Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE To examine demographic, socioeconomic, and biological risk factors for all-cause, cardiovascular, and noncardiovascular mortality in patients with type 2 diabetes over 8 years and to construct mortality prediction equations. RESEARCH DESIGN AND METHODS Beginning in 2000, survey and medical record information was obtained from 8,334 participants in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. The National Death Index was searched annually to obtain data on deaths over an 8-year follow-up period (2000–2007). Predictors examined included age, sex, race, education, income, smoking, age at diagnosis of diabetes, duration and treatment of diabetes, BMI, complications, comorbidities, and medication use. RESULTS There were 1,616 (19%) deaths over the 8-year period. In the most parsimonious equation, the predictors of all-cause mortality included older age, male sex, white race, lower income, smoking, insulin treatment, nephropathy, history of dyslipidemia, higher LDL cholesterol, angina/myocardial infarction/other coronary disease/coronary angioplasty/bypass, congestive heart failure, aspirin, β-blocker, and diuretic use, and higher Charlson Index. CONCLUSIONS Risk of death can be predicted in people with type 2 diabetes using simple demographic, socioeconomic, and biological risk factors with fair reliability. Such prediction equations are essential for computer simulation models of diabetes progression and may, with further validation, be useful for patient management

Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial

Background: Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry. Methods: SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices. Discussion: Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care

Supporting Practices to Adopt Registry-Based Care (SPARC): protocol for a randomized controlled trial

Background: Diabetes is predicted to increase in incidence by 42% from 1995 to 2025. Although most adults with diabetes seek care from primary care practices, adherence to treatment guidelines in these settings is not optimal. Many practices lack the infrastructure to monitor patient adherence to recommended treatment and are slow to implement changes critical for effective management of patients with chronic conditions. Supporting Practices to Adopt Registry-Based Care (SPARC) will evaluate effectiveness and sustainability of a low-cost intervention designed to support work process change in primary care practices and enhance focus on population-based care through implementation of a diabetes registry. Methods: SPARC is a two-armed randomized controlled trial (RCT) of 30 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN). Participating practices (including control groups) will be introduced to population health concepts and tools for work process redesign and registry adoption at a meeting of practice-level implementation champions. Practices randomized to the intervention will be assigned study peer mentors, receive a list of specific milestones, and have access to a physician informaticist. Peer mentors are clinicians who successfully implemented registries in their practices and will help champions in the intervention practices throughout the implementation process. During the first year, peer mentors will contact intervention practices monthly and visit them quarterly. Control group practices will not receive support or guidance for registry implementation. We will use a mixed-methods explanatory sequential design to guide collection of medical record, participant observation, and semistructured interview data in control and intervention practices at baseline, 12 months, and 24 months. We will use grounded theory and a template-guided approach using the Consolidated Framework for Implementation Research to analyze qualitative data on contextual factors related to registry adoption. We will assess intervention effectiveness by comparing changes in patient-level hemoglobin A1c scores from baseline to year 1 between intervention and control practices. Discussion: Findings will enhance our understanding of how to leverage existing practice resources to improve diabetes care in primary care practices by implementing and using a registry. SPARC has the potential to validate the effectiveness of low-cost implementation strategies that target practice change in primary care

Predictors and Impact of Intensification of Antihyperglycemic Therapy in Type 2 Diabetes: Translating Research into Action for Diabetes (TRIAD)

ObjectiveThe 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 methodsWe 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.ResultsOf 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.ConclusionsTreatment 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

Electronic Health Record Functionality Needed to Better Support Primary Care

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This manuscript presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and Meaningful Use (MU) objectives to define EHR functionality. Current objectives remain disease- rather than whole-person focused, ignoring factors like personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time as well as patient partnering activities, support for team based care, population management tools that deliver care, and reduced documentation burden. While Stage 3 MU’s focus on outcomes is laudable, enhanced functionality is still needed including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies

Extreme Districts, Moderate Winners: Same-Party Challenges, and Deterrence in Top-Two Primaries

