. Propensity scores were estimated using a data-adaptive approach (machine learning) based on 3 nested covariate adjustment sets. Sensitivity analyses were conducted to address potential residual confounding from unmeasured differences in risk factors across delivery systems. Results The 127 600 participants (mean [SD] age, 59.4 [12.6] years; 68 588 men [53.8%]; mean [SD] body mass index, 32.3 [7.1]) had a median follow-up of 4 quarters (interquartile range, 3-9 quarters) and experienced 5464 deaths overall (4.3%), 1729 MIs (1.4%), 1301 CVAs (1.0%), and 3082 CHF hospitalizations (2.4%). There were no differences in adjusted hazard ratios for continuous analogue vs human insulin exposure during 10 quarters for overall mortality (1.15; 95% CI, 0.97-1.34), CVD mortality (1.26; 95% CI, 0.86-1.66), MI (1.11; 95% CI, 0.77-1.45), CVA (1.30; 95% CI, 0.81-1.78), or CHF hospitalization (0.93; 95% CI, 0.75-1.11). Conclusions and Relevance Insulin-naive adults with type 2 diabetes who initiate and continue treatment with human vs analogue insulins had similar observed rates of major cardiovascular events, CVD mortality, and overall mortality.
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Affiliation(s)
- Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Linda Loes
- HealthPartners Institute, Minneapolis, Minnesota
| | - Wendy Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jay R. Desai
- HealthPartners Institute, Minneapolis, Minnesota
| | | | - P. Michael Ho
- Rocky Mountain Regional Veterans Affairs and University of Colorado (Anschutz) Medical Center, Denver
| | | | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Patrick J. O’Connor
- HealthPartners Institute, Minneapolis, Minnesota
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota
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Sperl-Hillen JM, Crain AL, Margolis KL, Ekstrom HL, Appana D, Amundson G, Sharma R, Desai JR, O'Connor PJ. Clinical decision support directed to primary care patients and providers reduces cardiovascular risk: a randomized trial. J Am Med Inform Assoc 2019; 25:1137-1146. [PMID: 29982627 DOI: 10.1093/jamia/ocy085] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/04/2018] [Indexed: 12/18/2022] Open
Abstract
Objective To test the hypothesis that use of a clinical decision support (CDS) system in a primary care setting can reduce cardiovascular (CV) risk in patients. Materials and Methods Twenty primary care clinics were randomly assigned to usual care (UC) or CDS. For CDS clinic patients identified algorithmically with high CV risk, rooming staff were prompted by the electronic health record (EHR) to print CDS that identified evidence-based treatment options for lipid, blood pressure, weight, tobacco, or aspirin management and prioritized them based on potential benefit to the patient. The intention-to-treat analysis included 7914 adults who met high CV risk criteria at an index clinic visit and had at least one post-index visit, accounted for clustering, and assessed impact on predicted annual rate of change in 10-year CV risk over a 14-month period. Results The CDS was printed at 75% of targeted visits, and providers reported 85% to 98% satisfaction with various aspects of the intervention. Predicted annual rate of change in absolute 10-year CV risk was significantly better in CDS clinics than in UC clinics (-0.59% vs. +1.66%, -2.24%; P < .001), with difference in 10-year CV risk at 12 months post-index favoring the CDS group (UC 24.4%, CDS 22.5%, P < .03). Discussion Deploying to both patients and providers within primary care visit workflow and limiting CDS display and print burden to two mouse clicks by rooming staff contributed to high CDS use rates and high provider satisfaction. Conclusion This EHR-integrated, web-based outpatient CDS system significantly improved 10-year CV risk trajectory in targeted adults.
