Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes

Spanish-language community-based mental health treatment programs, policy-required language-assistance programming, and mental health treatment access among Spanish-speaking clients

OBJECTIVES

We investigated the extent to which implementing language assistance programming through contracting with community-based organizations improved the accessibility of mental health care under Medi-Cal (California's Medicaid program) for Spanish-speaking persons with limited English proficiency, and whether it reduced language-based treatment access disparities.

METHODS

Using a time series nonequivalent control group design, we studied county-level penetration of language assistance programming over 10 years (1997-2006) for Spanish-speaking persons with limited English proficiency covered under Medi-Cal. We used linear regression with county fixed effects to control for ongoing trends and other influences.

RESULTS

When county mental health plans contracted with community-based organizations, those implementing language assistance programming increased penetration rates of Spanish-language mental health services under Medi-Cal more than other plans (0.28 percentage points, a 25% increase on average; P < .05). However, the increase was insufficient to significantly reduce language-related disparities.

CONCLUSIONS

Mental health treatment programs operated by community-based organizations may have moderately improved access after implementing required language assistance programming, but the programming did not reduce entrenched disparities in the accessibility of mental health services.

Factors influencing self-management in patients with type 2 diabetes: a quantitative systematic review protocol

AIM

To describe a protocol for a quantitative systematic review, to identify critique and summarize factors that influence self-management education.

BACKGROUND

Self-management education enables patients to manage their condition successfully and it is associated with better self-care, good control over lifestyle and leading the best possible quality of life, notwithstanding the presence of a chronic disease. Type II Diabetes is a chronic disease that requires lifestyle adjustments and disease management to keep glycaemia and long-term complications under control. Education has to be customized and based on an assessment that includes factors influencing self-management, such as personal characteristics that can optimize the educational intervention.

DESIGN

The protocol for the systematic review was conducted according to the guidelines of the Centre for Reviews and Dissemination, York (UK).

METHOD

The review question was defined in terms of population, interventions, comparators, outcomes and study designs. The protocol included decisions about the review question, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis and plans for dissemination. Funding for the review was confirmed on January 2011 by the Centre of Excellence for Nursing Scholarship in Rome.

DISCUSSION

An initial summary will be made by tabulating the data; the review will be reported in a narrative style and be developed according to the PRISMA guidelines. The protocol for the systematic review will allow us to identify, among the factors influencing self-management in people with Type II diabetes, the personal characteristics most relevant to the factors of motivation and empowerment. In addition, the systematic review will also identify an appropriate self-management model.

Effect of culturally tailored diabetes education in ethnic minorities with type 2 diabetes: a meta-analysis

BACKGROUND

Diabetes is a major cause of cardiovascular morbidity and mortality. Ethnic minorities experience a disproportionate burden of diabetes; however, few studies have critically analyzed the effectiveness of a culturally tailored diabetes intervention for these minorities.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a culturally tailored diabetes educational intervention (CTDEI) on glycemic control in ethnic minorities with type 2 diabetes.

METHOD

We searched databases within PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), PsycINFO, and ProQuest for randomized controlled trials (RCTs). We performed a meta-analysis for the effect of diabetes educational intervention on glycemic control using glycosylated hemoglobin (HbA(1c)) value in ethnic minority groups with type 2 diabetes. We calculated the effect size (ES) with HbA(1c) change from baseline to follow-up between control and treatment groups.

RESULTS

The 12 studies yielded 1495 participants with a mean age of 63.6 years and a mean of 68% female participants. Most studies (84%) used either group education sessions or a combination of group sessions and individual patient counseling. The duration of interventions ranged from 1 session to 12 months. The pooled ES of glycemic control in RCTs with CTDEI was -0.29 (95% confidence interval, -0.46 to -0.13) at last follow-up, indicating that ethnic minorities benefit more from CTDEI when compared with the usual care. The effect of intervention was greatest and significant when HbA(1c) level was measured at 6 months (ES, -0.41; 95% confidence interval, -0.61 to -0.21). The ES also differed by each participant's baseline HbA1c level, with lower baseline levels associated with higher ESs.

CONCLUSIONS

Based on this meta-analysis, CTDEI is effective for improving glycemic control among ethnic minorities. The magnitude of effect varies based on the settings of intervention, baseline HbA1c level, and time of HbA1c measurement. More rigorous RCTs that examine tailored diabetes education, ethnically matched educators, and more diverse ethnic minority groups are needed to reduce health disparities in diabetes care.

Alcohol use of diabetes patients: the need for assessment and intervention

It is well known that diabetes self-care behaviors are critical to disease progression. Unfortunately, many patients do not adhere to diabetes self-care recommendations despite their importance. Alcohol use has been identified as a barrier to diabetes self-care adherence. Excessive alcohol consumption not only negatively impacts diabetes self-care adherence but also affects the course of diabetes. Diabetes patients who are at-risk drinkers are likely to have poor diabetes treatment adherence, leading to increased morbidity and mortality. Alcohol consumption by diabetes patients is often inadequately assessed and addressed in their medical care. Brief interventions to reduce at-risk drinking have been well validated in a variety of patient populations and offer the potential to improve diabetes treatment adherence and outcome. Assessment and treatment of at-risk drinking could be readily incorporated into routine diabetes care. Strategies for brief assessment of and intervention for at-risk drinking are offered.

Future Perspectives in Glucose Monitoring Sensors

The prevalence of diabetes is increasing. improved glucose control is fundamental to reduce both long-term micro- and macrovascular complications and short-term complications, such as diabetic ketoacidosis and severe hypoglycemia. Frequent blood glucose monitoring is an essential part of diabetes management. However, almost all available blood glucose monitoring devices are invasive. This determines a reduced patient compliance, which in turn reflects negatively on glucose control. Therefore, there is a need to develop noninvasive glucose monitoring devices that will reduce the need of invasive procedures, thus increasing patient compliance and consequently improving quality of life and health of patients with diabetes.

Acculturation, Dietary Acceptability, and Diabetes Management among Chinese in North America

Immigrants to a new country face many challenges when diagnosed with type 2 diabetes, a chronic disease with a complex treatment involving both medical and behavioral interventions. These challenges will depend upon the extent to which the patient has adapted to the new country's social and cultural norms, as well as individual factors such as age, education, and gender. This adaptation is termed acculturation. With respect to nutritional interventions for type 2 diabetes, uptake and adherence over the long term will depend upon overall health literacy, the cultural acceptability of the recommended diet. This review has focused on acculturation and its effects on diabetes management in ethnic Chinese in North America as an example of one populous minority and the challenges faced in adopting nutritional recommendations. Research directions and practical considerations are suggested.

