Diabetes Care Visits Research Articles

625-P: Psychosocial Factors Predict Health Care Usage in Young Adults with Youth-Onset Type 2 Diabetes—TODAY2 iCount Study

Background: Established diabetes care (“diabetes home”) and regular healthcare visits are important to achieve good outcomes. Nothing is known about psychosocial factors that predict healthcare usage (HCU) in young adults with youth-onset type 2 diabetes. Objective: To identify psychosocial predictors of HCU in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort. Design: Longitudinal, measured at T1 (baseline) and T2 (1 year later). Logistic and linear regressions, adjusted for covariates, were used to identify predictors of sub-optimal HCU (defined as no diabetes home, 0 routine care visits, ≥1 urgent care visit in prior 6 months). Participants: N= 366 TODAY2 participants. Mean age=26.0 years, 67.8% female, 37.7% non-Hispanic Black, 35.8% Hispanic, 20.2% non-Hispanic white, mean HbA1c=9.4%. Main measures: HCU survey; reliable, valid measures of diabetes self-efficacy, depressive symptoms, anxiety symptoms, diabetes distress, beliefs about medicines, diabetes attitudes, material need insecurities and self-management support. Key Results: 25.4% had no diabetes home, 23.7% had 0 routine care visits, 46% had ≥1 urgent care visit in prior 6 months. Beliefs in the necessity of (p<0.001), and concerns about (p=0.004), diabetes medicines, and diabetes having negative psychosocial impacts (p=0.034), predicted higher odds of having a diabetes home at T2. Beliefs that medicines are harmful predicted lower odds of having a diabetes home (p=0.006). Necessity beliefs (p=0.002), concerns (p=0.025), and self-management support (p=0.014) predicted higher odds of having ≥ 1 diabetes care visit in prior 6 months, harm beliefs predicted lower odds (p=0.005). Conclusions: Sub-optimal healthcare usage is common in young adults with youth-onset type 2 diabetes and is predicted by beliefs about medicines and self-management support. We must address these factors to help this vulnerable group establish a stable foundation for diabetes care. Disclosure P.M.Trief: None. D.Uschner: None. B.Anderson: None. H.Wen: None. J.D.Bulger: None. R.S.Weinstock: Consultant; Jaeb Center for Health Research, Other Relationship; Wolters Kluwer Health, Research Support; Insulet Corporation, Medtronic, Eli Lilly and Company, Novo Nordisk, Boehringer Ingelheim Inc., Hemsley Charitable Trust, National Institute of Diabetes and Digestive and Kidney Diseases, Tandem Diabetes Care, Inc., Kowa Pharmaceuticals America, Inc. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK110456)

Virtual Clinics for Diabetes Care.

Virtual Clinics for Diabetes Care.

Diabetes distress and HbA1c in racially/ethnically and socioeconomically diverse youth with type 1 diabetes.

Diabetes distress, the emotional burden of caring for the chronic demands of diabetes, has not been well described in children and preadolescents with type 1 diabetes (T1D). This gap is particularly evident among youth of lower socioeconomic status (SES) and/or racial/ethnic minorities. Since these groups are more likely to have disparities in health outcomes and healthcare related to their diabetes, factors that could potentially improve glycemic and other diabetes-related outcomes should be studied closely. We hypothesized that (a) diabetes distress levels would be elevated in children with markers of lower SES and those of racial/ethnic minorities, and (b) higher HbA1c would be predicted by higher diabetes distress levels, when controlling for race/ethnicity, SES, and clinical covariates. One hundred and eighty-seven youth age 9 to 13 with T1D completed age-appropriate Problem Areas in Diabetes (PAID) questionnaires using a web-based portal during routine diabetes care visits. PAID scores were significantly elevated in youth who had surrogate markers of lower SES and who were from racial/ethnic minority backgrounds. In multivariate models including race/ethnicity or the SES variables and controlling for clinical covariates, the factor most predictive of higher HbA1c was elevated PAID score. Diabetes distress is elevated in a younger population of children with T1D who are from racial/ethnic minority backgrounds or have markers of lower SES. Interventions that target distress and/or expand the safety net in these populations could potentially improve glycemic outcomes.