In an effort to break the link between districts\u27 lack of competitiveness and the election of ideologues, Washington and California recently adopted the “top-two” primary election system. Among other features, the top-two primary allows members of the same party to run against one another in the general election. Although proponents argue that this system encourages the election of more moderate candidates in highly partisan districts, early reports have uncovered mixed evidence of this effect. This study addresses this puzzle by first disentangling the conditions under which one should expect such primaries to encourage the election of more moderate candidates. Using election returns data from the 2008 through 2014 elections, I find that districts facing same-party general-election competition do elect more moderate legislators than similar districts not subject to same-party competition. However, using an application of a common regression discontinuity diagnostic test, I also find that elite actors appear able to strategically avoid this kind of competition—partially explaining why broader effects of the top-two have not been uncovered. The findings contribute not only to ongoing debates about the effectiveness of the top-two primary, but also to our understanding of how political elites may maneuver institutional changes to their own benefit

Multiple Vote Electoral Systems: A Remedy for Political Polarization

We examine the mechanical effect of a multiple vote, proportional representation electoral system on party vote share in n dimensions. In one dimension, Cox (1990) has proven that such a system is centripetal: it drives parties to the center of the political spectrum. However, as populism has swept across Western Europe and the United States, the importance of multiple policy dimensions has grown considerably. We use simulations to examine how a multiple vote system could alter electoral outcomes in all possible parliamentary systems. We find that multiple vote systems act centripetally in multiple dimensions too, though weakly in extreme cases where parties are sorted into ideological clusters at opposite corners of the ideological space. Even in these cases, though, we find that a slight disturbance of the conditions (by introducing an additional party- even if it is very small) strengthens the centripetal properties of the multiple vote system

Resources and Agendas: Combining Walker’s Insights with New Data Sources to Chart a Path Ahead

One of the central projects of Mobilizing Interest Groups in America was to chart the course that interests take to overcome the collective action problems inherent to founding and maintaining a group to be active in politics. Importantly, Walker found that interests’ pathways to organization and maintenance are dependent on the availability of a natural or existing membership base or the interests’ access to patronage or other resources. Put differently, an interest’s path to mobilization is largely a function of its “niche in the constituency and policy communities of which it is a part.” (Walker 1991, 9). This implies that not all pathways to organization are equally available to all interests. For example, citizens groups are disproportionately reliant on patronage from individual donors and foundations. Not only are not all paths open to all interests, but, consequentially, the manner by which interest groups originate and maintain themselves structures the rest of a group’s actions and strategy: “the choice of political strategies is intimately connected to the group’s prospects for organizational maintenance” (Walker 1991, 106).f Groups that rely more on patronage, for example, are much more likely to pursue “outside” strategies of influence. Because Walker’s analysis implies that the nature of an interest itself may dictate both its path towards organizational representation and the subsequent strategies and tactics the organization ultimately pursues, he describes a system with serious inherent representational inequalities if some types of activities are more effective than others. In this essay we explore how contemporary data sources and methods might be brought to bear in assessing these fundamental representational questions. We propose a forward-looking research agenda—using data and tools which have become available since Walker’s work—that incorporates his core insights regarding the political economy of interest representation. Using these tools can allow scholars to continue where Walker left off, examining both how interest origination affects political representation in American politics and how parties and elected officials may affect the landscape of interest representation by bolstering or undermining these organizational roots

Polarized Pluralism: Organizational Preferences and Biases in the American Pressure System

For decades, critics of pluralism have argued that the American interest group system exhibits a significantly biased distribution of policy preferences. We evaluate this argument by measuring groups’ revealed preferences directly, developing a set of ideal point estimates, IGscores, for over 2,600 interest groups and 950 members of Congress on a common scale. We generate the scores by jointly scaling a large dataset of interest groups’ positions on congressional bills with roll-call votes on those same bills. Analyses of the scores uncover significant heterogeneity in the interest group system, with little conservative skew and notable inter-party differences in preference correspondence between legislators and ideologically similar groups. Conservative bias and homogeneity reappear, however, when weighting IGscores by groups’ PAC contributions and lobbying expenditures. These findings suggest that bias among interest groups depends on the extent to which activities like PAC contributions and lobbying influence policymakers’ perceptions about the preferences of organized interests