To assess the impact of obesity, glucose tolerance, and weight loss on renal function, we measured serum creatinine and cystatin C and estimated glomerular filtration rate (GFR) indexed to 1.73m2 ...body surface area (BSA) and GFR indexed to actual BSA in subjects with normal and abnormal glucose tolerance before and up to 2 years after medical weight loss.
We studied 146 subjects at baseline and 3-to-6 months after 18% reduction in weight; 43 were also studied at 2-years. GFR was estimated using the MDRD, CKD-EPICr, CKD-EPICysCr, and the CKD-EPICys equations.
eGFR was consistently lower when creatinine-based rather than cystatin C-based estimating equations were used. eGFR was lower when creatinine-based or cystatin C-based equations were indexed to 1.73m2 BSA than when they were indexed to actual BSA. eGFR indexed to actual BSA was more likely to demonstrate hyperfiltration (eGFR ≥135 ml/min) than eGFR indexed to 1.73m2 BSA and decreased into the normal range with weight loss. eGFR was highest in subjects with impaired fasting glucose but there was little difference in the patterns of change in eGFR across groups by glucose tolerance status.
With severe obesity, high fat-free mass and BSA result in low estimates of eGFR indexed to 1.73m2 BSA, especially when creatinine-based estimating equations are used. GFR indexed to actual BSA is approximately 50% higher. When eGFR is indexed to actual BSA, many subjects display evidence of renal hyperfiltration which improves with weight loss. In subjects with severe obesity undergoing medical weight loss, estimating equations that use cystatin C and are indexed to actual BSA may provide a more accurate assessment of renal function.
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Rates of diagnosis of prediabetes and uptake of the National Diabetes Prevention Program (NDPP) are low. We evaluated a proactive three-level strategy to identify individuals with prediabetes in a ...population with employer-sponsored health insurance.
We studied 64,131 insured employees, dependents, and retirees ≥18 years of age without diagnosed diabetes, 19,397 (30%) of whom were estimated to have prediabetes. Individuals with prediabetes were identified by
) searching claims diagnoses and previously performed HbA
test results,
) risk stratifying people 40-64 years of age without diabetes, prediabetes, or documented normal HbA
to identify individuals at higher risk and encourage them to be tested, and
) using a media campaign to encourage employees not otherwise targeted to self-screen and, if at higher risk, to be tested.
Using claims and laboratory data, 11% of the population was identified as having prediabetes. Of those 40-64 years of age, 25% were identified as being at higher risk, and 27% of them were tested or diagnosed within 1 year. Of employees exposed to the media campaign, 14% were tested or diagnosed within 1 year. Individuals with prediabetes were older, heavier, and more likely to have hypertension and dyslipidemia. Testing and diagnosis were associated with receiving medical care and provider outreach. A total of 8,129 individuals, or 42% of those with prediabetes, were identified.
Analysis of existing health insurance data facilitated the identification of individuals with prediabetes. Better identification of people with prediabetes is a first step in increasing uptake of the NDPP.
To assess national changes in health insurance coverage and related costs before and after implementation of the Affordable Care Act (ACA) among U.S. adults with diabetes.
Data were cross-sectional ...from the 2009 and 2016 National Health Interview Surveys (NHIS). Participants were adults age ≥18 years with a previous diagnosis of diabetes who self-reported on their health insurance coverage, demographic information, diabetes-related factors, and amount spent on medical expenses and insurance premiums (
= 6,220).