Determinants and consequences of insulin initiation for type 2 diabetes in France: analysis of the National Health and Wellness Survey

BACKGROUND

The aim of the study was to identify the intrinsic patient characteristics and extrinsic environmental factors predicting prescription and use and, more specifically, early initiation (up to 5 years of disease duration) of insulin for type 2 diabetes in France. A secondary objective was to evaluate the impact of insulin therapy on mental and physical quality of life and patient adherence.

METHODS

The data used in this study were derived from the 2008, 2010, and 2011 France National Health and Wellness Survey. This survey is an annual, cross-sectional, self-administered, Internet-based questionnaire among a nationwide representative sample of adults (aged 18 years or older). Of the total of 45,958 persons recruited in France, 1,933 respondents (deduped) were identified as diagnosed with type 2 diabetes. All unique respondents from the three waves, currently using insulin or oral bitherapy or tritherapy at the time of assessment, were included in this analysis.

RESULTS

Early (versus late) initiation of insulin therapy was 9.9 times more likely to be prescribed by an endocrinologist or diabetologist than by a primary care physician (P < 0.0001). Younger age at diagnosis and current smoking habits were significant predictors of early (versus late) insulin initiation (odds ratio [OR] 1.031, 95% confidence interval [CI] 1.005-1.059, P = 0.0196, and OR 2.537, 95% CI 1.165-5.524, P = 0.0191, respectively). Patients with a yearly income ≥€50,000 were less likely to be put on insulin early (P = 0.0399). A link between insulin prescription and complications was shown only in univariate analysis. Mental quality of life was lower in patients on early (versus late) insulin, but only in patients with diabetes-related complications. Insulin users (versus oral bitherapy or tritherapy users) had 3.0 times greater odds of being adherent than uncontrolled oral bitherapy or tritherapy users (OR 2.983, 95% CI 1.37-6.495, P = 0.0059).

CONCLUSION

This study confirms the role of specialists in early initiation of insulin, and the data presented herein reflect the fact that early initiation is more frequent in younger patients, patients with diabetes-related complications, and current smokers, and less frequent in patients with a higher income. Moreover, we observed that being treated with insulin was not associated with deterioration in quality of life, and insulin-treated patients were more often adherent than uncontrolled oral bitherapy or tritherapy users. These data suggest that doctors' concerns about patient adherence and detrimental effects on quality of life should not be a barrier to their decision regarding early initiation of insulin therapy. Due to the nature of this cross-sectional survey (eg, inability to assess treatment flow), further research is needed to confirm its findings.

"Symptom-based insulin adjustment for glucose normalization" (SIGN) algorithm: a pilot study

BACKGROUND

Lack of self-monitoring of blood glucose (SMBG) records in actual practice settings continues to create therapeutic challenges for clinicians, especially in adjusting insulin therapy. In order to overcome this clinical obstacle, a "Symptom-based Insulin adjustment for Glucose Normalization" (SIGN) algorithm was developed to guide clinicians in caring for patients with uncontrolled type 2 diabetes who have few to no SMBG records. This study examined the clinical outcome and safety of the SIGN algorithm.

SUBJECTS AND METHODS

Glycated hemoglobin (HbA1c), insulin usage, and insulin-related adverse effects of a total of 114 patients with uncontrolled type 2 diabetes who refused to use SMBG or performed SMBG once a day for less than three times per week were studied 3 months prior to the implementation of the algorithm and prospectively at every 3-month interval for a total of 6 months after the algorithm implementation. Patients with type 1 diabetes, nonadherence to diabetes medications, or who were not on insulin therapy at any time during the study period were excluded from this study.

RESULTS

Mean HbA1c improved by 0.29% at 3 months (P = 0.015) and 0.41% at 6 months (P = 0.006) after algorithm implementation. A slight increase in HbA1c was observed when the algorithm was not implemented. There were no major hypoglycemic episodes. The number of minor hypoglycemic episodes was minimal with the majority of the cases due to irregular meal habits.

CONCLUSIONS

The SIGN algorithm appeared to offer a viable and safe approach when managing uncontrolled patients with type 2 diabetes who have few to no SMBG records.

Two character traits associated with adherence to long term therapies

Adherence is defined as the adequacy between the behaviours of patients and their medical prescriptions. Adherence is a general behaviour, which can explain why patients in the placebo arm of randomised clinical trials have a lower mortality rate when they are adherent. We propose that this behaviour is related to two character traits: patience (capacity to give priority to the future) and, more provocatively, obedience. To support this claim, we bring arguments from the literature and from two published personal studies. We previously showed that type 2 diabetic patients who respond as non-adherers to a questionnaire on adherence to medication and to whom one proposes a fictitious monetary choice between receiving 500 euros today or waiting one year to receive 1500 euros never make the remote choice. We also showed that obese diabetic patients who declare that they do not fasten their seat belt when they are seated in the rear of a car are more often non-adherent concerning medication than those patients who claim that they follow this road safety recommendation. Thus, one of the roles of empowerment and patient education could be to encourage the patients, if they wish it, to replace passive adherence behaviours with conscious active choices.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Efficacy and safety of biphasic insulin aspart 70/30 in type 2 diabetes patients of different race or ethnicity (INITIATEplus trial)

OBJECTIVE

To determine if self-titration using biphasic insulin aspart 70/30 (BIAsp 30) had a different impact on efficacy and safety across different racial/ethnic subgroups.

RESEARCH DESIGN/METHODS

This was an exploratory, post hoc analysis by race (White vs. Black/African-American) and ethnicity (Hispanic/Latino vs. non-Hispanic/Latino) of data from the INITIATEplus trial. Participants were treated twice-daily with BIAsp 30 over 24 weeks.

TRIAL REGISTRATION

NCT00101751.

MAIN OUTCOME MEASURES

Efficacy endpoints included reductions in mean glycated hemoglobin (A1C) and fasting plasma glucose (FPG). Safety endpoints included hypoglycemia rates (events/patient-year) and adverse events. Body weight changes were also measured.

RESULTS

Glycemic control improved by a similar extent for all demographic groups. Observed mean decreases in A1C ranged from 2.4% to 2.6% after 24 weeks' treatment. Baseline-adjusted mean A1C decreases for White vs. Black/African-American subjects were 2.56% and 2.13% (p < 0.0001), and for Hispanic/Latino vs. non-Hispanic/Latino subjects were 2.45% and 2.42% (p = 0.677), respectively. Final FPG values were similar among all groups (141-146 mg/dL [7.83-8.10 m mol/L]), and baseline-adjusted FPG decreases were not significantly different (p > 0.025) between groups. Hypoglycemia was low for White, Black/African-American, Hispanic/Latino, and non-Hispanic/Latino subjects (0.08, 0.04, 0.03, and 0.07 major events/patient-year, with 0.60, 0.30, 0.37, and 0.52 minor events/patient-year, respectively). Body weight increases were 3.17 and 3.06 kg (White vs. African-American) and 2.69 and 3.19 kg (Hispanic/Latino vs. non-Hispanic/Latino). Final weight-adjusted total daily insulin doses were 0.60 U/kg for Black/African-American subjects vs. 0.78 U/kg for White subjects (p < 0.0001), and 0.71 U/kg for Hispanic/Latino subjects vs. 0.74 U/kg for non-Hispanic/Latino subjects (p = 0.42).

