Impact of the COVID-19 Pandemic on Medical Expenditures Among Medicare Fee-for-Service Beneficiaries Aged ≥67 Years With Diabetes

OBJECTIVE

To compare total and out-of-pocket (OOP) medical expenditures between pre-COVID-19 (March 2019 to February 2020) and COVID-19 (March 2020 to February 2022) periods among Medicare beneficiaries with diabetes.

RESEARCH DESIGN AND METHODS

Data were from 100% Medicare fee-for-service claims. Diabetes was identified using ICD-10 codes. We calculated quarterly total and OOP medical expenditures at the population and per capita level in total and by service type. Per capita expenditures were calculated by dividing the population expenditure by the number of beneficiaries with diabetes in the same quarter. Changes in expenditures were calculated as the differences in the same quarters between the prepandemic and pandemic years.

RESULTS

Population total expenditure fell to $33.6 billion in the 1st quarter of the pandemic from $41.7 billion in the same prepandemic quarter; it then bounced back to $36.8 billion by the 4th quarter of the 2nd pandemic year. The per capita total expenditure fell to $5,356 in the 1st quarter of the pandemic from $6,500 in the same prepandemic quarter. It then increased to $6,096 by the 4th quarter of the 2nd pandemic year, surpassing the same quarter in the prepandemic year ($5,982). Both population and per capita OOP expenditures during the pandemic period were lower than the prepandemic period. Changes in per capita expenditure between the pre-COVID-19 and COVID-19 periods by service type varied.

CONCLUSIONS

COVID-19 had a significant impact on both total and per capita medical expenditures among Medicare beneficiaries with diabetes. The COVID-19 pandemic was associated with lower OOP expenditures.

State-level metabolic comorbidity prevalence and control among adults age 50-plus with diabetes: estimates from electronic health records and survey data in five states

BACKGROUND

Although treatment and control of diabetes can prevent complications and reduce morbidity, few data sources exist at the state level for surveillance of diabetes comorbidities and control. Surveys and electronic health records (EHRs) offer different strengths and weaknesses for surveillance of diabetes and major metabolic comorbidities. Data from self-report surveys suffer from cognitive and recall biases, and generally cannot be used for surveillance of undiagnosed cases. EHR data are becoming more readily available, but pose particular challenges for population estimation since patients are not randomly selected, not everyone has the relevant biomarker measurements, and those included tend to cluster geographically.

METHODS

We analyzed data from the National Health and Nutritional Examination Survey, the Health and Retirement Study, and EHR data from the DARTNet Institute to create state-level adjusted estimates of the prevalence and control of diabetes, and the prevalence and control of hypertension and high cholesterol in the diabetes population, age 50 and over for five states: Alabama, California, Florida, Louisiana, and Massachusetts.

RESULTS

The estimates from the two surveys generally aligned well. The EHR data were consistent with the surveys for many measures, but yielded consistently lower estimates of undiagnosed diabetes prevalence, and identified somewhat fewer comorbidities in most states.

CONCLUSIONS

Despite these limitations, EHRs may be a promising source for diabetes surveillance and assessment of control as the datasets are large and created during the routine delivery of health care.

TRIAL REGISTRATION

Not applicable.

The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR): Unique 1.4 M patient Electronic Health Record cohort

BACKGROUND

The Longitudinal Epidemiologic Assessment of Diabetes Risk (LEADR) study uses a novel Electronic Health Record (EHR) data approach as a tool to assess the epidemiology of known and new risk factors for type 2 diabetes mellitus (T2DM) and study how prevention interventions affect progression to and onset of T2DM. We created an electronic cohort of 1.4 million patients having had at least 4 encounters with a healthcare organization for at least 24-months; were aged ≥18 years in 2010; and had no diabetes (i.e., T1DM or T2DM) at cohort entry or in the 12 months following entry. EHR data came from patients at nine healthcare organizations across the U.S. between January 1, 2010-December 31, 2016.

RESULTS

Approximately 5.9% of the LEADR cohort (82,922 patients) developed T2DM, providing opportunities to explore longitudinal clinical care, medication use, risk factor trajectories, and diagnoses for these patients, compared with patients similarly matched prior to disease onset.

CONCLUSIONS

LEADR represents one of the largest EHR databases to have repurposed EHR data to examine patients' T2DM risk. This paper is first in a series demonstrating this novel approach to studying T2DM.

IMPLICATIONS

Chronic conditions that often take years to develop can be studied efficiently using EHR data in a retrospective design.