Among adults with diabetes age 18-64 years, health insurance coverage increased from 84.7% in 2009 to 90.1% in 2016 (
< 0.001). Coverage remained near universal for those age ≥65 years (99.5%). For adults age 18-64 years, coverage increased for almost all subgroups and significantly for men; non-Hispanic whites, non-Hispanic blacks, and Hispanics; those who were married; those with less than or more than a high school education, family income <$35,000, or diabetes duration <5 or >15 years; and those taking oral agents (
< 0.05 for all). Among adults age 18-64 years, Medicaid coverage significantly increased between 2009 and 2016 (19.4% vs. 24.3%,
= 0.006), and for those with private insurance, 7.8% acquired their plan through HealthCare.gov. For adults age ≥65 years, private insurance decreased and Medicare Part D increased (
< 0.007 for both). Among those age 18-64 years with an income <$35,000, the proportion of income spent on family medical costs decreased (6.3% vs. 4.8% for 2009 vs. 2016, respectively;
= 0.004).
Health insurance coverage among adults with diabetes age 18-64 years increased significantly after implementation of the ACA, and medical costs to families decreased among those with lower incomes.
The use of portfolios in postgraduate medical residency education to support competency development is increasing; however, the processes by which these assessment systems are designed, implemented, ...and maintained are emergent. The authors describe the needs assessment, development, implementation, and continuing quality improvement processes that have shaped the Portfolio Assessment Support System (PASS) used by the postgraduate family medicine program at Queen’s University since 2009. Their description includes the impetus for change and contextual realities that guided the effort, plus the processes used for selecting assessment components and developing strategic supports. The authors discuss the identification of impact measures at the individual, programmatic, and institutional levels and the ways the department uses these to monitor how PASS supports competency development, scaffolds residents’ self-regulated learning skills, and promotes professional identity formation. They describe the “academic advisor” role and provide an appendix covering the portfolio elements. Reflection elements include learning plans, clinical question logs, confidence surveys, and reflections about continuity of care and significant incidents. Learning module elements cover the required, online bioethics, global health, and consult-request modules. Assessment elements cover each resident’s research project, clinical audits, presentations, objective structured clinical exam and simulated office oral exam results, field notes, entrustable professional activities, multisource feedback, and in-training evaluation reports. Document elements are the resident’s continuing medical education activities including procedures log, attendance log, and patient demographic summaries.The authors wish to support others who are engaged in the systematic portfolio-design process or who may adapt aspects of PASS for their local programs.
OBJECTIVE
Screening involves the presumptive identification of asymptomatic individuals at increased risk for unrecognized disease. We examined changes in screening practices for prediabetes and ...diabetes since January 2010, when HbA1c was first recommended as an option for screening and diagnosis.
RESEARCH DESIGN AND METHODS
We studied members without diabetes of an HMO ≥45 years of age continuously enrolled for ≥3 years and assigned to primary care clinicians affiliated with a large academic health system. We defined screening as the first oral glucose tolerance test, HbA1c, or glucose test performed between 2010 and 2014.
RESULTS
Of 12,772 eligible patients, 9,941 (78%) were screened at least once over 3 years. HbA1c was the initial screening test 14% of the time and glucose 86% of the time. Of those screened with HbA1c, 63% had abnormal results defined as HbA1c ≥5.7% (≥39 mmol/mol). Of those tested with glucose, 30% had abnormal results defined as glucose ≥100 mg/dL, and 5% had abnormal results defined as glucose ≥126 mg/dL. Patients with abnormal HbA1c levels and those with glucose levels ≥126 mg/dL were equally likely to be scheduled for follow-up appointments (41% vs. 39%), but those with abnormal HbA1c levels were more likely to be diagnosed with prediabetes or diabetes (36% vs. 26%).
CONCLUSIONS
As we observed in 2004, rates of screening are high. HbA1c is still used less frequently than glucose for screening but is more likely to result in a clinical diagnosis. Evidence to support guidelines to define the role of random glucose screening, including definition of appropriate cut points and follow-up, is needed.
Objectives
Competency‐based medical education (CBME) requires that educators structure assessment of clinical competence using outcome frameworks. Although these frameworks may serve some outcomes ...well (e.g. represent eventual practice), translating these into workplace‐based assessment plans may undermine validity and, therefore, trustworthiness of assessment decisions due to a number of competing factors that may not always be visible or their impact knowable. Explored here is the translation process from outcome framework to formative and summative assessment plans in postgraduate medical education (PGME) in three Canadian universities.
