Objectives: We sought to identify patterns of knowledge, attitudes, and behaviors (KABs) about influenza and influenza vaccination among healthcare personnel (HCP) and define characteristics associated with these patterns. Methods: We used an Internet panel survey of HCP (N = 2265) during March 27-April 17, 2018; clustered HCP by their vaccination-related KABs. Results: Four clusters were identified: Immunization Champions (61.1% of the sample) received influenza vaccine to prevent disease; Unworried Vaccinators (15.4%) received the influenza vaccine but did not believe influenza is a serious threat to themselves; Fence Sitters (8.1%) believed the vaccine is safe and worth the time and expense but is not effective; Skeptics (15.4%) did not believe the vaccine is safe or effective. Influenza vaccination coverage was 78.4% overall and higher among Immunization Champions (90.2%) and Unworried Vaccinators (87.0%) than Fence Sitters (61.6%) or Skeptics (32.2%). Conclusions: Findings suggest that based on KABs, the 3 clusters comprising 85% of HCP might be vaccinated in the future. Using messages specific to each group may improve vaccination coverage among HCP.

AIMS: Although risk scores to predict type 2 diabetes exist, cost-effectiveness of risk thresholds to target prevention interventions are unknown. We applied cost-effectiveness analysis to identify optimal thresholds of predicted risk to target a low-cost community-based intervention in the USA. METHODS: We used a validated Markov-based type 2 diabetes simulation model to evaluate the lifetime cost-effectiveness of alternative thresholds of diabetes risk. Population characteristics for the model were obtained from NHANES 2001-2004 and incidence rates and performance of two noninvasive diabetes risk scores (German diabetes risk score, GDRS, and ARIC 2009 score) were determined in the ARIC and Cardiovascular Health Study (CHS). Incremental cost-effectiveness ratios (ICERs) were calculated for increasing risk score thresholds. Two scenarios were assumed: 1-stage (risk score only) and 2-stage (risk score plus fasting plasma glucose (FPG) test (threshold 100 mg/dl) in the high-risk group). RESULTS: In ARIC and CHS combined, the area under the receiver operating characteristic curve for the GDRS and the ARIC 2009 score were 0.691 (0.677-0.704) and 0.720 (0.707-0.732), respectively. The optimal threshold of predicted diabetes risk (ICER < $50,000/QALY gained in case of intervention in those above the threshold) was 7% for the GDRS and 9% for the ARIC 2009 score. In the 2-stage scenario, ICERs for all cutoffs >/= 5% were below $50,000/QALY gained. CONCLUSIONS: Intervening in those with >/= 7% diabetes risk based on the GDRS or >/= 9% on the ARIC 2009 score would be cost-effective. A risk score threshold >/= 5% together with elevated FPG would also allow targeting interventions cost-effectively.

INTRODUCTION: Vaccinating pregnant women with influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) can reduce influenza and pertussis risk for themselves and their infants. METHODS: Surveillance data were analyzed to ascertain influenza-associated hospitalization among pregnant women and infant hospitalization and death associated with influenza and pertussis. An Internet panel survey was conducted during March 27-April 8, 2019, among women aged 18-49 years who reported being pregnant any time since August 1, 2018. Influenza vaccination before or during pregnancy was assessed among respondents with known influenza vaccination status who were pregnant any time during October 2018-January 2019 (2,097). Tdap receipt during pregnancy was assessed among respondents with known Tdap status who reported a live birth by their survey date (817). RESULTS: From 2010-11 to 2017-18, pregnant women accounted for 24%-34% of influenza-associated hospitalizations per season among females aged 15-44 years. From 2010 to 2017, a total of 3,928 pertussis-related hospitalizations were reported among infants aged <2 months (annual range = 262-743). Maternal influenza and Tdap vaccination coverage rates reported as of April 2019 were 53.7% and 54.9%, respectively. Among women whose health care providers offered vaccination or provided referrals, 65.7% received influenza vaccine and 70.5% received Tdap. The most commonly reported reasons for nonvaccination were believing the vaccine is not effective (influenza; 17.6%) and not knowing that vaccination is needed during each pregnancy (Tdap; 37.9%), followed by safety concerns for the infant (influenza =15.9%; Tdap = 17.1%). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many pregnant women do not receive the vaccines recommended to protect themselves and their infants, even when vaccination is offered. CDC and provider organizations' resources are available to help providers convey strong, specific recommendations for influenza and Tdap vaccination that are responsive to pregnant women's concerns.

The association between chronic kidney disease (CKD) and tuberculosis disease (TB) has been recognized for decades. Recently CKD prevalence is increasing in low- to middle-income countries with high TB burden. Using data from the required overseas medical exam and the recommended US follow-up exam for 444,356 US-bound refugees aged >/= 18 during 2009-2017, we ran Poisson regression to assess the prevalence of TB among refugees with and without CKD, controlling for sex, age, diabetes, tobacco use, body mass index ( kg/m(2)), prior residence in camp or non-camp setting, and region of birth country. Of the 1117 (0.3%) with CKD, 21 (1.9%) had TB disease; of the 443,239 who did not have CKD, 3380 (0.8%) had TB. In adjusted analyses, TB was significantly higher among those with than without CKD (prevalence ratio 1.93, 95% CI: 1.26, 2.98, p < 0.01). Healthcare providers attending to refugees need to be aware of this association.

