Black-white differences in risk of developing retinopathy among individuals with type 2 diabetes

Autonomous Artificial Intelligence Increases Access and Health Equity in Underserved Populations with Diabetes

Diabetic eye disease (DED) is a leading cause of blindness in the world. Early detection and treatment of DED have been shown to be both sight-saving and cost-effective. As such, annual testing for DED is recommended for adults with diabetes and is a Healthcare Effectiveness Data and Information Set (HEDIS) measure. However, adherence to this guideline has historically been low, and access to this sight-saving intervention has particularly been limited for specific populations, such as Black or African American patients. In 2018, the US Food and Drug Agency (FDA) De Novo cleared autonomous artificial intelligence (AI) for diagnosing DED in a primary care setting. In 2020, Johns Hopkins Medicine (JHM), an integrated healthcare system with over 30 primary care sites, began deploying autonomous AI for DED testing in some of its primary care clinics. In this retrospective study, we aimed to determine whether autonomous AI implementation was associated with increased adherence to annual DED testing, and whether this was different for specific populations. JHM primary care sites were categorized as "non-AI" sites (sites with no autonomous AI deployment over the study period and where patients are referred to eyecare for DED testing) or "AI-switched" sites (sites that did not have autonomous AI testing in 2019 but did by 2021). We conducted a difference-in-difference analysis using a logistic regression model to compare change in adherence rates from 2019 to 2021 between non-AI and AI-switched sites. Our study included all adult patients with diabetes managed within our health system (17,674 patients for the 2019 cohort and 17,590 patients for the 2021 cohort) and has three major findings. First, after controlling for a wide range of potential confounders, our regression analysis demonstrated that the odds ratio of adherence at AI-switched sites was 36% higher than that of non-AI sites, suggesting that there was a higher increase in DED testing between 2019 and 2021 at AI-switched sites than at non-AI sites. Second, our data suggested autonomous AI improved access for historically disadvantaged populations. The adherence rate for Black/African Americans increased by 11.9% within AI-switched sites whereas it decreased by 1.2% within non-AI sites over the same time frame. Third, the data suggest that autonomous AI improved health equity by closing care gaps. For example, in 2019, a large adherence rate gap existed between Asian Americans and Black/African Americans (61.1% vs. 45.5%). This 15.6% gap shrank to 3.5% by 2021. In summary, our real-world deployment results in a large integrated healthcare system suggest that autonomous AI improves adherence to a HEDIS measure, patient access, and health equity for patients with diabetes - particularly in historically disadvantaged patient groups. While our findings are encouraging, they will need to be replicated and validated in a prospective manner across more diverse settings.

Considerations for addressing bias in artificial intelligence for health equity

Health equity is a primary goal of healthcare stakeholders: patients and their advocacy groups, clinicians, other providers and their professional societies, bioethicists, payors and value based care organizations, regulatory agencies, legislators, and creators of artificial intelligence/machine learning (AI/ML)-enabled medical devices. Lack of equitable access to diagnosis and treatment may be improved through new digital health technologies, especially AI/ML, but these may also exacerbate disparities, depending on how bias is addressed. We propose an expanded Total Product Lifecycle (TPLC) framework for healthcare AI/ML, describing the sources and impacts of undesirable bias in AI/ML systems in each phase, how these can be analyzed using appropriate metrics, and how they can be potentially mitigated. The goal of these "Considerations" is to educate stakeholders on how potential AI/ML bias may impact healthcare outcomes and how to identify and mitigate inequities; to initiate a discussion between stakeholders on these issues, in order to ensure health equity along the expanded AI/ML TPLC framework, and ultimately, better health outcomes for all.

Building a new regional home for implementation science: Annual Midwest Clinical & Translational Research Meetings

The vision of the Central Society for Clinical and Translational Research (CSCTR) is to "promote a vibrant, supportive community of multidisciplinary, clinical, and translational medical research to benefit humanity." Together with the Midwestern Section of the American Federation for Medical Research, CSCTR hosts an Annual Midwest Clinical & Translational Research Meeting, a regional multispecialty meeting that provides the opportunity for trainees and early-stage investigators to present their research to leaders in their fields. There is an increasing national and global interest in implementation science (IS), the systematic study of activities (or strategies) to facilitate the successful uptake of evidence-based health interventions in clinical and community settings. Given the growing importance of this field and its relevance to the goals of the CSCTR, in 2022, the Midwest Clinical & Translational Research Meeting incorporated new initiatives and sessions in IS. In this report, we describe the role of IS in the translational research spectrum, provide a summary of sessions from the 2022 Midwest Clinical & Translational Research Meeting, and highlight initiatives to complement national efforts to build capacity for IS through the annual meetings.

Social Determinants of Health and Impact on Screening, Prevalence, and Management of Diabetic Retinopathy in Adults: A Narrative Review

Diabetic retinal disease (DRD) is the leading cause of blindness among working-aged individuals with diabetes. In the United States, underserved and minority populations are disproportionately affected by diabetic retinopathy and other diabetes-related health outcomes. In this narrative review, we describe racial disparities in the prevalence and screening of diabetic retinopathy, as well as the wide-range of disparities associated with social determinants of health (SDOH), which include socioeconomic status, geography, health-care access, and education.

Sociodemographic variables associated with risk for diabetic retinopathy

BACKGROUND

Several systemic and sociodemographic factors have been associated with the development and progression of diabetic retinopathy (DR). However, there is limited investigation of the potential role sociodemographic factors may play in augmenting systemic risk factors of DR. We hypothesize that age, sex, race, ethnicity, income, and insurance payor have an impact on hemoglobin A1c (HbA1c), body mass index, and systolic blood pressure, and therefore an upstream effect on the development of DR and vision-threatening forms of DR (VTDR).

METHODS

Multivariable analysis of longitudinal electronic health record data at a large academic retina clinic was performed. Sociodemographic factors included race, ethnicity, income, and insurance payor. Systemic risk factors for DR included hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and body mass index (BMI). VTDR was identified from encounter diagnostic codes indicating proliferative retinopathy or diabetic macular edema. Patient-reported primary address zip codes were used to approximate income level, stratified into quartiles.

RESULTS

From 2016 to 2018, 3,470 patients with diabetes totaled 11,437 visits were identified. Black patients had higher HbA1c and SBP compared to White patients. White patients had higher BMI and SBP compared to patients of unknown/other race and greater odds of VTDR than the latter. Patients of Hispanic ethnicity had significantly higher SBP than non-Hispanic patients. Low-income patients had higher BMI and SBP than high-income patients and greater odds of VTDR than the latter. Medicaid recipients had greater odds of VTDR than those with Blue Care Network (BCN) and Blue Cross Blue Shield (BCBS) insurance. Medicaid and Medicare recipients had higher SBP compared to BCBS recipients. Finally, both higher HbA1c and SBP had greater odds of VTDR. There were no differences in odds of VTDR between White and Black patients or between Hispanic and non-Hispanic patients.

CONCLUSION

Significant associations exist between certain sociodemographic factors and well-known risk factors for DR. Income and payor were associated with increased severity of systemic risk factors and presence of VTDR. These results warrant further investigation of how risk factor optimization and disease prevention may be further improved by targeted intervention of these modifiable sociodemographic factors.

Gene Set Enrichment Analsyes Identify Pathways Involved in Genetic Risk for Diabetic Retinopathy

To identify functionally related genes associated with diabetic retinopathy (DR) risk using gene set enrichment analyses applied to genome-wide association study meta-analyses.

METHODS

We analyzed DR GWAS meta-analyses performed on 3246 Europeans and 2611 African Americans with type 2 diabetes. Gene sets relevant to 5 key DR pathophysiology processes were investigated: tissue injury, vascular events, metabolic events and glial dysregulation, neuronal dysfunction, and inflammation. Keywords relevant to these processes were queried in 4 pathway and ontology databases. Two GSEA methods, Meta-Analysis Gene set Enrichment of variaNT Associations (MAGENTA) and Multi-marker Analysis of GenoMic Annotation (MAGMA), were used. Gene sets were defined to be enriched for gene associations with DR if the P value corrected for multiple testing (Pcorr) was <.05.