Methods
We conducted a qualitative study involving in‐depth semi‐structured interviews with leaders of PGME programmes involved in assessment and/or CBME implementation, with a focus on their assessment‐based translational activities and evaluation strategies. Interviews were informed by Callon's theory of translation. Our analytical strategy involved directed content analysis, allowing us to be guided by Kane's validity framework, whilst still participating in open coding and analytical memo taking. We then engaged in axial coding to systematically explore themes across the dataset, various situations and our conceptual framework.
Results
Twenty‐four interviews were conducted involving 15 specialties across three universities. Our results suggest: (i) using outcomes frameworks for assessment is necessary for good assessment but are also viewed as incomplete constructs; (ii) there are a number of social and practical negotiations with competing factors that displace validity as a core influencer in assessment planning, including implementation, accreditation and technology; and (iii) validity exists as threatened, uncertain and assumed due to a number of unchecked assumptions and reliance on surrogates.
Conclusions
Translational processes in CBME involve negotiating with numerous influencing actors and institutions that, from an assessment perspective, provide challenges for assessment scientists, institutions and educators to contend with. These processes are challenging validity as a core element of assessment designs. Educators must reconcile these influences when preparing for or structuring validity arguments.
If A then B? Webster et al. explore if, when, how situational judgement tests can be used to evaluate personal attributes for medical trainee selection.
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•Sociodemographic and clinical characteristics and program characteristics were associated with an individual’s choice of National DPP.•In-person classroom-based programs had better retention and ...were associated with more weight loss and physical activity than the virtual program.•Nevertheless, when given a choice of National DPPs, enrolling in any program was associated with comparable health benefits.
To describe National Diabetes Prevention Program (NDPP) uptake, retention, and outcomes by enrollee characteristics and program type.
We studied 776 adult University of Michigan employees, dependents, and retirees with prediabetes and overweight or obesity who enrolled in one of four CDC-recognized NDPPs at no out-of-pocket cost. Programs included 1) an in-person classroom-based program led by certified diabetes educators in an endocrinology outpatient clinic; 2) an in-person classroom-based program led by trained peer instructors in community settings; 3) an in-person fitness-focused program led by trained lifestyle coaches; and 4) an online digital program led by personal health coaches with virtual group meetings. Data from the insurer and surveys were analyzed.
Older individuals with hypertension and cardiovascular disease were more likely to enroll in classroom-based programs. Program time, location, and perceived focus on diet or physical activity influenced program selection. Retention, weight loss, and physical activity were greater among enrollees in in-person classroom-based programs. Changes in blood pressure, lipid levels, self-rated health, and health-related quality-of-life did not differ by program, nor did Type 2 diabetes mellitus incidence.
Individuals with prediabetes who enrolled in a NDPP achieved health benefits regardless of the type of program they chose.