We thank Dr Burgner [1] for his interest in our study [2]. Dr Burgner pointed out the potential for oversimplification of our survival model by summarizing prematurity and low birth weight, which may have resulted in effect modification being overlooked. This is an interesting idea, and we agree that perhaps a stratified approach could provide more meaningful estimates of such effect measure modification. However, stratifying on these dichotomous variables is not possible with our data due to the small sample size. We think this would be an important approach for future studies and look forward to publications evaluating possible effect modification by gestational age or birth weight.

OBJECTIVES: To assess changes in US tuberculosis (TB) incidence rates by age, period, and cohort effects, stratified according to race/ethnicity and nativity. METHODS: We used US National Tuberculosis Surveillance System data for 1996 to 2016 to estimate trends through age-period-cohort models. RESULTS: Controlling for cohort and period effects indicated that the highest rates of TB incidence occurred among those 0 to 5 and 20 to 30 years of age. The incidence decreased by age for successive birth cohorts. There were greater estimated annual percentage decreases among US-born individuals (-7.3%; 95% confidence interval [CI] = -7.5, -7.1) than among non-US-born individuals (-4.3%; 95% CI = -4.5, -4.1). US-born individuals older than 25 years exhibited the largest decreases, a pattern that was not reflected among non-US-born adults. In the case of race/ethnicity, the greatest decreases by nativity were among US-born Blacks (-9.3%; 95% CI = -9.6, -9.1) and non-US-born Hispanics (-5.7%; 95% CI = -6.0, -5.5). CONCLUSIONS: TB has been decreasing among all ages, races and ethnicities, and consecutive cohorts, although these decreases are less pronounced among non-US-born individuals.

We examined changes in the prevalence of chronic health conditions among US-bound refugees originating from Burma resettling over 8 years by the type of living arrangement before resettlement, either in camps (Thailand) or in urban areas (Malaysia). Using data from the required overseas medical exam for 73,251 adult (>/= 18 years) refugees originating from Burma resettling to the United States during 2009-2016, we assessed average annual percent change (AAPC) in proportion >/= 45 years and age- and sex-standardized prevalence of obesity, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and musculoskeletal disease, by camps versus urban areas. Compared with refugees resettling from camps, those coming from urban settings had higher prevalence of obesity (mean 18.0 vs. 5.9%), diabetes (mean 6.5 vs. 0.8%), and hypertension (mean 12.7 vs. 8.1%). Compared with those resettling from camps, those from urban areas saw greater increases in the proportion with COPD (AAPC: 109.4 vs. 9.9) and musculoskeletal disease (AAPC: 34.6 vs. 1.6). Chronic conditions and their related risk factors increased among refugees originating from Burma resettling to the United States whether they had lived in camps or in urban areas, though the prevalence of such conditions was higher among refugees who had lived in urban settings.

OBJECTIVE: The impact of weight loss intervention on disability-free life expectancy in adults with diabetes is unknown. We examined the impact of a long-term weight loss intervention on years spent with and without physical disability. RESEARCH DESIGN AND METHODS: Overweight or obese adults with type 2 diabetes age 45-76 years (n = 5,145) were randomly assigned to a 10-year intensive lifestyle intervention (ILI) or diabetes support and education (DSE). Physical function was assessed annually for 12 years using the SF-36. Annual incidence of physical disability, mortality, and disability remission were incorporated into a Markov model to quantify years of life spent active and physically disabled. RESULTS: Physical disability incidence was lower in the ILI group (6.0% per year) than in the DSE group (6.8% per year) (incidence rate ratio 0.88 [95% CI 0.81-0.96]), whereas rates of disability remission and mortality did not differ between groups. ILI participants had a significant delay in moderate or severe disability onset and an increase in number of nondisabled years (P < 0.05) compared with DSE participants. For a 60-year-old, this effect translates to 0.9 more disability-free years (12.0 years [95% CI 11.5-12.4] vs. 11.1 years [95% CI 10.6-11.7]) but no difference in total years of life. In stratified analyses, ILI increased disability-free years of life in women and participants without cardiovascular disease (CVD) but not in men or participants with CVD. CONCLUSIONS: Long-term lifestyle interventions among overweight or obese adults with type 2 diabetes may reduce long-term disability, leading to an effect on disability-free life expectancy but not on total life expectancy.

Background: Recent studies have shown that some vaccines have beneficial effects that could not be explained solely by the prevention of their respective targeted disease(s). Methods: We used the MarketScan(R) United States (US) Commercial Claims Databases from 2005-2014 to assess the risk of hospital admission for non-targeted infectious diseases in children from 16 through 24 months according to the last vaccine type (live and/or inactivated). We included children continuously enrolled within a month of birth through 15 months who received at least three doses of Diphtheria-Tetanus-acellular Pertussis vaccine by end of 15 months of age. We used Cox regression to estimate hazard ratios (HRs), stratifying by birthdate to control for age, year and seasonality, and adjusting for sex, chronic diseases, prior hospitalizations, number of outpatient visits, region of residence, urban/rural area of domicile, prematurity, low birth weight, and mother's age. Results: 311,663 children were included. In adjusted analyses, risk of hospitalization for non-targeted infections from ages 16 through 24 months was reduced for those who received live vaccine alone compared with inactivated alone or concurrent live and inactivated vaccines (HR 0.50, 95% CI 0.43, 0.57 and HR 0.78, 95% CI 0.67, 0.91, respectively), and for those who received live and inactivated vaccines concurrently compared with inactivated only (HR 0.64, 95% CI 0.58, 0.70). Conclusions: We found lower risk of non-targeted infectious disease hospitalizations from 16 through 24 months among US children whose last vaccine received was live compared with inactivated vaccine, as well as concurrent receipt compared with inactivated vaccine.

