Worse Diabetes Control Research Articles

Correlation of Neutrophil–Lymphocyte Ratio with Glycemic Control: An Analytical Cross-sectional Study

Abstract Background: Poorly controlled diabetes is one of the most common risk factors for cardiovascular disease. Neutrophil–Lymphocyte ratio (NLR) is a potential marker to predict inflammation. Many studies have shown it to be a predictor of adverse cardiovascular events in Type 2 diabetic patients. Our study was done to examine and establish a relationship between NLR and poor glycemic control and to examine whether a correlation exists between NLR and HbA1c. Materials and Methods: An analytical cross-sectional study was conducted with 104 randomly selected Type 2 diabetic patients (39 females and 65 males). They were randomly divided into three groups based on glycemic control according to the American Diabetes Association criteria. Patients with HbA1c <7% as excellent control, HbA1c 7%–9% as poor control, and HbA1c >9% as worst control were considered. Total leukocyte count, fasting blood sugar (FBS), low-density lipoprotein (LDL), and NLR were assessed. Results: Our study showed that the mean neutrophil count was significantly higher and the mean lymphocyte count was significantly lower in patients with the worst diabetic control. NLR was also significantly higher in patients with worse diabetic control. However, our study did not find any statistically significant correlation between total leukocyte count and glycemic control. Mean LDL and mean FBS were also significantly higher in patients with the worst diabetic control. Conclusions: Increased NLR was associated with high HbA1c and poor glycemic control. Thus, NLR can be used as a tool in follow-up of Type 2 diabetic patients and as a predictor of poor glycemic control and adverse cardiovascular events.

THU329 Healthcare Disparities In Diabetes Management During The COVID-19 Pandemic

Abstract Disclosure: E.D. Frontera: None. M.K. Cavaghan: None. Z.I. Saeed: None. Aim: Healthcare disparities in diabetes and COVID-19 have been described, but the impact of COVID-19 on diabetes management based on sex, age, race and socioeconomic status is less known. This study examines impact on diabetes care during the two years of the pandemic in an academic endocrinology practice while assessing for disparities. Methods: A retrospective cohort study was conducted in adult patients with diabetes being managed during the pandemic by our endocrinology group. Gender, age, race, and social deprivation index (SDI) were compared between three time periods ( T1= March 2019- Feb 2020; T2= March 2020 to Feb 2021; T3= March 2021 to Feb 2022) to test for differences in clinical outcomes and frequency of care checks using chi-square test and generalized linear mixed models. Results: Our cohort included of 4909 patients, 46.2% were females, 73.2% were white, and 32% were older than 65 years. The median (IQR) SDI was 45 (17-79), and nearly half (48.1%) of the patients were on Medicare or Medicaid. Our results showed that during the first year of pandemic (T2), the frequencies of Hemoglobin A1c (A1c) checks and BMI measurements fell by 36% and 47%, respectively (p <0.001). These rates recovered mostly in T3; A1c checks remained 8% lower (p<0.001), and BMI 13% lower (p = 0.01) than pre-pandemic levels. Similarly, there was a 14.3% reduction in LDL checks during T2 which did recover in our study period (p = 0.001). Urine microalbumin (ACR) rates did not drop during the study period. Other than the frequency of BMI checks, there was no difference in the frequency of care checks between different sex, race, age, or SDI groups. Women had less BMI checks and in person visits in T2 . The overall cohort averages through the pandemic of Systolic Blood Pressure (SBP) , ACR and BMI remained stable while A1C and LDL decreased during the study period. Blacks had persistently higher average A1C, SBP, BMI, and LDL values through all three study times. While these disparities persisted throughout the pandemic, they did not worsen. The average number of clinic visits per person during the study period did not drop during T2 and increased by 7.6% in T3 compared to T1 which was driven by a dramatic increase in virtual appointment (from none to 1.71 per person in T2) (p<0.001). There was no subgroup variation in clinic visits and types. Conclusion: Our study examined the impact of COVID-19 on ambulatory visits, and health maintenance in patients with diabetes seen at a large endocrinology practice. Compared to pre-pandemic, we showed that overall, the frequency of most diabetes-related healthcare checks decreased and continued to be lower than expected two years into the pandemic. However, these changes did not translate into worse diabetes control and management in our cohort. Moreover, our data highlighted important disparities in health outcomes already present in our patient population prior to the pandemic. Presentation: Thursday, June 15, 2023

