Melissa M. Parker

Barriers to Insulin Initiation The Translating Research Into Action for Diabetes Insulin Starts Project

OBJECTIVE Reasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. We investigated barriers to insulin initiation following a new prescription. RESEARCH DESIGN AND METHODS We surveyed insulin-naïve patients with poorly controlled type 2 diabetes, already treated with two or more oral agents who were recently prescribed insulin. We compared responses for respondents prescribed, but never initiating, insulin (n = 69) with those dispensed insulin (n = 100). RESULTS Subjects failing to initiate prescribed insulin commonly reported misconceptions regarding insulin risk (35% believed that insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death), plans to instead work harder on behavioral goals, sense of personal failure, low self-efficacy, injection phobia, hypoglycemia concerns, negative impact on social life and job, inadequate health literacy, health care provider inadequately explaining risks/benefits, and limited insulin self-management training. CONCLUSIONS Primary adherence for insulin may be improved through better provider communication regarding risks, shared decision making, and insulin self-management training.

Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients.

Objective.When patients miss scheduled medical appointments, continuity and effectiveness of healthcare delivery is reduced, appropriate monitoring of health status lapses, and the cost of health services increases. We evaluated the relationship between missed appointments and glycemic control (glycosylated hemoglobin or HbA1c) in a large, managed care population of diabetic patients. Research Design and MethodsMissed appointment rate was related cross-sectionally to glycemic control among 84,040 members of the Kaiser Permanente Northern California Diabetes Registry during 2000. Adjusted least-square mean estimates of HbA1c were derived by level of appointment keeping (none missed, 1–30% missed, and >30% missed appointments for the calendar year) stratified by diabetes therapy. ResultsTwelve percent of the subjects missed more than 30% of scheduled appointments during 2000. Greater rates of missed appointments were associated with significantly poorer glycemic control after adjusting for demographic factors (age, sex), clinical status, and health care utilization. The adjusted mean HbA1c among members who missed >30% of scheduled appointments was 0.70 to 0.79 points higher (P <0.0001) relative to those attending all appointments. Patients who missed more than 30% of their appointments were less likely to practice daily self-monitoring of blood glucose and to have poor oral medication refill adherence. ConclusionPatients who underuse care lack recorded information needed to determine level of risk. Frequently missed appointments were associated with poorer glycemic control and suboptimal diabetes self-management practice, are readily ascertained in clinical settings, and therefore could have clinical utility as a risk-stratifying criterion indicating the need for targeted case management.

New Prescription Medication Gaps: A Comprehensive Measure of Adherence to New Prescriptions

OBJECTIVE Describe a novel approach to comprehensively summarize medication adherence. DATA SOURCES/STUDY SETTING Kaiser Permanente Northern California Diabetes Registry (n approximately 220,000) STUDY DESIGN In a new prescription cohort design (27,329 subjects prescribed new medications), we used pharmacy utilization data to estimate adherence during 24 months follow-up. Proportion of time without sufficient medications (medication gaps) was estimated using a novel measure (New Prescription Medication Gaps [NPMG]) and compared with a traditional measure of adherence. DATA COLLECTION/EXTRACTION METHODS Data derived from electronic medical records and survey responses. PRINCIPAL FINDINGS Twenty-two percent of patients did not become ongoing users (had zero or only one dispensing of the new prescription). The proportion of newly prescribed patients that never became ongoing users was eightfold greater than the proportion who maintained ongoing use, but with inadequate adherence. Four percent of those with at least two dispensings discontinued therapy during the 24 months follow-up. NPMG was significantly associated with high out-of-pocket costs, self-reported adherence, and clinical response to therapy. CONCLUSIONS NPMG is a valid adherence measure. Findings also suggest a larger burden of inadequate adherence than previously thought. Public health efforts have traditionally focused on improving adherence in ongoing users; clearly more attention is needed to address nonpersistence in the very first stages after a new medication is prescribed.

Pioglitazone initiation and subsequent hospitalization for congestive heart failure.

Aims  Thiazolidinediones (TZD) have been associated with an expansion in plasma volume and the development of peripheral oedema. A recent study reported an association between the use of TZDs and development of congestive heart failure (CHF). The objective of this study was to determine if short‐term use of pioglitazone, a TZD, is associated with increased risk of admission to hospital because of CHF in a well‐characterized, community‐based cohort of Type 2 diabetic patients without prevalent CHF.

