Temporal trends in recording of diabetes on death certificates: results from Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE

To determine the frequency that diabetes is reported on death certificates of decedents with known diabetes and describe trends in reporting over 8 years.

RESEARCH DESIGN AND METHODS

Data were obtained from 11,927 participants with diabetes who were enrolled in Translating Research into Action for Diabetes, a multicenter prospective observational study of diabetes care in managed care. Data on decedents (N = 2,261) were obtained from the National Death Index from 1 January 2000 through 31 December 2007. The primary dependent variables were the presence of the ICD-10 codes for diabetes listed anywhere on the death certificate or as the underlying cause of death.

RESULTS

Diabetes was recorded on 41% of death certificates and as the underlying cause of death for 13% of decedents with diabetes. Diabetes was significantly more likely to be reported on the death certificate of decedents dying of cardiovascular disease than all other causes. There was a statistically significant trend of increased reporting of diabetes as the underlying cause of death over time (P < 0.001), which persisted after controlling for duration of diabetes at death. The increase in reporting of diabetes as the underlying cause of death was associated with a decrease in the reporting of cardiovascular disease as the underlying cause of death (P < 0.001).

CONCLUSIONS

Death certificates continue to underestimate the prevalence of diabetes among decedents. The increase in reporting of diabetes as the underlying cause of death over the past 8 years will likely impact estimates of the burden of diabetes in the U.S.In 2005, the National Center for Health Statistics ranked diabetes as the fifth leading cause of death in the U.S (1). Although it is difficult to determine the true extent to which diabetes should be recorded as a cause of death, this is likely an underestimate since diabetes is listed anywhere on the death certificate of fewer than half of people with known diabetes who die (2–5). Although using mortality data for epidemiologic studies is a common practice, it has drawbacks. When one studies mortality rates over time using death certificates one generally assumes that the likelihood of recording the condition remains constant over time, so that observed changes in mortality reflect true changes in the rate and not simply changes in recording practices. The last national study investigating trends in reporting of diabetes on death certificates used the 1986 and 1993 National Mortality Follow-back Survey and documented consistent underreporting over time (2). One smaller, more recent study looking at the sensitivity and specificity of reporting of diabetes on death certificates reported similar results (4).We hypothesize that diabetes reporting on death certificates may have improved since 2000 because of the increasing prevalence of diabetes and the increased media attention to diabetes. The objective of this study was to determine the frequency of reporting of diabetes on death certificates of decedents with known diabetes and to describe trends over 8 years using data from Translating Research into Action for Diabetes (TRIAD). TRIAD was ideal for this study because it involved a racially and ethnically diverse sample of adults with diabetes from six sites across the United States and because all participants had been diagnosed with diabetes for at least 1 year before enrollment.     

Out-of-pocket costs and diabetes preventive services: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: Despite the increased shifting of health care costs to consumers, little is known about the impact of financial barriers on health care utilization. This study investigated the effect of out-of-pocket expenditures on the utilization of recommended diabetes preventive services. RESEARCH DESIGN AND METHODS: This was a survey-based observational study (2000-2001) in 10 managed care health plans and 68 provider groups across the U.S. serving approximately 180,000 patients with diabetes. From 11,922 diabetic survey respondents, we studied the occurrence of self-reported annual dilated eye exams and diabetes health education and among insulin users, daily self-monitoring of blood glucose (SMBG). Conditional probabilities were estimated for outcomes at each level of self-reported out-of-pocket expenditure by using hierarchical logistic regression models with random intercepts. RESULTS: Conditional probabilities of utilization (95% CI) varied by expenditure for dilated eye exam [no cost 78% (75-82), copay 79% (75-82), and full price 70% (64-75); P < 0.0001]; diabetes health education [no cost 29% (23-36), copay 29% (23-36), and full price 19% (14-25); P < 0.0001]; and daily SMBG [no cost 75% (68-81), copay 68% (60-75), and full price 59% (49-68); P < 0.0001]. Extensive adjustment for patient factors had no discernible effect on the estimates or their significance, and cost-utilization relationships were similar across income levels and other patient characteristics. CONCLUSIONS: Benefit packages structured to derive greater fiscal contribution from the health plan membership result in suboptimal use of diabetes preventive services and may thus lead to poorer clinical outcomes, greater future costs, and lower health plan quality ratings.     

