Andrew J Karter

Kaiser Permanente, Oakland, California, United States

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Publications (163)957.87 Total impact

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    ABSTRACT: An observational cohort analysis was conducted within the Surveillance, Prevention, and Management of Diabetes Mellitus (SUPREME-DM) DataLink, a consortium of 11 integrated health-care delivery systems with electronic health records in 10 US states. Among nearly 7 million adults aged 20 years or older, we estimated annual diabetes incidence per 1,000 persons overall and by age, sex, race/ethnicity, and body mass index. We identified 289,050 incident cases of diabetes. Age- and sex-adjusted population incidence was stable between 2006 and 2010, ranging from 10.3 per 1,000 adults (95% confidence interval (CI): 9.8, 10.7) to 11.3 per 1,000 adults (95% CI: 11.0, 11.7). Adjusted incidence was significantly higher in 2011 (11.5, 95% CI: 10.9, 12.0) than in the 2 years with the lowest incidence. A similar pattern was observed in most prespecified subgroups, but only the differences for persons who were not white were significant. In 2006, 56% of incident cases had a glycated hemoglobin (hemoglobin A1c) test as one of the pair of events identifying diabetes. By 2011, that number was 74%. In conclusion, overall diabetes incidence in this population did not significantly increase between 2006 and 2010, but increases in hemoglobin A1c testing may have contributed to rising diabetes incidence among nonwhites in 2011. © The Author 2014. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail:
    American Journal of Epidemiology 12/2014; · 4.98 Impact Factor
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    ABSTRACT: The role that environmental factors, such as neighborhood socioeconomics, food, and physical environment, play in the risk of obesity and chronic diseases is not well quantified. Understanding how spatial distribution of disease risk factors overlap with that of environmental (contextual) characteristics may inform health interventions and policies aimed at reducing the environment risk factors. We evaluated the extent to which spatial clustering of extreme body mass index (BMI) values among a large sample of adults with diabetes was explained by individual characteristics and contextual factors. We quantified spatial clustering of BMI among 15,854 adults with diabetes from the Diabetes Study of Northern California (DISTANCE) cohort using the Global and Local Moran's I spatial statistic. As a null model, we assessed the amount of clustering when BMI values were randomly assigned. To evaluate predictors of spatial clustering, we estimated two linear models to estimate BMI residuals. First we included individual factors (demographic and socioeconomic characteristics). Then we added contextual factors (neighborhood deprivation, food environment) that may be associated with BMI. We assessed the amount of clustering that remained using BMI residuals. Global Moran's I indicated significant clustering of extreme BMI values; however, after accounting for individual socioeconomic and demographic characteristics, there was no longer significant clustering. Twelve percent of the sample clustered in extreme high or low BMI clusters, whereas, only 2.67% of the sample was clustered when BMI values were randomly assigned. After accounting for individual characteristics, we found clustering of 3.8% while accounting for neighborhood characteristics resulted in 6.0% clustering of BMI. After additional adjustment of neighborhood characteristics, clustering was reduced to 3.4%, effectively accounting for spatial clustering of BMI. We found substantial clustering of extreme high and low BMI values in Northern California among adults with diabetes. Individual characteristics explained somewhat more of clustering of the BMI values than did neighborhood characteristics. These findings, although cross-sectional, may suggest that selection into neighborhoods as the primary explanation of why individuals with extreme BMI values live close to one another. Further studies are needed to assess causes of extreme BMI clustering, and to identify any community level role to influence behavior change.
    International Journal of Health Geographics 12/2014; 13(1):48. · 2.62 Impact Factor
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    ABSTRACT: To estimate the incidence of remission in adults with type 2 diabetes not treated with bariatric surgery and to identify variables associated with remission RESEARCH DESIGN AND METHODS: We quantified the incidence of diabetes remission and examined its correlates among 122,781 adults with type 2 diabetes in an integrated healthcare delivery system. Remission required the absence of ongoing drug therapy and was defined as follows: 1) partial: at least 1 year of subdiabetic hyperglycemia (hemoglobin A1c [HbA1c] level 5.7-6.4% [39-46 mmol/mol]); 2) complete: at least 1 year of normoglycemia (HbA1c level <5.7% [<39 mmol/mol]); and 3) prolonged: complete remission for at least 5 years.
