bluuebunny/crossref_metadata_2025_split huggingface dataset:
1281-P: Proactive Chronic Care Management for Patients with Poorly Controlled Diabetes in an Academic Health-Care System: The Emory Diabetes Management Program
Authors: NAMBI ANDIRAN AYANAMBAKKAM , SMITH ZIRKA T. , PRESSWOOD MARGARET S. , JACOBS SOL , MCALEER ALISA F. , CASTELLANO PENNY A. , KHOSRAVANIPOUR MARJAN , GALINDO RODOLFO J. , TURTON FREDERICK E. , DEE JOSEPH , MASI CHRISTOPHER M. , ESPER GREGORY J. , UMPIERREZ GUILLERMO E. 
Published: June 2019

Fragmented care with limited access to specialized diabetes care and self-management education programs and a suboptimal referral system account for the high prevalence of poorly controlled diabetes in academic health systems. In the Emory Healthcare System, the largest health system in Georgia with over 65,000 patients with DM, ∼15-20% of patients have HbA1c &gt;9%. We implemented the Emory Diabetes Management Program (DMP), a chronic care management model that proactively invited patients with HbA1c &gt;9% scheduled to attend an ambulatory clinic to be seen by a Diabetes Educator/Nurse Practitioner team supervised by an endocrinologist.
Among 898 patients scheduled from 01/01/18 to 11/30/2018, 630 (70.2%) patients attended the program (age 56.2 years, females 62%, African-Americans 73%) with a baseline HbA1c of 10.4±2.0%. The intervention resulted in significant reduction in HbA1c levels and higher number of patients achieving HbA1c &lt;9% compared to patients who did not attend the intervention. In addition, more patients in the intervention achieved an LDL &lt; 100 mg/dl and a blood pressure goal &lt;130/80 mm HG (Table 1).
The Emory-DMP, a proactive chronic care model of focused diabetes education and management, is an effective approach for improving care of patients with diabetes, resulting in significant improvement in HbA1c, blood pressure and lipid control.

Disclosure
A. Ayanambakkam Nambi: None. Z.T. Smith: None. M.S. Presswood: None. S. Jacobs: None. A.F. McAleer: None. P.A. Castellano: Advisory Panel; Self; Vizient. M. Khosravanipour: None. R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. F.E. Turton: None. J. Dee: None. C.M. Masi: None. G.J. Esper: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US.
1282-P: Patient-Related Factors Affecting Utilization of Diabetes Care
Authors: GARG RAJESH , CADE WILLIAM H. , BERNAL-MIZRACHI ERNESTO 
Published: June 2019

Factors affecting utilization of diabetes care are not well-studied. This information may help develop strategies to improve the efficiency of healthcare systems. We conducted a study to determine factors associated with repeatedly missing an appointment at a major diabetes care center. Data were obtained from electronic medical records. All patients with two or more appointments during the year 2017 were included in analysis. Patients who missed ≥50% of their clinic visits without cancelling an appointment were defined as the repeatedly missed appointment (RMA) group and those who missed &lt;50% appointments were defined as the regularly attended appointment (RAA) group. All patients had equal opportunity to keep or cancel an appointment irrespective of their insurance coverage. Out of 1,417 patients, 147 (10.4%) had missed ≥50% of their scheduled clinic visits. Mean number of appointments was similar in the RMA group (3.0 ± 1.3) and in the RAA group (2.8 ± 1.2; P = 0.29). A comparison of characteristics between the two groups is shown in Table 1. Multivariate regression analysis showed that younger age, higher BMI, higher HbA1c and lower serum albumin were independent predictors of the percentage of missed appointments. We conclude that patients who repeatedly miss their diabetes appointments have poor overall health and worse diabetes control. Strategies need to be developed to improve utilization of diabetes care by these patients.

Disclosure
R. Garg: None. W.H. Cade: None. E. Bernal-Mizrachi: None.
1284-P: Mobile Patient Portal Access and Diabetes Outcomes
Authors: GRAETZ ILANA , HUANG JIE , FIREMAN BRUCE , HSU JOHN , REED MARY 
Published: June 2019

