Translating Research Into Action For Diabetes Research Articles

Foot Complications and Mortality: Results from Translating Research Into Action for Diabetes (TRIAD).

We sought to study the impact of foot complications on 10-year mortality independent of other demographic and biological risk factors in a racially and socioeconomically diverse managed-care population with access to high-quality medical care. We studied 6,992 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Foot complications were assessed using administrative claims data. The National Death Index was searched for deaths across 10 years of follow-up (2000-2009). Charcot's neuro-osteoarthropathy and diabetic foot ulcer with debridement were associated with an increased risk of mortality; however, the associations were not significant in fully adjusted models. Lower-extremity amputation (LEA) was associated with an increased risk of mortality in unadjusted (hazard ratio [HR], 3.21; 95% confidence interval [CI], 2.50-4.12) and fully adjusted (HR, 1.84; 95% CI, 1.28-2.63) models. When we examined the associations between LEA and mortality stratified by sex and race, risk was increased in men (HR, 1.96; 95% CI, 1.25-3.07), Hispanic individuals (HR, 5.17; 95% CI, 1.48-18.01), and white individuals (HR, 2.18; 95% CI, 1.37-3.47). In sensitivity analyses, minor LEA tended to increase the risk of mortality (HR, 1.48; 95% CI, 0.92-2.40), and major LEA was associated with a significantly higher risk of death at 10 years (HR, 1.89; 95% CI, 1.18-3.01). In this managed-care population with access to high-quality medical care, LEA remained a robust independent predictor of mortality. The association was strongest in men and differed by race.

Revisit frequency and its association with quality of care among diabetic patients: Translating Research Into Action for Diabetes (TRIAD)

ObjectiveTo describe patient and provider characteristics associated with outpatient revisit frequency and to examine the associations between the revisit frequency and the processes and intermediate outcomes of diabetes care. Research design and methodsWe analyzed data from Translating Research Into Action for Diabetes (TRIAD), a prospective, multicenter, observational study of diabetes care in managed care. ResultsOur analysis included 6040 eligible adult participants with type 2 diabetes (42.6%≥65years of age, 54.1% female) whose primary care providers were the main provider of the participants’ diabetes care. The median (interquartile range) revisit frequency was 4.0 (3.7, 6.0) visits per year. Being female, having lower education, lower income, more complex diabetes treatment, cardiovascular disease, higher Charlson comorbidity index, and impaired mobility were associated with higher revisit frequency. The proportion of participants who had annual assessments of HbA1c and LDL-cholesterol, foot examinations, advised or documented aspirin use, and influenza immunizations were higher for those with higher revisit frequency. The proportion of participants who met HbA1c (<9.5%) and LDL-cholesterol (<130mg/dL) treatment goals were higher for those with a higher revisit frequency. The predicted probabilities of achieving more aggressive goals, HbA1c <8.5%, LDL-cholesterol <100mg/dL, and blood pressure <130/85 or even <140/90mmHg were not associated with higher revisit frequency. ConclusionsRevisit frequency was highly variable and was associated with both sociodemographic characteristics and disease severity. A higher revisit frequency was associated with better processes of diabetes care, but the association with intermediate outcomes was less clear.

Depression and all-cause mortality in persons with diabetes mellitus: are older adults at higher risk? Results from the Translating Research Into Action for Diabetes Study.

To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus. A survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥ 65) and younger (18-65) adults. Managed care. Persons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341). The primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire. After controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant. This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment.

Capsule Commentary on Duru, et al., Potential Savings Associated with Drug Substitution in Medicare Part D: the Translating Research into Action for Diabetes (TRIAD) Study