SAT089 Natural History Of Generalized Lipodystrophy Following Early Vs. Late Metreleptin Treatment

Abstract Disclosure: M. Brush: None. M. Lightbourne: None. S. Auh: None. R.J. Brown: None. Generalized lipodystrophy (GLD) is characterized by near total loss of subcutaneous fat resulting in low leptin concentrations. Patients with GLD exhibit metabolic abnormalities such as severe insulin resistance, diabetes mellitus, hypertriglyceridemia, proteinuria, and non-alcoholic fatty liver disease (NAFLD), that are progressive over time. Leptin replacement therapy using metreleptin is effective in improving these metabolic abnormalities. It is unknown if starting metreleptin therapy early versus late in the clinical course will change the natural history of this disease. We hypothesize that starting metreleptin early versus late will lead to better long-term control of diabetes, hypertriglyceridemia, and proteinuric nephropathy. This is a single-center retrospective analysis of subjects with congenital and acquired generalized lipodystrophy (n=67). Fasting serum insulin, glucose, lipids, HbA1c (A1c), and 24 hr urine protein excretion, and insulin and c-peptide areas under the cover (AUC) from oral glucose tolerance tests were assessed at baseline, after 6 months of metreleptin, and at 12 month intervals thereafter. For each outcome parameter, subjects were divided into early and late treatment groups. For A1c, early treatment was defined as <7%. For all other parameters, early treatment was defined as being < the upper limit of normal for that parameter. The effect of early vs late treatment for each parameter was analyzed using linear mixed models adjusted for age and genetics, and excluding baseline metabolic parameters. Follow-up diabetes control was better with early metreleptin treatment as assessed by both glucose and A1c. Fasting glucose was 47 mg/dl lower during follow-up with early (<100 mg/dL) vs. late (≥ 100 mg/dL) treatment (p=0.0038) and A1c was 1.37% lower with early (<7%) vs late (≥7%) treatment (p=0.0015). At baseline, the early group defined by A1c had higher insulin secretion based on 48.3% higher c-peptide AUC (p=0.0185) and 161% higher insulin AUC (p=0.0029). At follow-up, the early group maintained a 37.8% higher c-peptide (p<0.0001) and 80.4% higher insulin AUC (p<0.0001). Urine protein excretion was 366 mg/24hr lower during follow-up in the early group (<300 mg/24hr) compared to the late group (≥300 mg/24hr) (P=0.0031). Triglycerides were 96 mg/dL lower during follow-up between the early (<150 mg/dL) vs late (≥150) groups (p=0.0116). In conclusion, patients with generalized lipodystrophy treated with metreleptin prior to the onset of clinically significant metabolic disease showed better age-adjusted metabolic control over time for diabetes, hypertriglyceridemia, and proteinuria. Lower insulin and C-peptide secretion in the late treatment group suggest that worse diabetes control after metreleptin in this group may be attributable to irreversible loss of beta cell function prior to metreleptin. Presentation: Saturday, June 17, 2023

Impact of limited English proficiency on the control of diabetes and associated cardiovascular risk factors. The National Health and Nutrition Examination Survey, 2003–2018

