Catherine Kim

Recurrence of gestational diabetes mellitus: A systematic review

OBJECTIVE—The purpose of this study was to examine rates and factors associated with recurrence of gestational diabetes mellitus (GDM) among women with a history of GDM. RESEARCH DESIGN AND METHODS—We conducted a systematic literature review of articles published between January 1965 and November 2006, in which recurrence rates of GDM among women with a history of GDM were reported. Factors abstracted included recurrence rates, time elapsed between pregnancies, race/ethnicity, diagnostic criteria, and, when available, maternal age, parity, weight or BMI at the initial and subsequent pregnancy, weight gain at the initial or subsequent pregnancy and between pregnancies, insulin use, gestational age at diagnosis, glucose tolerance test levels, baby birth weight and presence of macrosomia, and breast-feeding. RESULTS—Of 45 articles identified, 13 studies were eligible for inclusion. After the index pregnancy, recurrence rates varied between 30 and 84%. Lower rates were found in non-Hispanic white (NHW) populations (30–37%), and higher rates were found in minority populations (52–69%). Exceptions to observed racial/ethnic variations in recurrence were found in cohorts that were composed of a significant proportion of both NHW and minority women or that included women who had subsequent pregnancies within 1 year. No other risk factors were consistently associated with recurrence of GDM across studies. The rates of future preexisting diabetes in pregnancy, socioeconomic status, postpartum diabetes screening rates after the index pregnancy, and the average length of time between pregnancies were generally not reported. CONCLUSIONS—Recurrence of GDM was common and may vary most significantly by NHW versus minority race/ethnicity.

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.

Caregiving Behavior Is Associated With Decreased Mortality Risk

Traditional investigations of caregiving link it to increased caregiver morbidity and mortality, but do not disentangle the effects of providing care from those of being continuously exposed to an ailing loved one with serious health problems. We explored this possible confound in a national, longitudinal survey of elderly married individuals (N = 3,376). Results showed that spending at least 14 hr per week providing care to a spouse predicted decreased mortality for the caregiver, independently of behavioral and cognitive limitations of the care recipient (spouse), and of other demographic and health variables. These findings suggest that it may be premature to conclude that health risks for caregivers are due to providing active help. Indeed, under some circumstances, caregivers may actually benefit from providing care.

Trends in Postpartum Diabetes Screening and Subsequent Diabetes and Impaired Fasting Glucose Among Women With Histories of Gestational Diabetes Mellitus A report from the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE—The purpose of this study was to examine trends in postpartum glucose screening for women with gestational diabetes mellitus (GDM), predictors of screening, trends in postpartum impaired fasting glucose (IFG) and diabetes, and diabetes and pre-diabetes detected by postpartum fasting plasma glucose (FPG) versus a 75-g oral glucose tolerance test (OGTT). RESEARCH DESIGN AND METHODS—This was a cohort study of 14,448 GDM pregnancies delivered between 1995 and 2006. Postpartum screening was defined as performance of either an FPG or OGTT at least 6 weeks after delivery and within 1 year of delivery. RESULTS—Between 1995 and 2006, the age- and race/ethnicity-adjusted proportion of women who were screened postpartum rose from 20.7% (95% CI 17.8–23.5) to 53.8% (51.3–56.3). Older age, Asian or Hispanic race/ethnicity, higher education, earlier GDM diagnosis, use of diabetes medications during pregnancy, and more provider contacts after delivery were independent predictors of postpartum screening. Obesity and higher parity were independently associated with lower screening performance. Among women who had postpartum screening, the age- and race/ethnicity-adjusted proportion of IFG did not change over time (24.2 [95% CI 20.0–27.8] in 1995–1997 to 24.3 [22.6–26.0] in 2004–2006), but the proportion of women with diabetes decreased from 6.1 (95% CI 4.2–8.1) in 1995–1997 to 3.3 (2.6–4.0) in 2004–2006. Among women who received an OGTT in 2006, 38% of the 204 women with either diabetes or pre-diabetes were identified only by the 2-h glucose measurements. CONCLUSIONS—Postpartum screening has increased over the last decade, but it is still suboptimal. Compared with FPGs alone, the 2-h values identify a higher proportion of women with diabetes or pre-diabetes amenable to intervention.

Recurrence of gestational diabetes: a systematic review

OBJECTIVE—The purpose of this study was to examine rates and factors associated with recurrence of gestational diabetes mellitus (GDM) among women with a history of GDM. RESEARCH DESIGN AND METHODS—We conducted a systematic literature review of articles published between January 1965 and November 2006, in which recurrence rates of GDM among women with a history of GDM were reported. Factors abstracted included recurrence rates, time elapsed between pregnancies, race/ethnicity, diagnostic criteria, and, when available, maternal age, parity, weight or BMI at the initial and subsequent pregnancy, weight gain at the initial or subsequent pregnancy and between pregnancies, insulin use, gestational age at diagnosis, glucose tolerance test levels, baby birth weight and presence of macrosomia, and breast-feeding. RESULTS—Of 45 articles identified, 13 studies were eligible for inclusion. After the index pregnancy, recurrence rates varied between 30 and 84%. Lower rates were found in non-Hispanic white (NHW) populations (30–37%), and higher rates were found in minority populations (52–69%). Exceptions to observed racial/ethnic variations in recurrence were found in cohorts that were composed of a significant proportion of both NHW and minority women or that included women who had subsequent pregnancies within 1 year. No other risk factors were consistently associated with recurrence of GDM across studies. The rates of future preexisting diabetes in pregnancy, socioeconomic status, postpartum diabetes screening rates after the index pregnancy, and the average length of time between pregnancies were generally not reported. CONCLUSIONS—Recurrence of GDM was common and may vary most significantly by NHW versus minority race/ethnicity.