Structured lifestyle interventions can reduce diabetes incidence and cardiovascular disease (CVD) risk among persons with impaired glucose tolerance (IGT), but it is unclear whether they should be implemented among persons without IGT. We conducted a systematic review and meta-analyses to assess the effectiveness of lifestyle interventions on CVD risk among adults without IGT or diabetes. We systematically searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Library, and PsychInfo databases, from inception to May 4, 2016. We selected randomized controlled trials of lifestyle interventions, involving physical activity (PA), dietary (D), or combined strategies (PA+D) with follow-up duration ≥12 months. We excluded all studies that included individuals with IGT, confirmed by 2-hours oral glucose tolerance test (75g), but included all other studies recruiting populations with different glycemic levels. We stratified studies by baseline glycemic levels: (1) low-range group with mean fasting plasma glucose (FPG) <5.5mmol/L or glycated hemoglobin (A1C) <5.5%, and (2) high-range group with FPG ≥5.5mmol/L or A1C ≥5.5%, and synthesized data using random-effects models. Primary outcomes in this review included systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides (TG). Totally 79 studies met inclusion criteria. Compared to usual care (UC), lifestyle interventions achieved significant improvements in SBP (-2.16mmHg[95%CI, -2.93, -1.39]), DBP (-1.83mmHg[-2.34, -1.31]), TC (-0.10mmol/L[-0.15, -0.05]), LDL-C (-0.09mmol/L[-0.13, -0.04]), HDL-C (0.03mmol/L[0.01, 0.04]), and TG (-0.08mmol/L[-0.14, -0.03]). Similar effects were observed among both low-and high-range study groups except for TC and TG. Similar effects also appeared in SBP and DBP categories regardless of follow-up duration. PA+D interventions had larger improvement effects on CVD risk factors than PA alone interventions. In adults without IGT or diabetes, lifestyle interventions resulted in significant improvements in SBP, DBP, TC, LDL-C, HDL-C, and TG, and might further reduce CVD risk.

OBJECTIVE: In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended behavioral counseling interventions for overweight or obese adults with the following known cardiovascular disease risk factors: impaired fasting glucose (IFG), hypertension, dyslipidemia, or metabolic syndrome. We assessed the long-term cost-effectiveness (CE) of implementing the recommended interventions in the U.S. RESEARCH DESIGN AND METHODS: We used a disease progression model to simulate the 25-year CE of the USPSTF recommendation for eligible U.S. adults and subgroups defined by a combination of the risk factors. The baseline population was estimated using 2005-2012 National Health and Nutrition Examination Surveys. The cost and effectiveness of the intervention were obtained from systematic reviews. Incremental CE ratios (ICERs), measured in cost/quality-adjusted life year (QALY), were used to assess the CE of the intervention compared with no intervention. Future QALYs and costs (reported in 2014 U.S. dollars) were discounted at 3%. RESULTS: We estimated that approximately 98 million U.S. adults (44%) would be eligible for the recommended intervention. Compared with no intervention, the ICER of the intervention would be $13,900/QALY. CE varied widely among subgroups, ranging from a cost saving of $302 per capita for those who were obese with IFG, hypertension, and dyslipidemia to a cost of $103,200/QALY in overweight people without these conditions. CONCLUSIONS: The recommended intervention is cost effective based on the conventional CE threshold. Considerable variation in CE across the recommended subpopulations suggests that prioritization based on risk level would yield larger total health gains per dollar spent.

This study systematically assessed the effectiveness of lifestyle interventions on glycemic indicators among adults (18years) without IGT or diabetes. Randomized controlled trials using physical activity (PA), diet (D), or their combined strategies (PA+D) with follow-up 12months were systematically searched from multiple electronic-databases between inception and May 4, 2016. Outcome measures included fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), fasting insulin (FI), homeostasis model assessment-estimated insulin resistance (HOMA-IR), and bodyweight. Included studies were divided into low-range (FPG <5.5mmol/L or HbA1c <5.5%) and high-range (FPG 5.5mmol/L or HbA1c 5.5%) groups according to baseline glycemic levels. Seventy-nine studies met inclusion criteria. Random-effect models demonstrated that compared with usual care, lifestyle interventions achieved significant reductions in FPG (-0.14mmol/L [95%CI, -0.19, -0.10]), HbA1c (-0.06% [-0.09, -0.03]), FI (%change: -15.18% [-20.01, -10.35]), HOMA-IR (%change: -22.82% [-29.14, -16.51]), and bodyweight (%change: -3.99% [-4.69, -3.29]). The same effect sizes in FPG reduction (0.07) appeared among both low-range and high-range groups. Similar effects were observed among all groups regardless of lengths of follow-up. D and PA+D interventions had larger effects on glucose reduction than PA alone. Lifestyle interventions significantly improved FPG, HbA1c, FI, HOMA-IR, and bodyweight among adults without IGT or diabetes, and might reduce progression of hyperglycemia to type 2 diabetes mellitus.

