Performance of Comorbidity, Risk Adjustment, and Functional Status Measures in Expenditure Prediction for Patients With Diabetes

OBJECTIVE—To compare the ability of generic comorbidity and risk adjustment measures, a diabetes-specific measure, and a self-reported functional status measure to explain variation in health care expenditures for individuals with diabetes

Patient perspectives on having multiple versus single prescribers of chronic disease medications: results of a qualitative study in a veteran population

BackgroundPatients with multiple chronic conditions often have multiple prescribers, which has been associated with greater health care utilization and medication nonadherence in claims-based analyses. This qualitative study was conducted to understand the reasons why patients have increasing numbers of prescribers of medications and to understand patient perspectives on advantages and disadvantages of having multiple prescribers, including effects on medication supply.MethodsThis qualitative study involved three focus groups comprising 23 outpatients from a single Veterans Affairs (VA) Medical Center with at least one chronic cardiometabolic condition (hypertension, diabetes, dyslipidemia, or congestive heart failure). Participants were asked about their experiences, including perceived of advantages and disadvantages, of having multiple prescribers of cardiometabolic medications. Conventional content analysis was used to analyze the data.ResultsMultiple prescribers arose through referrals and patients actively seeking non-VA prescribers (primary care and/or specialist) to maximize timeliness and access to medications, provide access to medications not on the VA formulary, and minimize out-of-pocket costs. Patients seeking non-VA care had to coordinate own their care by sharing prescriptions and test results to their prescribers within and outside VA.ConclusionsPrescribing physicians should engage in open dialogue with patients to create a shared understanding of patient and provider goals and priorities for chronic disease medications

Control Outcomes and Exposures for Improving Internal Validity of Nonrandomized Studies

Control outcomes and exposures can improve internal validity of nonrandomized studies by assessing residual bias in effect estimates. Control outcomes are those expected to have no treatment effect or the opposite effect of the primary outcome. Control exposures are treatments expected to have no effect on the primary outcome. We review examples of control outcomes and exposures from prior studies and provide recommendations for conducting and reporting these analyses

Impacts of Geographic Distance on Peritoneal Dialysis Utilization: Refining Models of Treatment Selection

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/136011/1/hesr12489.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/136011/2/hesr12489-sup-0001-AuthorMatrix.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/136011/3/hesr12489_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/136011/4/hesr12489-sup-0002-Appendix.pd

Continuity of medication management in Medicaid patients with chronic comorbid conditions: An examination by mental health status

Patients with serious mental illness (SMI) often have comorbid cardiometabolic conditions (CMCs) that may increase the number of prescribers involved in treatment. This study examined whether patients with SMI (depression and schizophrenia) and comorbid CMCs experience greater discontinuity of prescribing than patients with CMCs alone

Omega-3-Fatty Acids Hold Therapeutic Potential for the Prevention and Treatment of Diabetic Neuropathy

Diabetic neuropathy is a debilitating complication of diabetes, affecting over 50% of diabetic patients. Overweight humans display manifestations of diabetic neuropathy before developing overt diabetes and mice fed a high fat diet exhibit signs of neuropathy including mechanical hindpaw hypersensitivity and neuronal inflammation, suggesting fat diet-induced inflammation may play a role in the development of neuropathy. Omega-3 (n-3) fatty acids have anti-inflammatory properties and may hold therapeutic potential as a preventative treatment for prediabetic and diabetic patients at risk for neuropathy. PURPOSE: Investigate the impact of diet composition on signs of neuropathy. We hypothesized that a diet rich in n-3 fatty acids would attenuate hindpaw hypersensitivity during prolonged feeding of a high fat diet. METHODS: C57BL/6 mice were randomized into four diet groups (n = 12/group) for 32 weeks: 10% low fat-fish oil (LFFO), 41% high fat-fish oil (HFFO), 10% low fat-lard (LFL), or 41% high fat-lard (HFL). Neuropathy was characterized at baseline and every other week thereafter using the von Frey behavioral test for hindpaw mechanical sensitivity. A glucose tolerance test was performed at end study, and total area under the curve (AUC) was calculated using the trapezoidal method. RESULTS: At end study, body weight was greater in HFL compared to all other groups. Body weight was also greater in HFFO compared to LFFO. Fasting glucose and glucose AUC were higher in HFL compared to LFFO and HFFO. Following the same pattern as body weight, fasting glucose was higher in HFFO compared to LFFO. Although percent paw withdrawal was greater in HFL compared to HFFO and LFFO, there were no significant differences for LF vs. HF for fish oil or lard. CONCLUSION: A HFL diet induced signs of neuropathy including hindpaw hypersensitivity, whereas a fish oil diet was protective against hindpaw hypersensitivity. Moreover, omega-3-fatty acids may hold therapeutic potential for neuropathy prevention in nondiabetic and diabetic patients

