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Annals of Internal Medicine | 2006

Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002.

Jinan B. Saaddine; Betsy L. Cadwell; Edward W. Gregg; Michael M. Engelgau; Frank Vinicor; Giuseppina Imperatore; Narayan Km

Context As the target of many quality improvement programs, positive change in diabetes care is a good marker for progress toward better health care. Content The authors analyzed measures of diabetes care from national population-based surveys that were conducted between 1988 and 2002. Improvements occurred in the proportion of patients with hemoglobin A1c between 6% and 8%, low-density lipoprotein (LDL) cholesterol levels less than 3.4 mmol/L (<130 mg/dL), annual influenza vaccination, and aspirin use. Blood pressure did not change. Substantial proportions of patients still had poor control of LDL cholesterol levels, glycemia, and blood pressure. Implications Despite some progress, population-based measurements show that care for many Americans with diabetes falls far short of targets. The Editors Diabetes currently affects 20.8 million people in the United States (1), and that number is projected to reach 39 million by the year 2050 (2). If current trends continue, 1 in 3 Americans will develop diabetes sometime in his or her lifetime, and those with diabetes will lose, on average, 10 to 15 life-years (3). In 2002, diabetes cost the nation an estimated


Pediatrics | 2005

Prevalence of impaired fasting glucose and its relationship with cardiovascular disease risk factors in US adolescents, 1999-2000.

Desmond E. Williams; Betsy L. Cadwell; Yiling J. Cheng; Catherine C. Cowie; Edward W. Gregg; Linda S. Geiss; Michael M. Engelgau; K.M. Venkat Narayan; Giuseppina Imperatore

132 billion in direct and indirect costs (4). There is, however, a growing array of effective and cost-effective treatments to help prevent or delay diabetes complications and also diabetes itself (5-17). Diabetes care has been suboptimal and varied in the United States (18-21). The National Diabetes Quality Improvement Project, founded in 1997, developed a comprehensive set of measures of diabetes quality of care (22). These measures have been incorporated into the Health Plan Employer Data and Information Set, the American Diabetes Association Provider Recognition Program, the American Medical Association Diabetes Measures Group, the Veterans Administration performance monitoring program, and other activities. The Diabetes Quality Improvement Project partners now continue their work as a coalition of 13 influential private and public national organizations called the National Diabetes Quality Improvement Alliance. The Alliance develops, maintains, and promotes the use of an updated standardized measurement set (the Alliance measures) for quality of diabetes care (23). We previously established a national benchmark for diabetes quality of care in the United States for the years 1988 to 1995 by using the standard measurements recommended by the Diabetes Quality Improvement Project (18). On the basis of nationally representative data collected in 1999 to 2002, we report the changes in the quality of diabetes care from the 1990s to 2000s by using the standardized Alliance measures for both time periods. Methods Surveys We used data from 2 federally funded, nationally representative surveys: the National Health and Nutrition Examination Survey, 19881994 (NHANES III) and 19992002 (NHANES 19992002), and the Behavioral Risk Factor Surveillance System, 1995 (BRFSS 1995) and 2002 (BRFSS 2002). As previously explained (18), we used both BRFSS and NHANES to obtain data on all the process and intermediate outcome measures needed for the analysis. In our report, we refer to NHANES III and BRFSS 1995 as baseline surveys and NHANES 19992002 and BRFSS 2002 as recent surveys. We analyzed data from each survey separately. Table 1 presents the indicators used and their respective data source. Table 1. National Diabetes Quality Improvement Alliance and Additional Indicators of Diabetes Processes and Outcomes of Care National Health and Nutrition Examination Survey The NHANES consists of nationally representative samples of the U.S. civilian, noninstitutionalized population. Samples were obtained by using a stratified multistage probability design with planned oversampling of older and minority groups. Household interviews were conducted to ascertain sociodemographic characteristics and medical and family history. After the household interview, clinical examinations were conducted at a mobile examination center. Detailed descriptions of the design and data collection of each survey have been published elsewhere (24-27). Data from NHANES were self-reported (demographic characteristics and clinical variables) or were obtained during the clinical examination (hemoglobin A1c, cholesterol level, triglycerides level, and blood pressure level). Hemoglobin A1c measurements were standardized to the Diabetes Control and Complications Trial. Cholesterol levels were standardized by using the criteria established by the Centers for Disease Control and Prevention and the National Heart, Lung, and Blood Institute Lipid Standardization Program II. For persons who fasted for more than 8 hours and had triglyceride levels less than 4.5 mmol/L (<400 mg/dL), the Friedewald equation was applied to calculate low-density lipoprotein (LDL) cholesterol level. We log-transformed triglyceride levels because data were not normally distributed. We used the average of each persons blood pressure readings that were taken in the seated position during the clinical examination. Because we did not have data on annual testing for microalbuminuria, we assessed the absence of microalbuminuria, defined as albumin-to-creatinine ratio greater than 30 g/mg in spot urine collection (28). We analyzed the data for all indicators regardless of respective treatment status. Behavioral Risk Factor Surveillance System The BRFSS is an ongoing random-digit telephone survey of the noninstitutionalized U.S. adult population in each of the 50 states and the District of Columbia. Detailed descriptions of the design and data collection of the BRFSS have been published elsewhere (29). We used the diabetes-specific module that contains questions on clinical and preventive care practices to collect information from the participants with diabetes. Participants We included adults 18 to 75 years of age who reported a previous diagnosis of diabetes by a health care professional. We excluded women with gestational diabetes. We analyzed data from 1024 participants in NHANES III and 750 participants in NHANES 19992002 who selfreported a diagnosis of diabetes and who completed the clinical examination. We analyzed data from 3065 persons in BRFSS 1995 and 13078 persons in BRFSS 2002 who identified themselves as having diabetes. Participants reporting diabetes in all surveys were similar in age, sex, education, smoking, and insurance status at each point of time. Among participants of the recent surveys compared with those of the baseline surveys, the proportion of women and non-Hispanic white persons was lower and the proportion of participants with more than a high school education and an annual household income of