LIMITATIONS

The trial was not designed or powered for comparisons across racial or ethnic groups, subjects were not stratified for pre-baseline medication regimens between each race and ethnic group, and unequal subject numbers and baseline A1C disparities existed between the pairs of groups being compared.

CONCLUSIONS

Diabetes self-management with BIAsp 30 using an easily followed self-titration algorithm produced low hypoglycemia rates. All subgroups achieved A1C reductions >2.1% and FPG declines >82 mg/dL that were similar across groups, demonstrating that self-titration of BIAsp 30 can successfully be pursued in a primary care setting by patients who had previously failed to meet ADA A1C targets under oral antidiabetes therapy, with race or ethnicity not an obstacle to achieving better glycemic control.

A study of national physician organizations' efforts to reduce racial and ethnic health disparities in the United States

PURPOSE

To characterize national physician organizations' efforts to reduce health disparities and identify organizational characteristics associated with such efforts.

METHOD

This cross-sectional study was conducted between September 2009 and June 2010. The authors used two-sample t tests and chi-square tests to compare the proportion of organizations with disparity-reducing activities between different organizational types (e.g., primary care versus subspecialty organizations, small [<1,000 members] versus large [>5,000 members]). Inclusion criteria required physician organizations to be (1) focused on physicians, (2) national in scope, and (3) membership based.

RESULTS

The number of activities per organization ranged from 0 to 22. Approximately half (53%) of organizations had 0 or 1 disparity-reducing activities. Organizational characteristics associated with having at least 1 disparity-reducing effort included membership size (88% of large groups versus 58% of small groups had at least 1 activity; P = .004) and the presence of a health disparities committee (95% versus 59%; P < .001). Primary care (versus subspecialty) organizations and racial/ethnic minority physician organizations were more likely to have disparity-reducing efforts, although findings were not statistically significant. Common themes addressed by activities were health care access, health care disparities, workforce diversity, and language barriers. Common strategies included education of physicians/trainees and patients/general public, position statements, and advocacy.

CONCLUSIONS

Despite the national priority to eliminate health disparities, more than half of national physician organizations are doing little to address this problem. Primary care and minority physician organizations, and those with disparities committees, may provide leadership to extend the scope of disparity-reduction efforts.

Mobile phone-based video messages for diabetes self-care support

BACKGROUND

This study examined whether mobile phone-based, one-way video messages about diabetes self-care improve hemoglobin A1c (A1C) and self-monitoring of blood glucose (SMBG).

METHODS

This was a 1-year prospective randomized trial with two groups. The active intervention lasted 6 months. The study enrolled 65 people with A1C >8.0% who were established (>6 months) patients in the endocrinology clinics of the Walter Reed Health Care System. Participants were randomized to receive "usual care" or self-care video messages from their diabetes nurse practitioner. Video messages were sent daily to cell phones of study participants. Hemoglobin A1c and SMBG data were collected at 0, 3, 6, 9, and 12 months.

RESULTS

Participants who received the messages had a larger rate of decline in A1C than people who received usual care (0.2% difference over 12 months, adjusting for covariates; p = .002 and p = .004 for the interaction between time and group and for the quadratic effect of time by group, respectively). Hemoglobin A1c decline was greatest among participants who received video messages and viewed >10 a month (0.6% difference over 12 months, adjusting for covariates; p < .001 for the interaction between time and group and the quadratic effect). Self-monitoring of blood glucose metrics were not related to the intervention.

CONCLUSIONS

A one-way intervention using mobile phone-based video messages about diabetes self-care can improve A1C. Engagement with the technology is an important predictor of its success. This intervention is simple to implement and sustain.

Assessment of metabolic control among patients in a capillary glucose self-monitoring program

OBJECTIVE: To assess the metabolic control of diabetes mellitus patients registered in a capillary glucose self-monitoring program at home. METHODS: In this longitudinal retrospective study, 97 subjects at four health institutions in a Brazilian city were followed during 37 months between 2005 and 2008. The health files were analyzed of patients selected to register the evolution of variables related to capillary glucose self-monitoring at home and metabolic control of diabetes mellitus. RESULTS: During the assessment, both mean and monthly percentages of capillary blood glucose measurements at home decreased from 34.1 (65.1%) to 33.6 (64.8%), respectively (p <0.001). Mean HbA1c levels dropped from 9.20% to 7.94% (p<0.001). HDL cholesterol decreased from 51 mg/dl to 47 mg/dl (p=0.001). CONCLUSION: Patients' metabolic control improved, characterized by a significant reduction in HbA1C.

Closing the gap: eliminating health care disparities among Latinos with diabetes using health information technology tools and patient navigators

Latinos have higher rates of diabetes and diabetes-related complications compared to non-Latinos. Clinical diabetes self-management tools that rely on innovative health information technology (HIT) may not be widely used by Latinos, particularly those that have low literacy or numeracy, low income, and/or limited English proficiency. Prior work has shown that tailored diabetes self-management educational interventions are feasible and effective in improving diabetes knowledge and physiological measures among Latinos, especially those interventions that utilize tailored coaching and navigator programs. In this article, we discuss the role of HIT for diabetes management in Latinos and describe a novel "eNavigator" role that we are developing to increase HIT adoption and thereby reduce health care disparities.

Factors affecting the likelihood of presentation to the emergency department of trauma patients after discharge

STUDY OBJECTIVE

We determine the rate at which trauma patients re-present to the emergency department (ED) after discharge from the hospital and determine whether re-presentation is related to race, insurance, and socioeconomic factors such as neighborhood income level.

METHODS

Trauma patients admitted to a Level I trauma center between January 1, 1997, and December 31, 2007, were identified with the hospital's trauma registry. These patients were linked to administrative data to obtain information about re-presentation to the hospital. Neighborhood income was obtained with census block data; multiple imputation was implemented to account for missing income data. Logistic regression analysis was used to determine the predictors of re-presentation.

RESULTS

There were 6,675 patients who were included in the study. A total of 886 patients (13.3%) returned to the ED within 30 days of discharge from the hospital. Uninsured patients (odds ratio [OR]=1.64; 95% confidence interval [CI] 1.30 to 2.06) and publicly insured patients (OR=1.60; 95% CI 1.20 to 2.14) were more likely to re-present to the ED than those with commercial insurance. Residing in a neighborhood with a median household income less than $20,000 was associated with a higher odds of re-presentation (OR=1.77; 95% CI 1.37 to 2.29). Only 13.2% of patients who came to the ED were readmitted to the hospital.

