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

Aging and medical adherence: the use of automatic processes to achieve effortful things

This research examined whether forming detailed implementation plans for achieving a goal improved older adults' adherence to a health behavior. Nondiabetic participants (N = 31) rehearsed, deliberated, or formed implementation intentions to perform home blood glucose monitoring, 4 times daily for 3 weeks. The implementation group performed tests nearly 50% more often than the 2 comparison groups. Results were not attributable to a priori differences in intentions to perform testing. Findings indicate that implementation intentions can facilitate older adults' performance of important medical self-care tasks in naturalistic settings over sustained periods of time and concur with previous research that implicates automatic cognitive processes that do not show age-related decline. These results support the utility of this technique for improving adherence to health behaviors in clinical populations.

Lack of insurance coverage for testing supplies is associated with poorer glycemic control in patients with type 2 diabetes

BACKGROUND

Public insurance for testing supplies for self-monitoring of blood glucose is highly variable across Canada. We sought to determine if insured patients were more likely than uninsured patients to use self-monitoring and whether they had better glycemic control.

METHODS

We used baseline survey and laboratory data from patients enrolled in a randomized controlled trial examining the effect of paying for testing supplies on glycemic control. We recruited patients through community pharmacies in Alberta and Saskatchewan from Nov. 2001 to June 2003. To avoid concerns regarding differences in provincial coverage of self-monitoring and medications, we report the analysis of Alberta patients only.

RESULTS

Among our sample of 405 patients, 41% had private or public insurance coverage for self-monitoring testing supplies. Patients with insurance had significantly lower hemoglobin A(1c) concentrations than those without insurance coverage (7.1% v. 7.4%, p = 0.03). Patients with insurance were younger, had a higher income, were less likely to have a high school education and were less likely to be married or living with a partner. In multivariate analyses that controlled for these and other potential confounders, lack of insurance coverage for self-monitoring testing supplies was still significantly associated with higher hemoglobin A(1c) concentrations (adjusted difference 0.5%, p = 0.006).

INTERPRETATION

Patients without insurance for self-monitoring test strips had poorer glycemic control.

Variations in glucose self-monitoring during oral hypoglycaemic therapy in primary care

OBJECTIVE

To describe the prescription of glucose self-monitoring materials in the first 12 months after initiation of oral hypoglycaemic therapy.

METHODS

Cohort study of subjects registered with UK general practices and prescribed oral hypoglycaemic drugs for the first time between January 1993 and December 1998. Analyses were adjusted for age, sex, year, prevalent coronary heart disease and clustering by practice.

RESULTS

Data were analysed for 11 688 subjects registered with 262 practices. The proportion who received no prescriptions for monitoring increased from 24% in 1993 to 30% in 1998; urine glucose monitoring only decreased from 45 to 27%; while blood glucose monitoring only increased from 19 to 32%. In those under 45 years, 25% were not prescribed monitoring, increasing to 53% in those aged 85 years and over. In the same age groups, the proportion prescribed blood glucose monitoring only declined from 37 to 16%. At different general practices, the proportion of patients prescribed monitoring strips ranged from 12 to 100%. Practices with more registered diabetic patients were more likely to prescribe urine glucose monitoring only. Monitoring prescriptions varied widely between England, Scotland, Wales and Northern Ireland. Among eight English regions, the proportion prescribed blood glucose monitoring only ranged from 18 to 37%.

CONCLUSIONS

Prescription of glucose monitoring varies according to patient and practice characteristics and geographical location. Monitoring patterns are changing over time. These variations may reflect uncertainty concerning the effectiveness of monitoring, and diversity of patient and professional preferences with respect to monitoring.