U.S. military personnel assigned to areas deemed to be at high risk for anthrax attack receive Anthrax Vaccine Adsorbed (AVA). Few cases of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have been reported in persons who received AVA. Using a matched case-control study design, we assessed the relationship of RA and SLE with AVA vaccination using the Defense Medical Surveillance System. We identified potential cases using International Classification of Diseases, 9th Revision, Clinical Modification codes and confirmed cases with medical record review and rheumatologist adjudication. Using conditional logistic regression, we estimated odds ratios (OR) for AVA exposure during time intervals ranging from 90 to 1,095 days before disease onset. Among 77 RA cases, 13 (17%) had ever received AVA. RA cases were no more likely than controls to have received AVA when looking back 1,095 days (OR: 1.03; 95% confidence interval [CI]: 0.48-2.19) but had greater odds of exposure in the prior 90 days (OR: 3.93; 95% CI: 1.08-14.27). Among the 39 SLE cases, 5 (13%) had ever received AVA; no significant difference in receipt of AVA was found when compared with controls (OR: 0.91; 95% CI: 0.26-3.25). AVA was associated with recent onset RA, but did not increase the risk of developing RA in the long term.

BACKGROUND: No comparative review of Vaccine Adverse Event Reporting System (VAERS) submissions following pandemic influenza A (H1N1) 2009 and seasonal influenza vaccinations during the pandemic season among U.S. military personnel has been published. METHODS: We compared military vs. civilian adverse event reporting rates. Adverse events (AEs) following vaccination were identified from VAERS for adults aged 17-44years after pandemic (monovalent influenza [MIV], and seasonal (trivalent inactivated influenza [IIV3], live attenuated influenza [LAIV3]) vaccines. Military vaccination coverage was provided by the Department of Defense's Defense Medical Surveillance System. Civilian vaccination coverage was estimated using data from the National 2009 H1N1 Flu Survey and the Behavioral Risk Factor Surveillance System survey. RESULTS: Vaccination coverage was more than four times higher for MIV and more than twenty times higher for LAIV3 in the military than in the civilian population. The reporting rate of serious AE reports following MIV in service personnel (1.19 per 100,000) was about half that reported by the civilian population (2.45 per 100,000). Conversely, the rate of serious AE reports following LAIV3 among service personnel (1.32 per 100,000) was more than twice that of the civilian population. Although fewer military AEs following MIV were reported overall, the rate of Guillain-Barre Syndrome (GBS) (4.01 per million) was four times greater than that in the civilian population. (1.04 per million). CONCLUSIONS: Despite higher vaccination coverage in service personnel, the rate of serious AEs following MIV was about half that in civilians. The rate of GBS reported following MIV was higher in the military.

BACKGROUND: The life expectancy of the average American with diabetes has increased, but the quality of health and functioning during those extra years are unknown. We aimed to investigate the net effect of recent trends in diabetes incidence, disability, and mortality on the average age of disability onset and the number of healthy and disabled years lived by adults with and without diabetes in the USA. We assessed whether disability expanded or was compressed in the population with diabetes and compared the findings with those for the population without diabetes in two consecutive US birth cohorts aged 50-70 years. METHODS: In this prospective longitudinal analysis, we analysed data for two cohorts of US adults aged 50-70 years from the Health and Retirement Study, including 1367 people with diabetes and 11 414 without diabetes. We assessed incident disability, remission from disability, and mortality between population-based cohort 1 (born 1931-41, follow-up 1992-2002) and cohort 2 (born 1942-47, follow up 2002-12). Disability was defined by mobility loss, difficulty with one or more instrumental activities of daily living, and difficulty with one or more activities of daily living. We entered age-specific probabilities representing the two birth cohorts into a five-state Markov model to estimate the number of years of disabled and disability-free life and life-years lost by age 70 years. FINDINGS: In people with diabetes, compared with cohort 1 (n=1067), cohort 2 (n=300) had more disability-free and total years of life, later onset of disability, and fewer disabled years. Simulations of the Markov models suggest that in men with diabetes aged 50 years, this difference between cohorts amounted to a 0.8-2.3 year delay in disability across the three metrics (mobility, 63.0 [95% CI 62.3-63.6] to 64.8 [63.6-65.7], p=0.01; instrumental activities of daily living, 63.5 [63.0-64.0] to 64.3 [63.0-65.3], p=0.24; activities of daily living, 62.7 [62.1-63.3] to 65.0 [63.5-65.9], p<0.0001) and 1.3 fewer life-years lost (ie, fewer remaining life-years up to age 70 years; from 2.8 [2.5-3.2] to 1.5 [1.3-1.9]; p<0.0001 for all three measures of disability). Among women with diabetes aged 50 years, this difference between cohorts amounted to a 1.1-2.3 year delay in disability across the three metrics (mobility, 61.3 [95% CI 60.5-62.1] to 63.2 [61.5-64.5], p=0.0416; instrumental activities of daily living, 63.0 [62.4-63.7] to 64.1 [62.7-65.2], p=0.16; activities of daily living, 62.3 [61.6-63.0] to 64.6 [63.1-65.6], p<0.0001) and 0.8 fewer life-years lost by age 70 years (1.9 [1.7-2.2] to 1.1 [0.9-1.5]; p<0.0001 for all three measures of disability). Parallel improvements were gained between cohorts of adults without diabetes (cohort 1, n=8687; cohort 2, n=2727); within both cohorts, those without diabetes had significantly more disability-free years than those with diabetes (p<0.0001 for all comparisons). INTERPRETATION: Irrespective of diabetes status, US adults saw a compression of disability and gains in disability-free life-years. The decrease in disability onset due to primary prevention of diabetes could play an important part in achieving longer disability-free life-years. FUNDING: US Department of Health & Human Services and the US Centers for Disease Control and Prevention.