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Affiliation(s)
- JoAnn M Sperl-Hillen
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
| | | | - Karen L Margolis
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Heidi L Ekstrom
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
| | | | | | - Rashmi Sharma
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Jay R Desai
- HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Patrick J O'Connor
- HealthPartners Center for Chronic Care Innovation, Minneapolis, Minnesota, USA.,HealthPartners Institute, Minneapolis, Minnesota, USA
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Sperl-Hillen JM, Rossom RC, Kharbanda EO, Gold R, Geissal ED, Elliott TE, Desai JR, Rindal DB, Saman DM, Waring SC, Margolis KL, O’Connor PJ. Priorities Wizard: Multisite Web-Based Primary Care Clinical Decision Support Improved Chronic Care Outcomes with High Use Rates and High Clinician Satisfaction Rates. EGEMS (Wash DC) 2019; 7:9. [PMID: 30972358 PMCID: PMC6450247 DOI: 10.5334/egems.284] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 01/29/2019] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Priorities Wizard is an electronic health record-linked, web-based clinical decision support (CDS) system designed and implemented at multiple Health Care Systems Research Network (HCSRN) sites to support high quality outpatient chronic disease and preventive care. The CDS system (a) identifies patients who could substantially benefit from evidence-based actions; (b) presents prioritized evidence-based treatment options to both patient and clinician at the point of care; and (c) facilitates efficient ordering of recommended medications, referrals or procedures. METHODS The CDS system extracts relevant data from electronic health records (EHRs), processes the data using Web-based clinical decision support algorithms, and displays the CDS output seamlessly on the EHR screen for use by the clinician and patient. Through a series of National Institutes of Health-funded projects led by HealthPartners Institute and the HealthPartners Center for Chronic Care Innovation and HCSRN partners, Priorities Wizard has been evaluated in cluster-randomized trials and expanded to include over 20 clinical domains. RESULTS Cluster-randomized trials show that this CDS system significantly improved glucose and blood pressure control in diabetes patients, reduced 10-year cardiovascular (CV) risk in high-CV risk adults without diabetes, improved management of smoking in dental patients, and improved high blood pressure identification and management in adolescents. CDS output was used at 71-77 percent of targeted visits, 85-98 percent of clinicians were satisfied with the CDS system, and 94 percent reported they would recommend it to colleagues. CONCLUSIONS Recently developed EHR-linked, Web-based CDS systems have significantly improved chronic disease care outcomes and have high use rates and primary care clinician satisfaction.
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11
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Harry ML, Saman DM, Allen CI, Ohnsorg KA, Sperl-Hillen JM, O’Connor PJ, Ziegenfuss JY, Dehmer SP, Bianco JA, Desai JR. Understanding Primary Care Provider Attitudes and Behaviors Regarding Cardiovascular Disease Risk and Diabetes Prevention in the Northern Midwest. Clin Diabetes 2018; 36:283-294. [PMID: 30363898 PMCID: PMC6187954 DOI: 10.2337/cd17-0116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
IN BRIEF We sought to fill critical gaps in understanding primary care providers' (PCPs') beliefs regarding diabetes prevention and cardiovascular disease risk in the prediabetes population, including through comparison of attitudes between rural and non-rural PCPs. We used data from a 2016 cross-sectional survey sent to 299 PCPs practicing in 36 primary clinics that are part of a randomized control trial in a predominately rural northern Midwestern integrated health care system. Results showed a few significant, but clinically marginal, differences between rural and non-rural PCPs. Generally, PCPs agreed with the importance of screening for prediabetes and thoroughly and clearly discussing CV risk with high-risk patients.
