O. Kenrik Duru

Thiazolidinediones and fractures: evidence from translating research into action for diabetes.

BACKGROUND Thiazolidinedione (TZD) treatment has been associated with fractures. The purpose of this study was to examine the association between TZD treatment and fractures in type 2 diabetic patients. METHODS Using data from Translating Research into Action for Diabetes, a multicenter prospective observational study of diabetes care in managed care, we conducted a matched case-control study to assess the odds of TZD exposure in patients with type 2 diabetes with and without fractures. We identified 786 cases based on fractures detected in health plan administrative data. Up to four controls without any fracture diagnoses were matched to each case. Controls were matched on health plan, date of birth within 5 yr, sex, race/ethnicity, and body mass index within 5 kg/m(2). We performed conditional logistic regression for premenopausal and postmenopausal women and men to assess the odds of exposure to potential risk factors for fracture, including medications, self-reported limited mobility, and lower-extremity amputations. RESULTS We found statistically significant increased odds of exposure to TZDs, glucocorticoids, loop diuretics, and self-reported limited mobility for women 50 yr of age and older with fractures. Exposure to both loop diuretics and TZDs, glucocorticoids, and insulin and limited mobility and lower-extremity amputation were associated with fractures in men. CONCLUSION Postmenopausal women taking TZDs and the subset of men taking both loop diuretics and TZDs were at increased risk for fractures. In postmenopausal women, risk was associated with higher TZD dose. No difference between rosiglitazone and pioglitazone was apparent.

Sisters in Motion: A Randomized Controlled Trial of a Faith‐Based Physical Activity Intervention

OBJECTIVES: To evaluate a faith‐based intervention (Sisters in Motion) intended to increase walking in older, sedentary African‐American women.

Understanding the gap between good processes of diabetes care and poor intermediate outcomes Translating Research into Action for Diabetes (TRIAD)

Background:Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. Objectives:To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. Population:Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002–2003). Methods:Comparison of 1003 patients with good control of A1c (<8%), systolic blood pressure (<140 mm Hg) and LDL-cholesterol (<130 mg/dL) versus 812 patients with poor control for at least 2 of these factors. Results:Poorly controlled patients were younger, more frequently female, African American, with lower education and income (P < 0.001 for each). General health status was lower, body mass index higher, and insulin treatment more frequent; history of prior coronary heart disease was less frequent. They were more likely to indicate depression and hopelessness and to identify costs as a barrier to self-care; less likely to report trust in their regular physician; and more likely to smoke cigarettes and be physically inactive. Adjusting for demographic and clinical variables, concerns about costs, low trust in ones physician, current smoking, and physical inactivity remained associated with poor control. However, inclusion of these 4 variables in a single model did not diminish associations of race/ethnicity or education with control. Conclusions:Clinical, socioeconomic, psychosocial, and behavioral factors were independently associated with poor control. However, these factors did not fully explain observed racial and socioeconomic disparities in control.

Identifying risk factors for racial disparities in diabetes outcomes: The translating research into action for diabetes study

Background:Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications. Objective:To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites. Design:Case-control study. Subjects:A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans. Measures:Cases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c ≥8.0%, SBP ≥140 mmHg, LDL cholesterol ≥130 mg/dL) and controls were patients with good control of all 3 (HbA1c <8.0%, SBP <140 mmHg, LDL cholesterol <130 mg/dL). In multivariate analyses, we determined whether each of several potentially mutable risk factors, including depression, poor adherence to medications, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status. Results:Among blacks but not whites, in multivariate analyses depression (odds ratio: 2.28; 95% confidence interval: 1.09–4.75) and having missed medication doses (odds ratio: 1.96; 95% confidence interval: 1.01–3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites. Conclusions:Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These 2 risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.

Correlates of sex without serostatus disclosure among a national probability sample of HIV patients

We examined potential correlates of sex without HIV disclosure within a sample of 875 participants from the HIV Cost and Services Utilization Study. Interviews with each participant assessed sexual activities with up to six recent partners, and this study included both respondent and partnership characteristics. Compared with marriage and/or primary same-sex relationsips, occasional partnerships and one-time encounters were associated with sex with disclosure, and shorter relationships were more likely to involve sex without disclosure. Knowledge of partner scrostatus was also associated with sex without disclosure. Women were less likely to have sex without disclosure than men having sex with men. We found an association between the perceived duty to disclosure to all partners and sex without disclosure, while we found no association in multivariate analyses between outcome expectancies and sex without disclosure.

Allostatic Load Burden and Racial Disparities in Mortality

BACKGROUND Black-white disparities in mortality persist after adjustment for socioeconomic status and health behaviors. We examined whether allostatic load, the physiological profile influenced by repeated or chronic life stressors, is associated with black-white mortality disparities independent of traditional sociobehavioral risk factors. METHODS We studied 4515 blacks and whites aged 35 to 64 years from the third National Health and Nutrition Examination Survey (1988-1994), using the linked mortality file, to ascertain participant deaths through 2006. We estimated unadjusted sex-specific black-white disparities in cardiovascular/diabetes-related mortality and noninjury mortality. We constructed baseline allostatic load scores based on 10 biomarkers and examined attenuation of mortality disparities in 4 sets of sex-stratified multivariate models, sequentially adding risk factors: (1) age/clinical conditions, (2) socioeconomic status (SES) variables, (3) health behaviors, and (4) allostatic load. RESULTS Blacks had higher allostatic load scores than whites; for men, 2.5 vs 2.1, p < .01; and women, 2.6 vs 1.9, p < .01. For cardiovascular/diabetes-related mortality among women, the magnitude of the disparity after adjustment for other risk factors (hazard ratio [HR], 1.63; 95% confidence interval [CI], 0.96-2.75) decreased after adjustment for allostatic load (HR, 1.15; 95% CI, 0.70-1.88). For noninjury mortality among women, the magnitude of the disparity after adjustment for other risk factors (HR, 1.43; 95% CI, 1.00-2.04) also decreased after adjustment for allostatic load (HR, 1.26; 95% CI, 0.90-1.78). For men, disparities were attenuated but persisted after adjustment for allostatic load. CONCLUSIONS Allostatic load burden partially explains higher mortality among blacks, independent of SES and health behaviors. These findings underscore the importance of chronic physiologic stressors as a negative influence on the health and lifespan of blacks in the United States.

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.

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study.

Objective:We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. Research Design and Methods:Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. Results:Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes. Conclusions:For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

Depression and All-Cause Mortality in Persons with Diabetes Mellitus: Are Older Adults at Higher Risk? Results from the Translating Research Into Action for Diabetes Study

To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus.

Correlates of Alcohol‐Related Discussions Between Older Adults and Their Physicians

OBJECTIVES: To identify predictors of alcohol‐related patient–physician discussions.