Arleen F. Brown

Guidelines for improving the care of the older person with diabetes mellitus.

BACKGROUND AND SIGNIFICANCE iabetes mellitus (DM) is highly prevalent and increasing in persons aged 65 and older, particularly among racial and ethnic minorities. Estimates have placed the proportion of adults aged 65 to 74 with physician-diagnosed DM at nearly 25% in some ethnic groups. 1 Estimates from the Centers for Disease Control and Prevention indicate that, in 1998, 12.7% of persons aged 70 and older had a diagnosis of DM, up from 11.6% in 1990. 2 There are also large numbers of older adults, almost 11% of the U.S. population aged 60 to 74, with undiagnosed DM. 1 Older persons with DM have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, coronary heart disease (CHD), and stroke 3,4 than do those without DM. Older adults with DM are also at greater risk than other older persons for several common geriatric syndromes, such as depression, 5,6 cognitive impairment, 7 urinary incontinence, 8 injurious falls, 9–11 and persistent pain. 12,13 Although there are numerous evidence-based guidelines for DM, few guidelines are specifically targeted toward the needs of older persons 14 and help clinicians prioritize care for the heterogeneous population of older adults they may see in their practices. Moreover, the main emphasis of most DM guidelines is on intensive blood glucose control and prevention of microvascular complications. Although control of hyperglycemia is important, in older persons with DM, greater reduction in morbidity and mortality may result from control of cardiovascular risk factors than from tight glycemic control. Additionally, little is known about how well providers of health care for older persons with DM adhere to recommendations for the screening and treatment of common geriatric syndromes, such as depression, injurious falls, urinary incontinence, cognitive impairment, chronic pain, and polypharmacy, which are more prevalent with DM and may significantly influence quality of life. Although interventions to reduce the incidence of geriatric syndromes and to ameliorate their symptoms have been studied in general populations of older adults, few studies have focused on the identification and treatment of these common syndromes in older adults with DM. Moreover, because conditions such as cognitive impairment, polypharmacy, and injurious falls may interfere with the provision of appropriate DM care, the identification and management of these syndromes may enhance the effectiveness of DM management for the busy primary care provider. The purpose of this guideline is to improve the care of older persons with DM by providing a set of evidencebased recommendations that include DM-specific recommendations individualized to persons with DM who are aged 65 and older and recommendations for the screening and detection of geriatric syndromes. Table 1 summarizes the components of care included in the guidelines and the number of randomized controlled trials (RCTs) and systematic evidence reviews that were evaluated for the care recommendations.

Health Disparities in Endocrine Disorders: Biological, Clinical, and Nonclinical Factors—An Endocrine Society Scientific Statement

OBJECTIVE The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Societys Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement. EVIDENCE The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society. CONCLUSIONS Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs