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

Sex Disparities in Control and Treatment of Modifiable Cardiovascular Disease Risk Factors Among Patients With Diabetes: Translating Research Into Action for Diabetes (TRIAD) Study

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

Association Between Iron Deficiency and A1C Levels Among Adults Without Diabetes in the National Health and Nutrition Examination Survey, 1999–2006

OBJECTIVE—Cardiovascular disease (CVD) mortality has decreased in men but not in women with diabetes. We investigated whether sex differences in control and treatment of CVD risk factors might underlie this disparity. RESEARCH DESIGN AND METHODS—We performed cross-sectional analyses from a cohort of patients with diabetes sampled from 10 U.S. managed care health plans. Study end points included not being in control for CVD risk factors (≥140 mmHg for systolic blood pressure [SBP], ≥3.35 mmol/l for LDL cholesterol, and ≥8.0% for A1C) and the intensity of medication management (number of medication classes) for patients not in control. Logistic regression models with random intercepts were used to adjust probabilities of control and management for demographics, clinical characteristics, and clustering within health plans. RESULTS—There were 1,315 women and 1,575 men with a history of CVD and 3,415 women and 2,516 men without a history of CVD. Among patients with CVD, adjusted estimated probabilities for not being in control and risk differences varied significantly between men and women for SBP (men 41.2%, women 46.6%; risk difference −5.4% [95% CI −9.5 to −1.3]) and LDL cholesterol (men 22.4%, women 28.3%; risk difference −5.9% [−9.9 to −1.8]). There were no significant sex differences in intensity of medication management for patients not in control. In patients without CVD there were no significant differences in control or intensity of medication management. CONCLUSIONS—In diabetic patients with CVD, poorer control of SBP and LDL cholesterol for women may contribute to the sex disparity in CVD mortality trends.

Missed Opportunities for Type 2 Diabetes Mellitus Screening Among Women With a History of Gestational Diabetes Mellitus

OBJECTIVE Iron deficiency has been reported to elevate A1C levels apart from glycemia. We examined the influence of iron deficiency on A1C distribution among adults without diabetes. RESEARCH DESIGN AND METHODS Participants included adults without self-reported diabetes or chronic kidney disease in the National Health and Nutrition Examination Survey 1999–2006 who were aged ≥18 years of age and had complete blood counts, iron studies, and A1C levels. Iron deficiency was defined as at least two abnormalities including free erythrocyte protoporphyrin >70 μg/dl erythrocytes, transferrin saturation <16%, or serum ferritin ≤15 μg/l. Anemia was defined as hemoglobin <13.5 g/dl in men and <12.0 g/dl in women. RESULTS Among women (n = 6,666), 13.7% had iron deficiency and 4.0% had iron deficiency anemia. Whereas 316 women with iron deficiency had A1C ≥5.5%, only 32 women with iron deficiency had A1C ≥6.5%. Among men (n = 3,869), only 13 had iron deficiency and A1C ≥5.5%, and only 1 had iron deficiency and A1C ≥6.5%. Among women, iron deficiency was associated with a greater odds of A1C ≥5.5% (odds ratio 1.39 [95% CI 1.11–1.73]) after adjustment for age, race/ethnicity, and waist circumference but not with a greater odds of A1C ≥6.5% (0.79 [0.33–1.85]). CONCLUSIONS Iron deficiency is common among women and is associated with shifts in A1C distribution from <5.5 to ≥5.5%. Further research is needed to examine whether iron deficiency is associated with shifts at higher A1C levels.

Risk Factors for Mortality among Patients with Diabetes: The Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVES We sought to determine rates and factors associated with screening for type 2 diabetes mellitus (DM) in women with a history of gestational diabetes mellitus. METHODS We retrospectively studied women with diagnosed gestational diabetes mellitus who delivered at a university-affiliated hospital (n=570). Data sources included medical and administrative record review. Main outcome measures were the frequency of any type of glucose testing at least 6 weeks after delivery and the frequency of recommended glucose testing. We assessed demographic data, past medical history, and prenatal and postpartum care characteristics. RESULTS Rates of glucose testing after delivery were low. Any type of glucose testing was performed at least once after 38% of deliveries, and recommended glucose testing was performed at least once after 23% of deliveries. Among women with at least 1 visit to the health care system after delivery (n=447), 42% received any type of glucose test at least once, and 35% received a recommended glucose test at least once. Factors associated with testing were being married, having a visit with an endocrinologist after delivery, and having more visits after delivery. CONCLUSIONS These findings suggest that most women with gestational diabetes mellitus are not screened for type 2 DM after delivery. Opportunities for DM prevention and early treatment are being missed.