Diabetes disease management in managed care organizations

Recent clinical trials and disease management programs sponsored by managed care organizations have demonstrated achievements in limiting complications, improving health measures, reducing costs, and enhancing the quality of life of the person with diabetes. In one managed care organization, Group Health, Inc., persons with diabetes received discounted supplies and educational material as encouragement to participate in a diabetes disease management program [Disease Management Solutions (DMS)]. Health risk appraisals (HRAs) were provided at enrollment, and at 6-month intervals thereafter. Over 8,000 persons with diabetes participated in the DMS program over a 2 and 1/2-year period. Claims data over a 3-year period (pre- and post-enrollment) for 1,368 persons with diabetes demonstrated that participation in DMS resulted in greater utilization of primary care services by enrolled persons than by non-enrolled, but a lower increase in costs for those enrolled. In addition to evaluating the program impact through changes in services and costs, HRAs provided self-reported scores on (1) several compliance measures and (2) general health impressions and productivity. In the DMS population, self-reported compliance with physician-recommended office visits and tests (eg, cholesterol screening) improved for persons with diabetes once they enrolled in the program. Participants also reported greater productivity (eg, fewer missed work days) once enrolled in the program. To validate self-reported results, medical claims were used to verify compliance with general office, ophthalmologic, and emergency room visits and hospital admissions. A high level of validity between self-reported results and claims data recording office and emergency room visits and hospital admissions was found.

Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes

BACKGROUND

Diabetes causes 45% of incident end-stage renal disease (ESRD). Risk of progression is higher in those with clinical risk factors (albuminuria and hypertension), and in ethnic minorities (including blacks, Asians, and Latinos). Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) slow the progression of diabetic nephropathy, yet little is known about their use among patients at high risk for progression to ESRD.

OBJECTIVES

To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use.

DESIGN

Observational cohort study.

SETTING

Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes.

PATIENTS

Individuals (N= 38887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey.

INTERVENTIONS AND MEASUREMENTS

Pharmacy dispensing of ACE/ARB.

RESULTS

Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P =.0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found.

CONCLUSIONS

In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.

The Value of Home Monitoring Kits in Diabetes, Hypertension, Asthma, and Oral Anticoagulation Therapy

Home monitoring devices encourage people to actively participate in their health care management. In addition, access to more data may help to make better decisions, which may ultimately lead to better health outcomes. The primary focus of this article will be on blood glucose, blood pressure, prothrombin time, and peak flow meters. The empirical evidence on the accuracy and usefulness of these home monitoring devices is discussed. Based on the evidence from the literature, erroneous reporting of the readings by the patients is a major concern. Therefore, primary practitioners are encouraged to consult with patients’ log books and their meters (if memory feature is available), instead of relying solely on self-reported values. Patients also need to be educated and trained adequately about the proper measurement technique and relevance and interpretation of the readings. Continuing education is necessary regarding the behavioral and therapeutic changes patients should carry out in accordance with performing regular home monitoring.

Quality improvement and cost reduction realized by a purchaser through diabetes disease management

This report documents the clinical improvements and costs experienced by a purchaser after introduction of a diabetes disease management program. A purchaser contracted with American Healthways, a disease management organization, to initiate a diabetes disease management program called Diabetes Decisions. Started in 1998, the program grew to include 662 participants. The results reported are based on the continuously participating population (12 months of participation in the program for the reporting year). Participants were entered into American Healthways' clinical information system and risk-stratified, and an individualized treatment plan was devised. Outbound telephone calls by specially trained nurses were a key intervention. Data were collected on key process measures, financial parameters, and participant satisfaction. By year 3, there were 422 continuously participating participants. From baseline to the third year of the program, significant increases in frequency of A1C testing (21.3% to 82.2%), dilated retinal exams (17.2% to 70.7%), and performance of foot exams (2.0% to 75.6%) were noted. For 166 participants with five A1C determinations, A1C values dropped from 8.89% to 7.88%. Participants experienced a 36% drop in inpatient costs. Without adjustment for medical inflation, total medical costs decreased by 26.8% from the baseline period, dropping to $268.63 per diabetes participant per month (PDPPM) by year 3, a gross savings of $98.49 PDPPM. After subtracting the fees paid to Diabetes Decisions, a net savings of $986,538 was realized. This yielded a return on investment of 3.37. By investing in a diabetes disease management program, a purchaser was able to realize significant improvements in clinical care, substantial cost savings, and a favorable return on investment.