To determine rates of diabetes, hypertension, and hyperlipidemia in Cambodian refugees, and to assess the proportion whose conditions are satisfactorily managed in comparison to the general population. Self-report and laboratory/physical health assessment data obtained from a household probability sample of U.S.-residing Cambodian refugees (N = 331) in 2010-2011 were compared to a probability sample of the adult U.S. population (N = 6,360) from the 2009-2010 National Health and Nutrition Examination Survey. Prevalence of diabetes, hypertension and hyperlipidemia in Cambodian refugees greatly exceeded rates found in the age- and gender-adjusted U.S. POPULATION: Cambodian refugees with diagnosed hypertension or hyperlipidemia were less likely than their counterparts in the general U.S. population to have blood pressure and total cholesterol within recommended levels. Increased attention should be paid to prevention and management of diabetes and cardiovascular disease risk factors in the Cambodian refugee community. Research is needed to determine whether this pattern extends to other refugee groups.

OBJECTIVE: Quantify the impact of diabetes status on healthy and disabled years of life for older adults in the U.S. and provide a baseline from which to evaluate ongoing national public health efforts to prevent and control diabetes and disability. RESEARCH DESIGN AND METHODS: Adults (n = 20,008) aged 50 years and older were followed from 1998 to 2012 in the Health and Retirement Study, a prospective biannual survey of a nationally representative sample of adults. Diabetes and disability status (defined by mobility loss, difficulty with instrumental activities of daily living [IADL], and/or difficulty with activities of daily living [ADL]) were self-reported. We estimated incidence of disability, remission to nondisability, and mortality. We developed a discrete-time Markov simulation model with a 1-year transition cycle to predict and compare lifetime disability-related outcomes between people with and without diabetes. Data represent the U.S. population in 1998. RESULTS: From age 50, adults with diabetes died 4.6 years earlier, developed disability 6-7 years earlier, and spent about 1-2 more years in a disabled state than adults without diabetes. With increasing baseline age, diabetes was associated with significant (P < 0.05) reductions in the number of total and disability-free life-years, but the absolute difference in years between those with and without diabetes was less than at younger baseline age. Men with diabetes spent about twice as much of their remaining years disabled (20-24% of remaining life across the three disability definitions) as men without diabetes (12-16% of remaining life across the three disability definitions). Similar associations between diabetes status and disability-free and disabled years were observed among women. CONCLUSIONS: Diabetes is associated with a substantial reduction in nondisabled years, to a greater extent than the reduction of longevity.

BACKGROUND: Estimation of incidence of the state of undiagnosed chronic disease provides a crucial missing link for the monitoring of chronic disease epidemics and determining the degree to which changes in prevalence are affected or biased by detection. METHODS: We developed a four-part compartment model for undiagnosed cases of irreversible chronic diseases with a preclinical state that precedes the diagnosis. Applicability of the model is tested in a simulation study of a hypothetical chronic disease and using diabetes data from the Health and Retirement Study (HRS). RESULTS: A two dimensional system of partial differential equations forms the basis for estimating incidence of the undiagnosed and diagnosed disease states from the prevalence of the associated states. In the simulation study we reach very good agreement between the estimates and the true values. Application to the HRS data demonstrates practical relevance of the methods. DISCUSSION: We have demonstrated the applicability of the modeling framework in a simulation study and in the analysis of the Health and Retirement Study. The model provides insight into the epidemiology of undiagnosed chronic diseases.

INTRODUCTION: Diabetes is one of the most common and fastest-growing comorbidities of pregnancy. Temporal trends in gestational diabetes mellitus (GDM) have not been examined at the state level. This study examines GDM prevalence trends overall and by age, state, and region for 19 states, and by race/ethnicity for 12 states. Sub-analysis assesses trends among GDM deliveries by insurance type and comorbid hypertension in pregnancy. METHODS: Using the Agency for Healthcare Research and Quality's National and State Inpatient Databases, deliveries were identified using diagnosis-related group codes for GDM and comorbidities using ICD-9-CM diagnosis codes among all community hospitals. General linear regression with a log-link and binomial distribution was used in 2014 to assess annual change in GDM prevalence from 2000 through 2010. RESULTS: The age-standardized prevalence of GDM increased from 3.71 in 2000 to 5.77 per 100 deliveries in 2010 (relative increase, 56%). From 2000 through 2010, GDM deliveries increased significantly in all states (p<0.01), with relative increases ranging from 36% to 88%. GDM among deliveries in 12 states reporting race and ethnicity increased among all groups (p<0.01), with the highest relative increase in Hispanics (66%). Among GDM deliveries in 19 states, those with pre-pregnancy hypertension increased significantly from 2.5% to 4.1% (relative increase, 64%). The burden of GDM delivery payment shifted from private insurers (absolute decrease of 13.5 percentage points) to Medicaid/Medicare (13.2-percentage point increase). CONCLUSIONS: Results suggest that GDM deliveries are increasing. The highest rates of increase are among Hispanics and among GDM deliveries complicated by pre-pregnancy hypertension.

