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Impact of chronic comorbid illnesses on diabetes care among veterans with type 2 diabetes mellitus

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TitleInfo
Title
Impact of chronic comorbid illnesses on diabetes care among veterans with type 2 diabetes mellitus
Name (type = personal)
NamePart (type = family)
Pentakota
NamePart (type = given)
Sri Ram
DisplayForm
Sri Ram Pentakota
Role
RoleTerm (authority = RULIB)
author
Name (type = personal)
NamePart (type = family)
Halperin
NamePart (type = given)
William
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William Halperin
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Advisory Committee
Role
RoleTerm (authority = RULIB)
chair
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NamePart (type = family)
Holland
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Bart
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Bart Holland
Affiliation
Advisory Committee
Role
RoleTerm (authority = RULIB)
internal member
Name (type = personal)
NamePart (type = family)
Lu
NamePart (type = given)
Shou-En
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Shou-En Lu
Affiliation
Advisory Committee
Role
RoleTerm (authority = RULIB)
internal member
Name (type = personal)
NamePart (type = family)
Pogach
NamePart (type = given)
Leonard
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Leonard Pogach
Affiliation
Advisory Committee
Role
RoleTerm (authority = RULIB)
outside member
Name (type = personal)
NamePart (type = family)
Tseng
NamePart (type = given)
Chin-lin
DisplayForm
Chin-lin Tseng
Affiliation
Advisory Committee
Role
RoleTerm (authority = RULIB)
outside member
Name (type = corporate)
NamePart
Rutgers University
Role
RoleTerm (authority = RULIB)
degree grantor
Name (type = corporate)
NamePart
Graduate School - New Brunswick
Role
RoleTerm (authority = RULIB)
school
TypeOfResource
Text
Genre (authority = marcgt)
theses
OriginInfo
DateCreated (qualifier = exact)
2013
DateOther (qualifier = exact); (type = degree)
2013-10
Place
PlaceTerm (type = code)
xx
Language
LanguageTerm (authority = ISO639-2b); (type = code)
eng
Abstract (type = abstract)
Clinical management of diabetes is complicated by chronic comorbidities. We examined the impact of close to 60 comorbidities on diabetes care, which were categorized into 5 chronic comorbid illness groups (CCIGs) based on degree of overlap/relatedness of their management plans with those for diabetes (Piette and Kerr framework): none (no comorbidity), concordant (very related, e.g. cardiovascular diseases), discordant (unrelated, e.g. mental/musculoskeletal illnesses), both concordant and discordant, and dominant (can overwhelm care priorities, e.g. metastatic cancer). We conducted 5 separate analyses on cohorts of veterans with recent-onset diabetes who sought care at Veterans Health Administration (VHA) facilities nation-wide (95% male; average age 66 years) and hypothesized that having discordant/dominant illnesses would be associated with poor diabetes care, rapid rise in mean HbA1c levels following initial drop after treatment initiation for diabetes, lower adherence/persistence with diabetes medication regimens, and lower treatment intensification following diabetes treatment failure. Concordant illnesses presence was hypothesized to have limited or a positive impact on diabetes care. We first evaluated association between CCIGs and diabetes care in a cohort of 42, 826 veterans with new onset diabetes in fiscal year (FY) 2003. Study outcomes were 5 guideline measures (HbA1c and LDL-C testing, diabetes-related visits, HbA1c < 8%, and LDL-C < 130 mg/dL) assessed in FY2004. Those with concordant illnesses received similar or better diabetes care compared to those with no comorbidities. Those with discordant and dominant illnesses received poorer care (odds lower by 10-21% and 32-54%, respectively). The second analysis followed 79,249 veterans who initiated diabetes oral mono-therapy in FY2000-02 until they were censored at either the end of FY2010, death (28.6%), or lost to follow-up (5.8%). We compared HbA1c trends (992,196 tests) using piecewise linear random effects models. The models compared 3 HbA1c parameters: initial drop for first 6 months, HbA1c at end of 6 months, subsequent rise till end of study. Rate of rise of mean HbA1c was steeper for none (0.071%/year) and discordant CCIGs (0.081%/year). Rise in mean HbA1c for veterans with concordant (0.055%/year) and dominant (0.052%/year) illnesses were more moderate. The third and fourth analyses (n=79,249) compared medication adherence (proportion of days covered (PDC) =>0.8) and non-persistence (treatment gap => 60 days) across CCIGs using logistic and Cox proportional hazards models, respectively. Half the cohort had PDC =>0.8. Discordant and dominant illnesses lowered odds for adherence by 12-32%. Dominant CCIG was more likely to be non-persistent [hazard ratio (95% CI)-1.12 (1.08-1.17)]. The fifth analysis utilized a cohort of 28, 472 veterans who failed initial diabetes treatment (first HbA1c > 8%). Treatment intensification (addition of second oral agent or insulin initiation) rates within 1 year of treatment failure were compared across CCIGs. Concordant and dominant CCIGs were associated with lower treatment intensification odds (by 10%). In a large well-integrated managed care organization like VHA with limited access barriers, we found mixed support for the Piette and Kerr framework. Dominant illnesses lowered HbA1c regardless of inferior care processes, supporting need for patient-specific treatment goals to avoid complications from hypoglycemia. This questions the validity of HbA1c as quality measure for that group. Veterans with no or discordant comorbidities were associated with relatively lower adherence and poor maintenance of glycemic control, representing need for intervention via better care coordination. Strengths include large, population-based study with high prevalence of comorbidity. Key limitation is results not generalizable to the U.S. population.
