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Background In the digital age, a growing literature suggests that broadband coverage and high-speed internet access are social determinants of health. However, there is little research on regional broadband connectivity and its relationship to the prevalence of common health conditions such as type 2 diabetes, hypertension, and obesity/overweight. Using the California Health Interview Survey (CHIS) and US Census data, we aimed to assess if local broadband connectivity at the census tract level was related to prevalence of cardiometabolic dysfunction (diabetes, hypertension, and obesity/overweight) in these census tracts. Methods  Using a cross-sectional design, we analyzed data from 2019 California Health Interview Survey (CHIS) respondents aged 18 years or older (n = 21,905). Broadband connectivity and population density at the census tract level was determined from 2010 US Census data. Health information, secondary predictors, and covariates were self-reported by California Health Interview Survey CHIS respondents. Results The prevalence of type 2 diabetes was greater in broadband connectivity areas with less than 40% high-speed connectivity (OR 2.4, 95% CI 1.6–3.7, p < 0.001) as compared with broadband connectivity areas with greater than 80% high-speed connectivity. As compared to areas with greater than 80% high-speed connectivity, we did not find differences in diabetes prevalence for areas with 40–60% high-speed connectivity (OR 1.2, 95% CI 0.8–1.7) or areas with 60–80% high-speed connectivity (OR 1.2, 95% CI 0.97–1.4). There were trends toward greater hypertension prevalence in areas with lower high-speed broadband connectivity as compared to higher broadband connectivity, but none of the differences reached statistical significance (all p values between 0.05 and 0.1). We did not find statistically differences in the prevalence of obesity/overweight for areas with different penetration of high-speed broadband connectivity. Conclusions In California, the prevalence of cardiometabolic conditions, particularly type 2 diabetes, is highest in areas with lowest broadband connectivity. More research is needed to better understand the direct relationship between broadband connectivity, the usage of online health resources and the management or prevention of cardiometabolic dysfunction.

ImportanceIntensive lifestyle change (e.g., the Diabetes Prevention Program) and metformin reduce type 2 diabetes risk among patients with prediabetes. However, real-world uptake remains low. Shared decision-making (SDM) may increase awareness and help patients select and follow through with informed options for diabetes prevention that are aligned with their preferences.ObjectiveTo test the effectiveness of a prediabetes SDM intervention.DesignCluster randomized controlled trial.SettingTwenty primary care clinics within a large regional health system.ParticipantsOverweight/obese adults with prediabetes (BMI ≥ 24 kg/m2 and HbA1c 5.7–6.4%) were enrolled from 10 SDM intervention clinics. Propensity score matching was used to identify control patients from 10 usual care clinics.InterventionIntervention clinic patients were invited to participate in a face-to-face SDM visit with a pharmacist who used a decision aid (DA) to describe prediabetes and four possible options for diabetes prevention: DPP, DPP ± metformin, metformin only, or usual care.Main Outcomes and MeasuresPrimary endpoint was uptake of DPP (≥ 9 sessions), metformin, or both strategies at 4 months. Secondary endpoint was weight change (lbs.) at 12 months.ResultsUptake of DPP and/or metformin was higher among SDM participants (n = 351) than controls receiving usual care (n = 1028; 38% vs. 2%, p < .001). At 12-month follow-up, adjusted weight loss (lbs.) was greater among SDM participants than controls (− 5.3 vs. − 0.2, p < .001).LimitationsAbsence of DPP supplier participation data for matched patients in usual care clinics.Conclusions and RelevanceA prediabetes SDM intervention led by pharmacists increased patient engagement in evidence-based options for diabetes prevention and was associated with significantly greater uptake of DPP and/or metformin at 4 months and weight loss at 12 months. Prediabetes SDM may be a promising approach to enhance prevention efforts among patients at increased risk.Trial RegistrationThis study was registered at clinicaltrails.gov (NCT02384109)).

