Diabetes health disparities: a systematic review of health care interventions

Interventions to improve care related to colorectal cancer among racial and ethnic minorities: a systematic review

OBJECTIVE

To systematically review the literature to identify interventions that improve minority health related to colorectal cancer care.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL, and Cochrane databases, from 1950 to 2010.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Interventions in US populations eligible for colorectal cancer screening, and composed of ≥50 % racial/ethnic minorities (or that included a specific sub-analysis by race/ethnicity). All included studies were linked to an identifiable healthcare source. The three authors independently reviewed the abstracts of all the articles and a final list was determined by consensus. All papers were independently reviewed and quality scores were calculated and assigned using the Downs and Black checklist.

RESULTS

Thirty-three studies were included in our final analysis. Patient education involving phone or in-person contact combined with navigation can lead to modest improvements, on the order of 15 percentage points, in colorectal cancer screening rates in minority populations. Provider-directed multi-modal interventions composed of education sessions and reminders, as well as pure educational interventions were found to be effective in raising colorectal cancer screening rates, also on the order of 10 to 15 percentage points. No relevant interventions focusing on post-screening follow up, treatment adherence and survivorship were identified.

LIMITATIONS

This review excluded any intervention studies that were not tied to an identifiable healthcare source. The minority populations in most studies reviewed were predominantly Hispanic and African American, limiting generalizability to other ethnic and minority populations.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Tailored patient education combined with patient navigation services, and physician training in communicating with patients of low health literacy, can modestly improve adherence to CRC screening. The onus is now on researchers to continue to evaluate and refine these interventions and begin to expand them to the entire colon cancer care continuum.

Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review

OBJECTIVES

To systematically review the literature to determine which interventions improve the screening, diagnosis or treatment of cervical cancer for racial and/or ethnic minorities.

DATA SOURCES

Medline on OVID, Cochrane Register of Controlled Trials, CINAHL, PsycINFO and Cochrane Systematic Reviews.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

We searched the above databases for original articles published in English with at least one intervention designed to improve cervical cancer prevention, screening, diagnosis or treatment that linked participants to the healthcare system; that focused on US racial and/or ethnic minority populations; and that measured health outcomes. Articles were reviewed to determine the population, intervention(s), and outcomes. Articles published through August 2010 were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

One author rated the methodological quality of each of the included articles. The strength of evidence was assessed using the criteria developed by the GRADE Working Group.

RESULTS

Thirty-one studies were included. The strength of evidence is moderate that telephone support with navigation increases the rate of screening for cervical cancer in Spanish- and English-speaking populations; low that education delivered by lay health educators with navigation increases the rate of screening for cervical cancer for Latinas, Chinese Americans and Vietnamese Americans; low that a single visit for screening for cervical cancer and follow up of an abnormal result improves the diagnosis and treatment of premalignant disease of the cervix for Latinas; and low that telephone counseling increases the diagnosis and treatment of premalignant lesions of the cervix for African Americans.

LIMITATIONS

Studies that did not focus on racial and/or ethnic minority populations may have been excluded. In addition, this review excluded interventions that did not link racial and ethnic minorities to the health care system. While inclusion of these studies may have altered our findings, they were outside the scope of our review.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Patient navigation with telephone support or education may be effective at improving screening, diagnosis, and treatment among racial and ethnic minorities. Research is needed to determine the applicability of the findings beyond the populations studied.

Interventions to improve outcomes for minority adults with asthma: a systematic review

OBJECTIVES

To systematically review the literature to characterize interventions with potential to improve outcomes for minority patients with asthma.

DATA SOURCES

Medline, PsycINFO, CINAHL, Cochrane Trial Databases, expert review, reference review, meeting abstracts. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTEVENTIONS: Medical Subject Heading (MeSH) terms related to asthma were combined with terms to identify intervention studies focused on minority populations.

INCLUSION CRITERIA

adult population; intervention studies with majority of non-White participants. STUDY APPRAISAL AND SYNTHESIS OF METHODS: Study quality was assessed using Downs and Black (DB) checklists. We examined heterogeneity of studies through comparing study population, study design, intervention characteristics, and outcomes.

RESULTS

Twenty-four articles met inclusion criteria. Mean quality score was 21.0. Study populations targeted primarily African American (n = 14), followed by Latino/a (n = 4), Asian Americans (n = 1), or a combination of the above (n = 5). The most commonly reported post-intervention outcome was use of health care resources, followed by symptom control and self-management skills. The most common intervention-type studied was patient education. Although less-than half were culturally tailored, language-appropriate education appeared particularly successful. Several system-level interventions focused on specialty clinics with promising findings, although health disparities collaboratives did not have similarly promising results.

LIMITATIONS

Publication bias may limit our findings; we were unable to perform a meta-analysis limiting the review's quantitative evaluation.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. Few were culturally tailored and one included a comparison group, limiting the conclusions that can be drawn from cultural tailoring. System-redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Future research should evaluate the role of tailoring educational strategies, focus on patient-centered education, and incorporate outpatient follow-up and/or a team-based approach.

A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care

Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care. Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities. Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care. The roadmap outlines a dynamic process in which individual interventions are just one part. It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts. Additionally, we summarize the major lessons learned through the Finding Answers program. We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature. Our research shows that promising interventions frequently are culturally tailored to meet patients' needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient's pathway of care. Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches. Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients. We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care.

Racial/ethnic disparities in the prevalence of selected chronic diseases among US Air Force members, 2008

INTRODUCTION

Few studies have evaluated possible racial/ethnic disparities in chronic disease prevalence among US Air Force active-duty members. Because members have equal access to free health care and preventive screening, the presence of health disparities in this population could offer new insight into the source of these disparities. Our objective was to identify whether the prevalence of 4 common chronic diseases differed by race/ethnicity in this population.

METHODS

We compiled de-identified clinical and administrative data for Air Force members aged 21 or older who had been on active duty for at least 12 months as of October 2008 (N = 284,850). Multivariate logistic regression models were used to determine the prevalence of hypertension, dyslipidemia, type 2 diabetes, and asthma by race/ethnicity, controlling for rank and sex.

RESULTS

Hypertension was the most prevalent chronic condition (5.3%), followed by dyslipidemia (4.6%), asthma (0.9%), and diabetes (0.3%). Significant differences were noted by race/ethnicity for all conditions. Compared with non-Hispanic whites, the prevalence of all chronic diseases was higher for non-Hispanic blacks; disparities for adults of other minority race/ethnicity categories were evident but less consistent.