Real-world utilization patterns and outcomes of colesevelam hcl in the ge electronic medical record

Abstract Background In randomized controlled trials (RCTs), colesevelam HCI, added to other anti-diabetic therapy, reduced hemoglobin A1C by approximately 0.3% to 0.4% over 16- to 26-weeks compared with an increase of approximately 0.1% to 0.2% for placebo, for a placebo-adjusted treatment effect of approximately 0.5%. Evidence on real-world effectiveness is unknown. This retrospective cohort study examined A1C changes following colesevelam HCL initiation in patients with diabetes, regardless of concomitant anti-diabetic medication use. Methods 2000–2011 GE Centricity electronic medical records data were used to identify patients with type 2 diabetes mellitus (T2DM) aged 18 or older initiating colesevelam HCL. The sample was further restricted to uncontrolled patients with database activity ≥ 395 days before and after colesevelam HCL initiation, A1C > 7% during 90 days prior to starting colesevelam HCL, without prior use of bile acid sequestrants, and with at least one A1C result between 42 to 210 days after initiation. Three overlapping time intervals were created for A1C measurement, including 16-weeks, 26-weeks, and 52-weeks following therapy initiation. The last observed A1C lab measurement during each interval was used to define change from baseline. Mean change in A1C was examined using paired t-tests. Sensitivity analyses considered only patients who remained on colesevelam HCL through each respective measurement period, as well as the effect of concomitant diabetes medications. Results Of 1,709,393 patients in the GE database with T2DM, 1,747 met inclusion criteria. The cohort was 58% female, 38% age ≥ 65, and the majority was white. For the 16-week endpoint (N = 1,385), A1C dropped from a mean of 8.22% to 7.75% (mean change −0.47%; P < 0.0001). For the 26- and 52-week endpoints (N = 1,747), A1C dropped from a mean of 8.25% to 7.81% (mean change −0.44%; P < 0.0001) and 8.25% to 7.79% (mean change −0.46%; P < 0.0001), respectively. Sensitivity analyses showed that A1C reductions were of similar direction and magnitude for patients who remained on treatment, and for the subgroups of patients stratified by receipt of concomitant T2DM treatments. Conclusions The 0.44% to 0.47% A1C reduction observed in this study was similar to the reduction observed in RCTs, supporting the real-world effectiveness of colesevelam HCL in reducing A1C

Informing the dosing of interventions in randomized trials

Dosing is potentially the most important decision that must be made when building or refining behavioral interventions. In this paper, we propose standardized terminology and reporting of dosing information, which would inform intervention development, refinement for dissemination, and systematic reviews of dose-response relationships. Dosing of interventions may be characterized by duration, frequency, and amount. To illustrate the value of operationalizing these three parameters to evaluate dose-response relationships, 31 published reports of behavioral interventions to increase adherence to antiretroviral therapy (ART) were reviewed. The ART literature was characterized by under-reporting of dosing parameters, heterogeneity in dosing schedules, and heterogeneity in type of control group, which complicate analysis of dose-response relationships in systematic review and determination of the optimal dose for intervention dissemination. Improved reporting of the three dosing parameters and comparison of intended to actual delivery can inform the identification of the most effective intervention doses and the efficient implementation of efficacious interventions in clinical practice

Extent and reasons for nonadherence to antihypertensive, cholesterol, and diabetes medications: the association with depressive symptom burden in a sample of American veterans

ObjectivePersons with depressive symptoms generally have higher rates of medication nonadherence than persons without depressive symptoms. However, little is known about whether this association differs by comorbid medical condition or whether reasons for nonadherence differ by depressive symptoms or comorbid medical condition.MethodsSelf-reported extent of nonadherence, reasons for nonadherence, and depressive symptoms among 1,026 veterans prescribed medications for hypertension, dyslipidemia, and/or type 2 diabetes were assessed.ResultsIn multivariable logistic regression adjusted for clinical and demographic factors, the odds of nonadherence were higher among participants with high depressive symptom burden for dyslipidemia (n=848; odds ratio [OR]: 1.42, P=0.03) but not hypertension (n=916; OR: 1.24, P=0.15), or type 2 diabetes (n=447; OR: 1.15, P=0.51). Among participants reporting nonadherence to antihypertensive and antilipemic medications, those with greater depressive symptom burden had greater odds of endorsing medication nonadherence reasons related to negative expectations and excessive economic burden. Neither extent of nonadherence nor reasons for nonadherence differed by depressive symptom burden among patients with diabetes.ConclusionThese findings suggest that clinicians may consider tailoring interventions to improve adherence to antihypertensive and antilipemic medications to specific medication concerns of participants with depressive symptoms