Potential solutions to the quality-adjusted life-year, assessing quality, and more.

Read the July Issue of AJAC

This AJMC® Profiles in Care provides an in-depth look into the results of the outcomes-based agreement between Boehringer Ingelheim and Highmark Inc.

AJMC® Profiles in Care Launches

If 2020 was dominated by the news of how COVID-19 spread across the globe, then 2021 has so far been focused on ending the pandemic through vaccine distribution.

A Timeline of COVID-19 Vaccine Developments in 2021

We interview experts on investigational treatments such as liso-cel, and ask how to bring them to community practice.

Spotlight on CAR T-Cell Therapy

The American Journal of Accountable Care® features research and commentary on new payment models.

New Members for AJAC Board

A recent study examined the utilization and costs of potentially inappropriate medications (PIMs) used by older adults in the United States with multiple chronic conditions, a situation that can lead to higher health care costs and potential adverse events.

The researchers said that to their knowledge, it is the first study to specifically focus on the issue of polypharmacy, or the use of 5 or more medications, which is common in older adults with multiple health issues. The authors noted that polypharmacy is likely to rise as the US population ages. According to one study, 39% of US adults aged 65 or older used 5 or more medications.

Gaining more clarity on polypharmacy “could inform interventions and policy discussions on how to optimize pharmacotherapy in this population group,” 

 and electronic health records from 7 Massachusetts facilities between 2007 and 2014, including 2 medical centers, 3 community hospitals, a rehabilitation center, and a psychiatric hospital. Records included demographics, inpatient and outpatient data, labs, prescribing and dispensing records, and other medical care. The Medicare claims included parts A, B, and D. Data included information about drugs dispensed and medical diagnoses.

Using the Chronic Condition Indicator (CCI) of the Agency for Healthcare Research and Quality and doing further analysis with 

International Classification of Diseases, Ninth Edition

, codes, researchers came up with 77 categories of chronic conditions. Patients were considered multimorbid if they had diagnoses from 2 or more categories. Polypharmacy was defined as using prescription drugs from 5 or more pharmaceutical classes for 90 days or more.

PIMs were identified with the 2019 Beers criteria and the analysis considered dispensed medications, not prescribed ones. The study calculated the percentage of patients with 1 or more PIMs as well as the percentages of patients using different types of PIMs. Multivariable logistic regression was used to test the odds of taking 1 or more PIMs and mean costs spent on PIMs was calculated by dividing the costs spent on PIMs by the total medication cost.

Of all 569,969 patients in the database, between 61,500 and 103,153 met criteria for inclusion. Demographics and clinical characteristics did not change over the course of the study. The mean number of drugs was 7.2; the average age range was between 77.3 and 77.8. Body mass index ranged between 28.7 to 29.1.

Most the patients used 1 or more PIM (≥ 69%) and the differences did not change over the course of the study.

What did change, however, between the beginning and end of the time period was the mean number of chronic conditions, rising from 7.2 to 8.4, as well as certain chronic conditions. In addition, the majority of those affected were women, although the percentage fell from 65.2% in 2007 to 59.3% in 2014. Hispanic ethnicity was also linked with PIMs.

Gastrointestinal drugs (proton-pump inhibitors) and central nervous system drugs (such as benzodiazepines, antidepressants, antipsychotics) were the most commonly-used PIMs, and there was no difference by sex. However, men were more likely to use cardiovascular PIMs.

In patients using ≥1 PIM, >10% of medication costs were spent on PIMs. Between 11.0% and 12.8% of medication costs were spent on PIMs in women and between 11.0% and 12.2% in men between 2007 to 2014; the average amount spent on PIMs ranged from $392 to $719 for women and $395 to $759 for men.

The study did have a few limitations. Different tools are available to examine PIMs, and since this study used Beers criteria, the results may not be applicable to other research using other methods. In addition, while Beers is the most commonly used metric in the United States, the authors noted that “Beers criteria are criterion rather than judgment-based. Despite using diagnoses and clinical criteria to determine PIM use, some medications defined as potentially inappropriate may have been used as a last resort. In other cases, alternative to PIMs might have been more expensive.”

