Background

Although patients with type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10 year dementia risk for individuals with type 2 diabetes.

Methods

Using data from two longitudinal cohorts of patients with type 2 diabetes (aged ≥60 years) with 10 years of follow-up, we created (n=29,961) and validated (n=2413) the risk score. We built our prediction model by evaluating 45 candidate predictors using Cox proportional hazard models and developed a point system for the risk score based on the size of the predictor's β coefficient. Model prediction was tested by discrimination and calibration methods. Dementia risk per sum score was calculated with Kaplan-Meier estimates.

Findings

Microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education were most strongly predictive of dementia and constituted the risk score (C statistic 0·736 for creation cohort and 0·746 for validation cohort). The dementia risk was 5·3% (95% CI 4·2-6·3) for the lowest score (-1) and 73·3% (64·8-81·8) for the highest (12-19) sum scores.

Interpretation

To the best of our knowledge, this is the first risk score for the prediction of 10 year dementia risk in patients with type 2 diabetes mellitus. The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials.

Funding

Kaiser Permanente Community Benefit, National Institute of Health, Utrecht University, ZonMw, and Fulbright.

Background

Although many studies have shown that diabetes increases the risk for urinary incontinence, it is unclear whether poor glycemic control in women with diabetes is associated with incontinence. This study aims to determine the relationship between the hemoglobin A1c (HbA1c) level and urinary incontinence in a large, diverse cohort of older women.

Methods

We examined 6026 older women who responded to a survey (62% response rate) and were enrolled in the Diabetes and Aging Study, an ethnically stratified random sample of patients with diabetes enrolled in Kaiser Permanente Northern California. Our primary independent variable was the mean of all HbA1c measurements in the year preceding the survey. Outcomes included the presence/absence of incontinence and limitations in daily activities due to incontinence. We used modified Poisson regression and ordinal logistic regression models to account for age, race, body mass index, parity, diabetes treatment, duration of diabetes, and comorbidity.

Results

Sixty-five percent of women reported incontinence (mean age 59±10 years). After adjustment, HbA1c levels were not associated with the presence or absence of incontinence. However, among women reporting incontinence, HbA1c ≥9% was associated with more limitations due to incontinence than HbA1c <6% (adjusted odds ratio 1.67, 95% confidence interval: 1.09-2.57).

Conclusion

In this cross-sectional analysis, HbA1c level is not associated with the presence or absence of incontinence. However, for women with incontinence, poor glycemic control (HbA1c ≥9%) is associated with more limitations in daily activities due to incontinence. Longitudinal studies are needed to determine whether improving glycemic control to HbA1c <9% leads to fewer limitations in daily activities due to incontinence.

Objective

To compare total annual costs for Medicare beneficiaries receiving primary care in federally funded health centers (HCs) to Medicare beneficiaries in physician offices and outpatient clinics.

Data sources/study settings

Part A and B fee-for-service Medicare claims from 14 geographically diverse states. The sample was restricted to beneficiaries residing within primary care service areas (PCSAs) with at least one HC.

Study design

We modeled separately total annual costs, annual primary care costs, and annual nonprimary care costs as a function of patient characteristics and PCSA fixed effects.

Data collection

Data were obtained from the Centers for Medicare & Medicaid Services.

Principal findings

Total median annual costs (at $2,370) for HC Medicare patients were lower by 10 percent compared to patients in physician offices ($2,667) and by 30 percent compared to patients in outpatient clinics ($3,580). This was due to lower nonprimary care costs in HCs, despite higher primary care costs.

Conclusions

HCs may offer lower total cost practice style to the Centers for Medicare & Medicaid Services, which administers Medicare. Future research should examine whether these lower costs reflect better management by HC practitioners or more limited access to specialty care by HC patients.

Objectives

To assess changes in medication use after a diagnosis of dementia in individuals with type 2 diabetes mellitus.

Design

Difference-in-differences analysis of changes in the number of dispensed chronic medications between individuals with and without newly diagnosed dementia.

Setting

Integrated healthcare delivery system, Kaiser Permanente Northern California.

Participants

Individuals aged 50 and older without prevalent dementia with type 2 diabetes mellitus enrolled in a baseline survey. During 5 years of follow-up, 193 individuals with a new diagnosis of dementia were identified, and risk-set sampling was used to randomly select five reference subjects per case matched on 5-year age categories and sex (965 matched participants), resulting in an analytical sample of 1,158.

Measurements

The exposure was new diagnosis of dementia. The primary outcome was change in number of current chronic medications (total, cardiovascular (blood pressure and lipid control), diabetes mellitus) at three times: 1 year before index date (preindex date), date of diagnosis of dementia or matched reference date (index date), and up to 1 year after index date or end of follow-up if censored before 1 year (postindex date).

Results

After adjustment, the number of chronic medications and the subset of cardiovascular medications declined after a dementia diagnosis in the overall cohort and in age-, sex-, and time-matched reference individuals, but the decline was significantly greater in the group with dementia (0.71 medications fewer than the reference group, P = .02). The number of diabetes mellitus medications declined in both groups, but the declines were not statistically different (0.18 medications fewer than the reference group, P = .008).

Conclusions

Use of cardiometabolic medications fell after a diagnosis of dementia, as recommended in national guidelines.

Objectives

To explore racial and ethnic (ethnic hereafter) differences in health-related quality of life (HRQL) in older adults with diabetes mellitus in an integrated delivery system.

Design

Observational cross-sectional study.

Setting

Kaiser Permanente Northern California.

Participants

Ethnic-stratified, random sample of 6,096 adults with diabetes mellitus aged 60 to 75 who completed a HRQL questionnaire.