Association of Depression With Increased Risk of Dementia in Patients With Type 2 Diabetes The Diabetes and Aging Study

CONTEXT Although depression is a risk factor for dementia in the general population, its association with dementia among patients with diabetes mellitus has not been well studied. OBJECTIVE To determine whether comorbid depression in patients with type 2 diabetes increases the risk of development of dementia. DESIGN The Diabetes and Aging Study was a cohort investigation that surveyed a racially/ethnically stratified random sample of patients with type 2 diabetes. SETTING A large, integrated, nonprofit managed care setting in Northern California. PARTICIPANTS A sample of 19,239 diabetes registry members 30 to 75 years of age. MAIN OUTCOME MEASURES The Patient Health Questionnaire 8, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses of depression, and/or antidepressant prescriptions in the 12 months prior to baseline were used to identify prevalent cases of depression. Clinically recognized dementia was identified among subjects with no prior ICD-9 Clinical Modification (ICD-9-CM) diagnoses of dementia. To exclude the possibility that depression was a prodrome of dementia, dementia diagnoses were only based on ICD-9-CM diagnoses identified in years 3 to 5 postbaseline. The risk of dementia for patients with depression and diabetes relative to patients with diabetes alone was estimated using Cox proportional hazard regression models that adjusted for sociodemographic, clinical, and health risk factors and health use. RESULTS During the 3- to 5-year period, 80 of 3766 patients (2.1%) with comorbid depression and diabetes (incidence rate of 5.5 per 1000 person-years) vs 158 of 15,473 patients (1.0%) with diabetes alone (incidence rate of 2.6 per 1000 person-years) had 1 or more ICD-9-CM diagnoses of dementia. Patients with comorbid depression had a 100% increased risk of dementia during the 3 to 5 years postbaseline (adjusted hazard ratio, 2.02; 95% confidence interval, 1.73-2.35). CONCLUSION Depression in patients with diabetes was associated with a substantively increased risk for development of dementia compared with those with diabetes alone.

Use of the Refill Function through an Online Patient Portal Is Associated with Improved Adherence to Statins in an Integrated Health System

Background:Online patient portals are being widely implemented, but their impact on health behaviors are not well-studied. Objective:To determine whether statin adherence improved after initiating use of the portal refill function. Research Design:Observational cohort study within an integrated health care delivery system. Subjects:Diabetic patients on statins who had registered for online portal access by 2010. A total of 8705 subjects initiated the online refill function use within the study window, including “exclusive” and “occasional” users (ie, requesting all vs. some refills online, respectively). Using risk-set sampling, we temporally matched 9055 reference group patients who never used online refills. Measures:We calculated statin adherence before and after refill function initiation, assessed as percent time without medications (nonadherence defined as a gap of >20%). Secondary outcome was dyslipidemia [low-density lipoprotein (LDL)≥100]. Difference-in-differences regression models estimated pre-post changes in nonadherence and dyslipidemia, comparing refill function users to the reference group and adjusting for age, sex, race/ethnicity, medications, frequency of portal use, and outpatient visits. Results:In unadjusted examinations, nonadherence decreased only among patients initiating occasional or exclusive use of the refill function (26%–24% and 22%–15%, respectively). In adjusted models, nonadherence declined by an absolute 6% (95% confidence interval, 4%–7%) among exclusive users, without significant changes among occasional users. Similar LDL decreases were also seen among exclusive users. Conclusions:Compared with portal users who did not refill medications online, adherence to statin medications and LDL levels improved among diabetic patients who initiated and exclusively used the patient portal for refills, suggesting that wider adoption of online refills may improve adherence.

The Comparative Effectiveness of Mail Order Pharmacy Use vs. Local Pharmacy Use on LDL-C Control in New Statin Users

BACKGROUNDMail order pharmacies are commonly used to deliver CVD risk factor medications. Previous studies have shown that mail order pharmacy use is associated with greater medication adherence; however, no studies have examined whether mail order pharmacy use is related to improved CVD risk factor outcomes.OBJECTIVETo examine the comparative effectiveness of mail order pharmacy vs. local pharmacy use on LDL-C control in new statin users.DESIGNObservational cohort study.PATIENTS100,298 adult Kaiser Permanente Northern California (KPNC) members who were new users of statins between January 1, 2005 and December 31, 2007.MEASUREMENTSThe main outcome measure was LDL-C control in the 3–15 month period after statin therapy was initiated.RESULTSAfter adjustment for patient, clinical, and census-block characteristics, and for potential unmeasured differences between mail order and local KPNC pharmacy users with instrumental variables analysis, 85.0% of patients who used the mail order pharmacy to deliver their statin at any time achieved target LDL-C levels compared with 74.2% of patients who only used the local KPNC pharmacy to dispense the statin (p < 0.001). Greater adjusted rates of LDL-C control in mail order pharmacy users were seen across all gender and race/ethnicity subgroups.CONCLUSIONSMail order pharmacy use was positively associated with LDL-C control in new statin users. Future research should continue to explore the relationship between mail order pharmacy use and outcomes, and address how to appropriately target mail order services to patients most likely to benefit without compromising patient choice, care, and safety.

