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1.  Characteristics of Insured Patients with Persistent Gaps in Diabetes Care Services: The Translating Research into Action for Diabetes (TRIAD) Study 
Medical care  2010;48(1):31-37.
Although prevention of complications in diabetes requires careful control over many years, little is known about which patients persistently fail to get recommended care.
To determine the frequency and correlates of persistent long-term gaps in diabetes care.
Patient surveys and reviews of medical records were used to assess preventive care services for diabetes among 8392 patients who were continuously enrolled in 10 US managed care plans from 1999 to 2002. Demographic and socioeconomic characteristics, access to care, social support, and mental and physical health were determined by interview. Five preventive care services of diabetes care (testing of hemoglobin A1c, cholesterol, and albuminuria, dilated eye exams, and foot exams) were assessed by survey and chart abstraction for a 3-year period (1999–2002). We defined a “persistent lapse” as a participant’s missing a preventive care service for the entire 3 years.
In all, 70% of patients had no persistent lapses, 22% had 1, 6% had 2, and 2% had ≥ 3. Persistent lapses occurred most often for lipid testing (11.6%), microalbuminuria testing (9.7%), and eye exams (9.0%), but less frequently for foot exams (6.9%) and A1c tests (4.2%). In multivariate analyses, the odds of a persistent lapse in care was 42% higher for young (age 18–44) than middle aged persons and 26% higher among lean than very obese persons. In addition, the odds of a persistent lapse was 26% higher for those of low income, 29% higher among employed persons, 18% higher for smokers, 27% higher in those with fewer than 5 years of diabetes than those with > 15 years, and 42% higher for persons with zero or 1 comorbid conditions (compared to ≥ 3). In addition, non-Hispanic blacks were particularly likely to miss lipid tests (15.3%) and those not taking medications were especially likely to miss foot exams (7.1%), A1c tests (10.6%), and proteinuria tests (10.8%). Sex, education, marital status, family demands, transportation, trust in physicians, and mental health were not associated with lapses in care.
Even in an insured cohort, 3 in 10 participants had 1 or more persistent lapses in diabetes care. Patients with lower income, younger age, having fewer co-morbidities, taking fewer medications and poor health behaviors are particularly vulnerable to persistent lapses in care and a group who warrant targeted interventions to improve preventive diabetes care.
PMCID: PMC4269465  PMID: 20009778
2.  Correlates of depression among people with diabetes: The Translating Research Into Action for Diabetes (TRIAD) study 
Primary care diabetes  2010;4(4):215-222.
The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care.
Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data.
Nearly 18% of patients had major depression, with prevalence 2-3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care.
In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.
PMCID: PMC4269468  PMID: 20832375
3.  Physician reimbursement perception for outpatient procedures and procedures among managed care patients with diabetes 
To examine the association between physicians’ reimbursement perceptions and outpatient test performance. Previous studies have documented an association between reimbursement perceptions and electrocardiogram performance, but not for other common outpatient procedures.
Cross-sectional analysis.
Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiograms, radiographs or x-rays, urine microalbumin measures, hemoglobin A1cs, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for plan as a fixed effect. Thus, we estimated variation between physicians using only the variance within health plans.
Patients of physicians who reported reimbursement for electrocardiograms were more likely to receive electrocardiograms than patients of physicians who did not perceive reimbursement (unadjusted mean difference 4.9% (95% confidence interval, 1.1% to 8.9%)) and adjusted mean difference 3.9% (95% confidence interval, 0.21% to 7.8%)). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.
Our findings suggest that reimbursement perception was associated with electrocardiograms, but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and interactions with other influences upon test-ordering behavior such as perceived appropriateness.
PMCID: PMC3833066  PMID: 19146362
managed care; reimbursement; outpatient
4.  Prevalence of Diabetes and Intermediate Hyperglycemia Among Adults From the First Multinational Study of Noncommunicable Diseases in Six Central American Countries 
Diabetes Care  2012;35(4):738-740.
The increasing burdens of obesity and diabetes are two of the most prominent threats to the health of populations of developed and developing countries alike. The Central America Diabetes Initiative (CAMDI) is the first study to examine the prevalence of diabetes in Central America.
The CAMDI survey was a cross-sectional survey based on a probabilistic sample of the noninstitutionalized population of five Central American populations conducted between 2003 and 2006. The total sample population was 10,822, of whom 7,234 (67%) underwent anthropometry measurement and a fasting blood glucose or 2-h oral glucose tolerance test.
The total prevalence of diabetes was 8.5%, but was higher in Belize (12.9%) and lower in Honduras (5.4%). Of the screened population, 18.6% had impaired glucose tolerance/impaired fasting glucose.
As this population ages, the prevalence of diabetes is likely to continue to rise in a dramatic and devastating manner. Preventive strategies must be quickly introduced.
PMCID: PMC3308278  PMID: 22323417
6.  Evaluation of risk equations for prediction of short-term coronary heart disease events in patients with long-standing type 2 diabetes: the Translating Research into Action for Diabetes (TRIAD) study 
To evaluate the U.K. Prospective Diabetes Study (UKPDS) and Framingham risk equations for predicting short-term risk of coronary heart disease (CHD) events among adults with long-standing type 2 diabetes, including those with and without preexisting CHD.
Prospective cohort of U.S. managed care enrollees aged ≥ 18 years and mean diabetes duration of more than 10 years, participating in the Translating Research into Action for Diabetes (TRIAD) study, was followed for the first occurrence of CHD events from 2000 to 2003. The UKPDS and Framingham risk equations were evaluated for discriminating power and calibration.