CONCLUSION

The existence of racial/ethnic disparities among active-duty Air Force members, despite equal access to free health care, indicates that premilitary health risks continue after enlistment. Racial and ethnic disparities in the prevalence of these chronic diseases suggest the need to ensure preventive health care practices and community outreach efforts are effective for racial/ethnic minorities, particularly non-Hispanic blacks.

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.

Home Availability and the Impact of Weekly Stressful Events Are Associated with Fruit and Vegetable Intake among African American and Hispanic/Latina Women

Background. Mediating and moderating variables may interfere with the association between neighborhood availability of grocery stores (NAG) and supermarkets (NAS) and fruit and vegetable (FV) intake. Objective. The purpose of this study was to test mediation of home availability of FV (HAFV) and moderation of impact of weekly stressful events (IWSE) on the association between NAG and NAS with FV consumption among African American (AA) and Hispanic/Latina (HL) women. Methods. Three hundred nine AA and HL, 25-60 year old women in the Health Is Power (HIP) randomized controlled trial completed validated measures of HAFV, IWSE, and FV intake at baseline. Trained field assessors coded NAG and NAS. Institutional Review Board approval was obtained. Results. NAG and NAS were not associated with FV intake or HAFV, so HAFV was not a mediator. HAFV (std. Beta = .29, P < 0.001) and IWSE (std. Beta = .17; P < 0.05) were related to FV intake (R(2) = 0.17; P < 0.001), but IWSE was not a moderator. Conclusion. Increasing HAFV and decreasing the IWSE should increase FV consumption. The extent to which the neighborhood environment is related to the home food environment and diet, and the mechanisms for the association between IWSE and diet should be examined in future research.

Early lessons from an initiative on Chicago's South Side to reduce disparities in diabetes care and outcomes

Interventions to improve health outcomes among patients with diabetes, especially racial or ethnic minorities, must address the multiple factors that make this disease so pernicious. We describe an intervention on the South Side of Chicago-a largely low-income, African American community-that integrates the strengths of health systems, patients, and communities to reduce disparities in diabetes care and outcomes. We report preliminary findings, such as improved diabetes care and diabetes control, and we discuss lessons learned to date. Our initiative neatly aligns with, and can inform the implementation of, the accountable care organization-a delivery system reform in which groups of providers take responsibility for improving the health of a defined population.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial

BACKGROUND

Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

OBJECTIVE

To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.

DESIGN

A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956)

SETTING

Philadelphia Veterans Affairs Medical Center.

PATIENTS

African American veterans aged 50 to 70 years with persistently poor diabetes control.

INTERVENTION

118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%.

MEASUREMENTS

Change in HbA(1c) level at 6 months.

RESULTS

Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group.

LIMITATION

The study included only veterans and lasted only 6 months.

CONCLUSION

Peer mentorship improved glucose control in a cohort of African American veterans with diabetes.

PRIMARY FUNDING SOURCE

National Institute on Aging Roybal Center.

Does SES explain more of the black/white health gap than we thought? Revisiting our approach toward understanding racial disparities in health

Studies of racial health gaps often find that disparities persist even after adjusting for socioeconomic status (SES). We contend that the persistent residual variation may, in part, be the result of conceptual and methodological problems in the operationalization of SES. These include inadequate attention to the content validity of SES measures and insufficient adjustments for SES differences across racial groups. Using data from the 1997-2007 U.S. Panel Study of Income Dynamics (N = 9932), we use longitudinal and multi-level measures of SES and apply a propensity score adjustment strategy to examine the black/white disparity in self-rated health. Compared to conventional regression estimates that yield unexplained racial health gaps, propensity score adjustment accounts for the entire racial disparity in self-rated health. Results suggest that previous studies may have inadequately adjusted for differences in SES across racial groups, that social factors should be carefully and conscientiously considered, and that acknowledgment of the possibility of incomplete SES adjustments should be weighed before any inferences to non-SES etiology can be made.

Clinicians' views of an intervention to reduce racial disparities in diabetes outcomes

RATIONALE

Interventions that improve clinicians' awareness of racial disparities and improve their communication skills are considered promising strategies for reducing disparities in health care. We report clinicians' views of an intervention involving cultural competency training and race-stratified performance reports designed to reduce racial disparities in diabetes outcomes.

RESEARCH DESIGN AND METHODS

Semistructured interviews were conducted with 12 physicians and 5 nurse practitioners who recently participated in a randomized intervention to reduce racial disparities in diabetes outcomes. Clinicians were asked open-ended questions about their attitudes towards the intervention, the causes of disparities, and potential solutions to them.

RESULTS

Thematic analysis of the interviews showed that most clinicians acknowledged the presence of racial disparities in diabetes control among their patients. They described a complex set of causes, including socioeconomic factors, but perceived only some causes to be within their power to change, such as switching patients to less-expensive generic drugs. The performance reports and training were generally well received but some clinicians did not feel empowered to act on the information. All clinicians identified additional services that would help them address disparities; for example, culturally tailored nutrition advice. Some clinicians challenged the premise of the intervention, focusing instead on socioeconomic factors as the primary cause of disparities rather than on patients' race.

CONCLUSIONS

The cultural competency training and performance reports were well received by many but not all of the clinicians. Clinicians reported the intervention alone had not empowered them to address the complex, root causes of racial disparities in diabetes outcomes.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial

BACKGROUND

Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

OBJECTIVE

To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.

DESIGN

A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956)

SETTING

Philadelphia Veterans Affairs Medical Center.

PATIENTS

African American veterans aged 50 to 70 years with persistently poor diabetes control.

INTERVENTION

118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%.

MEASUREMENTS

Change in HbA(1c) level at 6 months.

RESULTS

Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group.

LIMITATION

The study included only veterans and lasted only 6 months.

CONCLUSION

Peer mentorship improved glucose control in a cohort of African American veterans with diabetes.

PRIMARY FUNDING SOURCE

National Institute on Aging Roybal Center.

Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial

BACKGROUND

Compared with white persons, African Americans have a greater incidence of diabetes, decreased control, and higher rates of microvascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes.

OBJECTIVE

To determine whether peer mentors or financial incentives are superior to usual care in helping African American veterans decrease their hemoglobin A(1c) (HbA(1c)) levels.

DESIGN

A 6-month randomized, controlled trial. (ClinicalTrials.gov registration number: NCT01125956)

SETTING

Philadelphia Veterans Affairs Medical Center.

PATIENTS

African American veterans aged 50 to 70 years with persistently poor diabetes control.