Factors associated with adherence to self-monitoring of blood glucose among persons with diabetes

PURPOSE

The purpose of this study was to investigate the relationship between demographic, biological, and psychosocial characteristics of self-monitoring of blood glucose (SMBG) among people with diabetes.

METHODS

A total of 933 adults with diabetes were invited to participate in the study. A self-administered survey was used to address the study objective. Adherence to SMBG was assessed by comparing the number of glucose tests performed by the patient with the number recommended by the healthcare provider. Multivariate logistic regression analysis was used to assess the relationship among the variables.

RESULTS

Adherence to SMBG was 52%. Approximately one third of the participants (n = 213) could be categorized as adherent to SMBG. Multivariate logistic regression analysis revealed that study participants with type 1 diabetes who experienced fewer environmental barriers (e.g., lifestyle interference, inconvenience, painfulness, and cost) were significantly more adherent to SMBG (P < .05).

CONCLUSIONS

Adherence to SMBG was suboptimal. The most significant factors that interfered with adherence were having type 2 diabetes and environmental barriers. Knowing the importance of these factors may assist diabetes educators and other healthcare professionals in identifying people at risk for low adherence to SMBG and potentially long-term health complications.

Facilitating access to glucometer reagents increases blood glucose self-monitoring frequency and improves glycaemic control: a prospective study in insulin-treated diabetic patients

AIMS

To investigate whether availability of glucometer reagents increases the frequency of self-blood glucose monitoring (SBGM) and improves glycaemic control in diabetic patients.

METHODS

Sixty-two insulin-treated diabetic patients were randomized to two groups, matched for age, gender, education, income, type and duration of diabetes, years of insulin treatment, number of daily insulin injections, and haemoglobin (Hb)A1c. All patients were given a glucometer, but one group (no cost, NC) was provided glucometer test strips free of charge. The other group (control, C) had to purchase strips as they found it necessary. Both groups of patients were followed longitudinally at 2-monthly intervals for 12 months with measurement of blood glucose and HbA1c, and the frequency of SBGM was determined by downloading the glucometer memory.

RESULTS

The SBGM frequency was significantly higher in the NC group vs. the C group during the first 4 months (2.0 +/- 0.2 tests/day vs. 1.4 +/- 0.1 tests/day, P<0.025). Mean HbA1c remained stable over the 12 months in the NC group, whereas an increase with time was observed in the C group. The difference in HbA1c between the two groups was significant (P<0.002) after 6 months. Random blood glucose measured at each visit and average glucose recorded by the glucometer were also lower in the NC group vs. the C group (P<0.005). There was a negative correlation between HbA1c and SBGM frequency, and HbA1c in patients testing at least twice a day was lower than in those testing less than twice a day (8.8 +/- 0.2% vs. 9.6 +/- 0.2%, P<0.001).

CONCLUSIONS

In this prospective study, having easy access to glucometer strips provided free of charge to patients increased SBGM frequency. The relationship between HbA1c and SBGM frequency supports the view that SBGM is an essential tool in diabetes management.

Missed Appointments and Poor Glycemic Control

OBJECTIVE

When patients miss scheduled medical appointments, continuity and effectiveness of healthcare delivery is reduced, appropriate monitoring of health status lapses, and the cost of health services increases. We evaluated the relationship between missed appointments and glycemic control (glycosylated hemoglobin or HbA1c) in a large, managed care population of diabetic patients.

RESEARCH DESIGN AND METHODS

Missed appointment rate was related cross-sectionally to glycemic control among 84,040 members of the Kaiser Permanente Northern California Diabetes Registry during 2000. Adjusted least-square mean estimates of HbA1c were derived by level of appointment keeping (none missed, 1-30% missed, and >30% missed appointments for the calendar year) stratified by diabetes therapy.

