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Both community health workers and the Project ECHO model of specialist telementoring are innovative approaches to support primary care providers in the care of complex patients with diabetes. We studied the effect of an intervention that combined these 2 approaches on glycemic control. Patients with diabetes were recruited from 10 federally qualified health centers in New Mexico. We used electronic health record (EHR) data to compare HbA1c levels prior to intervention enrollment with HbA1c levels after 3 months (early follow-up) and 12 months (late follow-up) following enrollment. We propensity matched intervention patients to comparison patients from other sites within the same electronic health records databases to estimate the average treatment effect. Among 557 intervention patients with HbA1c data, mean HbA1c decreased from 10.5% to 9.3% in the pre- versus postintervention periods (P <.001). As compared to the comparison group, the intervention was associated with a change in HbA1c of −0.2% (95% confidence interval [CI] −0.4%-0.5%) and −0.3 (95% CI −0.5–0.0) in the early and late follow-up cohorts, respectively. The intervention was associated with a significant increase in percentage of patients with HbA1c <8% in the late follow-up cohort (8.1%, 95% CI 2.2%−13.9%) but not the early follow-up cohort (3.6%, 95% CI −1.5% to 8.7%) The intervention was associated with a substantial decrease in HbA1c in intervention patients, although this improvement was not different from matched comparison patients in early follow-up. Although combining community health workers with Project ECHO may hold promise for improving glycemic control, particularly in the longer term, further evaluations are needed. [ABSTRACT FROM AUTHOR]

Background: Comorbid diabetes is common in heart failure and associated with increased hospitalization and mortality. Nonetheless, the association between glycemic control and outcomes among patients with heart failure and diabetes remains poorly characterized, particularly among low income and minority patients.Methods: We performed a retrospective cohort study of outpatients with heart failure and diabetes in the New York City Health and Hospitals Corporation, the largest municipal health care system in the United States. Cox proportional hazard models were used to measure the association between HbA1c levels and outcomes of all-cause hospitalization, heart failure hospitalization, and mortality.Results: Of 4723 patients with heart failure and diabetes, 42.6 % were black, 30.5 % were Hispanic/Latino, 31.4 % were Medicaid beneficiaries and 22.9 % were uninsured. As compared to patients with an HbA1c of 8.0-8.9 %, patients with an HbA1c of <6.5, 6.5-6.9, 7.0-7.9, and ≥9.0 % had an adjusted hazard ratio (aHR) (95 % CI) for all-cause hospitalization of 1.03 (0.90-1.17), 1.05 (0.91-1.22), 1.03 (0.90-1.17), and 1.13 (1.00-1.28), respectively. An HbA1c ≥ 9.0 % was also associated with an increased risk of heart failure hospitalization (aHR 1.33; 95 % CI 1.11-1.59) and a non-significant increased risk in mortality (aHR 1.20; 95 % CI 0.99-1.45) when compared to HbA1c of 8.0-8.9 %.Conclusions: Among a cohort of primarily minority and low income patients with heart failure and diabetes, an increased risk of hospitalization was observed only for an HbA1c greater than 9 %. [ABSTRACT FROM AUTHOR]

OBJECTIVE--To examine the association between diabetes, glycemic control, and risk of fracture-related hospitalization in the Atherosclerosis Risk in Communities (ARIC) Study. RESEARCH DESIGN AND METHODS--Fracture-related hospitalization was defined using International Classification of Diseases, 9th revision, codes (733.1-733.19, 733.93- 733.98, or 800-829). We calculated the incidence rate of fracture-related hospitalization by age and used Cox proportional hazards models to investigate the association of diabetes with risk of fracture after adjustment for demographic, lifestyle, and behavioral risk factors. RESULTS--There were 1,078 incident fracture-related hospitalizations among 15,140 participants during a median of 20 years of follow-up. The overall incidence rate was 4.0 per 1,000 person-years (95% confidence interval [CI], 3.8-4.3). Diagnosed diabetes was significantly and independently associated with an increased risk of fracture (adjusted hazard ratio [HR], 1.74; 95% CI, 1.42-2.14). There also was a significantly increased risk of fracture among persons with diagnosed diabetes who were treated with insulin (HR, 1.87; 95% CI, 1.15-3.05) and among persons with diagnosed diabetes with hemoglobin A1c (HbA1c) ≥8% (1.63; 1.09-2.44) compared with those with HbA1c < 8%. Undiagnosed diabetes was not significantly associated with risk of fracture (HR, 1.12; 95% CI, 0.82-1.53). CONCLUSIONS--This study supports recommendations from the American Diabetes Association for assessment of fracture risk and implementation of prevention strategies in persons with type 2 diabetes, particularly those persons with poor glucose control. [ABSTRACT FROM AUTHOR]

