bluuebunny/crossref_metadata_2025_split huggingface dataset:
1249-P: Development and Validation of a Measure for Appropriateness of Glucose-Lowering Therapy
Authors: MCCOY ROZALINA G. , LIPSKA KASIA J. , HOUTEN HOLLY VAN , SHAH NILAY 
Published: June 2019

Current diabetes quality indicators do not reflect considerations of clinical complexity, hypoglycemia risk, and treatment burden in identifying optimal therapeutic regimens and targets.
Based on existing evidence and input from patients and clinician, payer, and quality measurement experts, we developed a metric that incorporates HbA1c level, comorbidity burden, and number/type of glucose lowering medications (Table) to classify patients as potentially overtreated, undertreated, or appropriately treated. Measure was tested in a national cohort of commercial and Medicare Advantage enrollees with diabetes using the OptumLabs® Data Warehouse.
Among 215,429 adults ≥18 years (mean 65 years, 49.6% female, 59.4% white, 4.2% type 1 diabetes, 12.1% clinically complex, 52.7% with HbA1c &lt;7%), 71.0% were treated appropriately, 21.3% undertreated, and 7.7% overtreated in 2015. Compared with current measures (HbA1c &lt;8% for all), 4.4% low complexity and 12.6% high complexity patients were reclassified as no longer appropriately treated. Rates of hypoglycemia-related ED/hospitalization visits in 2016 were 7.0, 12.4, and 22.9 per 1000 persons/year for those appropriately, under-, and over-treated in 2015. Rates of hyperglycemia-related visits were 2.5, 12.2, and 4.6.
Implementation of this measure to minimize over- and under-treatment through a patient-centered approach to glucose lowering therapy is planned.

Disclosure
R.G. McCoy: None. K.J. Lipska: Consultant; Self; Health Services Advisory Group (HSAG). Research Support; Self; National Institute on Aging. Other Relationship; Self; Centers for Medicare and Medicaid Services. H. Van Houten: None. N. Shah: None.

Funding
American Association of Retired Persons; OptumLabs; National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)
1250-P: Developing an “Appropriateness of Glucose-Lowering Therapy” Measure: Qualitative Analysis of Delphi Panel Deliberations
Authors: LAVECCHIA CHRISTINA M. , MONTORI VICTOR M. , SHAH NILAY , MCCOY ROZALINA G. 
Published: June 2019

Despite the increasing focus on individualized diabetes care, current diabetes quality measures are still based on meeting generic HbA1c targets. We proposed an alternative measure to assess the appropriateness (vs. over- or under-treatment) of glucose-lowering therapy that accounts for patient complexity and treatment burden. We worked with OptumLabs® to convene a 12-member modified Delphi panel, selected from among its partner institutions and the NQF Measure Incubator® network, to refine the measure. Members included clinicians (endocrinology, primary care, geriatrics), pharmacists, nurses, researchers, and representatives of public and private health plans. In this study, we examined the factors the panel valued in an ideal appropriateness measure.
Two researchers independently coded panelists’ written responses to a range of questions about the appropriateness measure. Conducting an inductive analysis, codes and overarching themes emerged by consensus. Participants conveyed that an ideal measure must promote individualized care (evidence-based treatments that are consistent with patient psychosocial and biological context, their values and preferences), allow for clinical decision making, and have optimal accountability properties (be easy to implement with reasonable accuracy and reliability, without unintended effects on utilization). Panelists prioritized protecting patient and clinician autonomy, reducing patient treatment burden and clinician punitive potential, and allowing for reasonable clinical exceptions.
Our analysis identified factors that stakeholders value in formulating an appropriateness measure for glucose-lowering therapy. Addressing these factors, and those identified by people with diabetes in subsequent research, may produce a quality measure that strikes a patient-centered balance between glucose control targets and the everyday complexities of being, and treating, people with diabetes.

Disclosure
C.M. LaVecchia: None. V.M. Montori: None. N. Shah: None. R.G. McCoy: None.

