Tremendous strides have been made in the diagnosis and treatment of human immunodeficiency virus (HIV); perhaps now the largest barrier to controlling HIV is retaining those diagnosed in care. Data on out-of-care populations are needed to develop effective retention methods, yet obtaining these remains methodologically challenging due to inherent difficulties in sampling. The purpose of this study was to evaluate whether individuals identified by two sampling methods commonly used to approximate out-of-care populations were significantly different from a sample of newly identified out-of-care persons. We compared medical records of 345 out-of-care persons identified by a novel population-based health information exchange who had not received CD4 or viral load monitoring in >1 year with: medical records from a randomly selected, time-matched sample of 488 HIV-infected persons with at least one HIV care visit in the past 5 years, and interviews with 382 participants from a time-matched clinic-based convenience sample. Newly identified out-of-care persons were significantly different from both proxies with respect to demographic, clinical, and utilization characteristics, suggesting that samples of in-care proxy persons are inadequate to describe those not engaged in care. Novel approaches to sampling out-of care populations are urgently needed in order to better understand these populations and ways to improve retention and slow the HIV/AIDS epidemic.

Background: It is recognized that a history of gestational diabetes mellitus (GDM) predicts incident type 2 diabetes in women. However, it is unclear if there is a racial disparity between the association of GDM and type 2 diabetes.Methods: We studied 1,142 women with a history of GDM and 18,856 women without a history of GDM aged 13-50 years with their first record of pregnancy in Louisiana State University Hospital-Based Longitudinal Study database between 1990 and 2009. History of GDM was used to predict incident type 2 diabetes.Results: During a mean follow-up of 8.6 years, 1,394 women developed type 2 diabetes. The multivariable adjusted hazard ratio (HR) of type 2 diabetes was 6.52 (95% confidence interval [CI] 5.73-7.43) among women with GDM compared to women without GDM. Stratification by age, race, and body mass index (BMI) gave similar results. Compared with African American and white women without a history of GDM, the relative risk for type 2 diabetes was higher in African American women than in white women with a history of GDM. Compared with non-GDM women compartments, GDM women after delivery for <1, 1.0-3.9, 4.0-5.9, 6.0-7.9, 8-9.9, and >= 10.0 years had 4.00, 5.44, 4.26, 3.16, 4.49, and 4.17 times higher risk of having type 2 diabetes, respectively.Conclusions: A history of GDM is a strong predictor of subsequent type 2 diabetes among Louisiana women, especially among African American women.

BACKGROUND:The association between obesity and dementia risk remains debatable and no studies have assessed this association among diabetic patients. The aim of our study was to investigate the association between body mass index (BMI) and dementia risk among middle and low income diabetic patients. METHODOLOGY/PRINCIPAL FINDINGS:The sample included 44,660 diabetic patients (19,618 white and 25,042 African American) 30 to 96 years of age without a history of dementia in the Louisiana State University Hospital-Based Longitudinal Study. During a mean follow-up period of 3.9 years, 388 subjects developed incident dementia. The age- and sex-adjusted hazards ratios (HRs) for incident dementia at different levels of BMI (≤ 25, 25-26.9, 27-29.9, 30-34.9, and ≥ 35 kg/m(2)) were 1.00, 0.53 (95% CI 0.34-0.83), 0.29 (0.18-0.45), 0.37 (0.25-0.56), and 0.31 (0.21-0.48) (P(trend)<0.001) in white diabetic patients, and 1.00, 1.00 (95% CI 0.62-1.63), 0.62 (0.39-0.98), 0.56 (0.36-0.86), and 0.65 (0.43-1.01) (P(trend) = 0.029) in African American diabetic patients. Further adjustment for other confounding factors affected the results only slightly. There was a significant interaction between race and BMI on dementia risk (χ(2) = 5.52, 1df, p<0.025), such that the association was stronger in white patients. In stratified analyses, the multivariate-adjusted inverse association between BMI and risk of dementia was present in subjects aged 55-64 years, 65-74 years, and ≥ 75 years, in men and women, in non-smokers and smokers, and in subjects with different types of health insurance. CONCLUSIONS/SIGNIFICANCE:Higher baseline BMI was associated with a lower risk of dementia among diabetic patients, and this association was stronger among white than among African American diabetic patients.