Language barriers pose a challenge to managing health conditions for various personal, interpersonal, and structural reasons. This study estimates the impact of limited English proficiency (LEP) on diabetes mellitus control and associated cardiovascular risk factors in a large representative sample of United States adults. Cross-sectional data from the National Health and Nutrition Examination Survey (NHANES, 2003–18) was used to estimate the impact of language proficiency on glycemic control (glycated hemoglobin [HbA1c]) and cardiovascular risk status (blood pressure [BP] and low-density lipoprotein [LDL]) in adult participants with known diabetes disease. The analysis included descriptive statistics and generalized linear models to adjust for sociodemographic characteristics. The study sample included 5017 participants with self-reported, physician-diagnosed diabetes mellitus. Most participants completed NHANES interview in English (90.8%), whereas some participants completed the interview in Spanish (LEP-Spanish; 6.6%) or requested an interpreter (LEP-interpreter; 2.6%). Compared to English-speaking participants, LEP-interpreter participants were more likely to have HbA1c ≥ 7% (OR = 1.6, 95% CI = 1.1, 2.4) or a combination of HbA1c ≥ 7%, LDL ≥ 2.6 mmol/L, and BP ≥ 130/80 mmHg (OR = 3.1; 95% CI = 1.2, 8.2). We observed no differences in the odds of diabetes control.between English-speaking and LEP-Spanish participants, whereas LEP-interpreter participants had worse diabetes control, possibly owing to the greater likelihood of patient-provider language discordance for non-English non-Spanish-speaking patients. Given that many patients, yet few providers, speak languages other than English or Spanish, innovative ways are needed to facilitate patient-provider communications (e.g., digital communication assistance tools).

Type 1 diabetes and anxiety in adolescence. A case report

Introduction Type 1 diabetes (T1D) incidence is increasing around the world, being the third chronic medical condition in childhood. It is characterized by pancreatic β-cell loss which leads to insulin deficiency. Treatment includes insulin medication and lifestyle changes. Youngsters with T1D are at a high risk of psychological comorbidity (depression, anxiety, eating disorders), and especially anxiety symptoms have been correlated with worse diabetes control.ObjectivesOur purpose is to examine the impact of T1D in adolescence regarding a case report and literature review.MethodsWe present the case of a 14-year-old female with T1D onset and no psychiatric history. She is referred to our service three months after the T1D onset. Both her parents and the patient were anxious about the diagnostic implications and the treatment. The patient sometimes refused to follow insulin treatment and was angry and labile. Both family and individual assessment interviews were accomplished.ResultsRegarding our assessment and after coordination with endocrine service (doctor and nurse) we diagnosed an [F43.23] Adjustment Disorder (acute, with mixed anxiety and depressed mood). Following recent evidence Acceptance and Commitment Therapy and Family Therapy were the election treatment with good outcomes. The patient was released after 3 months of follow-up.Conclusions T1D treatment entails lifestyle changes and self-control, which may be stressful and challenging for adolescents and their families, causing mental health problems. Since learning self-care and emotional coping strategies can improve both psychological well-being and glucose management, an interdisciplinary approach including psychological care, especially on the onset, can be crucial.DisclosureNo significant relationships.

Quality of care in patients with type 1 diabetes during the COVID-19 pandemic: a cohort study from Southern Brazil

BackgroundOptimal glycemic control is the main goal for patients with diabetes. The results of type 1 diabetes patients’ neglected demands during the pandemic can determine a long-term negative clinical, social, and economic impact, and result in worse diabetes control and a higher incidence of chronic complications. Therefore, this study aims to evaluate the impact of the COVID-19 outbreak in the quality of care of patients with type 1 diabetes in Southern Brazil.MethodsCohort study based on electronic medical records of patients with type 1 diabetes, with scheduled appointments between January 1st 2020, and November 6th 2020, at a university public hospital. The quality indicators used were: assessment of albuminuria and/or serum creatinine, lipid profile, thyroid-stimulating hormone, glycated hemoglobin, retinopathy, and neuropathy. McNemar test was used to analyze categorical variables and the Wilcoxon test for continuous variables.ResultsOut of 289 patients, 49.5% were women aged 40 ± 12 years old. During the pandemic, 252 patients had at least one face-to-face appointment canceled. The quality of care indicators showed a significant worsening during the COVID-19 pandemic compared to the previous year (p < 0.001). In 2019, 23.2% of the participants had all the indicators evaluated, while in 2020, during the pandemic, only 3.5% had all of them evaluated.ConclusionThe COVID-19 pandemic hindered the offer of comprehensive and quality care to patients with type 1 diabetes.

Using Structural Equation Modelling in Routine Clinical Data on Diabetes and Depression: Observational Cohort Study.