CONCLUSION

A substantial number of trauma patients return to the ED within 30 days of being discharged, but only a small proportion of these patients required readmission. Re-presentation is associated with being uninsured or underinsured and with lower neighborhood income level.

Disparities in patient-physician communication for persons with a disability from the 2006 Medical Expenditure Panel Survey (MEPS)

BACKGROUND

Ineffective patient-physician communication has been shown to result in poorer health outcomes for various vulnerable populations. However, little research has been done on patient-physician communication issues as perceived by persons with disabilities. The purposes of this study are to determine if there is a relationship between disability and patient-physician communication and how disability affects the likelihood of effective patient-physician communication. The research questions for this study are: (1) Is there a significant difference in patient-physician communication for persons with disabilities compared to persons without disabilities? (2) Does having a disability influence the likelihood of ineffective patient-physician communication?

METHODS

Data were obtained from the 2006 Medical Expenditure Panel Survey (MEPS). Chi-square analyses were performed to determine if there a significant difference in patient-physician communication for persons with disabilities compared with persons without disabilities. A series of logistic regression analyses were conducted examining the likelihood of ineffective patient-physician communication with the independent variable of disability status.

RESULTS

Those with a disability are significantly more likely than persons without a disability to perceive that the physician does not listen to them, does not explain treatment so that they understand, does not treat them with respect, does not spend enough time with them, and does not involve them in treatment decisions. Regression analyses further revealed that persons with a disability are from 1.36 to 1.78 times as likely to perceive inadequate patient-physician communication.

CONCLUSIONS

This study revealed that persons with disabilities are at increased risk of experiencing ineffective patient-physician communication, compromising current health status and increasing the possibility of secondary health conditions. Several suggestions were made with regard to incorporation of "disability literacy" mechanisms such as physician training, health facility environmental assessment, and use of technologies such as telehealth and e-health. Further research in partnership with the disability community is needed to determine the effectiveness of these methods in improving patient-physician communication.

Do physicians with self-reported non-English fluency practice in linguistically disadvantaged communities?

BACKGROUND

Language concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP.

OBJECTIVE

To investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP.

DESIGN

Cross-sectional cohort study.

PARTICIPANTS

A total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001-2007.

MEASURES

Self-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households.

METHODS

Practice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status.

RESULTS

Physicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63-1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43-1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency.

CONCLUSIONS

Physicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.

An overview of management issues in adult patients with type 2 diabetes mellitus

Despite some progress in reducing the rate of diabetic complications, the epidemic rise in incidence of diabetes mellitus ensures that there will be an increasing number of patients in the coming decades with complex health care management issues who will need efficient and effective care. The management of patients with diabetes is an ever-challenging endeavor attributable to several factors. These include, among others, (1) limited provider expertise, (2) decreasing time of a patient visit, (3) increasing complexity of drug management, (4) limited use of self-monitoring of blood glucose by patients and/or providers, (5) clinical inertia, and (6) nonadherence. Technology-driven innovative solutions, including those using virtual reality, are desperately needed to assist both patients and their providers in overcoming the exigencies of this protean disease.

Understanding Self-Monitoring of Blood Glucose Among Individuals With Type 1 and Type 2 Diabetes

Purpose

To evaluate self-monitoring of blood glucose (SMBG) information deficits, motivational obstacles, and behavioral skills limitations in individuals with type 1 and type 2 diabetes, and to assess the relationship of these deficits with SMBG frequency.

Methods

Individuals with type 1 (n = 208; 103 male, 105 female) and type 2 (n = 218; 107 male, 111 female) diabetes participated in an online survey assessing SMBG information, motivation, behavioral skills, and behavior.

Results

A substantial proportion of participants scored as SMBG uninformed, unmotivated, and unskilled on specific assessment items. SMBG information, motivation, and behavioral skills deficits were significantly correlated with SMBG frequency, such that individuals with type 1 or type 2 diabetes, who were less informed, less motivated, and less behaviorally skilled, reported lower frequency of SMBG.

Conclusion

Common and consequential SMBG information, motivation, and behavioral skills deficits were present, and patients with these gaps were less likely to test frequently. Clinical education focusing on relevant SMBG information, motivation to act, and behavioral skills for acting effectively may be a priority.

Risk of acute complications of diabetes among people with schizophrenia in Ontario, Canada

OBJECTIVE

Diabetes mellitus (DM) is a complex, chronic disease requiring active self-management and coordinated care. This study aimed to evaluate the relationship between schizophrenia and risk of preventable, acute DM complications.

RESEARCH DESIGN AND METHODS

With the use of administrative data, a retrospective study assessed acute DM complications (emergency department [ED] visits or hospitalization for hypo- or hyperglycemia and hospital admissions for infections) among Ontario residents ages 18-50 with schizophrenia and newly diagnosed DM between 1995 and 2005, comparing people with and without pre-existing schizophrenia. Primary outcome was ED visit or hospitalization for hypo- or hyperglycemia. Secondary outcome was the first of either the primary outcome or hospitalization for infection.

RESULTS

People with schizophrenia had a 74% greater risk of requiring a hospital visit for hypo- or hyperglycemia (hazard ratio [HR] = 1.74, 95% confidence interval 1.42-2.12) compared with those without schizophrenia. The risk was similar when the outcome included infection (HR = 1.62, 95% CI 1.39-1.89). Outcomes remained significant after adjustment for baseline characteristics.

CONCLUSIONS

People with schizophrenia are at greater risk for developing an acute complication of DM. Understanding this relationship will direct future studies assessing barriers to care and implementation of individualized approaches to care for this population.

Barriers to and facilitators of self-management adherence in Korean older adults with type 2 diabetes

AIM

The aim of this study was to identify the barriers to and facilitators of self-management adherence in Korean older adults with type 2 diabetes.

DESIGN AND METHODS

Qualitative data collected from 24 participants in three focus groups who had previously taken part in a diabetes self-management education programme in a community setting were analyzed using an interpretive method.

RESULTS

The barriers to adherence to self-management included ageing-related physical and psychological changes, restrictions related to specific cultural factors, lack of self-discipline and poor understanding of self-management. Facilitators of self-management were knowing the benefits of and having a system to reinforce self-management, being the master of oneself by reshaping historical life habits and family support. The perceived barriers and facilitators differed with gender as a result of the characteristics of Korean culture.

CONCLUSIONS

This study identified the major barriers to and facilitators of self-management adherence specific to Korean older adults with diabetes, which can be used to develop better diabetes self-management education programmes for this population.