INTERVENTION

118 patients were randomly assigned to 1 of 3 groups: usual care, a peer mentoring group, and a financial incentives group. Usual care patients were notified of their starting HbA(1c) level and recommended goals for HbA(1c). Those in the peer mentoring group were assigned a mentor who formerly had poor glycemic control but now had good control (HbA(1c) level ≤7.5%). The mentor was asked to talk with the patient at least once per week. Peer mentors were matched by race, sex, and age. Patients in the financial incentive group could earn $100 by decreasing their HbA(1c) level by 1% and $200 by decreasing it by 2% or to an HbA(1c) level of 6.5%.

MEASUREMENTS

Change in HbA(1c) level at 6 months.

RESULTS

Mentors and mentees talked the most in the first month (mean calls, 4; range, 0 to 30), but calls decreased to a mean of 2 calls (range, 0 to 10) by the sixth month. Levels of HbA(1c) decreased from 9.9% to 9.8% in the control group, from 9.8% to 8.7% in the peer mentor group, and from 9.5% to 9.1% in the financial incentive group. Mean change in HbA(1c) level from baseline to 6 months relative to control was -1.07% (95% CI, -1.84% to -0.31%) in the peer mentor group and -0.45% (CI, -1.23% to 0.32%) in the financial incentive group.

LIMITATION

The study included only veterans and lasted only 6 months.

CONCLUSION

Peer mentorship improved glucose control in a cohort of African American veterans with diabetes.

PRIMARY FUNDING SOURCE

National Institute on Aging Roybal Center.

Self-reported neighborhood safety and nonadherence to treatment regimens among patients with type 2 diabetes

BACKGROUND

Few studies have explored the association between neighborhood characteristics and adherence to diabetes self-management behaviors, and none have examined the influence of neighborhood safety on adherence to treatment regimens among patients with diabetes.

OBJECTIVE

To assess whether neighborhood safety is associated with self-reports of technical quality of care and with nonadherence to diabetes treatment regimens.

DESIGN

A cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression models were used to examine the association of self-reported neighborhood safety with technical quality of care and treatment nonadherence, adjusted for sociodemographic characteristics, barriers to access to care, and health status.

PARTICIPANTS

Adults with type 2 diabetes currently receiving medical treatment.

MAIN MEASURES

Patient-reported neighborhood safety, performance of recommended processes of care by provider, treatment nonadherence (patient delays in filling prescriptions and obtaining needed medical care).

KEY RESULTS

Self-reported neighborhood safety was not associated with process measures of technical quality of care, but was associated with treatment nonadherence. Specifically, compared to those who report living in a safe neighborhood, a higher proportion of patients living in unsafe neighborhoods reported delays in filling a prescription for any reason (21.9% vs. 12.8%, aOR = 1.69, 95%CI 1.19, 2.40) and delays in filling a prescription due to cost (12.2% vs. 6.8%, aOR = 1.63, 95%CI 1.02, 2.62).

CONCLUSIONS

Contextual factors, such as neighborhood safety, may contribute to treatment nonadherence in daily life, even when the technical quality of care delivered in the clinic is not diminished.

The twin epidemics of poverty and diabetes: understanding diabetes disparities in a low-income Latino and immigrant neighborhood

In the United States, low-income immigrant groups experience greater health disparities and worse health-related outcomes than Whites, including but not limited to higher rates of type 2 diabetes (T2DM). The prevention and adequate management of T2DM are, to a great extent, contingent on access to healthy food environments. This exploratory study examines "upstream" antecedent factors contributing to "downstream" health disparities, with a focus on disparities in the structural sources of T2DM risk, especially food environments. Our target group is Latino immigrants receiving services from a non-profit organization (NGO) in Northern California. Methods are mixed and data include focus groups and surveys of our target group, interviews to NGO staff members, and estimation of the thrifty food market basket in local grocery stores. We find that while participants identify T2DM as the greatest health problem in the community, access to healthy foods is severely restricted, geographically, culturally, and economically, with 100% of participants relying on formal or informal food assistance and local food stores offering limited variety of healthy foods and at unaffordable prices. While this article is empirical, its goal is primarily conceptual--to integrate empirical findings with the growing literature underscoring the sociopolitical context of the social determinants of health in general and of T2DM disparities in particular. We propose that interventions to reduce T2DM and comparable health disparities must incorporate a social justice perspective that guarantees a right to adequate food and other health-relevant environments, and concomitantly, a right to health.

Racial/ethnic variation in prevalence estimates for United States prediabetes under alternative 2010 American Diabetes Association criteria: 1988-2008

OBJECTIVE

To compare the racial/ethnic variation in United States prediabetes prevalence estimates for alternative prediabetes definitions currently approved by the American Diabetes Association (ADA) across 20 years and in detailed multivariate comparisons.

DESIGN

Using nationally representative National Health and Nutrition Examination Survey (NHANES) data from 1988-2008, we compared trends in the prevalence of impaired fasting glucose (IFG) and impaired glycated hemoglobin (IGH) for non-Hispanic Black, non-Hispanic White, and Mexican American/other Hispanic adults. Using NHANES 2005-2008, we compared prevalence by race/ethnicity in more detail for the three current ADA prediabetes definitions--IFG, IGH, and impaired glucose tolerance (IGT)--controlling for associated factors (education, income, weight, age, sex).

RESULTS

Prediabetes prevalence during the last 20 years was consistently significantly lower among non-Hispanic Blacks compared to non-Hispanic Whites when measured by IFG, but was significantly higher among non-Hispanic Blacks when measured by IGH. In adjusted models, non-Hispanic Blacks were significantly more likely than non-Hispanic Whites to have IGH (OR: 2.22; 95% CI: 1.33-3.70) and less likely to have IFG (OR: 0.46; 0.30-0.73) or IGT (OR: 0.35; 0.24-0.50), but Mexican American/other Hispanic rates did not differ significantly from non-Hispanic White rates. However, rates of prediabetes, when defined by any of three individual diagnostic criteria, were not statistically significantly different across groups (36.8% for non-Hispanic Whites, 36.0% AA, 37.3% Mexican American/other Hispanics).

CONCLUSIONS

National prediabetes prevalence estimates vary dramatically across racial/ethnic groups according to diagnostic method, though over 35% in all three racial/ethnic groups met at least one ADA diagnostic criteria for prediabetes.

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.

