Neda Laiteerapong

Rates of Complications and Mortality in Older Patients With Diabetes Mellitus: The Diabetes and Aging Study

IMPORTANCE In the coming decades, the population of older adults with type 2 diabetes mellitus is expected to grow substantially. Understanding the clinical course of diabetes in this population is critical for establishing evidence-based clinical practice recommendations, identifying research priorities, allocating resources, and setting health care policies. OBJECTIVE To contrast the rates of diabetes complications and mortality across age and diabetes duration categories. DESIGN, SETTING, AND PARTICIPANTS This cohort study (2004-2010) included 72,310 older (≥ 60 years) patients with type 2 diabetes enrolled in a large, integrated health care delivery system. Incidence densities (events per 1000 person-years) were calculated for each age category (60-69, 70-79, and ≥ 80 years) and duration of diabetes (shorter [0-9 years] vs longer [≥ 10 years]). MAIN OUTCOMES AND MEASURES Incident acute hyperglycemic events, acute hypoglycemic events (hypoglycemia), microvascular complications (end-stage renal disease, peripheral vascular disease, lower limb amputation, and diabetic eye disease), cardiovascular complications (coronary artery disease, cerebrovascular disease, and congestive heart failure), and all-cause mortality. RESULTS Among older adults with diabetes of short duration, cardiovascular complications followed by hypoglycemia were the most common nonfatal complications. For example, among individuals aged 70 to 79 years with a short duration of diabetes, coronary artery disease and hypoglycemia rates were higher (11.47 per 1000 person-years and 5.03 per 1000 person-years, respectively) compared with end-stage renal disease (2.60 per 1000 person-years), lower limb amputation (1.28 per 1000 person-years), and acute hyperglycemic events (0.82 per 1000 person-years). We observed a similar pattern among patients in the same age group with a long duration of diabetes, with some of the highest incidence rates in coronary artery disease and hypoglycemia (18.98 per 1000 person-years and 15.88 per 1000 person-years, respectively) compared with end-stage renal disease (7.64 per 1000 person-years), lower limb amputation (4.26 per 1000 person-years), and acute hyperglycemic events (1.76 per 1000 person-years). For a given age group, the rates of each outcome, particularly hypoglycemia and microvascular complications, increased dramatically with longer duration of the disease. However, for a given duration of diabetes, rates of hypoglycemia, cardiovascular complications, and mortality increased steeply with advancing age, and rates of microvascular complications remained stable or declined. CONCLUSIONS AND RELEVANCE Duration of diabetes and advancing age independently predict diabetes morbidity and mortality rates. As long-term survivorship with diabetes increases and as the population ages, more research and public health efforts to reduce hypoglycemia will be needed to complement ongoing efforts to reduce cardiovascular and microvascular complications.

Correlates of Quality of Life in Older Adults With Diabetes: The Diabetes & Aging Study

OBJECTIVE To evaluate associations between health-related quality of life (HRQL) and geriatric syndromes, diabetes complications, and hypoglycemia in older adults with diabetes. RESEARCH DESIGN AND METHODS A race-stratified random sample of 6,317 adults with type 2 or type 1 diabetes, aged 60 to 75 years, enrolled in Kaiser Permanente Northern California, who completed a survey that included a HRQL instrument based on the Short Form 8-item health survey. Administrative records were used to ascertain diagnoses of geriatric syndromes, diabetes complications, and hypoglycemia. Associations were estimated between HRQL and exposures in exposure-specific and combined exposure models (any syndrome, any complication, or hypoglycemia). Conservatively, differences of ≥3 points were considered the minimally important difference in HRQL scores. RESULTS HRQL was lower with nearly all exposures of interest. The lowest physical HRQL was associated with amputation. In combined exposure models, geriatric syndromes (−5.3 [95% CI −5.8 to −4.8], P < 0.001) and diabetes complications (−3.5 [−4.0 to −2.9], P < 0.001) were associated with lower physical HRQL. The lowest mental HRQL was associated with depression, underweight (BMI <18 kg/m2), amputation, and hypoglycemia. In combined exposure models, only hypoglycemia was associated with lower mental HRQL (−4.0 [−7.0 to −1.1], P = 0.008). CONCLUSIONS Geriatric syndromes and hypoglycemia are associated with lower HRQL to a comparable degree as diabetes complications. Addressing geriatric syndromes and avoiding hypoglycemia should be given as high a priority as preventing diabetes complications in older adults with diabetes.