    Diabetes Care 09/2014; · 8.57 Impact Factor
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    ABSTRACT: Objective To assess the impact of a pharmacy benefit change on mail order pharmacy (MOP) uptake.Data Sources/Study SettingRace-stratified, random sample of diabetes patients in an integrated health care delivery system.Study DesignIn this natural experiment, we studied the impact of a pharmacy benefit change that conditionally discounted medications if patients used MOP and prepaid two copayments. We compared MOP uptake among those exposed to the benefit change (n = 2,442) and the reference group with no benefit change (n = 8,148), and estimated differential MOP uptake across social strata using a difference-in-differences framework.Data Collection/Extraction Methods Ascertained MOP uptake (initiation among previous nonusers).Principal FindingsThirty percent of patients started using MOP after receiving the benefit change versus 9 percent uptake among the reference group (p < .0001). After adjustment, there was a 26 percentage point greater MOP uptake (benefit change effect). This benefit change effect was significantly smaller among patients with inadequate health literacy (15 percent less), limited English proficiency (14 percent less), and among Latinos and Asians (24 and 16 percent less compared to Caucasians).Conclusions Conditionally discounting medications delivered by MOP effectively stimulated MOP uptake overall, but it unintentionally widened previously existing social gaps in MOP use because it stimulated less MOP uptake in vulnerable populations.
    Health Services Research 08/2014; · 2.49 Impact Factor
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    ABSTRACT: Inadequate literacy is common among patients with diabetes and may lead to adverse outcomes. The authors reviewed the relationship between literacy and health outcomes in patients with diabetes and potential interventions to improve outcomes.
    The Diabetes Educator 06/2014; · 1.92 Impact Factor
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    ABSTRACT: IMPORTANCE The increasing intensity of diabetes mellitus management over the past decade may have resulted in lower rates of hyperglycemic emergencies but higher rates of hospital admissions for hypoglycemia among older adults. Trends in these hospitalizations and subsequent outcomes are not known. OBJECTIVE To characterize changes in hyperglycemia and hypoglycemia hospitalization rates and subsequent mortality and readmission rates among older adults in the United States over a 12-year period, and to compare these results according to age, sex, and race. DESIGN, SETTING, AND PATIENTS Retrospective observational study using data from 33 952 331 Medicare fee-for-service beneficiaries 65 years or older from 1999 to 2011. MAIN OUTCOMES AND MEASURES Hospitalization rates for hyperglycemia and hypoglycemia, 30-day and 1-year mortality rates, and 30-day readmission rates. RESULTS A total of 279 937 patients experienced 302 095 hospitalizations for hyperglycemia, and 404 467 patients experienced 429 850 hospitalizations for hypoglycemia between 1999 and 2011. During this time, rates of admissions for hyperglycemia declined by 38.6% (from 114 to 70 admissions per 100 000 person-years), while admissions for hypoglycemia increased by 11.7% (from 94 to 105 admissions per 100 000 person-years). In analyses designed to account for changing diabetes mellitus prevalence, admissions for hyperglycemia and hypoglycemia declined by 55.2% and 9.5%, respectively. Trends were similar across age, sex, and racial subgroups, but hypoglycemia rates were 2-fold higher for older patients (≥75 years) when compared with younger patients (65-74 years), and admission rates for both hyperglycemia and hypoglycemia were 4-fold higher for black patients compared with white patients. The 30-day and 1-year mortality and 30-day readmission rates improved during the study period and were similar after an index hospitalization for either hyperglycemia or hypoglycemia (5.4%, 17.1%, and 15.3%, respectively, after hyperglycemia hospitalizations in 2010; 4.4%, 19.9%, and 16.3% after hypoglycemia hospitalizations). CONCLUSIONS AND RELEVANCE Hospital admission rates for hypoglycemia now exceed those for hyperglycemia among older adults. Although admissions for hypoglycemia have declined modestly since 2007, rates among black Medicare beneficiaries and those older than 75 years remain high. Hospital admissions for severe hypoglycemia seem to pose a greater health threat than those for hyperglycemia, suggesting new opportunities for improvement in care of persons with diabetes mellitus.
