The Challenges of Identifying Environmental Determinants of Type 1 Diabetes: In Search of the Holy Grail.

Type 1 diabetes is the result of autoimmune-mediated destruction and inflammation of the insulin-producing ß-cells of the pancreas. The excess morbidity and mortality from its complications coupled with its increasing incidence emphasize the importance to better understand the etiology of this condition. It has a strong genetic component, but a genetic predisposition is not the sole contributor to disease development as only 30% to 50% of identical twins both develop the disease. In addition, there are multiple lines of evidence to support that environmental factors contribute to the pathogenesis of type 1 diabetes. Environmental risk factors that have been proposed include infections, dietary factors, air pollution, vaccines, location of residence, childhood obesity, family environment and stress. Researchers have conducted many observational studies to identify and characterize these potential environmental factors, but findings have been inconsistent or inconclusive. Many studies have had inherent methodological issues in recruitment, participation, defining cases and exposures, and/or data analysis which may limit the interpretability of findings. Identifying and addressing these limitations may allow for greatly needed advances in our understanding of type 1 diabetes. As such, the purpose of this article is to review and discuss the limitations of observational studies that aim to determine environmental risk factors for type 1 diabetes and propose recommendations to overcome them.

Variation in Patient Experience Across the Clinic Day: a Multilevel Assessment of Four Primary Care Practices.

BACKGROUND: Patient satisfaction with healthcare is associated with clinical outcomes, provider satisfaction, and success of healthcare organizations. As the clinic day progresses, provider fatigue, deterioration with communication within the care team, and appointment spillover may decrease patient experience. OBJECTIVE: To understand the relationship between likelihood to recommend a primary care practice and scheduled appointment time across multiple practice settings. DESIGN: Retrospective cohort. PARTICIPANTS: A retrospective cohort was created of all patients seen within four primary care practices between July 1, 2016, and September 30, 2017. MAIN MEASURES: We looked at scheduled appointment time against patient likelihood to recommend a practice as a measure of overall patient experience collected routinely for clinical practice improvement by the Press Ganey Medical Practice Survey®. Adjusted mixed effects logistic regression models were created to understand the relationship between progressing appointment time on patient likelihood to recommend a practice. We constructed locally weighted smoothing (LOESS) curves to understand how reported patient experience varied over the clinic day. RESULTS: We had a response rate of 14.0% (n = 3172), 80.2% of whom indicated they would recommend our practice to others. Appointment time scheduling during the last hour (4:00-4:59 PM) had a 45% lower odds of recommending our practice when compared to the first clinic hour (adjusted OR = 0.55, 95% CI 0.35-0.86) which is similar when controlling for patient-reported wait time (aOR = 0.59, 95% CI 0.37-0.95). LOESS plots demonstrated declining satisfaction with subsequent appointment times compared with the first session hour, with no effect just after the lunch hour break. CONCLUSIONS: In primary care, appointment time of day is associated with patient-reported experience.

Skin cancer knowledge and photoprotective practices of organ transplant recipients.

BACKGROUND: Long-term use of immunosuppressive medications by organ transplant recipients (OTRs) leads to an increased risk of non-melanoma skin cancers (NMSCs). The objective of this study was to assess photoprotective knowledge and practices among OTRs and to identify predictors of poor sunscreen adherence and barriers to photoprotection. METHODS: A written survey was administered to 300 solid OTRs attending the Southern Alberta Transplant Program. Demographics, transplant and NMSC history, ultraviolet radiation (UVR) exposure, photoprotective knowledge and practices, and barriers to implementing photoprotection were collected. Relevant statistical analyses and univariate and multivariable regression models on sunscreen use were performed. RESULTS: One hundred and seventy-nine of the 300 respondents reported not using sunscreen most days despite 79.3% recalling have received photoprotection education. Of the surveyed OTRs, 45.7% reported no barriers to implementing photoprotective practices. On average, respondents scored 74.5% on a commonly used tool to assess photoprotective knowledge (SD 30.6%). In multivariable analyses, older age, male gender, and lack of post-secondary education were associated with lower rates of self-reported sunscreen use. The most commonly patient-reported barriers to photoprotection were "hassle/time consuming" (16.7%) and "sunscreen is uncomfortable or unpleasant" (10.0%). CONCLUSIONS: Despite OTRs self-reporting having received sufficient sun-protective knowledge and demonstrating reasonable recollection of photoprotective education on assessment, implementation of sun protection in the studied OTRs remains suboptimal.