Journal of Diabetes | 2013

Association of statin use with peripheral neuropathy in the US population 40 years of age or older (美国40岁及以上人群的他汀使用情况与周围神经病变的关系)

Edward F. Tierney; David J. Thurman; Gloria L. Beckles; Betsy L. Cadwell

20000 or more was higher (Table 2). The proportion of people with diabetes who use insulin was also lower in the recent surveys but was statistically significant only in BRFSS 2002. Table 2. Characteristics of Participants 18 to 75 Years of Age with Self-Reported Diabetes in the National Health and Nutrition Examination Survey, 19881994 and 19992002, and Behavioral Risk Factors Surveillance System, 1995 and 2002 Performance Measurement Set We assessed the quality of diabetes care by using the Alliance measurement set (22) (Table 1). We used the Alliance measures of diabetes care wherever data were available, and we also examined additional measures that may be indicators of quality care in the future: pneumococcal vaccination, diabetes education, annual dental examination, and self-monitoring of blood glucose level. The BRFSS did not have a question about smoking counseling. We, therefore, used the proportion of smokers who tried to quit smoking. Questions about aspirin use were asked only every other year, so we used data from BRFSS 1996 for this variable. Statistical Analysis We conducted statistical analyses by using SAS for Windows software, version 7.0 (SAS Institute, Inc., Cary, North Carolina), for data management. We used SUDAAN software (Research Triangle Institute, Research Triangle Park, North Carolina) to obtain point estimates and SEs based on sampling weights to produce national estimates accounting for the complex survey design. We used Taylor series linearization for variance estimation. We computed the percentage of respondents who reported receipt of each measure. We examined the diabetes care measures by age, sex, race or ethnicity, education, insulin use, and health insurance status because our previous analysis had variations by these factors (18). However, insulin users were not asked to fast; hence, we did not examine LDL levels by insulin use. We used multiple logistic regression and predictive margins to estimate the probability of receiving or meeting the care measure after controlling for all known potential confounders. Predictive margins are a type of direct standardization, where the predicted values from the logistic regression models are averaged over the covariate distribution in the population (30). This statistic has several advantages over the odds ratio: It is not influenced if the outcome is not rare; a comparison group is not required; and it provides a measure of absolute difference rather than relative difference. We included an interaction term between time and each measure in the models to allow estimation of the probability for each period. To assess the difference in the percentage change between the 2 comparison groups, we tested the interaction term of each demographic characteristic and clinical variable (age, sex, race or ethnicity, education, insulin use, and health insurance status) with time. Role of the Funding Source No funding was received for this study. Results Half of the quality care measures that we analyzed improved between the baseline and recent surveys, and the only measure that worsened was the proportion of participants with hemoglobin A1c < 6%. We observed absolute increases for LDL levels less than 3.4 mmol/L (<130 mg/dL) (22 percentage points), annual lipid profil


Health Economics | 2009

Investing time in health: do socioeconomically disadvantaged patients spend more or less extra time on diabetes self‐care?

