The state of diabetes in North Carolina.

The diabetes epidemic is rapidly growing in North Carolina. In 1999, an estimated 366,000 residents were living with diagnosed diabetes. Ten years later, the prevalence of diagnosed cases had increased to approximately 659,000. Diabetes is the seventh leading cause of death in the state and decreases life expectancy by up to 15 years. If the epidemic remains unchecked in the state, annual health care costs are predicted to exceed $17 billion by 2025. Prevention of diabetes and diabetes-related complications through treatment and disease self-management is paramount in changing this deadly and costly course and demands continued innovation in health programs and services and new partnerships among health professionals. This article reviews the diabetes burden in North Carolina and sets the stage for commentaries and sidebars in the accompanying policy forum.

Cardiovascular and mortality risk prediction and stratification using urinary albumin excretion in older adults ages 68-102: the Cardiovascular Health Study.

BACKGROUND: Elevated urinary albumin excretion (UAE) is associated with the risk of cardiovascular disease (CVD) and all-cause mortality. We tested the hypothesis that elevated UAE improves cardiovascular risk stratification in an elderly cohort aged 68-102 years. METHODS: We evaluated UAE in 3112 participants of the Cardiovascular Health Study who attended the 1996-1997 examination and had median follow up of 5.4 years. Elevated UAE was defined as urinary albumin to creatinine ratio > or =30 microg/mg. Microalbuminuria and macroalbuminuria were defined as urinary albumin to creatinine ratio 30-300 microg/mg and >300 microg/mg, respectively. Outcomes included CVD (myocardial infarction, stroke, cardiovascular death) and all-cause mortality. Cox proportional hazards models were used to assess the risk of outcomes associated with elevated UAE. RESULTS: The prevalence of elevated UAE was 14.3%, 17.1% and 26.9% in those aged 68-74, 75-84 and 85-102 years, respectively. CVD incidence and all-cause mortality were doubled (7.2% and 8.1% per year) in those with microalbuminuria and tripled (11.1% and 12.3% per year) in those with macroalbuminuria compared to those with normal UAE (3.3% and 3.8% per year). The increased CVD and mortality risks were observed in all age groups after adjustment for conventional risk factors. The adjusted population attributable risk percent of CVD and all-cause mortality for elevated UAE was 11% and 12%, respectively. When participants were cross-classified by UAE and Framingham Risk Score categories, the 5-year cumulative incidence of coronary heart disease among participants with elevated UAE and a 5-year predicted risk of 5-10% was 20%, substantially higher than 6.3% in those with UAE <30m microg/mg. CONCLUSION: Elevated UAE was associated with an increased risk of CVD and all-cause mortality in all age groups from 68 to 102 years. Combining elevated UAE with the Framingham risk scores may improve risk stratification for CVD in the elderly.

Improving diabetes care among low-income North Carolinians: Project IDEAL.

OBJECTIVES: Many barriers exist in implementing evidence-based guidelines for diabetes care, particularlyfor low-income patients. To address this, the North Carolina Project IDEAL (Improving Diabetes Education, Access to Care, and Living) Diabetes Initiative was created STUDY DESIGN/SETTING: Fourteen programs representing different types of agencies and intervention strategies across the state participated in the initiative. DATA COLLECTION: Separate random samples of medical charts of participating patients were reviewed at baseline (n=429) and three-year follow-up (n=656) to assess changes in six process (assessment of hemoglobin A1c, cholesterol blood pressure, and urinary protein; conduction of foot and retina examination) and three outcome (glycemia, blood pressure, and lipid control) measures. Four national guidelines (DQIP, HEDIS, NCEP and ADA) were used as benchmarks. RESULTS: Large increases were observed for some measures (hemoglobin A1c control and testing, LDL-cholesterol testing), while modest increases were observed for others (dilated eye exam, blood pressure testing, and control). CONCLUSIONS/RELEVANCE: Project IDEAL was successful in improving access to high-quality diabetes care for low-income patients. Additional effort is needed to address specific areas of concern, particularly retinopathy screening.