Large data sets comprising routine clinical data are becoming increasingly available for use in health research. These data sets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of "research-friendly" clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. SEM was applied to a large data set of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilization, and increased health care costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical data sets. Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and Accident & Emergency (A&E) use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. The results provided partial support for the application of SEM to routine clinical data. Overall, 19% (3106/16,353) of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β=.034, P<.001) and increased A&E use (β=.071, P<.001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β=-.055, P<.001) and receipt of mental health treatment did not impact upon diabetic control (P=.39). Receipt of diabetes care was associated with better diabetic control (β=-.072, P<.001), having depression (β=.018, P=.007), and receiving mental health treatment (β=.046, P<.001), which might suggest that comprehensive integrated care packages are being delivered in East London. Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this data set.

Does the SDMQ-9 Predict Changes in HbA1c Levels? An Ecuadorian Cohort.

Background and Objectives: Diabetes mellitus affects 422 million people around the world, positioning it as a major health problem. According to the WHO(World Health Organization), 90% corresponds to type 2. The shared-decision making (SDM) is a method used to facilitate patient control, medication, maintenance, and assessment of health status according to their priorities and preferences. With the application of SDM in patients with diabetes, it is expected there will be an increase in treatment adherence and a reduction in HbA1c levels. The aim of this study is to determine the predictors of the change in HbA1c. Material and Methods: A sample of 76 participants attending as endocrinology outpatients was obtained. Data collected within the sample included: sex, age, educational level, body mass index, and the level of SDM using the SDMQ-9. In addition, HbA1c levels were measured twice: at baseline and three months after the first measurement. Results: The linear regression indicates that the level of SDM is a significant predictor of the change in HbA1c, specifically in men. However, the direction of the relationship was a somewhat opposite trend than we expected. Higher levels of SDM imply an increase in HbA1c rather than a reduction. Conclusions: Contrary to the literature, our results shows that elevated levels of perceived SDM may be associated with worse diabetic control. However, more investigation is needed as these results are not generalizable, due to the specific population used and the sample size. Furthermore, to better understand the effect of SDM on the change in HbA1c in patients with poorly controlled diabetes.

Association of a housing based individual socioeconomic status measure with diabetic control in primary care practices

AimsSocioeconomic status (SES) is an important variable that impacts healthcare outcomes. However, grouped SES data is not always representative of all members and it is difficult to obtain individual level data. A validated individual housing-based measure termed HOUSES is available, but has not been studied in diabetes. We hypothesize that patients in the lowest HOUSES quartile are associated with worse diabetic control as measured by the D5. MethodsA retrospective cohort study of 5463 patients with diabetes in 5 patient centered medical home practices in southeast Minnesota was conducted. HOUSES is a validated, standardized housing-based SES measure constructed from publicly available county assessor’s office data. Diabetic control was assessed by the D5 (HgbA1c < 8, BP < 140/90, statin use, nonsmoking status, and antiplatelet therapy). ResultsIn the lowest HOUSES quartile, more patients had an uncontrolled D5 (56.4%) than any of the other quartiles (49.2%, 49.8%, 49.6% respectively, p < 0.001). A multivariate analysis shows the adjusted odds of D5 control for patients in the 2nd, 3rd or 4th HOUSES quartiles as opposed to the 1st quartile are 1.28, 1.21, and 1.20, respectively. ConclusionLower SES as represented by the first quartile of HOUSES index, is associated with lower odds of D5 control and thus worse diabetic outcomes. Using the HOUSES index to identify these individuals in a patient centered medical home might prove useful in deciding where to focus diabetic control efforts.

Abstract 10401: Uptake and Predictors of SGLT2i in Patients with Type 2 Diabetes and Cardiovascular Disease

