Importance: Consistent medication use is critical for diabetes management. Population surveillance of consistency of medication use may identify opportunities to improve diabetes care. Objective: To evaluate trends in longitudinal use of glucose-, blood pressure-, and lipid-lowering medications by adults with diabetes. Design, Setting, and Participants: This serial cross-sectional study assessed trends in longitudinal use of glucose-, blood pressure-, and lipid-lowering medications by adults with diagnosed diabetes participating in the Medical Expenditure Panel Survey (MEPS), which allows serial cross-sections and 2-year longitudinal follow-up, between the 2005 to 2006 panel and 2018 to 2019 panel. Population-weighted, nationally representative estimates for the US were reported. Included individuals were adult MEPS participants with diagnosed diabetes during both years (ie, during 2005 and 2006 or during 2018 and 2019) who participated in all survey rounds. Data were analyzed from August 2021 to November 2022. Main Outcomes and Measures: Longitudinal use over the 2 years was categorized as continued use (at least 1 fill per year), no use, inconsistent use, and new use by medication type (glucose-, blood pressure-, and lipid-lowering medications). New medications were defined as prescription fills for a medication type first prescribed and filled in year 2 of MEPS participation. Results: A total of 15 237 participants with diabetes (7222 individuals aged 45-64 years [47.4%]; 8258 [54.2%] female participants; 3851 Latino [25.3%]; 3619 non-Latino Black (23.8%), and 6487 non-Latino White [42.6%]) were included in the analytical sample. A mean of 19.5% (95% CI, 18.6%-20.3%), 17.1% (95% CI, 16.2%-18.1%), and 43.3% (95% CI, 42.2%-44.3%) of participants did not maintain continuity in use of glucose-, blood pressure-, or lipid-lowering medications, respectively, during both years of follow-up. The proportion of participants who continued use of glucose-lowering medication in both years trended down from 84.5% (95% CI, 81.8%-87.3%) in 2005 to 2006 to 77.4% (95% CI, 74.8%-80.1%) in 2018 to 2019; this decrease coincided with rate increases in inconsistent use (3.3% [95% CI, 1.9%-4.7%] in 2005-2006 to 7.1% [95% CI, 5.6%-8.6%] in 2018-2019) and no use (8.1% [95% CI, 6.0%-10.1%] in 2005-2006 to 12.9% [95% CI, 10.9%-14.9%] in 2018-2019). Inconsistent use of blood pressure-lowering medications trended upward from 3.9% (95% CI, 1.8%-6.0%) in 2005 to 2006 to 9.0% (95% CI, 7.0%-11.0%) in 2016 to 2017. Inconsistent use of lipid-lowering medication trended up to a high of 9.9% (95% CI, 7.0%-12.7%) in 2017 to 2018. Conclusions and Relevance: This study found that a mean of 19.5% of participants did not maintain continuity in use of glucose-lowering medication, with recent decreases, while a mean of 17.1% and 43.2% of participants did not maintain continuity of use of blood pressure- or lipid-lowering medications, respectively.

The price of insulin has increased threefold since 2007 (1), imposing a substantial economic burden on patients and payers, which has resulted in reduced insulin adherence and dosage rationing (2). Significant legislative efforts were made in 2022 to cap the copayments needed to access insulin to $35 per month to ensure its affordability. In a previous analysis (3), we showed that this copayment cap policy is likely to reduce copayment for insulin by about $500 per year for 1.6 million people and avoid thousands of diabetes complications and fatal events that would lead to generating an additional 32,000 life-years and 21,000 quality-adjusted life-years (QALYs). However, even after accounting for the cost-saving due to a reduced risk for diabetes complications, the policy would still increase total medical costs by $5.6 billion over 20 years. To assess whether the additional costs are justifiable, in this work, we report the cost-effectiveness of this policy and draw economic implications on future policy interventions.

