Food insecurity is associated with poor glycemic control and increased risk for diabetes-related complications. The clinical benefit of addressing these challenges through a medically supportive grocery prescription (GRx) program in patients with type 2 diabetes mellitus (T2D) remains unclear. We…
Social barriers to health care, such as food insecurity, financial distress, and housing instability, may impede effective clinical management for individuals with chronic illness. Systematic strategies are needed to more efficiently identify at-risk individuals who may benefit from proactive outreach…
Severe hypoglycemia is a serious adverse drug event associated with hypoglycemia-prone medications; older patients with diabetes are particularly at high risk. Economic food insecurity (food insecurity due to financial limitations) is a known risk factor for hypoglycemia; however, less is…
To examine the willingness of older patients to take less diabetes medication (de-intensify) and to identify characteristics associated with willingness to de-intensify treatment. Survey conducted in 2019 in an age-stratified, random sample of older (65-100 years) adults with diabetes on glucose-lowering…
Learning health systems require a workforce of researchers trained in the methods of identifying and overcoming barriers to effective, evidence-based care. Most existing postdoctoral training programs, such as NIH-funded postdoctoral T32 awards, support basic and epidemiological science with very limited…
Optimal care for persons with multiple chronic conditions (MCC) requires primary and specialty care continuity, access to multiple providers, social risk assessment, and self-management support. The COVID-19 pandemic abruptly changed primary care delivery to increase reliance on telehealth and virtual…
BACKGROUND: Unmet social health needs are associated with medication nonadherence. Although pharmacists are well positioned to address medication nonadherence, there is limited experience with screening for and addressing social health needs. OBJECTIVES: To compare the prevalence of social health needs…
For older adults with type 2 diabetes (T2D) treated with insulin or sulfonylureas, Endocrine Society guideline recommends HbA1c between 7% to
Introduction Information about demographic differences in social risks, needs, and attitudes toward social health screening in non-highly vulnerable adult populations is lacking. Methods The authors analyzed data for 2869 Kaiser Permanente Northern California non-Medicaid-covered members aged 35 to 85 who…
Estimated life expectancy for older patients with diabetes informs decisions about treatment goals, cancer screening, long-term and advanced care, and inclusion in clinical trials. Easily implementable, evidence-based, diabetes-specific approaches for identifying patients with limited life expectancy are needed. Develop and…
This 3-arm randomized pragmatic clinical trial will test the efficacy of patient-focused continuous glucose monitoring (Arm 1 - "patient-only CGM") and patient/provider-focused continuous glucose monitoring (Arm 2 - "patient + provider CGM") intervention strategies, compared to an active comparator (Arm…
We set out to identify empirically-derived health status classes of older adults with diabetes based on clusters of comorbid conditions which are associated with future complications. We conducted a cohort study among 105,786 older (≥65 years of age) adults with type…
Background: Adults with chronic medical conditions complicated by food insecurity or physical limitations may have higher barriers to accessing telehealth implemented during the COVID-19 pandemic. Objective: To examine the relationships of self-reported food insecurity and physical limitations with changes in…
This study explores whether using a Hypoglycemia Champion to target high-risk patients with type 2 diabetes is a feasible and effective model of care to reduce hypoglycemia risk in this population. We will develop an evidence-based, expert consensus clinical guideline,…
To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D). A population-based observational study using electronic health records data. An integrated healthcare…
To estimate rates of severe hypoglycemia and falls among older adults with diabetes and evaluate their association. Survey in an age-stratified, random sample adults with diabetes age 65-100 years; respondents were asked about severe hypoglycemia (requiring assistance) and falls in…
Adverse social conditions are a key contributor to health disparities. Improved understanding of how social risk factors interact with each other and with neighborhood characteristics may inform efforts to reduce health disparities. A questionnaire of 29,281 patients was collected through…
Introduction The objective of this study was to identify and operationalize measures of potential housing insecurity within existing electronic health record data and to quantify the association between address changes and diabetes management goals among patients with type 2 diabetes.…
Kaiser Permanente has set a national goal to increase social health screening among members. Dr. Grant and his DOR Complex Care Team will work with KP National Office of Community Health in a consultative role to address barriers and facilitators…
Social Needs Network for Evaluation and Translation (SONNET) is a national network of applied researchers who help design, evaluate, and implement effective social health interventions to improve member health across Kaiser Permanente. The SONNET Evaluation and Research Committee (ERC) is…
Communities of color have been disproportionately impacted by the COVID-19 epidemic in the USA. To examine the relationship of self-reported social health needs with SARS-COV-2 infection by race/ethnicity among insured adults with access to high-quality health care. A prospective cohort…
Adults with type 2 diabetes diagnosed at a younger age are at increased risk for poor outcomes. We examined life stage-related facilitators and barriers to early self-management among younger adults with newly diagnosed type 2 diabetes. We conducted 6 focus…
Our DOR Complex Care Team is working with Dr. Anand Shah and his team in a consultative role to address barriers and facilitators to social health screening. This work focuses on evaluating and implementing novel informatics-based strategies to guide member…
Cardiovascular disease (CVD) continues to be a leading cause of morbidity in the U.S. Managing CVD risk factors, such as diabetes or hypertension, can be challenging for many individuals. We investigated the barriers experienced by patients who persistently struggled to…
This study will evaluate TracFone/CareLink program within Kaiser Permanente (KP) Digital Health Equity portfolio. It will involve engaging local leaders, end users, and KP members in the planning, implementation, and initial assessment of barriers and facilitators of the TracFone/CareLink program.