Background: Although coronary heart disease (CHD), heart failure (HF), stroke, and end-stage renal disease (ESRD) are major microvascular and macrovascular complications of diabetes, they are less clear for diabetic subgroups especially on those with middle and low income. Aim: To investigate racial disparities in the incidence of diabetic complications in middle and low income adults. Methods: We performed a prospective cohort study (1985-2010) on diabetic patients enrolled in the LSU Hospital-Based Longitudinal Study. Study cohorts included 89,353 diabetic patients (16,326 White men, 21,496 White women, 19,422 African American men and 32,109 African American women) who were 30 to 96 years of age. We calculated the gender specific age-standardized incident rates using the direct method to the year 2010 Census population. Cox proportional hazard models were used to compare racial or gender specific hazard ratios for CHD, HF, stroke and ESRD after adjustment for age, race, type of health insurance, family income, body mass index, smoking, systolic blood pressure, LDL cholesterol, HDL cholesterol, HbA 1c , estimated GFR, albuminuria, and drug treatments for diabetes, hypertension and hyperlipidemia. Results: During an average 4.0 years of follow-up, 16,935 CHD, 13,421 HF, 6,804 stroke, and 13,281 ESRD incident cases were ascertained. The age-standardized incident rates of the four diabetic complications are presented in table 1 . Compared with White diabetic patients, African Americans experienced higher rates of ESRD and lower rates of CHD, HF, and stroke. Female diabetic patients had lower rates of the four complications than males. Results of the Cox proportional hazard models confirmed the racial disparity and gender difference we found in the age-standardized incident rates. Conclusions: The results support the existence of racial differences in the incidence of diabetic complications in this population. Table 1 Age-adjusted incident rates of type 2 diabetes complications in the LSUHLS study Age-standardized incident rates White African American Male Female Male Female Coronary Heart Disease 101.6 (98.8-104.5) 62.0 (60.4-63.7) 50.7 (49.2-52.2) 44.4 (43.4-45.5) Heart Failure 54.9 (52.9-56.8) 41.9 (40.6-43.1) 43.4 (42.0-44.8) 38.4 (37.4-39.3) Stroke 22.1 (20.9-23.3) 20.7 (19.8-21.6) 19.9 (19.0-20.8) 18.5 (17.8-19.1) End-stage Renal Disease 43.3 (41.6-45.0) 33.4 (32.2-34.5) 51.4 (50.0-52.9) 35.2 (34.3-36.1)

Background: Hypertension risk in local areas may vary from national estimates; however, the data on the prevalence of hypertension in some local areas are limited. We investigate the trend in the prevalence of hypertension in Louisiana from 2000 to 2009.Methods: We conducted a retrospective study among the subjects aged >= 20 years who received medical care from the Louisiana State University Health Care Services Division (LSUHCSD) hospital system during 2000-2009. Hypertensive cases were identified by using ICD-9 codes. The annual hypertension prevalence was calculated as the number of unique hypertensive individuals during the year divided by the number of unique individuals visiting the LSUHCSD hospital during the year.Results: The age-standardized prevalence of hypertension in LSUHCSD hospital patients aged >= 20 years increased by 49.4% during 2000-2009, from 24.1% in 2000 to 36.0% in 2009. The rise in age-standardized prevalence of hypertension from 2000 to 2009 occurred in both men (from 20.1% to 32.8%) and women (from 26.8 % to 38.3%), and in White (from 20.1% to 33.0%), African (from 27.4% to 37.6%) and other race Americans (from 14.9% to 22.3%). The age-standardized prevalence of hypertension was higher in women than in men, and higher in African Americans than in White and other race Americans.Conclusion: The annual prevalence of hypertension has dramatically increased from 2000 to 2009 in both men and women and in all races of the population served by the LSUHCSD hospitals. (C) 2012 European Federation of Internal Medicine. Published by Elsevier B. V. All rights reserved.

PURPOSE:The purpose of this study was to evaluate HIV-related outcomes associated with use of a novel public health information exchange that was designed to identify out of care HIV-infected individuals seen within a large, integrated delivery network (IDN). METHODS:A novel, secure, bidirectional health care delivery-public health information exchange, the Louisiana Public Health Information Exchange (LaPHIE) was developed between a multi-geographical IDN and the Louisiana public health authority in response to the high proportion of out of care HIV-infected persons. The system provides real-time provider alerts when any HIV-infected person who has not had CD4 or HIV viral load (VL) monitoring in >1 year receives non-HIV care within the IDN, allowing immediate linkage to HIV specialty care. Persons identified over the first 30 months of the system's implementation were characterized using a case-cohort approach to compare out-of-care individuals with randomly sampled, time-matched in-care controls. RESULTS:Between 2/1/09 and 7/31/11, 549 alerts identified 419 unduplicated HIV-infected individuals without a CD4 count or VL in >1 year. Patients were identified at 60 clinics and alerts shown to 223 clinicians in 7 participating facilities. A quarter (24%) of those identified had not had a CD4 count or VL conducted since their initial diagnosis. Of the remaining 76% who had been in care previously, over half (55%) had been out of care for ≥18 months, with a median time of 19.4 months [IQR 15.0-32.5] since their previous visit. Following LaPHIE identification, 42% had CD4 counts<200 cells/mm(3) and 62% had VL>10,000 RNA copies/mL. Of the 344 patients with at least 6 months of follow up, 85% had at least one CD4 and/or VL test after being identified. CONCLUSIONS:The results of this study demonstrate that an information exchange can effectively facilitate engagement, re-engagement, and retention of out-of care HIV-infected persons in HIV specialty care. Within two years, we were able to observe significant improvements in HIV-related utilization and disease progression indices. Future programs should consider adopting this innovative strategy to improve HIV care at both the individual and population levels.

