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Conway RBN, Peltier A, Figaro MK. Constipation and glycemic control. J Diabetes Complications 2021; 35:107799. [PMID: 33303296 DOI: 10.1016/j.jdiacomp.2020.107799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Rebecca B N Conway
- Department of Community Health, University of Texas Health Science Center at Tyler, Tyler, TX, United States of America.
| | - Amanda Peltier
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Figaro MK, Long DM, May ME, Ndetan H, Cook A, Conway RB. Racial Variation in the Relationship of Glycemic Control with Fracture Risk in Elderly Patients with Diabetes. Diabetes Metab Syndr Obes 2020; 13:4153-4155. [PMID: 33177855 PMCID: PMC7652224 DOI: 10.2147/dmso.s272076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Abstract
We investigated racial variation in glycemic control (glycated hemoglobin A1c [HbA1c]) with fracture risk in geriatric patients with diabetes. Compared to an HbA1c of 7.0-7.9% [53-63 mmol/mol], HbA1c ≥9.0% [≥75 mmol/mol] was associated with increased fracture risk among Blacks and those of Unknown race only. This increase was attenuated in Blacks after accounting for the relative frequency of patient-provider interaction.
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Affiliation(s)
| | - Dustin M Long
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael E May
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Harrison Ndetan
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Alan Cook
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at Tyler, Tyler, TX, USA
| | - Rebecca Baqiyyah Conway
- Department of Epidemiology and Biostatistics, University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Department of Community Health, University of Texas Health Science Center at Tyler, Tyler, TX, USA
- Correspondence: Rebecca Baqiyyah Conway Department of Community Health, University of Texas Health Science Center at Tyler, 11937 US Highway 271, Suite #H250, Tyler, TX75708, USATel +1 412-721-2779 Email
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [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: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Mechanick JI, Pessah-Pollack R, Camacho P, Correa R, Figaro MK, Garber JR, Jasim S, Pantalone KM, Trence D, Upala S. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE. Endocr Pract 2017; 23:1006-1021. [PMID: 28786720 DOI: 10.4158/ep171866.gl] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment. ABBREVIATIONS AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.
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Conway BN, Long DM, Figaro MK, May ME. Glycemic control and fracture risk in elderly patients with diabetes. Diabetes Res Clin Pract 2016; 115:47-53. [PMID: 27242122 PMCID: PMC4930877 DOI: 10.1016/j.diabres.2016.03.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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: 10/30/2015] [Revised: 02/29/2016] [Accepted: 03/04/2016] [Indexed: 01/31/2023]
Abstract
AIMS Elderly patients with diabetes are at increased fracture risk. Although long exposure to hyperglycemia may increase fracture risk via adverse effects on bone metabolism, tight glycemic control may increase risk via trauma subsequent to hypoglycemia. We tested the prospective relationship between glycemic control and fracture risk in 10,572 elderly patients (age ≥65) with diabetes. METHODS Geriatric patients with diabetes were drawn from Vanderbilt University Medical Center's Electronic Health Record. Baseline was defined as age at first HbA1c after the latter of age 65 or ICD 9 code for diabetes. Cox analysis was used to test the relationship of updated mean HbA1c (average HbA1c over follow-up) with time to first fracture since baseline. HbA1c was categorized as follows: <6.5% [<48mmol/mol]; 6.5-6.9% [48-52mmol/mol]; 7-7.9% [53-63mmol/mol]; 8-8.9% [64-74 mmol-mol]; ≥9% [≥75mmol/mol]. The number of BMI measurements was used as a surrogate for relative frequency of outpatient visits, i.e. patient-provider contacts. RESULTS During follow-up, there were 949 fracture events. HbA1c demonstrated a cubic relationship with fracture risk (p<0.05). In analyses accounting for age, sex, race, and number of BMI measures (a surrogate for patient-provider interaction), compared to an HbA1c of 7-7.9%, HRs (95% CIs) were: HbA1c<6.5% HR=0.97 (0.82-1.14), 6.5-6.9% HR=0.80 (0.66-0.97), 8-8.9% HR=1.13 (0.92-1.40), ≥9% HR=1.19 (0.93-1.54). CONCLUSIONS An HbA1c of 6.5-6.9% is associated with the lowest risk of fracture in elderly patients with diabetes. Risk associated with an HbA1c ≥9% may be a marker of infrequent patient-provider interaction.