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Affiliation(s)
| | - Daniel M. Saman
- Essentia Health, Essentia Institute of Rural Health, Duluth, MN
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12
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Allen EM, Lee HY, Pratt R, Vang H, Desai JR, Dube A, Lightfoot E. Facilitators and Barriers of Cervical Cancer Screening and Human Papilloma Virus Vaccination Among Somali Refugee Women in the United States: A Qualitative Analysis. J Transcult Nurs 2018; 30:55-63. [PMID: 30170512 DOI: 10.1177/1043659618796909] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Eastern Africa has the highest rates of cervical cancer incidence (42.7 per 100,000) and mortality (27.6 per 100,000), substantially higher than worldwide incidence (14.0 per 100,000) and mortality (6.8 per 100,000). The purpose of this study was to explore facilitators and barriers to cervical cancer screening and human papilloma virus (HPV) vaccination among Somali refugee women and their children. METHOD Focus group discussions were conducted in August of 2016. Investigators performed systematic, comparative, and thematic data analyses. RESULTS The 31 Somali refugee participants ranged from 23 to 64 years old. Four major themes emerged: (1) knowledge, (2) facilitators, (3) decision making, and (4) views on intervention strategies. Doctor recommendation and family support were important facilitators. Community education was the most popular strategy in promoting screening and vaccine uptake. DISCUSSION Multilevel targeted interventions should increase knowledge and include family members to increase cervical cancer screening and HPV vaccination uptake in the Somali community.
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Affiliation(s)
| | - Hee Yun Lee
- 2 University of Alabama, Tuscaloosa, AL, USA
| | | | - Houa Vang
- 4 University of Minnesota, St. Paul, MN, USA
| | - Jay R Desai
- 5 HealthPartners Institute, Bloomington, MN, USA
| | - Amano Dube
- 6 Brian Coyle Center, Minneapolis, MN, USA
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Pawar JD, Jagtap RS, Doijad RC, Pol SV, Desai JR, Jadhav VV, Jagtap SR. LIQUISOLID COMPACTS: A PROMISING APPROACH FOR SOLUBILITY ENHANCEMENT. ACTA ACUST UNITED AC 2017. [DOI: 10.22270/jddt.v7i4.1466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Desai JR, Vazquez-Benitez G, Xu Z, Schroeder EB, Karter AJ, Steiner JF, Nichols GA, Reynolds K, Xu S, Newton K, Pathak RD, Waitzfelder B, Lafata JE, Butler MG, Kirchner HL, Thomas A, O'Connor PJ. Who Must We Target Now to Minimize Future Cardiovascular Events and Total Mortality?: Lessons From the Surveillance, Prevention and Management of Diabetes Mellitus (SUPREME-DM) Cohort Study. Circ Cardiovasc Qual Outcomes 2016; 8:508-16. [PMID: 26307132 DOI: 10.1161/circoutcomes.115.001717] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Examining trends in cardiovascular events and mortality in US health systems can guide the design of targeted clinical and public health strategies to reduce cardiovascular events and mortality rates. METHODS AND RESULTS We conducted an observational cohort study from 2005 to 2011 among 1.25 million diabetic subjects and 1.25 million nondiabetic subjects from 11 health systems that participate in the Surveillance, Prevention and Management of Diabetes Mellitus (SUPREME-DM) DataLink. Annual rates (per 1000 person-years) of myocardial infarction/acute coronary syndrome (International Classification of Diseases-Ninth Revision, 410.0–410.91, 411.1–411.8), stroke (International Classification of Diseases-Ninth Revision, 430–432.9, 433–434.9), heart failure (International Classification of Diseases-Ninth Revision, 428–428.9), and all-cause mortality were monitored by diabetes mellitus (DM) status, age, sex, race/ethnicity, and a prior cardiovascular history. We observed significant declines in cardiovascular events and mortality rates in subjects with and without DM. However, there was substantial variation by age, sex, race/ethnicity, and prior cardiovascular history. Mortality declined from 44.7 to 27.1 (P<0.0001) for those with DM and cardiovascular disease (CVD), from 11.2 to 10.9 (P=0.03) for those with DM only, and from 18.9 to 13.0 (P<0.0001) for those with CVD only. Yet, in the [almost equal to]85% of subjects with neither DM nor CVD, overall mortality (7.0 to 6.8; P=0.10) and stroke rates (1.6–1.6; P=0.77) did not decline and heart failure rates increased (0.9–1.15; P=0.0005). CONCLUSIONS To sustain improvements in myocardial infarction, stroke, heart failure, and mortality, health systems that have successfully focused on care improvement in high-risk adults with DM or CVD must broaden their improvement strategies to target lower risk adults who have not yet developed DM or CVD.
