Barriers to self-monitoring of blood glucose among adults with diabetes in an HMO: A cross sectional study

BACKGROUND: Recent studies suggest that patients at greatest risk for diabetes complications are least likely to self-monitor blood glucose. However, these studies rely on self-reports of monitoring, an unreliable measure of actual behavior. The purpose of the current study was to examine the relationship between patient characteristics and self-monitoring in a large health maintenance organization (HMO) using test strips as objective measures of self-monitoring practice. METHODS: This cross-sectional study included 4,565 continuously enrolled adult managed care patients in eastern Massachusetts with diabetes. Any self-monitoring was defined as filling at least one prescription for self-monitoring test strips during the study period (10/1/92–9/30/93). Regular SMBG among test strip users was defined as testing an average of once per day for those using insulin and every other day for those using oral sulfonylureas only. Measures of health status, demographic data, and neighborhood socioeconomic status were obtained from automated medical records and 1990 census tract data. RESULTS: In multivariate analyses, lower neighborhood socioeconomic status, older age, fewer HbA1c tests, and fewer physician visits were associated with lower rates of self-monitoring. Obesity and fewer comorbidities were also associated with lower rates of self-monitoring among insulin-managed patients, while black race and high glycemic level (HbA1c>10) were associated with less frequent monitoring. For patients taking oral sulfonylureas, higher dose of diabetes medications was associated with initiation of self-monitoring and HbA1c lab testing was associated with more frequent testing. CONCLUSIONS: Managed care organizations may face the greatest challenges in changing the self-monitoring behavior of patients at greatest risk for poor health outcomes (i.e., the elderly, minorities, and people living in low socioeconomic status neighborhoods)

LongSAGE profiling of nine human embryonic stem cell lines

Analysis of a 2.6 million longSAGE sequence tag resource generated from nine human embryonic stem cell lines reveals an enrichment of RNA binding proteins and novel ES-specific transcripts

Effects of Health Maintenance Organization Coverage of Self-monitoring Devices on Diabetes Self-care and Glycemic Control

Background Increasingly, government mandates require insurance coverage of blood glucose monitors and test strips for patients with type 1 and type 2 diabetes. No data exist on the effects of such coverage on self-monitoring of blood glucose (SMBG), medication compliance, or blood glucose control. We evaluated whether a policy providing free blood glucose monitors increased SMBG and whether initiating SMBG was associated with increased regularity of medication use and improved glucose control (hemoglobin A1c [HbA1c] level). Methods Using interrupted time-series analysis and controlling for preintervention trends, we determined changes in rates of SMBG 2 years before and after the policy among 3219 continuously enrolled patients with diabetes receiving drug therapy within a multispecialty medical group (part of a health maintenance organization) serving approximately 300 000 patients. We also compared changes over time in regularity of medication use (mean days between dispensings) and mean HbA1c level among initiators and noninitiators of SMBG. Results The policy resulted in a small, significant increase in SMBG among insulin-treated patients (n = 1428). Among sulfonylurea-treated patients (n = 1791), the monthly initiation rate of SMBG increased by 14 new patients per 1000 (95% confidence interval [CI], 10 to 17), a doubling of the expected initiation rate. Test strip consumption increased during the first 6 months after the policy by 17.9 strips per cohort member (75% relative increase by 6 months; 95% CI, 50% to 101%). Compared with noninitiators of SMBG, initiators (n = 593) showed sudden, significant improvements in regularity of medication use by 6 months after initiation (−19.5 days between dispensings among those with low refill regularity [95% CI, −27.7 to −11.3]; −9.7 days among those with moderate regularity [95% CI, −12.3 to −7.1]), and in glucose control (−0.63% mean HbA1c level [as percentage of total hemoglobin] among those with poor baseline glycemic control [HbA1c >10%; 95% CI, −1.14% to −0.12%]). Conclusions Providing free glucose monitors improved rates of self-monitoring in this health maintenance organization population, possibly by offering an initial incentive for patients to engage in more desirable patterns of care. Initiating SMBG was associated with increased regularity of medication use and a reduction in high blood glucose levels