CONTEXT:It is unclear whether there is a racial difference in the incidence of diabetic complications in underinsured populations.OBJECTIVE:The objective of the study was to investigate racial disparities in the incidence of diabetic complications within the Louisiana State University (LSU) Hospital System.DESIGN AND PARTICIPANTS:This study (1997-2009) was conducted on a diabetic cohort enrolled in the LSU Hospital-Based Longitudinal Study. The cohort included 16,808 non-Hispanic white men, 21,983 non-Hispanic white women, 20,621 African-American men, and 33,753 African-American women who were 30-96 yr of age and had a mean value of family income of $9641/yr at baseline.RESULTS:The study cohort had a mean follow-up of 4.4 years. The age- and sex-adjusted incidence rates and 95% confidence intervals of end-stage renal disease (ESRD), coronary heart disease (CHD), heart failure (HF), and stroke for white diabetic patients were 15.1 (14.3-15.8), 80.9 (78.9-82.9), 48.0 (46.6-49.4), and 21.4 (20.5-22.2) per 1000 person-years, respectively. Compared with white diabetic patients, African-American diabetic patients experienced higher incident rates of ESRD [17.3 (16.6-18.0)] and lower rates of CHD [47.5 (46.3-48.6)], HF [40.7 (39.6-41.8)], and stroke [19.1 (18.4-19.9)]. Female diabetic patients had lower rates of the four complications than male diabetic patients. Results of the Cox proportional hazard models confirmed sex and race disparity observed in the age-adjusted incidence rates.CONCLUSIONS:Despite equal access to care, diabetic African-Americans have a higher risk of ESRD than their white counterparts, whereas diabetic whites have higher risks of CHD, HF, and stroke than their African-American counterparts.

Louisiana is severely affected by HIV/AIDS, ranking fifth in AIDS rates in the USA. The Louisiana Public Health Information Exchange (LaPHIE) is a novel, secure bidirectional public health information exchange, linking statewide public health surveillance data with electronic medical record data. LaPHIE alerts medical providers when individuals with HIV/AIDS who have not received HIV care for > 12 months are seen at any ambulatory or inpatient facility in an integrated delivery network. Between 2/1/2009 and 1/31/2011, 488 alerts identified 345 HIV positive patients. Of those identified, 82% had at least one CD4 or HIV viral load test over the study follow-up period. LaPHIE is an innovative use of health information exchange based on surveillance data and real time clinical messaging, facilitating rapid provider notification of those in need of treatment. LaPHIE successfully reduces critical missed opportunities to intervene with individuals not in care, leveraging information historically collected solely for public health purposes, not health care delivery, to improve public health.

Objective: To examine the trends in the prevalence of diabetes in patients who received medical care from the Louisiana State University Health Care Services Division (LSUHCSD) hospital system between 2000 and 2009.Methods: The study population included 969,609 unique outpatients and inpatients between 2000 and 2009. The diabetes cases were identified by using ICD-9 code (250*). The annual diabetes prevalence was calculated as the number of unique individuals with an ICD-9 diabetes during the year divided by the number of unique individuals visiting the LSUHCSD hospitals during the year.Results: The age-standardized prevalence of diabetes in LSUHCSC hospital patients aged >= 20 years increased by 36.2% during 2000-2009, from 10.5% to 14.3%. The rise in age-standardized prevalence of diabetes from 2000 to 2009 occurred in men (from 8.9% to 13.3%) and women (from 11.5% to 15.0%), and in white (from 8.9% to 13.1%), African (from 11.7% to 15.8%) and other race Americans (from 8.2% to 10.4%). The age-standardized prevalence of diabetes was higher in women than in men (p < 0.001).Conclusion: The annual prevalence of diabetes has dramatically increased from 2000 to 2009 in both men and women and in all races of the population served by the LSUHCSD hospitals. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

BACKGROUND:Gestational diabetes mellitus (GDM) is one of the most common pregnancy complications. Although long-term trends are available at the national level, they are less clear for population subgroups, especially those with middle or low income and also at high risk of obesity.METHOD:We conducted a retrospective study among women aged 15-50 years with live deliveries between January 1, 1997, and December 31, 2009, at the Louisiana State University Health Care Services Division hospital system. Pregnancies and GDM cases were identified by using ICD-9 code from the Louisiana State University Hospital-Based Longitudinal Study database. The annual incidence of GDM and its standard error (SE) were calculated and stratified by age group and race.RESULTS:A total of 2751 GDM incident cases were identified among 62,685 pregnancies between 1997 and 2009. The crude incidence of GDM increased from 4.1% in 1997 to 4.4% in 2009 (increased by 7.3%), and the age-standardized incidence of GDM increased from 5.8% to 7.5% (increased by 29.3%). The incidence of GDM increased with age and reached a peak at 35-39 years of age and then declined in women who were 40-50 years old. Among the three studied races, Asians had significantly higher incidence of GDM than whites and African Americans.CONCLUSIONS:The incidence of GDM increased in most years from 1997 to 2009 and reached a peak in 2002 in the women served by Louisiana State University Health Care Services Division hospitals. GDM has become an important public health problem, particularly among women aged 35-39 years.