Incidence of Remission in Adults With Type 2 Diabetes: The Diabetes & Aging Study

OBJECTIVE To estimate the incidence of remission in adults with type 2 diabetes not treated with bariatric surgery and to identify variables associated with remission. RESEARCH DESIGN AND METHODS We quantified the incidence of diabetes remission and examined its correlates among 122,781 adults with type 2 diabetes in an integrated healthcare delivery system. Remission required the absence of ongoing drug therapy and was defined as follows: 1) partial: at least 1 year of subdiabetic hyperglycemia (hemoglobin A1c [HbA1c] level 5.7–6.4% [39–46 mmol/mol]); 2) complete: at least 1 year of normoglycemia (HbA1c level <5.7% [<39 mmol/mol]); and 3) prolonged: complete remission for at least 5 years. RESULTS The incidence density (remissions per 1,000 person-years; 95% CI) of partial, complete, or prolonged remission was 2.8 (2.6–2.9), 0.24 (0.20–0.28), and 0.04 (0.01–0.06), respectively. The 7-year cumulative incidence of partial, complete, or prolonged remission was 1.47% (1.40–1.54%), 0.14% (0.12–0.16%), and 0.007% (0.003–0.020%), respectively. The 7-year cumulative incidence of achieving any remission was 1.60% in the whole cohort (1.53–1.68%) and 4.6% in the subgroup with new-onset diabetes (<2 years since diagnosis) (4.3–4.9%). After adjusting for demographic and clinical characteristics, correlates of remission included age >65 years, African American race, <2 years since diagnosis, baseline HbA1c level <5.7% (<39 mmol/mol), and no diabetes medication at baseline. CONCLUSIONS In community settings, remission of type 2 diabetes does occur without bariatric surgery, but it is very rare.

Ethnic Differences in Geriatric Conditions and Diabetes Complications Among Older, Insured Adults With Diabetes: The Diabetes and Aging Study.

Objective: The aim of this study was to evaluate ethnic differences in burden of prevalent geriatric conditions and diabetic complications among older, insured adults with diabetes. Method: An observational study was conducted among 115,538 diabetes patients, aged ≥60, in an integrated health care system with uniform access to care. Results: Compared with Whites, Asians and Filipinos were more likely to be underweight but had substantively lower prevalence of falls, urinary incontinence, polypharmacy, depression, and chronic pain, and were least likely of all groups to have at least one geriatric condition. African Americans had significantly lower prevalence of incontinence and falls, but higher prevalence of dementia; Latinos had a lower prevalence of falls. Except for end-stage renal disease (ESRD), Whites tended to have the highest rates of prevalent diabetic complications. Discussion: Among these insured older adults, ethnic health patterns varied substantially; differences were frequently small and rates were often better among select minority groups, suggesting progress toward the Healthy People 2020 objective to reduce health disparities.

Social Support and Lifestyle vs. Medical Diabetes Self-Management in the Diabetes Study of Northern California (DISTANCE)

BackgroundIn chronic illness self-care, social support may influence some health behaviors more than others.PurposeExamine social support’s association with seven individual chronic illness self-management behaviors: two healthy “lifestyle” behaviors (physical activity, diet) and five more highly skilled and diabetes-specific (medical) behaviors (checking feet, oral medication adherence, insulin adherence, self-monitored blood glucose, primary care appointment attendance).MethodsUsing cross-sectional administrative and survey data from 13,366 patients with type 2 diabetes, Poisson regression models estimated the adjusted relative risks (ARR) of practicing each behavior at higher vs lower levels of social support.ResultsHigher emotional support and social network scores were significantly associated with increased ARR of both lifestyle behaviors. Both social support measures were also associated with increased ARR for checking feet. Neither measure was significantly associated with other medical behaviors.ConclusionsFindings suggest that social support diminished in importance as self-care progresses from lifestyle to more skilled “medical” behaviors.