Janese M. Willis

Education, glucose control, and mortality risks among U.S. older adults with diabetes

AIMS Studies have shown that diabetes mellitus disproportionately afflicts persons of low socioeconomic status and that the burden of disease is greatest among the disadvantaged. However, our understanding of educational differences in the control of diabetes and its impact on survival is limited. This study investigated the associations among education, hemoglobin A1c (HbA1c), and subsequent mortality in adults with diabetes. METHODS Prospective cohort data from the 2006, 2008, and 2010 Health and Retirement Study were linked with biomarker data for U.S. older adults with diabetes (n=3312). Weighted distributions were estimated for all subjects at baseline and by the American Diabetes Associations general guidelines for HbA1c control (<7.0% [53 mmol/mol] vs. ≥7.0% [53 mmol/mol]). Proportional hazard models were used to estimate educational differences in all-cause mortality by HbA1c level with sequential adjustments for contributing risk factors. RESULTS Mortality risks associated with HbA1c≥7.0% [53 mmol/mol] were significantly greater in lower-educated adults than higher-educated adults (P<0.001). We found that the hazard ratios (HR) associated with HbA1c ≥7.0% [53 mmol/mol] were highest among low-educated adults (HR=2.18, 95% CI: 1.62, 2.94) and that a combination of socioeconomic, psychosocial, and behavioral factors accounted for most, but not all, of the associations. CONCLUSIONS Educational differences in HbA1c control have significant implications for mortality and efforts to reduce these disparities should involve more vigilant screening and monitoring of lower-educated adults with diabetes.

Decision support for evidence-based pharmacotherapy detects adherence problems but does not impact medication use

Although evidence-based pharmacotherapies are a principal component of patient care, 30-50% of patients do not take their medications as prescribed. We conducted a randomized trial of two clinical decision support (CDS) interventions in 2219 patients: patient adherence reports to providers (n=744), patient adherence reports to providers + email notices to care managers (n=736), and controls (739). At 18-month follow-up, there were no treatment-related differences in patient medication adherence (overall, by medication class, and by medical condition). There also were no treatment-related differences in patient clinical and economic outcomes. Thus, while this studys CDS information interventions were successfully delivered to providers and care managers, and were effective in identifying medication adherence deficits and in increasing care manager responses to medication adherences issues, these interventions were not able to alter patient medication behavior.

A randomized clinical trial of clinical decision support in a rural community health network serving lower income individuals: study design and baseline characteristics.

Lower income individuals in the US frequently experience difficulties in obtaining access to needed health care services. We describe a randomized clinical trial that seeks to improve the quality of, and access to healthcare services for medically underserved populations in five rural counties of North Carolina. We propose to achieve these improvements by implementing system-to-system integration via a telehealth network with an asynchronous clinical decision support system for health care providers.

Access to routine care and risks for 30-day readmission in patients with cardiovascular disease

Background Studies have shown that access to routine medical care is associated with the prevention, diagnosis, and treatment of chronic diseases. However, studies have not examined whether patient‐reported difficulties in access to care are associated with rehospitalization in patients with cardiovascular disease. Methods Electronic medical records and a standardized survey were used to examine cardiovascular patients admitted to a large medical center from January 1, 2015 through January 10, 2017 (n = 520). All‐cause readmission within 30 days of discharge was the primary outcome for analysis. Logistic regression models were used to examine the association between access to care and 30‐day readmission while adjusting for patient demographics, socioeconomic status, healthcare utilization, and health status. Results Nearly 1‐in‐6 patients (15.7%) reported difficulty in accessing routine medical care; and those who were younger, male, non‐white, uninsured, with heart failure, and had low social support were significantly more likely to report difficulty. Patients who reported difficulty in accessing care had significantly higher rates of 30‐day readmission than patients who did not report difficulty (33.3% vs. 17.9%; P = .001); and the risks remained largely unchanged after accounting for nearly two dozen covariates (unadjusted odds ratio [OR] = 2.29; 95% CI, 1.46‐3.60 vs. adjusted OR = 2.17; 95% CI, 1.29‐3.66). Risks for readmission were especially high for patients who reported issues with transportation (OR = 3.24; 95% CI, 1.28‐8.16) and scheduling appointments (OR = 3.56; 95% CI, 1.43‐8.84), but not for other reasons (OR = 1.47; 95% CI, 0.61‐3.54). Conclusions Cardiovascular patients who reported difficulty in accessing routine care had substantial risks of readmission within 30 days after discharge. These findings have important implications for identifying high‐risk patients and developing interventions to improve access to routine medical care.