Introduction: While sodium glucose cotransporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in type 2 diabetes (T2D) and cardiovascular disease (CVD), their uptake in clinical practice in this population is unclear. Therefore, we evaluated trends in SGLT2i use and identified predictors of use in patients with concomitant T2D and CVD. Methods: We conducted an observational study using population-based health data in Ontario, Canada from 4/2016-3/2020 of patients ≥65 years old with a first diagnosis of T2D plus CVD. In each yearly cohort, we estimated the prevalent use of SGLT2i (≥1 prescription) within 1 year, including by demographic and comorbidity subgroups. In the overall cohort, we used multivariable logistic regression models to identify factors associated with SGLT2i use. Results: We identified 208,303 patients with T2D and CVD [median age 74.0 years (IQR 68.0-80.0); 63.5% male]. The proportion of patients dispensed an SGLT2i increased over time, from 7.0% in 2016 to 20.1% in 2019. In 2019, use in those ≥75 years was 50% lower than those &lt;75 years (12.9% vs. 28.3%;p&lt;.0001), and use in those without chronic kidney disease (CKD) was 50% higher than those with CKD (22.0% vs. 15.0%;p&lt;.0001); although SGLT2i use increased in all groups over time. Independent factors associated with increased odds of SGLT2i use were HbA1c ≥8 vs. &lt;7 (OR 3.33, 95%CI:3.22-3.46), use of 2+ non-insulin antihyperglycemic agents (OR 2.63, 95%CI:2.56-2.71), and an endocrinologist visit in prior year (OR 1.50, 95%CI:1.45-1.55). Those &gt;75 years (OR 0.39, 95%CI:0.38-0.40), with high frailty score (OR 0.38, 95%CI:0.35-0.42), or serum creatinine 1.4-2mg/dL vs. &lt;1.4 (OR 0.55, 95%CI:0.52-0.57) were less likely to use SGLT2i. Conclusions: In a real-world population of T2D and CVD, only 1 in 5 patients used an SGLT2i, although use increased over time. Markers of worse diabetes control were associated with increased SGLT2i use, while markers of more comorbidity were associated with less use.

Insulin Basal Dose Is Associated With Better Metabolic Control in Type 1 Diabetes Children and Adolescents

Basal insulin dose in type 1 diabetes has been established empirically, since 2011 all guidelines suggest insulin basal dose less than 50% of total insulin dose in the pediatric population. However, in real life, basal dose indication has not changed in all patients in the basal-bolus treatment scheme. Objective: To measure how the physician indicates in real-life basal insulin dose in pediatric patients with type 1 diabetes in the basal-bolus scheme, and correlate this dose with metabolic control measured by glycated hemoglobin. Methods. This was a retrospective study, subjects include pediatric T1D (2 to 16 years, non-obese, using insulin more than 0.3 UI/Kg/d), more than 1 year of diagnostic, none of them in ketoacidosis, attended during 2019. The protocol was revised and accepted in the institution. Data were analyzed with Kruskal-Wallis, U Mann Withney, Pearson correlation test. Results: There were 141 subjects, male (51%), median age 13.3 years (3.6-15.9), median evolution time since diagnosis 8 years (1-14), pre-pubertal (Tanner stage 1, 22%), total daily dose 1.02 UI/Kg/d (0.3-2.19 UI/Kg/d). Basal insulin was glargine 50.4%, and NPH 49.6%, prandial insulin was lispro 66.7%, and regular human 29.8%. Children using 50% or less basal insulin of total insulin dose was 40.4%. The basal dose was 38% of total insulin dose in children less than 6 years, and 59% in children older than 6 years. (p=0.033). Glycated hemoglobin was less than 7.5% in 12.8%. The persons with glycated hemoglobin less than 7.5% used less basal insulin 0.38 u/kg/d, than those with higher glycated hemoglobin 0.57 U/kg/d (p=0.02) with no impact in total insulin dose (0.86 vs 1.05 UI/Kg/d, p=0.129). The correlation of the percentage of insulin basal dose and glycated hemoglobin was 0.279, p=0.001, meaning, more basal insulin, worse diabetes control. Conclusion: Lower basal insulin dose percentage from total daily dose is associated with better metabolic control in children treated with the basal-bolus scheme. There is high clinical inertia in the indication of basal insulin in older children.

Attachment representations to parents and emotional-behavioral problems: A comparison between children with type 1 diabetes mellitus and healthy children in middle childhood.