Prioritization of care in adults with diabetes and comorbidity

Approximately half of adults with diabetes have at least one comorbid condition. However, diabetes care guidelines focus on diabetes‐specific care, and their recommendations may not be appropriate for many patients with diabetes and comorbidity. We describe Piette and Kerrs typology of comorbid conditions, which categorizes conditions based on if they are clinically dominant (eclipse diabetes management), symptomatic versus asymptomatic, and concordant (similar pathophysiologic processes as diabetes) versus discordant. We integrate this typology with clinical evidence and shared decision‐making methods to create an algorithmic approach to prioritizing care in patients with diabetes and comorbidity. Initial steps are determining the patients goals of care and preferences for treatment, whether there is a clinically dominant condition or inadequately treated symptomatic condition, and the risk of cardiovascular disease. With these data in hand, the clinician and patient prioritize diabetes treatments during a shared decision‐making process. These steps should be repeated, especially when the patients clinical status changes. This patient‐centered process emphasizes overall quality of life and functioning rather than a narrow focus on diabetes.

Public Health Implications of Recommendations to Individualize Glycemic Targets in Adults With Diabetes

OBJECTIVE To estimate how many U.S. adults with diabetes would be eligible for individualized A1C targets based on 1) the 2012 American Diabetes Association (ADA) guideline and 2) a published approach for individualized target ranges. RESEARCH DESIGN AND METHODS We studied adults with diabetes ≥20 years of age from the National Health and Nutrition Examination Survey 2007–2008 (n = 757). We assigned A1C targets based on duration, age, diabetes-related complications, and comorbid conditions according to 1) the ADA guideline and 2) a strategy by Ismail-Beigi focused on setting target ranges. We estimated the number and proportion of adults with each A1C target and compared individualized targets to measured levels. RESULTS Using ADA guideline recommendations, 31% (95% CI 27–34%) of the U.S. adult diabetes population would have recommended A1C targets of <7.0%, and 69% (95% CI 66–73%) would have A1C targets less stringent than <7.0%. Using the Ismail-Beigi strategy, 56% (51–61%) would have an A1C target of ≤7.0%, and 44% (39–49%) would have A1C targets less stringent than <7.0%. If a universal A1C <7.0% target were applied, 47% (41–54%) of adults with diabetes would have inadequate glycemic control; this proportion declined to 30% (26–36%) with the ADA guideline and 31% (27–36%) with the Ismail-Beigi strategy. CONCLUSIONS Using individualized glycemic targets, about half of U.S. adults with diabetes would have recommended A1C targets of ≥7.0% but one-third would still be considered inadequately controlled. Diabetes research and performance measurement goals will need to be revised in order to encourage the individualization of glycemic targets.

A Resident-Led Quality Improvement Initiative to Improve Obesity Screening

Instruction on quality improvement (QI) methods is required as part of residency education; however, there is limited evidence regarding whether internal medicine residents can improve patient care using these methods. Because obesity screening is not done routinely in clinical practice, residents aimed to improve screening using QI techniques. Residents streamlined body mass index (BMI) documentation, created educational materials about obesity, and launched an obesity screening QI initiative in a residency clinic. Residents designed plan-do-study-act cycles focused on increasing awareness and maintaining improvements in screening over a 1-year period. Documentation rates were collected at baseline, 2 weeks, 6 months, and 1 year post-intervention. At 1 year, obesity treatment rates also were collected. BMI documentation rates after 1 year were higher than baseline (43% vs 4%, P < .0001). In obese patients, BMI documentation was associated with lifestyle counseling (34% vs 14%, P < .01). An internal medicine resident-led QI project targeting obesity can improve screening.

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.

Revisiting Disparities in Quality of Care Among US Adults With Diabetes in the Era of Individualized Care, NHANES 2007-2010.

Background:Diabetes quality of care standards promote uniform goals and are used routinely for performance measurement and reimbursement. Diabetes health disparities have been characterized using these universal goals. However, guidelines emphasize individualized goals. Objectives:To assess diabetes care disparities using individualized goals to (1) determine their racial/ethnic distribution and (2) compare disparities using individualized versus uniform goals. Research Design, Subjects, and Measures:A nationally representative sample of non-Hispanic white, non-Hispanic black, and Hispanic adults with self-reported diabetes aged 20 years or more in the National Health and Nutrition Examination Survey, 2007–2010. Individualized glycemic goals (A1C<6.5%, <7.0%, or <8.0%) assigned based on age, duration, complications, and comorbidity, and cholesterol goals [low-density lipoprotein cholesterol (LDL) <70 or <100 mg/dL] assigned based on cardiovascular history. Results:More Hispanics were recommended an individualized A1C<7.0% compared with whites (54% vs. 42%, P=0.008). Fewer blacks and Hispanics were recommended an individualized LDL<70 mg/dL than whites (21% and 19% vs. 28%, P=0.02 and 0.001). Fewer Hispanics had adequate individualized A1C control (56% vs. 68%, P<0.001), and fewer blacks and Hispanics had adequate individualized LDL control (31% and 36% vs. 51%, P⩽0.001 and P=0.004). A uniform A1C<7% goal did not reveal disparities in glycemic control; individualized A1C and LDL, blood pressure <140/90 mm Hg, and nonsmoking was achieved by few adults (18%), and fewer blacks and Hispanics than whites (6% and 11% vs. 22%, P<0.001 and P=0.005). Conclusions:Individualized goals for diabetes care may unearth greater racial/ethnic disparities in clinical performance compared with uniform goals. Diabetes performance measures should include individualized goals to prevent worsening disparities in diabetes outcomes.