Context Little is known about the effects of quality-of-care improvement programs on the process of care and outcomes of diabetes. Contribution The study involved 8661 patients with diabetes, 63 provider groups, and 3 disease management strategies (provider feedback, reminders, and structured care). The quality measures included 8 processes of care, 3 intermediate diabetes outcomes, and medication management of these outcomes. More intense disease management strategies predicted higher measures of many processes of care but only 1 intermediate outcome and 1 medication management outcome. Implications The disease management strategies improved processes of care but not outcomes. Experts in quality improvement may need to refocus their efforts. The Editors Persons with diabetes continue to receive suboptimal care (16). To improve quality, many health systems have implemented disease management programs for diabetes and other chronic conditions (79). These programs typically incorporate population-based strategies, such as disease registries, clinical guidelines, performance feedback, physician reminders, self-management support for patients, and targeted case management for high-risk patients (10). Evidence for the effectiveness of disease management comes primarily from small efficacy trials (1020). Such studies consistently found improved processes of diabetes care; however, improvements in outcomes (such as control of cardiovascular disease risk factors) were less consistent (12, 17, 18, 2022). Furthermore, most studies evaluated only 1 or 2 strategies (instead of multicomponent programs) in selected clinical settings. It is unclear how well findings from these smaller studies apply to entire patient populations. Many components of disease management focus on improving processes of care. Early performance measurement projects, such as the Health Plan Employer Data Information System (23) and the Diabetes Quality Improvement Program (5), emphasized the importance of such processes as annual retinal screening or hemoglobin A1c determination. Particularly for health plans, process measures are more readily available than are outcomes data. However, if disease management is to improve patient outcomes, it must also improve intermediate outcomes, such as hemoglobin A1c levels, systolic blood pressure, and serum low-density lipoprotein (LDL) cholesterol levels. Translating Research into Action for Diabetes (TRIAD) (24) is a multicenter study of diabetes care in managed care. The TRIAD studys central hypothesis is that health care systems features can affect quality of care. Here, we examine how 3 disease management strategies vary in intensity across physician groups and whether physician groups with more intensive disease management have higher quality of diabetes care. We assess quality by processes of care, by levels of intermediate outcomes, and by current clinical management of these outcomes. Methods Overview of the TRIAD Study and Sample The TRIAD studys sampling frame, methods, key hypotheses, and power calculations are detailed elsewhere (24). The study comprised 6 collaborating translational research centers that were partnered with 10 managed care health plans in 7 states. Of the 10 plans, 7 contracted with 1 to 26 physician groups (total, 68 groups), whereas 4 plans directly contracted with individual physicians. A standard algorithm was applied to automated pharmacy, laboratory utilization, and inpatient and outpatient diagnostic data (25) to identify all community-dwelling patients with diabetes who were 18 years of age and older and who had been continuously enrolled in the TRIAD health plan for at least 18 months. The study cohort was randomly sampled from this population. Sampled patients were recruited between July 2000 and October 2001 by using computer-assisted telephone interviews or written surveys that were conducted in English or Spanish. Eligibility was confirmed if patients verified that they had had diabetes for at least 12 months and had received most of their diabetes care through the TRIAD health plan. Permission was sought from all respondents to request copies of their outpatient medical records for the previous 18 months. All health plan and physician group directors received mailed surveys (Appendix Figure) during the same interval. Face-to-face or telephone interviews were used to complete and clarify responses. Each director was offered

Income-related differences in the use of evidence-based therapies in older persons with diabetes mellitus in for-profit managed care