    JAMA Internal Medicine 05/2014; · 13.25 Impact Factor
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    ABSTRACT: In chronic illness self-care, social support may influence some health behaviors more than others. Examine social support's association with seven individual chronic illness self-management behaviors: two healthy "lifestyle" behaviors (physical activity, diet) and five more highly skilled and diabetes-specific (medical) behaviors (checking feet, oral medication adherence, insulin adherence, self-monitored blood glucose, primary care appointment attendance). Using cross-sectional administrative and survey data from 13,366 patients with type 2 diabetes, Poisson regression models estimated the adjusted relative risks (ARR) of practicing each behavior at higher vs lower levels of social support. Higher emotional support and social network scores were significantly associated with increased ARR of both lifestyle behaviors. Both social support measures were also associated with increased ARR for checking feet. Neither measure was significantly associated with other medical behaviors. Findings suggest that social support diminished in importance as self-care progresses from lifestyle to more skilled "medical" behaviors.
    Annals of Behavioral Medicine 05/2014; · 4.20 Impact Factor
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    ABSTRACT: Objectives To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus.DesignA survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥65) and younger (18–65) adults.SettingManaged care.ParticipantsPersons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341).MeasurementsThe primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire.ResultsAfter controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant.Conclusion This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment.
    Journal of the American Geriatrics Society 05/2014; · 4.22 Impact Factor
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    ABSTRACT: Depression and adherence to antidepressant treatment are important clinical concerns in diabetes care. While patient-provider communication patterns have been associated with adherence for cardiometabolic medications, it is unknown whether interpersonal aspects of care impact antidepressant medication adherence. To determine whether shared decision-making, patient-provider trust, or communication are associated with early stage and ongoing antidepressant adherence. Observational new prescription cohort study. Kaiser Permanente Northern California. One thousand five hundred twenty-three adults with type 2 diabetes who completed a survey in 2006 and received a new antidepressant prescription during 2006-2010. Exposures included items based on the Trust in Physicians and Interpersonal Processes of Care instruments and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) communication scale. Measures of adherence were estimated using validated methods with physician prescribing and pharmacy dispensing data: primary non-adherence (medication never dispensed), early non-persistence (dispensed once, never refilled), and new prescription medication gap (NPMG; proportion of time without medication during 12 months after initial prescription). After adjusting for potential confounders, patients' perceived lack of shared decision-making was significantly associated with primary non-adherence (RR = 2.42, p < 0.05), early non-persistence (RR = 1.34, p < 0.01) and NPMG (estimated 5 % greater gap in medication supply, p < 0.01). Less trust in provider was significantly associated with early non-persistence (RRs 1.22-1.25, ps < 0.05) and NPMG (estimated NPMG differences 5-8 %, ps < 0.01). All patients were insured and had consistent access to and quality of care. Patients' perceptions of their relationships with providers, including lack of shared decision-making or trust, demonstrated strong associations with antidepressant non-adherence. Further research should explore whether interventions for healthcare providers and systems that foster shared decision-making and trust might also improve medication adherence.