RESULTS

Five gene sets were significantly enriched for numerous modest genetic associations with DR in one method (MAGENTA or MAGMA) and also at least nominally significant (uncorrected P < .05) in the other method. These pathways were regulation of the lipid catabolic process (2-fold enrichment, Pcorr = .014); nitric oxide biosynthesis (1.92-fold enrichment, Pcorr = .022); lipid digestion, mobilization, and transport (1.6-fold enrichment, P = .032); apoptosis (1.53-fold enrichment, P = .041); and retinal ganglion cell degeneration (2-fold enrichment, Pcorr = .049). The interferon gamma (IFNG) gene, previously implicated in DR by protein-protein interactions in our GWAS, was among the top ranked genes in the nitric oxide pathway (best variant P = .0001).

CONCLUSIONS

These GSEA indicate that variants in genes involved in oxidative stress, lipid transport and catabolism, and cell degeneration are enriched for genes associated with DR risk. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Association of Patient Characteristics With Delivery of Ophthalmic Telemedicine During the COVID-19 Pandemic

Importance

Telemedicine has been shown to have had reduced uptake among historically marginalized populations within multiple medical specialties during the COVID-19 pandemic. An evaluation of health disparities among patients receiving ophthalmic telemedical care during the pandemic is needed.

Objective

To evaluate disparities in the delivery of ophthalmic telemedicine at Massachusetts Eye and Ear (MEE) during the COVID-19 pandemic.

Design, Setting, and Participants

This retrospective, cross-sectional study analyzed clinical visits at a single tertiary eye care center (MEE) from January 1 to December 31, 2020. Patients who had ophthalmology and optometry clinical visits at the MEE during the study period were included.

Exposures

Telemedicine vs in-person clinical encounters.

Main Outcomes and Measures

Variables associated with use of ophthalmic telemedicine during the study period.

Results

A total of 2262 telemedicine ophthalmic encounters for 1911 patients were included in the analysis. The median age of the patients was 61 (interquartile range, 43-72) years, and 1179 (61.70%) were women. With regard to race and ethnicity, 87 patients (4.55%) identified as Asian; 128 (6.70%), as Black or African American; 23 (1.20%), as Hispanic or Latino; and 1455 (76.14%), as White. On multivariate analysis, factors associated with decreased receipt of telemedical care included male sex (odds ratio [OR], 0.86; 95% CI, 0.77-0.96), Black race (OR, 0.69; 95% CI, 0.56-0.86), not speaking English (OR, 0.63; 95% CI, 0.48-0.81), educational level of high school or less (OR, 0.83; 95% CI, 0.71-0.97), and age (OR per year of age, 0.99; 95% CI, 0.989-0.998). When comparing telephone- and video-based telemedicine visits, decreased participation in video-based visits was associated with age (OR per year of age, 0.96; 95% CI, 0.94-0.98), educational level of high school or less (OR, 0.54; 95% CI, 0.29-0.99), being unemployed (OR, 0.28; 95% CI, 0.12-0.68), being retired (OR, 0.22; 95% CI, 0.10-0.42), or having a disability (OR, 0.09; 95% CI, 0.04-0.23).

Conclusions and Relevance

The findings of this cross-sectional study, though limited to retrospective data from a single university-based practice, suggest that historically marginalized populations were less likely to receive ophthalmic telemedical care compared with in-person care during the first year of the COVID-19 pandemic in the US. Understanding the causes of these disparities might help those who need access to virtual care.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review

Background

Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients.

Methods

The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed.

Results

Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies.

Conclusions

Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01209-w.

Ethnic differences in beta cell function occur independently of insulin sensitivity and pancreatic fat in black and white men

INTRODUCTION

It is increasingly recognized that type 2 diabetes (T2D) is a heterogenous disease with ethnic variations. Differences in insulin secretion, insulin resistance and ectopic fat are thought to contribute to these variations. Therefore, we aimed to compare postprandial insulin secretion and the relationships between insulin secretion, insulin sensitivity and pancreatic fat in men of black West African (BA) and white European (WE) ancestry.

RESEARCH DESIGN AND METHODS

A cross-sectional, observational study in which 23 WE and 23 BA men with normal glucose tolerance, matched for body mass index, underwent a mixed meal tolerance test with C peptide modeling to measure beta cell insulin secretion, an MRI to quantify intrapancreatic lipid (IPL), and a hyperinsulinemic-euglycemic clamp to measure whole-body insulin sensitivity.

RESULTS

Postprandial insulin secretion was lower in BA versus WE men following adjustment for insulin sensitivity (estimated marginal means, BA vs WE: 40.5 (95% CI 31.8 to 49.2) × 10³ vs 56.4 (95% CI 48.9 to 63.8) × 10³ pmol/m² body surface area × 180 min, p=0.008). There was a significantly different relationship by ethnicity between IPL and insulin secretion, with a stronger relationship in WE than in BA (r=0.59 vs r=0.39, interaction p=0.036); however, IPL was not a predictor of insulin secretion in either ethnic group following adjustment for insulin sensitivity.

CONCLUSIONS

Ethnicity is an independent determinant of beta cell function in black and white men. In response to a meal, healthy BA men exhibit lower insulin secretion compared with their WE counterparts for their given insulin sensitivity. Ethnic differences in beta cell function may contribute to the greater risk of T2D in populations of African ancestry.

Cocoa olein glycerolysis with lipase

In this paper we present the valorization of cocoa olein obtained from the acid fat-splitting of soapstocks. The aim is to develop a solvent free process (enzymatically catalyzed) to maximize the production of a final product with high content of monoglycerides (MAG) and diglycerides (DAG). The effect of the enzyme dose, glycerol content, reaction times as well as the modification of the raw material and pressure were studied. The yield of the reaction increased up to 90-95% when using a vacuum of 2-3 mbar at 65 °C, enough to evaporate the water which is generated as a by-product, an enzyme dose of 1% and molar ratio oil:glycerol of 1:2. The highest yield in terms of MAG and DAG production was obtained by starting from a raw material which was rich in free acidity (FFA), rendering oil with 33.4 and 44.2% MAG and DAG, respectively. Short reaction times (6-8 h) were observed compared to previously reported results (24 h).

Assessment of retinal vascular oxygenation and morphology at stages of diabetic retinopathy in African Americans

BACKGROUND

Diabetic retinopathy (DR) is a microvascular complication of diabetes and a leading cause of blindness in working-age adults. The likelihood of visual impairment associated with DR is two-fold higher in the African-American (AA) compared to non-Hispanic white. Although alterations in retinal vessel oxygenation and morphology have been reported in DR, there is limited knowledge about these vascular changes in AA subjects. The purpose of the current study was to investigate alterations in retinal vascular oxygen saturation (SO2), vessel diameter (D) and tortuosity at severity stages of DR in AA subjects.

METHODS

A nested case-control study of 56 AA subjects was conducted. Right eyes were grouped as non-diabetic (ND) (N = 26), no clinical DR (NDR) (N = 19), or moderate/severe non-proliferative DR (NPDR) (N = 11). Imaging was performed using a commercially available scanning laser ophthalmoscope. Images were analyzed to determine retinal arterial and venous SO2 (SO2A and SO2V), diameter (DA and DV), and vessel tortuosity index (VTI) (VTIA and VTIV).

RESULTS

SO2V and DV were higher in NPDR compared to ND and NDR groups (P < 0.05). There were no significant differences in SO2A and DA among ND, NDR, and NPDR groups (P > 0.8). Maximum VTIA was higher in diabetics (NDR and NPDR) compared to non-diabetics (P < 0.03). There was no significant difference in maximum VTIV among the 3 groups (P = 0.5).

CONCLUSIONS

The findings advance our understanding of DR pathophysiology in the AA population and may propel identification of race-specific retinal vascular biomarkers for improved diagnosis and monitoring of DR.