Other limitations include possible data misclassification; possible underestimated usage of PIMs as over-the-counter drugs were not included; and the fact that the patient population was from a large urban area, where patients may have access to more health care.

Screening for PIMs by pharmacists or primary care physicians should become a regular part of practice, the authors concluded, and deprescribing interventions should be considered.

Tabea Jungo K, Streit S, Lauffenburger JC. Utilization and spending on potentially inappropriate medications by us older adults with multiple chronic conditions using multiple medications. 

2021;93:104326. doi:10.1016/j.archger.2020.104326

Articles

The study was conducted to shed more light on the growing issue of polypharmacy, an issue that is expected to increase as the US population ages.

Study Highlights Use of PIMs in US Adults With Multimorbidity, Polypharmacy

 while binge drinking correlated with the worsening of 4 facets of neurocognitive functioning—global neurocognition, processing speed, delayed recall, and working memory—in a recent study carried out among 4 groups of patients participating in National Institutes of Health–funded research studies at the University of California, San Diego (UCSD) HIV Neurobehavioral Research Program.

These findings of a secondary analysis of the patients’ baseline visits to the program appeared online recently in 

Journal of the International Neuropsychological Society

“In addition to increased risk for physical illness (eg, liver disease and cardiovascular risk),” the authors wrote, “there is substantial evidence indicating that comorbid HIV and heavy alcohol use is more detrimental to brain structure and results in higher rates of neurocognitive impairment than either condition alone.”

Participants living with HIV (n = 86) and without HIV (n = 61) were stratified by their HIV and binge drinking status into 4 cohorts:

To be included, all participants had to report alcohol use of at least 1 drink in the previous 30 days. Binge drinking was defined as consuming 4 or more drinks in 2 hours for women and consuming 5 or more drinks in 2 hours for men. Analyses were carried out 3 ways:

A comprehensive neuropsychological battery for neurocognitive T scores

Analysis of covariance (ANCOVA) models for independent/interactive influences of HIV and binge drinking on neurocognitive outcomes

Multiple linear regressions for whether HIV/binge group status influenced the relationship between age and neurocognition

Among the 4 groups evaluated, those with dual HIV-positive status and who were considered binge drinkers fared worst overall. Not only did they have worse outcomes regarding the 4 areas of neurocognitive ability previously stated compared with the other 3 groups (all 

< .05), but the interaction between HIV status and binge drinking did not predict these outcomes (all 

However, when they narrowed their analysis to a comparison between the HIV+/Binge+ and HIV−/Binge− groups, “Significant interactions between age and HIV/Binge group showed that HIV+/Binge+ participants demonstrated steeper negative relationships between age and neurocognitive outcomes of learning, delayed recall, and motor skills compared to HIV−/Binge− participants (all 

A majority of the patients in the 4 groups were male and White. Those in the HIV+/Binge− group had the oldest mean (SD) age, at 46.42 (1.34), whereas those in the HIV−/Binge− group were the youngest, at 35.50 (11.95) years. The most common comorbidity was lifetime major depressive disorder, and all groups reported a history of lifetime alcohol use disorder (HIV−/Binge−, 13.2%; HIV−/Binge+, 82.6%; HIV+/Binge–, 27.3%; HIV+/Binge+, 83.3%; all 

 difference across the 4 patient groups in mean global neurocognitive function (F [3142] = 4.39; 

 = .006), as driven by differences in the following:

In addition, the cumulative negative effects of HIV and binge drinking could be seen in results from Jonckheere–Terpstra tests that indicated significantly lower global (JT = 2303.5; 

 < .001) and processing speed (JT = 2414.0; 

 = .001) performance per risk increase (0 risks = HIV−/Binge−; 1 risk = HIV−/Binge+ or HIV+/Binge−; 2 risks = HIV+/Binge+), and delayed recall and working memory deficits were more likely with binge drinking.

For the influence of age on these outcomes, through multiple linear regression, the investigators found significantly worse results in the HIV+/Binge+ group upon comparison with the HIV-/Binge- group for the following:

“Given the rapidly growing population of older adults with and without HIV along with the increased rates of binge drinking among them, studying the combined effects of HIV and binge drinking across the lifespan is timely and important,” the authors wrote. “Our finding of HIV/Binge group differences in neurocognitive domains of processing speed, delayed recall, and working memory is also consistent with the frontostriatal and frontolimbic neural damage that has been observed in studies of adults with HIV and heavy alcohol use.”

