Sara R. Adams

Novel use and utility of integrated electronic health records to assess rates of prediabetes recognition and treatment: brief report from an integrated electronic health records pilot study.

OBJECTIVE This study uses novel methods to examine the frequency of diagnosis and treatment of prediabetes in real-world clinical settings using electronic health record (EHR) data. RESEARCH DESIGN AND METHODS We identified a cohort of 358,120 adults with incident prediabetes (fasting plasma glucose [FPG] 100–125 mg/dL or glycated hemoglobin 5.7–6.4% [39–46 mmol/mol]) between 2006 and 2010 and examined rates of diagnosis and treatment in the 6 months after identification. RESULTS In the 6 months after identification of prediabetes, 18% of patients had their blood glucose levels retested; 13% received a physician diagnosis of prediabetes/hyperglycemia; 31.0% had prediabetes, diabetes, or lifestyle documented in the clinical notes; and <0.1% initiated metformin. Among patients with FPG 120–125 mg/dL, 31% were retested; metformin initiation remained <1%. CONCLUSIONS Documented rates of follow-up and treatment for prediabetes are low. EHR data may be a valuable tool to improve identification and treatment of prediabetes in the U.S.

Health-plan and employer-based wellness programs to reduce diabetes risk: The Kaiser Permanente Northern California NEXT-D Study.

Primary prevention of diabetes is increasingly recognized by both health plans and employers as an important strategy to improve the health of insured populations. As a part of the Natural Experiments in Translation for Diabetes (NEXT-D) network, the Kaiser Permanente Northern California (KPNC) Division of Research is assessing the effectiveness of 2 health plan-initiated programs to prevent the onset of diabetes in patients at high risk. The first study evaluates a telephonic health-coaching program that provides counseling on healthful eating, active living, and weight loss to KPNC members. The second evaluation examines a postpartum glucose screening and educational diabetes prevention program for women with gestational diabetes mellitus that KPNC implemented in 2006. Identifying effective approaches to preventing diabetes will be of value to health care systems, policy makers, and public health officials seeking to understand the roles systems and employers can play in preventing chronic illness.

Patient satisfaction and perceived success with a telephonic health coaching program: the Natural Experiments for Translation in Diabetes (NEXT-D) Study, Northern California, 2011.

Introduction Health coaching can improve lifestyle behaviors known to prevent or manage chronic conditions such as diabetes. However, little is known about the patient experience with telephonic coaching programs in real-world care settings. We examined patient satisfaction, patient’s perceived success in achieving program goals, and the patient-level correlates of these outcomes in a voluntary telephonic coaching program at a large integrated health care delivery system in northern California. Methods Kaiser Permanente Northern California patients who participated in a telephonic coaching program in 2011 were sent a cross-sectional survey about their satisfaction with health coaching and perceived success with program goals. We examined associations with patient characteristics. Results The survey response rate was 34%; analyses were based on the 32% who completed the survey. Of those who had completed 2 or more sessions (n = 232 [52%]), most reported being satisfied (70%) or neutral (20%) with the program, and 71% would recommend health coaching. Healthy weight, healthful eating, and physical activity were the most common topics discussed (88%). Adjusting for demographic characteristics, 73% of those who had 2 or more sessions reported that health coaching helped achieve their weight-related goal. Outcomes were positively correlated with patient activation but not consistently correlated with patient demographic characteristics. Conclusion Levels of satisfaction and perceived success with telephonic health coaching provided by a health plan were high and positively correlated with the number of sessions completed and patient activation. Voluntary telephonic health coaching programs should promote retention and assess patients’ activation levels.

Telephone-Based Coaching A Comparison of Tobacco Cessation Programs in an Integrated Health Care System

Purpose. Many Americans continue to smoke, increasing their risk of disease and premature death. Both telephone-based counseling and in-person tobacco cessation classes may improve access for smokers seeking convenient support to quit. Little research has assessed whether such programs are effective in real-world clinical populations. Design. Retrospective cohort study comparing wellness coaching participants with two groups of controls. Setting. Kaiser Permanente Northern California, a large integrated health care delivery system. Subjects. Two hundred forty-one patients who participated in telephonic tobacco cessation coaching from January 1, 2011, to March 31, 2012, and two control groups: propensity-score–matched controls, and controls who participated in a tobacco cessation class during the same period. Wellness coaching participants received an average of two motivational interviewing–based coaching sessions that engaged the patient, evoked their reason to consider quitting, and helped them establish a quit plan. Measures. Self-reported quitting of tobacco and fills of tobacco cessation medications within 12 months of follow-up. Analysis. Logistic regressions adjusting for age, gender, race/ethnicity, and primary language. Results. After adjusting for confounders, tobacco quit rates were higher among coaching participants vs. matched controls (31% vs. 23%, p < .001) and comparable to those of class attendees (31% vs. 29%, p = .28). Coaching participants and class attendees filled tobacco-cessation prescriptions at a higher rate (47% for both) than matched controls (6%, p < .001). Conclusion. Telephonic wellness coaching was as effective as in-person classes and was associated with higher rates of quitting compared to no treatment. The telephonic modality may increase convenience and scalability for health care systems looking to reduce tobacco use and improve health.