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15
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Schroeder EB, Powers JD, O'Connor PJ, Nichols GA, Xu S, Desai JR, Karter AJ, Morales LS, Newton KM, Pathak RD, Vazquez-Benitez G, Raebel MA, Butler MG, Lafata JE, Reynolds K, Thomas A, Waitzfelder BE, Steiner JF. Prevalence of chronic kidney disease among individuals with diabetes in the SUPREME-DM Project, 2005-2011. J Diabetes Complications 2015; 29:637-43. [PMID: 25936953 DOI: 10.1016/j.jdiacomp.2015.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/11/2015] [Indexed: 11/19/2022]
Abstract
AIMS Diabetes is a leading cause of chronic kidney disease (CKD). Different methods of CKD ascertainment may impact prevalence estimates. We used data from 11 integrated health systems in the United States to estimate CKD prevalence in adults with diabetes (2005-2011), and compare the effect of different ascertainment methods on prevalence estimates. METHODS We used the SUPREME-DM DataLink (n = 879,312) to estimate annual CKD prevalence. Methods of CKD ascertainment included: diagnosis codes alone, impaired estimated glomerular filtration rate (eGFR) alone (eGFR < 60 mL/min/1.73 m(2)), albuminuria alone (spot urine albumin creatinine ratio > 30 mg/g or equivalent), and combinations of these approaches. RESULTS CKD prevalence was 20.0% using diagnosis codes, 17.7% using impaired eGFR, 11.9% using albuminuria, and 32.7% when one or more method suggested CKD. The criteria had poor concordance. After age- and sex-standardization to the 2010 U.S. Census population, prevalence using diagnosis codes increased from 10.7% in 2005 to 14.3% in 2011 (P < 0.001). The prevalence using eGFR decreased from 9.7% in 2005 to 8.6% in 2011 (P < 0.001). CONCLUSIONS Our data indicate that CKD prevalence and prevalence trends differ according to the CKD ascertainment method, highlighting the necessity for multiple sources of data to accurately estimate and track CKD prevalence.
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Affiliation(s)
- Emily B Schroeder
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
| | - J David Powers
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Patrick J O'Connor
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | | | - Stanley Xu
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Jay R Desai
- HealthPartners Institute for Education and Research, Minneapolis, Minnesota
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Leo S Morales
- Group Health Research Institute, Seattle, Washington
| | | | | | | | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado
| | - Melissa G Butler
- Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Jennifer Elston Lafata
- Department of Social and Behavioral Health, Virginia Commonwealth University, Richmond, Virginia; Henry Ford Health System, Detroit, Michigan
| | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | | | | | - John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; University of Colorado School of Medicine, Aurora, Colorado
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Vazquez-Benitez G, Desai JR, Xu S, Goodrich GK, Schroeder EB, Nichols GA, Segal J, Butler MG, Karter AJ, Steiner JF, Newton KM, Morales LS, Pathak RD, Thomas A, Reynolds K, Kirchner HL, Waitzfelder B, Elston Lafata J, Adibhatla R, Xu Z, O'Connor PJ. Preventable major cardiovascular events associated with uncontrolled glucose, blood pressure, and lipids and active smoking in adults with diabetes with and without cardiovascular disease: a contemporary analysis. Diabetes Care 2015; 38:905-12. [PMID: 25710922 PMCID: PMC4876667 DOI: 10.2337/dc14-1877] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/28/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking. RESEARCH DESIGN AND METHODS Study subjects included 859,617 adults with diabetes enrolled for more than 6 months during 2005-2011 in a network of 11 U.S. integrated health care organizations. Inadequate risk factor control was classified as LDL-C ≥100 mg/dL, A1C ≥7% (53 mmol/mol), BP ≥140/90 mm Hg, or smoking. Major CV events were based on primary hospital discharge diagnoses for myocardial infarction (MI) and acute coronary syndrome (ACS), stroke, or heart failure (HF). Five-year incidence rates, rate ratios, and average attributable fractions were estimated using multivariable Poisson regression models. RESULTS Mean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD. CONCLUSIONS Additional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.