They recommend instituting clinical screening for binge drinking behavior in patients living with HIV, notably because alcohol use disorder (AUD) is not a frequent diagnosis despite the binge drinking behavior. Psychoeducation and psychosocial interventions could also help to reduce binge drinking among older patients.

Future studies, too, should investigate outcomes following reducing or stoppage of binge drinking behavior in persons living with HIV “given evidence that improvements in neurocognitive functioning may be possible after sustained sobriety following AUD recovery among HIV− populations.”

Paolillo EW, Saloner R, Kohli M, et al. Binge drinking relates to worse neurocognitive functioning among adults aging with HIV. 

 Published online July 26, 2021. doi:10.1017/S1355617721000783

The cumulative effects of binge drinking and HIV on neurocognitive functioning were investigated among 4 groups of patients in this recent study from researchers at San Diego State University and the University of California San Diego. 

Neurocognitive Decline Seen Among Binge Drinkers Living With HIV

's parent company, MJH Life Sciences, since 2011. She has an MA in business and economic reporting from New York University.

Patient-reported outcome measures (PROMs) may help to improve prediction models for which patients with cirrhosis with be readmitted to the hospital, according to a study 

Patients with cirrhosis have high rates of early, often preventable, readmission following hospital discharge. In addition to being expensive, these readmissions are associated with poor outcomes. However, interventions to reduce these readmissions have shown limited evidence for efficacy, underlining the need for risk stratification tools to refine and target interventions to the patients who will benefit the most.

“Multiple models have been developed to predict readmission, with disappointing results,” the authors wrote.

The authors hypothesized that socioeconomic status, functional status, and quality of life would enhance a prediction tool and sought to develop a model using these factors to predict readmissions in hospitalized patients with cirrhosis. They performed a prospective cohort study of 654 adults with cirrhosis who were admitted to Indiana University Hospital between June 2014 and March 2020.

They collected functional status using the functional status questionnaire and disease-specific quality of life using the chronic liver disease questionnaire (CLDQ). The patients were asked to reflect on the time prior to their admission when answering the questionnaires.

Model 1: only used electronically available variables

Model 2: added clinically available variables to model 1

Model 3: added socioeconomic variables to model 2

Model 4: added functional status to model 3

Model 5: added quality of life to model 4

More than one-third (35.3%) of patients were admitted in the prior 30 days, 79.8% had a history of ascites, and 70.2% had hepatic encephalopathy (HE). The median Charlson Comorbidity Index score was 6; 41.9% had diabetes, and 23.5% had chronic kidney disease.

HE was the most common reason for admission (21.9%), followed by ascites/volume overload (20.5%) and abdominal pain (17.9%). Half (50.6%) of the patients were unemployed, 69.9% had a high school education or less, and 27.2% had saved less than 6 months of expenses.

More than one-third (37.8%) had a readmission: 22% for HE, 16% for acute kidney injury/electrolyte disturbance, 13% for gastrointestinal bleeding, and 10% for ascites/volume overload. Thirty-nine patients (6%) died within 30 days of discharge.

The factors associated with readmission in univariate analysis were cerebrovascular disease, prior admissions and emergency department visits, ascites, Model for End Stage Liver Disease (MELD) score, albumin, hemoglobin, use of an antibiotic for HE, Child-Pugh score, discharge transportation, and discharge to a facility. No socioeconomic variables were associated with readmission, and of the PROMs, only basic activities of daily living (ADL) impairment was associated. The presence of any cancer was associated with a reduced risk of readmission.

In a multivariable analysis, predictors of readmission included cerebrovascular disease, ascites, admission in the prior 30 days, admission via emergency department, lower admission albumin, higher discharge MELD score, and discharge via public transportation. Basic ADL impairment and impaired CLDQ activity domain was associated with readmission. However, having children in the home, one of the socioeconomic variables, was associated with a reduced readmission risk, as were cancer and admission for infection.