IntroductionTo examine the association of a novel disease-specific health plan, known as the Diabetes Health Plan (DHP), with emergency room (ER) and hospital utilization among patients with diabetes and pre-diabetes.Research design and methodsQuasi-experimental design, with employer group as the unit of analysis, comparing changes in any ER and inpatient hospital utilization over a 3-year period. Inverse probability weighting was used to control for differences between employers purchasing DHP versus standard plans. Estimated differences in utilization are calculated as average treatment effects on the treated. We used employees and dependents from employer groups contracting with a large, national private insurer between 2009 and 2012. Eligibility and claims data from continuously covered employees and dependents with diabetes and pre-diabetes (n=74 058) were aggregated to the employer level. The analysis included 9 DHP employers (n=7004) and 183 control employers (n=67 054).ResultsDHP purchase was associated with 2.4 and 1.8 percentage points absolute reduction in mean rates of any ER utilization, representing 13% and 10% relative reductions at 1 and 2 years post-DHP (p=0.012 and p=0.046, respectively). There was no significant association between DHP purchase and hospital utilization.ConclusionEmployers purchasing diabetes-specific health benefit designs may experience lower rates of resource-intensive services such as ER utilization.

BackgroundPre-diabetes affects one-third of adults in the USA and a subset will progress to type 2 diabetes. Our objective was to determine whether a disease-specific health plan, known as the Diabetes Health Plan (DHP), designed to improve care for persons with pre-diabetes and diabetes also led to lower rates of incident diabetes among adults with pre-diabetes.MethodsWe examined eligibility and claims data from a large payer who offered the DHP to a national sample of employers. We included adult employees and dependents who were continuously covered by the DHP over a 4-year study window. The primary outcome was incident diabetes. We conducted propensity score matching at the employer level to find comparable control employer groups offering standard plans. Using an adjusted logistic regression model at the individual level, we tested the association between DHP employer group status and incident diabetes diagnosis during the 3 years of postbaseline follow-up.FindingsOur analysis included data from 11 965 continuously enrolled adults with pre-diabetes (n=1538 from nine employers offering DHP; n=10 427 from 105 control employers offering standard plans). DHP employees and covered dependents with pre-diabetes had an 8% lower absolute predicted probability of incident diabetes compared with individuals from employer groups offering standard benefit plans (29% predicted probability of incident diabetes for DHP vs 37% for controls, p<0.001).ConclusionsA pre-diabetes-specific health benefit design was associated with lower rates of incident diabetes and represents an area of needed future study.

OBJECTIVES/SPECIFIC AIMS: Intensive lifestyle change (e.g., the Diabetes Prevention Program) and metformin reduce type 2 diabetes risk among patients with prediabetes. However, real-world uptake remains low. Shared decision-making (SDM) may increase awareness and help patients select and follow through with informed options for diabetes prevention that are aligned with their preferences.The objective was to test the effectiveness of a prediabetes SDM intervention. METHODS/STUDY POPULATION: This was a cluster-randomized controlled trial in 20 primary care clinics within a large regional health system. Participants were overweight/obese adults with prediabetes (BMI>24 kg/m2 and HbA1c 5.7-6.4%) were enrolled from 10 SDM intervention clinics. Propensity score matching was used to identify control patients from 10 usual care clinics.Intervention clinic patients were invited to participate in a face-to-face SDM visit with a pharmacist who used a decision aid (DA) to describe prediabetes and four possible options for diabetes prevention; DPP, DPP +/− metformin, metformin only, or usual care. RESULTS/ANTICIPATED RESULTS: Uptake of DPP and/or metformin was higher among SDM participants (n=351) than controls receiving usual care (n = 1,028; 38% vs. 2%, p<.001). At 12-months follow-up, adjusted weight loss (lbs.) was greater among SDM participants than controls (−5.3 vs. −0.2, p < .001). DISCUSSION/SIGNIFICANCE OF IMPACT: A prediabetes SDM intervention led by pharmacists increased patient engagement in evidence-based options for diabetes prevention and was associated with significantly greater uptake of DPP and/or metformin at 4-months and weight loss at 12-months. Prediabetes SDM may be a promising approach to enhance prevention efforts among patients at increased risk.