RELEVANCE TO CLINICAL PRACTICE

Korean nurses working with Korean older adults with diabetes can utilize the findings of this study to structure better tailored and culturally appropriate self-management programmes specific to older adults.

Use of communication technologies to cost-effectively increase the availability of interpretation services in healthcare settings

Poor patient-provider communication due to limited English proficiency (LEP) costs healthcare providers and payers through lower patient use of preventive care, misdiagnosis, increased testing, poor patient compliance, and increased hospital and emergency room admissions. Scarcity of bilingual healthcare professionals and prohibitive interpretation costs hinder full implementation of language service despite federal and state laws requiring their provision. We review recent published literature and unpublished data documenting the use of telephonic and video interpretation methodologies to improve healthcare communication with LEP persons. For example, a cooperative of nine California public hospitals and their associated community clinics, psychiatric facilities, skilled nursing facilities, and public health departments have implemented shared video interpretation services with video/voice-over Internet Protocol call center technology that automatically routes requests for interpretation in 15 languages to a pool of 30 full-time interpreters and 4 trained bilingual staff. For organizations seeking to initiate or expand their language services, the Internet provides access to translated documents, promising practices, step-by-step guides, planning tools, and research briefs. Such recent technological advances make provision of language services-to respond to federal and state mandates and improve access and quality of care to LEP persons-more feasible than is widely believed. Increased government and foundation support, and collaboration among provider organizations themselves can catalyze these efforts.

Self management and patient understanding of diabetes in the older person

AIM

To examine knowledge and management of diabetes by older people.

METHODS

A representative sample of 1047 people with Type 2 diabetes, aged 75 years and over, were asked a series of questions relating to their diabetes management and their understanding of self management. The impact of cognitive impairment and socio-economic status were assessed.

RESULTS

The majority of people, 1015 (96.9%), were under the care of a health professional and 1018 (97.2%) were taking insulin, tablets, controlling their diet or a combination. Cognitive impairment (Mini-Mental State Examination ≤ 23) was found in 235 (22.5%) people. Recent eye, foot and dietician assessment was reported by 813 (77.7%), 836 (79.7%) and 326 (31.1%) people, respectively. A quarter overall and 70% of those taking insulin tested their blood glucose. In the insulin group, 78 (54.2%) reported hypoglycaemia and those with cognitive impairment gave more incorrect responses when asked about diabetes management. Socio-economic status made very little difference to any of these outcomes.

CONCLUSIONS

Most older people with diabetes, regardless of their socio-economic status, are under the care of a healthcare professional and use medication or diet to manage their disease. Large numbers also attend foot and eye examinations. However, over one fifth of older people with diabetes have cognitive impairment. Older people had a reasonable understanding of their diabetes management but this was worse in those people with cognitive impairment.

Perspectives and Experiences of Health Care Professionals and Patients with Diabetes regarding Self-Monitoring of Blood Glucose in Canada

Objective:

To explore the current perspectives and experiences of Canadian health care professionals and patients with diabetes regarding self-monitoring of blood glucose (SMBG).

Design:

Qualitative analysis of focus groups in Ottawa, Vancouver and Edmonton.

Methods:

Seventeen focus groups involving 59 health care professionals (19 pharmacists, 18 certified diabetes educators and 22 physicians) and 40 patients with type 1 or type 2 diabetes were held, using separate moderator's guides. Thematic analysis was used to analyze responses.

Results:

Health care professionals reported recommending SMBG to most patients with diabetes, regardless of insulin use. They also reported periodically reviewing glucometer results, providing education on interpreting the results and proper use of SMBG devices. The majority of patients with diabetes indicated that they regularly monitored their blood glucose levels and recorded their results. Advantages of SMBG cited by health care professionals included a sense of control over diabetes, the ability to make lifestyle and treatment choices and increased patient confidence. Patients listed expense, discomfort and inconvenience as disadvantages to SMBG. Although patients discussed SMBG readings with their health care professionals, many reported that treating physicians were often uninterested in SMBG results. Physicians tended to refer to SMBG in the context of disease-specific benefits, while certified diabetes educators more often cited the psychological and educational benefits of SMBG. Compared with physicians, pharmacists focused more on the lifestyle and educational benefits of SMBG rather than on changes to medications.

Conclusion:

SMBG is commonly recommended by health care professionals and regularly performed by most patients with diabetes. Pharmacists and other health care professionals play an important role in educating patients on the appropriate use of SMBG and interpretation of results. To ensure optimal use, pharmacists and other health care providers should review the desired outcomes of SMBG with patients on a regular basis.

Is there an impatience genotype leading to non-adherence to long-term therapies?

In chronic diseases such as diabetes, adherence to therapy aims to preserve health, which is a long-term objective, whereas non-adherence tends to present an immediate 'reward'. We propose that non-adherence, like addiction, is at least in part due to the fact that, for physiological, and maybe genetic reasons described in a new field, neuroeconomics, a number of people have a taste for the present rather than the future. Thus, for 'impatient patients' it is natural not to adhere to therapeutic prescriptions that share the characteristic of being future-oriented. This hypothesis may apply to any disease requiring long-term therapy.

Pascal's wager: combining continuous glucose monitoring and continuous subcutaneous insulin infusion

Pascal's Wager is a suggestion posed by the French Philosopher, Blaise Pascal, that even though the existence of God cannot be determined through reason, a person should wager that God exists because he or she has everything to gain and nothing to lose. In the area of consideration here, the optimum experimental trial of the combined use of continuous subcutaneous insulin infusion and real-time continuous glucose monitoring in free-living individuals with type 1 diabetes providing rock-solid evidence of clinical benefit has not been performed. Nevertheless, there is considerable enthusiasm for combining the technologies among healthcare professionals, patients, and manufacturers based on the belief that this approach to diabetes care must be beneficial beyond the available evidence (i.e., reason).

Impact of state mandatory insurance coverage on the use of diabetes preventive care

BACKGROUND

46 U.S. states and the District of Columbia have passed laws and regulations mandating that health insurance plans cover diabetes treatment and preventive care. Previous research on state mandates suggested that these policies had little impact, since many health plans already covered the benefits. Here, we analyze the contents of and model the effect of state mandates. We examined how state mandates impacted the likelihood of using three types of diabetes preventive care: annual eye exams, annual foot exams, and performing daily self-monitoring of blood glucose (SMBG).