To identify opportunities to align care with the personal values of patients from three distinct groups with complex medical, behavioral, and social needs. Between June and August 2019, we conducted semi-structured interviews with individuals with complex care needs in two…
Adults diagnosed with type 2 diabetes at a younger age are at increased risk for poor outcomes. Yet, little is known about the early experiences of these individuals, starting with communication of the diagnosis. Addressing this knowledge gap is important…
The primary care visit is an important opportunity to discuss and modify diabetes management. To gain insight into doctor-patient communication during primary care visits among English and Spanish speaking patients with type 2 diabetes and suboptimal glycemic control (HbA1c >…
Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. To define distinct patient clinical…
The goal of this study is to apply the patient-centered advance care planning paradigm of values elicitation and decision-making and communication preparation to hypoglycemia-related adverse outcomes in vulnerable older patients with type 2 diabetes. This will involve a randomized clinical…
This study will gather data to estimate the prevalence of several different social and financial risk factors among adults aged 35-84 and assess whether risk factor prevalence significantly differs across age, race, health status, and income groups.
The COVID epidemic has exposed the fragility of the social network that supports our most complex and vulnerable members. We have established an interdisciplinary team of researchers, clinicians, and operational leaders at KPNC, KPCO, KPWA to study socially determined barriers…
My team has been working collaboration with The Permanente Medical Group and Kaiser Foundation Health Plan to implement and evaluate care models to improve health outcomes of medically and socially complex patients. We are currently conducting a rapid cycle randmomized…
This pragmatic, randomized clinical trial will compare the effect of primary care physician academic detailing with or without patient pre-visit preparation on insulin de-prescribing rates among older patients with type 2 diabetes at high risk for insulin-related hypoglycemia. We will…
The prevalence of type 2 diabetes is increasing among adults under age 45. Onset of type 2 diabetes at a younger age increases an individual's risk for diabetes-related complications. Given the lasting benefits conferred by early glycemic control, we compared…
In studies based on electronic health records (EHR), the frequency of covariate monitoring can vary by covariate type, across patients, and over time, which can limit the generalizability of inferences about the effects of adaptive treatment strategies. In addition, monitoring…
Background Despite the success of current cardiovascular disease (CVD) management programs, many patients do not achieve optimal control of CVD-related risk factors. New strategies are needed to better activate and engage these patients. Methods and Results We conducted a parallel,…
Among older individuals with type 2 diabetes, those with poor health have greater risk and derive less benefit from tight glycemic control with insulin. To examine whether insulin treatment is used less frequently and discontinued more often among older individuals…
Personal health records offer patients access to view their own health information and to manage their care online through secure patient portal tools. Little is known about the patient-reported experience in using health portals to manage chronic conditions. In a…
This study will leverage the rich electronic data sources within Kaiser Permanente to create pragmatic tools for improving health and equity among primary care patients with the highest medical and social needs. Aim 1: Use advanced analytic methods to predict…
People with type 2 diabetes vary greatly in their use of high-cost health care resources. We examined the association of anxiety with high-cost use after accounting for depression and medical comorbidity. Using electronic health record data, we assessed past anxiety…
Electronic health records (EHR) data provide a cost- and time-effective opportunity to conduct cohort studies of the effects of multiple time-point interventions in the diverse patient population found in real-world clinical settings. Because the computational cost of analyzing EHR data…
Primary care providers (PCPs) are often challenged to address multiple patient concerns during time-limited visits. The need for PCPs to limit the number of issues addressed may have a negative impact on discussion of patient-defined visit priorities. Using data from…
Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits. To test the hypothesis that a "Pre-Visit Prioritization" secure email message could…
Health information technology (IT) tools are increasingly used to improve patient care. However, implementation of English-only health IT tools could potentially worsen health disparities for non-English speakers. We aim to describe the "trans-creation" process of developing linguistically and culturally appropriate…
