Aviva G. Nathan

Public Health Implications of Recommendations to Individualize Glycemic Targets in Adults With Diabetes

OBJECTIVE To estimate how many U.S. adults with diabetes would be eligible for individualized A1C targets based on 1) the 2012 American Diabetes Association (ADA) guideline and 2) a published approach for individualized target ranges. RESEARCH DESIGN AND METHODS We studied adults with diabetes ≥20 years of age from the National Health and Nutrition Examination Survey 2007–2008 (n = 757). We assigned A1C targets based on duration, age, diabetes-related complications, and comorbid conditions according to 1) the ADA guideline and 2) a strategy by Ismail-Beigi focused on setting target ranges. We estimated the number and proportion of adults with each A1C target and compared individualized targets to measured levels. RESULTS Using ADA guideline recommendations, 31% (95% CI 27–34%) of the U.S. adult diabetes population would have recommended A1C targets of <7.0%, and 69% (95% CI 66–73%) would have A1C targets less stringent than <7.0%. Using the Ismail-Beigi strategy, 56% (51–61%) would have an A1C target of ≤7.0%, and 44% (39–49%) would have A1C targets less stringent than <7.0%. If a universal A1C <7.0% target were applied, 47% (41–54%) of adults with diabetes would have inadequate glycemic control; this proportion declined to 30% (26–36%) with the ADA guideline and 31% (27–36%) with the Ismail-Beigi strategy. CONCLUSIONS Using individualized glycemic targets, about half of U.S. adults with diabetes would have recommended A1C targets of ≥7.0% but one-third would still be considered inadequately controlled. Diabetes research and performance measurement goals will need to be revised in order to encourage the individualization of glycemic targets.

Personalized decision support in type 2 diabetes mellitus: current evidence and future directions.

The management of type 2 diabetes comprises a complex series of medical decisions regarding goals of care, self-care behaviors, and medical treatments. The quality of these medical decisions is critical to determining whether an individual diabetes patient is treated appropriately, overtreated, or undertreated. It is hypothesized that the quality of these medical decisions can be enhanced by personalized decision support tools that summarize patient clinical characteristics, treatment preferences, and ancillary data at the point of care. We describe the current state of personalized diabetes decision support on the basis of 13 recently described tools. Three tools provided support for personalized decisions based on preferences, while the remaining 10 provided support for treatment decisions designed to achieve standard diabetes goals. For the tools that supported personalized decisions, patient participation in medical decisions improved. Future decision support tools must be designed to account for both clinical characteristics and patient preferences.

Health Care Utilization and Receipt of Preventive Care for Patients Seen at Federally Funded Health Centers Compared to Other Sites of Primary Care

OBJECTIVE To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings. DATA SOURCES A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004-2008). STUDY DESIGN HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non-HC patients. PRINCIPAL FINDINGS Compared to non-HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non-HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non-HC patients. CONCLUSIONS Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.

Improving Shared Decision Making with LGBT Racial and Ethnic Minority Patients.

Improving Shared Decision Making with LGBT Racial and Ethnic Minority Patients Marshall H. Chin, MD, MPH, Fanny Y. Lopez, MPP, Aviva G. Nathan, MPH, and Scott C. Cook, PhD Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL, USA; Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change National Program Office, University of Chicago, Chicago, IL, USA.

Cost-effectiveness of Continuous Glucose Monitoring for Adults With Type 1 Diabetes Compared With Self-Monitoring of Blood Glucose: The DIAMOND Randomized Trial

OBJECTIVE This study evaluated the societal cost-effectiveness of continuous glucose monitoring (CGM) in patients with type 1 diabetes (T1D) using multiple insulin injections. RESEARCH DESIGN AND METHODS In the Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes (DIAMOND) trial, 158 patients with T1D and HbA1c ≥7.5% were randomized in a 2:1 ratio to CGM or control. Participants were surveyed at baseline and 6 months. Within-trial and lifetime cost-effectiveness analyses were conducted. A modified Sheffield T1D policy model was used to simulate T1D complications. The main outcome was cost per quality-adjusted life-year (QALY) gained. RESULTS Within the 6-month trial, the CGM group had similar QALYs to the control group (0.462 ± 0.05 vs. 0.455 ± 0.06 years, P = 0.61). The total 6-month costs were

Physician perspectives on de-intensifying diabetes medications.

11,032 (CGM) vs.

Impact and Feasibility of Personalized Decision Support for Older Patients with Diabetes A Pilot Randomized Trial

7,236 (control). The CGM group experienced reductions in HbA1c (0.60 ± 0.74% difference in difference [DiD]), P < 0.01), the daily rate of nonsevere hypoglycemia events (0.07 DiD, P = 0.013), and daily test strip use (0.55 ± 1.5 DiD, P = 0.04) compared with the control group. In the lifetime analysis, CGM was projected to reduce the risk of T1D complications and increase QALYs by 0.54. The incremental cost-effectiveness ratio (ICER) was

Use of Decision Aids with Minority Patients: a Systematic Review

98,108 per QALY for the overall population. By extending sensor use from 7 to 10 days in a real-world scenario, the ICER was reduced to

Patients’ Future Expectations for Diabetes and Hypertension Treatments: “Through the Diet… I Think This is Going to Go Away.”

33,459 per QALY. CONCLUSIONS For adults with T1D using multiple insulin injections and still experiencing suboptimal glycemic control, CGM is cost-effective at the willingness-to-pay threshold of

How information about the time requirements and legacy effects of treatments influence decision-making in patients with diabetes and hypertension.

100,000 per QALY, with improved glucose control and reductions in nonsevere hypoglycemia.