Background The socioeconomic status (SES) gradient in hospital and emergency room utilization among adults with type 2 diabetes (T2DM) is partially driven by cost-related non-adherence. Objective To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific health plan incorporating value-based insurance design principles on healthcare utilization among low-income adults with T2DM. Design To examine the impact of the DHP on healthcare utilization, we employed a difference-in-differences (DID) study design with a propensity-matched comparison group. We modeled count and dichotomous outcomes using Poisson and logit models, respectively. Participants Cohort of adults (18–64) with T2DM, with an annual household income <$ 30,000, and who were continuously enrolled in an employer-sponsored UnitedHealthcare plan for at least 2 years between 2009 and 2014. Interventions The DHP reduces or eliminates out-of-pocket costs for disease management visits, diabetes-related medicines, and diabetes self-monitoring supplies. The DHP also provides access to diabetes-specific telephone case management as well as other online resources. Main Measures Number of disease management visits ( N = 1732), any emergency room utilization ( N = 1758), and any hospitalization ( N = 1733), within the year. Key Results DID models predicting disease management visits suggested that DHP-exposed beneficiaries had 1.7 fewer in-person disease management visits per year (− 1.70 [95% CI: − 2.19, − 1.20], p < 0.001), on average, than comparison beneficiaries. Models for emergency room (0.00 [95% CI: − 0.06, 0.06], p = 0.966) and hospital utilization (− 0.03 [95% CI: − 0.08, − 0.01], p = 0.164) did not demonstrate statistically significant changes associated with DHP exposure. Conclusions While no relationship between DHP exposure and high-cost utilization was observed in the short term, fewer in-person disease management visits were observed. Future studies are needed to determine the clinical implications of these findings.

BackgroundMany Diabetes Prevention Program (DPP) translation efforts have been less effective for underresourced populations. In the cluster-randomized Prediabetes Informed Decision and Education (PRIDE) trial, which evaluated a shared decision-making (SDM) intervention for diabetes prevention, Hispanic and non-Hispanic Black participants lost less weight than non-Hispanic White participants at 12-month follow-up.ObjectiveTo explore perspectives about weight loss from PRIDE participants of different racial and ethnic groups.ParticipantsSample of participants with prediabetes who were randomized to the PRIDE intervention arm (n=24).ApproachWe conducted semi-structured interviews within three groups stratified by DPP participation and % weight loss at 12 months: (DPP+/WL+, enrolled in DPP and lost >5% weight; DPP+/WL−, enrolled in DPP and lost <3% weight; DPP−/WL−, did not enroll in DPP and lost <3% weight). Each group was further subdivided on race and ethnicity (non-Hispanic Black (NHB), non-Hispanic White (NHW), Hispanic). Interviews were conducted on Zoom and transcripts were coded and analyzed with Dedoose.Key ResultsCompared to NHW participants, Hispanic and NHB participants more often endorsed weight loss barriers of limited time to make lifestyle changes due to long work and commute hours, inconvenient DPP class locations and offerings, and limited disposable income for extra weight loss activities. Conversely, facilitators of weight loss regardless of race and ethnicity included retirement or having flexible work schedules; being able to identify convenient DPP classes; having a strong, positive support system; and purchasing supplementary resources to support lifestyle change (e.g., gym memberships, one-on-one activity classes).ConclusionsWe found that NHB and Hispanic SDM participants report certain barriers to weight loss more commonly than NHW participants, particularly barriers related to limited disposable income and/or time constraints. Our findings suggest that increased lifestyle change support and flexible program delivery options may be needed to ensure equity in DPP reach, participant engagement, and outcomes.

Background/Objectives: History of gestational diabetes mellitus (GDM) is a strong risk factor in the development of type 2 diabetes (T2D). We sought to examine the association between perceived risk of developing T2D and relevant health behaviors in this population. Methods: We analyzed self-reported survey items and objective electronic health record data of participants in the Gestational diabetes Risk Attenuation for New Diabetes (GRAND) Study, a multisite randomized control trial testing the effectiveness of shared decision-making for women with elevated body mass index (BMI), prediabetes and history of GDM. Data on demographics, health behaviors, and perceived T2D risk were self-reported. We ran four regression models to study the association between women’s perceived risk of developing T2D and four key health behaviors: (1) physical activity, (2) consumption of sugar-sweetened beverages, (3) consumption of ultra-processed foods, and (4) consumption of meals prepared outside the home. All models were adjusted for age, race, ethnicity, income, HbA1c, BMI, family history of T2D, and study arm. Results: Our sample included 242 women who on average were 41 years old (±6 years) with BMI of 32.7 (±6.9 kg/m2). Perceived risk of developing T2D was not significantly associated with physical activity, consumption of sugar-sweetened beverages, ultra-processed food consumption, or meals prepared outside of the home. Higher BMI was significantly associated with increased consumption of sugar-sweetened beverages (OR 1.05, 95% CI 1.01–1.10), but not other health behaviors. Conclusions: We found perceived risk of developing T2D was not independently associated with four key health behaviors. Women with GDM are at high risk of developing T2D and may benefit from tailored or more intensive strategies promoting health behavior changes shown to lower T2D risk.