Funding
American Association of Retired Persons; OptumLabs; National Institute of Diabetes and Digestive and Kidney Diseases (K23DK114497)
1251-P: The Diabetes Transition of Hospital Care (DiaTOHC) Pilot Study: A Randomized Controlled Trial of an Intervention Designed to Reduce Readmission Risk of Patients with Diabetes
Authors: RUBIN DANIEL J. , GOLDEN SHERITA , FOSTER GARY , FISHER SUSAN , VAZ CHERIE LISA , ZHAO HUAQING , TANNER SAMUEL , RECCO DOMINIC , TIVON MADELINE , DILLARD FELICIA R. , WATTS SAMANTHA , JOYCE KATHERINE E. , KARUNAKARAN ABHIJANA , REZNICK TANYA , IWAMAYE AMY , MILLER ELI , MATHAI CHRISTINE , ALBURY BONNIE S. 
Published: June 2019

Hospital readmission within 30 days of discharge (30dRe) is a high-priority quality measure and target for cost reduction. Patients with diabetes are at higher risk of 30dRe than patients without diabetes. There have been no published studies of interventions designed to reduce 30dRe risk specifically among diabetes patients.
We conducted a pilot randomized controlled trial (RCT) of the DiaTOHC intervention in adult patients with diabetes admitted to any medical-surgical unit at Temple University Hospital between 10/2017 and 12/2018. Patients predicted to be high risk (&gt;=27%) for 30dRe based on a validated tool (DERRITM) were randomized 1:1 to the intervention (INT) or usual care (UC). The intervention consisted of novel, brief inpatient diabetes education, coordination of care, and post-discharge support by a nurse practitioner and an A1C-based algorithm to adjust diabetes therapy. Patients received weekly calls for 30 days after discharge. The primary outcome was unplanned 30dRe.
Follow-up data was available for 26 INT and 30 UC patients. Mean age was 57.5 years, duration of diabetes 17 years, and median admission A1C 7.9%. The cohort was 75% black, 20% white, 13% Hispanic, 55% female, mostly low-income, and mostly insured by Medicare and/or Medicaid. Most patients (95%) had type 2 diabetes. There were few baseline differences between groups, including years of school (13.5 INT, 11.9 UC, p=0.03) and preadmission insulin use (59.6% INT, 40.4% UC, p&lt;0.01). Six INT and 10 UC patients had a 30dRe (23.1%, 33.3%, P=0.40), yielding a non-significant relative risk reduction of 30.6%, absolute risk reduction of 10.2% and number needed to treat of 10. Median A1C at 3 months among the 18 patients with data was 6.7% INT and 8.4% UC, p=0.19.
This small pilot trial shows the DiaTOHC intervention is feasible. The non-significant but measurable reductions in readmission risk and A1C merit further investigation in a larger RCT.

Disclosure
D.J. Rubin: Research Support; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc. S. Golden: Research Support; Self; Merck & Co., Inc. G. Foster: Employee; Self; Weight Watchers International, Inc. S. Fisher: None. C. Vaz: None. H. Zhao: None. S. Tanner: None. D. Recco: None. M. Tivon: None. F.R. Dillard: None. S. Watts: None. K.E. Joyce: None. A. Karunakaran: None. T. Reznick: None. A. Iwamaye: None. E. Miller: None. C. Mathai: None. B.S. Albury: None.

Funding
National Institute of Diabetes and Digestive and Kidney Diseases (K23DK102963 to D.J.R.)
1253-P: High Health-Care Utilization (HCU) and Costs Associated with Diabetes Mellitus (DM) and Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis (NAFLD/NASH) in Medicare Patients
Authors: GORDON STUART , FRAYSSE JEREMY , LI SUYING , OZBAY A. BURAK , WONG ROBERT 
Published: June 2019