Patient access to healthcare services and optimisation of self-management for ethnic minority populations living with diabetes: a systematic review

A higher risk of diabetes mellitus in South Asian and Black African populations combined with lower reported access and self-management-related health outcomes informed the aims of this study. Our aims were to synthesise and evaluate evidence relating to patient self-management and access to healthcare services for ethnic minority groups living with diabetes. A comprehensive search strategy was developed capturing a full range of study types from 1995-2010, including relevant hand-searched literature pre-dating 1995. Systematic database searches of MEDLINE, Cochrane, DARE, HTA and NHSEED, the British Nursing Index, CAB abstracts, EMBASE, Global Health, Health Management Information Consortium and PsychInfo were conducted, yielding 21,288 abstracts. Following search strategy refinement and the application of review eligibility criteria; 11 randomised controlled trials (RCTs), 18 qualitative studies and 18 quantitative studies were evaluated and principal results extracted. Results suggest that self-management practices are in need of targeted intervention in terms of patients' knowledge and understanding of their illness, inadequacy of information and language and communication difficulties arising from cultural differences. Access to health-care is similarly hindered by a lack of cultural sensitivity in service provision and under use of clinic-based interpreters and community-based services. Recommendations for practice and subsequent intervention primarily rest at the service level but key barriers at patient and provider levels are also identified.

Predictors of adherence with self-care guidelines among persons with type 2 diabetes: results from a logistic regression tree analysis

Type 2 diabetes is known to contribute to health disparities in the U.S. and failure to adhere to recommended self-care behaviors is a contributing factor. Intervention programs face difficulties as a result of patient diversity and limited resources. With data from the 2005 Behavioral Risk Factor Surveillance System, this study employs a logistic regression tree algorithm to identify characteristics of sub-populations with type 2 diabetes according to their reported frequency of adherence to four recommended diabetes self-care behaviors including blood glucose monitoring, foot examination, eye examination and HbA1c testing. Using Andersen's health behavior model, need factors appear to dominate the definition of which sub-groups were at greatest risk for low as well as high adherence. Findings demonstrate the utility of easily interpreted tree diagrams to design specific culturally appropriate intervention programs targeting sub-populations of diabetes patients who need to improve their self-care behaviors. Limitations and contributions of the study are discussed.

A critical review of diabetes, glycemic control, and dental implant therapy

OBJECTIVES

To systematically examine the evidence guiding the use of implant therapy relative to glycemic control for patients with diabetes and to consider the potential for both implant therapy to support diabetes management and hyperglycemia to compromise implant integration.

MATERIAL AND METHODS

A systematic approach was used to identify and review clinical investigations directly assessing implant survival or failure for patients with diabetes. A MEDLINE (PubMED) database search identified potential articles for inclusion using the search strategy: (dental implants OR oral implants) AND (diabetes OR diabetic). Inclusion in this review required longitudinal assessments including at least 10 patients, with included articles assessed relative to documentation of glycemic status for patients.

RESULTS

Although the initial search identified 129 publications, this was reduced to 16, for inclusion. Reported implant failure rates for diabetic patients ranged from 0% to 14.3%. The identification and reporting of glycemic control was insufficient or lacking in 13 of the 16 studies with 11 of these enrolling only patients deemed as having acceptable glycemic control, limiting interpretation of findings relative to glycemic control. Three of the 16 studies having interpretable information on glycemic control failed to demonstrate a significant relationship between glycemic control and implant failure, with failure rates ranging from 0% to 2.9%.

CONCLUSIONS

Clinical evidence is lacking for the association of glycemic control with implant failure while support is emerging for implant therapy in diabetes patients with appropriate accommodations for delays in implant integration based on glycemic control. The role for implants to improve oral function in diabetes management and the effects of hyperglycemia on implant integration remain to be determined.

Addressing diabetes racial and ethnic disparities: lessons learned from quality improvement collaboratives

A review of national data confirms that while the quality of healthcare in the USA is slowly improving, disparities in diabetes prevalence, processes of care and outcomes for racial/ethnic minorities are not. Many quality measures can be addressed through system level interventions, referred to as quality improvement (QI), and QI collaboratives have been found to effectively improve processes of care for chronic conditions, including diabetes. However, the impact of QI collaboratives on the reduction of health disparities has been mixed. Lessons learned from previous QI collaboratives including the complexity of impacting clinical outcomes, the need for expert support for skills outside of QI methodology, limiting impact of poor data, and the need to develop disparities quality measures, can be used to inform future QI collaborative approaches to reduce diabetes racial/ethnic minority health disparities.

Racial and ethnic disparities in the quality of diabetes care in a nationally representative sample

INTRODUCTION

Previous studies have consistently documented that racial/ethnic minority patients with diabetes receive lower quality of care, based on various measures of quality of care and care settings. However, 2 recent studies that used data from Medicare or Veterans Administration beneficiaries have shown improvements in racial/ethnic disparities in the quality of diabetes care. These inconsistencies suggest that additional investigation is needed to provide new information about the relationship between racial/ethnic minority patients and the quality of diabetes care.

METHODS

We analyzed 3 years of data (2005-2007) from the Medical Expenditure Panel Survey and used multivariate models that adjusted for sociodemographic characteristics, regional location, insurance status, health behaviors, health status, and comorbidity to examine racial/ethnic disparities in the quality of diabetes care.

RESULTS

We found that Asian patients with diabetes were less likely to have received 2 or more glycated hemoglobin (HbA1c) tests or a foot examination during the past year compared with their white counterparts. Hispanic patients with diabetes were also less likely to have received a foot examination during the past year compared with white patients with diabetes. Conversely, black patients with diabetes were more likely to have received a foot examination during the past year compared with white patients with diabetes. The differences in the quality of diabetes care remained significant even after controlling for socioeconomic status (SES), health insurance status, self-rated health status, comorbid conditions, and lifestyle behavior variables.

CONCLUSION

Although the link between racial/ethnic minority status and the quality of care for patients with diabetes is not completely understood, our results suggest that factors such as SES, health insurance status, self-rated health status, and other health conditions are potential antecedents of quality of diabetes care.

Feasibility and usability of a text message-based program for diabetes self-management in an urban African-American population

PURPOSE

We pilot-tested a text message-based diabetes care program in an urban African-American population in which automated text messages were sent to participants with personalized medication, foot care, and appointment reminders and text messages were received from participants on adherence.

METHODS

Eighteen patients participated in a 4-week pilot study. Baseline surveys collected data about demographics, historical cell phone usage, and adherence to core diabetes care measures. Exit interview surveys (using close-coded and open-ended questions) were administered to patients at the end of the program. A 1-month follow-up interview was conducted surveying patients on perceived self-efficacy. Wilcoxon signed-rank tests were used to compare baseline survey responses about self-management activities to those at the pilot's end and at 1-month follow-up.

RESULTS

Eighteen urban African-American participants completed the pilot study. The average age was 55 and the average number of years with diabetes was 8. Half the participants were initially uncomfortable with text messaging. Example messages include "Did you take your diabetes medications today" and "How many times did you check your feet for wounds this week?" Participants averaged 220 text messages with the system, responded to messages 80% of the time, and on average responded within 6 minutes. Participants strongly agreed that text messaging was easy to perform and helped with diabetes self-care. Missed medication doses decreased from 1.6 per week to 0.6 (p = .003). Patient confidence in diabetes self-management was significantly increased during and 1 month after the pilot (p = .002, p = .008).