The last several decades have seen advances in pharmaceutical technology. Diseases once untreated or only treated by surgery are now managed by medications. This advanced technology brings both increased numbers and costs of prescriptions. From 1999 to 2011, the number of prescriptions increased from 2.8 billion to 4 billion.1 In 2010, the U.S. spent 259 billion dollars on prescription medications, and this is projected to double by the end of this decade.2 What if there was a means of reducing the skyrocketing costs of prescription medications without limiting services or compromising care? In this study, Duru et al. examine therapeutic substitution as a means of doing just this.3 Common in many hospitals, therapeutic substitution is the use of an alternative medication that is not biologically equivalent, but has a similar effect as the original medication. Using a subset of 2007 Medicare part D data from a large national insurer, the authors identified the 50 highest costs drugs for the payor. The research team identified potential therapeutic substitutions for 27 to 30 of the 50 high cost drugs and calculated the potential cost savings to the patient, health plan and government. Their findings indicate a potential savings of 452 dollars per beneficiary—two to three times greater than that of generic substitution programs. There is general agreement that health care costs are too high and that the government needs to trim its expenditures. As the Affordable Care Act nears complete implementation and the number of insured increases, containment of prescription drug expenses will play an increasingly important role in controlling overall health care costs. This paper demonstrates a potential means of lowering pharmacy costs to patients, health plans and the government while still providing quality care. It is consistent with other ongoing efforts, including the National Physicians Alliance “Good Stewardship” program,4 that gave rise to the ABIM Foundation’s “Choosing Wisely” campaign.5 While further study to test multiple insurers and also the acceptability of therapeutic substitution to both patients and providers is needed, payers should take notice of this study as a potential method of cost savings.

Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)

AimsThe objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors. MethodsWe assessed the period prevalence of foot complications on 6992 patients using ICD-9 diagnosis codes from health plan administrative data. Demographic and biological variables were ascertained from surveys and medical record reviews. We defined four mutually exclusive groups: any Charcot foot, DFU with debridement, amputation±DFU and debridement, and no foot conditions. ResultsOverall, 55 (0.8%) patients had Charcot foot, 205 (2.9%) had DFU with debridement, and 101 (1.4%) had a lower-extremity amputation. There were 6631 patients with no prevalent foot conditions. Racial/ethnic minorities were less likely to have Charcot foot (OR=0.21; 95% CI: 0.10, 0.46) or DFU (OR=0.61; 95% CI: 0.44, 0.84) compared to non-Hispanic Whites, but there were no racial/ethnic differences in amputation. Histories of micro- or macrovascular disease were associated with a two- to four-fold increase in the odds of foot complications. ConclusionIn managed care patients with uniform access to health care, we found a relatively high prevalence of foot complications, but attenuation of the racial/ethnic differences of rates reported in the literature.

Potential Savings Associated with Drug Substitution in Medicare Part D: The Translating Research into Action for Diabetes (TRIAD) Study

Drug substitution is a promising approach to reducing medication costs. To calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs. Cross-sectional, simulation analysis. Low-income subsidy (LIS) beneficiaries (n = 145,056) and non low-income subsidy (non-LIS) beneficiaries (n = 1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution. Using administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy. Overall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries. Our findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.

Self-reported physical functioning and mortality among individuals with type 2 diabetes: insights from TRIAD

AimsTo examine the association between physical functioning and mortality in people with type 2 diabetes, and determine if this association differs by race/ethnicity in managed care. MethodsWe studied 7894 type 2 diabetic patients in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Physical functioning was assessed with the Short Form Health Survey. The National Death Index was searched for deaths over 10years of follow-up (2000–2009). ResultsAt baseline, mean age was 61.7years, 50% were non-Hispanic White, 22% were Black, and 16% of participants reported good physical functioning. Over 10years, 28% of participants died; 39% due to cardiovascular disease. Relative to those reporting good functioning, those reporting poor physical functioning had a 39% higher all-cause death rate after adjusting for age, sex, race/ethnicity, education, income, body mass index, smoking, and comorbidities (Hazard Ratio=1.39; 95% Confidence Interval: 1.16, 1.67). Although Blacks were less likely than Whites to report good functioning (p<0.01), the association between functioning and mortality did not differ by race/ethnicity. ConclusionsIn this managed care population, self-reported physical functioning was a robust independent predictor of mortality and may be a useful benchmark for tailoring clinical care.