RESULTS

Twelve percent of the subjects missed more than 30% of scheduled appointments during 2000. Greater rates of missed appointments were associated with significantly poorer glycemic control after adjusting for demographic factors (age, sex), clinical status, and health care utilization. The adjusted mean HbA1c among members who missed >30% of scheduled appointments was 0.70 to 0.79 points higher (P <0.0001) relative to those attending all appointments. Patients who missed more than 30% of their appointments were less likely to practice daily self-monitoring of blood glucose and to have poor oral medication refill adherence.

CONCLUSION

Patients who underuse care lack recorded information needed to determine level of risk. Frequently missed appointments were associated with poorer glycemic control and suboptimal diabetes self-management practice, are readily ascertained in clinical settings, and therefore could have clinical utility as a risk-stratifying criterion indicating the need for targeted case management.

Closing the gap: effect of diabetes case management on glycemic control among low-income ethnic minority populations: the California Medi-Cal type 2 diabetes study

OBJECTIVE

Disparities exist in the diabetes health status of ethnic minority and/or low-income populations relative to other groups. A primary objective of diabetes management is to improve glycemic control. The feasibility of implementing intensive diabetes case management in disparate populations remains largely untested.

RESEARCH DESIGN AND METHODS

Clinical sites in three southern California counties serving low-income, ethnic minority populations participated in our study. We randomized 362 Medicaid (called Medi-Cal in California) recipients with type 2 diabetes for at least 1 year to intervention (diabetes case management) or control (traditional primary care treatment) groups. Fifty-five percent of participants were minorities. Participants with HbA(1c) levels less than 7.5%, serious diabetes-related complications, or other serious medical conditions were excluded. We assessed the effect of the intervention (ongoing diabetes case management added to primary care) on glycemic control using serial HbA(1c) measurements over several years.

RESULTS

The mean duration of follow-up was 25.3 months. HbA(1c) decreased substantially in both groups from an average of 9.54-7.66% (a reduction of 1.88%) in the intervention group and from an average of 9.66-8.53% (a reduction of 1.13%) in the control group. This improvement was sustained throughout the study. The reduction in HbA(1c) was consistently greater in the intervention group at each time point (P < 0.001), ranging between 0.65 at 6 months and 0.87 at study end.

CONCLUSIONS

Diabetes case management, added to primary care, substantially improved glycemic control compared with the control group. Diabetes case management can help reduce disparities in diabetes health status among low-income ethnic populations.

Health behaviors and quality of care among Latinos with diabetes in managed care

OBJECTIVES

We evaluated whether ethnicity and language are associated with diabetes care for Latinos in managed care.

METHODS

Using data from 4685 individuals in the Translating Research Into Action for Diabetes (TRIAD) Study, a multicenter study of diabetes care in managed care, we constructed multivariate regression models to compare health behaviors, processes of care, and intermediate outcomes for Whites and English- and Spanish-speaking Latinos.

RESULTS

Latinos had lower rates of self-monitoring of blood glucose and worse glycemic control than did Whites, higher rates of foot self-care and dilated-eye examinations, and comparable rates of other processes and intermediate outcomes of care.

CONCLUSIONS

Although self-management and quality of care are comparable for Latinos and Whites with diabetes, important ethnic disparities persist in the managed care settings studied.

Self-management of type 2 diabetes: a survey of low-income urban Puerto Ricans

PURPOSE

This study explored self-reported barriers to diabetes self-management in a population of urban, low-income Puerto Rican individuals.

METHODS

A cross-sectional exploratory survey was conducted with 30 Puerto Rican adults with type 2 diabetes. Participants were randomly selected and recruited from a health center, an elder center, and a community outreach database. A survey was used to assess participants' diabetes-related knowledge, attitudes, and patterns of and barriers to self-management.