Type 1 diabetes mellitus (T1D) is one of the most demanding chronic diseases for children and their families, since controlling diabetes involves a process of co-regulation with attachment figures. However, there is insufficient evidence in middle childhood on psychological mechanisms involved that might complicate the adaptation of these children. Therefore, 106 children (N = 31 with T1D and N = 75 as matched healthy group [HG]) aged 8 to 13 were assessed using the Child Attachment Interview, the Child Behavior Checklist, and the measure of glycated hemoglobin. Results showed that insecure T1D children did not have worse diabetes control than the secure ones. However, T1D children differed from HG for higher levels of idealization to father and withdrawn/depressed problems. Moreover, T1D children with insecure attachment to mother scored significantly higher in anxious/depressed, withdrawn/depressed, attention problems, and rule-breaking behavior, while T1D children with insecure attachment to father scored significantly higher only in the withdrawn/depressed scale compared to the remaining children. Therefore, diabetes does not in itself determine a psychological vulnerability in middle childhood, but the presence of an insecure attachment, especially to the mother, worsens the psychological adaptation of T1D children. Psychological support should be provided for these young patients and their families.

Risk factors for elevated serum colorectal cancer markers in patients with type 2 diabetes mellitus.

The study aims to examine the risk factors for increased colorectal cancer (CRC) markers in patients with type 2 diabetes mellitus (T2DM). The 229 patients retrospectively reviewed were categorized into two groups: CRC tumor marker-positive and -negative groups. Patients who tested positive for all three of the following CRC markers were included in the CRC tumor marker-positive group: serum carcinoembryonic antigen, carbohydrate antigen 19-9 and septin9 methylation. Univariate analysis revealed that most CRC marker-positive patients had higher age, a family history of CRC, history of smoking and alcohol intake, high body mass index (BMI; overweight), longer history of T2DM, worse diabetes control (with high glycated hemoglobin A1c [HbA1c]), lower level of serum vitamin D (VD), high-density lipoprotein cholesterol and higher level of total cholesterol and triglyceride (TG). Logistic regression analysis showed that BMI, VD, HbA1c and TG were independent predictors of CRC marker-positive status (OR, 95% confidence intervals and P values were 1.912 [1.346–2.716], <0.001; 0.773 [0.633–0.943], 0.011; 9.082 [3.52–23.433], <0.001; and 11.597 [3.267–41.164], <0.001, respectively). In this retrospective study, high BMI, HbA1c and TG as well as low level of VD were correlated with CRC tumor marker-positive status in T2DM patients. Patients with these risk factors may benefit from more frequent screening for CRC tumor markers.

The Effect of Select Systemic Medications on Visual Outcomes in Diabetics With Branch Retinal Vein Occlusion

Purpose: The purpose of this article is to evaluate the effect of systemic medications and glycemic control on the visual outcome and treatment burden in patients with diabetes and branch retinal vein occlusion (BRVO). Methods: A retrospective review was performed for patients with diabetes diagnosed with a BRVO at an academic eye center from 2009 to 2017. The use of select antihypertensives, antiplatelet agents, anticoagulants, and hypoglycemics was reviewed. Data on visual acuity (VA), central subfield thickness (CST), treatment course, and hemoglobin (Hb)A1c were obtained throughout follow-up. Results: A total of 121 eyes met criteria with a median follow-up duration of 19.4 months. The mean baseline logarithm of the minimum angle of resolution (logMAR) VA was 0.56 (Snellen equivalent, 20/72) and mean final logMAR VA was 0.5 (20/63). At final follow-up, aspirin 325 mg was associated with 4.8 fewer injections (n = 13, P = .04), insulin was associated with 3.6 more injections (n = 26, P = .04), warfarin was associated with a 79 µm increase in CST ( P = .02), and a 1% increase in HbA1c was associated with 0.86 more injections ( P &lt; .01). Conclusions: The VA outcome of BRVO in diabetics may be worse than that of BRVO in nondiabetics. Worse diabetic control was associated with a higher treatment burden. High-dose aspirin was associated with fewer injections.