Susan L. Ettner; Betsy L. Cadwell; Louise B. Russell; Arleen F. Brown; Andrew J. Karter; Monika M. Safford; Carol Mangione; Gloria L. Beckles; William H. Herman; Theodore J. Thompson; David G. Marrero; Ronald T. Ackermann; Susanna R. Williams; Matthew J. Bair; Ed Brizendine; Aaro E. Carroll; Gilbert C. Liu; Paris Roach; Usha Subramanian; Honghong Zhou; Joseph V. Selby; Bix E. Swain; Assiamira Ferrara; John Hsu; Julie A. Schmittdiel; Connie S. Uratsu; David J. Curb; Beth Waitzfelder; Rosina Everitte; Thomas Vogt

Objective. PEDIATRICS (ISSN 0031 4005). Published in the public domain by the American Academy of Pediatrics.Several studies have reported increases in the occurrence of type 2 diabetes in youths. People with prediabetic states such as impaired fasting glucose (IFG) are at increased risk for developing diabetes and cardiovascular disease (CVD). The objective of this study was to examine the prevalence of IFG and its relationship with overweight and CVD risk factors in a nationally representative sample of US adolescents who were aged 12 to 19 years. Methods. We used data from the 1999–2000 National Health and Nutrition Examination Survey (NHANES). Adolescents who had fasted for 8 hours or more were included in the study (n = 915). IFG was defined as a fasting glucose of 100 to 125 mg/dL. Participants were classified as overweight when their age- and gender-specific BMI was ≥95th percentile and as at-risk for overweight when their BMI was ≥85th and <95th percentile. Results. In 1999–2000, the prevalence of IFG in US adolescents was 7.0% and was higher in boys than in girls (10.0% vs 4.0%). Prevalence of IFG was higher in overweight adolescents (17.8%) but was similar in those with normal weight and those who were at risk for overweight (5.4% vs 2.8%). The prevalence of IFG was significantly different across racial/ethnic groups (13.0%, 4.2%, and 7% in Mexican Americans, non-Hispanic black individuals, and non-Hispanic white individuals, respectively). Adolescents with IFG had significantly higher mean hemoglobin A1c, fasting insulin, total and low-density lipoprotein cholesterol, triglycerides, and systolic blood pressure and lower high-density lipoprotein cholesterol than those with normal fasting glucose concentrations. Conclusions. These data, representing 27 million US adolescents, reveal a very high prevalence of IFG (1 in 10 boys and 1 in 25 girls) among adolescents; the condition affects 1 in every 6 overweight adolescents. Adolescents with IFG have features of insulin resistance and worsened CVD risk factors. Evidence for prevention is still forthcoming in this age group.


Influenza and Other Respiratory Viruses | 2013

Seroepidemiologic investigation of an outbreak of pandemic influenza A H1N1 2009 aboard a US Navy Vessel—San Diego, 2009

Christina B. Khaokham; Monica U. Selent; Fleetwood Loustalot; Shauna Mettee Zarecki; Douglas Harrington; Eileen Hoke; Dennis J. Faix; Ryan G. Ortiguerra; Bryan Alvarez; Nathaniel Almond; Kellie McMullen; Betsy L. Cadwell; Timothy M. Uyeki; Patrick J. Blair; Stephen H. Waterman

Peripheral neuropathy is a serious complication of diabetes and several conditions that may lead to the loss of lower extremity function and even amputations. Since the introduction of statins, their use has increased markedly. Recent reports suggest a role for statins in the development of peripheral neuropathy. The aims of the present study were to assess the association between statin use and peripheral neuropathy, and to determine whether this association varied by diabetes status.


American Journal of Preventive Medicine | 2012

2009 Pandemic Influenza A Vaccination of Pregnant Women: King County, Washington State, 2009–2010

Meagan Kay; Kathryn G. Koelemay; Tao Sheng Kwan-Gett; Betsy L. Cadwell; Jeffrey S. Duchin

BACKGROUND Research on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time. OBJECTIVE To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes. DATA Eleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001. METHODS Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics. RESULTS Proportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day. DISCUSSION Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.


Statistics in Medicine | 2008

An analysis of eight 95 per cent confidence intervals for a ratio of Poisson parameters when events are rare

Lawrence E. Barker; Betsy L. Cadwell

During summer 2009, a US Navy ship experienced an influenza‐like illness outbreak with 126 laboratory‐confirmed cases of pandemic influenza A (H1N1) 2009 virus among the approximately 2000‐person crew.