LEVEL OF EVIDENCE

While much is already known about T2DM risk, this EHR's cohort's 160 M data points for 1.4 M people over six years, provides opportunities to investigate new unique risk factors and evaluate research hypotheses where results could modify public health practice for preventing T2DM.

Imputed State-Level Prevalence of Achieving Goals To Prevent Complications of Diabetes in Adults with Self-Reported Diabetes - United States, 2017-2018

Diabetes increases the risk for developing cardiovascular, neurologic, kidney, eye, and other complications. Diabetes and related complications also pose a huge economic cost to society: in 2017, the estimated total economic cost of diagnosed diabetes was $327 billion in the United States (1). Diabetes complications can be prevented or delayed through the management of blood glucose (measured by hemoglobin A1C), blood pressure (BP), and non-high-density lipoprotein cholesterol (non-HDL-C) levels, and by avoiding smoking; these are collectively known as the ABCS goals (hemoglobin A1C, Blood pressure, Cholesterol, Smoking) (2-5). Assessments of achieving ABCS goals among adults with diabetes are available at the national level (4,6); however, studies that assess state-level prevalence of meeting ABCS goals have been lacking. This report provides imputed state-level proportions of adults with self-reported diabetes meeting ABCS goals in each of the 50 U.S. states and the District of Columbia (DC). State-level estimates were created by raking and multiple imputation methods (7,8) using data from the 2009-2018 National Health and Nutrition Examination Survey (NHANES), 2017-2018 American Community Survey (ACS), and 2017-2018 Behavioral Risk Factor Surveillance System (BRFSS). Among U.S. adults with diabetes, an estimated 26.4% met combined ABCS goals, and 75.4%, 70.4%, 55.8%, and 86.0% met A1C <8%, BP <140/90 mmHg, non-HDL-C <130 mg/dL and nonsmoking goals, respectively. Public health departments could use these data in their planning efforts to achieve ABCS goal levels and reduce diabetes-related complications at the state level.

US Trends in Prevalence of Sleep Problems and Associations with Chronic Kidney Disease and Mortality

BACKGROUND

To better understand the relation between sleep problems and CKD, we examined temporal trends in the prevalence of self-reported sleep problems in adults in the United States and their associations with CKD and all-cause mortality.

METHODS

Using data from 27,365 adult participants in five biannual National Health and Examination Surveys (2005-2006 through 2013-2014), we studied five self-reported sleep problems-trouble sleeping, sleep disorder, nocturia (urinating ≥2 times/night), inadequate sleep (<7 hours/night), and excessive sleep (>9 hours/night)-plus a composite index. We conducted three types of analysis: temporal trends in the prevalence of each sleep measure by CKD status, using model-based standardization; cross-sectional analysis of associations between four CKD measures and each sleep measure, using logistic regression; and survival analysis of the association between each sleep measure and mortality, using Cox regression.

RESULTS

The prevalence of trouble sleeping and sleep disorder increased over the five surveys by 4% and 3%, respectively, whereas the other sleep problems remained relatively stable. All sleep problems, except inadequate sleep, were more common during the study period among adults with CKD than without CKD (40% versus 21% for nocturia; 5% versus 2% for excessive sleep; 30% versus 25% for trouble sleeping; 12% versus 8% for sleep disorder). Both eGFR <30 ml/min per 1.73 m² and albuminuria were positively associated with nocturia and excessive sleep. Excessive sleep and nocturia were also associated with higher mortality (adjusted hazard ratio for >9 versus 7-9 hours/night=1.7; 95% CI, 1.3 to 2.1; and for nocturia=1.2; 95% CI, 1.1 to 1.4).

CONCLUSIONS

The high prevalence of sleep problems among persons with CKD and their associations with mortality suggest their potential importance to clinical practice. Future work could examine the health effects of identifying and treating sleep problems in patients with CKD.

Resurgence of Diabetes-Related Nontraumatic Lower-Extremity Amputation in the Young and Middle-Aged Adult U.S. Population

OBJECTIVE

To determine whether declining trends in lower-extremity amputations have continued into the current decade.

RESEARCH DESIGN AND METHODS

We calculated hospitalization rates for nontraumatic lower-extremity amputation (NLEA) for the years 2000-2015 using nationally representative, serial cross-sectional data from the Nationwide Inpatient Sample on NLEA procedures and from the National Health Interview Survey for estimates of the populations with and without diabetes.