Wellness Coaching for People With Prediabetes: A Randomized Encouragement Trial to Evaluate Outreach Methods at Kaiser Permanente, Northern California, 2013

Introduction Health coaching can improve lifestyle behaviors known to prevent or manage chronic conditions. Little is known about effective ways to encourage health and wellness coaching among people who might benefit. The purpose of this randomized encouragement trial was to assess the relative success of 3 outreach methods (secured email message, telephone message, and mailed letter) on the use of wellness coaching by people with prediabetes. Methods A total of 14,584 Kaiser Permanente Northern California (KPNC) patients with diagnosed prediabetes (fasting plasma glucose, 110–125mg/dL) were randomly assigned to be contacted via 1 of 4 intervention arms from January through May 2013. The uptake rate (making an appointment at the Wellness Coaching Center [WCC]) was assessed, and the association between uptake rate and patient characteristics was examined via multivariable logistic regression. Results The overall uptake rate across intervention arms was 1.9%. Secured email message had the highest uptake rate (3.0%), followed by letters and telephone messages (P < .05 for all pairwise comparisons). No participants in the usual-care arm (ie, no outreach) made an appointment with the WCC. For each year of increased age, the estimated odds of the uptake increased by 1.02 (odds ratio [OR] = 1.02; 95% CI, 1.01–1.04). Women were nearly twice as likely to make an appointment at the WCC as men (OR = 1.87; 95% CI, 1.40–2.51). Conclusion Our results suggest that the WCC can recruit and encourage KPNC members with prediabetes to participate in the WCC. Future research should focus on increasing participation rates in health coaching among patients who may benefit.

Screening for impaired fasting glucose and diabetes using available health plan data

AIMS To develop and validate prediction equations to identify individuals at high risk for type 2 diabetes using existing health plan data. METHODS Health plan data from 2005 to 2009 from 18,527 members of a Midwestern HMO without diabetes, 6% of whom had fasting plasma glucose (FPG) ≥110mg/dL, and health plan data from 2005 to 2006 from 368,025 members of a West Coast-integrated delivery system without diabetes, 13% of whom had FPG ≥110mg/dL were analyzed. Within each health plan, we used multiple logistic regression to develop equations to predict FPG ≥110mg/dL for half of the population and validated the equations using the other half. We then externally validated the equations in the other health plan. RESULTS Areas under the curve for the most parsimonious equations were 0.665 to 0.729 when validated internally. Positive predictive values were 14% to 32% when validated internally and 14% to 29% when validated externally. CONCLUSION Multivariate logistic regression equations can be applied to existing health plan data to efficiently identify persons at higher risk for dysglycemia who might benefit from definitive diagnostic testing and interventions to prevent or treat diabetes.

The Impact of Telephonic Wellness Coaching on Weight Loss: A “Natural Experiments for Translation in Diabetes (NEXT-D)” Study

To evaluate the impact of a population‐based telephonic wellness coaching program on weight loss.

Employer-Based Screening for Diabetes and Prediabetes in an Integrated Health Care Delivery System: A Natural Experiment for Translation in Diabetes (NEXT-D) Study.

Objective: This study evaluates an employer-based diabetes/prediabetes screening intervention that invited at-risk employees via letters, secure e-mails, and automated voice messages to complete blood glucose testing at a health plan facility. Methods: Quasi-experimental cohort study among health plan members insured by two employers that received the intervention and three employers that were selected as control sites. Results: The proportion of at-risk members that completed a screening was higher in the intervention group than in the control group (36% vs 13%, P < 0.001, adjusted for patient characteristics). Among those screened in the intervention group, the presence of obesity, hypertension, hyperlipidemia, and tobacco use were significant predictors of having a result that indicated diabetes or prediabetes (P < 0.05, all comparisons). Conclusions: A low-intensity, employer-based intervention conducted in collaboration with a health care delivery system effectively increased screening for diabetes/prediabetes.

Influence of a New Diabetes Diagnosis on the Health Behaviors of the Patient’s Partner

PURPOSE When a person is given a diagnosis of diabetes, the changes in his or her health behaviors may influence the behaviors of his or her partner. The diabetes diagnosis may affect household members’ perceptions of their own health risks, which could trigger behavioral change. The purpose of this study was to assess whether partners of persons with newly diagnosed diabetes changed their health behaviors compared with partners of persons without diabetes. METHODS The study population consisted of Kaiser Permanente Northern California health plan members from 2007 to 2011. This cohort study assessed differences in change of 8 health behaviors. The study compared coresiding partners of persons with newly diagnosed diabetes before and after a diabetes diagnosis with a 5 to 1 matched sample of coresiding partners of persons without diabetes. RESULTS A total of 180,910 couples were included in the analysis. After adjusting for baseline characteristics, partners of persons with newly diagnosed diabetes had significantly higher rates of participation in weight management–related health education classes (risk ratio [RR] = 1.50; 95% CI, 1.39-1.63); smoking cessation medication use (RR = 1.25; 95% CI, 1.05-1.50); glucose screening (RR = 1.07; 95% CI, 1.05-1.08); clinically meaningful weight loss (RR = 1.06; 95% CI, 1.02-1.11); lipid screening (RR = 1.05; 95% CI, 1.04-1.07); influenza vaccination (RR = 1.03; 95% CI, 1.02-1.04); and blood pressure screening (RR = 1.02; 95% CI, 1.02-1.03) compared with partners of persons without diabetes. CONCLUSIONS There were small but significant differences in health-related behavioral changes among partners of persons with newly diagnosed diabetes compared with partners of persons without diabetes, even when no intervention occurred. This finding suggests a diabetes diagnosis within a family may be a teachable moment to improve health behaviors at the household level.