American Journal of Public Health | 2014

Effect of Vaccination Coordinators on Socioeconomic Disparities in Immunization Among the 2006 Connecticut Birth Cohort

Jessica A. Kattan; Kathy Kudish; Betsy L. Cadwell; Kristen Soto; James L. Hadler

PURPOSE The objectives were to estimate 2009 pandemic influenza A (pH1N1) vaccination coverage among pregnant women and identify associated factors. METHODS A multimodal survey was distributed to 5341 women who gave birth between November 1, 2009, and January 31, 2010, identified by hospitals in King County, Washington State, with maternity services (n=11). RESULTS Of 4205 respondents, 3233 (76.9%) reported that they had received pH1N1 vaccine during pregnancy or within 2 weeks after delivery. Women whose prenatal care provider recommended vaccine had a higher vaccination prevalence than women whose provider did not (81.5% vs 29.6%; adjusted prevalence ratio=2.1; 95% CI=1.72, 2.58). Vaccination prevalence was lower among women who had received prenatal care from a midwife only compared with women who had received care from other providers (62.9% vs 78.8%; adjusted prevalence ratio=0.89; 95% CI=0.83, 0.96). CONCLUSIONS Among pregnant women in King County, pH1N1 vaccination coverage was high. To improve coverage during nonpandemic seasons, influenza vaccine should be recommended routinely by prenatal care providers and vaccination provided where prenatal care is received. Barriers to midwives providing vaccination recommendations to patients should be explored.


Emerging Infectious Diseases | 2011

Shedding of pandemic (H1N1) 2009 virus among health care personnel, Seattle, Washington, USA.

Meagan Kay; Danielle M. Zerr; Janet A. Englund; Betsy L. Cadwell; Jane Kuypers; Paul Swenson; Tao Kwan-Gett; Shaquita L. Bell; Jeffrey S. Duchin

We compared eight nominal 95 per cent confidence intervals for the ratio of two Poisson parameters, both assumed small, on their true coverage (the probability that the interval includes the ratio of Poisson parameters) and median width. The commonly used log-linear interval, justified by asymptotic considerations, provided coverage and relatively narrow intervals, despite small numbers of arrivals. However, the uniform and scores intervals, defined in the text, come very close to providing coverage while providing substantially narrower intervals. These intervals might have practical applications. In a sensitivity analysis, none of the intervals maintained coverage for negative binomial data, indicating that distributional assumptions should be checked before taking our recommendations.


Pediatrics | 2006

Low prevalence of impaired fasting glucose in obese adolescents from Southern Europe.

Desmond E. Williams; Betsy L. Cadwell; Yiling J. Cheng; Edward W. Gregg; Linda S. Geiss; Michael M. Engelgau; K.M. Venkat Narayan; Giuseppina Imperatore; Catherine C. Cowie

OBJECTIVES We examined socioeconomic status (SES) disparities and the influence of state Immunization Action Plan-funded vaccination coordinators located in low-SES areas of Connecticut on childhood vaccination up-to-date (UTD) status at age 24 months. METHODS We examined predictors of underimmunization among the 2006 birth cohort (n = 34,568) in the states Immunization Information System, including individual demographic and SES data, census tract SES data, and residence in an area with a vaccination coordinator. We conducted multilevel logistic regression analyses. RESULTS Overall, 81% of children were UTD. Differences by race/ethnicity and census tract SES were typically under 5%. Not being UTD at age 7 months was the strongest predictor of underimmunization at age 24 months. Among children who were not UTD at age 7 months, only Medicaid enrollment (adjusted odds ratio [AOR] = 0.6; 95% confidence interval [CI] = 0.5, 0.7) and residence in an area with a vaccination coordinator (AOR = 0.7; 95% CI = 0.6, 0.9) significantly decreased the odds of subsequent underimmunization. CONCLUSIONS SES disparities associated with underimmunization at age 24 months were limited. Efforts focused on vaccinating infants born in low SES circumstances can minimize disparities.

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Michael M. Engelgau

National Institutes of Health

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Edward W. Gregg

Centers for Disease Control and Prevention

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Linda S. Geiss

Centers for Disease Control and Prevention

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Theodore J. Thompson

Centers for Disease Control and Prevention

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Desmond E. Williams

Centers for Disease Control and Prevention

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Edward F. Tierney

Centers for Disease Control and Prevention

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Giuseppina Imperatore

Centers for Disease Control and Prevention

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James P. Boyle

Centers for Disease Control and Prevention

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Yiling J. Cheng

Centers for Disease Control and Prevention

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