Creation of a Patient-Centered Journey Map to Improve the Patient Experience: A Mixed Methods Approach.

OBJECTIVE: To use a mixed methods approach to focus quality improvement efforts to enhance patient experience through human-centered design. PATIENTS AND METHODS: A mixed method approach began with returned Press Ganey Medical Practice Surveys from a large, multidisciplinary, outpatient medicine practice from July 1, 2016, through June 30, 2017, using correlation and gap analysis. The second phase deployed human-centered design approaches to process map patient journeys and generate opportunities for care improvement and to generate a theoretical framework for designing optimal care experiences. RESULTS: Our outpatient medical practices have the greatest ability to improve patient experience scores by focusing on how care teams deliver and educate patients on medications, instructions for follow-up care, and explanations about problems or conditions. By leveraging communication, the expertise of our care team members, and connection between patients and care team members, we can employ a variety of observed opportunities to enhance patient experience. Specific opportunities include leveraging tools in the electronic health record, fostering connection through empathy between patients and members of the care team, and capitalizing on the expertise of nurses on the care team. CONCLUSION: A mixed methods approach to the analysis and observation of clinical care and business operations allows for the detection of opportunities with the highest potential impact for improvement when resources are constrained.

Attributes, Attitudes, and Practices of Clinicians Concerned with Opioid Prescribing.

BACKGROUND: Many clinicians who prescribe opioids for chronic noncancer pain (CNCP) express concerns about opioid misuse, addiction, and physiological dependence. We evaluated the association between the degree of clinician concerns (highly vs less concerned), clinician attributes, other attitudes and beliefs, and opioid prescribing practices. METHODS: A web-based survey of clinicians at a multispecialty medical practice. RESULTS: Compared with less concerned clinicians, clinicians highly concerned with opioid misuse, addiction, and physiological dependence were more confident prescribing opioids (risk ratio [RR] = 1.34, 95% confidence interval [CI] = 1.08-1.67) but were more reluctant to do so (RR = 1.13, 95% CI = 1.03-1.25). They were more likely to report screening patients for substance use disorder (RR = 1.18, 95% CI = 1.01-1.37) and to discontinue prescribing opioids to a patient due to aberrant opioid use behaviors (RR = 1.30, 95% CI = 1.13-1.50). They were also less likely to prescribe benzodiazepines and opioids concurrently (RR = 0.40, 95% CI = 0.25-0.65). Highly concerned clinicians were more likely to work in clinics which engage in "best practices" for opioid prescribing requiring urine drug screening (RR = 4.65, 95% CI = 2.51-8.61), prescription monitoring program review (RR = 2.90, 95% CI = 1.84-4.56), controlled substance agreements (RR = 4.88, 95% CI = 2.64-9.03), and other practices. Controlling for clinician concern, prescribing practices were also associated with clinician confidence, reluctance, and satisfaction. CONCLUSIONS: Highly concerned clinicians are more confident but more reluctant to prescribe opioids. Controlling for clinician concern, confidence in care and reluctance to prescribe opioids were associated with more conservative prescribing practices.

Exploring novel diabetes surveillance methods: a comparison of administrative, laboratory and pharmacy data case definitions using THIN.

