Marshall H. Chin

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

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ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult—Summary Article

The American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines regularly reviews existing guidelines to determine when an update or full revision is needed. This process gives priority to areas where major changes in text, particularly recommendations,

The prevention or delay of type 2 diabetes: American Diabetes Association and National Institute of Diabetes, Digestive and Kidney Diseases

D iabetes is one of the most costly and burdensome chronic diseases of our time and is a condition that is increasing in epidemic proportions in the U.S. and throughout the world (1). The complications resulting from the disease are a significant cause of morbidity and mortality and are associated with the damage or failure of various organs such as the eyes, kidneys, and nerves. Individuals with type 2 diabetes are also at a significantly higher risk for coronary heart disease, peripheral vascular disease, and stroke, and they have a greater likelihood of having hypertension, dyslipidemia, and obesity (2–6). There is also growing evidence that at glucose levels above normal but below the diabetes threshold diagnostic now referred to as pre-diabetes, there is a substantially increased risk of cardiovascular disease (CVD) and death (5,7–10). In these individuals, CVD risk factors are also more prevalent (5–7,9,11–14), which further increases the risk but is not sufficient to totally explain it. In contrast to the clear benefit of glucose lowering to prevent or retard the progression of microvascular complications associated with diabetes (15– 18,21), it is less clear whether the high rate of CVD in people with impaired glucose homeostasis, i.e., those with impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes, is caused by elevated blood glucose levels or will respond to treatments that lower blood glucose. Epidemiological studies have shown a clear relationship (19,20), whereas intervention trials in people with diabetes suggest, but have not demonstrated, a clear benefit of glycemic control (15,16,21,22). Additionally, there are no studies that have investigated a benefit of glucose lowering on macrovascular disease in subjects with only pre-diabetes (IFG or IGT) but not diabetes. Although the treatment of diabetes has become increasingly sophisticated, with over a dozen pharmacological agents available to lower blood glucose, a multitude of ancillary supplies and equipment available, and a clear recognition by health care professionals and patients that diabetes is a serious disease, the normalization of blood glucose for any appreciable period of time is seldom achieved (23). In addition, in well-controlled socalled “intensively” treated patients, serious complications still occur (15–18,21), and the economic and personal burden of diabetes remains. Furthermore, microvascular disease is already present in many individuals with undiagnosed or newly diagnosed type 2 diabetes (11,24– 28). Given these facts, it is not surprising that studies have been initiated in the last decade to determine the feasibility and benefit of various strategies to prevent or delay the onset of type 2 diabetes. Two early reports (29,30) suggested that changes in lifestyle can prevent diabetes, but weaknesses in study design limited their general relevance. Recently, however, four well-designed randomized controlled trials have been reported (31–35). In the Finnish study (31), 522 middleaged (mean age 55 years) obese (mean BMI 31 kg/m) subjects with IGT were randomized to receive either brief diet and exercise counseling (control group) or intensive individualized instruction on weight reduction, food intake, and guidance on increasing physical activity (intervention group). After an average follow-up of 3.2 years, there was a 58% relative reduction in the incidence of diabetes in the intervention group compared with the control subjects. A strong correlation was also seen between the ability to stop the progression to diabetes and the degree to which subjects were able to achieve one or more of the following: lose weight (goal of 5.0% weight reduction), reduce fat intake (goal of 30% of calories), reduce saturated fat intake (goal of 10% of calories), increase fiber intake (goal of 15 g/1,000 kcal), and exercise (goal of 150 min/week). No untoward effects of the lifestyle interventions were observed. In the Diabetes Prevention Program (DPP) (32–34), the 3,234 enrolled subjects were slightly younger (mean age 51 years) and more obese (mean BMI 34 kg/m) but had nearly identical glucose intolerance compared with subjects in the Finnish study. About 45% of the participants were from minority groups (e.g, AfricanAmerican, Hispanic), and 20% were 60 years of age. Subjects were randomized to one of three intervention groups, which included the intensive nutrition and exercise counseling (“lifestyle”) group or either of two masked medication treatment groups: the biguanide metformin group or the placebo group. The latter interventions were combined with standard diet and exercise recommendations. After an average follow-up of 2.8 years (range 1.8–4.6 years), a 58% relative reduction in the progression to diabetes was observed in the lifestyle group (absolute incidence 4.8%), and a 31% relative reduction in the progression of diabetes was observed in the metformin group (absolute incidence 7.8%) compared with control subjects (absolute incidence 11.0%). ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Correlates of Early Hospital Readmission or Death in Patients With Congestive Heart Failure