Background: One of the common comorbidities in NAFLD/NASH patients is DM. This study evaluated HCU and costs in NAFLD/NASH patients with varying liver disease severity by DM status.
Methods: This was a retrospective study from 2007-2015 of a 20% sample of U.S. Medicare beneficiaries and included NAFLD/NASH patients (ICD codes) with and without DM (ICD codes/medications). Mean annual healthcare costs were reported in 2015 USD and stratified by NAFLD/NASH only, compensated cirrhosis (CC), decompensated cirrhosis (DCC), liver transplant (LT), and hepatocellular carcinoma (HCC) and presence of DM.
Results: This study identified 260,950 NAFLD/NASH patients, of which 144,862 (55.5%) also had comorbid DM. NAFLD/NASH CC patients with DM had high rates of additional metabolic comorbidities: 77.5% with cardiovascular disease and 87.5% with both hypertension and hyperlipidemia. Mean annual number of hospitalizations in NAFLD/NASH only with DM was 0.6, which significantly increased in CC (0.8) and DCC (2.2) DM patients. Mean annual healthcare costs were significantly higher in those with comorbid DM (except HCC) (Figure).
Conclusions: Comorbid DM among NAFLD/NASH patients is associated with high metabolic comorbidity burden and significantly higher HCU and healthcare costs in U.S. Medicare patients.

Disclosure
S. Gordon: Consultant; Self; Gilead Sciences, Inc., Intercept Pharmaceuticals, Inc. J. Fraysse: Employee; Self; Gilead Sciences, Inc. S. Li: Consultant; Self; Gilead Sciences, Inc. A. Ozbay: Employee; Self; Gilead Sciences, Inc. Stock/Shareholder; Self; Gilead Sciences, Inc. R. Wong: Advisory Panel; Self; Gilead Sciences, Inc. Consultant; Self; Gilead Sciences, Inc. Research Support; Self; Gilead Sciences, Inc. Speaker's Bureau; Self; Gilead Sciences, Inc.
1258-P: Physician Survey on Discontinuing Dipeptidyl Peptidase-4 Inhibitors (DPP-4is) following Insulin Initiation in Patients with Type 2 Diabetes (T2D) in the U.S.
Authors: FERNANDES GAIL , JAFFE DENA H. , BEYER GRACE DIBONAVENTURA , MATOS JOANA E. , IGLAY KRISTY , GANTZ IRA , RAJPATHAK SWAPNIL 
Published: June 2019

At the time of insulin initiation, physicians often discontinue oral therapies in patients with T2D. A recent randomized clinical trial demonstrated continuing sitagliptin, a DPP-4i, results in a clinically meaningful greater reduction in HbA1c without an increase in hypoglycemia. An online U.S. physician survey (n=400) is being conducted to understand reasons for discontinuation of DPP-4i therapy. Preliminary analysis is based on completed surveys (n=180; 41 endocrinologists, 74 family practice, 63 internal medicine, 2 diabetologists) from physicians treating a monthly average of 137 patients. Table lists key physician characteristics and their responses for continuing/discontinuing DPP-4i on initiation of insulin. The top responses for continuing DPP-4i include meeting treatment goals, using a lower dose of insulin, good tolerability, reducing weight gain and hypoglycemia. The top responses for discontinuing include adverse events/tolerability, cost, treatment goals not being met, patient preference, and prior authorization requirements. In this ongoing study, further data is being collected on the remaining physician sample and a medical chart review will be conducted on a sub-sample of patients treated by these physicians to explore patient characteristics associated with DPP-4i discontinuation.

Disclosure
G. Fernandes: None. D.H. Jaffe: Consultant; Self; Merck & Co., Inc. G. DiBonaventura Beyer: None. J.E. Matos: None. K. Iglay: Employee; Self; Merck & Co., Inc. Stock/Shareholder; Self; Merck & Co., Inc. I. Gantz: Employee; Self; Merck & Co., Inc. S. Rajpathak: None.
126-OR: Fat Catch-Up Growth in Early Infancy and Cardiometabolic Outcomes at 5 Years of Age
Authors: ANDERSEN GREGERS S. , WIBAEK RASMUS , ADMASSU BITIYA , VISTISEN DORTE , JØRGENSEN MARIT E. , MICHAELSEN KIM F. , WELLS JONATHAN C. , FRIIS HENRIK 
Published: June 2019