Objective: Patient portal use can support self-management and expanding mobile portal access can potentially increase use. We examined the association between adding mobile portal access and medication adherence and glycemic levels among patient with diabetes.
Research Design and Methods: Eligible patients were adults with diabetes in an integrated delivery system who filled an oral diabetes prescription at baseline (4/14-3/15), and who did not use insulin. For each study month (4/15-12/17), we categorized patients’ portal access status: never used, personal computer (PC) only, mobile only, or both PC and mobile (first four-months of any status change was categorized separately as a wash-out period). We measured adherence by monthly percent of days covered (PDC) with oral diabetes drugs. To examine glycemic control, we included the subset of patients with HbA1c results (72% of all patients). We assessed the association between portal access and study outcomes (PDC and HbA1c), using linear regression with patient-level fixed effects to account for unmeasured time-stable patient-level confounders, adjusting for temporal trend, and time-varying numbers of drugs and health events.
Results: Among study patients (N= 111,463), the proportion with PC only portal access decreased from 30% to 13%, while the proportion using both mobile and PC increased from 34% to 62%. At baseline, 71.6% of patients had PDC≥80% and 78.8% had HbA1c&lt;8%. Gaining both mobile and PC access was associated with a 1.67 percentage point increase in PDC among those with no portal access initially, and a 0.50 percentage point increase in among those with PC only access initially. Adding both mobile and PC access was associated with a 0.13 reduction in A1c level among those with no portal access initially, and a 0.07 reduction among those with only PC access initially (N=80,072, all p&lt;0.05).
Conclusions: The addition of mobile portal access is associated with higher medication adherence and improved glycemic control for patients with diabetes.

Disclosure
I. Graetz: None. J. Huang: None. B. Fireman: None. J. Hsu: None. M. Reed: None.

Funding
National Institute of Diabetes and Digestive and Kidney Diseases (R01DK085070 to M.R.)
1285-P: Impact of Adding a GLP-1 Receptor Agonist to the Medication Regimen
Authors: JACOBS MICHELLE , ROSE TAYLA , REID DEBRA J. , BOUWMEESTER CARLA , CONLEY MICHAEL , FATEHI BORNA , MATTA THOMAS M. , BARR JUDITH 
Published: June 2019

Glucagon-like peptide-1 receptor agonists (GLP-1 RA) are preferred injectable therapies for type 2 diabetes, but it is uncertain if advantages justify higher medication cost. This real-world, retrospective cohort study at eight ambulatory care sites evaluated change in monthly glucose-lowering medication cost, HbA1c, weight and polytherapy at GLP-1 RA initiation (baseline) and after 6-12 months (follow-up). The population was analyzed as a whole and as subgroups based on baseline medication regimen and demographics.
Results: The study population (n=120) was 67.5% female, age 55.8±11.7 years, obese, 71% minority, equal English and non-English speaking, had high pill and injection burden, and baseline HbA1c 10%. Figure 1 summarizes changes in monthly glucose-lowering medication costs. Overall change in HbA1c was -1.7%, p&lt;0.001. This decrease was consistent in each baseline medication regimen subgroup. Weight decreased overall (-1.8kg, p&lt;0.001), and there was a significant shift to taking fewer oral agents and insulin as well as fewer daily injections, but no meaningful differences were noted when stratified by age (&lt;65 or ≥65 years), gender, English vs. non-English speaking, or race.
Conclusion: Although a positive impact resulted in glycemic control, weight, and reducing polytherapy 6-12 months after adding a GLP-1 RA to the medication regimen, the increase to monthly medication cost will serve as a barrier to treatment.

Disclosure
M. Jacobs: None. T. Rose: None. D.J. Reid: None. C. Bouwmeester: None. M. Conley: None. B. Fatehi: None. T.M. Matta: None. J. Barr: None.
1286-P: U.S. Air Force Project ECHO Diabetes: Our Seven-Year Experience
Authors: BECKMAN DARRICK , TRUE MARK W. , MORROW CONNIE C. , WATSON NINA , WARDIAN JANA L. , TATE JOSHUA M. , SAUERWEIN TOM J. 
Published: June 2019

The U.S. Air Force Medical Service (AFMS) provides medical care for active duty and retired service members and their families, which includes approximately 50,000 patients with diabetes at 76 clinics worldwide. With only 12 AFMS endocrinologists, the majority of diabetes care is provided by primary care providers (PCPs).
In a strategic PCP knowledge expansion effort in 2012, the AFMS Diabetes Center of Excellence (DCOE) established a continuing telemedicine education program patterned after the Project Extension for Community Healthcare Outcomes (ECHO) model. Content of twice monthly video teleconference sessions included various diabetes standard of care topics and opportunities to discuss actual cases in real time.
After seven years, this program has reached 560 unique individuals at 93 locations across the three military services and the Veterans’ Administration. Over time, groups of participants have expanded from providers only to a spectrum of diabetes care delivery disciplines: PCP, specialists, PharmD, NP, PA, RN, RD, and educators. From April through September 2018 alone, 11 presentations resulted in 499 potential CMEs at 33 locations. A total of 200 out of a potential 499 surveys were completed (40% response rate), which indicated an increase in moderate or strong agreement from 28 to 84% in knowledge sufficiency as a result of ECHO session participation. More importantly, those who felt moderate or strong confidence in the treatment of complex diabetes patients increased from 33 to 72%. Virtually all survey participants (96%) indicated a likelihood to make changes to their treatment practice based on content learned during ECHO sessions.
In contrast to a traditional tertiary care referral model, models like Project ECHO Diabetes provide far greater reach, leveraging expert knowledge to increase the quality of diabetes care at the primary care level. In the context of the national diabetes epidemic and endocrinologist shortage, this model represents a realistic and responsible use of diabetes experts.