The authors evaluated the prediction of the models using the continuous net reclassification index (NRI) and integrated discrimination improvement (IDI). Using NRI, there were significant improvements when including PROMs, but there were no significant differences between models 3, 4, and 5. Using IDI, none of the models did better than any of the others.

Overall, adding socioeconomic information and PROMs had “marginal effects on prediction,” according to the authors. They did wonder if other PROMs, such as health literacy, self-management, and caregiver burden, could add value and improve prediction.

The findings did suggest that interventions related to poor social support could help with readmissions, the authors noted.

“In addition to targeting the population of high utilizers with more severe liver disease, prevention efforts must also address the negative effects of poor social support and disability,” they concluded. “These goals may be achieved through complex, multicomponent interventions, focused on enhancing self-care and linking patients to community resources.”

Orman ES, Ghabril MS, Desai AP, et al. Patient-reported outcome measures modestly enhance prediction of readmission in patients with cirrhosis. 

. Published online July 23, 2021. doi:10.1016/j.cgh.2021.07.032

Patient-reported outcome measures may have a small impact on predicting which patients with cirrhosis will be readmitted to the hospital. 

Developing a Model to Predict and Prevent Readmission in Patients With Cirrhosis

 since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey. 

Retinal nerve fiber layer (RNFL) atrophy and the presence of oligoclonal bands (OCBs) were related to cognitive decline in patients with 

 (MS) over a 5-year follow-up period, according to results of an observational cohort study. The findings, published in 

 suggest these 2 factors may serve as potential biomarkers for cognitive decline in MS.

Although it remains unknown whether early degeneration is an independent process in MS or is secondary to inflammation, “understanding the mechanism and causes of neurodegeneration in MS may be fundamental to developing therapies that can help halt this process and presumably prevent the progression of disability,” authors explained.

To assess the impact of both neurodegenerative and inflammatory markers on cognitive decline among patients with MS, investigators conducted a prospective, single-center, observational cohort study at a university in Lithuania. 

Between 2012 and 2019, patients between the ages of 18 and 60 years with relapsing-remitting MS underwent physical and neurological examinations including the Brief International Cognitive Assessment for MS (BICAMS), ophthalmological examinations using optical coherence tomography (OCT), and brain magnetic resonance imaging (MRI). After 5 years, the same tests were performed again.

Of the 63 patients originally enrolled, 5-year follow-up data were available for 49 individuals.

A significant reduction in information processing speed, visual learning, temporal RNFL thickness, the Huckman index, and third ventricle mean diameter was found in all 49 patients with relapsing MS over the observation period (

Of the patients, 63.3% had positive OCBs and 59.2% had elevated immunoglobin G (IgG) indices

The atrophy of the temporal segment and papillomacular bundle (PMB) and the presence of OCBs were significantly related to a decline in information processing speed in these patients (

Brain atrophy markers were not found to be significant on the general linear models

Despite finding that OCBs and elevated IgG indices were not correlated with each other, researchers noted both are biomarkers of inflammation and are supportive of an MS diagnosis.

“The absence of such a correlation is possible because OCBs reflect the production of several monoclones, while the IgG index is a general indicator of enhanced autoimmune response,” they wrote.

Authors also found the average thickness in the temporal segment and PMB in both eyes constituted the most important OCT measure related to cognitive decline in study participants.

The study’s relatively small sample size and lack of control group mark limitations to the current analysis.

“Our results confirm that the BICAMS and OCT measure different aspects of neurodegeneration and that the thinning of the RNFL is a potential biomarker for cognitive disability in MS, because we found that cognitive decline may be predicted not only by markers of degeneration but also by markers of intrathecal inflammation,” researchers said.

“These results imply that both the thinning of the RNFL and the presence of CSF-OCBs are feasible biomarkers for cognitive decline in MS,” they concluded.

Giedraitiene N, Drukteiniene E, Kizlaitiene R, Cimbalas A, Asoklis R, and Kaubrys G. Cognitive decline in multiple sclerosis is related to the progression of retinal atrophy and presence of oligoclonal bands: a 5-year follow-up study. 

Published online July 13, 2021. doi:10.3389/fneur.2021.678735

Results of an observational study suggest retinal nerve fiber layer atrophy and the presence of oligoclonal bands may serve as biomarkers for cognitive decline in patients with multiple sclerosis (MS).