RESULTS

Age-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93-5.84]) and 2009 (3.07 [95% CI 2.79-3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25-5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22-0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17-0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83-2.22] to 3.29 [95% CI 3.01-3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94-1.13] to 1.34 [95% CI 1.22-1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18-44 years) and middle-aged (age 45-64 years) adults and more pronounced in men than women.

CONCLUSIONS

After a two-decade decline in lower-extremity amputations, the U.S. may now be experiencing a reversal in the progress, particularly in young and middle-aged adults.

State-level estimation of diabetes and prediabetes prevalence: Combining national and local survey data and clinical data

Many statisticians and policy researchers are interested in using data generated through the normal delivery of health care services, rather than carefully designed and implemented population-representative surveys, to estimate disease prevalence. These larger databases allow for the estimation of smaller geographies, for example, states, at potentially lower expense. However, these health care records frequently do not cover all of the population of interest and may not collect some covariates that are important for accurate estimation. In a recent paper, the authors have described how to adjust for the incomplete coverage of administrative claims data and electronic health records at the state or local level. This article illustrates how to adjust and combine multiple data sets, namely, national surveys, state-level surveys, claims data, and electronic health record data, to improve estimates of diabetes and prediabetes prevalence, along with the estimates of the method's accuracy. We demonstrate and validate the method using data from three jurisdictions (Alabama, California, and New York City). This method can be applied more generally to other areas and other data sources.

Changes in diabetes-related complications in the United States, 1990-2010

BACKGROUND

Preventive care for adults with diabetes has improved substantially in recent decades. We examined trends in the incidence of diabetes-related complications in the United States from 1990 through 2010.

METHODS

We used data from the National Health Interview Survey, the National Hospital Discharge Survey, the U.S. Renal Data System, and the U.S. National Vital Statistics System to compare the incidences of lower-extremity amputation, end-stage renal disease, acute myocardial infarction, stroke, and death from hyperglycemic crisis between 1990 and 2010, with age standardized to the U.S. population in the year 2000.

RESULTS

Rates of all five complications declined between 1990 and 2010, with the largest relative declines in acute myocardial infarction (-67.8%; 95% confidence interval [CI], -76.2 to -59.3) and death from hyperglycemic crisis (-64.4%; 95% CI, -68.0 to -60.9), followed by stroke and amputations, which each declined by approximately half (-52.7% and -51.4%, respectively); the smallest decline was in end-stage renal disease (-28.3%; 95% CI, -34.6 to -21.6). The greatest absolute decline was in the number of cases of acute myocardial infarction (95.6 fewer cases per 10,000 persons; 95% CI, 76.6 to 114.6), and the smallest absolute decline was in the number of deaths from hyperglycemic crisis (-2.7; 95% CI, -2.4 to -3.0). Rate reductions were larger among adults with diabetes than among adults without diabetes, leading to a reduction in the relative risk of complications associated with diabetes. When expressed as rates for the overall population, in which a change in prevalence also affects complication rates, there was a decline in rates of acute myocardial infarction and death from hyperglycemic crisis (2.7 and 0.1 fewer cases per 10,000, respectively) but not in rates of amputation, stroke, or end-stage renal disease.

CONCLUSIONS

Rates of diabetes-related complications have declined substantially in the past two decades, but a large burden of disease persists because of the continued increase in the prevalence of diabetes. (Funded by the Centers for Disease Control and Prevention.).

Americans' use of dietary supplements that are potentially harmful in CKD

BACKGROUND

The prevalence in the United States of dietary supplement use that may be harmful to those with chronic kidney disease (CKD) is unknown. We sought to characterize potentially harmful supplement use by individual CKD status.

STUDY DESIGN

Cross-sectional national survey (National Health and Nutrition Examination Survey, 1999-2008).

SETTING & PARTICIPANTS

Community-based survey of 21,169 nonpregnant noninstitutionalized US civilian adults (aged ≥20 years).

PREDICTOR

CKD status (no CKD, at risk of CKD [presence of diabetes, hypertension, and/or cardiovascular disease], stages 1/2 [albuminuria only (albumin-creatinine ratio ≥30 mg/g)], or stages 3/4 [estimated glomerular filtration rate of 15-59 mL/min/1.73 m(2)]).

OUTCOME

Self-reported use of dietary supplements containing any of 37 herbs the National Kidney Foundation identified as potentially harmful in the setting of CKD.