Disclosure
D. Beckman: None. M.W. True: None. C.C. Morrow: None. N. Watson: None. J.L. Wardian: None. J.M. Tate: None. T.J. Sauerwein: Speaker's Bureau; Self; AstraZeneca, Merck & Co., Inc.
1306-P: Cost Effectiveness of Point-of-Care HbA1c in Primary Care Setting in Brazil
Authors: MEDEIROS DANIELLE S. , ROSA LORENA S. , MISTRO SOSTENES , KOCHERGIN CLAVDIA N. , SOARES DANIELA A. , SILVA KELLE O. , LOUZADO JOSÉ A. , CORTES MATHEUS L. , BEZERRA VANESSA M. , AMORIM WELMA W. , OLIVEIRA MÁRCIO G. 
Published: June 2019

Background: Point-of-care (POC) devices allow to assess HbA1c results in a single visit and facilitates the physicians’ decision making for DM control. This study aimed to assess the cost-effectiveness of POC in comparison to standard laboratory (HPLC method) for HbA1c testing in Brazilian primary care.
Methods: A Markov model was developed in a 10-year time horizon for the perspective of the public health system. Effectiveness was assessed by the rate of HbA1c control after 6-months follow-up. Data were obtained from an ongoing cohort. Controlled and uncontrolled subjects were included in transition states for negative outcomes (cardiovascular diseases and complications). Probabilities and costs of transition states were extracted from a literature review.
Results: Estimated annual cost for patients monitored by HPLC was U.S. $4,884.92 (SD 629.46) for an effectiveness of 0.39. For those monitored by POC, cost and effectiveness were U.S. $5,960.64 (SD 2,514.00) and 0.91, respectively. The evolution of the net monetary benefit is presented in the chart below.
Conclusions: HbA1c tested by POC appears to be cost-effective in comparison with laboratory testing to improve glycemic control and prevent DM-related cardiovascular diseases and complications.

Disclosure
D.S. Medeiros: None. L.S. Rosa: None. S. Mistro: None. C.N. Kochergin: None. D.A. Soares: None. K.O. Silva: None. J.A. Louzado: None. M.L. Cortes: None. V.M. Bezerra: None. W.W. Amorim: None. M.G. Oliveira: None.

Funding
Medtronic Foundation
1319-P: The Ratio of Unmethylated to Methylated Insulin DNA Is Negatively Correlated to Age in Adolescents with Type 2 Diabetes
Authors: HSIA DANIEL S. , MERCER SHELLY , COLLIER JASON , JOHNSON WILLIAM D. , MCCORMICK KEN 
Published: June 2019

Previous studies have inferred that type 2 diabetes diagnosed during adolescence is more fulminant compared to type 2 diabetes diagnosed during adulthood. One hypothesis to explain this disparity is the exaggerated loss of the insulin-producing β-cells in the pancreas. The only known significant source of unmethylated insulin DNA is through the death of β-cells; therefore, the ratio of serum unmethylated to methylated (U/M) insulin DNA, as measured by droplet digital PCR (ddPCR), is predicted to be proportional to the degree of β cell death. While this method has been explored to identify those at risk for type 1 diabetes, it has not been explored to characterize adolescents with type 2 diabetes. Some degree of β-cell loss may account for the exaggerated decompensation in glucose control over time seen in adolescents. The purpose of this pilot study was to determine the extent of β-cell death in adolescents with type 2 diabetes using this novel biomarker. We recruited 18 participants between the ages of 10 and 18 years with an established diagnosis of type 2 diabetes for a single fasting study visit. Genomic DNA was isolated from each participant and was templated for ddPCR using two different primer/probe sets (reported previously by Miramira and colleagues) that discriminated DNA from β-cell sources (unmethylated) and from non-β-cell peripheral tissues (methylated). The U/M ratio was inversely correlated with age (r=-0.72, p&lt;0.001) and with age at diagnosis (r=-0.56, p=0.015) via Spearman correlation. These results suggest that younger adolescents with type 2 diabetes may exhibit more extensive β-cell death compared to older adolescents and that adolescents diagnosed at a younger age may exhibit more extensive β-cell death compared to those diagnosed at an older age as indicated by a higher ratio of U/M insulin DNA.

