We present a new approach to population health, in which data-driven predictive models are learned for outcomes such as type 2 diabetes. Our approach enables risk assessment from readily available electronic claims data on large populations, without additional screening cost. Proposed model uncovers early and late-stage risk factors. Using administrative claims, pharmacy records, healthcare utilization, and laboratory results of 4.1 million individuals between 2005 and 2009, an initial set of 42,000 variables were derived that together describe the full health status and history of every individual. Machine learning was then used to methodically enhance predictive variable set and fit models predicting onset of type 2 diabetes in 2009-2011, 2010-2012, and 2011-2013. We compared the enhanced model with a parsimonious model consisting of known diabetes risk factors in a real-world environment, where missing values are common and prevalent. Furthermore, we analyzed novel and known risk factors emerging from the model at different age groups at different stages before the onset. Parsimonious model using 21 classic diabetes risk factors resulted in area under ROC curve (AUC) of 0.75 for diabetes prediction within a 2-year window following the baseline. The enhanced model increased the AUC to 0.80, with about 900 variables selected as predictive (p < 0.0001 for differences between AUCs). Similar improvements were observed for models predicting diabetes onset 1-3 years and 2-4 years after baseline. The enhanced model improved positive predictive value by at least 50% and identified novel surrogate risk factors for type 2 diabetes, such as chronic liver disease (odds ratio [OR] 3.71), high alanine aminotransferase (OR 2.26), esophageal reflux (OR 1.85), and history of acute bronchitis (OR 1.45). Liver risk factors emerge later in the process of diabetes development compared with obesity-related factors such as hypertension and high hemoglobin A1c. In conclusion, population-level risk prediction for type 2 diabetes using readily available administrative data is feasible and has better prediction performance than classical diabetes risk prediction algorithms on very large populations with missing data. The new model enables intervention allocation at national scale quickly and accurately and recovers potentially novel risk factors at different stages before the disease onset.

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Objective. To assess whether adoption of the patient-centered medical home (PCMH) reduces emergency department (ED) utilization among patients with and without chronic illness. Data Sources. Data from approximately 460,000 Independence Blue Cross patients enrolled in 280 primary care practices, all converting to PCMH status between 2008 and 2012. Research Design. We estimate the effect of a practice becoming PCMH-certified on ED visits and costs using a difference-in-differences approach which exploits variation in the timing of PCMH certification, employing either practice or patient fixed effects. We analyzed patients with and without chronic illness across six chronic illness categories. Principal Findings. Among chronically ill patients, transition to PCMH status was associated with 5-8 percent reductions in ED utilization. This finding was robust to a number of specifications, including analyzing avoidable and weekend ED visits alone. The largest reductions in ED visits are concentrated among chronic patients with diabetes and hypertension. Conclusions. Adoption of the PCMH model was associated with lower ED utilization for chronically ill patients, but not for those without chronic illness. The effectiveness of the PCMH model varies by chronic condition. Analysis of weekend and avoidable ED visits suggests that reductions in ED utilization stem from better management of chronic illness rather than expanding access to primary care clinics. Key Words. Patient-centered medical home, emergency department, chronic illnessThe patient-centered medical home (PCMH) model has shown early promise as a vehicle for reorganizing health care systems and improving the management of chronic illness. Studies of the medical home and related interventions have shown improvements in provider experience (Reid et al.

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Aim To investigate the association between visit‐to‐visit HbA1c variability and the risk of cardiovascular disease in patients with type 2 diabetes. Materials and methods We performed a retrospective cohort study of 29 260 patients with at least four HbA1c measurements obtained within 2 years of their first diagnosis of type 2 diabetes. Different HbA1c variability markers were calculated, including the standard deviation (SD), coefficient of variation (CV) and adjusted SD. Cox proportional hazards regression models were used to estimate the association of these HbA1c variability markers with incident cardiovascular disease. Results During a mean follow‐up of 4.18 years, a total of 3746 incident cardiovascular disease cases were diagnosed. Multivariate‐adjusted hazard ratios for cardiovascular disease across the first, second, third and fourth quartiles of HbA1c SD values were 1.00, 1.30 (95% confidence interval [CI] 1.18‐1.42), 1.40 (95% CI 1.26‐1.55) and 1.59 (95% CI 1.41‐1.77) (P for trend <.001), respectively. When we utilized HbA1c CV and adjusted HbA1c SD values as exposures, similar positive associations were observed. HbA1c variability was also associated with the risk of first and recurrent severe hypoglycaemic events. A mediating effect of severe hypoglycaemia was observed between HbA1c variability and incident cardiovascular disease. Conclusions Large visit‐to‐visit HbA1c variability is associated with an increased risk of cardiovascular disease in patients with type 2 diabetes. Severe hypoglycaemia may mediate the association between HbA1c variability and incident cardiovascular disease.

This study provides clinical evidence in support of less invasive approaches to hysterectomy. In addition to other documented benefits of such less invasive procedures, the lower incidence of SSIs and lower rates of associated complications and costs with these procedures than with open abdominal hysterectomy should be taken into account when weighing the risks and benefits of a surgical approach for patients whose condition warrants hysterectomy.

Background and Purpose-Very few studies have assessed the association of high-density lipoprotein (HDL) cholesterol with stroke risk among patients with type 2 diabetes. We aimed to investigate the association of HDL cholesterol with total and type-specific stroke risk in patients with type 2 diabetes. Methods-We performed a retrospective cohort study of 27,113 African Americans and 40,431 whites with type 2 diabetes. Cox proportional hazards regression models were used to estimate the association of different levels of HDL cholesterol with stroke risk. Results-During a mean follow-up period of 3.0 years, 8,496 patients developed stroke (8,048 ischemic and 448 hemorrhagic). Multivariable-adjusted hazard ratios across levels of HDL at baseline (<30 [reference group], 30-39.9, 40-49.9, 50-59.9, 60-69.9, 70-79.9, and ≥80 mg/dL) were 1.00, 0.86, 0.77, 0.71, 0.71, 0.77, and 0.69 (P trend <0.001) for total stroke, 1.00, 0.89, 0.82, 0.75, 0.78, 0.76, and 0.75 (P trend <0.001) for ischemic stroke, and 1.00, 0.89, 0.69, 0.66, 0.47, and 0.94 (P trend =0.021) for hemorrhagic stroke, respectively. When we used an updated mean value of HDL cholesterol, the inverse association of HDL cholesterol with stroke risk did not change. This