Association Between Estimated GFR, Health-Related Quality of Life, and Depression Among Older Adults With Diabetes: The Diabetes and Aging Study

BACKGROUND Although chronic kidney disease (CKD) is a highly prevalent condition among older adults with diabetes, the associations between health-related quality of life (HRQoL) and severity of CKD in this population are not well understood. The objective of this study was to assess HRQoL and depressive symptoms across estimated glomerular filtration rate (eGFR) stages. STUDY DESIGN Cross-sectional. SETTING & PARTICIPANTS 5,805 members of Kaiser Permanente Northern California, 60 years or older with diabetes, from the 2005-2006 Diabetes Study of Northern California (DISTANCE) survey. PREDICTOR eGFR categories were defined as ≥90 (referent category), 75-89, 60-74, 45-59, 30-44, or ≤29 mL/min/1.73 m(2). OUTCOMES HRQoL was measured using the modified Short Form-8 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Depressive symptoms were measured using the Patient Health Questionnaire-8. RESULTS In unadjusted linear regression analyses, physical (PCS) and mental (MCS) HRQoL scores were significantly lower with worsening eGFR level. However, after adjustment for sociodemographics, diabetes duration, obesity, and cardiovascular comorbid conditions and taking into account interactions with proteinuria, none of the eGFR categories was significantly or substantively associated with PCS or MCS score. In both unadjusted and adjusted analyses, higher risk of depressive symptoms was observed in respondents with eGFR ≤29 mL/min/1.73 m(2) (relative risk, 2.02; 95% CI, 1.10-3.71; P < 0.05) compared with the referent group. However, this eGFR-depression relationship was no longer significant after adjusting for hemoglobin level. LIMITATIONS Participants are part of a single health care delivery system. CONCLUSIONS Our findings suggest the need for greater attention to and potential interventions for depression in patients with reduced eGFR.

Classification of Older Adults Who Have Diabetes by Comorbid Conditions, United States, 2005–2006

Introduction Older adults who have diabetes vary widely in terms of comorbid conditions; these conditions help determine the risks and benefits of intensive glycemic control. Not all people benefit from intensive glycemic control. The objective of this study was to classify by comorbid conditions older American adults who have diabetes to identify those who are less likely to benefit from intensive glycemic control. Methods We used latent class analysis to identify subgroups of a nationally representative sample of community-dwelling older adults (aged 57–85 y) who have diabetes (n = 750). The subgroups were classified according to 14 comorbid conditions prevalent in the older population. Using the Akaike Information Criterion, the Bayesian Information Criterion (BIC), the sample-size adjusted BIC, and the χ2 goodness-of-fit statistic, we assessed model fit. Results We found 3 distinct subgroups. Class 1 (63% of the sample) had the lowest probabilities for most conditions. Class 2 (29% of the sample) had the highest probabilities of cancer, incontinence, and kidney disease. Class 3 (9% of the sample) had the highest probabilities (>90%) of congestive heart failure and myocardial infarction. Class 1 had only 0, 1, or 2 comorbid conditions, and both class 2 and class 3 had 6 or more comorbid conditions. The 5-year death rates for class 2 (17%) and class 3 (33%) were higher than the rate for class 1 (9%). Conclusion Older adults who have diabetes, cardiovascular disease, and 6 or more comorbid conditions may represent a subgroup of older adults who are less likely to benefit from intensive glycemic control.

Health Care Reform and Chronic Diseases: Anticipating the Health Consequences

DEBATE SURROUNDING HEALTH CARE REFORM AND the Patient Protection and Affordable Care Act (PPACA) was contentious and focused mainly on disagreement about the costs of providing insurance to more Americans. Minimal discussion was devoted to how reform might change chronic disease outcomes, even though chronic diseases represent a major source of unsustainable growth in health care costs. Because of its numerous provisions, the PPACA has the potential to reshape the treatment and course of chronic diseases in America. The degree to which the PPACA brings about changes in chronic disease management will depend on whom the law affects, how specific provisions alter service delivery, and how recent discoveries in chronic disease prevention and treatment affect health outcomes.