Study Identifies Potential Biomarkers for MS-Related Cognitive Decline 

Dietary iron intake leads to different effects on 

 among women of different ages, according to findings of a cross-sectional study published in 

. Researchers hypothesized these differences could be due to age-related menstrual changes.

As iron is closely related to menstruation—during which iron is depleted—and because patients with iron-deficiency or iron-deficiency anemia tend to have a high frequency of migraine, investigators sought to determine whether iron deficiency was associated with severe headache or migraine.

In addition, “ferritin, an important biomarker of body iron stores, deserves attention for its relationship with migraines,” authors explained, while “dopamine plays a role in the pathogenesis of migraine, and iron is an essential trace element for the synthesis of dopamine,” they said.

Using data from the National Health and Nutrition Examination Surveys (NHANES), which are administered by the National Center for Health Statistics at the CDC, investigators assessed responses from 7880 adults (3575 men and 4305 women).

Individuals aged 20 years or older completed the questionnaires between 1999 and 2004. Of the 7880 adults surveyed, 1702 (21.6%) responded "yes" to the question: "During the past 3 months, did you have severe headaches or migraines?"

“Compared with the participants without headache, the participants with headache were more likely to be younger, female, and living alone, had a lower education level, a lower body mass index (BMI), a lower dietary protein intake, a lower dietary iron intake, a lower cholesterol level, a lower hemoglobin level, a lower serum iron level, a lower serum ferritin level, and more likely to take birth control pill,” researchers wrote.

Most women aged 20 to 50 years consumed less dietary iron than their recommended dietary allowances

Dietary iron intake was inversely associated with severe headache or migraine in women aged 20 to 50 years

For women over 50 years, serum ferritin was negatively associated with severe headache or migraine

For men, there was no significant relationship between dietary iron and serum ferritin, and severe headache or migraine

After adjusting for possible confounders, the odds ratio for the association between dietary iron intake and severe headache or migraine was 0.721 (95% CI, 0.565–0.920) comparing the highest quintile of iron intake (≥ 19.94 mg/day) with the lowest quintile of iron intake (≤ 8.20 mg/day)

Previous studies have shown iron absorption is closely related to the level of sufficient iron in the body, meaning absorption increases when there is insufficient iron storage and decreases when storage is sufficient. An additional investigation also found that a lower ferritin level corresponds with high iron absorption.

“Therefore, women aged 20-50 years may have higher iron absorption than men and women over 50 years, which may be the reason why dietary iron was associated with migraine only in women aged 20-50 years,” researchers hypothesized.

A lack of information on perimenopause marks a limitation to the investigation, while the cross-sectional nature of the study precludes any causal inferences from being made.

Meng S, Zhou H, Li X, et al. Association between dietary iron intake and serum ferritin and severe headache or migraine. 

 Published online July 6, 2021. doi:10.3389/fnut.2021.685564

Results of a cross-sectional study point to a potential link between iron intake and migraine that may be dependent on age. 

Does Low Iron Intake Impact Migraineurs? 

The rates of admission for intensive care and need for ventilatory support due to COVID-19 seem to be almost twice as common during pregnancy, said David McIntyre, MD, FRACP, a professor of medicine and an endocrinologist at the University of Queensland in Brisbane, Australia.

Can you discuss the intersection of metabolic and respiratory complications that could arise from a COVID-19 infection in a pregnant person with diabetes?

So this is something that's becoming clearer over time. In the beginning, it was thought that COVID-19 was no more severe at all in pregnancy than at other times. I guess with increasing case numbers, we know that the COVID-19 symptoms appear to be less prominent. So major fever and cough and shortness of breath are perhaps a bit less common, but nonetheless, the infection can quite rapidly become more severe. The rates of admission to intensive care and need for ventilatory support, etc, do seem to be at least one-and-a-half to twice more common during pregnancy in pregnant women who are affected. And we know that underlying comorbidities—and particularly the 2 big ones that are relevant here are preexisting obesity and type 2 diabetes—are major risk factors for severe COVID-19 infection of the sort that might end up requiring intensive care unit admission or even causing death. Tragically, that's been the case very much in the United States, I believe, where particularly certain ethnic groups who have high rates of diabetes and obesity have been very disproportionately affected.