Differences in macular capillary parameters between healthy black and white subjects with Optical Coherence Tomography Angiography (OCTA)

Purpose

To investigate if there are differences in macular capillaries between black and white subjects using optical coherence tomography angiography (OCTA) and identify potential factors underlying the epidemiologically-based higher vulnerability of black populations to diabetic retinopathy (DR).

Methods

This prospective, observational cross-sectional study included 93 eyes of 47 healthy subjects with no medical history and ocular history who self-identified as black or white and were matched for age, sex, refractive error, and image quality. Subjects underwent OCTA imaging (RTVue-XR Avanti) of the superficial (SCP) and deep (DCP) capillary plexuses and choriocapillaris. AngioAnalytics was used to analyze vessel density (VD) and choriocapillaris % blood flow area (BFA) in the 1mm-diameter fovea, parafovea, and 3mm-diameter circular area including the fovea and parafovea (3x3mm image). Foveal avascular zone (FAZ) was also analyzed. Linear mixed models were used to evaluate for differences between the study groups.

Results

Compared to the white subjects in this study, black subjects were found to have: lower foveal VD in the SCP (p<0.05); lower VD in the parafovea and in the 3x3mm image in the DCP (p<0.05); larger FAZ in SCP and DCP (p<0.05); and decreased choriocapillary BFA in the area underlying the fovea, parafovea, and 3x3mm image (p<0.05).

Conclusion

In our study, our black subjects had decreased macular capillary vasculature compared to matched white subjects, even in early adulthood and the absence of any systemic or ocular conditions. To our knowledge, this is the first report showing that retinal and choriocapillary vascular differences may contribute to racial disparities in vulnerability to DR.

Association of first-trimester HbA1c levels with adverse pregnancy outcomes in different ethnic groups

AIM

To determine, in a multi-ethnic cohort, the association of first-trimester HbA1c levels with the development of pregnancy complications.

METHODS

A prospective study between April 2013-October 2016. Participants were stratified in five ethnic groups. Women had an HbA1c measurement added to their first antenatal bloods. Primary outcome was macrosomia and secondary outcomes included preeclampsia and large-for-gestational age (LGA). A multivariate logistic regression analysis was performed to adjust for potential confounders in determining the association between different HbA1c cut-off points and obstetric outcomes on each ethnic group.

RESULTS

1,882 pregnancies were included. Analysis was limited to the three main ethnic groups: Caucasian (54.3%), South-Central Asian (19%) and Latin-American (12.2%). There was no association between HbA1c levels and obstetric outcomes among Caucasians. In Latin-Americans, an HbA1c ≥ 5.8% (40 mmol/mol) was associated with higher risk of macrosomia, whereas an HbA1c ≥ 5.9% (41 mmol/mol) was associated with LGA. In South-Central Asian, an HbA1c ≥ 5.7% (39 mmol/mol) was associated with increased risk of macrosomia and a continuous graded relationship between HbA1c levels and preeclampsia and LGA was detected starting at HbA1c levels of 5.4% (36 mmol/mol).

CONCLUSION

First-trimester HbA1c levels perform as a suitable predictor of pregnancy complications in South-Central Asian and Latin-American women whereas in Caucasian no significant associations were found.

Can the appropriateness of eye care be measured through cross-sectional retrospective patient record review in eye care practices in Australia? The iCareTrack feasibility study

OBJECTIVES

The CareTrack study found that a wide range of appropriateness of care (ie, care in line with evidence-based or consensus-based guidelines) was delivered across many health conditions in Australia. This study therefore aimed to demonstrate the feasibility of using the CareTrack method (a retrospective onsite record review) to measure the appropriateness of eye care delivery.

DESIGN

Cross-sectional feasibility study.

SETTING AND PARTICIPANTS

Two hundred and thirteen patient records randomly selected from eight optometry and ophthalmology practices in Australia, selected through a combination of convenience and maximum variation sampling.

METHODS

Retrospective record review designed to assess the alignment between eye care delivered and 93 clinical indicators (Delphi method involving 11 experts) extracted from evidence-based clinical practice guidelines.

PRIMARY OUTCOME MEASURE

Number of eligible patient records, sampling rates and data collection time. This feasibility study also tested the ability of 93 clinical indicators to measure percentage appropriate eye care for preventative, glaucoma and diabetic eye care. A secondary outcome was the percentage of practitioner-patient encounters at which appropriate eye care was received.

RESULTS

A median of 20 records (range 9 to 63) per practice were reviewed. Data collection time ranged from 3 to 5.5 hours (median 3.5). The most effective sampling strategy involved random letter generation followed by sequential sampling. The appropriateness of care was 69% (95% CI 67% to 70%) for preventative eye care, 60% (95% CI 56% to 58%) for glaucoma and 63% (95% CI 57% to 69%) for diabetic eye care.

CONCLUSIONS

Appropriateness of eye care can be measured effectively using retrospective record review of eye care practices and consensus-based care indicators.

Incidence of diabetic eye disease among migrants: A cohort study of 100,000 adults with diabetes in Denmark

AIMS

To examine the incidence rates of any and referable diabetic retinopathy (DR) among migrants in Denmark.

METHODS

Nationwide clinical data on diabetes patients followed since 2005 were analysed. Patients were classified according to country of origin into six groups: Denmark, other Europe, Sub Saharan Africa, Middle East/North Africa, Asia, and America/Oceania. A total of 93,780 or 110,897 patients without any (including unspecific diagnoses) or referable (proliferative) DR at baseline were analyzed. We estimated event rates and hazard ratios (HRs) for incidence of any and referable DR according to country of origin.

RESULTS

After an average follow-up of 3.59 years 6727 had incident any DR and 4747 patients had referable DR. Compared to people of Danish origin, migrants from the Middle East/North Africa and Asia had a higher risk of any and referable DR after adjustment for age, sex, body mass index, smoking status, types and duration of diabetes, clinic type (general practice vs outpatient clinic), HbA1c, blood pressure and lipid levels. The associations remained significant after further adjustment for frequency of eye screening.

CONCLUSIONS

Migrants from the Middle East/North Africa and Asia were at increased risk of developing any and referable DR compared to native Danes, and these differences were not fully explained by differences in underlying clinical, diabetic and cardiometabolic risk factors.

Diabetic Retinopathy: Focus on Minority Populations

Diabetic retinopathy is a major cause of blindness in the United States. With rise of the epidemic of obesity and diabetes in the USA and around the globe, serious and common diabetic complications are evolving as a major public health problem, particularly among minority populations. These populations are disproportionately affected by diabetes and 2-3 times more likely to develop visually significant complications. In this highly illustrated review article, we discuss the diabetic epidemic, highlighting the biology and the pathophysiologic mechanisms of this disorder on the anatomy of the eye. We also discuss the risk factors and the implications for minority populations. For the health care providers, we provide cutting edge information and imminently relevant information to help evaluate, manage, and know when to refer their patients to a specialist in ophthalmology to quell the tide of the epidemic.

The Effect of Physician Feedback and an Action Checklist on Diabetes Care Measures

The objective was to evaluate whether physician feedback accompanied by an action checklist improved diabetes care process measures. Eighty-three physicians in an academic general medicine clinic were provided a single feedback report on the most recent date and result of diabetes care measures (glycosylated hemoglobin [A1c], urine microalbumin, serum creatinine, lipid levels, retinal examination) as well as recent diabetes medication refills with calculated dosing and adherence on 789 patients. An educational session regarding the feedback and adherence information was provided. The physicians were asked to complete a checklist accompanying the feedback on each of their patients, indicating requested actions with respect to follow-up, testing, and counseling. The physicians completed 82% of patient checklists, requesting actions consistent with patient needs on the basis of the feedback. Of the physicians, 93% felt the patient information and intervention format to be useful. The odds of urine microalbumin testing, serum creatinine, lipid profile, A1c, and retinal examination increased in the 6 months after the feedback. The increase was sustained at 1 year only for microalbumin and retinal exams. There was no significant change in refill adherence for the group overall after the feedback, although adherence did improve among patients of physicians attending the educational session. No significant change was noted in lipid or A1c levels during the study period. In conclusion, a simple physician feedback tool with action checklist can be both helpful and popular for improving rates of diabetes care guideline adherence. More complex interventions are likely required to improve diabetes outcomes.