Subject (authority = RUETD)
Topic
Public Health
Subject (authority = ETD-LCSH)
Topic
Non-insulin-dependent diabetes--Complications
Subject (authority = ETD-LCSH)
Topic
Comorbidity
Subject (authority = ETD-LCSH)
Topic
Chronic diseases
Subject (authority = ETD-LCSH)
Topic
Diabetics--Case studies
Subject (authority = ETD-LCSH)
Topic
Veterans--Medical care--United States
Subject (authority = ETD-LCSH)
Topic
Veterans--Diseases--United Sttes
RelatedItem (type = host)
TitleInfo
Title
Rutgers University Electronic Theses and Dissertations
Identifier (type = RULIB)
ETD
Identifier
ETD_5046
PhysicalDescription
Form (authority = gmd)
electronic resource
InternetMediaType
application/pdf
InternetMediaType
text/xml
Extent
ix, 136 p. : ill.
Note (type = degree)
Ph.D.
Note (type = bibliography)
Includes bibliographical references
Note (type = statement of responsibility)
by Sri Ram Pentakota
RelatedItem (type = host)
TitleInfo
Title
Graduate School - New Brunswick Electronic Theses and Dissertations
Identifier (type = local)
rucore19991600001
Location
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NjNbRU
Identifier (type = doi)
doi:10.7282/T3BZ642P
Genre (authority = ExL-Esploro)
ETD doctoral
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RightsDeclaration (ID = rulibRdec0006)
The author owns the copyright to this work.
RightsHolder (type = personal)
Name
FamilyName
Pentakota
GivenName
Sri Ram
Role
Copyright Holder
RightsEvent
Type
Permission or license
DateTime (encoding = w3cdtf); (qualifier = exact); (point = start)
2013-09-25 13:30:18
AssociatedEntity
Name
Sri Ram Pentakota
Role
Copyright holder
Affiliation
Rutgers University. Graduate School - New Brunswick
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License
Name
Author Agreement License
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I hereby grant to the Rutgers University Libraries and to my school the non-exclusive right to archive, reproduce and distribute my thesis or dissertation, in whole or in part, and/or my abstract, in whole or in part, in and from an electronic format, subject to the release date subsequently stipulated in this submittal form and approved by my school. I represent and stipulate that the thesis or dissertation and its abstract are my original work, that they do not infringe or violate any rights of others, and that I make these grants as the sole owner of the rights to my thesis or dissertation and its abstract. I represent that I have obtained written permissions, when necessary, from the owner(s) of each third party copyrighted matter to be included in my thesis or dissertation and will supply copies of such upon request by my school. I acknowledge that RU ETD and my school will not distribute my thesis or dissertation or its abstract if, in their reasonable judgment, they believe all such rights have not been secured. I acknowledge that I retain ownership rights to the copyright of my work. I also retain the right to use all or part of this thesis or dissertation in future works, such as articles or books.
RightsEvent
DateTime (encoding = w3cdtf); (qualifier = exact); (point = start)
2013-10-31
DateTime (encoding = w3cdtf); (qualifier = exact); (point = end)
2015-10-31
Type
Embargo
Detail
Access to this PDF has been restricted at the author's request. It will be publicly available after October 31st, 2015.
Copyright
Status
Copyright protected
Availability
Status
Open
Reason
Permission or license
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