Managed care organization and the quality of diabetes care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: To examine the association between the organizational model and diabetes processes of care. RESEARCH DESIGN AND METHODS: We used data from the Translating Research into Action for Diabetes (TRIAD), a multicenter study of diabetes care in managed care, including 8354 patients with diabetes. We identified five model types: for-profit group/network, for-profit independent practice association (IPA), nonprofit group/network, nonprofit IPA, and nonprofit group/staff. Process measures included retinal, renal, foot, lipid, and HbA(1c) testing; aspirin recommendations; influenza vaccination; and a sum of these seven processes of care over 1 year. Hierarchical regression models were constructed for each process measure and accounted for clustering at the health plan and provider group levels and adjusted for participant age, sex, race, ethnicity, diabetes treatment and duration, education, income, health status, and survey language. RESULTS: Participant membership in the model types ranged from 9% in nonprofit IPA models to 38% in nonprofit group/staff models. Over 75% of participants received most of the processes of care, regardless of model type. However, among for-profit plans, group/network models provided on average more processes of care than IPA models (5.5 vs. 4.7, P < 0.0001), and group/network models generally increased the probability of receiving a process by >or=10 percentage points. Among nonprofit plans, no effect of model type was found. CONCLUSIONS: Among for-profit plans, group/network models provided better diabetes processes of care than IPA models. Although reasons are speculative, this may be due to the clinical infrastructure available in group models that is not available in IPA models.     

Predictors of mortality over 8 years in type 2 diabetic patients: Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE

To 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 METHODS

Beginning 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.

RESULTS

There 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.

CONCLUSIONS

Risk 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.In 2007, diabetes was the seventh leading cause of death in the U.S. with >71,000 death certificates listing diabetes as the underlying cause of death (1,2). Diabetes is reported as the underlying cause of death on 10–15% of death certificates of decedents with diabetes and is reported anywhere on the death certificate for 40% of decedents with diabetes (3–5). Since a diagnosis of diabetes cannot be ascertained from death certificates, the best way to examine mortality in people with diabetes is to use a prospective observational cohort design and follow diabetic participants until death. Unfortunately, few such studies have been undertaken in nationally representative populations of people with diabetes. Although many investigators have assessed risk factors for cardiovascular mortality, there are few published prediction models. Such models are needed to construct computer models to simulate the progression of diabetes, and may, with further validation, be useful for clinical decision making.Translating Research Into Action for Diabetes (TRIAD), which began in 1999, was a prospective observational study of people with diabetes enrolled in managed care health plans in the U.S. The primary objective of TRIAD was to study how health plan, provider, and patient characteristics impact the processes and outcomes of diabetes care. TRIAD enrolled ∼12,000 diabetic patients from eight geographically distinct regions in the U.S. We previously reported on the demographic, socioeconomic, and biological risk factors for 4-year mortality in the TRIAD population (6). Since our study was published, two studies have reported prediction equations for mortality in patients with type 2 diabetes. One was performed in Chinese patients living in Hong Kong (7). The other was limited to patients initially prescribed a single oral hypoglycemic agent (8).The objective of this study was to assess longer-term mortality in a large, diverse, U.S. population with type 2 diabetes and to create prediction equations for all-cause, cardiovascular, and noncardiovascular mortality among people with clinically diagnosed type 2 diabetes.     

Predictors and Impact of Intensification of Antihyperglycemic Therapy in Type 2 Diabetes: Translating Research into Action for Diabetes (TRIAD)

OBJECTIVE

The 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 METHODS

We 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.

RESULTS

Of 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.