Will the Affordable Care Act (ACA) Improve Racial/Ethnic Disparity of Eye Examination Among US Working-Age Population with Diabetes?

This study aimed to examine the racial/ethnic disparity of eye examination rates among US adults with diabetes before and after the ACA. Working-age adults (18-64 years) with diabetes for years 2014-2017 were simulated by bootstrapping from the working-age diabetes patient sample of Medical Expenditure Panel Survey (MEPS) Household Component 2011. Insurance coverage rates were separately predicted for each racial/ethnic group based on the Congressional Budgeting Office (CBO) report in 2014 and the proportions of Medicaid eligibility. Eye examination rates were weighted to national estimates and compared between racial/ethnic groups. Confidence intervals were estimated using the bootstrap percentile method. Health insurance coverage after the ACA is projected to increase from 90.23 % in 2011 to 98.33 % in 2014 among non-Hispanic Whites (NHW), reaching 98.96 % in 2017. Minorities are forecasted to have about 15 % expansion of insurance coverage from 2011 (80.65 %) to 2014 (96.00 %), reaching 97.25 % in 2017. In 2011, 63.01 % of NHW had eye examinations with forecasted increase to 65.83 % in 2014 and 66.05 % in 2017, while the eye examination rate in the minorities will increase from 55.75 % in 2011 to 59.23 % in 2014 and remain at 59.48 % in 2017. Therefore, racial disparity in eye examination rates is forecasted to persist (ranging from 6.57 % in 2017 to 6.69 % in 2016). The ACA is projected to improve the eye examination rate along with the expansion in insurance coverage. Although predicted racial/ethnic disparities will improve, some differences will persist. Comprehensive strategies need to be developed to eliminate the disparity.

Cultural and Cognitive Determinants of Personal Control in Older African Americans with Diabetes

ACKNOWLEDGEMENTS

The study was funded by Pennsylvania Department of Health's Commonwealth Universal Research Enhancement (CURE) Program (SAP#4100051727).

OBJECTIVE

To describe the determinants of personal control over diabetes complications in older African Americans (N=123) with type 2 diabetes.

METHODS

We administered structured instruments to assess perceptions of personal control, time orientation, religiosity, depression, and cognition in this cross-sectional study.

RESULTS

More years of education (p ≤ .001), better Clock Drawing (p ≤ .001), higher levels of Religiosity (p ≤ .04), and lower Present Time Orientation (p ≤ .01 ) were independent predictors of higher levels of Personal Control.

DISCUSSION

Risk perceptions of control over diabetes complications vary among older African Americans according to cultural constructs, executive function, and education. This finding highlights the cultural diversity in this population and the potential impact of culturally-determined views and cognitive function on health behaviors. Cognitive screening of older persons with diabetes and interventions that incorporate perceptions of time and religion to increase rates of eye examinations are needed.

Risk Factors for Proliferative Diabetic Retinopathy in African Americans with Type 2 Diabetes

PURPOSE

To assess personal and demographic risk factors for proliferative diabetic retinopathy in African Americans with type 2 diabetes.

METHODS

In this prospective, non-interventional, cross-sectional case-control study, 380 African Americans with type 2 diabetes were enrolled. Participants were recruited prospectively and had to have either: (1) absence of diabetic retinopathy after ≥10 years of type 2 diabetes, or (2) presence of proliferative diabetic retinopathy when enrolled. Dilated, 7-field fundus photographs were graded using the Early Treatment Diabetic Retinopathy Study scale. Covariates including hemoglobin A1C (HbA1C), blood pressure, height, weight and waist circumference were collected prospectively. Multivariate regression models adjusted for age, sex and site were constructed to assess associations between risk factors and proliferative diabetic retinopathy.

RESULTS

Proliferative diabetic retinopathy was associated with longer duration of diabetes (odds ratio, OR, 1.62, p < 0.001), higher systolic blood pressure (OR 1.65, p < 0.001) and insulin use (OR 6.65, p < 0.001) in the multivariate regression analysis. HbA1C was associated with proliferative diabetic retinopathy in the univariate analysis (OR 1.31, p = 0.002) but was no longer significant in the multivariate analysis.

CONCLUSIONS

In this case-control study of African Americans with type 2 diabetes, duration of diabetes, systolic hypertension and insulin use were strong risk factors for the development of proliferative diabetic retinopathy. Interestingly, HbA1C did not confer additional risk in this cohort.

African Ancestry Analysis and Admixture Genetic Mapping for Proliferative Diabetic Retinopathy in African Americans

PURPOSE

To examine the relationship between proportion of African ancestry (PAA) and proliferative diabetic retinopathy (PDR) and to identify genetic loci associated with PDR using admixture mapping in African Americans with type 2 diabetes (T2D).

METHODS

Between 1993 and 2013, 1440 participants enrolled in four different studies had fundus photographs graded using the Early Treatment Diabetic Retinopathy Study scale. Cases (n = 305) had PDR while controls (n = 1135) had nonproliferative diabetic retinopathy (DR) or no DR. Covariates included diabetes duration, hemoglobin A1C, systolic blood pressure, income, and education. Genotyping was performed on the Affymetrix platform. The association between PAA and PDR was evaluated using logistic regression. Genome-wide admixture scanning was performed using ANCESTRYMAP software.

RESULTS

In the univariate analysis, PDR was associated with increased PAA (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.16-1.59, P = 0.0002). In multivariate regression adjusting for traditional DR risk factors, income and education, the association between PAA and PDR was attenuated and no longer significant (OR = 1.21, 95% CI = 0.59-2.47, P = 0.61). For the admixture analyses, the maximum genome-wide score was 1.44 on chromosome 1.

CONCLUSIONS

In this largest study of PDR in African Americans with T2D to date, an association between PAA and PDR is not present after adjustment for clinical, demographic, and socioeconomic factors. No genome-wide significant locus (defined as having a locus-genome statistic > 5) was identified with admixture analysis. Further analyses with even larger sample sizes are needed to definitively assess if any admixture signal for DR is present.

"I Kept Coming for the Love": Enhancing the Retention of Urban African Americans in Diabetes Education

PURPOSE

The purpose of the study was to investigate how retention strategies employed by the Diabetes Empowerment Program (DEP) contributed to retention.

METHODS

An experienced moderator conducted in-depth interviews (n = 7) and 4 focus groups (n = 29) with former DEP participants. Interviews were recorded, transcribed, and coded using iteratively modified coding guidelines. Results were analyzed using Atlas.ti 4.2 software.

RESULTS

Participants were African American and predominantly female, low income, and with more than 1 diabetes complication. Key retention themes included: (1) educator characteristics and interpersonal skills ("The warmth of the staff . . . kept me coming back for more."), (2) accessible information ("I didn't know anything about diabetes [before]. I was just given the medicine."), (3) social support ("I realized I wasn't the only one who has diabetes."), (4) the use of narrative ("It's enlightening to talk about [my diabetes]."), and (5) the African American helping tradition ("I went not just for myself but for my husband.").

CONCLUSIONS

While many interventions focus on costly logistics and incentives to retain at-risk participants, study findings suggest that utilizing culturally tailored curricula and emphasizing interpersonal skills and social support may be more effective strategies to retain low-income African Americans in diabetes education programs.

Racial disparity of eye examinations among the U.S. working-age population with diabetes: 2002-2009

OBJECTIVE

Diabetes care differs across racial and ethnic groups. This study aimed to assess the racial disparity of eye examinations among U.S. adults with diabetes.