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Affiliation(s)
| | - Jay R Desai
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - Stanley Xu
- Kaiser Permanente Institute for Health Research, Denver, CO
| | | | | | | | | | - Melissa G Butler
- Kaiser Permanente Georgia, Center for Health Research Southeast, Atlanta, GA
| | - Andrew J Karter
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - John F Steiner
- Kaiser Permanente Institute for Health Research, Denver, CO
| | | | - Leo S Morales
- University of Washington School of Medicine, Seattle, WA
| | - Ram D Pathak
- Department of Endocrinology, Marshfield Clinic, Marshfield, WI
| | | | - Kristi Reynolds
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | | | - Jennifer Elston Lafata
- Lutheran Medical Center, Brooklyn, NY Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Renuka Adibhatla
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - Zhiyuan Xu
- HealthPartners Institute for Education and Research, Minneapolis, MN
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O'Connor PJ, Schmittdiel JA, Pathak RD, Harris RI, Newton KM, Ohnsorg KA, Heisler M, Sterrett AT, Xu S, Dyer WT, Raebel MA, Thomas A, Schroeder EB, Desai JR, Steiner JF. Randomized trial of telephone outreach to improve medication adherence and metabolic control in adults with diabetes. Diabetes Care 2014; 37:3317-24. [PMID: 25315207 PMCID: PMC4751474 DOI: 10.2337/dc14-0596] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Medication nonadherence is a major obstacle to better control of glucose, blood pressure (BP), and LDL cholesterol in adults with diabetes. Inexpensive effective strategies to increase medication adherence are needed. RESEARCH DESIGN AND METHODS In a pragmatic randomized trial, we randomly assigned 2,378 adults with diabetes mellitus who had recently been prescribed a new class of medication for treating elevated levels of glycated hemoglobin (A1C) ≥8% (64 mmol/mol), BP ≥140/90 mmHg, or LDL cholesterol ≥100 mg/dL, to receive 1) one scripted telephone call from a diabetes educator or clinical pharmacist to identify and address nonadherence to the new medication or 2) usual care. Hierarchical linear and logistic regression models were used to assess the impact on 1) the first medication fill within 60 days of the prescription; 2) two or more medication fills within 180 days of the prescription; and 3) clinically significant improvement in levels of A1C, BP, or LDL cholesterol. RESULTS Of the 2,378 subjects, 89.3% in the intervention group and 87.4% in the usual-care group had sufficient data to analyze study outcomes. In intent-to-treat analyses, intervention was not associated with significant improvement in primary adherence, medication persistence, or intermediate outcomes of care. Results were similar across subgroups of patients defined by age, sex, race/ethnicity, and study site, and when limiting the analysis to those who completed the intended intervention. CONCLUSIONS This low-intensity intervention did not significantly improve medication adherence or control of glucose, BP, or LDL cholesterol. Wide use of this strategy does not appear to be warranted; alternative approaches to identify and improve medication adherence and persistence are needed.