CONCLUSIONS

Text messaging may be a feasible and useful approach to improve diabetes self-management in urban African Americans.

The role of information in supporting self-care in vascular conditions: a conceptual and empirical review

Self-care has the potential to make a significant contribution to vascular conditions, but engagement with self-care support has been limited. Lack of relevant information is highlighted by patients and policy-makers as an important barrier to effective self-care, and information provides a potentially efficient platform for changing behaviour. However, work within the social sciences has generally seen information as a necessary but insufficient driver of health behaviours. Furthermore, some groups (such as the socially disadvantaged) are expected to be less amenable to information interventions. We conducted an integrated conceptual and empirical review on information-based interventions for people with vascular disease (diabetes, heart disease and kidney disease). We reviewed conceptual and empirical work concerning the role and impact of information in self-care support to generate an explanatory framework to determine why information was effective or ineffective in encouraging self-care in patients with vascular conditions. This involved mapping relevant theories and models linking information and self-care. We also explored published systematic reviews of educational interventions in diabetes, coronary heart disease and chronic kidney disease to examine the role of information and evidence concerning its effectiveness and impact in different patient populations. The conceptual review identified variation among information interventions in terms of type, function, and their relationship to behaviour change techniques and psychological mediators of behaviour change. Key moderators of the effect of information included types of disorder, and patient capacity and resources. A wealth of educational interventions exists for diabetes and heart conditions, but the precise components of these interventions that are effective are difficult to identify. There is little evidence concerning optimal ways of tailoring interventions for socially disadvantaged groups other than ethnic minorities. A focus on printed information may not provide access to effective methods of information delivery (e.g. tailored information, use of narratives and user generated content). Developing a framework for the effective use of information needs to take account the full range of the factors identified.

Implications of the new definition of diabetes for health disparities

In July 2009, an international committee announced a new diagnostic criterion for diabetes based on hemoglobin Alc (HbA1c) values. Our objective was to estimate how the new diabetes diagnostic criterion will affect the prevalence of diabetes among different race, age, and gender subpopulations, compared to the previously used fasting plasma glucose (FPG) criterion. We analyzed nationally representative data from The National Health and Nutrition Examination Survey (NHANES), aggregated from 1999 to 2006. We estimated the prevalence of known diabetes (prevalence static across either diagnostic criterion), unknown, and no diabetes (prevalence variable by criterion). We tested statistical significance of prevalence differences for unknown diabetes between the prior diagnostic criterion--FPG of at least 126 mg/dL--and the new diagnostic criterion--HbA1c of at least 6.5%--using conditional logistic regression. We further tested the association of these differences with demographic factors. The new HbA1c diagnostic criterion differentially affects different racial/ethnic groups. For non-Hispanic whites, the prevalence of undiagnosed diabetes was more than halved from 2.6% (95% confidence interval [CI], 2.2-3.1) with FPG diagnosis to 1.3% (95% CI, 1.0-1.7), P<.001 with HbAic diagnosis. For Hispanics and non-Hispanic blacks, the differences in prevalence by the 2 criteria were smaller and nonsignificant. Racial differences by diagnostic criteria were most pronounced among people aged over 55 years. Overall, the new definition of diabetes differentially affects ethnic groups, especially for older people. If the new criterion is widely adopted, over time, we may see an apparent widening of racial/ethnic disparities in diabetes prevalence.

Self-reported racial discrimination in health care and diabetes outcomes

BACKGROUND

Self-reported racial discrimination in healthcare has been associated with negative health outcomes, but little is known about its association with diabetes outcomes.

METHODS

We used data from the Behavioral Risk Factor Surveillance System to investigate associations between self-reported healthcare discrimination and the following diabetes outcomes: (1) quality of care, (2) self-management and (3) complications.

RESULTS

In unadjusted logistic regression models, significant associations were found between self-reported healthcare discrimination and most measures of quality of care [diabetes-related primary care visits odds ratio (OR), 0.38; 95% confidence interval (CI), 0.21-0.66), HbA1c testing (OR, 0.42; 95%CI, 0.21-0.82), and earlier eye examination interval (OR, 0.48; 95% CI, 0.24-0.93)] and health outcomes [foot disorders (OR, 2.32, 95%CI: 1.15, 4.68) and retinopathy (OR, 2.26; 95%CI, 1.24-4.12)], but not the number of provider foot examinations (P=0.48) or diabetes self-management (self glucose monitoring, P=0.42; self foot examinations, P=0.74; diabetes class participation, P=0.37). The effects of self-reported discrimination were attenuated or eliminated after controlling for sociodemographics, health status, and access to care.

CONCLUSIONS

Self-reported racial/ethnic discrimination in healthcare was associated with worse diabetes care and more diabetes complications, but not self-care behaviors, suggesting that factors beyond patients' own behaviors may be the main source of differential outcomes. The relationships between self-reported discrimination and diabetes outcomes were eliminated once adjusting for sociodemographics, health status, and access to care. Our findings suggest that other factors (ie, race, insurance, health status) may play equally or more important roles in determining diabetes health disparities, and that a comprehensive strategy is needed to effectively address health disparities.

Organizing and delivering diabetes education and self-care support: findings of scoping project

OBJECTIVE

To provide an overview of current research and development on the organization and delivery of diabetes education and self-care support, incorporating stakeholder perspectives.

METHOD

Four methods were used: literature review (159 papers and 52 grey literature items); patient participation event (n = 38); online survey of professionals (n = 423) and patients (n= 495); and, a conference.

RESULTS

The literature review identified themes relating to the organization and delivery of diabetes and self-care support: structure and flexibility in models of education; accessibility; patient choice; integrating self-care within the overall care system; quality improvement; peer educators; health literacy; efficiency in delivery; telecare models; feedback technologies; care planning; psychological intervention; and self-care outcome measures. This generated four models to provide a framework to help shape the development of diabetes self-care: a diabetes education pathway; integrating self-care and clinical care; choice as a method of optimizing care; and an integrated framework for delivering diabetes self-care.

CONCLUSION

The clinical benefit of the identified models need to be evaluated.

Acculturation, nutrition, and health disparities in Latinos

BACKGROUND

Latinos have become the largest minority group in the United States and will represent 25% of the US population by 2050. Latinos experience a disproportionate burden of poverty and poor health outcomes.