RESEARCH DESIGN AND METHODS

Working-age adults (age 18-64 years) with diabetes were studied using data from the Medical Expenditure Panel Survey Household Component (2002-2009) including the Diabetes Care Survey. Racial and ethnic groups were classified as non-Hispanic whites and minorities. People reporting one or more dilated eye examination were considered to have received an eye examination in a particular year. Eye examination rates were compared between racial/ethnic groups for each year, and were weighted to national estimates. Multivariate adjusted odds ratios (aORs) and 95% CIs for racial/ethnic difference were assessed annually using logistic regression models. Other influencing factors associated with eye examination were also explored.

RESULTS

Whites had consistently higher unadjusted eye examination rates than minority populations across all 8 years. The unadjusted rates increased from 56% in 2002 to 59% in 2009 among whites, while the rates in minorities decreased from 56% in 2002 to 49% in 2009. The largest significant racial gap of 15% was observed in 2008, followed by 11%, 10%, and 7% in 2006, 2009, and 2005, respectively (P < 0.05). Minorities were less likely to receive eye examination (2006: aOR 0.75 [95% CI 0.57-0.99]; 2008: 0.61 [0.45-0.84]).

CONCLUSIONS

The racial/ethnic differences in eye examinations for patients with diabetes have persisted over the last decade. National programs to improve screening and monitoring of diabetic retinopathy are needed to target minority populations.

Concordance of retinopathy and nephropathy over time in Type 1 diabetes: an analysis of data from the Diabetes Control and Complications Trial

AIMS

Little is known about the dynamic relationship over time between diabetic retinopathy and nephropathy. Thus, we sought to evaluate the concordance over time of retinopathy and nephropathy in patients with Type 1 diabetes during the Diabetes Control and Complications Trial.

METHODS

This analysis was conducted in patients with Type 1 diabetes participating in the Diabetes Control and Complications Trial. Only participants with urinary albumin excretion rate < 40 mg/24 h were included in the analysis (n = 1365). We evaluated the relationship between the progression of retinopathy and the development of nephropathy over a mean 6.5 years of follow-up. Progression of retinopathy was defined by 3-step change in Early Treatment Diabetic Retinopathy Study score on consecutive annual evaluations. Development of nephropathy was defined as incidence of urinary albumin excretion rate ≥ 40 mg/24 h on annual evaluation.

RESULTS

Over a mean 6.5 years of follow-up, the incidence of progression of retinopathy was higher in those who developed nephropathy than in those who did not (36.2 vs. 13.4%; P < 0.001). The development of nephropathy independently increased the risk for progression of retinopathy (hazard ratio 1.62, 95% CI 1.23-2.13, P = 0.001), after adjustment for age, gender, diabetes duration, treatment, HbA1c , BMI, HDL cholesterol and blood pressure. Similarly, the incidence of nephropathy was higher in participants who had progression of retinopathy than in those who did not (40.7 vs. 15.7%; P < 0.001). Furthermore, progression of retinopathy independently increased the risk for development of nephropathy (hazard ratio 1.72, 95% CI 1.30-2.27, P < 0.001).

CONCLUSIONS

Progression of retinopathy and development of nephropathy each increase the risk for incidence of the other, independent of established risk factors for microvascular complications, supporting the notion of a shared aetiologic basis.

Evaluation for fasting and 2-hour glucose and HbA1c for diagnosing diabetes based on prevalence of retinopathy in a Chinese population

Background

The glycemic thresholds for diabetes diagnosis have long been at the forefront of discussion. However, no information about glycemic cutoff points has been made available for the Chinese population. The aim of the present study was to examine the association of fasting plasma glucose (FPG), 2-h plasma glucose (2-h PG) and HbA₁c levels with diabetic retinopathy (DR) and determine the associated cutoff levels in a Chinese population.

Methodology and Principal Findings

In a cross-sectional population-based sample of 2551 Chinese (representing a population of 1,660,500 in a Beijing district) between 18–79 years of age, the three glycemic measures were measured in a 75 g oral glucose tolerance test, and DR was assessed by two 45° color digital retinal images. The prevalence of DR increased in the ninth decile of each variable, corresponding to an FPG of ≥7.2 mmol/l, a 2-h PG of ≥10.7 mmol/l, and HbA₁c of ≥6.4%, according to the Joinpoint regression method. After excluding individuals receiving antihyperglycemic medication, the prevalence significantly increased at an FPG of ≥6.8 mmol/l, a 2-h PG of ≥12.0 mmol/l, and HbA₁c of ≥6.7%. The area under the ROC curve for all three measures showed no significant differences for detecting DR. After excluding individuals receiving antihyperglycemic medication, the three measures also showed no significant differences.

Conclusions and Significance

A significant increase in retinopathy prevalence occurs among individuals with FPG ≥7.2 mmol/l, 2-h PG ≥10.5 mmol/and HbA₁c ≥6.4%; and measuring FPG or HbA₁c are equally reliable methods as measuring 2-h PG for the diagnosis of diabetes in the Chinese population.

Prevalence of diabetic retinopathy in various ethnic groups: a worldwide perspective

The alarming rise in diabetes prevalence is a global public health and economic problem. Diabetic retinopathy is the most common complication of diabetes and the leading cause of blindness among working-age populations in the Western world. Screening and prompt treatment of diabetic retinopathy are not top priorities in many regions of the world, because the impacts of other causes of preventable blindness remain an issue. Ethnicity is a complex, independent risk factor for diabetic retinopathy. Observations from white populations cannot be extrapolated fully to other ethnic groups. The prevalence of diabetic retinopathy, sight-threatening diabetic retinopathy, and clinically significant macular edema are higher in people of South Asian, African, Latin American, and indigenous tribal descent compared to the white population. Although all ethnic groups are susceptible to the established risk factors of diabetic retinopathy-such as length of exposure and severity of hyperglycemia, hypertension, and hyperlipidemia-ethnic-specific risk factors also may influence these rates. Such risk factors may include differential susceptibility to conventional risk factors, insulin resistance, differences in anthropometric measurements, truncal obesity, urbanization, variations in access to healthcare systems, genetic susceptibility, and epigenetics. The rates of nonproliferative diabetic retinopathy appear to be declining in the United States, supporting the observation that better medical management of diabetes and prompt treatment of sight-threatening diabetic retinopathy substantially improve the long-term diabetic retinopathy incidence; studies from other parts of the world are limited and do not mirror this finding, however. We examine the ethnicity and region-based prevalence of diabetic retinopathy around the world and highlight the need to reinforce ethnicity-based screening and treatment thresholds in diabetic retinopathy.

Enhanced statistical tests for GWAS in admixed populations: assessment using African Americans from CARe and a Breast Cancer Consortium

While genome-wide association studies (GWAS) have primarily examined populations of European ancestry, more recent studies often involve additional populations, including admixed populations such as African Americans and Latinos. In admixed populations, linkage disequilibrium (LD) exists both at a fine scale in ancestral populations and at a coarse scale (admixture-LD) due to chromosomal segments of distinct ancestry. Disease association statistics in admixed populations have previously considered SNP association (LD mapping) or admixture association (mapping by admixture-LD), but not both. Here, we introduce a new statistical framework for combining SNP and admixture association in case-control studies, as well as methods for local ancestry-aware imputation. We illustrate the gain in statistical power achieved by these methods by analyzing data of 6,209 unrelated African Americans from the CARe project genotyped on the Affymetrix 6.0 chip, in conjunction with both simulated and real phenotypes, as well as by analyzing the FGFR2 locus using breast cancer GWAS data from 5,761 African-American women. We show that, at typed SNPs, our method yields an 8% increase in statistical power for finding disease risk loci compared to the power achieved by standard methods in case-control studies. At imputed SNPs, we observe an 11% increase in statistical power for mapping disease loci when our local ancestry-aware imputation framework and the new scoring statistic are jointly employed. Finally, we show that our method increases statistical power in regions harboring the causal SNP in the case when the causal SNP is untyped and cannot be imputed. Our methods and our publicly available software are broadly applicable to GWAS in admixed populations.