Coverage by the news media of the benefits and risks of medications

Background: The news media are an important source of information about new medical treatments, but there is concern that some coverage may be inaccurate and overly enthusiastic. Methods: We studied coverage by U.S. news media of the benefits and risks of three medications that are used to prevent major diseases. The medications were pravastatin, a cholesterol-lowering drug for the prevention of cardiovascular disease; alendronate, a bisphosphonate for the treatment and prevention of osteoporosis; and aspirin, which is used for the prevention of cardiovascular disease. We analyzed a systematic probability sample of 180 newspaper articles (60 for each drug) and 27 television reports that appeared between 1994 and 1998. Results: Of the 207 stories, 83 (40 percent) did not report benefits quantitatively. Of the 124 that did, 103 (83 percent) reported relative benefits only, 3 (2 percent) absolute benefits only, and 18 (15 percent) both absolute and relative benefits. Of the 207 stories, 98 (47 percent) mentioned potential harm to patients, and only 63 (30 percent) mentioned costs. Of the 170 stories citing an expert or a scientific study, 85 (50 percent) cited at least one expert or study with a financial tie to a manufacturer of the drug that had been disclosed in the scientific literature. These ties were disclosed in only 33 (39 percent) of the 85 stories. Conclusions: News-media stories about medications may include inadequate or incomplete information about the benefits, risks, and costs of the drugs as well as the financial ties between study groups or experts and pharmaceutical manufacturers

Racial Disparities in Access After Regulatory Surveillance of Benzodiazepines

Background We examined the effects of a prescription-monitoring program on benzodiazepine access among Medicaid enrollees living in neighborhoods of different racial composition. Methods We used interrupted time series and logistic regression to analyze data from noninstitutionalized persons aged 18 years or older (N = 124 867) enrolled continuously in New York Medicaid 12 months before and 24 months and 7 years after initiation of the program. We used census data to identify the racial composition of the neighborhoods. Outcome measures were nonproblematic use (short term, within dosing guidelines), potentially problematic use (>120 days' use or more than twice the recommended dose), and pharmacy hopping (filling prescriptions for the same benzodiazepine in different pharmacies within 7 days). Results There was a sudden, sustained reduction in benzodiazepine use in all the neighborhoods after the program's introduction. Despite the lowest rates of baseline use, enrollees in predominantly (≥75%) black neighborhoods experienced the highest rates of discontinuation after introduction of the program. This difference remained 7 years after policy initiation. Compared with white participants, black participants were more likely to discontinue nonproblematic (odds ratio, 1.78; 95% confidence interval, 1.47-2.17) and potentially problematic (odds ratio, 1.77; 95% confidence interval, 1.45-2.17) benzodiazepine use, after adjusting for sex, eligibility status, neighborhood poverty, and baseline use. The program almost completely eliminated pharmacy hopping in all racial groups, although less among white participants (82.6%) vs black participants (88.7%). Conclusions A systematic benzodiazepine prescription-monitoring program reduced inappropriate prescribing, with a stronger effect in predominantly black neighborhoods despite lower baseline use. The policy may have resulted in an unintended decrease in nonproblematic use that disproportionately affects black populations

Lipid Management in Youth: What Are the Screening and Treatment Trends Within the Pediatric Cardiovascular Research Network?

Background/Aims: Atherosclerotic cardiovascular disease (ASCVD) accounts for 1 in every 3 deaths in the United States, and studies show that the precursors of atherosclerosis are apparent early in life. The correlation between childhood cardiovascular risk factors and the extent of atherosclerosis in adulthood has led to the development of guidelines aimed at attenuating ASCVD risks in youth. One major ASCVD risk factor is dyslipidemia, including both familial hypercholesterolemia (FH) and lifestyle-related hyperlipidemia. Currently, few studies have investigated temporal lipid screening and treatment trends in youth and guideline adherence before and after the 2011 update, which includes universal lipid screening and targeted screening recommendations. The purpose of this study is to identify lipid screening and treatment trends and guideline adherence in a diverse population of children and adolescents across multiple health care systems participating in the Pediatric Cardiovascular Risk Network (P-CVRN) study. This data is also essential to provide up-to-date cost-effective analyses (CEA). Methods: Institutional Review Board approval was obtained for this study. This retrospective database study includes \u3e 600,000 youth age 2 to 21 years with at least one outpatient visit captured across five P-CVRN sites between 2001 and 2013. The following de-identified data was captured and extracted at an individual patient level from inpatient and outpatient claims data: patient demographics, diagnoses, pretreatment laboratory values, initial lipid-lowering medications and doses, initial posttreatment laboratory values and presence of other risk factors or conditions. Results: The data collected was used to analyze trends in pediatric lipid management and inform contemporaneous CEA related to pediatric lipid screening and treatment. Our data revealed that screening rates declined at most sites and varied from a peak of ~25% to a low of ~5% of youth. Lipid-lowering medications were prescribed in 0.02–0.19% of all youth, and prescribing did not generally increase over time. Lipid-lowering medication and dose initiation, pre- and posttreatment laboratory values, and medication possession ratio were analyzed using logistic regression. CEA did not support the benefit of universal lipid screening in youth. Discussion: Current screening trends indicate that health care providers are nonadherent with guideline recommendations, and CEA reveals that universal screening in youth is not cost-effective