Among patients with heart failure who survive an admission to the hospital, those who are readmitted or die soon after discharge may warrant special attention. Therefore, we prospectively followed 257 patients admitted nonelectively to an urban university hospital, with a complaint of shortness of breath or fatigue and evidence of congestive heart failure on admission chest radiograph, who were discharged alive. Through survey of patients and families, review of the hospital computer system, and a search of the National Death Index, we recorded death and hospital readmission. Within 60 days of discharge, 13 patients (5%) died and 82 (32%) died or were readmitted to the hospital. Using Cox proportional-hazards modeling, the multivariable correlates of readmission or death were single marital status (adjusted hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.3 to 3.3), Charlson Comorbidity Index score (HR 1.3 per point to maximum 4 points, 95% CI 1.1 to 1.6), admission systolic blood pressure of < or = 100 mm Hg (HR 2.8, 95% CI 1.6 to 5.0), and absence of new ST-T-wave changes on the initial electrocardiogram (HR 1.9, 95% CI 1.1 to 3.3). Self-reported patient compliance and clinical instability at discharge were not correlates. Almost all patients stratified by these factors had at least a 25% risk of readmission or death. Our independent correlates of readmission or death support the importance of both medical and social factors in the pathway to clinical decline. However, we could not reliably identify a truly low-risk group. Interventions to decrease early readmission or death among patients with heart failure should target both medical management and the adequacy of social support, and probably need to be applied to all admitted patients.

Community-based participatory research: opportunities, challenges, and the need for a common language.