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Affiliation(s)
| | | | | | | | | | - Kris A Ohnsorg
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - Michele Heisler
- University of Michigan, Center for Clinical Management Research, Ann Arbor, MI
| | | | - Stanley Xu
- Institute for Health Research, Kaiser Permanente, Denver, CO
| | - Wendy T Dyer
- Kaiser Permanente Division of Research, Northern California, Oakland, CA
| | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente, Denver, CO
| | | | | | - Jay R Desai
- HealthPartners Institute for Education and Research, Minneapolis, MN
| | - John F Steiner
- Institute for Health Research, Kaiser Permanente, Denver, CO
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Affiliation(s)
- Jay R Desai
- HealthPartners Institute for Education & Research, Minneapolis, MN, USA
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Plimack ER, Desai JR, Issa JP, Jelinek J, Sharma P, Vence LM, Bassett RL, Ilagan JL, Papadopoulos NE, Hwu WJ. A phase I study of decitabine with pegylated interferon α-2b in advanced melanoma: impact on DNA methylation and lymphocyte populations. Invest New Drugs 2014; 32:969-75. [PMID: 24875133 DOI: 10.1007/s10637-014-0115-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/13/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Melanoma cell lines treated with decitabine show upregulation of cancer antigens, and interferon-α upregulates MHC Class I antigens in cancer cells, leading to enhanced T-cell recognition and T-cell mediated tumor apoptosis. We evaluated the synergy between the hypomethylating effects of decitabine and the immunomodulatory effects of interferon in a combination regimen administered to advanced melanoma patients in a phase 1 trial. METHODS Patients with one prior systemic therapy were eligible. Using a modified 3 + 3 design, patients received escalating doses of decitabine and pegylated interferon α-2b (PEG-IFN) during every 28-day treatment cycle. Global DNA methylation was measured on days 1 and 5 of cycles 1 and 3. Cytokine profiling and quantification of T-cell subpopulations by FACS were performed at baseline and cycle 3. RESULTS Seventeen patients were assigned to one of four dose levels. Decitabine 15 mg/m2/d + PEG-IFN 3 μg/kg was the maximum tolerated dose (MTD). Grade 3/4 cytopenias were seen across all dose levels: anemia (1), neutropenia (7), and thrombocytopenia (2). One patient remained progression-free for 37 weeks. The other 16 patients progressed at or before 12 weeks. Median overall survival was 39 weeks. Hypomethylation was seen at all dose levels. Due to treatment-induced lymphocytopenia, absolute changes in T-cell populations post-treatment were too small to be meaningfully interpreted. CONCLUSIONS The response to this combination regimen was characterized by significant myelosuppression, particularly neutropenia. Although disappointing efficacy and slow accrual led to early closure of the trial, hypomethylation showed pharmacodynamic evidence of a therapeutic effect of decitabine at all dose levels.
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Affiliation(s)
- E R Plimack
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA,
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Abstract
Early efforts to use point-of-care clinical decision support (CDS) were limited to the use of prompts and reminders, which improved test ordering but not intermediate outcomes of care, such as glucose, blood pressure, or lipid levels. More sophisticated diabetes CDS tools are now available that use electronic medical record data to provide patient-specific advice on medication use on the basis of previous treatment, distance from goal, and other clinical data. These tools have shown modest but significant improvement in glucose and blood pressure control. Promising next-generation developments will include prioritizing clinical actions that have maximum benefit to a given patient at the point of care and developing effective methods to communicate CDS information to patients to better incorporate patient preferences in care decisions.
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Affiliation(s)
- Patrick J O'Connor
- HealthPartners Institute for Education and Research, Minneapolis, MN 55425, USA.