Randomized Trial of Population-Based Clinical Decision Support to Facilitate Care Transitions.

Medicaid beneficiaries in 6 North Carolina counties were randomly assigned to 1 of 3 clinical decision support (CDS) care transition strategies: (1) usual care (Control), (2) CDS messaging to patients and their medical homes (Reports), or (3) CDS messaging to patients, their medical homes, and their care managers (Reports+). We included 7146 Medicaid patients and evaluated transitions from specialist visit, ER and hospital encounters back to the patients medical home. Patients enrolled in Medicare and Medicaid were not eligible. The number of care manager contacts was greater for patients in the Reports+ Group than in the Control Group. However, there were no treatment-related differences in emergency department (ED) encounter rates, or in the secondary outcomes of outpatient and hospital encounter rates and medical costs. Study monitors found study intervention documentation in approximately 60% of patient charts. These results highlight the importance of effectively integrating information interventions into healthcare delivery workflow systems.

Racial and Ethnic Differences in Trajectories of Hospitalization in US Men and Women With Heart Failure

Background Prior studies have documented racial and ethnic disparities in hospitalization among patients with heart failure (HF). However, racial/ethnic differences in trajectories of hospitalization following the diagnosis of HF have not been well characterized. This study examined racial/ethnic differences in individual‐level trajectories of hospitalization in older adults with diagnosed HF. Methods and Results Data from a nationally representative prospective cohort of US men and women aged 45 years and older were used to examine the number of hospitalizations reported every 24 months. Participants who were non‐Hispanic white, non‐Hispanic black, and Hispanic with a reported diagnosis of HF (n=3011) were followed from 1998 to 2014. Results showed a quadratic change in the number of reported hospitalizations following HF diagnosis, with an average of 2.36 (95% confidence interval [CI], 2.19–2.53; P<0.001) hospitalizations within 24 months that decreased by 0.35 (95% CI, −0.45 to −0.25; P<0.001) every 24 months and subsequently increased by 0.03 (95% CI, 0.02–0.05; P<0.001) thereafter. In men, there were no racial/ethnic differences in hospitalizations reported at the time of diagnosis; however, Hispanic men had significant declines in hospitalizations after diagnosis (Hispanic×time=−0.52; 95% CI, −0.99 to −0.05 [P=0.031]) followed by a sizeable increase in hospitalizations at later stages of disease (Hispanic×time2=0.06; 95% CI, 0.00–0.12 [P=0.047]). In women, hospitalizations were consistently high following their diagnosis and black women had significantly more hospitalizations throughout follow‐up than white women (black=0.28; 95% CI, 0.00–0.55 [P=0.048]). Racial/ethnic disparities varied by geography and the differences remained significant after adjusting for multiple sociodemographic, psychosocial, behavioral, and physiological factors. Conclusions There were significant racial/ethnic differences in trajectories of hospitalization following the diagnosis of HF in US men and women. Racial/ethnic disparities varied by place of residence and the differences persisted after adjustment for multiple risk factors. The findings have important implications that may be crucial to planning the immediate and long‐term delivery of care in patients with HF to reduce potentially preventable hospitalizations.

Barriers to care for patients with diabetes in Durham, North Carolina, why are we withholding life-sustaining medications from the patients who need them the most?

The diabetes epidemic and its complications disproportionately affect minorities and the poor. Medical treatments that can prevent or delay diabetes complications are widely available but poverty underlies much of why there are disparities in diabetes care and outcomes. Lack of access to care, food insecurity and inability to pay for medications prevents adherence to a medication and lifestyle regimen that can be life-sustaining. At the very least, US policies should be changed to provide life-sustaining medications that prevent costly complications to patients who cannot afford them. Adopting value-based insurance design would benefit patients with diabetes who cannot afford to pay for medications but would also reduce healthcare costs in the long run.

Clinical and economic results from a randomized trial of clinical decision support in a rural health network.

BACKGROUND Replication studies evaluate technologies in usual use settings. METHODS We conducted a clinical trial to determine whether reductions in clinical and economic results observed in a previous study could be replicated in a larger setting. Subjects were randomized to receive intervention (email notifications for sentinel health events sent to their care managers) or control. MAIN OUTCOME MEASURES The primary outcome was the rate of emergency department visits for low severity conditions. Secondary outcomes included: medical costs and other clinical event rates. RESULTS We randomized 13,454 individuals (intervention, 6740; control, 6714). Subjects in both groups had similar rates of clinical events and medical costs. CONCLUSION The use of email notifications to care managers was associated with no reductions in clinical events or medical costs.