    Journal of General Internal Medicine 04/2014; · 3.42 Impact Factor
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    ABSTRACT: Background: Persons with type 2 diabetes are at an increased risk of dementia compared to those without, but the etiology of this increased risk is unclear. Objective: Cerebral microvascular disease may mediate the link between diabetes and dementia. Given the anatomical and physiological similarities between cerebral and retinal microvessels, we examined the longitudinal association between diabetic retinal disease and dementia in patients with type 2 diabetes. Methods: Longitudinal cohort study of 29,961 patients with type 2 diabetes aged ≥60 years. Electronic medical records were used to collect diagnoses and treatment of severe diabetic retinal disease (i.e., diabetic proliferative retinopathy and macular edema) between 1996-1998 and dementia diagnoses for the next ten years (1998-2008). The association between diabetic retinal disease and dementia was evaluated by Cox proportional hazard models adjusted for sociodemographics, as well as diabetes-specific (e.g., diabetes duration, pharmacotherapy, HbA1c, hypoglycemia, hyperglycemia) and vascular (e.g., vascular disease, smoking, body mass index) factors. Results: 2,008 (6.8%) patients had severe diabetic retinal disease at baseline and 5,173 (17.3%) participants were diagnosed with dementia during follow-up. Those with diabetic retinal disease had a 42% increased risk of incident dementia (demographics adjusted Hazards Ratio (HR) = 1.42, 95% Confidence Interval (CI) 1.27, 1.58); further adjustment for diabetes-specific (HR1.29; 95%CI 1.14,1.45) and vascular-related disease conditions (HR 1.35; 95%CI 1.21,1.52) attenuated the relation slightly. Conclusion: Diabetic patients with severe diabetic retinal disease have an increased risk of dementia. This may reflect a causal link between microvascular disease and dementia.
    Journal of Alzheimer's disease: JAD 03/2014; · 3.61 Impact Factor
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    ABSTRACT: Background. Social risk factors for hypoglycemia are not well understood. Methods. Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005-2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. Results. 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19-1.91), $15,000-$24,999 (OR 1.57 95%CI 1.27-1.94), and high school or less education (OR 1.42, 95% CI 1.24-1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19-1.74). Conclusions. Low income and educational attainment are important risk factors for hypoglycemia.
    Journal of Health Care for the Poor and Underserved 01/2014; 25(2):478-90. · 1.10 Impact Factor
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    ABSTRACT: Online patient portals are being widely implemented, but their impact on health behaviors are not well-studied. To determine whether statin adherence improved after initiating use of the portal refill function. Observational cohort study within an integrated health care delivery system. Diabetic patients on statins who had registered for online portal access by 2010. A total of 8705 subjects initiated the online refill function use within the study window, including "exclusive" and "occasional" users (ie, requesting all vs. some refills online, respectively). Using risk-set sampling, we temporally matched 9055 reference group patients who never used online refills. We calculated statin adherence before and after refill function initiation, assessed as percent time without medications (nonadherence defined as a gap of >20%). Secondary outcome was dyslipidemia [low-density lipoprotein (LDL)≥100]. Difference-in-differences regression models estimated pre-post changes in nonadherence and dyslipidemia, comparing refill function users to the reference group and adjusting for age, sex, race/ethnicity, medications, frequency of portal use, and outpatient visits. In unadjusted examinations, nonadherence decreased only among patients initiating occasional or exclusive use of the refill function (26%-24% and 22%-15%, respectively). In adjusted models, nonadherence declined by an absolute 6% (95% confidence interval, 4%-7%) among exclusive users, without significant changes among occasional users. Similar LDL decreases were also seen among exclusive users. Compared with portal users who did not refill medications online, adherence to statin medications and LDL levels improved among diabetic patients who initiated and exclusively used the patient portal for refills, suggesting that wider adoption of online refills may improve adherence.