1282-P: Patient-Related Factors Affecting Utilization of Diabetes Care

Factors affecting utilization of diabetes care are not well-studied. This information may help develop strategies to improve the efficiency of healthcare systems. We conducted a study to determine factors associated with repeatedly missing an appointment at a major diabetes care center. Data were obtained from electronic medical records. All patients with two or more appointments during the year 2017 were included in analysis. Patients who missed ≥50% of their clinic visits without cancelling an appointment were defined as the repeatedly missed appointment (RMA) group and those who missed &amp;lt;50% appointments were defined as the regularly attended appointment (RAA) group. All patients had equal opportunity to keep or cancel an appointment irrespective of their insurance coverage. Out of 1,417 patients, 147 (10.4%) had missed ≥50% of their scheduled clinic visits. Mean number of appointments was similar in the RMA group (3.0 ± 1.3) and in the RAA group (2.8 ± 1.2; P = 0.29). A comparison of characteristics between the two groups is shown in Table 1. Multivariate regression analysis showed that younger age, higher BMI, higher HbA1c and lower serum albumin were independent predictors of the percentage of missed appointments. We conclude that patients who repeatedly miss their diabetes appointments have poor overall health and worse diabetes control. Strategies need to be developed to improve utilization of diabetes care by these patients. Disclosure R. Garg: None. W.H. Cade: None. E. Bernal-Mizrachi: None.

Urinary Neutrophil Gelatinase-Associated Lipocalin Is Complementary to Albuminuria in Diagnosis of Early-Stage Diabetic Kidney Disease in Type 2 Diabetes.

Background Two clinical phenotypes of diabetic kidney disease (DKD) have been reported, that is, with or without increased albuminuria. The aim of study was to assess the usefulness of urinary neutrophil gelatinase-associated lipocalin (uNGAL) for the early diagnosis of DKD in the type 2 diabetes mellitus (T2DM). Methods The study group consisted of 123 patients with T2DM (mean age 62 ± 14 years), with urine albumin/creatinine ratio (uACR) < 300 mg/g and eGFR ≥ 60 ml/min/1.73 m2. The control group included 22 nondiabetic patients with comparable age, sex, and comorbidities. uNGAL, albumin, and creatinine were measured in the first morning urine samples. uACR and uNGAL/creatinine ratios (uNCR) were calculated. Results In the control group, maximum uNCR was 39.64 µg/g. In T2DM group, 24 patients (20%) had higher results, with the maximum value of 378.6 µg/g. Among patients with uNCR > 39.64 µg/g, 13 (54%) did not have markedly increased albuminuria. Women with T2DM had higher uNCR than men (p < 0.001), without difference in uACR (p = 0.09). uNCR in T2DM patients correlated significantly with HbA1c. Sex, total cholesterol, and uACR were independent predictors of uNCR above 39.64 µg/g. Conclusions Increased uNGAL and uNCR may indicate early tubular damage, associated with dyslipidemia and worse diabetes control, especially in females with T2DM.

Impact of the Balanced School Day on Glycemic Control in Children with Type 1 Diabetes.

The balanced school day (BSD) is an alternative elementary school schedule whereby children have 2 20-minute eating periods instead of 1 20-minute lunch, as is found in the traditional schedule (TS). We assessed the glycated hemoglobin (A1C) levels of children with type 1 diabetes in the TS vs. the BSD because 2 eating periods have the potential to impact blood glucose control. A1C levels representative of the summer months (SumA1C) and A1C levels occurring at least 3 months after the start of the school year (SchA1C) were obtained retrospectively. A parental survey of perceptions of lunch planning, activity levels and diabetes management at school was also completed. Our sample included 97 students (TS=42, BSD=55). The mean age ± SD was 10.9±2.6 and 10.1±2.8 years in the TS and BSD, respectively (p=0.12). Sex distribution was not statistically different; 54% were female in TS vs. 36% in BSD; p=0.08. SumA1C was similar in the 2 groups (TS: 8.3±1.1% vs. BSD: 8.0±0.8%; p=0.08). There was a significant within-group increase from SumA1C to SchA1C in the BSD group only (p=0.001), with mean A1C values increasing from 8.0%±0.8% to 8.5%±1.0% in the BSD group compared to no significant increase in the TS group. Parental perceptions of lunch planning, physical activity and diabetes management were similar, regardless of school schedule. Children with type 1 diabetes in the BSD appear to have worse diabetes control during the school year compared to the summer, which is not evident in children in the TS. Additional school supports may assist students in the BSD.

