XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

An important component of routine visual behavior is the ability to find one item in a visual world filled with other, distracting items. This ability to performvisual search has been the subject of a large body of research in the past 15 years. This paper reviews the visual search literature and presents a model of human search behavior. Built upon the work of Neisser, Treisman, Julesz, and others, the model distinguishes between a preattentive, massively parallel stage that processes information about basic visual features (color, motion, various depth cues, etc.) across large portions of the visual field and a subsequent limited-capacity stage that performs other, more complex operations (e.g., face recognition, reading, object identification) over a limited portion of the visual field. The spatial deployment of the limited-capacity process is under attentional control. The heart of the guided search model is the idea that attentional deployment of limited resources isguided by the output of the earlier parallel processes. Guided Search 2.0 (GS2) is a revision of the model in which virtually all aspects of the model have been made more explicit and/or revised in light of new data. The paper is organized into four parts: Part 1 presents the model and the details of its computer simulation. Part 2 reviews the visual search literature on preattentive processing of basic features and shows how the GS2 simulation reproduces those results. Part 3 reviews the literature on the attentional deployment of limited-capacity processes in conjunction and serial searches and shows how the simulation handles those conditions. Finally, Part 4 deals with shortcomings of the model and unresolved issues.

/pdf/guided-search-2-0-a-revised-model-of-visual-search-1qi4v6qhev.pdf

Guided Search 2.0 A revised model of visual search

25. Multiple Imputation for Nonresponse in Surveys. By D. B. Rubin. ISBN 0 471 08705 X. Wiley, Chichester, 1987. 258 pp. £30.25.

Multiple Imputation for Nonresponse in Surveys

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(07)61415-9.pdf

Depression, chronic diseases, and decrements in health: results from the World Health Surveys

/pdf/national-health-and-nutrition-examination-survey-528esivp83.pdf

National Health and Nutrition Examination Survey

CONTEXT: Motor vehicle crash risk in older drivers has been associated with visual acuity loss, but only weakly so, suggesting other factors contribute. The useful field of view is a measure that reflects decline in visual sensory function, slowed visual processing speed, and impaired visual attention skills. OBJECTIVE: To identify whether measures of visual processing ability, including the useful field of view test, are associated with crash involvement by older drivers. DESIGN: Prospective cohort study with 3 years of follow-up, 1990-1993. SETTING: Ophthalmology clinic assessment of community-based sample. PATIENTS: A total of 294 drivers aged 55 to 87 years at enrollment. MAIN OUTCOME MEASURE: Motor vehicle crash occurrence. RESULTS: Older drivers with a 40% or greater impairment in the useful field of view were 2.2 times (95% confidence interval, 1.2-4.1) more likely to incur a crash during 3 years of follow-up, after adjusting for age, sex, race, chronic medical conditions, mental status, and days driven per week. This association was primarily mediated by difficulty in dividing attention under brief target durations. CONCLUSION: Reduction in the useful field of view increases crash risk in older drivers. Given the relatively high prevalence of visual processing impairment among the elderly, visual dysfunction and eye disease deserve further examination as causes of motor vehicle crashes and injury.

https://jamanetwork.com/journals/jama/articlepdf/187414/JOC71299.pdf

Visual Processing Impairment and Risk of Motor Vehicle Crash Among Older Adults

PURPOSE. To identify visual factors that are significantly associated with increased vehicle crashes in older drivers. METHODS. Several aspects of vision and visual information processing were assessed in 294 drivers aged 55 to 90 years. The sample was stratified with respect to age and crash frequency during the 5-year period before the test date. Variables assessed included eye health status, visual sensory function, the size of the useful field of view, and cognitive status. Crash data were obtained from state records. RESULTS. The size of the useful field of view, a test of visual attention, had high sensitivity (89%) and specificity (81%) in predicting which older drivers had a history of crash problems. This level of predictability is unprecedented in research on crash risk in older drivers. Older adults with substantial shrinkage in the useful field of view were six times more likely to have incurred one or more crashes in the previous 5-year period. Eye health status, visual sensory function, cognitive status, and chronological age were significantly correlated with crashes, but were relatively poor at discriminating between crash-involved versus crash-free drivers. CONCLUSIONS. This study suggests that policies that restrict driving privileges based solely on age or on common stereotypes of age-related declines in vision and cognition are scientifically unfounded. With the identification of a visual attention measure highly predictive of crash problems in the elderly, this study points to a way in which the suitability of licensure in the older adult population could be based on objective, performance-based criteria. Keywords: Driver distraction;

Visual attention problems as a predictor of vehicle crashes in older drivers.

Contrast sensitivity throughout adulthood

Previous studies of spatial contrast sensitivity in adulthood have produced conflicting results. To clarify the situation, we measured contrast sensitivity functions on a large sample of adults (n = 91), ranging in age from 19 to 87. All observers were free from significant ocular pathology and were individually refracted for the test distance. Sensitivity for stationary gratings of low spatial frequency remained the same throughout adulthood. At higher spatial frequencies, sensitivity decreased with age beginning around 40 to 50 years. When a low spatial frequency grating was drifted, young adults' sensitivity improved by a factor of 4-5 over sensitivity to a static grating; this motion enhancement was markedly diminished in adults over 60 years, implying an impairment of temporal processing in the elderly. Reduced retinal illuminance characteristic of the aged eye could account for a large part of older adults' deficit in spatial vision, but appeared to play little role in their deficit in temporal vision.

Older drivers have more accidents per miles driven than any other age group and tend to have significant impairments in their visual function, which could interfere with driving. Previous research has largely failed to document a link between vision and driving in the elderly. We have taken a comprehensive approach by examining how accident frequency in older drivers relates to the visual/cognitive system at a number of levels: ophthalmological disease, visual function, visual attention, and cognitive function. The best predictor of accident frequency as recorded by the state was a model incorporating measures of early visual attention and mental status, which together accounted for 20% of the variance, a much stronger model than in earlier studies. Those older drivers with a visual attentional disorder or with poor scores on a mental status test had 3-4 times more accidents (of any type) and 15 times more intersection accidents than those without these problems.

Cynthia Owsley

Papers

Visual Processing Impairment and Risk of Motor Vehicle Crash Among Older Adults

Visual attention problems as a predictor of vehicle crashes in older drivers.

Contrast sensitivity throughout adulthood

Contrast sensitivity throughout adulthood

Visual/cognitive correlates of vehicle accidents in older drivers.