OBJECTIVES

We critically examined the evidence for a link between acculturation and health disparities in Latinos with a focus on type 2 diabetes (T2D) and nutrition-related risk factors and illustrated how acculturation principles can help design a culturally appropriate T2D self-management intervention in Latinos.

DESIGN

Evidence presented in this article was drawn from 1) systematic reviews identified through PubMed searches, 2) backward searches that were based on articles cited, 3) experts in the field, and 4) the author's personal files.

RESULTS

The preponderance of the evidence supported an association of acculturation with poor dietary quality and obesity. These associations appeared to be modified by several socioeconomic and demographic factors and were not always linear. The association between acculturation and T2D is unclear.

CONCLUSIONS

Longitudinal studies and more sophisticated analytic approaches are needed to better understand if and how acculturation affects health-disparity outcomes in Latinos. Tailoring interventions to the acculturation level of individuals is likely to help reduce health disparities in Latinos.

Are there racial differences in patients' shared decision-making preferences and behaviors among patients with diabetes?

BACKGROUND

In the United States, African Americans are more likely to experience lower quality patient/provider communication and less shared decision making (SDM) than whites, which may be an important contributor to racial health disparities. Patient factors have not been fully explored as a potential contributor to communication disparities.

METHODS

The authors analyzed cross-sectional data from a survey of 974 patients with diabetes seen at 34 community health centers (HC) in 17 midwestern and west-central states. They used ordinal and logistic regression models to investigate racial differences in patients' preferences for SDM and in patients' behaviors that may facilitate SDM (initiating discussions about diabetes care).

RESULTS

The response rate was 67%. In bivariate and multivariate analyses, race was not associated with patient preference for a shared role in the 3 measured SDM domains: agenda setting (odds ratio [OR]: 1.13 [0.86, 1.49]), information sharing (OR: 1.26 [0.97, 1.64]), or decision making (OR: 1.16 [0.85, 1.59]). African Americans were more likely to report initiating discussions with their physicians about 4 of 6 areas of diabetes care-blood pressure measurement (66% v. 52%, P < 0.001), foot examination (54% v. 47%, P = 0.04), eye examination (57% v. 46%, P = 0.002), and microalbumin testing (38% v. 29%, P = 0.01)-but not HbA1c testing (39% v. 43%, P = 0.31) or cholesterol testing (53% v. 51%, P = 0.52). In multivariate analysis, African Americans were still more likely to report initiating conversations about diabetes care (OR: 1.78 [1.10, 2.89]).

CONCLUSIONS

The authors found that African Americans in this study preferred shared decision making as much as whites and were more likely to report initiating more discussions with their doctors about their diabetes care. This research suggests that, among diabetes patients receiving care at community health centers, patient preference or patient behaviors may be an unlikely cause of racial differences in shared decision making.

Interactive media for diabetes self-management: issues in maximizing public health impact

BACKGROUND

Diabetes self-management presents a series of challenging tasks, and primary care, where the majority of cases of adult diabetes are treated, is hard-pressed to address these issues given competing demands. This article discusses how interactive media (IM) can be used to support diabetes self-management.

METHODS

Following a brief review of the literature, the 5 As framework for enhancing the effectiveness of health behavior counseling and the RE-AIM model for estimating and enhancing public health impact are used to frame discussion of the strengths and limitations of IM for diabetes shared decision making and self-management support.

RESULTS

Data and lessons learned from a series of randomized trials of IM for diabetes self-management education are summarized around 2 key issues. The first is enhancing patient engagement in decision making and includes enhancing user experience and engagement, improving quality of care, and promoting collaborative action planning and follow-up. The second is getting such resources into place and sustaining them in real-world primary care settings and involves enhancing participation at patient, clinician, and health care system levels and enhancing the generalizability of results.

CONCLUSIONS

. Key opportunities for IM to support diabetes self-management include assessment of information for shared decision making, assistance with problem-solving self-management challenges, and provision of follow-up support. A key current challenge is the linkage of IM supports to the rest of the patient's care, and collection of cost-effectiveness data is a key need for future research.

Measuring quality of life in low-income, Spanish-speaking Puerto Ricans with type 2 diabetes residing in the mainland U.S

PURPOSE

This study assessed the psychometric properties of the Audit of Diabetes-Dependent Quality of Life (ADDQoL) modified for low-income, low-education, Spanish-speaking Puerto Ricans with type 2 diabetes residing in the northeastern United States.

METHODS

Cross-sectional data from 226 patients were analyzed. Scale modifications included simplification of instructions, question wording and response format, and oral administration. Reliability was assessed with Cronbach's alpha coefficient and internal structure by exploratory factor analysis. Criterion validity was assessed using correlation analysis and linear and logistic regression models assessing the association of the ADDQoL with standardized physical health status, mental health status, depression, and comorbidity indices.

RESULTS

Two ADDQoL items were dropped. The modified scale had excellent internal consistency and supported the original scale factor structure. Criterion validity results supported the validity of this measure.

CONCLUSIONS

The modified ADDQoL showed psychometric properties that support its use in low-income, Spanish-speaking Puerto Ricans with type 2 diabetes who reside in mainland U.S.

Transforming the urban food desert from the grassroots up: a model for community change

Confronted by continuing health disparities in vulnerable communities, Community Health Councils (CHC), a nonprofit community-based organization in South Los Angeles, worked with the African Americans Building a Legacy of Health Coalition and research partners to develop a community change model to address the root causes of health disparities within the community's African American population. This article discusses how the CHC Model's development and application led to public policy interventions in a "food desert." The CHC Model provided a systematic approach to engaging impacted communities in support of societal level reforms, with the goal to influence health outcomes.

Adapting the everyday discrimination scale to medical settings: reliability and validity testing in a sample of African American patients

OBJECTIVE

Despite evidence that discrimination within the health care system may play an important role in perpetuating health disparities, instruments designed to measure discrimination within the health care setting have not been adequately tested or validated. Consequently, we sought to test the psychometric properties of a modified version of the Everyday Discrimination scale, adapted for medical settings.

DESIGN

Cross-sectional study.

SETTING

Academic medical center in Chicago.

PARTICIPANTS

Seventy-four African American patients.

OUTCOME MEASURES

We measured factor analysis, internal consistency, test-retest reliability, convergent validity and discriminant validity.

