Race, Ethnicity, Socioeconomic Position, and Quality of Care for Adults With Diabetes Enrolled in Managed Care
The Translating Research Into Action for Diabetes (TRIAD) study
Arleen F. Brown , MD, ...PHD 1 ,
Edward W. Gregg , PHD 2 ,
Mark R. Stevens , MSPH, MA 2 ,
Andrew J. Karter , PHD 3 ,
Morris Weinberger , PHD 4 5 ,
Monika M. Safford , MD 6 ,
Tiffany L. Gary , PHD 7 ,
Dorothy A. Caputo , APRN, BC-ADM 8 ,
Beth Waitzfelder , PHD 9 ,
Catherine Kim , MD, MPH 10 and
Gloria L. Beckles , MD, MSC 2
1 Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine
at UCLA, Los Angeles, California
2 Centers for Disease Control and Prevention, Atlanta, Georgia
3 Division of Research, Kaiser Permanente, Oakland, California
4 Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
5 Center for Health Services Research in Primary Care, Durham VAMC, Durham, North Carolina
6 Deep South Center on Effectiveness at Birmingham VA Medical Center and Department of Preventive Medicine University of Alabama
at Birmingham, Birmingham, Alabama
7 Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
8 University of Medicine and Dentistry of New Jersey Continuing and Outreach Education, New Brunswick, New Jersey
9 Pacific Health Research Institute, Honolulu, Hawaii
10 Departments of Medicine and Obstetrics-Gynecology, University of Michigan, Ann Arbor, Michigan
Address correspondence and reprint requests to Arleen F. Brown, MD, PhD, Division of General Internal Medicine and Health
Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1736. E-mail: abrown{at}mednet.ucla.edu
Abstract
OBJECTIVE —To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings.
RESEARCH DESIGN AND METHODS —We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study,
a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed
processes of care (HbA 1c A1C, lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza
vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control).
RESULTS —Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP).
Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception
of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza
vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main
SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances,
racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or
more appropriate intensification of therapy relative to whites or those with higher SEP.
CONCLUSIONS —In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes,
and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities
in health may be reduced in managed-care settings.
CHD, coronary heart disease
DBP, diastolic blood pressure
MCS-12, Mental Component Summary
PCS-12, Physical Component Summary
SBP, systolic blood pressure
SEP, socioeconomic position
TRIAD, Translating Research Into Action for Diabetes
Footnotes
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
Accepted September 1, 2005.
Received May 19, 2005.
DIABETES CARE
Frontotemporal Degeneration (FTD) encompasses a spectrum of related neurodegenerative disorders with behavioral, language and motor phenotypes for which there are currently no effective therapies. ...This manuscript is the second of two articles that summarize the presentations and discussions that occurred at two symposia in 2011 sponsored by the Frontotemporal Dementia Treatment Study Group (FTSG), a collaborative group of academic and industry researchers that is devoted to developing treatments for FTD. This manuscript discusses the current status of FTD clinical research that is relevant to the conduct of clinical trials and why FTD research may be an attractive pathway for developing therapies for neurodegenerative disorders. The clinical and molecular features of FTD, including rapid disease progression and relatively pure molecular pathology, suggest that there are advantages to developing drugs for FTD as compared to other dementias. FTD qualifies as orphan indication, providing additional advantages for drug development. Two recent sets of consensus diagnostic criteria will facilitate the identification of patients with FTD, and a variety of neuropsychological, functional and behavioral scales have been shown to be sensitive to disease progression. Moreover, quantitative neuroimaging measurements demonstrate progressive brain atrophy in FTD at rates that may surpass Alzheimer's disease (AD). Finally, the similarities between FTD and other neurodegenerative diseases with drug development efforts already underway suggest that FTD researchers will be able to draw upon this experience to create a roadmap for FTD drug development. We conclude that FTD research has reached sufficient maturity to pursue clinical development of specific FTD therapies.
Using the Keck Planet Imager and Characterizer (KPIC), we obtained high-resolution (R\(\sim\)35,000) \(K\)-band spectra of the four planets orbiting HR 8799. We clearly detected \water{} and CO in ...the atmospheres of HR 8799 c, d, and e, and tentatively detected a combination of CO and \water{} in b. These are the most challenging directly imaged exoplanets that have been observed at high spectral resolution to date when considering both their angular separations and flux ratios. We developed a forward modeling framework that allows us to jointly fit the spectra of the planets and the diffracted starlight simultaneously in a likelihood-based approach and obtained posterior probabilities on their effective temperatures, surface gravities, radial velocities, and spins. We measured \(v\sin(i)\) values of \(10.1^{+2.8}_{-2.7}\)~km/s for HR 8799 d and \(15.0^{+2.3}_{-2.6}\)~km/s for HR 8799 e, and placed an upper limit of \(< 14\)~km/s of HR 8799 c. Under two different assumptions of their obliquities, we found tentative evidence that rotation velocity is anti-correlated with companion mass, which could indicate that magnetic braking with a circumplanetary disk at early times is less efficient at spinning down lower mass planets.
•Patients with semantic dementia (SD) have diminished autonomic activity at rest.•Lower autonomic activity correlated with left lateralized atrophy in the insula.•In SD, lower parasympathetic ...activity correlated with lower affiliative behavior.•This is the first study to show diminished autonomic activity in SD.
In semantic dementia (SD), asymmetric degeneration of the anterior temporal lobes is associated with loss of semantic knowledge and alterations in socioemotional behavior. There are two clinical variants of SD: semantic variant primary progressive aphasia (svPPA), which is characterized by predominant atrophy in the anterior temporal lobe and insula in the left hemisphere, and semantic behavioral variant frontotemporal dementia (sbvFTD), which is characterized by predominant atrophy in those structures in the right hemisphere. Previous studies of behavioral variant frontotemporal dementia, an associated clinical syndrome that targets the frontal lobes and anterior insula, have found impairments in baseline autonomic nervous system activity that correlate with left-lateralized frontotemporal atrophy patterns and disruptions in socioemotional functioning. Here, we evaluated whether there are similar impairments in resting autonomic nervous system activity in SD that also reflect left-lateralized atrophy and relate to diminished affiliative behavior. A total of 82 participants including 33 people with SD (20 svPPA and 13 sbvFTD) and 49 healthy older controls completed a laboratory-based assessment of respiratory sinus arrhythmia (RSA; a parasympathetic measure) and skin conductance level (SCL; a sympathetic measure) during a two-minute resting baseline period. Participants also underwent structural magnetic resonance imaging, and informants rated their current affiliative behavior on the Interpersonal Adjective Scale. Results indicated that baseline RSA and SCL were lower in SD than in healthy controls, with significant impairments present in both svPPA and sbvFTD. Voxel-based morphometry analyses revealed left-greater-than-right atrophy related to diminished parasympathetic and sympathetic outflow in SD. While left-lateralized atrophy in the mid-to-posterior insula correlated with lower RSA, left-lateralized atrophy in the ventral anterior insula correlated with lower SCL. In SD, lower baseline RSA, but not lower SCL, was associated with lower gregariousness/extraversion. Neither autonomic measure related to warmth/agreeableness, however. Through the assessment of baseline autonomic nervous system physiology, the present study contributes to expanding conceptualizations of the biological basis of socioemotional alterations in svPPA and sbvFTD.
IMPORTANCE Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant ...recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. OBJECTIVE To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. MAIN OUTCOMES AND MEASURES Incident skin cancerwas determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). RESULTS Overall, 10 649 organ transplant recipients (mean SD age, 51 12 years; 3873 women 36% and 6776 men 64%) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). CONCLUSIONS AND RELEVANCE Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.
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