OBJECTIVE: Diabetes care has changed substantially in the past 2 decades. We examined the change in medical spending and use related to diabetes between 1987 and 2011. RESEARCH DESIGN AND METHODS: Using the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Surveys in 2000-2001 and 2010-2011, we compared per person medical expenditures and uses among adults ≥18 years of age with and without diabetes at the three time points. Types of medical services included inpatient care, emergency room (ER) visits, outpatient visits, prescription drugs, and others. We also examined the changes in unit cost, defined by the expenditure per encounter for medical services. RESULTS: The excess medical spending attributed to diabetes was $2,588 (95% CI, $2,265 to $3,104), $4,205 ($3,746 to $4,920), and $5,378 ($5,129 to $5,688) per person, respectively, in 1987, 2000-2001, and 2010-2011. Of the $2790 increase, prescription medication accounted for 55%; inpatient visits accounted for 24%; outpatient visits accounted for 15%; and ER visits and other medical spending accounted for 6%. The growth in prescription medication spending was due to the increase in both the volume of use and unit cost; whereas, the increase in outpatient expenditure was almost entirely driven by more visits. In contrast, the increase in inpatient and ER expenditures was caused by the rise of unit costs. CONCLUSIONS: In the past 2 decades, managing diabetes has become more expensive, mostly due to the higher spending on drugs. Further studies are needed to assess the cost-effectiveness of increased spending on drugs.

CONTEXT: Maternal pregestational diabetes (PGDM) is a risk factor for development of congenital heart defects (CHDs). Glycemic control before pregnancy reduces the risk of CHDs. A meta-analysis was used to estimate summary ORs and mathematical modeling was used to estimate population attributable fractions (PAFs) and the annual number of CHDs in the U.S. potentially preventable by establishing glycemic control before pregnancy. EVIDENCE ACQUISITION: A systematic search of the literature through December 2012 was conducted in 2012 and 2013. Case-control or cohort studies were included. Data were abstracted from 12 studies for a meta-analysis of all CHDs. EVIDENCE SYNTHESIS: Summary estimates of the association between PGDM and CHDs and 95% credible intervals (95% CrIs) were developed using Bayesian random-effects meta-analyses for all CHDs and specific CHD subtypes. Posterior estimates of this association were combined with estimates of CHD prevalence to produce estimates of PAFs and annual prevented cases. Ninety-five percent uncertainty intervals (95% UIs) for estimates of the annual number of preventable cases were developed using Monte Carlo simulation. Analyses were conducted in 2013. The summary OR estimate for the association between PGDM and CHDs was 3.8 (95% CrI=3.0, 4.9). Approximately 2670 (95% UI=1795, 3795) cases of CHDs could potentially be prevented annually if all women in the U.S. with PGDM achieved glycemic control before pregnancy. CONCLUSIONS: Estimates from this analysis suggest that preconception care of women with PGDM could have a measureable impact by reducing the number of infants born with CHDs.

BACKGROUND: Trends in state-level prevalence of pre-pregnancy diabetes mellitus (PDM; i.e., type 1 or type 2 diabetes diagnosed before pregnancy) among delivery hospitalizations are needed to inform healthcare delivery planning and prevention programs. PURPOSE: To examine PDM trends overall, by age group, race/ethnicity, primary payer, and with comorbidities such as pre-eclampsia and pre-pregnancy hypertension, and to report changes in prevalence over 11 years. METHODS: In 2014, State Inpatient Databases from the Agency for Healthcare Research and Quality were analyzed to identify deliveries with PDM and comorbidities using diagnosis-related group codes and ICD-9-CM codes. General linear regression with a log-link and binomial distribution was used to assess the annual change. RESULTS: Between 2000 and 2010, PDM deliveries increased significantly in all age groups, all race/ethnicity groups, and in all states examined (p<0.01). The age-standardized prevalence of PDM increased from 0.65 per 100 deliveries in 2000 to 0.89 per 100 deliveries in 2010, with a relative change of 37% (p<0.01). Although PDM rates were highest in the South, some of the largest relative increases occurred in five Western states (≥69%). Non-Hispanic blacks had the highest PDM rates and the highest absolute increase (0.26 per 100 deliveries). From 2000 to 2010, the proportion of PDM deliveries with pre-pregnancy hypertension increased significantly (p<0.01) from 7.4% to 14.1%. CONCLUSIONS: PDM deliveries are increasing overall and particularly among those with PDM who have hypertension. Effective diabetes prevention and control strategies for women of childbearing age may help protect their health and that of their newborns.

OBJECTIVE: To determine whether macronutrient intake differs by awareness of glycemic status among people with diabetes and prediabetes. RESEARCH DESIGN AND METHODS: We used 24-h dietary recall and other data from 3,725 nonpregnant adults with diabetes or prediabetes aged ≥20 years from the morning fasting sample of the 2005-2010 National Health and Nutrition Examination Surveys. Diabetes and prediabetes awareness were self-reported; those unaware of diabetes and prediabetes were defined by fasting plasma glucose (FPG) ≥126 mg/dL or HbA1c ≥6.5% and FPG 100-125 mg/dL or HbA1c of 5.7%-6.4%, respectively. Components of nutrient intake on a given day assessed were total calories, sugar, carbohydrates, fiber, protein, fat, and total cholesterol, stratified by sex and glycemic status awareness. Estimates of nutrient intake were adjusted for age, race/ethnicity, education level, BMI, smoking status, and family history of diabetes. RESULTS: Men with diagnosed diabetes consumed less sugar (mean 86.8 vs. 116.8 g) and carbohydrates (mean 235.0 vs. 262.1 g) and more protein (mean 92.3 vs. 89.7 g) than men with undiagnosed diabetes. Similarly, women with diagnosed diabetes consumed less sugar (mean 79.1 vs. 95.7 g) and more protein (mean 67.4 vs. 56.6 g) than women with undiagnosed diabetes. No significant differences in macronutrient intake were found by awareness of prediabetes. All participants, regardless of sex or glycemic status, consumed on average less than the American Diabetes Association recommendations for fiber intake (i.e., 14 g/1,000 kcal) and slightly more saturated fat than recommended (>10% of total kilocalories). CONCLUSIONS: Screening and subsequent knowledge of glycemic status may favorably affect some dietary patterns for people with diabetes.