In pregnancy, that has also been the case, and certainly elevated body mass index or obesity in the presence of nondiabetes are risk factors for severe COVID-19. GDM

mellitus] itself at this point, slightly increased, but not significantly so. There are a number of people who are running what you would call a living review, where they're reviewing each piece of data as it comes in rather than just publishing a single paper. I guess we'll get better information about that in the longer term.


The other thing that's very relevant, which is only just starting to be realized, is the part of the so-called long COVID-19, or extended COVID-19, symptomatology. It does include metabolic dysfunction, in particular, hyperglycemia. So I think that will become clearer in the future about whether that long COVID-19 syndrome, which has a lot of other symptoms as well, to what extent that includes metabolic and gluco-metabolic dysfunction.

Videos

David McIntyre, MD, FRACP, outlines how metabolic factors could impact the severity of COVID-19 infections among pregnant people. 

Dr David McIntyre Describes the Intersection Between Covid-19, Obesity, and Gestational Diabetes

Florida Sets Daily COVID-19 Cases, Hospitalizations Record

, Florida yesterday broke its record for daily COVID-19 hospitalizations, surpassing a figure set more than half a year prior to the widespread availability of coronavirus vaccines. Leading the nation in per capita hospitalizations for COVID-19, hospitalizations were indicated by HHS data to be more than 10,200, with the previous record of 10,170 set on July 23, 2020. Moreover, the news came one day after Florida had recorded the most daily coronavirus cases since the start of the pandemic.

 spotlighted the importance of health equity in the workplace, and how to achieve it. With people 

 their jobs at a record rate, several aspects of health and wellness have become of growing importance amid the pandemic, particularly the need for health equity. Serving to provide a personalized approach through support and flexibility, the article notes that employers can integrate health equity through benefits packages that are tailored to each employee’s needs.

Where Masking Is Recommended in the United States

As 63% of US counties meet CDC recommendations of wearing a mask in public indoor spaces due to substantial or high transmission rates of COVID-19, an article by 

 addressed areas nationwide where masking is recommended. Notably, 23 of the top 25 destinations for flight bookings, as measured by the Hopper app, fall into the recommended masking guideline criteria, including Las Vegas, Orlando, Dallas, and Atlanta. Indoor mask mandates have also been reinforced in areas such as Washington, DC, and Los Angeles County, as well.

Florida sets record for daily COVID-19 cases and hospitalizations; spotlighting health equity in the workplace; delineating COVID-19 hotspots where masking is recommended.

What We're Reading: Florida Sets COVID-19 Records; Health Equity in the Workplace; Masking in Hotspots

Some patients with type 1 diabetes have issues that prevent them from having successful telehealth visits, said Leslie Eiland, MD, an endocrinologist at the University of Nebraska Medical Center in Omaha, Nebraska. Eiland's 

, "Use of Diabetes Technologies for Remote Monitoring in Ambulatory/Rural Settings," was presented at the American Diabetes Association's (ADA) 81st Scientific Sessions.

What are some barriers patients with type 1 diabetes (T1D) in rural America face and how can technology address these barriers?

When we started seeing more people with home visits after spring of 2020, we realized that home visits assume a lot, and some of our patients do have issues that prevent them from having successful telehealth visits. Home video visits assume that you have a decent level of tech or digital literacy. They assume that you have not only internet access, but just a stable internet connection that can perform at threshold speeds, able to have a 20-minute video visit with your provider or longer. And they assume that you have access to a connected device with a camera, which not everybody has. During my talk at ADA, I [went] over 6 specific patient examples: who the patients were, what their medical issues were, and then maybe how successful their video visit was and how we responded to some disparities that they had, like lack of internet or lack of smartphone and how we still were able to obtain their diabetes-related data during that visit.