Widespread adoption of electronic health records (EHRs) in medical care has resulted in increased physician documentation workload and decreased interaction with patients. Despite the increasing use of medical scribes for EHR documentation assistance, few methodologically rigorous studies have examined the…
Time during primary care visits is limited. We tested the hypothesis that a waiting room health information technology (IT) tool to help patients identify and voice their top visit priorities would lead to better visit interactions and improved quality of…
For patients with diabetes, many with multiple complex chronic conditions, using a patient portal can support self-management and coordination of health care services, and may impact the frequency of in-person health care visits. To examine the impact of portal access…
Latinos face unique challenges engaging with their health care providers for risk management of cardiovascular disease (CVD). To better understand differences in how Latinos and non-Latino whites (NLWs) experience CVD care. We examined self-reported activation, engagement, confidence, and communication comparing…
To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy. We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system.…
To examine the prevalence and person-level predictors of undiagnosed Type 2 diabetes among adults with elevated HbA1c values. We identified adults without diabetes who had a first elevated HbA1c (index HbA1c ≥ 48 mmol/mol; ≥ 6.5%) between January 2014 and…
This administrative supplement solicited by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) will provide two to six medical students with summer training opportunities in translational research. This supplement allows the existing T32 program based at the…
Diabetes remains a leading cause of morbidity and mortality, and it is a significant burden to the U.S. health care system, patients, and their families. The knowledge and skills necessary to overcome the final translational block from evidence into practice…
A relatively small proportion of patients with complex needs represent a major source of cost and utilization. The fundamental principle that distinguishes complex needs patients from other high-cost patients with well-defined medical issues is that "complex needs" is a highly…
A high proportion of U.S. health care costs are attributable to a relatively small proportion of patients. Understanding behavioral and social factors that predict initial and persistent high costs for these "high utilizers" is critical for health policy-makers. This prospective…
A large and increasing proportion of health care costs are spent caring for a small segment of medically and socially complex patients. To date, it has been difficult to identify which patients are best served by intensive care management. To…
Patients with type 2 diabetes are increasingly living with multiple concurrent conditions and complicated medical regimens. For these patients, diabetes management decisions and treatment goals must be addressed within the larger context of other competing health concerns. In parallel, clinical…
Evidence supporting the effectiveness of care management programs for complex patients has been inconclusive. However, past reviews have not focused on complexity primarily defined by multimorbidity and healthcare utilization. We conducted a systematic review of care management interventions targeting the…
Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions. We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n…
Cardiovascular disease (CVD) is the leading cause of death in the US. Many patients do not benefit from traditional disease management approaches to CVD risk reduction. Here we describe the rationale, development, and implementation of a multi-component behavioral intervention targeting…
Diabetic polyneuropathy is a highly prevalent and costly complication of diabetes that is frequently underdiagnosed and undertreated in primary care settings. In this article, we discuss challenges in the management of diabetic polyneuropathy symptoms, including diagnostic complexity, the limited efficacy…
The purpose of this study was to examine how patients with diabetes and their primary care physicians identify and discuss visit priorities prior to and during visits. We conducted a qualitative study involving patients with diabetes (4 focus groups, n=29)…
A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians. To…
The management of chronic conditions is characterized by frequent re-assessment of therapy decisions in response to the patient's changing condition over the course of the illness. Evidence most suitable to inform care thus often concerns the contrast of adaptive treatment…
Providing culturally competent care to the growing number of limited-English proficiency (LEP) Latinos with diabetes in the United States is challenging. To evaluate changes in risk factor control among LEP Latinos with diabetes who switched from language-discordant (English-only) primary care…
The Clinical and Translational Science Institute (CTSI) facilitates the rapid translation of research to improvements in patient and community health. It is a cross-school, campus-wide institute with scientist leaders at its helm. To achieve its goals, CTSI provides infrastructure, services…