    Medical care 12/2013; · 2.94 Impact Factor
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    ABSTRACT: IMPORTANCE In the coming decades, the population of older adults with type 2 diabetes mellitus is expected to grow substantially. Understanding the clinical course of diabetes in this population is critical for establishing evidence-based clinical practice recommendations, identifying research priorities, allocating resources, and setting health care policies. OBJECTIVE To contrast the rates of diabetes complications and mortality across age and diabetes duration categories. DESIGN, SETTING, AND PARTICIPANTS This cohort study (2004-2010) included 72 310 older (≥60 years) patients with type 2 diabetes enrolled in a large, integrated health care delivery system. Incidence densities (events per 1000 person-years) were calculated for each age category (60-69, 70-79, and ≥80 years) and duration of diabetes (shorter [0-9 years] vs longer [≥10 years]). MAIN OUTCOMES AND MEASURES Incident acute hyperglycemic events, acute hypoglycemic events (hypoglycemia), microvascular complications (end-stage renal disease, peripheral vascular disease, lower limb amputation, and diabetic eye disease), cardiovascular complications (coronary artery disease, cerebrovascular disease, and congestive heart failure), and all-cause mortality. RESULTS Among older adults with diabetes of short duration, cardiovascular complications followed by hypoglycemia were the most common nonfatal complications. For example, among individuals aged 70 to79 years with a short duration of diabetes, coronary artery disease and hypoglycemia rates were higher (11.47 per 1000 person-years and 5.03 per 1000 person-years, respectively) compared with end-stage renal disease (2.60 per 1000 person-years), lower limb amputation (1.28 per 1000 person-years), and acute hyperglycemic events (0.82 per 1000 person-years). We observed a similar pattern among patients in the same age group with a long duration of diabetes, with some of the highest incidence rates in coronary artery disease and hypoglycemia (18.98 per 1000 person-years and 15.88 per 1000 person-years, respectively) compared with end-stage renal disease (7.64 per 1000 person-years), lower limb amputation (4.26 per 1000 person-years), and acute hyperglycemic events (1.76 per 1000 person-years). For a given age group, the rates of each outcome, particularly hypoglycemia and microvascular complications, increased dramatically with longer duration of the disease. However, for a given duration of diabetes, rates of hypoglycemia, cardiovascular complications, and mortality increased steeply with advancing age, and rates of microvascular complications remained stable or declined. CONCLUSIONS AND RELEVANCE Duration of diabetes and advancing age independently predict diabetes morbidity and mortality rates. As long-term survivorship with diabetes increases and as the population ages, more research and public health efforts to reduce hypoglycemia will be needed to complement ongoing efforts to reduce cardiovascular and microvascular complications.
    JAMA Internal Medicine 12/2013; · 13.25 Impact Factor
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    ABSTRACT: Background:Although those with type 2 diabetes have double the risk of dementia, potential racial/ethnic differences in dementia risk have not been explored in this population. We evaluated racial/ethnic differences in dementia and potential explanatory factors among older diabetes patients.Methods: We identified 22,171 diabetes patients without preexisting dementia, aged ≥60 years (14,546 non-Hispanic whites, 2,484 African Americans, 2,363 Latinos, 2,262 Asians, 516 Native Americans) from the Kaiser Permanente Northern California Diabetes Registry. We abstracted prevalent medical history (1/1/1996-12/31/1997) and dementia incidence (1/1/1998-12/31/2007) from medical records and calculated age-adjusted incidence densities. We fit Cox proportional hazards models adjusted for age, sex, education, diabetes duration, and markers of clinical control.Results:Dementia was diagnosed in 3,796 (17.1%) patients. Age-adjusted dementia incidence densities were highest among Native Americans (34/1,000 person-years) and African Americans (27/1,000 person-years) and lowest among Asians (19/1,000 person-years). In the fully-adjusted model, hazard ratios (95% CIs) (relative to Asians) were 1.64 (1.30-2.06) for Native Americans, 1.44 (1.24-1.67) for African Americans, 1.30 (1.15-1.47) for non-Hispanic whites, and 1.19 (1.02-1.40) for Latinos. Adjustment for diabetes-related complications and neighborhood deprivation index did not change results.Conclusions:Among type 2 diabetes patients followed for ten years, African Americans and Native Americans had a 40-60% greater risk of dementia compared to Asians, and risk was intermediate for non-Hispanic whites and Latinos. Adjustment for sociodemographics, diabetes-related complications, and markers of clinical control did not explain observed differences. Future studies should investigate why these differences exist and ways to reduce them.