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According to the Health Belief Model, adults with prediabetes (pDM) who perceive higher personal risk for developing diabetes (DM) may be more enthusiastic about engaging in the Diabetes Prevention ...Program (DPP) than those who perceive lower personal risk. Between 2015 and 2019, the University of Michigan, a self-insured employer, offered to cover the DPP at no out-of-pocket cost for individuals with pDM among all its employees, dependents, and retirees. We surveyed 720 people with pDM who engaged in the DPP and a random sample of 2379 people with pDM who did not engage in the DPP. Perception of risk for developing DM was assessed using the item: “What do you think your risk is for getting diabetes over the next 5 years?”, and defined as a continuous variable (1-“almost no chance” to 4-“high chance”). Engagement in the DPP was defined as a dichotomous variable (yes-no). Linear regression was used to test associations between perceived risk for developing DM and engagement in the DPP. A cohort of 533 people who engaged in the DPP and 1023 people who did not engage in the DPP responded to the survey, response rates of 74% and 43%, respectively. Among the people with data on perceived DM risk (N=1547), the mean age was 55±11 years, 62% were women, 73% were non-Hispanic white, 64% had a level of education of 4-year college graduate or more, 60% had a family income ≥$75,000/year, the mean BMI was 31±7 kg/m2, 48% were aware of their pDM, 51% had a family history of DM, and 9% of the women had a history of gestational diabetes (GDM). In bivariate analyses, perceived personal DM risk differed by age, sex, education, BMI, awareness of pDM, family history of DM, and history of GDM (women only) (all at P<0.05). People who engaged in the DPP had a higher mean risk perception 2.52±0.04 vs. 2.40±0.03 (P=0.0044) than those who did not engage in the DPP. These findings suggest that for adults with pDM, perceived personal risk for developing DM may motivate engagement in risk-reducing programs such as the DPP.
Disclosure
K. Joiner: None. L.N. McEwen: None. W.H. Herman: Consultant; Spouse/Partner; Nestlé. Other Relationship; Self; Merck Sharp & Dohme Corp.
Funding
National Institutes of Health (R01DK109995)
To evaluate retention and outcomes of insured adults with prediabetes who enrolled or did not enroll in National Diabetes Prevention Programs (NDPPs).
Between 2015 and 2019, 776 University of ...Michigan employees, dependents, and retirees with prediabetes and overweight or obesity enrolled in one-year NDPPs.
Enrollees attended a median of 18 sessions. Median retention was 38 weeks. Retention was associated with older age, greater initial weight loss, and physical activity. At both 1- and 2-years, body mass index, triglycerides, and HbA1c were significantly improved among enrollees. After adjusting for age group, sex, and race, the odds of developing diabetes based on HbA1c ≥6.5 % was 40 % lower at 1-year and 20 % lower at 2-years, and the odds of self-reported diabetes was 57 % lower at 1-year and 46 % lower at 2-years in enrollees compared to non-enrollees. Enrollees who disenrolled before completing the core curriculum had higher odds and enrollees who completed the NDPP had lower odds of developing diabetes that non-enrollees.
In this population with prediabetes, NDPP retention was generally good, risk factors were improved, and diabetes was delayed or prevented for up to two years.
•Retention in the National DPP was associated with older age, greater initial weight loss, and more physical activity.•Risk factors were improved for two years after National DPP enrollment.•National DPP enrollment delayed or prevented diabetes for up to two years.
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To use the framework of the Health Belief Model (HBM) to explore factors associated with metformin use among adults with prediabetes.
We analyzed survey data from 200 metformin users and 1,277 ...nonmetformin users with prediabetes identified from a large, insured workforce. All subjects were offered the National Diabetes Prevention Program (DPP) at no out-of-pocket cost. We constructed bivariate and multivariate models to investigate how perceived threat, perceived benefits, self-efficacy, and cues to action impacted metformin use and how demographic, clinical, sociopsychological, and structural variables impacted the associations.
Adults with prediabetes who used metformin were younger and more likely to be women and to have worse self-rated health and higher BMIs than those with prediabetes who did not use metformin. Those who used metformin were also more likely to be aware of their prediabetes and to have a personal history of gestational diabetes mellitus or a family history of diabetes. After consideration of perceived threat, perceived benefits, self-efficacy, and cues to action, the only independent predictors of metformin use were younger age, female sex, higher BMI, and cues to action, most specifically, a doctor offering metformin therapy.
Demographic and clinical factors and cues to action impact the likelihood of metformin use for diabetes prevention. Perceived threat, perceived benefits, and self-efficacy were not independently associated with metformin use. These results highlight the importance of patient-centered primary care and shared decision-making in diabetes prevention. Clinicians should proactively offer metformin to patients with prediabetes to facilitate effective diabetes prevention.
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