840-P: Lower Health-Care Utilization among Diverse Adolescents and Young Adults (AYA) Who Receive Culturally Discordant Care

Background: AYA with T1D encounter many challenges in managing their diabetes, such as uncontrolled glycemic levels, higher probability of complications, and poor clinic attendance. AYA minorities often encounter health care disparities that could be addressed with culturally competent care, which considers the patient’s diverse background and sociocultural factors like communication, language, and beliefs that may influence health behaviors. Objective: To assess patient-reported provider cultural competence and health care utilization among diverse AYA population with T1D. Methods: Patients were recruited during routine diabetes outpatient care visits and asked to complete questionnaires on sociodemographic variables, health care utilization, and clinical experiences and cultural competence as assessed by the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Results: One-hundred forty three AYA (58.7% Male; 45.5% Latinx, 22.4% non-Latinx white) participated, with an average HbA1c of 9.8% in Latinx and 8.6% in non-Latinx whites. Participants who reported some negative experience with provider cultural competence were marginally lower health care utilizers. Specifically, these AYA went to the ER for diabetes-related problems less frequently (p=0.07), had fewer urgent care visits (p=0.08), went to urgent care for hypoglycemia issues less frequently (p=0.08), and attended fewer diabetes care visits (p=0.07). They also went to urgent care for reasons unrelated to diabetes less frequently (p=0.11) and spent fewer days in the hospital when admitted (p=0.13), but these results were not significant. Conclusions: AYA who experience culturally discordant care may utilize health care less frequently. It is unclear if AYA receiving discordant care need less healthcare support, or if their experiences lead to avoidance of needed care. Our results are hypothesis-generating and further investigation is needed. Disclosure J.J. Flores Garcia: None. J. Raymond: Other Relationship; Self; Insulet Corporation. S. Agarwal: None. A. Torres Sanchez: None. M.W. Reid: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Evaluation of an interprofessional continuing professional development course on comprehensive diabetes care: A mixed-methods approach.

Since there are only 33 endocrinologists within the Department of Defence and over 150000 beneficiaries with diabetes, most patients with diabetes will be treated by primary care providers (PCPs). Comprehensive diabetes care visits are extensive and the clinical practice guidelines (CPGs) routinely change; thus, providing current evidence-based care is difficult. Most professional development courses aim to update PCPs on CPGs but are often inadequate as they focus on only the PCPs (not the interdisciplinary team) without a plan to implement changes into practice. To evaluate the biannual (twice yearly), 3-day, interprofessional Diabetes Champion Course (DCC) developed by the US Air Force Diabetes Center of Excellence on comprehensive diabetes care. A mixed-methods approach was used to evaluate three iterations of the DCC course (Sept 2014-Sept 2015). Quantitatively, pre-course and post-course surveys were used to obtain impact on knowledge, skills, and intention to change clinical practice. Qualitatively, semi-structured phone interviews were conducted with participants to obtain benefits to their clinic related to attending the DCC and barriers to implementation of the CPG process improvement project. Twelve of 19 responding clinics (63%) reported implementing all or part of their original CPG project developed at the DCC, and 17 of 19 clinics (89%) reported improvements associated with attending the DCC. Post-course surveys, from on location participants, revealed significant improvements in knowledge (P<0.01). Likewise, foot exam skills and ability to demonstrate glucose meters to patients improved. Even with high pre-course confidence, 97% of providers reported acquiring new knowledge about prescribing and titrating insulin. The DCC is innovative as it employs a team-based, interprofessional, didactic, and interactive approach that is effective in improving knowledge, skills, and intention to change clinical practice, which should translate to better care for patients with diabetes.