RESULTS

Participants were older and had limited education and good access to health care. Although two thirds had participated in diabetes education, most demonstrated major deficits in diabetes knowledge. Negative attitudes about living with diabetes were common as was dietary knowledge and nonadherence. Most participants were overweight or obese, did regular self-monitoring of blood glucose but did not use the results to improve their diabetes control, and frequently missed doses of their diabetes medications. Self-reported barriers to self-management were financial and social obstacles and competing health and family concerns.

CONCLUSIONS

The knowledge and self-management behaviors in this population of Puerto Rican individuals with type 2 diabetes need to be improved.

Out-of-pocket costs and diabetes preventive services: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE

Despite the increased shifting of health care costs to consumers, little is known about the impact of financial barriers on health care utilization. This study investigated the effect of out-of-pocket expenditures on the utilization of recommended diabetes preventive services.

RESEARCH DESIGN AND METHODS

This was a survey-based observational study (2000-2001) in 10 managed care health plans and 68 provider groups across the U.S. serving approximately 180,000 patients with diabetes. From 11,922 diabetic survey respondents, we studied the occurrence of self-reported annual dilated eye exams and diabetes health education and among insulin users, daily self-monitoring of blood glucose (SMBG). Conditional probabilities were estimated for outcomes at each level of self-reported out-of-pocket expenditure by using hierarchical logistic regression models with random intercepts.

RESULTS

Conditional probabilities of utilization (95% CI) varied by expenditure for dilated eye exam [no cost 78% (75-82), copay 79% (75-82), and full price 70% (64-75); P < 0.0001]; diabetes health education [no cost 29% (23-36), copay 29% (23-36), and full price 19% (14-25); P < 0.0001]; and daily SMBG [no cost 75% (68-81), copay 68% (60-75), and full price 59% (49-68); P < 0.0001]. Extensive adjustment for patient factors had no discernible effect on the estimates or their significance, and cost-utilization relationships were similar across income levels and other patient characteristics.

CONCLUSIONS

Benefit packages structured to derive greater fiscal contribution from the health plan membership result in suboptimal use of diabetes preventive services and may thus lead to poorer clinical outcomes, greater future costs, and lower health plan quality ratings.

Management of chronic disease by patients

Chronic conditions dominate health care in most parts of the world, including the United States. Management of a disease by the patient is central to control of its effects. A wide range of influences in the person's social and physical environments enhance or impede management efforts. Interventions to improve management by patients can produce positive outcomes including better monitoring of a condition, fewer symptoms, enhanced physical and psychosocial functioning, and reduced health care use. Successful programs have been theory based. Self-regulation is a promising framework for the development of interventions. Nonetheless, serious gaps in understanding and improving disease management by patients remain because of an emphasis on clinical settings for program delivery, neglect of the factors beyond patient behavior that enable or deter effective management, limitations of study designs in much work to date, reliance on short-term rather than long-term assessments, and failure to evaluate the independent contribution of various program components.

A community-centered approach to diabetes in East Harlem

OBJECTIVE

Residents of East Harlem, an impoverished, non-white community in New York city (NYC), have up to 5 times the mortality and complication rates of diabetes compared with NYC residents overall. To determine potentially remediable problems underlying this condition, a community-based collaboration of health providers, community advocates, and researchers, surveyed East Harlem residents with diabetes to assess their knowledge, behaviors, barriers to care, and actions taken in response to barriers.

DESIGN

Telephone interviews.

SETTING

The 3 hospitals and 2 community clinics serving East Harlem.

PARTICIPANTS

Nine hundred thirty-nine of the 1,423 persons (66%) with diabetes identified from these 5 healthcare sites with 2 or more ambulatory visits for diabetes during 1998 who lived in East Harlem.

RESULTS

While most respondents (90%) said they know how to take their medicines, between 19% and 39% do not understand other aspects of their diabetes management. Many limit their diabetes care due to concerns about money (16% to 40%), and other barriers, such as language and transportation (19% to 22%). In multivariate analyses, Latinos (relative risk [RR] = 0.77; 95% confidence interval [95% CI] 0.63 to 0.91) and those who do not keep a diabetic diet due to concerns about money (RR = 0.85; 95% CI 0.70 to 0.99) had poorer health status.