Introduction: The role of infant fat growth in childhood obesity and adult type 2 diabetes is not clear. We have previously used latent class analysis (LCA) to identify four distinct fat mass (FM) growth patterns in early infancy. Here we examine their associations with adiposity and cardiometabolic outcomes at 5 years (y) of age.
Methods: Air Displacement Plethysmography (ADP) was used to repeatedly measure FM from 0-6 months of age in a cohort of 314 healthy urban-living Ethiopian infants and LCA was used to identify FM growth patterns (catch-up, accelerated, average and delayed) (Figure 1). At 5y of age, cardiometabolic outcomes were obtained from ADP and blood samples. Multiple linear regression was used to examine associations between infant FM growth patterns and cardiometabolic outcomes at 5y, adjusted for gender, birthweight, breastfeeding, maternal age and education and SES.
Results: Overall mean (SD) BMI at 5y was 14.98 (1.19) kg/m2. Compared to children with an “average fat” growth pattern, children with a "catch-up fat" pattern had significantly higher BMI (0.79 kg/m2 [95% CI, 0.04; 1.54]) and FMI (0.69 kg/m2 [95% CI, 0.06; 1.37]), but not FFMI (0.05 kg/m2 [-0.51; 0.62]) at 5y of age (Figure 1). There were no differences in any other cardiometabolic outcomes.
Conclusions: Fat catch-up growth in early infancy was associated with a higher BMI in childhood, which was almost entirely fueled by increased adipose tissue.

Disclosure
G.S. Andersen: Stock/Shareholder; Self; Novo Nordisk Inc. R. Wibaek: None. B. Admassu: None. D. Vistisen: Stock/Shareholder; Self; Novo Nordisk A/S. M.E. Jørgensen: Research Support; Self; Amgen Inc., AstraZeneca, Danish Diabetes Association, Sanofi-Aventis. Stock/Shareholder; Self; Novo Nordisk A/S. K.F. Michaelsen: None. J.C. Wells: None. H. Friis: Research Support; Self; Arla Food for Health.

Funding
Danish Council for Strategic Research; Danida (104.Dan.8-1207); Danish Diabetes Academy; Innovation Fund, Denmark
1260-P: A Clinical Care Improvement Pilot Program: Individualized Health Coaching and Use of Incentives for Youth with Type 1 Diabetes and Their Caregivers
Authors: CLARY LAUREN , DAUBER ANDREW , ARBOINE SUE-ANN , DILLON MEREDITH S. ,   BEAKAL (BK) ESHETE, HATCHELL SHAINA , JONES SHARI , VAIDYANATHAN PRIYA , COGEN FRAN R. 
Published: June 2019

In pediatric type 1 diabetes (T1D) care, collaboration among youth, caregivers, and medical providers is important for optimal glycemic control; however, many youth are still unable to achieve A1c goals (A1c &lt; 7.5%). This study examined the effect of a 10-week clinical care pilot program on A1c in youth with suboptimal diabetes control. The program consisted of two primary components: 1) weekly individualized health coaching and insulin dose adjustments and 2) incentives for program completion and decreases in A1c. The program was offered to 179 youth with T1D receiving routine diabetes care (A1c 8.6%-10%). Twenty-five caregivers/youth (youth ages 4-18; Mage=11.6 years, Mean A1c=9.4%) completed the 10-week coaching sessions and follow-up A1c measure. Coaching, conducted at no cost via phone call and email (with caregiver and/or youth), was individualized based on family needs and conducted by diabetes team members. Each youth/family who participated and returned for an A1c measure received a gift card to a local grocery store to further dietary goals. Youth were entered into a drawing to win an iPad upon completion of A1c measure and for reductions in A1c. Of the 25 participants, 20 (80%) exhibited a decrease in A1c level at the end of the 10 weeks (mean decreased A1c of 0.5% across 25). Seventeen youth (68%) had a decrease in A1c greater than 0.5% and 7 youth (28%) had a decrease greater than 1.0%. Results from qualitative interview with health coaches suggest increased engagement and empathy from diabetes team members. Communication via phone/email coupled with outcome based incentives was an effective strategy for decreasing A1c in the short-term. This data suggests that moving from an office centric model of care to a sustained health coaching model delivered via phone/email may be a more effective strategy to improve diabetes outcomes. Patient satisfaction and sustained effect of the intervention will be monitored over time.