    Diabetes care 11/2013; · 7.74 Impact Factor
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    ABSTRACT: Although patients with type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10 year dementia risk for individuals with type 2 diabetes. Using data from two longitudinal cohorts of patients with type 2 diabetes (aged ≥60 years) with 10 years of follow-up, we created (n=29 961) and validated (n=2413) the risk score. We built our prediction model by evaluating 45 candidate predictors using Cox proportional hazard models and developed a point system for the risk score based on the size of the predictor's β coefficient. Model prediction was tested by discrimination and calibration methods. Dementia risk per sum score was calculated with Kaplan-Meier estimates. Microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education were most strongly predictive of dementia and constituted the risk score (C statistic 0·736 for creation cohort and 0·746 for validation cohort). The dementia risk was 5·3% (95% CI 4·2-6·3) for the lowest score (-1) and 73·3% (64·8-81·8) for the highest (12-19) sum scores. To the best of our knowledge, this is the first risk score for the prediction of 10 year dementia risk in patients with type 2 diabetes mellitus. The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials. Kaiser Permanente Community Benefit, National Institute of Health, Utrecht University, ZonMw, and Fulbright.
    The lancet. Diabetes & endocrinology. 11/2013; 1(3):183-90.
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    ABSTRACT: OBackground: Although research suggests that mail order pharmacy use is associated with greater medication adherence and cardiovascular disease risk factor control, no research has examined the potential impact of mail order pharmacy use on patient safety and utilization. Objectives: To compare safety and utilization outcomes in patients using mail order versus local pharmacies. Study Design: Cross-sectional, observational study of 17,217 Kaiser Permanente Northern California adult diabetes patients prescribed new cardiometabolic medications in 2006. Methods: Multivariate logistic regressions assessed the association between mail order pharmacy use and all-cause and preventable hospitalizations and emergency department (ED) visits; laboratory tests for monitoring persistent medications; and overlapping days of supply of contraindicated medications. Results were stratified by patient age and converted to adjusted predicted percentages. Results: Patients aged less than 65 years using mail order had fewer ED visits (33.8% vs 40.2%; P <.001); preventable ED visits (7.7% vs 9.6%; P <.01); and serum creatinine laboratory monitoring tests after angiotensin-converting enzyme inhibitor/angiotensin receptor blocker or diuretic initiation (41.2% vs 47.2%; P <.01). Among patients aged 65 or more years, mail order users had fewer preventable ED visits (13.4% vs 16.3%; P <.01); but slightly more occurrences of overlapping days of supply of contraindicated medications (1.1% vs 0.7%; P <.01). Conclusions: Mail order pharmacy use is not associated with adverse outcomes in most diabetes patients, and is associated with lower ED use. Interventions to increase mail order pharmacy use should use a patient-centered approach that is sensitive to primary and preventive care access.