METHODS

We collected information on diabetes benefits specified in state mandates and time the mandates were enacted. To assess impact, we used data that the Behavioral Risk Factor Surveillance System gathered between 1996 and 2000. 4,797 individuals with self-reported diabetes and covered by private insurance were included; 3,195 of these resided in the 16 states that passed state mandates between 1997 and 1999; 1,602 resided in the 8 states or the District of Columbia without state mandates by 2000. Multivariate logistic regression models (with state fixed effect, controlling for patient demographic characteristics and socio-economic status, state characteristics, and time trend) were used to model the association between passing state mandates and the usage of the forms of diabetes preventive care, both individually and collectively.

RESULTS

All 16 states that passed mandates between 1997 and 1999 required coverage of diabetic monitors and strips, while 15 states required coverage of diabetes self management education. Only 1 state required coverage of periodic eye and foot exams. State mandates were positively associated with a 6.3 (P = 0.04) and a 5.8 (P = 0.03) percentage point increase in the probability of privately insured diabetic patient's performing SMBG and simultaneous receiving all three preventive care, respectively; state mandates were not significantly associated with receiving annual diabetic eye (0.05 percentage points decrease, P = 0.92) or foot exams (2.3 percentage points increase, P = 0.45).

CONCLUSIONS

Effects of state mandates varied by preventive care type, with state mandates being associated with a small increase in SMBG. We found no evidence that state mandates were effective in increasing receipt of annual eye or foot exams. The small or non-significant effects might be attributed to small numbers of insured people not having the benefits prior to the mandates' passage. If state mandates' purpose is to provide improved benefits to many persons, policy makers should consider determining the number of people who might benefit prior to passing the mandate.

The impact of health literacy on self-monitoring of blood glucose in patients with diabetes receiving care in an inner-city hospital

BACKGROUND

Self-monitoring of blood glucose (SMBG) is considered to be 1 of the cornerstones of diabetes self-management. It is unclear whether inadequate health literacy affects SMBG.

OBJECTIVE

The objective of this study was to examine the relationship between health literacy and SMBG.

METHODS

This was a cross-sectional survey of 189 patients with diabetes, aged 18 to 65 years, receiving care in a large urban, public health care setting. We measured health literacy using the shortened version of the Test of Functional Health Literacy in Adults. The diabetes care profile was used to determine the use of self-monitoring of blood glucose.

RESULTS

Most (60.9%) of the survey participants were assessed as functionally health literate. The majority (90.9%) of the study participants reported testing their blood sugar at least once daily. Although adequate health literacy was associated with recording of blood sugar testing (p = .049), we found no statistically significant relationship between health literacy and the frequency of SMBG. Persons self-reporting having diabetes for more than 10 years were less likely to self-monitor blood glucose (odds ratio, 0.33; 95% CI, 0.11-0.99).

CONCLUSIONS

SMBG frequency is not independently associated with health literacy, but SMBG result recording is noted among patients with inadequate literacy.

Race/ethnicity, social support, and associations with diabetes self-care and clinical outcomes in NHANES

PURPOSE

The purpose of this study was to evaluate how social support and race/ethnicity were associated with diabetes self-care behaviors and clinical outcomes.

METHODS

Using the cross-sectional 2005-2006 National Health and Nutrition Examination Survey (NHANES), the authors examined white, black, and Latino respondents who self-reported a diabetes diagnosis (n = 450), estimating the associations of social support on diabetes outcomes. The primary exposure was a social support index (0-5), which assessed the number of sources of support in one's life. Outcomes were self-care behaviors (controlling weight, exercising, controlling fat/caloric intake, checking feet, and self-monitoring blood glucose) and intermediate clinical outcomes (hemoglobin A1C, diastolic blood pressure, and low-density lipoprotein [LDL]).

RESULTS

There were no differences in social support by race/ethnicity. The authors observed several significant race/ethnicity by social support interactions in adjusted models, controlling for age, gender, education, self-reported health, depression, functional disability, insurance status, and insulin use. Among blacks, social support was associated with controlling weight (odds ratio [OR] = 1.55, P = .03), exercising (OR = 1.38, P = .03), controlling fat/calories (OR = 1.84, P = .03), and lower diastolic blood pressure (beta = -3.07, P = .02). Among whites, social support was associated with lower LDL (beta = -9.45, P = .01). No significant effects were noted for Latinos.

CONCLUSIONS

The relationship of social support with diabetes management differed by race/ethnicity, with the strongest findings among blacks. Social support may be influential for maintaining self-care behaviors among blacks and controlling lipid levels among whites.

Brief Alcohol Intervention Among At-Risk Drinkers with Diabetes

Twenty-eight patients with diabetes who screened positive for at-risk drinking were assigned to brief alcohol intervention (BAI) (n = 14) or standard care (SC) (n = 14) treatment conditions. All participants completed a baseline interview and one-, three, and six-month follow-up interviews. Across the six-month follow-up period, there was a significantly greater reduction in quantity of alcohol consumed in the BAI group. At the six-month follow-up, the BAI group had a greater reduction in quantity of alcohol consumed, percentage of heavy drinking days, and frequency of drinking. Reductions in alcohol use were associated with improved adherence in certain components of diabetes self-care behavior. The results of this study suggest that brief alcohol interventions are efficacious in reducing alcohol use among at-risk drinkers with diabetes and that reductions in alcohol use may result in some improvements in adherence to diabetes self-care behavior.

The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study

BACKGROUND

Use of four or more prescription medications is considered a risk factor for falls in older people. It is unclear whether this polypharmacy-fall relationship differs for adults with diabetes.

OBJECTIVE

We evaluated the association between number of prescription medications and incident falls in a multi-ethnic population of type-2 diabetes patients in order to establish an evidence-based medication threshold for fall risk in diabetes.

DESIGN

Baseline survey (1994-1997) with 5 years of longitudinal follow-up.

PARTICIPANTS

Eligible subjects (N = 46,946) had type-2 diabetes, were >or=18 years old, and enrolled in the Kaiser Permanente Northern California Diabetes Registry.

MEASUREMENTS AND MAIN RESULTS

We identified clinically recognized incident falls based on diagnostic codes (ICD-9 codes: E880-E888). Relative to regimens of 0-1 medications, regimens including 4 or more prescription medications were significantly associated with an increased risk of falls [4-5 medications adjusted HR 1.22 (1.04, 1.43), 6-7 medications 1.33 (1.12, 1.58), >7 medications 1.59 (1.34, 1.89)]. None of the individual glucose-lowering medications was found to be significantly associated with a higher risk of falls in predictive models.

CONCLUSIONS

The prescription of four or more medications was associated with an increased risk of falls among adult diabetes patients, while no specific glucose-lowering agent was linked to increased risk. Baseline risk of falls and number of baseline medications are additional factors to consider when deciding whether to intensify diabetes treatments.