Disclosure
D.S. Hsia: None. S. Mercer: None. J. Collier: None. W.D. Johnson: None. K. Mccormick: None.

Funding
National Institute of General Medical Sciences (U54GM104940); National Center for Advancing Translational Sciences (UL1TR001417)
1328-P: Racial Differences in Comorbidities in Youth with T2D in the Pediatric Diabetes Consortium (PDC)
Authors: BACHA FIDA , CHENG PEIYAO , GAL ROBIN L. , BEAULIEU LINDSEY C. , KOLLMAN CRAIG , ADOLPH ANNE , JINDAL ISHITA , SHOEMAKER ASHLEY H. , WOLF RISA M. , KLINGENSMITH GEORGEANNA J. , TAMBORLANE WILLIAM V. 
Published: June 2019

Background: Racial differences in diabetes control and cardiovascular disease risk factors have been reported in youth with diabetes, with minority youth having worse glycemic control and comorbidities compared with non-Hispanic white (NHW) peers.
Methods: We examined racial differences in comorbidities in youth (&lt;21 years at enrollment) with T2D (N=1217, 63% females) enrolled in the PDC Registry from February 2012 to June 2018. Demographic and clinical data collected from medical records and participant self-report were compared using logistic and linear regression models adjusted for relevant confounders.
Results: The mean age at presentation was 13.4 ± 2.4 years, and mean BMI Z-score was 2.30 ± 0.45. African-American (AA) and Hispanic (H) youth had higher HbA1c and lower C-peptide at diagnosis compared to NHW, with AA 3 times as likely to present in DKA compared with NHW. Microalbuminuria was present in 11%, hypertension in 34% and dyslipidemia in 42% with no significant differences in these comorbidities among racial groups. Nonalcoholic fatty liver disease (NAFLD) was diagnosed in 9% and 11% of H and NHW, respectively vs. 2% in AA (Table).
Conclusion: Minority youth with T2D presented with worse metabolic control compared with NHW, with higher rates of DKA in AA youth. Comorbidities exist in a large percentage of youth with T2D independent of ethnicity, except for NAFLD being less prevalent in AA.

Disclosure
F. Bacha: Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases, Pediatric Diabetes Consortium. Other Relationship; Self; AstraZeneca, Jaeb Center for Health Research. P. Cheng: None. R.L. Gal: None. L.C. Beaulieu: None. C. Kollman: None. A. Adolph: None. I. Jindal: None. A.H. Shoemaker: Advisory Panel; Self; Rhythm Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, GLWL Research Inc., Novo Nordisk Inc., Rhythm Pharmaceuticals, Inc., Soleno Therapeutics. R.M. Wolf: None. G.J. Klingensmith: Consultant; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Takeda Pharmaceutical Company Limited. Research Support; Self; Novo Nordisk Foundation. Stock/Shareholder; Spouse/Partner; Dexcom, Inc. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited.

Funding
Boehringer Ingelheim; Novo Nordisk; Takeda Pharmaceutical Company Limited
1332-P: Complement C3 and C4 Levels Predict Cardiometabolic Risk in Healthy Adolescents
Authors: HOFFMAN ROBERT P. , YU CHACK-YUNG 
Published: June 2019

Complement, in addition to its immunologic functions, also helps regulate inflammation and fat metabolism. Thus, complement may play a role in the development of the metabolic syndrome. In adults complement component C3 is a risk factor for the development of type 2 diabetes, and a determinant of cardiometabolic risk. Adult cardiometabolic disease has its origins in childhood and adolescence. Therefore, if we are to fully understand the role of complement in cardiometabolic disease we need to study this age group. 56 healthy, non-Hispanic white adolescents (28 F, age 15.4±1.7 years; BMI 22.0±4.9 kg/m2 (mean±SD) were studied. Cardiometabolic risk factors were studied in the fasting state and included measures of vascular function [reactive hyperemia (RH), augmentation index (AI)], lipids, inflammation [white blood cell (WBC) and neutrophil (ANC) count, c-reactive protein (CRP), interleukin 6 (IL6)], carbohydrate metabolism [OGTT: insulin sensitivity (ISEN), insulin secretion (ISEC), disposition index, DI], endothelin 1 and plasminogen activator inhibitor 1 (PAI-1). RH worsened, HDL decreased and ANC, LDL, triglycerides and ISEC increased with increasing C3. RH and HDL were also negatively related to C4 while WBC, ANC, IL6 and DI were positively related to C4. Adjustment for body habitus eliminated the relationships of HDL, LDL and ISEC but not ANC or triglycerides to C3 and/or C4. Adjusted PAI-1 was significantly related to C3. Except for the positive relationship between C4 and DI these relationships demonstrate that increasing levels of C3 and C4 are associated with increasing cardiometabolic risk in healthy, non-Hispanic white adolescents. Increasing C3 levels may influence increasing triglyceride levels while increasing C4 is more closely related to increasing inflammation.