Measurements

Physical and mental HRQL were measured based on the Medical Outcomes Study 8-item Short Form Survey (range 0-100, mean 50). Age- and sex-adjusted weighted linear regression models estimated associations between ethnicity and HRQL and evaluated potential mediators (socioeconomic status, acculturation, health behaviors, diabetes mellitus-related conditions). Differences in ethnic-specific, adjusted mean HRQL scores were tested (reference whites).

Results

Physical HRQL was better for Filipinos (48.3, 95% confidence interval (CI) = 47.0-49.6, P < .001), Asians (48.1, 95% CI = 46.8-49.3, P < .001), Hispanics (45.1, 95% CI = 44.2-46.0, P < .001), and blacks (44.2, 95% CI = 43.3-45.1, P = .04) than whites (42.9, 95% CI = 42.6-43.2). Adjusting for potential mediators did not change these relationships. Mental HRQL was better only for Asians (52.7, 95% CI = 51.6-53.7, P = .01) than for whites (51.0, 95% CI = 50.7-51.3), but this difference was small and became nonsignificant after adjustment for socioeconomic status, acculturation, health behaviors, and diabetes mellitus-related conditions.

Conclusion

In older adults with diabetes mellitus in a well-established integrated healthcare delivery system, ethnic minorities had better physical HRQL than whites. Equal access to care in an integrated delivery system may hold promise for reducing health disparities in diabetes mellitus-related patient-reported outcomes.

Patient-provider relationships influence diabetes care; less is known about their impact on online patient portal use. Diabetes patients rated provider communication and trust. In this study, we linked responses to electronic medical record data on being a registered portal user and using secure messaging (SM). We specified regression models to evaluate main effects on portal use, and subgroup analyses by race/ethnicity and age. 52% of subjects were registered users; among those, 36% used SM. Those reporting greater trust were more likely to be registered users (relative  risk (RR)=1.14) or SM users (RR=1.29). In subgroup analyses, increased trust was associated with being a registered user among white, Latino, and older patients, as well as SM use among white patients. Better communication ratings were also related to being a registered user among older patients. Since increased trust and communication were associated with portal use within subgroups, this suggests that patient-provider relationships encourage portal engagement.

Objectives

To compare health care use and spending of Medicaid enrollees seen at federally qualified health centers versus non-health center settings in a context of significant growth.

Methods

Using fee-for-service Medicaid claims from 13 states in 2009, we compared patients receiving the majority of their primary care in federally qualified health centers with propensity score-matched comparison groups receiving primary care in other settings.

Results

We found that health center patients had lower use and spending than did non-health center patients across all services, with 22% fewer visits and 33% lower spending on specialty care and 25% fewer admissions and 27% lower spending on inpatient care. Total spending was 24% lower for health center patients.

Conclusions

Our analysis of 2009 Medicaid claims, which includes the largest sample of states and more recent data than do previous multistate claims studies, demonstrates that the health center program has provided a cost-efficient setting for primary care for Medicaid enrollees.

Background

Reducing symptom burden is paramount at the end-of-life, but typically considered secondary to risk factor control in chronic disease, such as diabetes. Little is known about the symptom burden experienced by adults with type 2 diabetes and the need for symptom palliation.

Objective

To examine pain and non-pain symptoms of adults with type 2 diabetes over the disease course - at varying time points before death and by age.

Design

Survey follow-up study.

Participants

13,171 adults with type 2 diabetes, aged 30-75 years, from Kaiser Permanente, Northern California, who answered a baseline symptom survey in 2005-2006.

Main measures

Pain and non-pain symptoms were identified by self-report and medical record data. Survival status from baseline was categorized into ≤ 6, >6-24, or alive >24 months.

Key results

Mean age was 60 years; 48 % were women, and 43 % were non-white. Acute pain was prevalent (41.8 %) and 39.7 % reported chronic pain, 24.6 % fatigue, 23.7 % neuropathy, 23.5 % depression, 24.2 % insomnia, and 15.6 % physical/emotional disability. Symptom burden was prevalent in all survival status categories, but was more prevalent among those with shorter survival, p< .001. Adults ≥ 60 years who were alive >24 months reported more physical symptoms such as acute pain and dyspnea, whereas participants <60 years reported more psychosocial symptoms, such as depressed mood and insomnia. Adjustment for duration of diabetes and comorbidity reduced the association between age and pain, but did not otherwise change our results.

Conclusions

In a diverse cohort of adults with type 2 diabetes, pain and non-pain symptoms were common among all patients, not only among those near the end of life. However, symptoms were more prevalent among patients with shorter survival. Older adults reported more physical symptoms, whereas younger adults reported more psychosocial symptoms. Diabetes care management should include not only good cardiometabolic control, but also symptom palliation across the disease course.

Objective

The aim of this study was to evaluate ethnic differences in burden of prevalent geriatric conditions and diabetic complications among older, insured adults with diabetes.

Method

An observational study was conducted among 115,538 diabetes patients, aged ≥60, in an integrated health care system with uniform access to care.

Results

Compared with Whites, Asians and Filipinos were more likely to be underweight but had substantively lower prevalence of falls, urinary incontinence, polypharmacy, depression, and chronic pain, and were least likely of all groups to have at least one geriatric condition. African Americans had significantly lower prevalence of incontinence and falls, but higher prevalence of dementia; Latinos had a lower prevalence of falls. Except for end-stage renal disease (ESRD), Whites tended to have the highest rates of prevalent diabetic complications.

Discussion

Among these insured older adults, ethnic health patterns varied substantially; differences were frequently small and rates were often better among select minority groups, suggesting progress toward the Healthy People 2020 objective to reduce health disparities.