100 for completing the survey. Appendix Figure. Translating Research into Action for Diabetes (TRIAD) Physician Group Survey. The TRIAD study was reviewed and approved by the institutional review boards of each research center and by the Centers for Disease Control and Prevention (CDC). Informed consent was obtained from all survey respondents. Data Sources Patient surveys included questions on health status, diabetes duration, current diabetes treatment, and demographic characteristics. Of 13086 contacted and eligible persons, 11927 (91%) completed the survey (56.6% by computer-assisted telephone interview and 43.4% by written survey) (Figure). We were unable to contact many individuals. Using a practice that is endorsed by the Council of American Survey Research Organizations (26), we assumed that persons whom we could not contact or for whom we could not confirm eligibility had the same eligibility rate as those contacted. Under that assumption, the response rate was 69%. Figure. Description of sampling and response rate. xx Of 11927 patients who completed a survey, 8661 (73%) consented to medical record review and subsequently had charts available for review. Centrally trained reviewers used standardized data collection software to abstract process measures, most recent levels of hemoglobin A1c, upper limits of normal for hemoglobin A1c measurements that were recorded, serum LDL cholesterol levels, systolic blood pressure, current medications, and comorbid conditions. Interrater reliability () for the main quality measures ranged from 0.86 to 0.94. All 10 health plan directors and 52 of 68 physician group directors completed surveys. Surveys assessed organizational age, size, structure, profit status, insurance products, contracting arrangements, history of involvement with managed care, and detailed information on the organizations use of diabetes disease management strategies. Of the physician groups that did not respond (443 participants), 11 existed solely for the purpose of contracting with plans and had no diabetes disease management. These physician groups were assumed to have no care management strategies and were included in the analyses, as were patient groups (1150 participants) from the 4 health plans that contracted directly with physicians. The remaining 5 groups (159 participants) did not respond and were excluded from analyses (Figure). Consequently, the resulting sample included a total of 8661 survey respondents with charts available for review and data from 63 physician groups and 4 additional health plans (Figure). Mean duration of diabetes, body mass index, and health status did not meaningfully differ between persons whose medical records and physician group variables were available to the study team and those whose records were unavailable. Predictors, End Points, and Covariates The primary predictors were 3 measures of the intensity of disease management strategies: physician reminders, performance feedback, and structured care. These were calculated for physician groups and health plans from multiple survey items. A detailed description of the methods used to calculate composite intensity scores is provided in Appendix 2. Selected item-level responses for physician groups in the most intense versus least intense tercile of each strategy are displayed in Table 1. Table 1. Selected Item-Level Responses for Provider Groups for Each Disease Management Strategy* The physician reminders intensity score was derived from 2 questions, which detailed the types and content of the reminders physicians received. Groups whose use of reminders represented the upper tercile of intensity were found to have reminded physicians about 4 care processes on average. Most groups in the upper tercile delivered reminders electronically at the point of care. Performance feedback intensity was obtained by tallying responses to a checklist of possible diabetes process and outcome feedback items. A total of 86% and 82% of groups in the upper tercile included levels of hemoglobin A1c and serum LDL cholesterol, respectively, in feedback to physicians (Table 1). Physician feedback focused on many of the same elements of care as reminders. The use of formal case management, diabetes guidelines, patient reminders, and diabetes education correlated highly in physician groups (Pearson correlation coefficients ranged from 0.63 to 0.88); therefore, we could not look at these approaches independently. Consequently, we combined the 4 approaches into a single composite score for structured diabetes care management. Use of formal case management was assessed by the proportion of patients with diabetes who were enrolled, the number of case managers per 10000 patients, the extent to which the program targeted high-risk patients, and a checklist of case management activities. The clinical guidelines were scored to reflect the extent of implementation. The highest score was assigned to physician groups that incorporated guidelines into automated physician or patient reminders. Patient reminder intensity incorporated the number, type, and frequency of reminders sent. On average, physician groups in the upper tercile had diabetes education as a covered benefit, whereas those in the lowest tercile generally did not have these programs. Because of the differing numbers of questions and wide range of possible values within each intensity score, each question was z-transformed to a mean of 0.0 and standard deviation near or equal to 1.0 to facilitate comparison. Sco

A Systematic Review of Diabetes Self-Care Interventions for Older, African American, or Latino Adults

OBJECTIVES: To determine whether income influences evidence‐based medication use by older persons with diabetes mellitus in managed care who have the same prescription drug benefit.

Health behaviors and quality of care among Latinos with diabetes in managed care.

PURPOSE this study system dente and exained published self-care ntetion desgd to *nrv glycenu control or quality of life (QoL) among ole, African Americn or Latino adults. METHODS Six electronic databases were searchecl Eligible publicato were thoe that described an intervnin to change knowledge, belie, or behavior among adults with diabetes who were either older than 55 years, African American, or Latino, and that measured the outcomes ofglyeic control or QoL. RESULTS Twelve studies met the inclusion criteria, of which 8 were rdomized conrlld trials (RCTs). Of the 8 RCTs, i7provd glycemic control was reported in the intervention arm of S RCTs comparedwith the control arm Of the 4 RCTs theat amined QoL, inprd QoL was reported in the idention ann of 1 study Charaaristics of sssid inter dio s ed poor glcmvic control at baseline (AlC>1 1%), adtural or agetaioring the inevto use of group counseling or support, and inzdmt of spouses and adult children. CONCLUSIONS Large-scale cinial trials designed according to aural and age cieria speciic for older Ltins and African Americas uh diabetes are needed to determine hbow best to adess this growing publc heath problem.