OBJECTIVE: We assess whether functional decline and physical disability increase the subsequent risk of diabetes. RESEARCH DESIGN AND METHODS: The Health and Retirement Study, an observational study of a nationally representative survey of adults aged 51 years and older with no diabetes at baseline were followed up to 12 years (1998 to 2010). We assessed baseline disability status and incident disability with subsequent risk of diabetes, accounting for death as a competing risk and controlling for BMI, age, sex, race/ethnicity, net wealth, mother's level of education, respondents' level of education, and time of follow-up. Disability was defined as none, mild, moderate, and severe, based on a validated scale of mobility measures. Diabetes was identified by self-report of a diagnosis from a doctor. Population attributable fraction (PAF) was calculated to assess the percentage of diabetes cases that were attributable to mobility disability. RESULTS: The sample included 22,878 adults with an average of 8.7 years of follow-up; 9,649 (41.2%) reported some level of disability at baseline, and 8,175 (35.7%) additional participants developed disability during follow-up; 3,546 (15.5%) participants developed diabetes; and 5,869 (25.6%) died. Regression analyses found a statistically significant dose-response relationship of increased risk of diabetes (28-95%) among those with any level of functional decline, prevalent or incident. Among the subanalytic sample, including incident disability only, the PAF was 6.9% (CI 4.2-9.5). CONCLUSIONS: Our findings suggest those who become disabled, even mildly, are at increased risk of developing diabetes. This finding raises the possibility that approaches to prevent disability in older adults could also reduce diabetes incidence.

OBJECTIVES:To examine the relationship between county-level measures of social determinants and use of preventive care among US adults with diagnosed diabetes. To inform future diabetes prevention strategies. METHODS: Data are from the Behavioral Risk Factor Surveillance System (BRFSS) 2004 and 2005 surveys, the National Diabetes Surveillance System, and the Area Resource File. Use of diabetes care services was defined by self-reported receipt of 7 preventive care services. Our study sample included 46 806 respondents with self-reported diagnosed diabetes. Multilevel models were run to assess the association between county-level characteristics and receipt of each of the 7 preventive diabetes care service after controlling for characteristics of individuals. Results were considered significant if P < .05. RESULTS: Controlling for individual-level characteristics, our analyses showed that 7 of the 8 county-level factors examined were significantly associated with use of 1 or more preventive diabetes care services. For example, people with diabetes living in a county with a high uninsurance rate were less likely to have an influenza vaccination, visit a doctor for diabetes care, have an A1c test, or a foot examination; people with diabetes living in a county with a high physician density were more likely to have an A1c test, foot examination, or an eye examination; and people with diabetes living in a county with more people with less than high-school education were less likely to have influenza vaccination, pneumococcal vaccination, or self-care education (all P < .05). CONCLUSIONS: Many of the county-level factors examined in this study were found to be significantly associated with use of preventive diabetes care services. County policy makers may need to consider local circumstances to address the disparities in use of these services.

OBJECTIVE: To use structural modeling to test a hypothesized model of causal pathways related with prediabetes among older adults in the U.S. RESEARCH DESIGN AND METHODS: Cross-sectional study of 2,230 older adults (≥50 years) without diabetes included in the morning fasting sample of the 2001-2006 National Health and Nutrition Examination Surveys. Demographic data included age, income, marital status, race/ethnicity, and education. Behavioral data included physical activity (metabolic equivalent hours per week for vigorous, moderate, muscle-strengthening, walking/biking, and house/yard work), and poor diet (refined grains, red meat, added sugars, solid fats, and high-fat dairy). Structural-equation modeling was performed to examine the interrelationships among these variables with family history of diabetes, high blood pressure, BMI, large waist (waist circumference: women, ≥35 inches; men, ≥40 inches), triglycerides ≥200 mg/dL, and total- and HDL (≥60 mg/dL) cholesterol. RESULTS: After dropping BMI and total cholesterol, our best-fit model included three single factors: socioeconomic position (SEP), physical activity, and poor diet. Large waist had the strongest direct effect on prediabetes (0.279), followed by male sex (0.270), SEP (-0.157), high blood pressure (0.122), family history of diabetes (0.070), and age (0.033). Physical activity had direct effects on HDL (0.137), triglycerides (-0.136), high blood pressure (-0.132), and large waist (-0.067); poor diet had direct effects on large waist (0.146) and triglycerides (0.148). CONCLUSIONS: Our results confirmed that, while including factors known to be associated with high risk of developing prediabetes, large waist circumference had the strongest direct effect. The direct effect of SEP on prediabetes suggests mediation by some unmeasured factor(s).