    The American journal of managed care 11/2013; 19(11):882-7. · 2.17 Impact Factor
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    ABSTRACT: Abstract Background: Although many studies have shown that diabetes increases the risk for urinary incontinence, it is unclear whether poor glycemic control in women with diabetes is associated with incontinence. This study aims to determine the relationship between the hemoglobin A1c (HbA1c) level and urinary incontinence in a large, diverse cohort of older women. Methods: We examined 6026 older women who responded to a survey (62% response rate) and were enrolled in the Diabetes and Aging Study, an ethnically stratified random sample of patients with diabetes enrolled in Kaiser Permanente Northern California. Our primary independent variable was the mean of all HbA1c measurements in the year preceding the survey. Outcomes included the presence/absence of incontinence and limitations in daily activities due to incontinence. We used modified Poisson regression and ordinal logistic regression models to account for age, race, body mass index, parity, diabetes treatment, duration of diabetes, and comorbidity. Results: Sixty-five percent of women reported incontinence (mean age 59±10 years). After adjustment, HbA1c levels were not associated with the presence or absence of incontinence. However, among women reporting incontinence, HbA1c ≥9% was associated with more limitations due to incontinence than HbA1c <6% (adjusted odds ratio 1.67, 95% confidence interval: 1.09-2.57). Conclusion: In this cross-sectional analysis, HbA1c level is not associated with the presence or absence of incontinence. However, for women with incontinence, poor glycemic control (HbA1c ≥9%) is associated with more limitations in daily activities due to incontinence. Longitudinal studies are needed to determine whether improving glycemic control to HbA1c <9% leads to fewer limitations in daily activities due to incontinence.
    Journal of Women's Health 09/2013; · 1.90 Impact Factor
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    ABSTRACT: OBJECTIVE We examined the association between HbA1c level and self-reported severe hypoglycemia in patients with type 2 diabetes.RESEARCH DESIGN AND METHODS Type 2 diabetic patients in a large, integrated healthcare system, who were 30-77 years of age and treated with glucose-lowering therapy, were asked about severe hypoglycemia requiring assistance in the year prior to the Diabetes Study of Northern California survey conducted in 2005-2006 (62% response rate). The main exposure of interest was the last HbA1c level collected in the year preceding the observation period. Poisson regression models adjusted for selected demographic and clinical variables were specified to evaluate the relative risk (RR) of severe hypoglycemia across HbA1c levels. We also tested whether the HbA1c-hypoglycemia association differed across potential effect modifiers (age, diabetes duration, and category of diabetes medication).RESULTSAmong 9,094 eligible survey respondents (mean age 59.5 ± 9.8 years, mean HbA1c 7.5 ± 1.5%), 985 (10.8%) reported experiencing severe hypoglycemia. Across HbA1c levels, rates of hypoglycemia were 9.3-13.8%. Compared with those with HbA1c of 7-7.9%, the RR of hypoglycemia was 1.25 (95% CI 0.99-1.57), 1.01 (0.87-1.18), 0.99 (0.82-1.20), and 1.16 (0.97-1.38) among those with HbA1c <6, 6-6.9, 8-8.9, and ≥9%, respectively, in a fully adjusted model. Age, diabetes duration, and category of diabetes medication did not significantly modify the HbA1c-hypoglycemia relationship.CONCLUSIONS Severe hypoglycemia was common among patients with type 2 diabetes across all levels of glycemic control. Risk tended to be higher in patients with either near-normal glycemia or very poor glycemic control.
    Diabetes care 07/2013; · 7.74 Impact Factor
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    ABSTRACT: To examine the association between physical functioning and mortality in people with type 2 diabetes, and determine if this association differs by race/ethnicity in managed care. We studied 7894 type 2 diabetic patients in Translating Research Into Action for Diabetes (TRIAD), a prospective observational study of diabetes care in managed care. Physical functioning was assessed with the Short Form Health Survey. The National Death Index was searched for deaths over 10years of follow-up (2000-2009). At baseline, mean age was 61.7years, 50% were non-Hispanic White, 22% were Black, and 16% of participants reported good physical functioning. Over 10years, 28% of participants died; 39% due to cardiovascular disease. Relative to those reporting good functioning, those reporting poor physical functioning had a 39% higher all-cause death rate after adjusting for age, sex, race/ethnicity, education, income, body mass index, smoking, and comorbidities (Hazard Ratio=1.39; 95% Confidence Interval: 1.16, 1.67). Although Blacks were less likely than Whites to report good functioning (p<0.01), the association between functioning and mortality did not differ by race/ethnicity. In this managed care population, self-reported physical functioning was a robust independent predictor of mortality and may be a useful benchmark for tailoring clinical care.