Background: The objective of this study was to identify patients with diabetes in a comprehensive primary care electronic medical records database using a number of different case definitions (clinical, pharmacy, laboratory definitions and a combination thereof) and understand the differences in patient populations being captured by each definition. Methods: Data for this population-based retrospective cohort study was obtained from The Health Information Network (THIN). THIN is a longitudinal, primary care medical records database of over 9 million patients in UK. Primary outcome was a diagnosis of diabetes, defined by the presence of a diabetes read code, or an abnormal laboratory result, or a prescription for an Oral Anti-diabetic drug or insulin. A 2-year washout period was applied prior to the index of diabetes to avoid inclusion of prevalent cases for each case definition. Results: This study demonstrated that different case definitions of diabetes identify different sub-populations of patients. When the cohorts were observed based on any measure of central tendency, each of the cohorts were reasonably comparable to each other. However, the distribution of each of the cohorts when grouped by age categories and sex, reveal differences. For example, using pharmacy case definition results in a bimodal distribution among women, one between 1-19 year and 35-39 age categories, and then again between 60-64 and 85 years-however, the histogram becomes more normally distributed when metformin was removed from the case definition. Conclusion: Our results suggest that clinical, pharmacy, laboratory case definitions identify different sub-populations and using multiple case definitions is likely required to optimally identify the entire diabetes population within THIN. Our study also suggests that age and sex of patients may affect the indexing of diabetes in THIN and is critical to better understand these variations.

Proportion of Patients With Hypertension Resolution Following Adrenalectomy for Primary Aldosteronism: A Systematic Review and Meta-Analysis.

Unilateral primary aldosteronism (PA) is often treated with adrenalectomy, but hypertension resolution rates are variable. A valid estimate of the postoperative normotension rate is necessary to inform the utility of PA testing and treatment. The authors searched MEDLINE In-Process & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials. Prospective adult cohort studies with surgically treated PA that reported resolution of hypertension without the aid of medications were included. Among 2620 abstracts identified by the search, 25 studies in the systematic review with data on 1685 patients were investigated. The pooled proportion of normotension following adrenalectomy was 52% (95% confidence interval, 0.44-0.60). Meta-regression demonstrated a significant negative association between length of follow-up and proportion of normotension, with normotension dropping by 6.7% per year of follow-up (coefficient -0.006; 95% confidence interval, -0.01 to 0.002). Overall, approximately half of the patients experienced hypertension resolution, although this outcome may not be durable in all patients.

Systematic review of validated case definitions for diabetes in ICD-9-coded and ICD-10-coded data in adult populations.

OBJECTIVES: With steady increases in 'big data' and data analytics over the past two decades, administrative health databases have become more accessible and are now used regularly for diabetes surveillance. The objective of this study is to systematically review validated International Classification of Diseases (ICD)-based case definitions for diabetes in the adult population. SETTING, PARTICIPANTS AND OUTCOME MEASURES: Electronic databases, MEDLINE and Embase, were searched for validation studies where an administrative case definition (using ICD codes) for diabetes in adults was validated against a reference and statistical measures of the performance reported. RESULTS: The search yielded 2895 abstracts, and of the 193 potentially relevant studies, 16 met criteria. Diabetes definition for adults varied by data source, including physician claims (sensitivity ranged from 26.9% to 97%, specificity ranged from 94.3% to 99.4%, positive predictive value (PPV) ranged from 71.4% to 96.2%, negative predictive value (NPV) ranged from 95% to 99.6% and κ ranged from 0.8 to 0.9), hospital discharge data (sensitivity ranged from 59.1% to 92.6%, specificity ranged from 95.5% to 99%, PPV ranged from 62.5% to 96%, NPV ranged from 90.8% to 99% and κ ranged from 0.6 to 0.9) and a combination of both (sensitivity ranged from 57% to 95.6%, specificity ranged from 88% to 98.5%, PPV ranged from 54% to 80%, NPV ranged from 98% to 99.6% and κ ranged from 0.7 to 0.8). CONCLUSIONS: Overall, administrative health databases are useful for undertaking diabetes surveillance, but an awareness of the variation in performance being affected by case definition is essential. The performance characteristics of these case definitions depend on the variations in the definition of primary diagnosis in ICD-coded discharge data and/or the methodology adopted by the healthcare facility to extract information from patient records.