ABSTRACT Background Reducing patient cost-sharing and engaging patients in disease management activities have been shown to increase uptake of evidence-based care. Objective To evaluate the effect of employer purchase of a disease-specific plan with reduced cost-sharing and disease management (the Diabetes Health Plan/DHP) on medication adherence among eligible employees and dependents. Design Employer-level “intent to treat” cohort study, including data from eligible employees and their dependents with diabetes, regardless of whether they were enrolled in the DHP. Setting Employers that contracted with a large national health plan administrator in 2009, 2010, and/or 2011. Participants Ten employers that purchased the DHP and 191 employers that did not (controls). Inverse probability weighting (IPW) estimation was used to adjust for inter-group differences. Intervention The DHP includes free or low-cost medications and physician visits. Enrollment strategies and specific benefit designs are determined by the employer and vary in practice. DHP participants are notified up front that they must engage in their own health care (e.g., receiving diabetes-related screening) in order to remain enrolled. Main Outcome Measure Mean employee adherence to metformin, statins, and ACE/ARBs at the employer level at one year post-DHP implementation, as measured by the proportion of days covered (PDC). Results Baseline adherence to the three medications was similar across DHP and control employers, ranging from 64 to 69 %. In the first year after DHP implementation, predicted employer-level adherence for metformin (+4.9 percentage points, p = 0.017), statins (+4.8, p = 0.019), and ACE/ARBs (+4.4, p = 0.02) was higher with DHP purchase. Limitations Non-randomized, observational study. Conclusions The Diabetes Health Plan, an innovative health plan that combines reduced cost-sharing and disease management with an up-front requirement of enrollee participation in his or her own health care, is associated with a modest improvement in medication adherence at 12 months.

ABSTRACT BACKGROUND Drug substitution is a promising approach to reducing medication costs. OBJECTIVE To calculate the potential savings in a Medicare Part D plan from generic or therapeutic substitution for commonly prescribed drugs. DESIGN Cross-sectional, simulation analysis. PARTICIPANTS Low-income subsidy (LIS) beneficiaries ( n  = 145,056) and non low-income subsidy (non-LIS) beneficiaries ( n  = 1,040,030) enrolled in a large, national Part D health insurer in 2007 and eligible for a possible substitution. MEASUREMENTS Using administrative data from 2007, we identified claims filled for brand-name drugs for which a direct generic substitute was available. We also identified the 50 highest cost drugs separately for LIS and non-LIS beneficiaries, and reached consensus on which drugs had possible therapeutic substitutes (27 for LIS, 30 for non-LIS). For each possible substitution, we used average daily costs of the original and substitute drugs to calculate the potential out-of-pocket savings, health plan savings, and when applicable, savings for the government/LIS subsidy. RESULTS Overall, 39 % of LIS beneficiaries and 51 % of non-LIS beneficiaries were eligible for a generic and/or therapeutic substitution. Generic substitutions resulted in an average annual savings of $160 in the case of LIS beneficiaries and $127 in the case of non-LIS beneficiaries. Therapeutic substitutions resulted in an average annual savings of $452 in the case of LIS beneficiaries and $389 in the case of non-LIS beneficiaries. CONCLUSIONS Our findings indicate that drug substitution, particularly therapeutic substitution, could result in significant cost savings. There is a need for additional studies evaluating the acceptability of therapeutic substitution interventions within Medicare Part D.