CONCLUSIONS

Treatment 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.Over the past decade, the number of therapies available for the management of type 2 diabetes has increased dramatically. Much of the evidence demonstrating the efficacy of these therapies has come from randomized, controlled, clinical trials (1,2). The effectiveness of these therapies in real-world clinical settings has not been studied as thoroughly.Clinical inertia, defined as the failure of health care providers to appropriately intensify medical management (3), and patient nonadherence, defined as the failure of patients to initiate or continuephysician-recommended changes in management, contribute to suboptimal glycemic control (4–6). A previous study of patients with poorly controlled diabetes showed that older patients and those of nonwhite race/ethnicity were less likely to have their treatment intensified than younger, white individuals (7). Physicians cite concerns about hypoglycemia, weight gain, and patient preferences as reasons for not intensifying therapy, and patients often express concerns about injections and the negative impact on quality of life as reasons for not intensifying therapy. Ideally, diabetes treatment regimens should be individually designed to prevent complications and comorbidities while respecting patient preferences and optimizing quality of life.The current analyses were designed to assess the impact of changes in antihyperglycemic therapies on health outcomes in managed care patients with type 2 diabetes. Specifically, we assessed the predictors of intensification of antihyperglycemic therapy, its impact on A1C, body weight, symptoms of anxiety/depression, and health status, and patient characteristics associated with improvement in A1C.     

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

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.     

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE: We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care. RESEARCH DESIGN AND METHODS: Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry. RESULTS: Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes. CONCLUSIONS: For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.     

Competing demands for time and self-care behaviors, processes of care, and intermediate outcomes among people with diabetes: Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE

To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes.

RESEARCH DESIGN AND METHODS

We 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.

RESULTS

Fifty-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 HbA_1c.

CONCLUSIONS

Accommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.Diabetes self-management entails a complex set of health behaviors. For people living with young children or dependent adults and for those who work outside the home, caregiving responsibilities and/or expectations in the workplace may be barriers to self-management (1).We conducted a cross-sectional analysis using data from Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care, to assess whether there are associations between competing demands for time and diabetes self-care behaviors, processes of care, and intermediate health outcomes.     

Understanding the gap between good processes of diabetes care and poor intermediate outcomes: Translating Research into Action for Diabetes (TRIAD)

BACKGROUND: Performance of diabetes clinical care processes has improved recently, but control of hemoglobin A1c (A1c) and other vascular disease risk factors has improved more slowly. OBJECTIVES: To identify patient factors associated with control of vascular disease risk factors among diabetes patients receiving recommended care processes. POPULATION: Managed care enrollees who participated in the TRIAD (Translating Research into Action for Diabetes) Study and received at least 5 of 7 recommended care processes during the 12 months before the second survey (2002-2003). METHODS: Comparison of 1003 patients with good control of A1c (<8%), systolic blood pressure (<140 mm Hg) and LDL-cholesterol (<130 mg/dL) versus 812 patients with poor control for at least 2 of these factors. RESULTS: Poorly controlled patients were younger, more frequently female, African American, with lower education and income (P < 0.001 for each). General health status was lower, body mass index higher, and insulin treatment more frequent; history of prior coronary heart disease was less frequent. They were more likely to indicate depression and hopelessness and to identify costs as a barrier to self-care; less likely to report trust in their regular physician; and more likely to smoke cigarettes and be physically inactive. Adjusting for demographic and clinical variables, concerns about costs, low trust in one's physician, current smoking, and physical inactivity remained associated with poor control. However, inclusion of these 4 variables in a single model did not diminish associations of race/ethnicity or education with control. CONCLUSIONS: Clinical, socioeconomic, psychosocial, and behavioral factors were independently associated with poor control. However, these factors did not fully explain observed racial and socioeconomic disparities in control.     