Abstract: Background: Diabetes is associated with increased risk of mortality in heart failure. We examined the association of diabetes with expenditures, hospitalizations, and procedures among Medicare beneficiaries with heart failure during the last 6 months of life. Methods and Results: In a 5% national Medicare sample, the prevalence of diabetes was 41.7% among 16,613 beneficiaries who died in 2007 with a diagnosis of heart failure. Diabetes was associated with higher expenditures during the last 6 months of life (mean $39,042 vs $29,003; P < .001), even after adjusting for covariates, including age, sex, race, geographic location, comorbidities, and preceding hospitalizations (cost ratio 1.08, 95% CI 1.05–1.12). For both diabetic and nondiabetic adults, more than one-half of Medicare expenditures were related to hospitalization costs (mean $22,516 vs $15,721; P < .001). Compared with their counterparts without diabetes, beneficiaries with diabetes had higher rates of hospitalization (adjusted incidence rate ratio 1.09, 95% CI 1.05–1.12) and days spent in the intensive care unit. Conclusions: Comorbid diabetes was common in heart failure and associated with higher expenditures, much of which was driven by increased rates of hospitalizations. Programs that focus on prevention of hospitalizations may reduce the substantial costs associated with heart failure near the end of life. [Copyright &y& Elsevier]

OBJECTIVE--This study sought to investigate an association of HbA1c (A1C) with incident heart failure among individuals without diabetes and compare it to fasting glucose. RESEARCH DESIGN AND METHODS--We studied 11,057 participants of the Atherosclerosis Risk in Communities (ARIC) Study without heart failure or diabetes at baseline and estimated hazard ratios of incident heart failure by categories of A1C (<5.0, 5.0-5.4 [reference], 5.5-5.9, and 6.0-6.4%) and fasting glucose (<90, 90-99 [reference], 100-109, and 110-125 mg/dl) using Cox proportional hazards models. RESULTS--A total of 841 cases of incident heart failure hospitalization or deaths (International Classification of Disease, 9th/10th Revision, 428/I50) occurred during a median follow-up of 14.1 years (incidence rate 5.7 per 1,000 person-years). After the adjustment for covariates including fasting glucose, the hazard ratio of incident heart failure was higher in individuals with A1C 6.0-6.4% (1.40 [95% CI, 1.09-1.79]) and 5.5-6.0% (1.16 [0.98-1.37]) as compared with the reference group. Similar results were observed when adjusting for insulin level or limiting to heart failure cases without preceding coronary events or developed diabetes during follow-up. In contrast, elevated fasting glucose was not associated with heart failure after adjustment for covariates and A1C. Similar findings were observed when the top quartile (A1C, 5.7-6.4%, and fasting glucose, 108-125 mg/dl) was compared with the lowest quartile (<5.2% and <95 mg/dl, respectively). CONCLUSIONS--Elevated A1C (≥5.5-6.0%) was associated with incident heart failure in a middle-aged population without diabetes, suggesting that chronic hyperglycemia prior to the development of diabetes contributes to development of heart failure. Diabetes 59:2020-2026, 2010 [ABSTRACT FROM AUTHOR]

Discusses research being done on the effectiveness of losartan-based therapy in reducing stroke and new-onset diabetes in hypertensive patients. Reference to study by R.B. Devereux and colleagues, published in the March 2002 issue of the journal 'Lancet'; Information on the study population; Intervention administered to the patients.