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Affiliation(s)
- Baqiyyah N Conway
- Department of Epidemiology, West Virginia University, Morgantown, West Virginia P.O. Box 9127, Morgantown, WV 26505, United States.
| | - Dustin M Long
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia P.O. Box 9127, Morgantown, WV 26505, United States.
| | - M Kathleen Figaro
- Genesis Health Group Endocrinology, Bettendorf, Iowa 2535 Maplecrest Rd, Suite 10, Bettendorf, IA 52722, United States.
| | - Michael E May
- Department of Medicine, Vanderbilt University, Nashville, Tennessee 1215 21st Ave S #8210, Nashville, TN 37212, United States.
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Draznin B, Gilden J, Golden SH, Inzucchi SE, Baldwin D, Bode BW, Boord JB, Braithwaite SS, Cagliero E, Dungan KM, Falciglia M, Figaro MK, Hirsch IB, Klonoff D, Korytkowski MT, Kosiborod M, Lien LF, Magee MF, Masharani U, Maynard G, McDonnell ME, Moghissi ES, Rasouli N, Rubin DJ, Rushakoff RJ, Sadhu AR, Schwartz S, Seley JJ, Umpierrez GE, Vigersky RA, Low CC, Wexler DJ. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013; 36:1807-14. [PMID: 23801791 PMCID: PMC3687296 DOI: 10.2337/dc12-2508] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [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
Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.
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Affiliation(s)
- Boris Draznin
- Division of Endocrinology, Diabetes and Metabolism, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Belue R, Figaro MK, Peterson J, Wilds C, William P. The diabetes healthy outcomes program: results of free health care for uninsured at a federally qualified community health center. J Prim Care Community Health 2013; 5:4-8. [PMID: 23799668 DOI: 10.1177/2150131913481807] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 11/17/2022] Open
Abstract
BACKGROUND Uninsured patients with diabetes are at increased risk for poor outcomes and often have limited access to health and prescription services necessary to manage diabetes. Hamilton Health Center, a federally qualified community health center, with support from the Highmark Foundation, implemented a Diabetes Healthy Outcomes Program (DHOP) for uninsured patients. PURPOSE To evaluate the effectiveness of DHOP that is designed to provide health care and supportive services for uninsured diabetic patients at a federally qualified community health center. METHODS Mixed quantitative and qualitative analyses of participant outcomes and satisfaction were used to assess program effectiveness. RESULTS A total of 189 participants enrolled in DHOP over 2 years. Thirty-four (18%) participants had adequate glycemic control with hemoglobin A1c (HbA1c) ≤ 7%. Overall, 105 participants received prescription drugs, 101 participants received eye care services, 23 participants received dental services, 45 received podiatry services, 37 received nutrition services, and 28 patients engaged in an exercise program. More participants (38%, 34) had controlled diabetes mellitus at study start than at the end (28%, 25). However, 30% versus 17% of participants with 2 HbA1c measurements achieved or maintained HbA1c ≤ 7% by the end of the program compared with the start. Participants who accessed more services were more likely to achieve glycemic control as measured by HbA1c (P > .01). CONCLUSION Although 30% of participants improved or maintained glycemic control over 2 years, more were uncontrolled at the end than at study start. Participants who accessed more primary and specialty care services were more likely to achieve glycemic control. Multidisciplinary care may improve diabetes control in low-income patients.
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Affiliation(s)
- Rhonda Belue
- The Pennsylvania State University, University Park, PA, USA
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Belue R, Oluwole AN, Degboe ANF, Figaro MK. Hypertension control in ambulatory care patients with diabetes. Am J Manag Care 2012; 18:17-23. [PMID: 22435745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE Hypertension (HTN) control among diabetics is essential to preventing macrovascular complications. We investigated correlates of HTN control among a national sample of 1313 patients with diabetes receiving care in ambulatory care settings. METHODS The current study employed extant data from the 2008 National Ambulatory Care Survey. Multivariate logistic regression analyses were employed to examine the relationship between HTN control and candidate covariates, including race, income, provider, and facility characteristics, and patient demographic and health status indicators among patients with diabetes receiving care in ambulatory care facilities. RESULTS Approximately 28.7% of patients achieved HTN control at the level of 130/80 mm Hg and 57.0% at 140/90 mm Hg. Patients seen at physician offices or academic medical center/hospital settings had greater probability of HTN control compared with outpatient departments and community health centers. Patients seen in academic medical centers or other hospital settings had the greatest probability of control (47.9% at 130/80 mm Hg and 70% at 140/90 mm Hg, P < .0001). Despite being more likely to be on antihypertensive medications, black patients with diabetes had the lowest probability of HTN control at the level of 140/90 mm Hg (41.1%) or 130/80 mm Hg (19.0%) compared with other race/ethnic groups (P < .0001). CONCLUSIONS Patients with diabetes seen in diverse primary care settings had a low probability of having blood pressure (BP) controlled to the recommended levels. Care setting-specific policies may prove useful in improving BP control. Continued attention is still warranted for racial and ethnic disparities in HTN control.