Is the physical functioning of older adults with diabetes associated with the processes and outcomes of care? Evidence from Translating Research Into Action for Diabetes (TRIAD)

To examine the relationship between physical function limitations and diabetes self-management, processes of care and intermediate outcomes in adults ≥ 65 years of age with Type 2 diabetes. We studied 1796 participants 65 years of age and older in managed care health plans enrolled in Translating Research into Action for Diabetes (TRIAD). Physical functioning was assessed at baseline with the Physical Component Summary of the Short Form-12 Health Survey. Diabetes self-management was assessed with follow-up surveys, and processes of care (eye examinations, urine microalbumin testing, foot examinations, etc.) and intermediate health outcomes (HbA(1c), blood pressure, LDL cholesterol) were assessed with medical chart reviews. Multivariate regression models were constructed to examine the associations between physical function limitations and outcomes. Frequency of eye examinations (odds ratio 0.69, 95% CI 0.49-0.99) was the only process of care that was worse for participants with physical function limitations (n = 573) compared with those without limitations (n = 618). Neither self-management nor intermediate outcomes differed by whether patients had or did not have physical function limitations. Limitations in physical functioning as assessed by the Short Form-12 were not associated with substantial difference in diabetes care in adults ≥ 65 years of age enrolled in managed care health plans.

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

BackgroundTo 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.MethodsProspective 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.ResultsA 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.ConclusionsThe 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.

Predictors of Mortality Over 8 Years in Type 2 Diabetic Patients

OBJECTIVETo 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 METHODSBeginning 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.RESULTSThere 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.CONCLUSIONSRisk 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.

The Association of Depression and the Cardiovascular Risk Factors of Blood Pressure, HbA1c, and Body Mass Index among Patients with Diabetes: Results from the Translating Research into Action for Diabetes Study

Diabetic patients are nearly three times as likely to have depression as their nondiabetic counterparts. Patients with diabetes are already at risk for poor cardiovascular health. Using cross-sectional data from the translating research into action for diabetes (TRIAD) study, the authors tested the association of depression with cardiovascular risk factors in diabetic patients. Depression was measured using the patient health questionnaire (PHQ8). Patients who scored greater than 9 on the PHQ8 were classified as depressed and were compared with those who were not depressed (n = 2,341). Depressed patients did not have significantly different blood pressure levels than those who were not depressed. However, those who were depressed had higher HbA1c levels than those who were not depressed (P < 0.01) and higher BMIs than those who were not depressed (P < 0.01). These results indicate that depressed diabetic patients are at greater risk of having poor control of cardiovascular risk factors and suggest that depression screening should be a standard practice among this patient group.

Competing Demands for Time and Self-Care Behaviors, Processes of Care, and Intermediate Outcomes Among People With Diabetes

OBJECTIVETo determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes.RESEARCH DESIGN AND METHODSWe used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD) and hierarchical regression models to examine the cross-sectional associations between competing demands for time and diabetes outcomes, including self-management, processes of care, and intermediate health outcomes.RESULTSFifty-two percent of participants reported no competing demands, 7% reported caregiving responsibilities only, 36% reported employment responsibilities only, and 6% reported both caregiving and employment responsibilities. For both women and men, employment responsibilities (with or without caregiving responsibilities) were associated with lower rates of diabetes self-care behaviors, worse processes of care, and, in men, worse HbA1c.CONCLUSIONSAccommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.

Correlates of depression among people with diabetes: The Translating Research Into Action for Diabetes (TRIAD) study

Aim 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. Methods 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. Results 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. Conclusions 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.

Thiazolidinediones, cardiovascular disease and cardiovascular mortality: translating research into action for diabetes (TRIAD)

Studies have associated thiazolidinedione (TZD) treatment with cardiovascular disease (CVD) and questioned whether the two available TZDs, rosiglitazone and pioglitazone, have different CVD risks. We compared CVD incidence, cardiovascular (CV), and all-cause mortality in type 2 diabetic patients treated with rosiglitazone or pioglitazone as their only TZD. We analyzed survey, medical record, administrative, and National Death Index (NDI) data from 1999 through 2003 from Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Medications, CV procedures, and CVD were determined from health plan (HP) administrative data, and mortality was from NDI. Adjusted hazard rates (AHR) were derived from Cox proportional hazard models adjusted for age, sex, race/ethnicity, income, history of diabetic nephropathy, history of CVD, insulin use, and HP. Across TRIAD's 10 HPs, 1,815 patients (24%) filled prescriptions for a TZD, 773 (10%) for only rosiglitazone, 711 (10%) for only pioglitazone, and 331 (4%) for multiple TZDs. In the seven HPs using both TZDs, 1,159 patients (33%) filled a prescription for a TZD, 564 (16%) for only rosiglitazone, 334 (10%) for only pioglitazone, and 261 (7%) for multiple TZDs. For all CV events, CV, and all-cause mortality, we found no significant difference between rosiglitazone and pioglitazone. In this relatively small, prospective, observational study, we found no statistically significant differences in CV outcomes for rosiglitazone- compared to pioglitazone-treated patients. There does not appear to be a pattern of clinically meaningful differences in CV outcomes for rosiglitazone- versus pioglitazone-treated patients.