Environmental Risk Factors and Type 1 Diabetes: Past, Present, and Future.

Type 1 diabetes is an autoimmune condition that results from the destruction of the insulin-producing beta cells of the pancreas. The excess morbidity and mortality resulting from its complications, coupled with its increasing incidence, emphasize the importance of better understanding the causes of this condition. Over the past several decades, a substantive amount of work has been done and, although many advances have occurred in identifying disease-susceptibility genes, there has been a lag in understanding the environmental triggers. Several putative environmental risk factors have been proposed, including infections, dietary factors, air pollution, vaccines, location of residence, family environment and stress. However, most of these factors have been inconclusive, thus supporting the need for further study into the causes of type 1 diabetes.

Perceived Barriers to and Facilitators of Patient-to-Provider E-Mail in the Management of Diabetes Care.

OBJECTIVES: 1) to describe current utilization of e-mail in the clinical care of patients with diabetes; and 2) to identify barriers to and facilitators of the adoption of e-mail in diabetes care. METHODS: Participants included diabetes care providers, including 9 physicians and 7 allied health professionals (AHPs). Participation involved, first, completing a self-administered survey to evaluate the use of e-mail within diabetes-related clinical practice. Second, focus group discussions were conducted with diabetes care providers using semistructured interviews to collect data about their perceptions of using e-mail to exchange information with patients diagnosed with diabetes. Patients' perspectives on the use of e-communication with their care providers was also proposed on the basis of the discussions. RESULTS: Significant differences were found between physicians and AHPs concerning questions that were related to the use of e-mail and the amount of time spent using e-mail to communicate to patients. There was perceived function and value to the use of e-mail among AHPs, while few physicians used e-mail routinely and were uncertain about its potential in improving care. Five themes, including barriers, benefits, risks, safeguards and compensation, were developed from the focus group interviews. CONCLUSIONS: Currently, most of the physicians surveyed do not e-mail patients directly; however, AHPs frequently use e-mail in diabetes care and find this tool valuable. Variation in practices regarding clinical e-mail across care disciplines suggest that appropriate policy with guidelines for e-mail and e-communication within the health care system may improve uptake of clinical e-mail and perhaps, by extension, improve efficiency and access in diabetes care.

Effectiveness of mobile electronic devices in weight loss among overweight and obese populations: a systematic review and meta-analysis.

BACKGROUND: Mobile electronic devices, such as mobile phones and PDAs, have emerged as potentially useful tools in the facilitation and maintenance of weight loss. While RCTs have demonstrated a positive impact of mobile interventions, the extent to which mobile electronic devices are more effective than usual care methods is still being debated. RESULTS: Electronic databases were systematically searched for RCTs evaluating the effectiveness of mobile electronic device interventions among overweight and obese adults. Weighted mean difference for change in body weight was the primary outcome. The search strategy yielded 559 citations and of the 108 potentially relevant studies, six met the criteria. A total of 632 participants were included in the six studies reporting a mean change in body weight. Using a random-effects model, the WMD for the effect of using mobile electronic devices on reduction in body weight was -1.09 kg (95% CI -2.12, -0.05). When stratified by the type of mobile electronic device used, it suggests that interventions using mobile phones were effective at achieving weight loss, WMD = -1.78 kg (95% CI -2.92, -0.63). CONCLUSIONS: This systematic review and meta-analysis suggests that mobile electronic devices have the potential to facilitate weight loss in overweight and obese populations, but further work is needed to understand if these interventions have sustained benefit and how we can make these mHealth tools most effective on a large scale. As the field of healthcare increasingly utilizes novel mobile technologies, the focus must not be on any one specific device but on the best possible use of these tools to measure and understand behavior. As mobile electronic devices continue to increase in popularity and the associated technology continues to advance, the potential for the use of mobile devices in global healthcare is enormous. More RCTs with larger sample sizes need to be conducted to look at the cost-effectiveness, technical and financial feasibility of adapting such mHealth interventions in a real clinical setting.