Disclosure
L. Clary: None. A. Dauber: Consultant; Self; Novo Nordisk Inc. Research Support; Self; Novo Nordisk Inc. S. Arboine: None. M.S. Dillon: None. B. Eshete: None. S. Hatchell: None. S. Jones: None. P. Vaidyanathan: None. F.R. Cogen: None.
1262-P: Physicians’ Perceptions and Attitudes towards Digitalization and New Technologies in Diabetes Care
Authors: KULZER BERNHARD , ROOS TIMM , HERMANNS NORBERT , EHRMANN DOMINIC , HEINEMANN LUTZ 
Published: June 2019

Digitalization is an emerging field. However, little is known about the perceptions and expectations of physicians towards digitalization and new technologies in diabetes care. We conducted a survey in secondary care practices throughout Germany. A total of 422 physicians completed the online survey (46% female; mean age: 53 years; mean work experience: 25 years). Per practice, 160 people with diabetes used Flash sensor-based glucose monitoring, 41 used real-time continuous glucose monitoring, and 60 used insulin pump therapy. 79.6% of physicians reported a positive or very positive attitude towards digitalization in diabetes care which was somewhat higher than for general digitalization (63.7% reported a positive or very positive attitude). Major advantages of digitalization referred to patient safety (63.4%), better quality of care (62.4%), and decision support (61.9%). The three major barriers were costs (54.6%), legal issues (49.2%), and concerns about data security (40.3%). Current and expected use in 5 years of new technologies are shown in the Figure. The potential for digitalization in diabetes is perceived as very high by physicians. However, costs and safety issues need to be addressed to overcome barriers towards implementation of digital solutions. Currently, the use of digital solutions in routine practice is not common and is expected to grow only marginally in the next 5 years.

Disclosure
B. Kulzer: Advisory Panel; Self; Ascensia Diabetes Care, Berlin-Chemie AG, Medtronic, Novo Nordisk Inc., Roche Diabetes Care. Research Support; Self; Abbott, Berlin-Chemie AG, Roche Diabetes Care. Speaker's Bureau; Self; Abbott, Ascensia Diabetes Care, Berlin-Chemie AG, Eli Lilly and Company, Novo Nordisk Inc., Roche Diabetes Care. T. Roos: None. N. Hermanns: Advisory Panel; Self; Abbott. Board Member; Self; Eli Lilly and Company. Research Support; Self; Abbott, Berlin-Chemie AG, Dexcom, Inc., Roche Diabetes Care. Speaker's Bureau; Self; Berlin-Chemie AG, Dexcom, Inc., Novo Nordisk A/S. D. Ehrmann: Advisory Panel; Self; Medtronic. Speaker's Bureau; Self; Abbott, Berlin-Chemie AG, Dexcom, Inc. L. Heinemann: Consultant; Self; Roche Diabetes Care. Research Support; Self; Dexcom, Inc. Stock/Shareholder; Self; Profil Institute for Metabolic Research, ProSciento.

Funding
Berlin-Chemie AG
1264-P: Predictors of Success in Usual and Intensive Specialty Diabetes Programs
Authors: DEL VALLE KAYLA L. , GRIZALES ANA MARIA , DONAHUE MARINA , TURCHIN ALEXANDER , MCDONNELL MARIE E. 
Published: June 2019

Intensive management (IM) is recognized as an important approach in treatment of poorly controlled diabetes. However, it is unknown what factors determine response to usual diabetes specialty care (UC) vs. IM and understanding these will improve allocation of costly resources. We sought to identify predictors of response in UC and IM, a high-resource 6-month service designed for those who fail UC that includes telemedicine, remote data sharing, and in-person visits. A response metric was defined as an A1c reduction of &gt;/=0.5 within 12 months of the initial visit. We analyzed two groups with baseline A1c &gt;8: 1) UC patients referred to a diabetes specialty clinic between 12/2016 and 8/2017 (N= 163) and 2) IM patients, who were referred after failing metric between 10/2015 and 6/2018 (N=62). The majority met metric (UC-Met: 74%, IM-Met: 61%). In UC and IM, there were no differences between those who met metric and those who did not in age, gender, race or ethnicity. The UC-Met vs. UC-Notmet were similar across quality parameters (SBP, statin prescription, LDL), prior A1c pattern (peak and nadir A1c), and the presence of cognitive impairment. However, IM-Notmet had more cognitive dysfunction (20% vs. 2.6%, p=0.04) and substance abuse (16% vs. 5%, p=0.35) than IM-Met. Those in IM-Met had a lower A1c nadir in the last decade (6.87 vs. 7.26, p=0.04). Prevalence of psychiatric disease was high in both IM groups (60% IM-Notmet and 53% IM-Met).
In conclusion, specialty diabetes services delivered via UC was effective in 74% of patients. The majority of those who fail to achieve clinically significant A1c lowering benefit from resource-intensive programs, especially those who achieved lower A1c levels in the past. However, cognitive impairment and active substance abuse appear to be risk factors for lack of response to high intensity programs, suggesting that resources designed to manage these conditions should be prioritized in affected individuals with diabetes.