Objective: We assessed the impact of a collaborative care intervention on anxiety symptoms among participants in India with comorbid depression, poorly controlled diabetes, and moderate to severe anxiety symptoms. Method: We analyzed data from a randomized controlled trial conducted at four diabetes clinics in India. Participants received either collaborative care or usual care. We included only participants who scored ⩾10 on the Generalized Anxiety Disorder-7 (GAD-7) at baseline. We estimated the effect of the intervention on clinically significant reduction in anxiety symptoms; we considered several potential baseline moderators and mediation by anti-depressant use. Results: One hundred and seventy-two participants scored 10 or above on the GAD-7 at baseline. Collaborative care participants were more likely than control participants to achieve a clinically significant reduction in anxiety symptoms at 6 and 12 months (65.7% vs. 41.4% at 12 months, p = 0.002); these differences were not sustained at 18 or 24 months. There was little evidence of moderation by participant characteristics at baseline, and effects were not mediated by anti-depressant use. Conclusions: Collaborative care for the treatment of depression and type 2 diabetes can lead to clinically significant reductions in anxiety symptoms among patients with anxiety. Effects were notable during the active intervention period but not over the year post-intervention.

OBJECTIVE We characterized annual trends of severe hypoglycemic and hyperglycemic crises (diabetic ketoacidosis/hyperglycemic hyperosmolar state) in patients with diabe¬tes and end-stage kidney disease (ESKD). RESEARCH DESIGN AND METHODS This was a nationwide, retrospective study of adults (S18 years old) with diabetes/ ESKD, from the United States Renal Data System registry, between 2013 and 2017. Pri¬mary outcome was annual rates of emergency department visits or hospitalizations for hypoglycemic and hyperglycemic crises, reported as number of events/1,000 per¬son-years. Event rates and risk factors were adjusted for patient age, sex, race/ethnic¬ity, dialysis modality, comorbidities, treatment regimen, and U.S. region. RESULTS Among 521,789 adults with diabetes/ESKD (median age 65 years [interquartile range 73], 56.1% male, and 46% White), overall adjusted rates of hypoglycemic and hyperglycemic crises were 53.64 and 18.24 per 1,000 person-years, respectively. For both hypoglycemia and hyperglycemia crises, respectively, the risks decreased with age and were lowest in older patients (S75 vs. 18-44 years old: Incidence rate ratio 0.35, 95% CI 0.33-0.37, and 0.03, 0.02-0.03), women (1.09, 1.06-1.12, and 1.44, 1.35-1.54), and those with smoking (1.36, 1.28-1.43, and 1.71, 1.53-1.91), substance abuse (1.27, 1.15-1.42, and 1.53, 1.23-1.9), retinopathy (1.10, 1.06-1.15, and 1.36, 1.26-1.47), and insulin therapy (vs. no therapy; 0.60, 0.59-0.63, and 0.44, 0.39-0.48). For hypoglycemia, specifically, additional risk was conferred by Black race (1.11, 1.08-1.15) and amputation history (1.20, 1.13-1.27). CONCLUSIONS In this nationwide study of patients with diabetes/ESKD, hypoglycemic crises were threefold more common than hyperglycemic crises, greatly exceeding national reports in nondialysis patients with chronic kidney disease. Young, Black, and female patients were disproportionately affected.

AIMS: We aimed to determine what key resources, mechanisms, and contextual factors are necessary to integrate depression and diabetes treatment into low-resource settings. METHODS: A realist evaluation framework was employed to conduct a comparative case study. Data were collected through document review, key informant interviews (n = 4), activity logs, and interviews with implementing health care providers (n = 11) to test and refine program theories for collaborative care. RESULTS: Efforts to enhance patient care coordination (i.e., adapting clinics' patient flow and resources, on-going trainings, and on-site support for care coordinators) improved implementation of depression treatment by usual care diabetes physicians. Clinician's avoidance of the term depression was identified as a barrier to mental health counseling and treatment. CONCLUSIONS: The variations in organizational features and processes linked to implementation activities across two clinics provided an opportunity to examine how and why different contextual factors help or hinder the implementation process. Findings from this study demonstrate that successful implementation of an integrated depression and diabetes care model is feasible in a low-resource setting, while the revised program theories provide an explanatory framework of coordinated care implementation processes that can inform future efforts to disseminate and scale this care model.

Introduction: The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined. Methods: A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008–2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18–64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020. Results: In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= −16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment. Conclusions: Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.