    Journal of diabetes and its complications 07/2013; · 2.11 Impact Factor
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    ABSTRACT: To explore racial and ethnic (ethnic hereafter) differences in health-related quality of life (HRQL) in older adults with diabetes mellitus in an integrated delivery system. Observational cross-sectional study. Kaiser Permanente Northern California. Ethnic-stratified, random sample of 6,096 adults with diabetes mellitus aged 60 to 75 who completed a HRQL questionnaire. Physical and mental HRQL were measured based on the Medical Outcomes Study 8-item Short Form Survey (range 0-100, mean 50). Age- and sex-adjusted weighted linear regression models estimated associations between ethnicity and HRQL and evaluated potential mediators (socioeconomic status, acculturation, health behaviors, diabetes mellitus-related conditions). Differences in ethnic-specific, adjusted mean HRQL scores were tested (reference whites). Physical HRQL was better for Filipinos (48.3, 95% confidence interval (CI) = 47.0-49.6, P < .001), Asians (48.1, 95% CI = 46.8-49.3, P < .001), Hispanics (45.1, 95% CI = 44.2-46.0, P < .001), and blacks (44.2, 95% CI = 43.3-45.1, P = .04) than whites (42.9, 95% CI = 42.6-43.2). Adjusting for potential mediators did not change these relationships. Mental HRQL was better only for Asians (52.7, 95% CI = 51.6-53.7, P = .01) than for whites (51.0, 95% CI = 50.7-51.3), but this difference was small and became nonsignificant after adjustment for socioeconomic status, acculturation, health behaviors, and diabetes mellitus-related conditions. In older adults with diabetes mellitus in a well-established integrated healthcare delivery system, ethnic minorities had better physical HRQL than whites. Equal access to care in an integrated delivery system may hold promise for reducing health disparities in diabetes mellitus-related patient-reported outcomes.
    Journal of the American Geriatrics Society 06/2013; · 4.22 Impact Factor

Publication Stats

6k Citations
957.87 Total Impact Points


  • 1996–2014
    • Kaiser Permanente
      Oakland, California, United States
  • 2013
    • Yale-New Haven Hospital
      • Department of Laboratory Medicine
      New Haven, Connecticut, United States
  • 2011–2013
    • University of Chicago
      • Department of Medicine
      Chicago, IL, United States
    • CSU Mentor
      Long Beach, California, United States
    • University of Washington Seattle
      • Department of Psychiatry and Behavioral Sciences
      Seattle, WA, United States
  • 2006–2013
    • University of Michigan
      • Department of Internal Medicine
      Ann Arbor, MI, United States
    • University of Lausanne
      • Department of Community Health and Medicine
      Lausanne, VD, Switzerland
  • 2012
    • San Francisco VA Medical Center
      San Francisco, California, United States
  • 2006–2012
    • University of California, San Francisco
      • • Division of Hospital Medicine
      • • Center for Vulnerable Populations (CVP)
      San Francisco, CA, United States
  • 2004–2011
    • University of Texas Health Science Center at San Antonio
      • • Division of Clinical Epidemiology
      • • Division of Hospital Medicine
      San Antonio, TX, United States
  • 2003–2010
    • University of California, Los Angeles
      • • Department of Medicine
      • • Division of General Internal Medicine and Health Services Research
      Los Angeles, CA, United States
  • 2009
    • Centers for Disease Control and Prevention
      • Division of Diabetes Translation
      Druid Hills, GA, United States
  • 2008
    • University of Hawai'i System
      Honolulu, Hawaii, United States
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Epidemiology
      Baltimore, MD, United States
    • University of Hawaiʻi at Hilo
      Hilo, Hawaii, United States
  • 2001–2004
    • Wake Forest School of Medicine
      • Division of Public Health Sciences
      Winston-Salem, NC, United States
  • 1997
    • Wake Forest University
      • Department of Public Health Sciences
      Winston-Salem, North Carolina, United States