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Affiliation(s)
- Rhonda Belue
- Health Policy and Administration, The Pennsylvania State University, University Park, PA 16802, USA.
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Figaro MK, Clayton W, Usoh C, Brown K, Kassim A, Lakhani VT, Jagasia S. Thyroid abnormalities in patients treated with lenalidomide for hematological malignancies: results of a retrospective case review. Am J Hematol 2011; 86:467-70. [PMID: 21544854 DOI: 10.1002/ajh.22008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [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: 12/20/2010] [Revised: 01/27/2011] [Accepted: 01/31/2011] [Indexed: 12/31/2022]
Abstract
Lenalidomide is an antiangiogenic drug associated with hypothyroidism. We describe a case-series of lenalidomide use in hematological cancers and the prevalence of thyroid abnormalities. We reviewed medical records of patients treated with lenalidomide at a single center form 2005 to 2010 and extracted demographic, clinical, and laboratory data. Of 170 patients with confirmed lenalidomide use (age 64.9 ± 15 years), 148 were treated for multiple myeloma and 6% had thyroid abnormalities attributable only to lenalidomide. In patients with a previous diagnosis of thyroid dysfunction, the addition of lenalidomide therapy was associated with a higher incidence of subsequent TFTF abnormality (17%) as compared to patients with no previous diagnosis of thyroid dysfunction (6%) (P=0.0001). Many patients (44%) with pre-existing disease and a change in thyroid function before or while on lenalidomide had no further follow-up of their thyroid abnormalities, Of 20 patients who did not undergo any thyroid function testing either before starting or while on lenalidomide for a median of 9.4 months (± 6.5), 35% developed new symptoms compatible with hypothyroidism, including worsened fating, constipation or cold intolerance. Symptoms of thyroid dysfunction overlap with side effects of lenalidomide. Thyroid hormone levels are not regularly evaluated in patients on lenalidomide. While on this treatment, thyroid abnormalities can occur in patients with no previous diagnoses and in patients with pre-existing abnormalities. Because symptoms of thyroid dysfunction could be alleviated by appropriate treatment, thyroid function should be evaluated during the course of lenalidomide to improve patients quality of life.
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Affiliation(s)
- M Kathleen Figaro
- Vanderbilt University Medical Center, Division of Diabetes, Endocrinology and Metabolism, Vanderbilt University, Nashville, Tennessee 37232-0475, USA.
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Wharam JF, Paasche-Orlow MK, Farber NJ, Sinsky C, Rucker L, Rask KJ, Figaro MK, Braddock C, Barry MJ, Sulmasy DP. High quality care and ethical pay-for-performance: a Society of General Internal Medicine policy analysis. J Gen Intern Med 2009; 24:854-9. [PMID: 19294471 PMCID: PMC2695523 DOI: 10.1007/s11606-009-0947-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Revised: 12/23/2008] [Accepted: 01/26/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain. OBJECTIVE The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation. RESULTS We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients. CONCLUSION We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.
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Affiliation(s)
- J Frank Wharam
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02114, USA.