RESULTS

Seventy-four participants completed the baseline interviews and 66 participants (89%) completed the follow-up interviews. Eighty percent were women. The Discrimination in Medical Settings (DMS) Scale had a single factor solution (eigenvalue of 4.36), a Cronbach's alpha of 0.89 and test-retest reliability of .58 (P<.0001). The DMS was significantly correlated with an overall measure of societal discrimination (EOD) (r=.51, P<.001) as well as two of its three subscales (unfair: r=-.04, P=.76; discrimination: r=.45, P<0.001; worry: r=-.36, P=.002). The DMS was associated with the overall African American Trust in Health Care Scale (r=.27, P=.02) as well as two key subscales (racism: r=.31, P<.001; disrespect: r=.44, P<.001). The DMS scale was inversely associated with the Social Desirability Scale (r=.18, P=.13). The DMS scale was not correlated with the Center for Epidemiologic Studies Depression Scale (r=.03, P=.80).

CONCLUSIONS

The Discrimination in Medical Settings Scale has excellent internal consistency, test-retest reliability, convergent validity and discriminant validity among our sample of African American patients. Further testing is warranted among other racial/ethnic groups.

The impact of clinical pharmacy services integrated into medical homes on diabetes-related clinical outcomes

BACKGROUND

Pharmacist services have expanded in the US health-care system from traditional roles to include comprehensive clinical services, but many studies lack comparison groups to evaluate outcomes of these clinical services.

OBJECTIVE

To evaluate the clinical outcomes of uninsured or underinsured patients with type 2 diabetes who received care from pharmacists in local "safety net" clinic medical homes compared to outcomes of patients from clinics receiving usual care without the services of clinical pharmacists.

METHODS

Pharmacists provided comprehensive pharmacy services in safety net clinic medical homes for uninsured patients in a major urban city. Referred patients had poor diabetes control (hemoglobin A(1c) [A1C] >9%). Pharmacists conducted comprehensive evaluations of medications, made adjustments, monitored adherence, and provided education and follow-up. Intervention patients were compared to similar patients who were receiving usual care but were not seen by a pharmacist. Outcomes evaluated were the change in A1C levels and achievement of treatment goals. Data were derived from chart reviews retrospectively. Multivariate least-squares and logistic regression models were used to estimate the impact of the intervention.

RESULTS

Two hundred twenty-two intervention and 262 control patients were evaluated. Patients receiving care from pharmacists had adjusted A1C levels reduced by 1.38% relative to usual care, increasing the likelihood of achieving an A1C <7% by 3-fold (p < 0.001 for both estimates).

CONCLUSIONS

The integration of clinical pharmacy services into safety net medical homes was associated with improvement in clinical outcomes of patients with diabetes.

Managing the space between visits: a randomized trial of disease management for diabetes in a community health center

BACKGROUND

Diabetes outcomes are worse for underserved patients from certain ethnic/racial minority populations. Telephonic disease management is a cost-effective strategy to deliver self-management services and possibly improve diabetes outcomes for such patients.

OBJECTIVE

We conducted a trial to test the effectiveness of a supplemental telephonic disease management program compared to usual care alone for patients with diabetes cared for in a community health center.

DESIGN

Randomized controlled trial.

PARTICIPANTS

All patients had type 2 diabetes, and the majority was Hispanic or African American. Most were urban-dwelling with low socioeconomic status, and nearly all had Medicaid or were uninsured.

MEASUREMENTS

Clinical measures included glycemic control, blood pressure, lipid levels, and body mass index. Validated surveys were used to measure dietary habits and physical activity.

RESULTS

A total of 146 patients were randomized to the intervention and 149 to the control group. Depressive symptoms were highly prevalent in both groups. Using an intention to treat analysis, there were no significant differences in the primary outcome (HbA1c) between the intervention and control groups at 12 months. There were also no significant differences for secondary clinical or behavioral outcome measures including BMI, systolic or diastolic blood pressure, LDL cholesterol, smoking, or intake of fruits and vegetables, or physical activity.

CONCLUSIONS

A clinic-based telephonic disease management support for underserved patients with diabetes did not improve clinical or behavioral outcomes at 1 year as compared to patients receiving usual care alone.

The use of quality improvement and health information technology approaches to improve diabetes outcomes in African American and Hispanic patients

Differences in rates of diabetes-related lower extremity amputations represent one of the largest and most persistent health disparities found for African Americans and Hispanics compared with Whites in the United States. Since many minority patients receive care in underresourced settings, quality improvement (QI) initiatives in these settings may offer a targeted approach to improve diabetes outcomes in these patient populations. Health information technology (health IT) is widely viewed as an essential component of health care QI and may be useful in decreasing diabetes disparities in underresourced settings. This article reviews the effectiveness of health care interventions using health IT to improve diabetes process of care and intermediate diabetes outcomes in African American and Hispanic patients. Health IT interventions have addressed patient, provider, and system challenges in the provision of diabetes care but require further testing in minority patient populations to evaluate their effectiveness in improving diabetes outcomes and reducing diabetes-related complications.

Use of enabling services by Asian American, Native Hawaiian, and other Pacific Islander patients at 4 community health centers

OBJECTIVES

We sought to examine the utilization and impact of enabling services, such as interpretation and eligibility assistance, among underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients served at 4 community health centers.

METHODS

For this project, we developed a uniform model for collecting data on enabling services and implemented it across 4 health centers that served primarily AANHOPI patients. We also examined differences in patient characteristics between users and nonusers of enabling services.

RESULTS

Health center patients used many enabling services, with eligibility assistance being the most used service. In addition, compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured (P < .05).

CONCLUSIONS

For underserved AANHOPI patients at community health centers, enabling services are critical for access to appropriate care. We were the first to examine uniform data on enabling services across multiple health centers serving underserved AANHOPI patients. More data on enabling services and evaluation are needed to develop interventions to improve the quality of care for underserved AANHOPI patients.

Incretin-based therapies for type 2 diabetes mellitus: current status and future prospects

Incretin-based therapies encompass two new classes of antidiabetic drugs: glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., liraglutide, exenatide, and exenatide long-acting release), which are structurally related to GLP-1, and the dipeptidyl peptidase-4 (DPP-4) inhibitors (e.g., sitagliptin and saxagliptin), which limit the breakdown of endogenous GLP-1. To evaluate the safety and effectiveness of incretin-based therapies for the treatment of type 2 diabetes mellitus and the role of these therapies in clinical practice, a MEDLINE search (January 1985-November 2009) was conducted. Relevant references from the publications identified were also reviewed. Of 28 studies identified, 22 were randomized controlled trials. Data show that these therapies affect insulin secretion in a glucose-dependent manner, achieving clinically meaningful reductions in hemoglobin A(1c) levels, with very low rates of hypoglycemia. In addition, reductions in body weight have been observed with GLP-1 receptor agonists, which also exert a pronounced effect on systolic blood pressure. Various human and animal studies show that GLP-1 improves beta-cell function and increases beta-cell proliferation in vitro, which may slow disease progression. Thus, incretin-based therapies represent a promising addition to the available treatments for type 2 diabetes.