MEASUREMENTS

Albuminuria and estimated glomerular filtration rate assessed from urine and blood samples; demographics and comorbid conditions assessed by standardized questionnaire.

RESULTS

An estimated 8.0% of US adults reported potentially harmful supplement use within the last 30 days. A lower crude estimated prevalence of potentially harmful supplement use was associated with higher CKD severity (no CKD, 8.5%; at risk, 8.0%; stages 1/2, 6.1%; and stages 3/4, 6.2%; P < 0.001). However, after adjustment for confounders, those with or at risk of CKD were as likely to use a potentially harmful supplement as those without CKD: at-risk OR, 0.93 (95% CI, 0.79-1.09); stages 1/2 OR, 0.83 (95% CI, 0.64-1.08); and stages 3/4 OR, 0.87 (95% CI, 0.63-1.18); all versus no CKD.

LIMITATIONS

Herb content was not available and the list of potentially harmful supplements examined is unlikely to be exhaustive.

CONCLUSIONS

The use of dietary supplements potentially harmful to people with CKD is common regardless of CKD status. Health care providers should discuss the use and potential risks of supplements with patients with and at risk of CKD.

Distribution of HbA(1c) levels for children and young adults in the U.S.: Third National Health and Nutrition Examination Survey

OBJECTIVE

To describe the distribution of HbA(1c) levels among children and young adults in the U.S. and to evaluate the effects of age, sex, race/ethnicity, socioeconomic status, parental history of diabetes, overweight, and serum glucose on HbA(1c) levels.

RESEARCH DESIGN AND METHODS

We analyzed HbA(1c) data from the Third National Health and Nutrition Examination Survey, 1988-1994, for 7,968 participants aged 5-24 years who had not been treated for diabetes. After adjusting for the complex sample design, we compared the distributions of HbA(1c) in subgroups and developed multiple linear regression models to examine factors associated with HbA(1c).

RESULTS

Mean HbA(1c) level was 4.99% (SD 0.50%) and varied from 4.93% (95% CI +/-0.04) in non-Hispanic whites to 5.05% (+/-0.02) in Mexican-Americans to 5.17% (+/-0.02) in non-Hispanic blacks. There were very small differences among subgroups. Within each age- group, among men and women, among overweight and nonoverweight subjects, and at any level of education, mean HbA(1c) levels were higher in non-Hispanic blacks than in non-Hispanic whites. After adjusting for confounders, HbA(1c) levels for non-Hispanic blacks (5.15%, 95% CI +/-0.04) and Mexican-Americans (5.01%, +/-0.04) were higher than those for non-Hispanic whites (4.93%, +/-0.04).

CONCLUSIONS

These data provide national reference levels for HbA(1c) distributions among Americans aged 5-24 years and show statistically significant racial/ethnic differences in HbA(1c) levels that are not completely explained by demographic and health-related variables.

Antimicrobial resistance of nasopharyngeal isolates of Streptococcus pneumoniae and Haemophilus influenzae from children in the Central African Republic

BACKGROUND

To assist the Central African Republic (CAR) develop national guidelines for treating children with pneumonia, a survey was conducted to determine antimicrobial resistance rates of nasopharyngeal isolates of Streptococcus pneumoniae (SP) and Haemophilus influenzae (HI). Secondary purposes of the survey were to identify risk factors associated with carriage of a resistant isolate and to compare the survey methods of including only children with pneumonia vs. including all ill children.

METHODS

A cross-sectional survey of 371 ill children was conducted at 2 outpatient clinics in Bangui, CAR.

RESULTS

In all 272 SP isolates and 73 HI isolates were cultured. SP resistance rates to penicillin, trimethoprim-sulfamethoxazole (TMP-SMX), tetracycline and chloramphenicol were 8.8, 6.3, 42.3 and 9.2%, respectively. All penicillin-resistant SP isolates were intermediately resistant. HI resistance rates to ampicillin, TMP-SMX and chloramphenicol were 1.4, 12.3 and 0%, respectively. The most common SP serotypes/groups were 19, 14, 6 and 1; 49% of HI isolates were type b. History of antimicrobial use in the previous 7 days was the only factor associated with carriage of a resistant isolate. Resistance rates were similar among ill children regardless of whether they had pneumonia.

CONCLUSIONS

Resistance rates were low for antimicrobials recommended by the World Health Organization for children with pneumonia. We recommended TMP-SMX as the first line treatment for pneumonia in CAR because of its low cost, ease of dosing and activity against malaria.