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BeLue R, Lanza ST, Figaro MK. Lifestyle therapy changes and hypercholesterolemia: identifying risk groups in a community sample of Blacks and Whites. Ethn Dis 2009; 19:142-147. [PMID: 19537224 PMCID: PMC2786171] [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] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To examine diet and exercise lifestyle therapy change (LTC), behaviors and their relation to hypercholesterolemia in a community sample of Blacks and Whites. DESIGN Latent class analysis (LCA) was employed to identify homogeneous subgroups of community dwelling Blacks and Whites related to LTC for hypercholesterolemia. LCA is a statistical technique used to identify subgroups of individuals who share a similar pattern of responses to a set of observations. The relation between hypercholesterolemia and latent class membership was assessed. PARTICIPANTS Adults age 18 and over who participated in a county-level adaptation of the Behavioral Risk Factor Surveillance System. MAIN OUTCOME MEASURE Hypercholesterolemia (absence or presence). RESULTS Eleven unique latent classes of LTC behavior emerged from LCA models. Exercisers and Fat Reducers represented between 19% and 29% of each race-sex group. Latent class membership probabilities varied substantially across race and sex. Only Black women had a class of Contemplators (21.5%). Overall, men and Blacks with self reported hypercholesterolemia were more likely to engage only in fat reduction but not increase in vegetable consumption, reduction of fat or regular exercise (odds ratios range from 1.8-3.5). CONCLUSIONS The distribution of diet and exercise related LTC behaviors in relation to self-reported hypercholesterolemia can help to identify, understand and tailor culturally and sex specific interventions based on the proportions of men and women in different latent classes.
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Affiliation(s)
- Rhonda BeLue
- Department of Health Policy and Administration, Methodology Center, Pennsylvania State University, University Park, PA 16803, USA.
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Figaro MK, Kritchevsky SB, Resnick HE, Shorr RI, Butler J, Shintani A, Penninx BW, Simonsick EM, Goodpaster BH, Newman AB, Schwartz AV, Harris TB. Diabetes, inflammation, and functional decline in older adults: findings from the Health, Aging and Body Composition (ABC) study. Diabetes Care 2006; 29:2039-45. [PMID: 16936150 DOI: 10.2337/dc06-0245] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Age, diabetes, and elevated inflammatory markers independently increase the risk of functional decline. We examined the effect of C-reactive protein (CRP) and interleukin-6 (IL-6) on the incident mobility limitation in older adults with and without diabetes. RESEARCH DESIGN AND METHODS We analyzed data from a cohort of 2,895 well-functioning adults aged 70-79 years, followed for development of persistent functional limitation over 3.5 years. Participants were assessed for the presence of diabetes according to fasting glucose and/or hypoglycemic medication use and were divided into three equal groups (tertiles) according to level of CRP or IL-6. Persistent functional limitation was defined as difficulty climbing 10 steps or walking one-quarter mile on two consecutive semiannual assessments. RESULTS At baseline, 702 participants (24%) had diabetes. CRP values were (median +/- SD) 2.8 +/- 4.4 versus 3.7 +/- 5.4 for those with normal glucose and diabetes, respectively (P < 0.001). The unadjusted incidence of functional limitation associated with increased levels of CRP and IL-6 was greater among participants with diabetes. After adjusting for clinical and demographic covariates, persistent functional limitation for the highest tertile was greater compared with that for the lowest tertile of CRP or IL-6 for those with and without diabetes. CRP hazard ratios (HRs) were 1.7 (95% CI 1.2-2.3) versus 1.4 (1.1-1.6), respectively. IL-6 HRs were 1.8 (1.3-2.5) versus 1.6 (1.4-2.0), respectively. CONCLUSIONS In initially high-functioning older adults, those with diabetes and higher inflammatory burden had an increased risk of functional decline. Interventions at early stages to reduce inflammation may preserve function in these individuals.
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Affiliation(s)
- M Kathleen Figaro
- Department of Medicine, Vanderbilt University Medical Center/GRECC, 1310 24th Ave. South, Room 4B111, Nashville, TN 37212, USA.
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Abstract
Participants in a Nashville Davidson County survey were queried regarding influenza vaccination, with the goal of developing strategies to improve vaccination coverage in the county. The Metropolitan Public Health Department used a locally adapted version of the Behavioral Risk Factor Surveillance System in a random-digit-dialing phone survey with a sample of 7901 residents of Davidson County, Tennessee, about health-related behaviors. Out of 7233 fully completed surveys, data for 7016 were analyzed. Thirty-six percent of the respondents were male; 17% were aged 18-24, 40% were aged 25-44, 26% were aged 45-64, and 16% were aged 65 or older. Seventy-six percent were white. Forty-five percent reported a chronic illness, increasing their risk for complications from influenza; 11% had asthma, 7% diabetes, 25% hypercholesterolemia, and 28% hypertension. Predictors for receipt of influenza vaccine were older age, presence of a primary care provider, health insurance, and employment. Those with chronic diseases were more likely to be vaccinated when compared to the general population. Among those 65 and older, blacks were less likely to be vaccinated (OR = 0.57, CI = 0.43, 0.76). The substantial disparity in receipt of influenza vaccine reflects the lack of recommendations and policies for vaccination coverage and suggests the need for greater community-based efforts to improve the preventive health behaviors of healthcare professionals and the public. In addition, new vaccine delivery strategies and systematic vaccination marketing efforts may be needed to increase influenza vaccination rates in communities of color and other underserved populations.