OBJECTIVE: To examine variability in diagnosed gestational diabetes mellitus (GDM) prevalence at delivery by race/ethnicity and state. RESEARCH DESIGN AND METHODS: We used data from the Healthcare Cost and Utilization Project State Inpatient Databases for 23 states of the United States with available race/ethnicity data for 2008 to examine age-adjusted and race-adjusted rates of GDM by state. We used multilevel analysis to examine factors that explain the variability in GDM between states. RESULTS: Age-adjusted and race-adjusted GDM rates (per 100 deliveries) varied widely between states, ranging from 3.47 in Utah to 7.15 in Rhode Island. Eighty-six percent of the variability in GDM between states was explained as follows: 14.7% by age; 11.8% by race/ethnicity; 5.9% by insurance; and 2.9% by interaction between race/ethnicity and insurance at the individual level; 17.6% by hospital level factors; 27.4% by the proportion of obese women in the state; 4.3% by the proportion of Hispanic women aged 15-44 years in the state; and 1.5% by the proportion of white non-Hispanic women aged 15-44 years in the state. CONCLUSIONS: Our results suggest that GDM rates differ by state, with this variation attributable to differences in obesity at the population level (or "at the state level"), age, race/ethnicity, hospital, and insurance.

During the 2009 influenza A (H1N1) pandemic, there was an ongoing need to monitor 2009 H1N1 vaccination coverage at the national and state level to evaluate the vaccination campaign; thus, precise vaccination coverage estimates were needed in a timely fashion. The current objective is to describe and evaluate the methodology used to combine 2009 H1N1 vaccination coverage estimates from the Behavioral Risk Factor Surveillance System (BRFSS) and the National 2009 H1N1 Flu Survey (NHFS). H1N1 state level vaccination coverage estimates were combined by taking weighted averages of the BRFSS and NHFS estimates, with more weight given to the estimate with the larger effective sample size (sample size/design effect). The impact of the choice of weights was evaluated by comparing estimates when the design effect was removed from the weights. Combined vaccination coverage estimates for children generally fell midway between NHFS and BRFSS estimates because of larger NHFS sample sizes but smaller BRFSS design effects. Adult estimates were more closely weighted to BRFSS estimates because of larger BRFSS sample sizes. Combined standard errors were smaller than the survey-specific standard errors. When removing the design effect from the weights, the child combined estimates were more closely weighted to those from NHFS, resulting in larger standard errors. Adult combined estimates were similar regardless of choice of weight because of similar design effects across the two surveys. Combining estimates by weighting by the effective sample size allowed timely release of more precise estimates in all states during the 2009 H1N1 pandemic. (Copyright (c) 2012 John Wiley & Sons, Ltd.)

OBJECTIVES: Nationwide among nursing home residents, receipt of the influenza vaccine is 8 to 9 percentage points lower among blacks than among whites. The objective of this study was to determine if the national inequity in vaccination is because of the characteristics of facilities and/or residents. DESIGN: Cross-sectional study with multilevel modeling. SETTING AND PARTICIPANTS: States in which 1% or more of nursing home residents were black and the difference in influenza vaccination coverage between white and black nursing home residents was 1 percentage point or higher (n = 39 states and the District of Columbia). Data on residents (n = 2,359,321) were obtained from the Centers for Medicare & Medicaid Service's Minimum Data Set for October 1, 2008, through March 31, 2009. MEASUREMENTS: Residents' influenza vaccination status (vaccinated, refused vaccine, or not offered vaccination). RESULTS: States with higher overall influenza vaccination coverage among nursing home residents had smaller racial inequities. In nursing homes with higher proportions of black residents, vaccination coverage was lower for both blacks and whites. The most dramatic inequities existed between whites in nursing homes with 0% blacks (L1) and blacks in nursing homes with 50% or more blacks (L5) in states with overall racial inequities of 10 percentage points or more. In these states, more black nursing home residents lived in nursing homes with 50% or more blacks (L5); in general, the same homes with low overall coverage. CONCLUSION: Inequities in influenza vaccination coverage among nursing home residents are largely because of low vaccination coverage in nursing homes with a high proportion of black residents. Findings indicate that implementation of culturally appropriate interventions to increase vaccination in facilities with larger proportions of black residents may reduce the racial gap in influenza vaccination as well as increase overall state-level vaccination.

OBJECTIVES: To determine whether the racial inequity between African Americans and Caucasians in receipt of influenza vaccine is narrower in residents of nursing homes with facility-wide vaccination strategies than in residents of facilities without vaccination strategies. DESIGN: Secondary data analysis using the National Nursing Home Survey 2004, a nationally representative survey. SETTING: One thousand one hundred seventy-four participating nursing homes sampled systematically with probability proportional to bed size. PARTICIPANTS: Thirteen thousand five hundred seven randomly sampled residents of nursing homes between August and December 2004. MEASUREMENTS: Receipt of influenza vaccine within the last year. Logistic regression was used to examine the relationship between facility-level influenza immunization strategy and racial inequity in receipt of vaccination, adjusted for characteristics at the resident, facility, state, and regional levels. RESULTS: Overall in the Untied States, vaccination coverage was higher for Caucasian and African-American residents; the racial vaccination gaps were smaller (<6 percentage points) and nonsignificant in residents of homes with standing orders for influenza vaccinations (P=.14), verbal consent allowed for vaccinations(P=.39), and routine review of facility-wide vaccination rates (P=.61) than for residents of homes without these strategies. The racial vaccination gap in residents of homes without these strategies were two to three times as high (P=.009, P=.002, and P=.002, respectively). CONCLUSION: The presence of several immunization strategies in nursing homes is associated with higher vaccination coverage for Caucasian and African-American residents, narrowing the national vaccination racial gap.