Racial differences in diabetes-related psychosocial factors and glycemic control in patients with type 2 diabetes

BACKGROUND

We examined whether diabetes-related psychosocial factors differ between African American and white patients with type 2 diabetes. We also tested whether racial differences in glycemic control are independent of such factors.

METHODS

Baseline glycosylated hemoglobin (HbA(1c)) and survey measures from 79 African American and 203 white adult participants in a diabetes self-management clinical trial were analyzed.

RESULTS

Several psychosocial characteristics varied by race. Perceived interference of diabetes with daily life, perceived diabetes severity, and diabetes-related emotional distress were higher for African Americans than for whites, as were access to illness-management resources and social support. Mean HbA(1c) levels were higher among African Americans than whites (8.14 vs 7.40, beta = 0.17). This difference persisted after adjusting for demographic, clinical, and diabetes-related psychosocial characteristics that differed by race (beta = 0.18). Less access to illness-management resources (beta = -0.25) and greater perceived severity of diabetes (beta = 0.21) also predicted higher HbA(1c).

DISCUSSION

Although racial differences in diabetes-related psychosocial factors were observed, African Americans continued to have poorer glycemic control than whites even after such differences were taken into account. Interventions that target psychosocial factors related to diabetes management, particularly illness-management resources, may be a promising way to improve glycemic control for all patients.

Ethnicity, race, and clinically significant macular edema in the Veterans Affairs Diabetes Trial (VADT)

OBJECTIVE

To determine risk factors in clinically significant macular edema (CSME) and if increased CSME in minorities is due to ethnicity or other factors in the Veterans Affairs Diabetes Trial (VADT).

METHODS

CSME prevalence based on 7-field stereo fundus photographs in 1268 patients with type 2 diabetes was related to ethnicity, demographics and biochemistries by univariate and multivariate analyses.

RESULTS

Hispanics (H) made up 17.5% and African Americans (AA) 17.7% of the cohort. CSME prevalence was 10%. In univariate analysis, CSME was more prevalent in H, 18%, and AA, 15.6% than in non-Hispanic Whites (NHW), 6.3%, p<0.01. Univariate regression of CSME associated with younger age, younger onset of diabetes; longer duration; retinopathy severity; and high HbA1c, BP, urine albumin/creatinine, and amputation, all p<0.01. In multivariate regression, CSME was associated with ethnicity/race (Hispanic White vs. non-Hispanic White, OR, (95% CI), 2.30, (1.35-3.92), p<0.01; African American vs. non-Hispanic White, 2.30, (1.33-4.00), p<0.01), diastolic BP (1.13 per 5 mm Hg, (1.02-1.23), p=0.03), amputation (3.0, (1.11-8.13), p=0.04), and retinopathy severity ( approximately 30, ( approximately 17 to approximately 59), p<0.01).

CONCLUSION

The prevalence of CSME in the VADT is associated with ethnicity as well as diastolic BP, amputation, and retinopathy severity.

Comparison of diabetic retinopathy phenotype between Latinos and Blacks

OBJECTIVE

The objective of this study was to delineate the difference in the phenotype of diabetic retinopathy (DR) in Latinos versus Blacks using characteristics shown on fundus photography (FP) and fluorescein angiography (FA).

RESEARCH DESIGN AND METHODS

This was a retrospective chart review of 203 adult Black and Latino diabetic patients from the King-Drew Medical Center eye clinic from January 1998 to March 2005. Systemic risk factors such as HbA(1c) and kidney function data were collected. FP and FA were analyzed and graded according to Early Treatment of Diabetic Retinopathy Study criteria. Statistical analysis was performed to determine whether a given lesion type was more characteristic of a particular racial group.

RESULTS

Gender, age, median microalbumin-to-creatinine ratio (ACR), and average HbA(1c) values were not significantly different between the groups. The presence of clinically significant macular edema (CSME), focal or diffuse, was very high in both groups (44% in Latinos and 46% in Blacks), and the overall DR grades were similar. However, upon individual lesion analysis, the Latinos were noted to have more prevalent intraretinal hemorrhages involving a greater area of the retina (P=.046).

CONCLUSIONS

Although Latinos and Blacks of comparable age and glycemic control are equally at risk for CSME and proliferative retinopathy, Latinos may be at greater risk for a specific phenotype of DR characterized by extravasation of intraretinal hemorrhages, which is associated with poor prognosis. Further prospective studies may uncover racial differences that may have implications for prognosis and therapy.

Screening for diabetic retinopathy: 1 and 3 nonmydriatic 45-degree digital fundus photographs vs 7 standard early treatment diabetic retinopathy study fields

PURPOSE

To evaluate if simple- or multiple-field digital color nonmydriatic (NM) retinal images can replace 7 standard stereoscopic fundus photographs in the screening of diabetic retinopathy (DR).

DESIGN

Prospective, masked, comparative case series.

METHODS

One hundred and eight eyes of 55 diabetics were studied to determine single lesions and to grade clinical levels of DR and diabetic macular edema (DME) using both 1 and 3 NM digital color retinal images compared with the Early Treatment Diabetic Retinopathy Study (ETDRS) 7 standard 35-mm stereoscopic color fundus photographs (7F-ETDRS). All eyes underwent NM 45-degree field images of 1 central field (1F-NM), NM 45-degree field images of 3 fields (3F-NM), and, after pupil dilatation, 30-degree 7F-ETDRS photography. Images were analyzed by 2 independent, masked retinal specialists (S.V. and E.B.), lesion-by-lesion according to the ETDRS protocol and for clinical severity level of DR and DME according to the international classification of DR.

RESULTS

Using 7F-ETDRS as the gold standard, agreement was substantial for grading clinical levels of DR and DME (kappa = 0.69 and kappa = 0.75) vs 3F-NM; moderate for DR level (kappa = 0.56) and substantial for DME (kappa = 0.66) vs 1F-NM; almost perfect for detecting presence or absence of DR (kappa = 0.88) vs both 1F-NM and 3F-NM; and almost perfect for presence or absence of DME (kappa = 0.97) vs 3F-NM and substantial (kappa = 0.75) vs 1F-NM. Sensitivity and specificity for detecting referable levels of DR were 82% and 92%, respectively, for 3F-NM and 71% and 96%, respectively, for 1F-NM.

CONCLUSIONS

Three color 45-degree NM fundus fields may be an effective tool in a screening setting to determine critical levels of DR and DME for prompt specialist referral. One central 45-degree image is sufficient to determine absence or presence of DR and DME, but not for grading it.

Prevalence and risk factors of diabetic retinopathy in a multi-racial underserved population

PURPOSE

To describe the prevalence, severity, and associated risk factors of diabetic retinopathy among different racial groups (whites, blacks, Hispanics, and Asians) within an urban, underserved population.

METHODS

2-field non-mydriatic retinal photographs of each eye were reviewed for 1073 patients referred to the San Francisco General Hospital mobile eye service, the Eye Van, for diabetic retinopathy screening. Presence and severity of diabetic retinopathy was determined based on a modification of the Airlie House classification system.

RESULTS

The prevalence of any retinopathy among all diabetics was 15.7%. There was no statistical difference in the prevalence of retinopathy among the racial groups. Significant independent predictors of presence and severity of retinopathy were longer duration of diabetes, and use of oral hypoglycemic medication or insulin (P < 0.05). Gender, age, primary language, income, and co-diagnosis of hypertension were not correlated.

CONCLUSIONS

In this population of similar socioeconomic status and access to healthcare, race was not an independent predictor of diabetic retinopathy. This suggests that racial differences described in previous studies may be eliminated when social factors are equalized.

Retinal vascular lesions in patients of Caucasian and Asian origin with type 2 diabetes: baseline results from the ADVANCE Retinal Measurements (AdRem) study

OBJECTIVE

The objective of this study was to describe prevalent vascular retinal lesions among patients with type 2 diabetes enrolled in the ADVANCE Retinal Measurements (AdRem) study, a substudy of the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial.