Introduction: Several interventions have been found to be effective for reversing prediabetes in adults. This systematic review and meta-analysis aims to compare the effectiveness of such interventions. Methods: MEDLINE, Embase, and Cochrane Library databases were searched for articles published between January 1, 2000 and June 27, 2018. RCTs in adults with prediabetes, testing nonsurgical interventions lasting for ≥3 months, and reporting the number of participants achieving normal glucose levels at intervention end were eligible. The pooled risk difference and number needed to treat for achieving normoglycemia were estimated using a random-effects, arm-based network meta-analysis. The strength of the evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Data were obtained in 2018 and analyzed in 2019 and 2021. Results: Of 54 studies included in the systematic review, 47 were meta-analyzed (n=26,460, mean age=53 years, 46% male, 31% White). Studies included 27 arms testing lifestyle modification interventions, 25 testing medications, 5 testing dietary supplements, and 10 testing Chinese medicine. There were 35 control/placebo arms. At a median follow-up of 1.6 years, more participants in the lifestyle modification groups achieved normoglycemia than those in the control (risk difference=0.18, number needed to treat=6). The strength of the evidence was strong for lifestyle modification. Over a median follow-up of 2.7 years, more participants receiving glucagon-like peptide-1 receptor agonists (risk difference=0.47, number needed to treat=2), α-glucosidase inhibitors (risk difference=0.29, number needed to treat=4), and insulin sensitizers (risk difference=0.23, number needed to treat=4) achieved normoglycemia than control. The strength of evidence was moderate for these medications. Discussion: Although several pharmacological approaches can reverse prediabetes, lifestyle modification provides the strongest evidence of effectiveness and should remain the recommended approach to address this condition.

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Background: Race/ethnic disparities in preventable diabetes-specific hospital care may exist among adults with diabetes who have Medicaid coverage. Objective: To examine race/ethnic disparities in utilization of preventable hospital care by adult Medicaid enrollees with diabetes across nine states over time. Design: Using serial cross-sectional state discharge records for emergency department (ED) visits and inpatient (IP) hospitalizations from the Healthcare Cost and Utilization Project, we quantified race/ethnicity-specific, state-year preventable diabetes-specific hospital utilization. Participants: Non-Hispanic Black, non-Hispanic White, and Hispanic adult Medicaid enrollees aged 18–64 with a diabetes diagnosis (excluding gestational or secondary diabetes) who were discharged from hospital care in Arizona, Iowa, Kentucky, Florida, Maryland, New Jersey, New York, North Carolina, and Utah for the years 2008, 2011, 2014, and 2017. Main Measures: Non-Hispanic Black-over-White and Hispanic-over-White rate ratios constructed using age- standardized state-year, race/ethnicity-specific ED, and IP diabetes-specific utilization rates. Key Results: The ratio of Black-over-White ED utilization rates for preventable diabetes-specific hospital care increased across the 9 states in our sample from 1.4 (CI 95, 1.31–1.50) in 2008 to 1.73 (CI 95, 1.68–1.78) in 2017. The cross-year-state average non-Hispanic Black-over-White IP rate ratio was 1.46 (CI 95, 1.42–1.50), reflecting increases in some states and decreases in others. The across-state-year average Hispanic-over-White rate ratio for ED utilization was 0.67 (CI 95, 0.63–0.71). The across-state-year average Hispanic-over-White IP hospitalization rate ratio was 0.72 (CI 95, 0.69–0.75). Conclusions: Hospital utilization by non-Hispanic Black Medicaid enrollees with diabetes was consistently greater and often increased relative to utilization by White enrollees within state programs between 2008 and 2017. Hispanic enrollee hospital utilization was either lower or indistinguishable relative to White enrollee hospital utilization in most states, but Hispanic utilization increased faster than White utilization in some states. Among broader patterns, there is heterogeneity in the magnitude of race/ethnic disparities in hospital utilization trends across states.

Background : Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear. Methods We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high ho usehold assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category. Results Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0-29.9 and ≥30 kg/m 2 ; waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups. Conclusions SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia.