Susan Lee Johnson

Missed Opportunities for Type 2 Diabetes Mellitus Screening Among Women With a History of Gestational Diabetes Mellitus

OBJECTIVES We sought to determine rates and factors associated with screening for type 2 diabetes mellitus (DM) in women with a history of gestational diabetes mellitus. METHODS We retrospectively studied women with diagnosed gestational diabetes mellitus who delivered at a university-affiliated hospital (n=570). Data sources included medical and administrative record review. Main outcome measures were the frequency of any type of glucose testing at least 6 weeks after delivery and the frequency of recommended glucose testing. We assessed demographic data, past medical history, and prenatal and postpartum care characteristics. RESULTS Rates of glucose testing after delivery were low. Any type of glucose testing was performed at least once after 38% of deliveries, and recommended glucose testing was performed at least once after 23% of deliveries. Among women with at least 1 visit to the health care system after delivery (n=447), 42% received any type of glucose test at least once, and 35% received a recommended glucose test at least once. Factors associated with testing were being married, having a visit with an endocrinologist after delivery, and having more visits after delivery. CONCLUSIONS These findings suggest that most women with gestational diabetes mellitus are not screened for type 2 DM after delivery. Opportunities for DM prevention and early treatment are being missed.

Predictors and impact of intensification of antihyperglycemic therapy in type 2 diabetes: Translating Research into Action for Diabetes (TRIAD)

OBJECTIVE The purpose of this study was to examine the predictors of intensification of antihyperglycemic therapy in patients with type 2 diabetes; its impact on A1C, body weight, symptoms of anxiety/depression, and health status; and patient characteristics associated with improvement in A1C. RESEARCH DESIGN AND METHODS We analyzed survey, medical record, and health plan administrative data collected in Translating Research into Action for Diabetes (TRIAD). We examined patients who were using diet/exercise or oral antihyperglycemic medications at baseline, had A1C >7.2%, and stayed with the same therapy or intensified therapy (initiated or increased the number of classes of oral antihyperglycemic medications or began insulin) over 18 months. RESULTS Of 1,093 patients, 520 intensified therapy with oral medications or insulin. Patients intensifying therapy were aged 58 ± 12 years, had diabetes duration of 11 ± 9 years, and had A1C of 9.1 ± 1.5%. Younger age and higher A1C were associated with therapy intensification. Compared with patients who did not intensify therapy, those who intensified therapy experienced a 0.49% reduction in A1C (P < 0.0001), a 3-pound increase in weight (P = 0.003), and no change in anxiety/depression (P = 0.5) or health status (P = 0.2). Among those who intensified therapy, improvement in A1C was associated with higher baseline A1C, older age, black race/ethnicity, lower income, and more physician visits. CONCLUSIONS Treatment intensification improved glycemic control with no worsening of anxiety/depression or health status, especially in elderly, lower-income, and minority patients with type 2 diabetes. Interventions are needed to overcome clinical inertia when patients might benefit from treatment intensification and improved glycemic control.

The impact of continuous subcutaneous insulin infusion and multiple daily injections of insulin on glucose variability in older adults with type 2 diabetes.

AIMS To determine whether continuous subcutaneous insulin infusion (CSII) or multiple daily injections of insulin (MDI) are associated with improved glycemic variability. METHODS Type 2 diabetic patients ≥60 years of age were randomized to 12 months of CSII (n=53) or MDI (n=54) therapy. Patients were asked to complete monthly eight-point self-monitored glucose profiles (n=78) and continuous glucose monitoring systems (CGMS) for up to 72 h at Months 0, 6, and 12 (n=77). Within-day mean glucose, standard deviation (SD), range, pre- and post-prandial glucose, M value, and mean amplitude of glycemic excursions (MAGE) were calculated from eight-point profiles. Mean glucose, SD, range, area under the curve (AUC) high (>180 mg/dl) and AUC-low (<70 mg/dl) were calculated from CGMS. Mixed model analyses of variance were used to examine the associations between treatment, time, and the study outcomes, adjusting for any effects of sex. RESULTS With the use of the eight-point profiles, CSII and MDI groups did not differ with respect to mean glucose, mean pre-prandial and post-prandial glucose, SD, range, M value, or MAGE. With the CGMS data, there were no significant between-group differences in measures of mean glucose, range, SD, AUC-high, or AUC-low. In both treatment groups, all measures improved over time (P<.0001) except for AUC-low (P=.68) which did not change. There were treatment-by-time interactions when considering the CGMS range (P=.04) and AUC-high (P=.001), but no significant differences were found at individual time points. CONCLUSIONS Glucose variability improved equally with CSII and MDI treatment in older patients with type 2 diabetes.

CT angiography is cost-effective for confirmation of internal carotid artery occlusions.

While sensitive to internal carotid artery (ICA) occlusion, carotid ultrasound can produce false‐positive results. CT angiography (CTA) has a high specificity for ICA occlusion and is safer and cheaper than catheter angiography, although less accurate. We determined the cost‐effectiveness of CTA versus catheter angiography for confirming an ICA occlusion first suggested by carotid ultrasound.

Who is tested for diabetic kidney disease and who initiates treatment? The Translating Research Into Action For Diabetes (TRIAD) Study.

OBJECTIVE—We examined factors associated with screening for albuminuria and initiation of ACE inhibitor or angiotensin receptor blocker (ARB) treatment in diabetic patients. RESEARCH DESIGN AND METHODS—We conducted surveys and medical record reviews for 5,378 patients participating in a study of diabetes care in managed care at baseline (2000–2001) and follow-up (2002–2003). Factors associated with testing for albuminuria were examined in cross-sectional analysis at baseline. Factors associated with initiating ACE inhibitor/ARB therapy were determined prospectively. RESULTS—At baseline, 52% of patients not receiving ACE inhibitor/ARB therapy and without known diabetic kidney disease (DKD) were screened for albuminuria. Patients ≥65 years of age, those with higher HbA1c, those with cardiovascular disease (CVD), and those without hyperlipidemia were less likely to be screened. Of the patients with positive screening tests, 47% began ACE inhibitor/ARB therapy. Initiation of therapy was associated with positive screening test results, BMI ≥25 kg/m2, treatment with insulin or oral antidiabetic agents, peripheral neuropathy, systolic blood pressure ≥140 mmHg, and CVD. Of the patients receiving ACE inhibitor/ARB therapy or with known DKD, 63% were tested for albuminuria. CONCLUSIONS—Screening for albuminuria was inadequate, especially in older patients or those with competing medical concerns. The value of screening could be increased if more patients with positive screening tests initiated ACE inhibitor/ARB therapy. The efficiency of screening could be improved by limiting screening to diabetic patients not receiving ACE inhibitor/ARB therapy and without known DKD.