Disclosure
R.P. Hoffman: Other Relationship; Self; Novo Nordisk A/S. C. Yu: None.

Funding
American Heart Association; National Institutes of Health
1340-P: Higher Morning Serum Cortisol (MSC) Associates with Prediabetes and Other Metabolic Syndrome (MetSyn) Components in Predominantly Latino Adolescents
Authors: TOLEDO-CORRAL CLAUDIA M. , LANE CHRISTIANNE J. , WEIGENSBERG MARC 
Published: June 2019

Chronic life stress and “allostatic load” may increase risk for MetSyn. This study examines the associations between MSC, prediabetes, and MetSyn components in adolescents with body mass index (BMI) ranging from underweight to obese. Fasting blood was drawn ∼8AM from 191 healthy adolescents (126F/65M; 16.4±0.6 years; 95% Latino) to measure MSC, glucose, HbA1C, and lipids; triplicate measurements of BMI, waist circumference, and systolic/diastolic blood pressure (BP). All analyses were adjusted for a priori covariates of age, sex, BMI, and ethnicity. MSC was higher in adolescents with prediabetes (fasting glucose 100-125 mg/dL, n=20) vs. normoglycemia (Figure). This relationship was not seen when applying the prediabetes definition of HbA1C 5.7-6.4%. Higher MSC was associated with higher fasting glucose (β=0.02±0.005, p&lt;0.001) and triglycerides (β=0.06±0.02, p=0.003). MSC was not associated with waist circumference, HDL cholesterol, HbA1c, or systolic/diastolic BP in linear modeling. However, adolescents with borderline/high BP (n=27) exhibited higher MSC compared to those with normal BP (516±32 vs. 392±12 nnol/L, p&lt;0.001). The significant relationships between MSC, prediabetes and other MetSyn components suggest further study of the link between allostatic load and diabetes/cardiometabolic risk in adolescents is warranted.

Disclosure
C.M. Toledo-Corral: None. C.J. Lane: None. M. Weigensberg: None.

Funding
National Institutes of Health (R01AT008330)
1344-P: Persistent ß-Cell Responsiveness in Children at High Risk for Type 1 Diabetes (T1D) Is Associated with Decreased Progression to T1D in the Diabetes Prevention Trial-Type 1 (DPT-1)
Authors: SIMS EMILY K. , ISMAIL HEBA M. , NATHAN BRANDON M. , SOSENKO JAY M. 
Published: June 2019

High-risk individuals with islet autoantibody positivity (Ab+) vary in their rates of progression to T1D. We hypothesized that changes in C-peptide over time account for some of this variation. Among Ab+ children (&lt;18.0 years) followed with 2-hour OGTTs for development of T1D in DPT-1, we compared Progressors to T1D with Non-Progressors for the change in AUC C-peptide from the baseline OGTT to the last available OGTT (last before diagnosis in Progressors). Results were stratified by low or high baseline DPT-1 Risk Score (DPTRS: fasting C-peptide, sum C-peptide and sum glucose values from 30-120 minutes, age and BMI; DPTRS &lt;7.00= lower risk and ≥7.00= higher risk). As shown in the Table, Non-Progressors from each group exhibited increases in AUC C-peptide over time, while Progressors showed no significant changes in AUC C-peptide. A logistic regression model with adjustment for age indicated an inverse association of T1D development with increasing AUC-C-peptide/year [Odds ratio: 0.587 (0.430, 0.802), p&lt;0.001].
In conclusion, even in individuals with high baseline risk assessments, increasing AUC C-peptide over time is associated with decreased progression to T1D. This persistent C-peptide responsiveness could result from increased β-cell reserve (either functional or mass) or β-cell regeneration.

Disclosure
E.K. Sims: None. H.M. Ismail: None. B.M. Nathan: None. J.M. Sosenko: None.

Funding
National Institutes of Health