Impact of Diabetes on Colorectal Cancer Screening Rates in U.S. Adults

Background: Individuals with diabetes have an increased risk for colorectal cancer, however routine diabetes care visits may increase colorectal screening rates. The aim of this study is to examine whether diabetes diagnosis influences screening completion in U.S. adults. Methods: This study used data from 464,664 adults completing the 2014 BRFSS national survey. Logistic regression models tested the likelihood of colorectal screening by diabetes status, and whether diabetes quality of care indicators predicted colorectal screening among diabetes patients. A stratified analysis examined predictors of screening by demographic status for diabetes/nondiabetes patients. Result: Of the population, 13.1% reported having diabetes and of these, 67% reported completing colorectal screening. Diabetes status, accounting for demographic variables, predicted blood stool screening in the last year (OR 1.09), colonoscopy (OR 1.17), and any colorectal screening technique (OR 1.08). For diabetes patients, non-Hispanic black patients were significantly more likely to receive any type of screening (OR 1.18), as well as women (OR 1.15). Diabetes patients reporting an HbA1c check (OR 1.49), having their eyes checked (OR 1.52), and receiving diabetes education (OR 1.37) were significantly more likely to have completed any screening technique, whereas primary care visits did not predict screening. Conclusions: Patients with diabetes are more likely to complete colorectal screening compared to patients without diabetes. Non-Hispanic blacks and women with diabetes were significantly more likely to complete any screening, whereas this was not the case in patients with no diabetes. Quality of care indicators and receiving diabetes education significantly predicted screening completion compared to having a physician visit alone. Colorectal screening interventions incorporating patient engagement may be warranted for both the diabetes and general population. Disclosure J.A. Campbell: None. R.J. Walker: None. C. Eiler: None. L.E. Egede: Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases. Advisory Panel; Self; Novo Nordisk Inc..

Access to Transportation and Health Care Visits for Medicaid Enrollees With Diabetes.

Diabetes is a chronic condition that requires frequent health care visits for its management. Individuals without nonemergency medical transportation often miss appointments and do not receive optimal care. This study aims to evaluate the association between Medicaid-provided nonemergency medical transportation and diabetes care visits. A retrospective analysis was conducted of demographic and claims data obtained from the Oklahoma Medicaid program. Participants consisted of Medicaid enrollees with diabetes who made at least 1 visit for diabetes care in a year. The sample was predominantly female and white, with an average age of 46.38 years. Two zero-truncated Poisson regression models were estimated to assess the independent effect of transportation use on number of diabetes care visits. Use of nonemergency medical transportation is a significant predictor of diabetes care visits. Zero-truncated Poisson regression coefficients showed a positive association between the use of transportation and number of visits (0.6563, P < .001). Age, gender, race/ethnicity, area of residence, and presence of additional chronic conditions had independent associations with number of visits. Older enrollees were likely to make more visits than younger enrollees with diabetes (0.02382); controlling for all other factors in the model, rural residents made more visits than urban; women made fewer visits than men (-0.09312; P < .001); and minorities made fewer visits than whites, with pronounced differences for Hispanics and Asians compared to whites. Findings underscore the importance of ensuring transportation to Medicaid populations with diabetes, particularly in the rural areas where the prevalence of diabetes and complications are higher and the availability of medical resources lower than in the urban areas.

Clinical and Psychosocial Outcomes of a Structured Transition Program Among Young Adults With Type 1 Diabetes