The Relationship Between Neighborhood Characteristics and Self-Rated Health for Adults With Chronic Conditions

OBJECTIVES We evaluated whether ethnicity and language are associated with diabetes care for Latinos in managed care. METHODS Using data from 4685 individuals in the Translating Research Into Action for Diabetes (TRIAD) Study, a multicenter study of diabetes care in managed care, we constructed multivariate regression models to compare health behaviors, processes of care, and intermediate outcomes for Whites and English- and Spanish-speaking Latinos. RESULTS Latinos had lower rates of self-monitoring of blood glucose and worse glycemic control than did Whites, higher rates of foot self-care and dilated-eye examinations, and comparable rates of other processes and intermediate outcomes of care. CONCLUSIONS Although self-management and quality of care are comparable for Latinos and Whites with diabetes, important ethnic disparities persist in the managed care settings studied.

Understanding the gap between good processes of diabetes care and poor intermediate outcomes Translating Research into Action for Diabetes (TRIAD)

OBJECTIVES We sought to determine whether the association between neighborhood characteristics and health differs for people with and without a chronic condition. METHODS We analyzed data from 2536 adults from the Los Angeles Family and Neighborhood Survey and evaluated the relationship between the presence of a chronic condition at the individual level, neighborhood socioeconomic status (SES), and self-rated health. We constructed multilevel models to evaluate the relationship between the neighborhood SES index and self-rated health for people with and without chronic conditions, after adjustment for other individual characteristics. RESULTS Having a chronic condition was associated with substantially poorer self-rated health among participants in a deprived area than among those in a more advantaged area. CONCLUSIONS Residence in a disadvantaged neighborhood may be associated with barriers to the management of a chronic condition. Further work is needed to identify the specific characteristics of disadvantaged areas associated with poorer self-rated health for adults with chronic conditions.

Identifying risk factors for racial disparities in diabetes outcomes: The translating research into action for diabetes study

Background:Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. Objectives:To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. Population:Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002–2003). Methods:Comparison of 1003 patients with good control of A1c (<8%), systolic blood pressure (<140 mm Hg) and LDL-cholesterol (<130 mg/dL) versus 812 patients with poor control for at least 2 of these factors. Results:Poorly controlled patients were younger, more frequently female, African American, with lower education and income (P < 0.001 for each). General health status was lower, body mass index higher, and insulin treatment more frequent; history of prior coronary heart disease was less frequent. They were more likely to indicate depression and hopelessness and to identify costs as a barrier to self-care; less likely to report trust in their regular physician; and more likely to smoke cigarettes and be physically inactive. Adjusting for demographic and clinical variables, concerns about costs, low trust in ones physician, current smoking, and physical inactivity remained associated with poor control. However, inclusion of these 4 variables in a single model did not diminish associations of race/ethnicity or education with control. Conclusions:Clinical, socioeconomic, psychosocial, and behavioral factors were independently associated with poor control. However, these factors did not fully explain observed racial and socioeconomic disparities in control.

Perception of Neighborhood Problems, Health Behaviors, and Diabetes Outcomes Among Adults With Diabetes in Managed Care: The Translating Research Into Action for Diabetes (TRIAD) Study

Background:Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications. Objective:To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites. Design:Case-control study. Subjects:A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans. Measures:Cases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c ≥8.0%, SBP ≥140 mmHg, LDL cholesterol ≥130 mg/dL) and controls were patients with good control of all 3 (HbA1c <8.0%, SBP <140 mmHg, LDL cholesterol <130 mg/dL). In multivariate analyses, we determined whether each of several potentially mutable risk factors, including depression, poor adherence to medications, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status. Results:Among blacks but not whites, in multivariate analyses depression (odds ratio: 2.28; 95% confidence interval: 1.09–4.75) and having missed medication doses (odds ratio: 1.96; 95% confidence interval: 1.01–3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites. Conclusions:Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These 2 risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.