Patient and provider prediabetes knowledge, attitudes, and behavior in a large urban family medicine practice.

Context: One-third of American adults have prediabetes. However, only 11% are aware of their condition, and they often do not receive prediabetes education or management. Prior studies have indicated knowledge gaps among primary care providers and patients on prediabetes management. Objective: To understand family medicine providers' and patients' attitudes, knowledge, and behaviors regarding prediabetes and its management to inform a prediabetes management intervention. Study Design: Cross-sectional surveys. Setting: A large academic family medicine practice in downtown Philadelphia with 30,000 patients making 80,000 visits annually. Population studied: Family medicine providers (attending physicians, nurse practitioners, residents) and adult patients seen within the last year, with HbA1c in the last 6 months between 5.7-6.4% (excluding pregnant, diabetes diagnosis). Instruments: Provider survey asking demographics, knowledge, attitudes, management, DPP awareness, barriers to prediabetes treatment, and open-ended question on how the practice could improve prediabetes management. Patient survey asking demographics, awareness of diagnosis and risk, knowledge, attitudes, experiences with DPP, prediabetes experiences with PCP, and same open-ended question as provider survey. Provider survey distributed via email; patient survey via Epic MyChart patient portal. Outcome Measures: Descriptive statistics for all quantitative survey items; thematic analysis of open-ended responses. Results: Fifty-four providers and 148 patients completed the surveys (57% and 16.5% response rates, respectively). Nearly all providers (96%) felt that prediabetes screening and management is important but most (74%) prescribe metformin to ≤ 25% of eligible patients. Over half (56%) were unaware of DPP, and 52% of those aware of DPP did not know how to refer a patient. Over half (59%) of patients reported having been told they have prediabetes and 84% thought diet and lifestyle changes were effective treatment, but 65% were unaware of medication options and only 5% had been referred to DPP. In open-ended responses, providers requested more nutrition counseling and an improved DPP referral process; patients also requested nutrition counseling and classes. Conclusions: Providers and patients saw prediabetes as important but reported knowledge and management gaps, particularly for metformin and DPP, and requested additional practice resources.

The Hearst Health Prize: The First Five Years.

The Hearst Health Prize is the first national annual award for excellence in population health. The prize was established "to discover, support, and showcase the work of an individual, group, organization, or institution that has successfully implemented a population health program or intervention that has made a measurable difference" in health outcomes. Now, 5 years since the award's inception, this article reflects on how submissions for the prize collectively mirror - and may even predict - changes within the field of population health. It examines how the most successful programs demonstrated genuine, measurable improvements in health outcomes and/or health behaviors. In exploring the work of these outstanding programs, the aim of this article is to help disseminate best practices, advance the mission of the prize, and inspire improvements in population health practices.

Oxygen Saturation of Retinal Vessels in All Stages of Diabetic Retinopathy and Correlation to Ultra-Wide Field Fluorescein Angiography.

PURPOSE: The purpose of this study was to determine retinal hemoglobin oxygen saturation (SO2) in patients with diabetic retinopathy (DR) using retinal oximetry (RO) and to correlate the degree of retinal ischemia using intravenous fluorescein angiography (IVFA). METHODS: This is a single-center cross-sectional cohort study. Twenty-seven controls and 60 adult patients with diabetes mellitus (16 without DR and 44 with DR) were enrolled. Patients were stratified according to DR severity. Using RO, SO2 was measured in major retinal arterioles (SaO2) and venules (SvO2). Using IVFA, the percentage of retinal ischemia in 31 patients with DR was calculated and correlated with RO. RESULTS: Pairwise one-way analysis of variance (ANOVA) showed a significant increase in SaO2 and SvO2 in patients with proliferative DR (PDR) compared with controls (SaO2: PDR, 100 ± 7% vs. controls, 91 ± 4% [P = 0.003]; SvO2: PDR, 66 ± 11% vs. controls, 53 ± 6% [P < 0.00001]). The percentage of retinal ischemia also increased with DR severity: ANOVA showed a significant difference in retinal ischemia between all categories of nonproliferative DR vs. PDR: 2.31 ± 2% vs. 7.92 ± 9% (P = 0.017), respectively. Pearson two-tailed correlation showed significant correlation between SaO2 and ischemia (R = 0.467, P = 0.011). CONCLUSIONS: Hemoglobin oxygen saturation of retinal arterioles and venules increases with DR severity; SaO2 correlates with increasing ischemia measured by IVFA. Retinal oximetry may complement current imaging strategies to noninvasively augment the diagnosis and risk stratification of patients with diabetes.

Neurocognitive changes after lung transplantation.

RATIONALE: Neurocognitive impairments are associated with reduced quality of life and may adversely affect medical compliance, but their prevalence after lung transplantation has not been extensively studied. OBJECTIVES: To examine the frequency of neurocognitive impairment after lung transplantation and to examine perioperative factors affecting post-transplant neurocognitive function. MEASUREMENTS AND MAIN RESULTS: We performed serial assessments of neurocognitive function in a consecutive series of 47 subjects who received transplants between March 2013 and November 2013 (45% women; mean age, 53.5 ± 17.2 yr). Neurocognitive function was assessed using a composite measure including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total score and Trail Making Test parts A and B obtained before transplant, at hospital discharge, and 3 months after discharge. The presence of neurocognitive impairment was assessed using the Montreal Cognitive Assessment Battery (MoCA), and in-hospital delirium was assessed using the Confusion Assessment Method. Results demonstrated that neurocognitive performance initially worsened among non-cystic fibrosis patients and improved over follow-up (P = 0.002). Time effects were strongest on Trail Making Test part B (P < 0.001) and the RBANS (P = 0.054). Participants who exhibited delirium during their hospitalization showed poorer performance during follow-up assessments (P = 0.006). Examination of cognitive impairment rates demonstrated that 21 participants (45%) exhibited neurocognitive impairment (MoCA < 26) before lung transplant, whereas 27 (57%) participants exhibited impairment after transplantation, and 19 (57%) participants continued to neurocognitive impairment during a 3-month follow-up. CONCLUSIONS: Neurocognitive impairments are prevalent among lung transplant candidates and appear to worsen in some patients after transplant. Delirium during hospitalization is associated with worse neurocognitive function after transplant among patients without cystic fibrosis.

Normative values and predictors of retinal oxygen saturation.

PURPOSE: To determine normal retinal oxygen saturation (SO2) values measured with retinal oximetry in a multiethnic group of healthy subjects and to evaluate the association of retinal SO2 with demographic and clinical parameters. METHODS: Retinal oximetry was performed in both eyes of 61 normal healthy subjects. Global and quadrant venous (SvO2) and arterial oxygen saturation (SaO2), arteriovenous difference in SO2, and venular and arteriolar width were measured. The association of SO2 parameters with age, gender, ethnicity, refraction, iris color, history of controlled systemic hypertension, and smoking was analyzed. RESULTS: Average SvO2 and SaO2 were 55.3 ± 7.1% and 90.4 ± 4.3%, respectively. All average measurements were comparable in both eyes, both genders, and among ethnic groups. Inferonasal quadrant SaO2 was higher in Asians. Age was associated with decreased SvO2 (ß = -0.19; P = 0.001) and SaO2 (ß = -0.11; P = 0.003). History of controlled systemic hypertension was associated with an increase in arteriovenous difference in SO2 (ß = 3.99; P = 0.013). CONCLUSION: This is the first description of retinal SO2 in healthy, multiethnic subjects. Aging decreases SvO2 and SaO2 and should be accounted for when interpreting retinal oximetry measurements. Other demographic and clinical parameters studied did not seem to significantly influence retinal SO2 measurements.