PurposeWe identified and treated young adults with type 1 diabetes who had been lost to follow-up during their transfer from pediatric to adult care, comparing their clinical, psychosocial, and health care utilization outcomes to participants receiving continuous care (CC) throughout the transition to adult care. MethodsIndividuals in their last year of pediatric care (CC group, n = 51) and individuals lost to follow-up in the transfer to adult care (“lapsed care” [LC] group, n = 24) were followed prospectively for 12 months. All participants were provided developmentally tailored diabetes education, case management, and clinical care through a structured transition program. ResultsAt baseline, LC participants reported lapses in care of 11.6 months. Compared with CC participants, they had higher hemoglobin A1C (A1C; p = .005), depressive symptoms (p = .05), incidence of severe hypoglycemia (p = .005), and emergency department visits (p = .004). At 12-month follow-up, CC and LC participants did not differ on the number of diabetes care visits (p = .23), severe hypoglycemia (no events), or emergency department visits (p = .22). Both groups' A1C improved during the study period (CC: p = .03; LC: p = .02). LC participants' depressive symptoms remained elevated (p = .10), and they reported a decline in life satisfaction (p = .007). There was greater loss to follow-up in the LC group (p = .04). ConclusionsOur study suggests that, for young adults with a history of lapses in care, a structured transition program is effective in lowering A1C, reducing severe hypoglycemia and emergency department utilization, and improving uptake of routine diabetes care. Loss to follow-up and psychosocial concerns remain significant challenges in this population.

Transfer from pediatric to adult health care: effects on diabetes outcomes

The transfer from pediatric to adult diabetes health care for emerging adults with type 1 diabetes (T1D) has received increasing attention in the literature. This review analyzes the effect of this health care transfer on the outcomes of diabetes care visit attendance, glycemic control, and acute diabetes-related complications, and assesses the methodological strength of the studies reporting observational and interventional data. Observational studies, often limited by incomplete data, report a decline in diabetes care visits but an improvement or no change in hemoglobin A1c (HbA1c) after transfer to adult care. Results from studies reporting a transition intervention are restricted by lack of appropriate control groups and the collection of data both before and after transfer of care. Very few methodologically strong studies are available to guide clinicians with the transition from pediatric to adult care, and these shortcomings should be addressed in future studies designed to facilitate and improve the care of emerging adults with T1D.

Bullying, regimen self-management, and metabolic control in youth with type I diabetes

To determine the association among diabetes-related bullying, diabetes self-management, metabolic control, and depression in children and adolescents with type I diabetes (TID). Measures of diabetes-related bullying and depression were administered to 167 youth with TID at their regularly scheduled diabetes care visits. Parents were administered a clinician-rated index of their child's diabetes self-management. HbA1c levels were assessed. Diabetes-related bullying was positively related to HbA1c concentration and negatively related to overall self-management and specifically to adherence to glucose testing and dietary tasks. Depressive symptoms partially mediated the relation between diabetes-related bullying and overall self-management. Given the associations between diabetes-related bullying and regimen self-management, the issue of illness-related bullying merits serious attention for pediatricians and school personnel.

Diabetic patients who smoke: are they different?

We wanted to identify differences between diabetic patients who smoke and those who do not smoke to design more effective strategies to improve their diabetes care and encourage smoking cessation. A random sample of adult health plan members with diabetes were mailed a survey questionnaire, with telephone follow-up, asking about their attitudes and behaviors regarding diabetes care and smoking. Among the 1,352 respondents (response rate 82.4%), we found 188 current smokers whose answers we compared with those of 1,264 nonsmokers, with statistical adjustment for demographic characteristics and duration of diabetes. Smokers with diabetes were more likely to report fair or poor health (odds ratio [OR] = 1.5, P = .03) and often feeling depressed (OR = 1.7, P = .004). Relative to nonsmokers, smokers had lower rates of checking blood glucose levels, were less physically active, and had fewer diabetes care visits, glycated hemoglobin (A1c) tests, foot examinations, eye examinations, and dental checkups (P < or = .01). Smokers also reported receiving and desiring less support from family and friends for specific diabetic self-management activities and had lower readiness to quit smoking than has been observed in other population groups. Clinicians should be aware that diabetic patients who smoke are more likely to report often feeling depressed and, even after adjusting for depression, are less likely to be active in self-care or to comply with diabetes care recommendations. Diabetic patients who smoke are special clinical challenges and are likely to require more creative and consistent clinical interventions and support.