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O'Connor PJ, Vazquez-Benitez G, Schmittdiel JA, Parker ED, Trower NK, Desai JR, Margolis KL, Magid DJ. Benefits of early hypertension control on cardiovascular outcomes in patients with diabetes. Diabetes Care 2013; 36:322-7. [PMID: 22966094 PMCID: PMC3554277 DOI: 10.2337/dc12-0284] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Solberg LI, Desai JR, O'Connor PJ, Bishop DB, Devlin HM. Diabetic patients who smoke: are they different? Ann Fam Med 2004; 2:26-32. [PMID: 15053280 PMCID: PMC1466617 DOI: 10.1370/afm.36] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2002] [Revised: 01/08/2003] [Accepted: 02/14/2003] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We wanted to identify differences between diabetic patients who smoke and those who do not smoke to design more effective strategies to improve their diabetes care and encourage smoking cessation. METHODS A random sample of adult health plan members with diabetes were mailed a survey questionnaire, with telephone follow-up, asking about their attitudes and behaviors regarding diabetes care and smoking. Among the 1,352 respondents (response rate 82.4%), we found 188 current smokers whose answers we compared with those of 1,264 nonsmokers, with statistical adjustment for demographic characteristics and duration of diabetes. RESULTS Smokers with diabetes were more likely to report fair or poor health (odds ratio [OR] = 1.5, P = .03) and often feeling depressed (OR = 1.7, P = .004). Relative to nonsmokers, smokers had lower rates of checking blood glucose levels, were less physically active, and had fewer diabetes care visits, glycated hemoglobin (A1c) tests, foot examinations, eye examinations, and dental checkups (P < or = .01). Smokers also reported receiving and desiring less support from family and friends for specific diabetic self-management activities and had lower readiness to quit smoking than has been observed in other population groups. CONCLUSIONS Clinicians should be aware that diabetic patients who smoke are more likely to report often feeling depressed and, even after adjusting for depression, are less likely to be active in self-care or to comply with diabetes care recommendations. Diabetic patients who smoke are special clinical challenges and are likely to require more creative and consistent clinical interventions and support.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Minneapolis, Minn 55440, USA.
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O'Connor PJ, Desai JR, Solberg LI, Rush WA, Bishop DB. Variation in diabetes care by age: opportunities for customization of care. BMC Fam Pract 2003; 4:16. [PMID: 14585101 PMCID: PMC280680 DOI: 10.1186/1471-2296-4-16] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/04/2003] [Accepted: 10/29/2003] [Indexed: 01/04/2023]
Abstract
Background The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45–64 years old. Methods We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes. Results Compared to those aged 45–64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year. Conclusion These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.
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Affiliation(s)
| | - Jay R Desai
- Minnesota Department of Health, St. Paul, Minnesota, USA
| | - Leif I Solberg
- HealthPartners Research Foundation, Minneapolis, Minnesota, USA
| | - William A Rush
- HealthPartners Research Foundation, Minneapolis, Minnesota, USA
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Sloane PD, Mathew LJ, Scarborough M, Desai JR, Koch GG, Tangen C. Physical and pharmacologic restraint of nursing home patients with dementia. Impact of specialized units. JAMA 1991; 265:1278-82. [PMID: 1995975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This case-control study of 31 specialized dementia units and 32 traditional units in five states investigated use of physical and pharmacologic restraints among 625 patients with the diagnosis of dementia. Physical restraints were observed in use on 18.1% of dementia unit patients and on 51.6% of comparison unit patients who were out of bed during the day (adjusted odds ratio, 0.283;95% confidence interval, 0.129 to 0.619). Pharmacologic restraints were routinely given to 45.3% of dementia unit patients and 43.4% of comparison unit patients (adjusted odds ratio, 0.950; 95% confidence interval, 0.611 to 1.477). We used multivariate logistic regression to identify residence in a nonspecialized nursing home unit, nonambulatory status, transfer dependency, mental status impairment, hip fracture history, and a high nursing staff-to-patient ratio, which we found to be independent predictors of physical restraint use. Physically abusive behavior, severe mental status impairment, and frequent family visitation were found to be significant predictors of pharmacologic restraint use, while advanced patient age, large nursing home size, and patient nonambulatory status were protective against such use. These results support the conclusion that physical and pharmacologic restraint constitute separate treatment modalities with different risk factors for use, and indicate that specialized dementia units are successful in reducing the use of physical but not pharmacologic restraints.
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Affiliation(s)
- P D Sloane
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill 27599-7595
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Parikh NK, Desai JR, Mehta PC. Gastritis. Study of 28 cases. J Assoc Physicians India 1971; 19:393-6. [PMID: 5559206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Desai JR, Naik SK, Desai NR. Successful cardiac resuscitation by external cardiac massage and mouth-to-mouth breathing. J Indian Med Assoc 1969; 52:391-392. [PMID: 5824586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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