Trends in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus: A report from the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE—The purpose of this study was to examine trends in postpartum glucose screening for women with gestational diabetes mellitus (GDM), predictors of screening, trends in postpartum impaired fasting glucose (IFG) and diabetes, and diabetes and pre-diabetes detected by postpartum fasting plasma glucose (FPG) versus a 75-g oral glucose tolerance test (OGTT).RESEARCH DESIGN AND METHODS—This was a cohort study of 14,448 GDM pregnancies delivered between 1995 and 2006. Postpartum screening was defined as performance of either an FPG or OGTT at least 6 weeks after delivery and within 1 year of delivery.RESULTS—Between 1995 and 2006, the age- and race/ethnicity-adjusted proportion of women who were screened postpartum rose from 20.7% (95% CI 17.8–23.5) to 53.8% (51.3–56.3). Older age, Asian or Hispanic race/ethnicity, higher education, earlier GDM diagnosis, use of diabetes medications during pregnancy, and more provider contacts after delivery were independent predictors of postpartum screening. Obesity and higher parity were independently associated with lower screening performance. Among women who had postpartum screening, the age- and race/ethnicity-adjusted proportion of IFG did not change over time (24.2 [95% CI 20.0–27.8] in 1995–1997 to 24.3 [22.6–26.0] in 2004–2006), but the proportion of women with diabetes decreased from 6.1 (95% CI 4.2–8.1) in 1995–1997 to 3.3 (2.6–4.0) in 2004–2006. Among women who received an OGTT in 2006, 38% of the 204 women with either diabetes or pre-diabetes were identified only by the 2-h glucose measurements.CONCLUSIONS—Postpartum screening has increased over the last decade, but it is still suboptimal. Compared with FPGs alone, the 2-h values identify a higher proportion of women with diabetes or pre-diabetes amenable to intervention.Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance with onset of or first recognition during pregnancy. Postpartum diabetes screening may detect diabetes that preceded pregnancy and therefore enable early treatment of hyperglycemia, reducing the risk of adverse fetal outcomes in subsequent pregnancies (1) and maternal microvascular complications (2). Screening can also identify women who might benefit from diabetes prevention interventions (3,4).Performance rates of postpartum diabetes screening have been low (5–7), but screening performance may have changed recently. At present, only one population-based report has examined postpartum diabetes screening practices, and this report examined fasting plasma glucose (FPG) only (8). We used data from a GDM registry in a large prepaid group practice managed health care organization (the Kaiser Permanente Medical Care Program in Northern California [KPNC]) and examined 1) postpartum diabetes screening over time, 2) predictors of postpartum screening in a detailed electronic medical record, 3) trends in impaired fasting glucose (IFG) or diabetes detected with postpartum screening, and 4) the proportion of women with diabetes or pre-diabetes identified by the FPG screen versus the proportion of women with these abnormal glucose values identified by the 75-g oral glucose tolerance test (OGTT).     

Translating the Diabetes Prevention Program Into American Indian and Alaska Native Communities: Results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project

OBJECTIVE

The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities.

RESEARCH DESIGN AND METHODS

The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated.

RESULTS

The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure.

CONCLUSIONS

Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.Type 2 diabetes, a serious global public health problem, affects disadvantaged populations disproportionately, especially American Indians and Alaska Natives (AI/ANs) (1). In 2009, the age-adjusted prevalence of diabetes for adults eligible for Indian Health Service (IHS) was 16.1%—more than twice that of non-Hispanic white adults (1). Landmark clinical trials, such as the Diabetes Prevention Program (DPP), have showed that lifestyle interventions can prevent or delay the onset of diabetes for those at risk (2–5). In addition, DPP found no significant differences in the reduction of diabetes incidence by race/ethnicity, including in American Indians (4). While under well-controlled circumstances (e.g., clinical trials) lifestyle intervention may have equivalent efficacy across race/ethnicity groups, the effectiveness of implementing such programs in community-based settings among underserved populations remains underexplored. In particular, implementations of large-scale public health interventions in AI/AN communities are plagued by lack of resources, diverse health care settings, and the highly mobile population, all of which are challenges to the successful recruitment, retention, and effectiveness of translational efforts.Translating the DPP intervention into real-world situations has occurred in other settings (6–16), such as urban medically underserved communities (7), faith-based settings (8), YMCAs (9), work sites (10), and primary care practices (11–13). However, most of these were small studies implemented in relatively uniform settings; particularly, none of them included a substantial number of AI/ANs—the U.S. population that suffers most from diabetes (1,17). Given the significant economic and sociocultural diversity of AI/AN communities, it is important to determine the feasibility and effectiveness of such an intervention in a large sample of this population.Mandated and funded by Congress, the IHS implemented the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project and collected data that allowed an unprecedented investigation of the translational effectiveness of the DPP lifestyle intervention in preventing diabetes across 36 diverse programs, representing rural, reservation, and urban AI/AN communities. This article reports the primary and secondary outcomes of SDPI-DP participants after a follow-up of 3 years.