Disclosure
K.L. Del Valle: None. A. Grizales: None. M. Donahue: None. A. Turchin: Advisory Panel; Self; Monarch Medical Technologies. Research Support; Self; Eli Lilly and Company. Stock/Shareholder; Self; Brio Systems. M.E. McDonnell: None.
1265-P: The Paradox of Care Delivery for Type 1 Diabetes in Primary Care Settings: A Call for Interventions to Reduce Health Disparities
Authors: WALKER ASHBY F. , CUTTRISS NICOLAS , HALLER MICHAEL J. , YABUT KATARINA , ANEZ-ZABALA CLAUDIA , LAL RAYHAN , SHEEHAN ELENI , BASINA MARINA , HOOD KOREY K. , BERNIER ANGELINA , BAER LINDA G. , FILIPP STEPHANIE L. , WANG C. JASON , TOWN MARISSA , GURKA MATTHEW J. , MAAHS DAVID M. 
Published: June 2019

Adults and children with type 1 diabetes (T1D) in the U.S. do not meet targets for HbA1c. These deficits are even more pronounced based on race/ethnicity and socioeconomic status (SES). Most studies on T1D health outcomes focus on data from endocrinology clinics, yet, primary care clinics play a central role in the management of patients, especially those affected by health disparities. To better understand barriers for individuals with T1D in primary care settings, survey research was conducted with 110 Primary Care Providers (PCPs) in Florida (n=52) and California (n=58) using publicly available state-wide provider directories. Surveys were completed by PCPs in a range of settings including solo (20%), multi-specialty group (35%), single-specialty group (21%), hospital/hospital-owned systems (12%) and ‘other’ (12%). For pediatric T1D populations, 58% of PCPs reported referring children to endocrinologists for diabetes care and only 45% checked HbA1c for children with T1D during clinic visits. For adult T1D populations, 30% of PCPs referred patients to endocrinologists and 65% checked for HbA1c. Overall, providers expressed a lack of confidence in caring for T1D patients, especially when it came to technologies like CGMs (only 28% said they were “moderately” or “extremely” confident herein) and insulin pumps (only 17% said they were “moderately” or “extremely” confident). The lack of confidence surrounding diabetes-technologies was especially evident for PCPs in practice 1-10 years or 31+ years (p&lt;.05 for CGMs and p&lt;.01 for pumps). Despite the lack of confidence in caring for patients with T1D, 73% of PCPs reported filling an insulin prescription for a T1D patient in the last year. Surveys with PCPs from a range of clinical settings demonstrate gaps in delivering standard of care and concurrently reveal the critical role PCPs play in T1D care. Efforts to improve outcomes in T1D must include targeted interventions in primary care settings.

Disclosure
A.F. Walker: None. N. Cuttriss: None. M.J. Haller: Advisory Panel; Self; Pancreum, SAB Biotherapeutics. K. Yabut: None. C. Anez-Zabala: None. R. Lal: Consultant; Self; Abbott. E. Sheehan: None. M. Basina: None. K.K. Hood: Consultant; Self; Lilly Diabetes. Research Support; Self; Dexcom, Inc. Speaker's Bureau; Self; Johnson & Johnson Diabetes Institute. A. Bernier: None. L.G. Baer: None. S.L. Filipp: None. C. Wang: None. M. Town: None. M.J. Gurka: None. D.M. Maahs: Advisory Panel; Self; Novo Nordisk Inc. Consultant; Self; Abbott, Sanofi. Research Support; Self; Dexcom, Inc., Tandem Diabetes Care.

Funding
The Leona M. and Harry B. Helmsley Charitable Trust