Practical steps to improving the management of type 1 diabetes: recommendations from the Global Partnership for Effective Diabetes Management

The Diabetes Control and Complications Trial (DCCT) led to considerable improvements in the management of type 1 diabetes, with the wider adoption of intensive insulin therapy to reduce the risk of complications. However, a large gap between evidence and practice remains, as recently shown by the Pittsburgh Epidemiology of Diabetes Complications (EDC) study, in which 30-year rates of microvascular complications in the 'real world' EDC patients were twice that of DCCT patients who received intensive insulin therapy. This gap may be attributed to the many challenges that patients and practitioners face in the day-to-day management of the disease. These barriers include reaching glycaemic goals, overcoming the reality and fear of hypoglycaemia, and appropriate insulin therapy and dose adjustment. As practitioners, the question remains: how do we help patients with type 1 diabetes manage glycaemia while overcoming barriers? In this article, the Global Partnership for Effective Diabetes Management provides practical recommendations to help improve the care of patients with type 1 diabetes.

The Limits of Self-Management: Community and Health Care System Barriers Among Latinos With Diabetes

Although numerous studies examine diabetes self-care, few regard ecological framework correlates such as community and institutional level factors as fundamental for understanding diabetes management for Latinos. This article addresses the dearth of research that exists regarding social contextual forces and diabetes management for Latinos. Given the scarcity of research on this topic, studies of non-Latino groups were reviewed to illustrate the importance of community and institutional influences on diabetes care. Consideration of fundamental correlates within the ecological framework may better discern the underlying rationale for inadequate diabetes self-management for individuals who live in impoverished communities.

Generational status and duration of residence predict diabetes prevalence among Latinos: the California Men's Health Study

Background

Diabetes disproportionately affects Latinos. However, examining Latinos as one group obscures important intra-group differences. This study examined how generational status, duration of US residence, and language preference are associated with diabetes prevalence and to what extent these explain the higher prevalence among Latinos.

Methods

We determined nativity, duration of US residence, language preference, and diabetes prevalence among 11 817 Latino, 6109 black, and 52 184 white participants in the California Men's Health Study. We combined generational status and residence duration into a single migration status variable with levels: ≥ third generation; second generation; and immigrant living in the US for > 25, 16-25, 11-15, or ≤ 10 years. Language preference was defined as language in which the participant took the survey. Logistic regression models were specified to assess the associations of dependent variables with prevalent diabetes.

Results

Diabetes prevalence was 22%, 23%, and 11% among Latinos, blacks, and whites, respectively. In age-adjusted models, we observed a gradient of risk of diabetes by migration status among Latinos. Further adjustment for socioeconomic status, obesity and health behaviors only partially attenuated this gradient. Language preference was a weak predictor of prevalent diabetes in some models and not significant in others. In multivariate models, we found that odds of diabetes were higher among US-born Latinos than US-born blacks.

Conclusion

Generational status and residence duration were associated with diabetes prevalence among middle-aged Latino men in California. As the Latino population grows, the burden of diabetes-associated disease is likely to increase and demands public health attention.

Accuracy and precision of four value-added blood glucose meters: the Abbott Optium, the DDI Prodigy, the HDI True Track, and the HypoGuard Assure Pro

PURPOSE

This study compared the accuracy and precision of four value-added glucose meters.

METHODS

Finger stick glucose measurements in diabetes patients were performed using the Abbott Diabetes Care (Alameda, CA) Optium, Diagnostic Devices, Inc. (Miami, FL) DDI Prodigy, Home Diagnostics, Inc. (Fort Lauderdale, FL) HDI True Track Smart System, and Arkray, USA (Minneapolis, MN) HypoGuard Assure Pro. Finger glucose measurements were compared with laboratory reference results. Accuracy was assessed by a Clarke error grid analysis (EGA), a Parkes EGA, and within 5%, 10%, 15%, and 20% of the laboratory value criteria (chi2 analysis). Meter precision was determined by calculating absolute mean differences in glucose values between duplicate samples (Kruskal-Wallis test).

RESULTS

Finger sticks were obtained from 125 diabetes patients, of which 90.4% were Caucasian, 51.2% were female, 83.2% had type 2 diabetes, and average age of 59 years (SD 14 years). Mean venipuncture blood glucose was 151 mg/dL (SD +/-65 mg/dL; range, 58-474 mg/dL). Clinical accuracy by Clarke EGA was demonstrated in 94% of Optium, 82% of Prodigy, 61% of True Track, and 77% of the Assure Pro samples (P < 0.05 for Optium and True Track compared to all others). By Parkes EGA, the True Track was significantly less accurate than the other meters. Within 5% accuracy was achieved in 34%, 24%, 29%, and 13%, respectively (P < 0.05 for Optium, Prodigy, and Assure Pro compared to True Track). Within 10% accuracy was significantly greater for the Optium, Prodigy, and Assure Pro compared to True Track. Significantly more Optium results demonstrated within 15% and 20% accuracy compared to the other meter systems. The HDI True Track was significantly less precise than the other meter systems.

CONCLUSIONS

The Abbott Optium was significantly more accurate than the other meter systems, whereas the HDI True Track was significantly less accurate and less precise compared to the other meter systems.

Frequency and motives of blood glucose self-monitoring in type 1 diabetes

AIMS

Recommendations for self-monitoring of blood glucose (SMBG) from the DCCT have not been implemented with the same rigour as recommendations for intensifying insulin therapy. We assessed the frequency of and motives for SMBG and compared SMBG behaviour with clinical, behavioural and demographic characteristics.

METHODS

Cross-sectional Danish-British multicentre survey of 1076 consecutive patients with type 1 diabetes, who completed a detailed questionnaire on SMBG and related issues. The key variables were test frequency and motive.

RESULTS

SMBG was performed daily by 39% of the patients and less than weekly by 24%. Sixty-seven percent reported to perform routine testing, while the remaining 33% only tested when hypo- or hyperglycaemia was suspected. Age, gender, and level of diabetes-related concern were associated with test pattern. Reported frequencies of mild and severe hypoglycaemia and awareness of hypoglycaemia were independently associated with testing behaviour, whereas the presence of late diabetic complications was not. Lower HbA1c was associated with more frequent testing.

CONCLUSION

Patient compliance regarding SMBG is limited. Thus, almost two thirds of the patients do not perform daily SMBG and one third do not perform routine tests.

Randomized controlled trial to assess the impact of continuous glucose monitoring on HbA(1c) in insulin-treated diabetes (MITRE Study)

AIMS

To determine whether continuous glucose information provided through use of either the GlucoWatch G2 Biographer or the MiniMed continuous glucose monitoring system (CGMS) results in improved glycated haemoglobin (HbA(1c)) for insulin-treated adults with diabetes mellitus, relative to an attention control and standard care group.