In January of 2002, a call for papers featuring community-based participatory research (CBPR) was issued. The intent was to highlight the outstanding work being done in this area and the role CBPR can play in improving the care and outcomes of populations at-risk.1 What emerged from this call was more than what any of the editors expected, and has been illustrative of both the superb scholarship and community engagement occurring in CBPR and how much more can be done in refining and broadening the application of CBPR in what we do. The body of research submitted for consideration also highlights several important realities: 1) CBPR is appropriate and applicable across disciplines and within many diverse community settings; 2) the potential for CBPR to make meaningful contributions to improving the health and well-being of traditionally disenfranchised population groups and communities is very real and, in many instances, being realized; and 3) we need to do a better job of articulating CBPR to our peers and colleagues as “research-plus” that is both methodologically rigorous and that makes unique contributions not possible using other means. The 11 original research papers presented in this Special Issue came from an impressive pool of 81 submissions. And while CBPR may seem somewhat straightforward in theory, as these articles demonstrate, the degree to which CBPR is applied and how it is represented are far more diverse and varied. The peer review process and several editor meetings for this Special Issue brought out many of the challenges inherent in CBPR. How do we define community? What is a meaningful impact? How do we distinguish between community-placed and community-based research? How do we balance the importance of the research process with the importance of the research product or findings? Is there a methodologic threshold with which to determine whether a project is or is not CBPR? What is evident from the submissions is how broadly CBPR is being applied, geographically, within specific population groups and clinical scenarios, and methodologically. For example, Angell et al.2 and Stratford et al.3 both describe CBPR projects in rural settings, while van Olphen et al.,4 Horowitz et al.,5 and Masi et al.6 all describe urban-based research. Initiatives targeting specific vulnerable or at-risk populations are featured in work by Lauderdale et al.7 with older Chinese immigrants, by Lam et al.8 with Vietnamese-American women, and by van Olphen et al. with African-American women. Similarly, CBPR was clearly applicable in several different clinical scenarios, including chronic disease management of diabetes,5 asthma,9 and cancer treatment and prevention.10 The partners engaged in the community-based research also varied across projects and included faith-based organizations,4,10 neighborhood and community leaders,6,8 and social service and support agencies.2,3,7 Finally, the research topics and interventions themselves also reflected a wide spectrum of CBPR applications. Sloane et al. examined the degree of nutritional resources available within a community, whereas Masi et al. evaluated the application of internet-based technologies.5,11 The articles presented also reflect the broad scope of research in which CBPR can be applied methodologically. Angell et al. and Corbie-Smith et al. report on findings where CBPR was applied to randomized controlled trials,2,10 while van Olphen et al., Masi et al., and Lam et al., all report data from intervention studies with pre–post comparisons.4,6,8 Horowitz et al. and Lauderdale et al. represent good examples of CBPR applied to survey research,5,7 and Parker et al. demonstrate CBPR applied to a qualitative study.9 Finally, the article by Nyden provides an overview of CBPR and highlights many of the issues and struggles to institutionalizing and legitimizing CBPR within the broader research community from an academic perspective.12 As the science and field of CBPR advance to the next level, it is clear that several things need to occur. We need more formal training in CBPR that is more broadly available to both academically-based researchers and community members. Post-doctoral training programs such as the Kellogg Community Scholars Program13 need to be expanded beyond the current 3 schools of public health, and need to be integrated into other health professional schools and within other established fellowship and post-doctoral training programs. Additionally, career development awards sponsored by federal agencies and private philanthropies need to be amenable to proposals that engage the candidate in CBPR projects and ideally should promote this in their solicitation and review process. We also need to encourage scholarship, not only in the application of CBPR, but also in better understanding the nuances of the model, so that it can truly live up to its potential. This includes developing a common language for describing CBPR-related research in the health services literature, so that it can stand on its own merits and be appreciated for the contributions it brings to the field. One possible framework for this common language is introduced in Table 1 and is meant to serve as a resource for authors considering submission of CBPR projects to peer-reviewed journals. Finally, we need to gain a greater appreciation for CBPR as “research-plus” that is reflected in funding priorities, review criteria, community empowerment, and academic advancement. Table 1 Proposed Process for Describing Community-based Participatory Research Findings in Health Sciences Literature In summary, it is best to view this Special Issue as a reflection of both where we are as a research community and where we need to go. The 11 papers ultimately chosen for this issue represent a small fraction of the excellent work ongoing in many of our communities. Yet there is much more than can and should be done. As the gap in health access and health outcomes grows wider and is further defined by socioeconomics, race, language, country of origin, and other markers and designations inherent in a multicultural, multiethnic society, we need CBPR to help find the answers and sustainable solutions.