RESEARCH DESIGN AND METHODS

Seven-field stereoscopic photographs of both eyes were obtained at the baseline assessment of the ADVANCE trial. All photographs were graded in a central reading center. Gradable retinal images were received from 1,605 patients.

RESULTS

The number of patients with any retinopathy (Early Treatment of Diabetic Retinopathy Study [ETDRS] score > or = 20) was 645 (40.2% [95% CI 37.8-42.6]); of these, 35 (2.2% [1.6-3.0]) had severe diabetic retinopathy (ETDRS score > or = 50). Focal arterial narrowing, venous beading, and arteriovenous nicking were present in 3.8, 5.1, and 9.8% of participants, respectively. Among participants included in this study, Chinese and South-Asian patients had more retinopathy than Caucasians, as defined both by ETDRS score (49.4, 46.0, and 31.3%, respectively; P < 0.001, adjusted for age, sex, A1C, systolic blood pressure, and duration of diabetes) and specific vascular lesions (e.g., arteriovenous nicking 12.3, 8.5, and 7.5%, respectively; adjusted P < 0.005). A1C, duration of diabetes, and systolic blood pressure were similarly associated with increased retinal lesions in Chinese, South-Asian, and Caucasian patients.

CONCLUSIONS

Using a sensitive diagnostic procedure, more than one-third of patients with type 2 diabetes enrolled in the AdRem study had retinal lesions at baseline. Despite differences in prevalence and severity of retinopathy among Chinese, South-Asian, and Caucasian patients included in this study, the cross-sectional associations among established risk factors for retinopathy and retinal lesions were similar across ethnic groups.

Gender and racial disparities in the management of diabetes mellitus among Medicare patients

BACKGROUND

Racial/ethnic disparities in diabetes care have been demonstrated in several settings, but few studies have evaluated whether racial/ethnic differences vary by gender. The objective of this study is to understand gender and racial effects on diabetes care for Medicare managed care beneficiaries.

METHODS

Using data from: (1) Healthcare Effectiveness Data and Information Set (HEDIS); (2) Medicare Enrollment Files; and (3) U.S. Census, hierarchical generalized linear analyses were conducted to model the six HEDIS comprehensive diabetes care quality indicators, including processes of care and intermediate outcome measures, as a function of gender and race/ethnicity.

RESULTS

Women were more likely to have received HbA(1c) screening or eye examination, but less likely to have LDL control at <100 mg/dL, compared to men. Racial disparities favored whites in five measures, where African Americans were less likely to have received HbA(1c) screening, eye examination, cholesterol screening, or achieve adequate HbA(1c) control or LDL control at <100 mg/dL. Enrollees in managed care plans where African Americans constituted more than 20% of their insured population tended to have lower likelihood of meeting the HbA(1c) screening, HbA(1c) control, and eye examination measures.

CONCLUSIONS AND DISCUSSION

Gender and racial disparities in performance indicators were present among persons enrolled in Medicare managed care. White women were more likely to have met the performance measures related to process of care, but African Americans fared worse in both process of care and intermediate health outcome measures, compared to their white counterparts. Poor performance in cholesterol control observed in women of both races suggests the possibility of less intensive cholesterol treatment in women. The differences in the pattern of care demonstrate the need for interventions tailored to address gender and race/ethnicity.

Improving diabetic retinopathy screening ratios using telemedicine-based digital retinal imaging technology: the Vine Hill study

OBJECTIVE

To evaluate the impact of a telemedicine, digital retinal imaging strategy on diabetic retinopathy screening rates in an inner-city primary care clinic.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included all diabetic patients aged > or = 18 years (n = 495) seen at Vine Hill Community Clinic between 1 September 2003 and 31 August 2004. Patients were offered ophthalmology referral or digital screening. Patients choosing referral received the next available (within 3 months) appointment at the Vanderbilt Eye Clinic; patients choosing digital screening were screened during the visit.

RESULTS

Retinal screening was documented for 293 (59.2%) patients, a significant improvement compared with the 23% baseline rate. Of 293 patients screened, 92 (31.4%) were screened in ophthalmology, and 201 (68.6%) were digitally screened. Among the 201 digitally screened patients, 104 (51.7%) screened negative and were advised to rescreen in 1 year, 75 (37.3%) screened positive and were nonurgently referred to ophthalmology, and 22 (11.0%) screened positive for sight-threatening eye disease and were urgently referred for ophthalmological follow-up. Digital imaging technical failure rate was 0.5%. Referral status was associated with race/ethnicity (chi2 = 7.9, P < 0.02) with whites more likely to screen negative than non-whites (62.4 vs. 47.8%, respectively). Sight-threatening disease among non-whites (14.7%) was more than double that observed for whites (5.9%).

CONCLUSIONS

Digital imaging technology in the primary care visit can significantly improve screening rates over conventional methods, increase access to recommended diabetic eye care, and focus specialty care on medically indigent patients with greatest need.

Apolipoprotein E gene polymorphisms are not associated with diabetic retinopathy: the atherosclerosis risk in communities study

PURPOSE

Polymorphism of the apolipoprotein E (APOE) gene has been associated with dyslipidemia and cardiovascular disease. This study examines the association of APOE polymorphisms and diabetic retinopathy.

DESIGN

Population-based cross-sectional study.

METHODS

We studied 1,398 people aged 49 to 73 years with diabetes selected from four United States communities. We performed retinal photography on one randomly selected eye and graded for the presence and severity of diabetic retinopathy using a modification of the Early Treatment Diabetic Retinopathy Study scale. We performed genotyping of common polymorphic APOE alleles using polymerase chain reaction on genomic DNA from venous blood leukocytes.

RESULTS

The prevalence of diabetic retinopathy and hard exudates was 15.0% and 5.3% in Caucasians (n = 935), and 24.6% and 9.7% in African-Americans (n = 463), with type 2 diabetes. APOE gene polymorphisms were not associated with diabetic retinopathy in either Caucasians or African-Americans. In African-Americans, the 2/4 genotype (n = 6) was associated with increased prevalence of hard exudates (odds ratio [OR] 4.10, 95% confidence interval [CI] 1.30 to 12.90), as was the 2/3 genotype (n = 9, OR 2.64, 95% CI 1.01 to 6.95). No association between APOE genotypes and hard exudates was found in Caucasians.

CONCLUSIONS

These data suggest that APOE gene polymorphisms are not associated with diabetic retinopathy in either Caucasians or African-Americans with type 2 diabetes.

Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study

Background

Racial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes.

Methods

We conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control.

Results

The study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c ≥ 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control.

Conclusion

In our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.

Race differences in long-term diabetes management in an HMO

OBJECTIVE

We examined race differences in diabetes outcomes over 4-8 years in a single HMO.

RESEARCH DESIGN AND METHODS

We identified black and white adult diabetic patients who were continuously enrolled (1992-2001) and in whom diabetes was 1) diagnosed before 1994 (n = 1,686) or 2) newly diagnosed in 1994-1997 (n = 1,280). We used hierarchical models to estimate the effect of race on average annual HbA(1c) (A1C) controlling for baseline A1C, BMI, and age, as well as annual measures of type of diabetes medications, diabetes-related hospitalization, time and the number of A1C tests, physician visits, and nondiabetes medications. Stratifying by sex accounted for significant interactions between sex and race.

RESULTS

At baseline, black and white patients had similar rates of A1C testing and physician visits, but blacks had higher unadjusted A1C values. In multivariate models, among patients with previously diagnosed diabetes, average A1C was nonsignificantly 0.11 higher (95% CI -0.12 to 0.34) in black than in white men but was 0.30 higher (0.14-0.46; P = 0.0007) in black than in white women. Among patients with newly diagnosed diabetes, the adjusted black-white gap was 0.49 among men (0.17-0.80; P = 0.007) and was 0.05 among women (-0.20 to -0.31), which was positive but not significant.