Systematic care to reduce ethnic disparities in diabetes care

AIMS

We sought to determine whether systematic care can reduce the gap in diabetes control between Maori and non-Maori.

METHODS

A Primary Health Organisation implemented a chronic care management programme for diabetes in 2005. The data constitute an open, prospective cohort followed for approximately two years. Data describing process were also collected.

RESULTS

There were 1311 people with diabetes (354 Maori, 957 non-Maori). Maori started with higher HbA(1c) (mean 8.1%, SD 1.9) than non-Maori (7.1%, SD 1.4) but over about 2 years HbA(1c) for Maori improved to that of non-Maori. LDL and systolic blood pressure decreased for both groups. Improved glucose in Maori was not due to starting insulin or metformin, and rates of sulphonylurea prescription increased in both groups. Urinary albumin:creatinine ratio remained higher for Maori throughout. Smoking rates and Body Mass Index (both higher in Maori) did not change. There is no evidence of selective retention in the cohort.

CONCLUSION

Likely essential components of the programme were that governance was equally shared between Maori and non-Maori; prolonged nurse consultations were free to the patient; nurses used a formal written wellness plan; nurses were formally trained to support patient self-management; and a computer template supported structured care.

Diabetes and cognitive systems in older black and white persons

We examined the association of type 2 diabetes mellitus to function in different cognitive systems in older black and white persons. Participants were 1437 persons (28.1% black; 72.9% women; mean age 78.4 y, education 14.5, Mini-Mental State Examination 27.9) free of dementia, enrolled in the Minority Aging Research Study or Memory and Aging Project, 2 epidemiologic, community-based cohort studies of aging and cognition. Summary measures of 5 cognitive domains and global cognition were derived from 19 neuropsychologic tests. Diabetes, by medication inspection and history, was present in 15.3% participants, including 23.5% blacks and 12.1% whites (P<0.001). In linear regression models adjusted for age, sex, education, and race, diabetes was associated with a lower level of semantic memory (P=0.042), but not other cognitive domains (episodic memory, working memory, perceptual speed, and visuospatial ability) or global cognition. In separate analyses adjusted for age, sex, education, race, and diabetes, there was no interaction of diabetes with race (all P values >0.333). In summary, diabetes was associated with semantic memory impairment in both black and white persons. We found similar effects of diabetes on cognition in both racial groups. Because diabetes is twice as common in blacks, the burden of diabetes on cognition is higher in black than white persons.

Impact of patient-centered medical home assignment on emergency room visits among uninsured patients in a county health system

The Medical Services Initiative program--a safety net-based system of care--in Orange County included assignment of uninsured, low-income residents to a patient-centered medical home. The medical home provided case management, a team-based approach for treating disease, and increased access to primary and specialty care among other elements of a patient-centered medical home. Providers were paid an enhanced fee and pay-for-performance incentives to ensure delivery of comprehensive treatment. Medical Services Initiative enrollees who were assigned to a medical home for longer time periods were less likely to have any emergency room (ER) visits or multiple ER visits. Switching medical homes three or more times was associated with enrollees being more likely to have any ER visits or multiple ER visits. The findings provide evidence that successful implementation of the patient-centered medical home model in a county-based safety net system is possible and can reduce unnecessary ER use.

Race and shared decision-making: perspectives of African-Americans with diabetes

Shared decision-making (SDM) is an important component of patient-centered healthcare and is positively associated with improved health outcomes (e.g. diabetes and hypertension control). In shared decision-making, patients and physicians engage in bidirectional dialogue about patients' symptoms and treatment options, and select treatment plans that address patient preferences. Existing research shows that African-Americans experience SDM less often than whites, a fact which may contribute to racial disparities in diabetes outcomes. Yet little is known about the reasons for racial disparities in shared decision-making. We explored patient perceptions of how race may influence SDM between African-American patients and their physicians. We conducted in-depth interviews (n=24) and five focus groups (n=27) among a purposeful sample of African-American diabetes patients aged over 21 years, at an urban academic medical center in Chicago. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was conducted iteratively; each transcription was independently coded by two research team members. Although there was heterogeneity in patients' perceptions about the influence of race on SDM, in each of the SDM domains (information-sharing, deliberation/physician recommendations, and decision-making), participants identified a range of race-related issues that may influence SDM. Participants identified physician bias/discrimination and/or cultural discordance as issues that may influence physician-related SDM behaviors (e.g. less likely to share information such as test results and more likely to be domineering with African-American patients). They identified mistrust of white physicians, negative attitudes and internalized racism as patient-related issues that may influence African-American patients' SDM behaviors (e.g. less forthcoming with physicians about health information, more deference to physicians, less likely to adhere to treatment regimens). This study suggests that race-related patient and physician-related barriers may serve as significant barriers to shared decision-making between African-American patients and their physicians. Finding innovative ways to address such communication barriers is an important area of future research.

The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States

BACKGROUND

There has been substantial research on psychosocial and health care determinants of health disparities in the United States (US) but less on the role of modifiable risk factors. We estimated the effects of smoking, high blood pressure, elevated blood glucose, and adiposity on national life expectancy and on disparities in life expectancy and disease-specific mortality among eight subgroups of the US population (the "Eight Americas") defined on the basis of race and the location and socioeconomic characteristics of county of residence, in 2005.

METHODS AND FINDINGS

We combined data from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to estimate unbiased risk factor levels for the Eight Americas. We used data from the National Center for Health Statistics to estimate age-sex-disease-specific number of deaths in 2005. We used systematic reviews and meta-analyses of epidemiologic studies to obtain risk factor effect sizes for disease-specific mortality. We used epidemiologic methods for multiple risk factors to estimate the effects of current exposure to these risk factors on death rates, and life table methods to estimate effects on life expectancy. Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP). SBP was highest in blacks, especially in the rural South--5-7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley. Nationally, these four risk factors reduced life expectancy at birth in 2005 by an estimated 4.9 y in men and 4.1 y in women. Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y). Standard deviation of life expectancies in the Eight Americas would decline by 0.50 y (18%) in men and 0.45 y (21%) in women if these risks had been reduced to optimal levels. Disparities in the probabilities of dying from cardiovascular diseases and diabetes at different ages would decline by 69%-80%; the corresponding reduction for probabilities of dying from cancers would be 29%-50%. Individually, smoking and high blood pressure had the largest effect on life expectancy disparities.

CONCLUSIONS

Disparities in smoking, blood pressure, blood glucose, and adiposity explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers, and some of the life expectancy disparities in the US. Please see later in the article for the Editors' Summary.