CONCLUSIONS

A community-based coalition was able to come together, identify areas of concern in diabetes care and assess the needs of adults with diabetes residing and obtaining care in East Harlem. The coalition found that even among those with access to care there remain significant financial barriers to good diabetes care, and a need to address and optimize how individuals with diabetes manage their disease.

Patients' understanding of anticoagulant therapy in a multiethnic population

To investigate whether knowledge and perceptions of antithrombotic therapy differ between ethnic groups in the UK, we conducted a cross-sectional questionnaire survey of patients attending anticoagulation clinics in three Birmingham teaching hospitals. 180 consecutive patients were recruited-135 white European, 29 Indo-Asian, 16 Afro-Caribbean. The average knowledge score was 5.5 out of 9, with no significant differences between the groups. Indo-Asians were significantly less likely than the other groups to know the name of the anticoagulant they were taking (warfarin) and Afro-Caribbeans to know the condition for which they were being anticoagulated. Few patients of any group were able to specify more than one side-effect of warfarin or the dose they were on. In logistic regression analysis the factors associated with a low score were age >61 years, having been born outside the UK, and the perception of difficulty in comprehension. Nearly half the Indo-Asians felt unable to understand what was said to them in the clinic, and 62% expressed a preference for a doctor of the same ethnic group. Although there were no significant between-group differences, this study points to gaps in the knowledge of patients from ethnic minorities and to deficiencies in the provision of information. In patient education, these groups should receive special attention.

Barriers to self-monitoring of blood glucose among adults with diabetes in an HMO: a cross sectional study

BACKGROUND

Recent studies suggest that patients at greatest risk for diabetes complications are least likely to self-monitor blood glucose. However, these studies rely on self-reports of monitoring, an unreliable measure of actual behavior. The purpose of the current study was to examine the relationship between patient characteristics and self-monitoring in a large health maintenance organization (HMO) using test strips as objective measures of self-monitoring practice.

METHODS

This cross-sectional study included 4,565 continuously enrolled adult managed care patients in eastern Massachusetts with diabetes. Any self-monitoring was defined as filling at least one prescription for self-monitoring test strips during the study period (10/1/92-9/30/93). Regular SMBG among test strip users was defined as testing an average of once per day for those using insulin and every other day for those using oral sulfonylureas only. Measures of health status, demographic data, and neighborhood socioeconomic status were obtained from automated medical records and 1990 census tract data.

RESULTS

In multivariate analyses, lower neighborhood socioeconomic status, older age, fewer HbA1c tests, and fewer physician visits were associated with lower rates of self-monitoring. Obesity and fewer comorbidities were also associated with lower rates of self-monitoring among insulin-managed patients, while black race and high glycemic level (HbA1c>10) were associated with less frequent monitoring. For patients taking oral sulfonylureas, higher dose of diabetes medications was associated with initiation of self-monitoring and HbA1c lab testing was associated with more frequent testing.

CONCLUSIONS

Managed care organizations may face the greatest challenges in changing the self-monitoring behavior of patients at greatest risk for poor health outcomes (i.e., the elderly, minorities, and people living in low socioeconomic status neighborhoods).

Barriers to blood glucose monitoring in a multiethnic community

OBJECTIVE

We studied a multiethnic community to determine factors associated with blood glucose monitoring (BGM) and to determine the independent association between barriers to diabetes care and BGM.

RESEARCH DESIGN AND METHODS

A total of 323 participants (35.6% European, 32.2% Maori, and 32.2% Pacific Islander) from the South Auckland Diabetes Project (free of major complications by self-report) completed a qualitative survey to determine barriers to diabetes care. Five barriers to diabetes care categories were generated including internal psychological (self efficacy/health beliefs), external psychological (psychosocial environment), internal physical (comorbidities/side effects of treatment), external physical (finance/access to care), and educational (knowledge of diabetes/services) barriers.