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Affiliation(s)
- M Kathleen Figaro
- Department of Medicine, Vanderbilt University Medical Center, 1310 24th Ave S, RM 4B111, Nashville, TN 37212, USA.
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Abstract
We investigated beliefs of blacks with osteoarthritis (OA) regarding total knee replacement (TKR) surgery. These beliefs potentially related to the known racial disparity in the use of TKR. Ninety-four community-dwelling blacks aged 50 to 89 with knee OA in Harlem, NY, were assessed for arthritis knowledge, expectations, quality of life (QoL), and disability. Subjects have had OA for a median of 6 years and the disability was severe. Only 36% believed that TKR was likely to improve knee pain; 45% stated that TKR would not improve their current health. Mean QoL was 7.6 +/- 1.7 (max 10). Despite debilitating OA, African American patients perceive a high QoL, yet have low expectations from TKR and are therefore less likely to consider TKR as a treatment for OA.
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Affiliation(s)
- M Kathleen Figaro
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn 37212, USA.
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Abstract
Despite greater disability from knee osteoarthritis among Blacks, Whites are 3-5 times more likely to have total knee replacement (TKR). The authors explored whether beliefs among Blacks about arthritis and surgery contribute to this disparity. Ninety-four Blacks, ages 50 to 89, with knee arthritis underwent semistructured qualitative interviews regarding disability, beliefs about arthritis, beliefs about TKR, and treatment preferences. Content analyses yielded 6 themes: preference for natural remedies, negative expectations of surgery, beliefs about God's control, preference for continuing in their current state, relationships with specialists, and fear of surgery or death. Given its high levels of disability, this cohort had low expectations of TKR. Culturally sensitive educational programs might improve patient altitudes and beliefs regarding TKR, ultimately increasing appropriate usage.
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Affiliation(s)
- M Kathleen Figaro
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, USA.
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Abstract
We examined the effect of oropharyngeal stimulation on thirst, secretion of arginine vasopressin ([AVP]p), and fluid intake in six healthy adults after dehydration (28.6 +/- 1.4 ml/kg water loss) induced by mild exercise in the heat (2 h, 38 degrees C, relative humidity < 30%). Subjects performed three identical dehydration protocols followed by 75 min of rehydration at 27 degrees C consisting of 1) ad libitum drinking (Con), 2) infusion of a similar volume of water directly into the stomach via a nasogastric tube (Inf) during the first 25 min followed by combined Inf and ad libitum drinking during the remaining 50 min of rehydration; or 3) ad libitum drinking with simultaneous extraction of ingested fluid via a nasogastric tube (Ext). Plasma osmolality (Posm), [AVP]p, fluid intake, and thirst perceptions were measured throughout. On average, for all three protocols, Posm increased 7.8 +/- 0.6 mosmol/kgH2O and plasma volume decreased 4.7 +/- 1.3%, whereas thirst ratings and [AVP]p increased 7.6 +/- 1.3 cm and 3.1 +/- 0.4 pg/ml, respectively. Reflex inhibition of [AVP]p and thirst occurred within 5 min of rehydration in Con and Ext (P < 0.05) but not during Inf, supporting the hypothesis that oropharyngeal reflexes modulate osmotically stimulated thirst and [AVP]p. However, the reduction in [AVP]p during the first 5 min of Ext (-1.1 +/- 0.3 pg/ml) was less than that seen during Con (-2.1 +/- 0.4 pg/ml), suggesting that oropharyngeal stimulation is not the only factor contributing to the rapid reduction in [AVP]p during the first 5 min of drinking. During Con, subjects ingested 20.0 +/- 2.0 ml/kg of water but only drank 15% more (31.3 +/- 7.1 ml/kg) during Ext, demonstrating a clear role of oropharyngeal metering in limiting total fluid intake in humans in the presence of a persistently high dipsogenic drive.
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Affiliation(s)
- M K Figaro
- John B. Pierce Laboratory, Yale University School of Medicine, New Haven, Connecticut 06519, USA
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