Sometimes we had somebody who didn't have a smartphone, didn't have home internet, but did live close to one of our rural community hospitals, where we had a telehealth visit, where he was able to meet with a local CDCES [certified diabetes care and education specialist] prior to the visit who could upload his diabetes technology. In this case, he was using a CGM, a continuous glucose monitor, she could secure that, email that to me prior to the visit. That way, when we did connect through a visit at his community hospital, I was able to access all of his diabetes data, even though he did not personally have the ability to upload that and share that with me. I have some other elderly patients that live in rural areas. Over the winter, weather was horrible, COVID-19 was raging in their communities, and they had no smartphone, had no home internet. But a couple of my patients did use a Freestyle Libre flash glucose monitor and also used the receiver and I was able to walk them over the phone, through a phone visit, through the receiver, to help me generate a decent amount of glucose data and we were able to make safe changes to their regimen.

Leslie Eiland, MD, outlines some of the challenges of delivering optimal care to patients with type 1 diabetes (T1D) living in rural America. 

Dr Leslie Eiland Discusses Challenges Faced by Patients With T1D in Rural America 

Central obesity was associated with an increased risk of 

 (HF) hospitalization or death among adults with 

 (T1D), according to study results published in 

Obesity is an established risk factor for HF in the general population, and although the prevalence of obesity has increased among those with T1D, “studies concerning HF in this population are scarce,” authors explained.

In addition to obesity, diabetes is also a risk factor for HF, and both are risk factors for diabetic nephropathy (DN), which constitutes another important risk factor of HF.

Researchers used the waist-height ratio (WHtR) and body mass index (BMI) measurements to investigate the association between body fat distribution and risk of hospitalization or death due to HF in adults with T1D at different stages of DN.

Data were gleaned from the observational, longitudinal Finnish Diabetic Nephropathy Study. The study had a follow-up period of 16.4 years (interquartile range, 12.4-18.5), while WHtR was used to determine central obesity and BMI to measure general obesity.

A total of 4668 individuals with T1D were included in the analysis and completed baseline visits between 1997 and 2017. “DN stage was based on the individuals’ urinary albumin excretion rate (UAER) in timed overnight or 24 h urine (mg/24 h) collections,” researchers explained.

Over the course of the follow-up period, 323 incident cases of hospitalization or death due to HF occurred.

From 308 hospitalizations due to HF, 35 resulted in death and 15 deaths occurred without previous hospitalization

The WHtR showed a stronger association with the outcome (HR 1.51; 95% CI, 1.26–1.81; z = 4.40) than BMI (HR 1.05; 95% CI, 1.01–1.08; z = 2.71)

Glycated hemoglobin (HR 1.35; 95% CI, 1.24–1.46; z = 7.19) was the most relevant modifiable risk factor for the outcome whereas WHtR ranked 3rd

According to the DN stage, 3.4% (n = 112), 9.6% (n = 62) and 21.3% (n = 149) of the incident cases occurred in individuals with normo-, micro- and macroalbuminuria stages, respectively

Comparing individuals above versus below the normal threshold at the microalbuminuria stage, individuals with central obesity (WHtR ≥ 0.5) had a 3-fold higher risk (HR 2.98; 

 = .002) of HF hospitalization or death than those without central obesity

Individuals with microalbuminuria but no central obesity had a similar risk of the outcome as those with normoalbuminuria

General obesity was associated with the outcome only at the macroalbuminuria stage

“We showed that WHtR, a hallmark of central obesity, is a relevant and modifiable risk factor among the most important well-known risk factors for HF,” researchers said.

They offered 2 explanations as to why WHtR was not an important HF risk factor at the normoalbuminuria stage. Namely, individuals with T1D in this stage have a lower percentage of visceral adipose tissue compared with those with albuminuria, reducing the power of central obesity to predict the outcome.

In addition, patients with normoalbuminuria lack albuminuria, an important risk factor for HF. It is possible, “central obesity may need the presence of albuminuria to impact the risk of HF hospitalization or death,” authors explained.

Lack of data on HF stage and its classification as reduced or preserved ejection fraction mark a limitation to the study. As the study population was a homogenous white Finnish population, results may also not be generalizable to other ethnicities.

However, “the WHtR, a hallmark of central obesity, may be considered in the routine consultations of people with T1D for screening high-risk individuals,” researchers concluded.