Depressive Symptoms and 3-Year Mortality in Older Hospitalized Medical Patients

Hospitalization is associated with a long-term increased risk for death, especially in older persons (1-4). Although the mediators for this increased risk have not been fully elucidated, depression may play an important role. Because depression is common in hospitalized older patients, an association between depression and mortality in this population would be of significant clinical importance (5-13). The hypothesis that depression may be a mediator of death in hospitalized patients is supported by studies demonstrating that depressive symptoms are associated with increased mortality in community-dwelling patients and in highly selected groups of hospitalized older patients, such as those with acute myocardial infarction (14-18). These studies have often been limited by inadequate accounting for the complex interrelations between depressive symptoms and other predictors of death, such as acute physiologic impairment, chronic comorbid illness, functional impairment, and cognitive impairment. Because depressive symptoms are clearly correlated with and may partly be the result of these other factors (5, 19-20), improving our understanding of the relation between depression and death requires use of standardized methods to measure and adjust for confounders. We tested the hypothesis that depressive symptoms are associated with long-term mortality in hospitalized older patients. We demonstrated previously that depressive symptoms are strongly associated with adverse health status outcomes in hospitalized medical patients through 90 days after admission (21). However, our initial study found no association between depressive symptoms and mortality during the first 90 days after admission (21). In this report, we extend mortality follow-up to 3 years by merging our data with a national mortality database. Furthermore, we adjusted for standard measures of physiologic impairment, comorbid illness, and functional impairment at hospital admission to control for the possibility that higher levels of these confounders in patients with more depressive symptoms affect the association between depressive symptoms and death. Methods Patients Patients were drawn from serial, prospective longitudinal studies of functional change in older hospitalized patients on the general medical service of University Hospitals of Cleveland. The inclusion and exclusion criteria for these studies are described elsewhere (3, 21, 22). The first study enrolled 206 patients 75 years of age or older who were admitted between March 1990 and July 1990. The second study, a controlled trial of an intervention to improve functional outcomes, enrolled 651 patients 70 years of age or older who were admitted between November 1990 and March 1992. The first study, which was a pilot study for the second study, enrolled consecutive patients. The second study randomly assigned patients to an intervention designed to improve functional outcomes in older persons or to usual care (22). In each study, patients admitted to the intensive care unit, telemetry service, or oncology service were excluded. Data collection procedures in both studies were almost identical. Other than a slightly higher mean patient age in the first study cohort, the demographic, clinical, and functional characteristics of patients in the first study, the control group of the second study, and the intervention group of the second study were similar. Additional analyses that adjusted for whether patients were in the first study cohort or the control group compared with the intervention group of the second study cohort yielded results that were almost identical to the results reported here. Of 857 older patients enrolled in the two studies, 284 were excluded from the current study because they were too ill or confused to be interviewed about depressive symptoms at the time of admission (n=164), were admitted from nursing homes (n=38), were not available for interview (n=37), declined interview (n=27), or died before being approached (n=18). We excluded patients admitted from nursing homes because interview data were less consistently obtained from these patients. Thus, the analytic sample for this study comprised 573 patients. Assessment of Depressive Symptoms Within 48 hours of admission, patients were interviewed by using the 15-item Geriatric Depression Scale to assess depressive symptoms over the past week (23, 24). The Geriatric Depression Scale is well suited for use in acutely ill older persons because it focuses on symptoms of depression that are less likely to be directly influenced by somatic illness. Examples of items on this scale include feeling bored, dropping activities and interests, feeling helpless, feeling worthless, feeling that life is empty, feeling that others are better off, preferring to stay at home instead of doing new things, and feeling hopeless. We divided patients into those reporting five or fewer symptoms and those reporting six or more symptoms; these are commonly recommended cutoffs on the 15-item Geriatric Depression Scale (24-26). Measurement of Mortality We determined mortality and date of death during the 3 years after hospitalization by merging our files with the National Death Index, a database of all deaths in the United States generated from state death certificates. Its sensitivity and specificity have been reported to be 98% and 100%, respectively (27). Measurement of Potential Confounders Shortly after admission, we surveyed each patients primary nurse about the patients independence in six activities of daily living (dressing, bathing, grooming, toileting, transferring, and eating) based on the scale of Katz (28). Within 48 hours of admission, we administered to patients the first 21 items of the 30-item Folstein Mini-Mental State Examination (29). To minimize respondent burden, we used only the first 21 items. Scores on the 21-item instrument have previously been shown to correlate highly (r=0.9) with scores on the 30-item instrument and to have construct validity on the basis of their strong association with functional outcomes (30). Data gathered from medical records included the reason for admission, the components of the Acute Physiology and Chronic Health Evaluation (APACHE) II score (31), and the components of the weighted Charlson comorbidity index of illness (32). The APACHE II score is a commonly used measure of physiologic severity, and the Charlson score is often used as a measure of the burden of comorbid illness. Statistical Analysis For our primary set of analyses, we compared patients who had six or more depressive symptoms (depressed patients) with patients who had five or fewer symptoms (nondepressed patients). We used the chi-square test or t-test to compare the characteristics of patients in each category at hospital admission. Survival curves describing mortality in the 3 years after hospitalization in each group were prepared by using the method of Kaplan and Meier. We used Cox regression to determine whether depressive symptoms were independently associated with mortality over 3 years. In the first model, we measured the unadjusted association between depressive symptoms and mortality. In the next four models, we determined the association between depressive symptoms and mortality after controlling for APACHE II scores, Charlson comorbidity index scores, dependence in activities of daily living, or cognitive function. In the sixth model, we controlled for all of these potential confounders as well as age, sex, ethnicity, and whether the patient lived alone. We did two secondary analyses. First, we modeled depression scores as the number of depressive symptoms on admission. We also determined the hazard ratio associated with multiple cut-points on the Geriatric Depression Scale. Results The mean age of the 573 patients was 79.9 years; 67.8% of patients were women and 39.4% were African-American. About half were independent in all activities of daily living at hospital admission. Table 1 lists the 10 most common reasons for hospital admission, classified by using the method of Charlson (33). The mean number of depressive symptoms at hospital admission was 4.5, and 34% of patients reported six or more symptoms. At admission, patients with six or more depressive symptoms had higher comorbidity scores, were more likely to have congestive heart failure or chronic obstructive pulmonary disease, had lower cognitive function scores, and were dependent in more activities of daily living (Table 2). Three years after admission (Figure), the mortality rate was higher among patients with six or more depressive symptoms than among patients with five or fewer depressive symptoms (56% compared with 40%; P<0.001). Of the 376 patients with five or fewer depressive symptoms at admission, 78 (21%) died during the first year of follow-up, 121 (32%) died during the first 2 years, and 151 (40%) died during the 3 years. Of the 197 patients with six or more depressive symptoms on admission, 58 (29%) died in the first year, 88 (45%) died during the first 2 years, and 110 (56%) died during the 3 years. The unadjusted hazard ratio over 3 years of follow-up for patients with six or more depressive symptoms was 1.56 (95% CI, 1.22 to 2.00). Patients with six or more depressive symptoms were also slightly more likely than patients with five or fewer symptoms to be discharged to a nursing home (8.3% compared with 4.9%; P=0.11). Table 1. Most Common Reasons for Hospital Admission (n=573) Table 2. Characteristics of Patients at Hospital Admission Figure. Mortality over 3 years (1095 days) in patients who had six or more depressive symptoms compared with patients who had five or fewer symptoms. Although adjustment for physiologic severity, comorbid illness, dependence in activities of daily living, and cognitive function each reduced the strength of the association between depressive symptoms and mortality, in each case this association remained statistically