Stress testing in the medical evaluation for hazardous materials duty: results and consequences in three groups of candidates.

OBJECTIVE: The objective of this study was to determine the yield of exercise stress testing (GXT) and other methods for evaluating candidates for HAZMAT duty. METHODS: The authors conducted an analysis of prior and current records of GXTs, medical examinations, blood tests, chest radiographs, spirometry, and audiometry in 190 candidates. The authors also conducted scrutiny of GXT results, using Duke Treadmill Score (DTS), Chronotropic Index (CI), and Heart Rate Recovery (HRR). RESULTS: Seven candidates were disapproved by history and/or physical examination. Twenty-one others were deferred for GXT-induced, marked hypertension, and/or ST depression >/=2 mm. The latter appeared to be false-positive indications of ischemia, low risks confirmed by DTS, CI, and HRR. Heat stress was not induced in 26 subjects so evaluated. CONCLUSIONS: GXT identified marked hypertension in 12 HAZMAT candidates and ischemic ST changes in 10, the latter appearing to be false-positives. Other testing yielded useful baselines, rarely disqualifying.

Differential impact of cardiovascular disease (CVD) risk factor clustering on CVD and renal disease among African-American and white patients with type 2 diabetes mellitus.

OBJECTIVES: To determine if clustering of cardiovascular disease (CVD) risk factors has a differential impact on CVD and renal disease among African Americans compared to Whites with type 2 diabetes DESIGN: Cross-sectional. METHODS: Prevalent CVD, macroalbuminuria, and CVD risk factors were measured in 323 African-American and White adult patients with type 2 diabetes. CVD risk factors were dichotomized according to standard guidelines. Data were analyzed by race according to the presence of any 3 or more CVD risk factors. RESULTS: Despite a similar prevalence of hypertension, the prevalence of macroalbuminuria in the presence of 3 or more CVD risk factors tended to be higher among African Americans compared to Whites (28.9% vs 13.6%, P = 0.05). The presence of 3+ CVD risk factors was associated with an odds ratio (OR) of 2.5 (P = 0.001, 95% CI, 1.44-4.27) for macroalbuminuria in African Americans compared to an OR of 1.4 (P = 0.25, 95% CI, 0.78-2.53) in Whites. The race/3+ CVD risk factors interaction was statistically significant (P = 0.007). Conversely, the presence of 3+ risk factors was associated with an OR of 1.6 (P = 0.019, 95% CI, 1.08-2.28) for CVD in Whites compared to an OR of 0.8 (P = .287, 95% CI, 0.54-1.20) in African Americans. The prevalence of any CVD in the presence of 3+ risk factors was 61% and 49% in Whites and African Americans respectively (P = .217). The race/3+ CVD risk factors interaction was statistically significant (P = 0.029). CONCLUSIONS: These findings suggest that among persons with diabetes, a clustering of 3+ CVD risk factors is more predictive for renal disease among African Americans, and more predictive for CVD in Whites. Further research should clarify the impact of CVD risk factor clustering on the incidence of vascular disease among African Americans and Whites with type 2 diabetes.

The state of community medicine training in family practice residency programs.

OBJECTIVES: This paper describes the state and nature of community medicine training in family practice residency programs. METHODS: A random sample of 224 family practice residency programs was surveyed about the perceived value of community medicine in their residency, the teaching modalities they use, the extent to which their training provides competency in four defined dimensions of community medicine, and which program characteristics and curricula were predictive of higher perceived competency. RESULTS: The participation rate of our survey was 72%. Respondents ranked professional interest, institutional support, and departmental support highly. Less than half the programs provide instruction in community-oriented primary care (COPC), and less than half rate their department's involvement in the community highly. Most programs report that their training provides at least a moderate level of competency in four defined dimensions of community medicine. Curricular methods that are predictive of perceived competency include health department clinical experiences, home visits, cultural sensitivity training, participation in a longitudinal project, meetings with community leaders, and instruction in COPC. CONCLUSIONS: Community medicine is valued in residency curricula, but there is limited uniformity in curricular content and methods. Active and structured education modalities might be more likely to result in competency in community medicine.