K24 Midcareer Investigator Awards in Patient-Oriented Research are designed to support established scientists with a track record of mentoring to devote time to research mentorship for junior investigators. The overarching goal of this K24 award is to develop innovative approaches…
Patients with type 2 diabetes are increasingly living with multiple concurrent conditions and complicated medical regimens. For these patients, diabetes management decisions and treatment goals must be addressed within the larger context of other competing health concerns. In parallel, clinical…
Disease management programs have had success in CVD risk factor control among uncomplicated patients but often fall short in more complex patients. New approaches are needed to address the multiple barriers faced by CVD patients with complex medical and behavioral…
Patients with type 2 diabetes are increasingly living with multiple concurrent conditions and complicated medical regimens. For these patients, diabetes management decisions and treatment goals must be addressed within the larger context of other competing health concerns. In parallel, clinical…
The primary care visit is a key opportunity for catalyzing changes in care for complex patients with multiple heath issues. With too many items to address in the time allotted, however, the decision of which items to focus on requires…
We examined the role of language and culture in the interactions between Spanish-speaking Latino patients with poorly controlled diabetes - a fast-growing population in the United States - and their primary care providers. We conducted four focus groups with 36…
This study assessed the effect of acculturation on type 2 diabetes and whether health literacy may mediate this association. The Boston Area Community Health cohort is a multi-stage stratified random sample of adults from Boston including 744 Latinos. We defined…
Challenges to effective pharmacologic management of symptomatic diabetic peripheral neuropathy include the limited effectiveness of available medicines, frequent side effects, and the need for ongoing symptom assessment and treatment titration for maximal effectiveness. We present here the rationale and implementation…
Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care. We designed a controlled,…
Complex patients with multiple chronic conditions often face significant challenges communicating and coordinating with their primary care physicians. These challenges are exacerbated by the limited time allotted to primary care visits. Our aim was to employ a user-centered design process…
Improving the ability to risk-stratify patients is critical for efficiently allocating resources within healthcare systems. The purpose of this study was to evaluate a physician-defined complexity prediction model against outpatient Charlson score (OCS) and a commercial risk predictor (CRP). Using…
Novel health information technology (IT)-based strategies harnessing patient registry data seek to improve care at a population level. We analyzed costs from a randomized trial of 2 health IT strategies to improve cancer screening compared with usual care from the…
To identify the predictors and clinical effects among inactive patients with diabetes who become physically active, in the setting of a large integrated health system. We studied adults with Type 2 diabetes with at least two clinic visits between December…
Improving colorectal cancer (CRC) screening rates for patients from socioeconomically disadvantaged backgrounds is a recognized public health priority. Our aim was to determine if implementation of a system-wide screening intervention could reduce disparities in the setting of improved overall screening…
Adoption of electronic health records (EHRs) has increased dramatically since the 2009 implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The latest data from the Centers for Disease Control and Prevention (CDC) indicate that the…
Lack of timely medication intensification and inadequate medication safety monitoring are two prevalent and potentially modifiable barriers to effective and safe chronic care. Innovative applications of health information technology tools may help support chronic disease management. To examine the clinical…
To investigate the prevalence, predictors, and costs associated with unused results from self-monitoring of blood glucose (SMBG). Observational cohort study. We studied 7320 patients with type 2 diabetes mellitus who were not prescribed insulin and who reported SMBG. Patients reported…
Genome-wide association studies have uncovered a large number of genetic variants associated with type 2 diabetes or related phenotypes. In many cases the causal gene or polymorphism has not been identified, and its impact on response to anti-hyperglycemic medications is…
To test among diabetes-free urban community-dwelling adults the hypothesis that the proportion of African genetic ancestry is positively associated with glycaemia, after accounting for other continental ancestry proportions, BMI and socioeconomic status (SES). The Boston Area Community Health cohort is…
To develop glycaemic goal individualization algorithms and assess potential impact on a healthcare system and different segments of the population with diabetes. A cross-sectional observational study of patients with diabetes in a primary care network age > 18 years with an HbA1c…