METHODS

Four hundred and four adults taking at least two daily insulin injections and with two consecutive HbA(1c) values > or = 7.5% were recruited to this randomized controlled trial (RCT). All were trained at baseline to use the same monitor for traditional capillary glucose testing throughout the 18-month study. The CGMS group were asked to wear the device three times during the first 3 months of the trial and on another three occasions thereafter. The GlucoWatch group wore the device a minimum of four times per month and a maximum of four times per week during the first 3 months and as desired for the remainder of the trial. Trained diabetes research nurses used downloaded data to guide therapy adjustments. Proportional reduction in HbA(1c) from baseline to 18 months was the primary outcome measure.

RESULTS

Neither an intention-to-treat nor per-protocol analysis showed improvement in HbA(1c) in the device groups compared with standard care. For the intention-to-treat analysis, when the standard care group was compared with each of the other groups, this equated to differences in mean relative HbA(1c) reduction (95% confidence interval) from baseline to 18 months of 3.5% (-1.3 to 8.3; GlucoWatch), 0.7% (-4.1 to 5.5; CGMS), and -0.1% (-4.6 to 4.3; attention control).

CONCLUSIONS

The additional information provided by these devices did not result in improvements in HbA(1c) in this population.

Identification and characteristics of vaccine refusers

Background

This study evaluated the utility of immunization registries in identifying vaccine refusals among children. Among refusers, we studied their socioeconomic characteristics and health care utilization patterns.

Methods

Medical records were reviewed to validate refusal status in the immunization registries of two health plans. Racial, education, and income characteristics of children claiming refusal were collected based on the census tract of each child. Health care utilization was identified using both electronic medical record and insurance claims. Within the immunization registries of two HMOs in the study, some providers use refusal and medical contraindication interchangeably, and some providers tend to always use "ever refusal." Therefore, we combined medical contraindication and refusal together and treated them all as "refusal" in this study.

Results

The immunization registry, compared to chart review, had negative predictive values of 85–92% and 90–97% for 2- and 6-year olds, and positive predictive values of only 52–74% and 59–62% to identify vaccine refusals. Refusers were more likely to reside in well-educated, higher income areas than non-refusers. Refusers had not opted out of health care system and continued, although less frequently for the age 2 and under group, to use services.

Conclusion

Without enhancements to immunization registries, identifying children with immunization refusal would be time consuming. Since communities where refusers live are well educated, interventions should target these communities to communicate vaccine adverse events and consequences of vaccine preventable diseases.

Racial differences in diabetes self-management and quality of care in Texas

AIM

To assess racial/ethnic differences in diabetes self-management behaviors and quality of care in Texas.

METHODS

This cross-sectional study assessed self-management behaviors and quality of care in 1720 adults with diabetes in the 2002-2004 Texas Behavioral Risk Factor Surveillance Survey. Multiple logistic regression models were used for assessing the independent association between race/ethnicity, self-management behaviors, and quality of care variables controlling for covariates. SAS (SAS Institute Inc, 2002-2003) was used for statistical analysis.

RESULTS

Eighteen percent of Hispanics, 14% of Blacks, and 10% of Whites reported never performing home glucose testing. Seventeen percent of Hispanics, 11% of Blacks, and 10% of Whites reported never doing home foot exam. Thirty-two percent of Hispanics, 21% of Blacks, and 16% of Whites did not have an A1C test in the prior 12 months. Twelve percent of Hispanics, 10% of Blacks, and 6% of Whites did not have a dilated eye exam in the prior 12 months. Fifty-four percent of Whites, 42% of Blacks, and 40% of Hispanics received a flu shot. Forty-nine percent of Whites, 30% of Blacks, and 26% of Hispanics received a pneumonia shot. In adjusted models, Hispanics were more likely to be sedentary (OR, 1.64; 95% CI, 1.08-2.49) compared to Whites. Blacks did not differ significantly from Whites (OR, 1.46; 95% CI, 0.92-2.34). Hispanics (OR, 1.61; 95% CI, 1.01-2.57) and Blacks (OR, 1.83; 95% CI, 1.10-3.03) were more likely to get an annual foot exam by a provider compared to Whites. Hispanics (OR, 0.54; 95% CI, 0.34-0.85) and Blacks (OR, 0.58; 95% CI, 0.35-0.98) were less likely to get a pneumonia shot compared to Whites.

CONCLUSIONS

Hispanics have poorer access to care and poorer health status compared to Whites or Blacks. Controlling for socioeconomic and access to care variables eliminated disparities in self-management but did not eliminate disparities in quality of diabetes care.

Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study

Background

Adherence to oral antidiabetic medications is often suboptimal. Adherence differences may contribute to health disparities for black diabetes patients, including higher microvascular event rates, greater complication-related disability, and earlier mortality.

Methods

In this longitudinal retrospective cohort study, we used 10 years of patient-level claims and electronic medical record data (1/1/1992–12/31/2001) to assess differences in short- and long-term adherence to oral antidiabetic medication among 1906 newly diagnosed adults with diabetes (26% black, 74% white) in a managed care setting in which all members have prescription drug coverage. Four main outcome measures included: (1) time from diabetes diagnosis until first prescription of oral antidiabetic medication; (2) primary adherence (time from first prescription to prescription fill); (3) time until discontinuation of oral antidiabetic medication from first prescription; and (4) long-term adherence (amount dispensed versus amount prescribed) over a 24-month follow-up from first oral antidiabetic medication prescription.

Results

Black patients were as likely as whites to initiate oral therapy and fill their first prescription, but experienced higher rates of medication discontinuation (HR: 1.8, 95% CI: 1.2, 2.7) and were less adherent over time. These black-white differences increased over the first six months of therapy but stabilized thereafter for patients who initiated on sulfonylureas. Significant black-white differences in adherence levels were constant throughout follow-up for patients initiated on metformin therapy.

Conclusion

Racial differences in adherence to oral antidiabetic drug therapy persist even with equal access to medication. Early and continued emphasis on adherence from initiation of therapy may reduce persistent racial differences in medication use and clinical outcomes.

At-risk drinking among diabetic patients

Diabetes Mellitus is a serious chronic disease, affecting an increasing number of individuals worldwide. Adherence to diabetes self-care behaviors is key to the successful management of the disease. At-risk drinking is common among diabetic patients and is associated with inferior diabetes treatment adherence and outcomes, resulting in increased mortality and morbidity. Furthermore, individuals with diabetes who engage in at-risk drinking are also in danger of incurring the negative consequences of at-risk drinking found in the general population. Research suggests that alcohol use screening and intervention do not commonly occur during the course of primary care treatment for diabetes. While methods for reducing alcohol use in this population have been largely unexplored to date, brief interventions to reduce at-risk drinking have been well-validated in other patient populations and offer the promise to reduce at-risk drinking among diabetic patients, resulting in improved diabetes treatment adherence and outcomes.