Physicians' Perceptions of Barriers to Cardiovascular Disease Risk Factor Control among Patients with Diabetes: Results from the Translating Research into Action for Diabetes (TRIAD) Study

Many patients with diabetes have poorly controlled blood glucose, lipid, or blood pressure levels, increasing their risk for cardiovascular disease (CVD) and other complications. Relatively little is known about what physicians perceive to be barriers to good CVD risk factor control or their own role in helping patients achieve good control. We interviewed 34 primary care physicians in 4 states to assess their perceptions of patients' barriers to CVD risk factor control. Interviews were coded and analyzed for emergent themes. Physicians attributed barriers primarily to patients (socioeconomic issues, competing medical conditions, and lack of motivation) or to health system barriers (cost of care or lack of a multidisciplinary team). Physicians also expressed high levels of frustration with their efforts to address barriers. Physicians felt that barriers to CVD risk factor control often were beyond their abilities to address. Training physicians or other members of the primary health care team to address patients' personal barriers and health system barriers to good control could help alleviate high frustration levels, improve relationships with patients, and improve the treatment of diabetes. Supporting such efforts with adequate reimbursement should be a focus of health care reform.

Investing time in health: do socioeconomically disadvantaged patients spend more or less extra time on diabetes self‐care?

Research on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time. To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes. Eleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001. Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics. Proportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day. Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

Predictors and Impact of Intensification of Antihyperglycemic Therapy in Type 2 Diabetes

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.

Are health-related quality-of-life and self-rated health associated with mortality? Insights from Translating Research Into Action for Diabetes (TRIAD)

To determine if health-related quality-of-life and self-rated health are associated with mortality in persons with diabetes. Survey and medical record data were obtained from 7892 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. Vital status at follow-up was determined from the National Death Index. Multivariable proportional hazard models were used to determine if a generic measure of health-related quality-of-life (EQ-5D) and self-rated health measured at baseline were associated with 4-year all-cause, cardiovascular, and noncardiovascular mortality. At baseline, the mean EQ-5D score for decedents was 0.73 (S.D.=0.20) and for survivors was 0.81 (S.D.=0.18) (p<0.0001). Fifty-five percent of decedents and 36% of survivors (p<0.0001) rated their health as fair or poor. Lower EQ-5D scores and fair or poor self-rated health were associated with higher rates of mortality after adjusting for the demographic, socioeconomic, and clinical risk factors for mortality. Health-related quality-of-life and self-rated health predict mortality in persons with diabetes. Health-related quality-of-life and self-rated health may provide additional information on patient risk independent of demographic, socioeconomic, and clinical risk factors for mortality.

Predictors of Sustained Walking among Diabetes Patients in Managed Care: The Translating Research into Action for Diabetes (TRIAD) Study

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 > or =65 years (63%) were less likely to sustain walking than patients between 45 and 64 (70%) or < 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.

Are Primary Care Physicians More Likely to Record Diabetes on Death Certificates?

Diabetes is recorded on the death certificate of decedents with known diabetes only 38–48% of the time (1–9). Few studies have examined whether recording of diabetes on death certificates is associated with the antemortem relationship between the decedent and the certifying physician. One study of 292 diabetic decedents with histories of ischemic heart disease found that if the certifying physician was the personal physician, diabetes was recorded 48% of the time, versus 33% for another physician and 8% for a medical examiner (2). Another study found that for 104 patients with diabetes who died in the hospital, there was no relationship between the level of training of the certifying physician and the recording of diabetes (7). Our objective was to examine whether primary care physicians (PCPs) are more likely than other physicians to record diabetes on the death certificates of decedents with known diabetes. The Translating Research Into Action for Diabetes (TRIAD) study has been described in detail elsewhere (10). This study was limited to the Michigan study site. Patients aged ≥ 18 years were sampled ( n = 1,650). The institutional review board approved the study, and all participants provided informed consent. A baseline survey was administered to TRIAD participants either by computer-assisted telephone interview or by mail, …