RESULTS

Characteristics associated with BGM greater than or equal to twice weekly were female sex, HbA(1c) >8%, higher diabetes knowledge scores, and insulin use. Multivariate analyses demonstrated that those reporting external physical barriers (OR 0.47, 95% CI 0.26-0.84), external psychological barriers (0.55, 0.30-1.0), and internal psychological barriers (0.56, 0.32-1.0) were less likely to perform BGM independent of ethnicity, insulin use, age, sex, diabetes knowledge, and glycemic control. Further multivariate analyses demonstrated that those reporting external physical barriers, particularly related to personal finance, were less likely to perform BGM.

CONCLUSIONS

These data demonstrate that patient-reported barriers to diabetes care are associated with BGM, particularly in relation to financial, psychosocial, and self-efficacy issues. Understanding these barriers and overcoming them within the context of the patient's ethnic environment may lead to increased participation in self-care.

Effect of patient socioeconomic status on physician profiles for prevention, disease management, and diagnostic testing costs

BACKGROUND

Previous research shows patient socioeconomic status (SES) affects physician profiles for health status and satisfaction, but effects on other aspects of care are not known.

OBJECTIVE

To examine the effect of patient SES on physician profiles for preventive care, disease management, and diagnostic testing costs.

RESEARCH DESIGN

Cross-sectional analysis of a managed care claims data.

SUBJECTS

Five hundred sixty-eight physicians and 600,618 patients.

MEASURES

Patient age, gender, case-mix, and SES based on zip code, likelihood of having a Papanicolaou smear, mammogram, for diabetics having had a glycosylated hemoglobin, diabetic eye exam, and diagnostic testing costs.

RESULTS

For each performance indicator, except glycosylated hemoglobin, there was a statistically significant effect of adjusting for patient SES. For diabetic eye checks, mammograms and Papanicolaou tests respectively, 5%, 16%, and 21% of physicians who were outliers (in the top or bottom 5% of rankings) were no longer outliers after socioeconomic adjustment. For all performance measures the change in physician ranking was strongly correlated with the mean practice SES.

CONCLUSIONS

Patient SES, as measured by zip code, appreciably affects physician profiles for preventive care and diabetes management. Monitoring patient SES using patient zip codes could be used to target resources to improve outcomes for higher risk patients.

The association between diabetes metabolic control and drug adherence in an indigent population

OBJECTIVE

Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population.

RESEARCH DESIGN AND METHODS

The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA(1c) determination during the study period. Multiple linear regression was used to examine the association of HbA(1c) level as well as change in HbA(1c) level with medication adherence, demographic, and clinical characteristics.

RESULTS

Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA(1c) decreased by 0.16% (P < 0.0001). Controlling for other demographic and clinical variables, the mean HbA(1c) of African-Americans was 0.29% higher than that of whites (P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA(1c) testing, or continuity of care.

CONCLUSIONS

Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.

Reaching underserved populations and cultural competence in diabetes education

Diabetes self-management education has gained in importance over the past decade as research has documented the benefits of such interventions in improving glucose control and reducing diabetes-related complications. Although minority populations bear a disproportionate burden of diabetes, past strategies have not addressed cultural characteristics of groups typically underrepresented in diabetes research. Recent research literature on the development of culturally competent diabetes self-management is summarized and an example of a culturally competent intervention designed for Spanish-speaking Mexican Americans is presented. Recent research is laying the foundation for future intervention development to meet the cultural needs of racial/ethnic groups.

Quality of diabetes care among low-income patients in North Carolina

BACKGROUND

Diabetes is a leading cause of death and disability, disproportionately affecting most ethnic minority groups, people of low socioeconomic status, the elderly, and people in rural areas. Despite the availability of evidence-based clinical recommendations, barriers exist in the delivery of appropriate diabetes care. The purpose of this study is to examine the level of diabetes care among low-income populations in North Carolina.