Psychosocial Features of Clinically Relevant Patient Subgroups With Serious Mental Illness and Comorbid Diabetes.

Care for people with serious mental illness and diabetes is complicated by clinical heterogeneity. This cross-sectional analysis of 200 individuals with comorbid serious mental illness and diabetes explored differentiation between patient subgroups that were characterized on the basis of selected dimensions within a biopsychosocial framework. Relationships between self-efficacy, treatment expectation, social support, and depression were first assessed via bivariate Spearman correlations among 200 individuals participating in a randomized controlled trial who had diabetes along with major depression, bipolar disorder, or schizophrenia. Next, latent profile analyses were conducted to determine underlying subgroups on the basis of these variables. The resultant groups were compared on diabetes control, function, and symptoms. Two subgroups emerged. One had more severe psychiatric symptoms, low scores on other psychosocial variables, and worse diabetes control. The other had low levels of psychiatric symptoms, better scores on other variables, and better diabetes control. Symptom presentation and internal and external resources appeared to be related to diabetes control for people with comorbid diabetes and serious mental illness. Care approaches need to go beyond standard education and consider biopsychosocial variables.

355 - Influence of Diabetes and Glycemic Control on Mortality in Left Ventricular Assist Device Patients

Introduction: Prior studies have shown that patients with diabetes have worse surgical outcomes compared with individuals without diabetes. Despite previous studies, the risk of mortality of diabetic patients post left ventricular assist device (LVAD) implant, remains unclear. In addition, the relationship between the degree of glycemic control and long-term mortality risk in LVAD patients with diabetes has not been established. Hypothesis: We hypothesized that LVAD patients without diabetes would have lower mortality than LVAD patients with diabetes, and amongst LVAD diabetic patients, mortality would increase with worse diabetes control (higher hemoglobin A1c). Methods: 95 non-diabetic and 96 diabetic patients from the University of Rochester Medical Center, Rochester, NY who received a HeartMate II continuous-flow LVAD between 8/26/2007 and 6/30/2014 were included in this study. Diabetics were defined as having a diagnosis of diabetes in medical records, or hemoglobin A1c greater than or equal to 6.5%, or random glucose greater than 200 mg/dL on more than one occasion prior to LVAD implantation. The primary outcome was all-cause mortality. Kaplan-Meier cumulative probabilities of long-term all-cause mortality were assessed by diabetes, and by the degree of glycemic control. Results: During follow-up, 32 (33%) individuals with diabetes and 15 (16%) individuals without diabetes died following LVAD implantation (P = .005). Cumulative probability of death was higher in diabetics when compared to non-diabetics (42% vs. 21% at 3 years, P = .008, Fig. 1). There was no statistically significant difference in cumulative probability of death between diabetics with pre-LVAD hemoglobin A1c < 7.5% and diabetics with pre-LVAD hemoglobin A1c ≥7.5% (P = .198, Fig. 2). Conclusions: Diabetics who undergo LVAD implantation have a higher probability of death compared with non-diabetic patients. However, the degree of glycemic control in patients with diabetes did not influence mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Association of Acculturation and Health Literacy with Prevalent Dysglycemia and Diabetes Control Among Latinos in the Boston Area Community Health (BACH) Survey.

This study assessed the effect of acculturation on type 2 diabetes and whether health literacy may mediate this association. The Boston Area Community Health cohort is a multi-stage stratified random sample of adults from Boston including 744 Latinos. We defined dysglycemia as a HbA1c ≥5.7%. Multivariable analyses examined the associations between acculturation and health literacy adjusting for demographic and clinical variables. Similar analyses were performed among participants with HbA1c ≥7.0% to assess the association between acculturation and diabetes control. Among an insured primarily foreign born Spanish speaking Latino population, with a long residence period in the US and good healthcare utilization, higher levels of acculturation were not associated with dysglycemia. Lower levels of acculturation were associated with worse diabetes control. Health literacy level did not modify these associations. Elucidating the components of heterogeneity among Latinos will be essential for understanding the influence of acculturation on diabetes.