CONCLUSIONS

Factors other than the quality of care may explain persistent race differences in A1C in this setting. Future interventions should target normalization of A1C by identifying potential psychosocial barriers to therapy intensification among patients and clinicians and development of culturally appropriate interventions to aid patients in successful self-management.

Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: a review

OBJECTIVE

To determine the influence of ethnic differences in diabetes care on inequalities in mortality and prevalence of end-stage complications among diabetic patients. The following questions were examined: 1) Are there ethnic differences among diabetic patients in mortality and end-stage complications and 2) are there ethnic differences among diabetic patients in quality of care?

RESEARCH DESIGN AND METHODS

A review of the literature on ethnic differences in the prevalence of complications and mortality among diabetic patients and in the quality of diabetes care was performed by systematically searching articles on Medline published from 1987 through October 2004.

RESULTS

A total of 51 studies were included, mainly conducted in the U.S. and the U.K. In general, after adjusting for confounders, diabetic patients from ethnic minorities had higher mortality rates and higher risk of diabetes complications. After additional adjustment for risk factors such as smoking, socioeconomic status, income, years of education, and BMI, in most instances ethnic differences disappear. Nevertheless, blacks and Hispanics in the U.S. and Asians in the U.K. have an increased risk of end-stage renal disease, and blacks and Hispanics in the U.S. have an increased risk of retinopathy. Intermediate outcomes of care were worse in blacks, and they were inclined to be worse in Hispanics. Likewise, ethnic differences in quality of care in the U.S. exist: process of care was worse in blacks.

CONCLUSIONS

Given the fact that there are ethnic differences in diabetes care and that ethnic differences in some diabetes complications persist after adjustment for risk factors other than diabetes care, it seems the case that ethnic differences in diabetes care contribute to the more adverse disease outcomes of diabetic patients from some ethnic minority groups. Although no generalizations can be made for all ethnic groups in all regions for all kinds of complications, the results do implicate the importance of quality of care in striving for equal health outcomes among ethnic minorities.

Ethnicity, race, and baseline retinopathy correlates in the veterans affairs diabetes trial

OBJECTIVE

The Veterans Affairs Diabetes Trial (VADT) cohort is enriched with approximately 20% Hispanics and 20% African Americans, affording a unique opportunity to study ethnic differences in retinopathy.

RESEARCH DESIGN AND METHODS

Cross-sectional analyses on the baseline seven-field stereo fundus photos of 1,283 patients are reported here. Diabetic retinopathy scores are grouped into four classes of increasing severity: none (10-14), minimal nonproliferative diabetic retinopathy (NPDR) (15-39), moderate to severe NPDR (40-59), and proliferative diabetic retinopathy (60+). These four groups have also been dichotomized to none or minimal (10-39) and moderate to severe diabetic retinopathy (40+).

RESULTS

The prevalence of diabetic retinopathy scores >40 was higher for Hispanics (36%) and African Americans (29%) than for non-Hispanic whites (22%). The difference between Hispanics and non-Hispanic whites was significant (P < 0.05). Similarly, the prevalence of diabetic retinopathy scores >40 was significantly higher in African Americans than in non-Hispanic whites (P < 0.05). These differences could not be accounted for by an imbalance in traditional risk factors such as age, duration of diagnosed diabetes, HbA(1c) (A1C), and blood pressure. Diabetic retinopathy severity scores were also significantly associated with increasing years of disease duration, A1C, systolic and diastolic blood pressure, the degree of microalbuminuria, fibrinogen, and the percentage of patients with amputations. There was no relationship between retinopathy severity and the percentage of people who had strokes or cardiac revascularization procedures. There was an inverse relationship between retinopathy severity and total cholesterol, triglycerides, and plasminogen activator inhibitor-1 as well as with smoking history. Diabetic retinopathy scores were not associated with age.

CONCLUSIONS

In addition to many well-known associations with retinopathy, a higher frequency of severe diabetic retinopathy was found in the Hispanic and African-American patients at entry into the VADT that is not accounted for by traditional risk factors for diabetic retinopathy, and these substantial ethnic differences remain to be explained.

Access to vision care in an urban low-income multiethnic population

OBJECTIVE

This study applied a well-known, recently revised theoretical model of healthcare access and utilization, the Behavioral Model for Vulnerable Populations, to examine the relationship between access to care and utilization of eye care services among a multiethnic, predominately minority sample of residents from low-income public housing.

DESIGN

Population-based, cross-sectional survey of community sample.

SETTING

Urban Public Housing Communities in Los Angeles County, California.

PARTICIPANTS

A geographically defined stratified random sample of 152 residents (86% Latino or African American) 40 years of age and older from three urban public housing communities.

RESULTS

Only 62% of our sample of persons 40 years and older had received an eye examination within the past 2 years. Sixty-one percent of participants reported having vision care coverage. Yet, one out of four respondents claimed that no health care provider had ever told them that they needed an eye-examination. Applying multiple logistic regression and controlling for a number of predisposing, enabling, and need-for-care characteristics, the variables 1) receiving advice from health care providers for eye examination (OR = 3.9, p < 0.01), 2) possessing coverage for eye-care (OR = 3.2, p < 0.01), and 3) having regular and continuity of medical care (OR = 2.4, p < 0.01) remained significant predictors of eye-examination within the past 2 years.

CONCLUSION

This study documents significantly diminished utilization of eye care services relative to recommended guidelines for a low-income, predominately minority sample of residents from public housing communities. We documented no association between presence of diabetes or hypertension and recency of eye examination. Affordability, continuity, and regular sources of care, as well as receiving physician advice, remain the core factors significantly associated with receiving vision care. These results underscore the need for continued efforts to ensure that the medically underserved minority have access to vision care services. These findings also point toward the urgent need for educational and motivational interventions that encourage health care providers serving underserved communities to promote eye examination, particularly among diabetic patients, hypertensive patients, and other individuals at risk for eye-related disease and complications.

Developing a new generation of ongoing: Diabetes self-management support interventions: a preliminary report

PURPOSE

The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes.

METHODS

Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed.

RESULTS

Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P < .001), total cholesterol (P < .01), high-density lipoprotein (P < .05), and low-density lipoprotein (P < .001). Significant increases were also found for self-care behaviors (P < .05).

CONCLUSIONS

Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.

Diabetic Retinopathy Analysis

Diabetic retinopathy is one of the common complications of diabetes. Unfortunately, in many cases the patient is not aware of any symptoms until it is too late for effective treatment. Through analysis of evoked potential response of the retina, the optical nerve, and the optical brain center, a way will be paved for early diagnosis of diabetic retinopathy and prognosis during the treatment process. In this paper, we present an artificial-neural-network-based method to classify diabetic retinopathy subjects according to changes in visual evoked potential spectral components and an anatomically realistic computer model of the human eye under normal and retinopathy conditions in a virtual environment using 3D Max Studio and Windows Movie Maker.

Prevalence of diabetic eye disease in Tayside, Scotland (P-DETS) study: methodology

AIMS

To describe the use of a validated diabetes register for sampling frame generation and assessment of the representative nature of participants in a fieldwork study of diabetic eye disease.

METHODS

We performed an observational, cross-sectional fieldwork study of diabetic retinal disease using reference standard eye examination. We sampled the entire diabetic population using the Diabetes Audit and Research in Tayside Study (DARTS) diabetes register.

RESULTS

The study population comprised 4825 diabetic patients aged over 16 years registered with one of 166 general practitioners (GPs) in 41 practices in Tayside in October 1999. This represented 61.1% of the Tayside diabetic population (7903). A total of 586 (66%; 95% confidence interval 63, 70) patients were examined from a sampling frame of 882 living patients registered with a Tayside GP. Demographic and disease parameters recorded on the DARTS patient register allowed comparison between participants and non-participants.

CONCLUSIONS

This study shows the clear benefit of using a complete diabetic population as a sampling frame. This allows potential selection bias and external validity to be evaluated using routine data sources. Studies performed and reported in this way will aid the critical appraisal process.