METHODS

Baseline medical record abstractions were performed (N=429) on diabetic patients at 11 agencies serving low-income populations (community health centers, free clinics, primary care clinics, and public health clinics) across the state participating in a quality-of-diabetes-care initiative. Data were collected for four process (measurement of glycosylated hemoglobin and lipids, dilated eye examination, nephropathy assessment) and two outcome (glycemic and lipid control) measures based on the Diabetes Quality Improvement Project (DQIP) and the Health Plan Employer Data and Information Set (HEDIS), and three additional indicators (blood pressure measurement and control, and lower limb assessment). Compliance rates to individual measures were calculated overall and by demographic and health characteristics.

RESULTS

Diabetes care compliance rates ranged from 77.9% for blood pressure testing to 3.3% for complete foot examinations. Differences in care were observed by age, insulin use, and prevalent disease.

CONCLUSIONS

This study indicates low compliance with diabetes care guidelines in underserved North Carolinians, and inconsistency of care according to some demographic and health characteristics. These results stress the need for quality improvement initiatives that enhance the level of care received by patients with diabetes, particularly those most vulnerable to diabetes and its complications.

Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry

PURPOSE

We sought to evaluate the effectiveness of self-monitoring blood glucose levels to improve glycemic control.

SUBJECTS AND METHODS

A cohort design was used to assess the relation between self-monitoring frequency (1996 average daily glucometer strip utilization) and the first glycosylated hemoglobin (HbA1c) level measured in 1997. The study sample included 24,312 adult patients with diabetes who were members of a large, group model, managed care organization. We estimated the difference between HbA1c levels in patients who self-monitored at frequencies recommended by the American Diabetes Association compared with those who monitored less frequently or not at all. Models were adjusted for age, sex, race, education, occupation, income, duration of diabetes, medication refill adherence, clinic appointment "no show" rate, annual eye exam attendance, use of nonpharmacological (diet and exercise) diabetes therapy, smoking, alcohol consumption, hospitalization and emergency room visits, and the number of daily insulin injections.

RESULTS

Self-monitoring among patients with type 1 diabetes (> or = 3 times daily) and pharmacologically treated type 2 diabetes (at least daily) was associated with lower HbA1c levels (1.0 percentage points lower in type 1 diabetes and 0.6 points lower in type 2 diabetes) than was less frequent monitoring (P < 0.0001). Although there are no specific recommendations for patients with nonpharmacologically treated type 2 diabetes, those who practiced self-monitoring (at any frequency) had a 0.4 point lower HbA1c level than those not practicing at all (P < 0.0001).

CONCLUSION

More frequent self-monitoring of blood glucose levels was associated with clinically and statistically better glycemic control regardless of diabetes type or therapy. These findings support the clinical recommendations suggested by the American Diabetes Association.

Detection of hypoglycemia with the GlucoWatch biographer

OBJECTIVE

Hypoglycemia is a common acute complication of diabetes therapy. The GlucoWatch biographer provides frequent and automatic glucose measurements with an adjustable low-glucose alarm. We have analyzed the performance of the biographer low-glucose alarm relative to hypoglycemia as defined by blood glucose < or = 3.9 mmol/l.

RESEARCH DESIGN AND METHODS

The analysis was based on 1,091 biographer uses from four clinical trials. which generated 14,487 paired (biographer and blood glucose) readings.

RESULTS

The results show that as the low-glucose alert level of the biographer is increased, the number of true positive alerts (alarm sounds and blood glucose < or = 3.9 mmol/l) and false positive alerts (alarm sounds but blood glucose >3.9 mmol/l) increased. When analyzed as a function of varying low-glucose alert levels, the results show receiver operator characteristic curves consistent with a highly useful diagnostic tool. Setting the alert level from 1.1 to 1.7 mmol/l above the level of concern is likely to optimize the trade-off between true positives and false positives for each user. When the same blood glucose data are analyzed for typical monitoring practices (two or four measurements per day), the results show that fewer hypoglycemic events are detected than those detected with the biographer.