Advances in information technology (IT) now permit population-based preventive screening, but the best methods remain uncertain. We evaluated whether involving primary care providers (PCPs) in a visit-independent population management IT application led to more effective cancer screening. We conducted a…
This study uses novel methods to examine the frequency of diagnosis and treatment of prediabetes in real-world clinical settings using electronic health record (EHR) data. We identified a cohort of 358,120 adults with incident prediabetes (fasting plasma glucose [FPG] 100-125…
Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk. To examine the clinical impact of a newly implemented program ("Exercise as a Vital Sign" [EVS]) designed to systematically ascertain patient-reported exercise levels at…
With the aging of the population and continuing advances in health care, patients seen in the primary care setting are increasingly complex. At the same time, the number of screening and chronic condition management tasks primary care providers are expected…
Elevated circulating levels of branched chain and aromatic amino acids (BCAA/AAAs) are associated with insulin resistance and incident type 2 diabetes (T2D). BCAA/AAAs decrease acutely during an oral glucose tolerance test (OGTT), a diagnostic test for T2D. It is unknown…
Genetic testing for chronic disease susceptibility may motivate young adults for preventive behavior change. This nationally representative survey gave 521 young adults hypothetical scenarios of receiving genetic susceptibility results for heart disease, type 2 diabetes, and stroke and asked their…
No current national data exist to characterize safety-net physicians and their attitudes toward and participation in quality improvement activities compared with non-safety-net physicians. The authors conducted a national random sample survey of internal medicine, family practice, and pediatrics primary care…
AIM: To examine the association of in-hospital diabetes regimen intensification with subsequent 30-day risk for unplanned readmission/emergency department admission. METHODS: We retrospectively studied 1949 adults with Type 2 diabetes receiving primary care within an academic health network admitted to the…
OBJECTIVE: To examine whether diabetes genetic risk testing and counseling can improve diabetes prevention behaviors. RESEARCH DESIGN AND METHODS: We conducted a randomized trial of diabetes genetic risk counseling among overweight patients at increased phenotypic risk for type 2 diabetes.…
Advances in genetic epidemiology have increased understanding of common, polygenic preventable diseases such as type 2 diabetes. As genetic risk testing based on this knowledge moves into clinical practice, we propose that genetic counselors will need to expand their roles…
OBJECTIVE: To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety. DESIGN: From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that…
OBJECTIVE: To determine whether the relationship between age and physical and mental health varies by diabetes status in older U.S. adults. RESEARCH DESIGN AND METHODS: Using data from the National Social Life, Health, and Aging Project, a national sample of…
The management of patients with Type 2 diabetes is based on a remarkably robust evidence base. Large clinical trials and lengthy observational cohort studies have clearly established the importance of glycemic, blood pressure and lipid level control. Indeed, most elements…
Latinos have higher rates of diabetes and diabetes-related complications compared to non-Latinos. Clinical diabetes self-management tools that rely on innovative health information technology (HIT) may not be widely used by Latinos, particularly those that have low literacy or numeracy, low…
BACKGROUND: Informatics tools may help support hypertension management. OBJECTIVE: To design, implement and evaluate a web-based system for patient anti-hypertensive medication self-titration. METHODS: Study stages included: six focus groups (50 patients) to identify barriers/facilitators to patient medication self-titration, software design…
BACKGROUND: Patients with complex health needs are increasingly the focus of health system redesign.OBJECTIVE: To characterize complex patients, as defined by their primary care physicians (PCPs), and to compare this definition with other commonly used algorithms.DESIGN: Cohort study.SETTING: 1 hospital-based…
CONTEXT: Physicians have increasingly become the focus of clinical performance measurement.OBJECTIVE: To investigate the relationship between patient panel characteristics and relative physician clinical performance rankings within a large academic primary care network.DESIGN, SETTING, AND PARTICIPANTS: Cohort study using data from…
BACKGROUND: Web-based personal health records (PHRs) have been advocated as a means to improve type 2 diabetes mellitus (DM) care. However, few Web-based systems are linked directly to the electronic medical record (EMR) used by physicians.METHODS: We randomized 11 primary…
OBJECTIVE: The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.RESEARCH DESIGN AND METHODS: We used a retrospective, longitudinal repeated-measures design to model…
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