Parente EB, Harjutsalo V, Forsblom C, Groop P, and on behalf of The FinnDiane Study Group. The impact of central obesity on the risk of hospitalization or death due to heart failure in type 1 diabetes: a 16-year cohort study. 

Published online July 27, 2021. doi:10.1186/s12933-021-01340-4

New research shows central obesity is associated with an increased risk of poor heart failure outcomes among those with type 1 diabetes. 

Examining the Impact of Central Obesity on HF Outcomes Among Adults With T1D

Peer support interventions that included nursing staff was found to effectively improve lung function and quality of life of nonsmoking patients with chronic obstructive pulmonary disease (

The study highlighted how the professional knowledge and communication skills that nurses possess can provide psychological comfort and encouragement to nonsmoking patients. Nurses can also use their knowledge and skills to guide patients to help them better manage their COPD.

“Peer-support nursing can not only effectively make nonsmoking patients feel positive energy such as respect and trust but also enable nonsmoking patients to get guidance from medical staff in the community, so as to promote the establishment and maintenance of their healthy lifestyle,” wrote the investigators.

Use of long-acting maintenance bronchodilators, inhaled corticosteroids, and pulmonary rehabilitation can decrease symptoms, reduce exacerbation frequency, and improve pulmonary function. However, few actions beyond these therapeutic methods have been taken to reduce disease progression or mortality rates.

Peer support generally involves nonprofessionals who have similar diseases or experience with disease management. If conducted effectively, patients can benefit from disease management assistance, links to clinical care, and social and emotional support that is available at all times.

The investigators enrolled 100 nonsmoking patients with COPD who were admitted at the Human Provincial People’s Hospital in Changsha, China between October 2018 and October 2020. The patients were split into a control group (n = 50), where they were treated with routine care, and an observation group (n = 50), where the patients received routine care and peer support nursing.

The observation and control groups had a mean (SD) age of 45.36 (15.68) years and 46.25 (14.65) years, respectively. Both groups had a higher number of male than female patients (observation group, n = 28 vs 22; control group; n = 27 vs 23).

Before the study, the researchers recruited nurses and peers to interact with the patients. Nurses had to have at least a bachelor degree and more than 5 years of experience working in a 

 department, at least 3 of which they had to be working as a senior nurse.

The observation group were given health education training through group interaction and situational dialogue. Peers functioned as group leaders to demonstrate pulmonary function exercises and share rehabilitation knowledge. Patients were added to a peer support group chat, where disease rehabilitation knowledge and psychological counseling were provided.

The groups were evaluated before the intervention and 3 months after the interventions. The patients were given a social support rating scale featuring a 5-point Likert scale. When tallied, the scored demonstrated the impact that the intervention had on patient lifestyle. The higher the score, the more improved the lifestyle.

Prior to the intervention, the groups did not differ much in values depicting subjective support, objective support, utilization of support, and total scores (

 > .05). However, scores for subjective support and support utilization were significantly higher in the observation group compared with the control group 3 months after receiving the intervention (

The groups also did not have significant different in scores for positive attitude, stress reduction, self-decision making, and total score prior to the intervention (

 > .05). Three months after the intervention, the values shifted to be significantly higher in the observation group than the control group (

There were also no differences prior to the intervention between the groups regarding health responsibility, self-realization, interpersonal support, and stress management (

 > .05), but the observation group had significantly higher scores than the control group for these values after the intervention (

After the intervention, the observation group performed better during the 6-minute walk test than the control group (

 < .05). Before the intervention, both groups performed similarly (

A limitation of the study was that the investigators did not look at the potential impact that family cooperation in nursing could have on the results. The investigators said that follow-up studies need to be conducted and should focus on formulating relevant intervention programs.

Yao X, Wang X, Tuan J, Huang Z, Wu D, Xu H

Benefits conferred by peer-support nursing intervention to pulmonary function and quality of life in nonsmoking patients with COPD. 

. Published online June 16, 2021. doi: 10.1155/2021/7450979

Peer support nursing intervention produced significant benefits in lung function and quality of life (QOL) in patients with chronic obstructive pulmonary disease (COPD), highlighting the importance that nurses can play in improving disease management.

Nurse-Led Peer Support Proves Effective at Improving Lung Function, QOL in COPD

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