A total of 8303 TRIAD participants, were identified to evaluate the UKPDS (n = 5914, 120 events), Framingham-initial (n = 5914, 218 events) and Framingham-secondary (n = 2389, 374 events) risk equations, according to their prior CHD history. All of these equations exhibited low discriminating power with Harrell’s c-index <0.65. All except the Framingham-initial equation for women and the Framingham-secondary equation for men had low levels of calibration. After adjsusting for the average values of predictors and event rates in the TRIAD population, the calibration of these equations greatly improved.
The UKPDS and Framingham risk equations may be inappropriate for predicting the short-term risk of CHD events in patients with long-standing type 2 diabetes, partly due to changes in medications used by patients with diabetes and other improvements in clinical care since the Frmaingham and UKPDS studies were conducted. Refinement of these equations to reflect contemporary CHD profiles, diagnostics and therapies are needed to provide reliable risk estimates to inform effective treatment.
PMCID: PMC3433369  PMID: 22776317
7.  Residence in a Distressed County in Appalachia as a Risk Factor for Diabetes, Behavioral Risk Factor Surveillance System, 2006-2007 
Preventing Chronic Disease  2010;7(5):A104.
We compared the risk of diabetes for residents of Appalachian counties to that of residents of non-Appalachian counties after controlling for selected risk factors in states containing at least 1 Appalachian county.
We combined Behavioral Risk Factor Surveillance System data from 2006 and 2007 and conducted a logistic regression analysis, with self-reported diabetes as the dependent variable. We considered county of residence (5 classifications for Appalachian counties, based on economic development, and 1 for non-Appalachian counties), age, sex, race/ethnicity, education, household income, smoking status, physical activity level, and obesity to be independent variables. The classification "distressed" refers to counties in the worst 10%, compared with the nation as a whole, in terms of 3-year unemployment rate, per capita income, and poverty.
Controlling for covariates, residents in distressed Appalachian counties had 33% higher odds (95% confidence interval, 1.10-1.60) of reporting diabetes than residents of non-Appalachian counties. We found no significant differences between other classifications of Appalachian counties and non-Appalachian counties.
Residents of distressed Appalachian counties are at higher risk of diabetes than are residents of other counties. States with distressed Appalachian counties should implement culturally sensitive programs to prevent diabetes.
PMCID: PMC2938398  PMID: 20712931
8.  Identifying Risk Factors for Racial Disparities in Diabetes Outcomes: the Translating Research into Action for Diabetes (TRIAD) Study 
Medical care  2009;47(6):700-706.
Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications.
To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites.
Case-control study.
A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans.
Cases were patients with poor control of at least two of three intermediate outcomes (HbA1c≥8.0%, SBP≥140 mmHg, LDL cholesterol≥130 mg/dl) and controls were patients with good control of all three (HbA1c<8.0%, SBP<140 mmHg, LDL cholesterol<130 mg/dl). In multivariate analyses, we determined whether each of five potentially mutable risk factors, including depression, low health literacy, poor adherence to medication, low self-efficacy for reducing cardiovascular risk, and poor patient-provider communication, predicted case or control status.
Among blacks but not whites, in multivariate analyses depression (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.09-4.75) and having missed medication doses (OR 1.96, 95% CI 1.01-3.81) were associated with greater odds of being a case rather than a control. None of the other risk factors were associated for either blacks or whites.
Depression and missing medication doses are more strongly associated with poor diabetes control among blacks than in whites. These two risk factors may represent important targets for patient-level interventions to address racial disparities in diabetes outcomes.
PMCID: PMC2743318  PMID: 19480090
Diabetes; Racial/Ethnic Groups; Health Outcomes
9.  Predictors of Sustained Walking among Diabetes Patients in Managed Care: The Translating Research into Action for Diabetes (TRIAD) Study 
Journal of General Internal Medicine  2008;23(8):1194-1199.
Although patients with diabetes may benefit from physical activity, few studies have examined sustained walking in this population.
To examine the factors associated with sustained walking among managed care patients with diabetes.
Longitudinal, observational cohort study with questionnaires administered 2.5 years apart.
Five thousand nine hundred thirty-five patients with diabetes walking at least 20 minutes/day at baseline.
The primary outcome was the likelihood of sustained walking, defined as walking at least 20 minutes/day at follow-up. We evaluated a logistic regression model that included demographic, clinical, and neighborhood variables as independent predictors of sustained walking, and expressed the results as predicted percentages.
The absence of pain was linked to walking behavior, as 62% of patients with new pain, 67% with ongoing pain, and 70% without pain were still walking at follow-up (p = .03). Obese patients were less likely (65%) to sustain walking than overweight (71%) or normal weight (70%) patients (p = .03). Patients ≥65 years (63%) were less likely to sustain walking than patients between 45 and 64 (70%) or ≤44 (73%) years (p = .04). Only 62% of patients with a new comorbidity sustained walking compared with 68% of those who did not (p < .001). We found no association between any neighborhood variables and sustained walking in this cohort of active walkers.
Pain, obesity, and new comorbidities were moderately associated with decreases in sustained walking. Whereas controlled intervention studies are needed, prevention, or treatment of these adverse conditions may help patients with diabetes sustain walking behavior.
PMCID: PMC2517953  PMID: 18452046
sustained walking; diabetes patients; managed care; TRIAD study; pain; obesity; comorbidities

Results 1-9 (9)