Factors contributing to the hospitalization of patients with congestive heart failure.

OBJECTIVES This study identifies acute precipitants of hospitalization and evaluates utilization of angiotension-converting enzyme inhibitors in patients admitted with congestive heart failure. METHODS Cross-sectional chart-review study was done of 435 patients admitted nonelectively from February 1993 to February 1994 to an urban university hospital with a complaint of shortness of breath or fatigue and evidence of congestive heart failure. RESULTS The most common identifiable abnormalities associated with clinical deterioration prior to admission were acute anginal chest pain (33%), respiratory infection (16%), uncontrolled hypertension with initial systolic blood pressure > or = 180 mm Hg (15%), atrial arrhythmia with heart rate > or = 120 (8%), and noncompliance with medications (15%) or diet (6%); in 34% of patients, no clear cause could be identified. After exclusion of those who were already on a different vasodilator or who had relative contraindications, 18 (32%) of the patients with ejection fractions < or = 0.35 measured prior to admission were not taking an angiotensin-converting enzyme inhibitor on presentation to the hospital. CONCLUSIONS Interventions to improve compliance, the control of hypertension, and the appropriate use of angiotensin-converting enzyme inhibitors may prevent many hospitalizations of heart-failure patients.

Screening and Intervention for Alcohol Problems

OBJECTIVE: To describe adult primary care physicians’ and psychiatrists’ approach to alcohol screening and treatment, and to identify correlates of more optimal practices. DESIGN: Cross-sectional mailed survey. PARTICIPANTS: A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry. MEASUREMENTS: Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales. MAIN RESULTS: Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object. CONCLUSIONS: Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols of offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians’ screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement

Interventions to Reduce Racial and Ethnic Disparities in Health Care

In 2005, the Robert Wood Johnson Foundation created Finding Answers: Disparities Research for Change, a program to identify, evaluate, and disseminate interventions to reduce racial and ethnic disparities in the care and outcomes of patients with cardiovascular disease, depression, and diabetes. In this introductory paper, we present a conceptual model for interventions that aim to reduce disparities. With this model as a framework, we summarize the key findings from the six other papers in this supplement on cardiovascular disease, diabetes, depression, breast cancer, interventions using cultural leverage, and pay-for-performance and public reporting of performance measures. Based on these findings, we present global conclusions regarding the current state of health disparities interventions and make recommendations for future interventions to reduce disparities. Multifactorial, culturally tailored interventions that target different causes of disparities hold the most promise, but much more research is needed to investigate potential solutions and their implementation.

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.