Racial differences in long-term self-monitoring practice among newly drug-treated diabetes patients in an HMO

"I did not want to take that medicine": African-Americans' reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence

BACKGROUND

Diabetes is disproportionally burdensome among African-Americans (AAs) and medication adherence is important for optimal outcomes. Limited studies have qualitatively examined reasons for nonadherence among AAs with type 2 diabetes, though AAs are less adherent to prescribed medications compared to whites. This study explored the reasons for medication nonadherence and adherence among AAs with type 2 diabetes and examined AAs' perceived solutions for enhancing adherence.

METHODS

Forty AAs, age 45-60 years with type 2 diabetes for at least 1 year prior, taking at least one prescribed diabetes medication, participated in six semistructured 90-minute focus groups. Using a phenomenology qualitative approach, reasons for nonadherence and adherence, as well as participants' perceived solutions for increasing adherence were explored. Qualitative content analysis was conducted.

RESULTS

AAs' reasons for intentional nonadherence were associated with 1) their perception of medicines including concerns about medication side effects, as well as fear and frustration associated with taking medicines; 2) their perception of illness (disbelief of diabetes diagnosis); and 3) access to medicines and information resources. Participants reported taking their medicines because they valued being alive to perform their social and family roles, and their belief in the doctor's recommendation and medication helpfulness. Participants provided solutions for enhancing adherence by focusing on the roles of health care providers, patients, and the church. AAs wanted provider counseling on the necessity of taking medicines and the consequences of not taking them, indicating the need for the AA community to support and teach self-advocacy in diabetes self-management, and the church to act as an advocate in ensuring medication use.

CONCLUSION

Intentional reasons of AAs with type 2 diabetes for not taking their medicines were related to their perception of medicines and illness. Solutions for enhancing diabetes medication adherence among AAs should focus on the roles of providers, patients, and the church.

Patients', caregivers', and providers' perceived strategies for diabetes care

OBJECTIVES

To explore strategies to improve type 2 diabetes mellitus (T2DM) self-management among low-income and minority groups.

METHODS

Focus groups centered on T2DM self-care behaviors were conducted using convenient sample of patients with T2DM (N = 17), caregivers (N = 5) and healthcare providers (N = 15).

RESULTS

Patients and caregivers perceived strategies included improving patient-provider communication, providers' accessibility and compassion, and flexible clinic hours. Strategies identified by providers were realistic patient's expectations, family support, and community resources.

CONCLUSIONS

To our knowledge, this study is the first to elicit strategies to improve T2DM self-management through a joint meeting of patients, caregivers, and healthcare providers. Study findings could help inform future efforts to assist patients better manage their T2DM.

Gender differences in diabetes self-management among African American adults

The rising incidence of diabetes complications among African Americans is a major health concern. Few studies have addressed gender differences in diabetes self-management in this population. The purpose of this study was to determine whether gender differences in facilitators and barriers to self-management exist among African American adults with type 2 diabetes. Thirty-eight participants were recruited from community agencies and each participated in one of seven audio-recorded focus group sessions. Regular health care visits, positive outlook, prioritization of health, and independence facilitated self-management behaviors in men, whereas acceptance of diabetes was a facilitator for women. Lack of time at work, lack of family support, and lack of knowledge were barriers for men, whereas lack of finances, embarrassment, negative outlook, perceived lack of disease control, and adverse effects of medications were barriers for women. Further research is necessary to design and test gender-specific tailored interventions to improve diabetes self-management in this population.

Food insecurity, processes of care, and self-reported medication underuse in patients with type 2 diabetes: results from the California Health Interview Survey

OBJECTIVE

To assess the independent association of food insecurity with processes of care and delays in filling prescriptions.

DATA SOURCE

2007 California Health Interview Survey.

STUDY DESIGN

Associations of food insecurity with processes of care and delays in filling prescriptions were examined using multivariable logistic regression analyses adjusted for sociodemographic characteristics, barriers to accessing care, and health status.

DATA EXTRACTION

Data were analyzed from adults currently receiving treatment for type 2 diabetes and who had seen a doctor in the prior 12 months (N = 3,401).

PRINCIPAL FINDINGS

For diabetes patients currently receiving medical care, food insecurity was not associated with lower rates of performance of recommended processes of care, but it was associated with delays in filling prescriptions (aOR = 2.15, 95 percent CI 1.25, 3.71).

CONCLUSIONS

Food insecurity may increase delays in filling prescriptions in daily life, even though the performance of recommended processes of care in the clinic is not diminished.

Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project

OBJECTIVES

Adherence to diabetes self care is poor for Hispanic American and African-American patients. This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients. We also examined whether adherence mediated the effect of the intervention on glycemic control (A1c).

DESIGN

The Informatics for Diabetes Education and Telemedicine project randomized medically underserved Medicare patients (n=1665) to telemedicine case management (televideo educator visits, individualized goal-setting/problem solving) or usual care. Hispanic and African-American educators delivered the intervention in Spanish if needed.

MAIN OUTCOME MEASURES

Annual assessment included A1c and self-reported adherence (Summary of Diabetes Self-Care Activities scale). A simple model (only time and group terms) and a model with covariates (e.g., age) were examined for baseline and 5 years of follow-up. SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c, by performing tests of the mediating path coefficients.

RESULTS

Over time, self-reported adherence improved for the treatment group compared to usual care (p<0.001). There was no significant interaction with racial/ethnic group membership, i.e., all groups improved. However, minority subjects were consistently less adherent than whites. Also, greater comorbidity and diabetes symptoms predicted poorer adherence, greater duration of diabetes and more years of education predicted better adherence. Adherence was a significant mediator of A1c (p<0.001).

CONCLUSIONS

A unique, tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care. However, African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention. The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity.

Afrocentric cultural values and beliefs: movement beyond the race and ethnicity proxy to understand views of diabetes

PURPOSE

The purpose of this study was to estimate the benefit of using a cultural characteristics scale to help diabetes educators understand how African Americans cope with diabetes. Illness representations are influenced by culture. Race and ethnicity as a proxy for culture provides an incomplete understanding of the mechanism by which cultural values influence representations of diabetes.

METHODS

A descriptive correlational design was employed by recruiting hospitalized adults with type 2 diabetes at 3 metropolitan northeast coast sites. The TRIOS Afrocentric cultural characteristics measure and the Illness perception Questionnaire were administered by paper-and-pencil to a diverse sample. Black race and African American ethnicity was used as a proxy for culture and compared to levels of agreement on an Afrocentric cultural scale to determine the relative ability to explain variance in illness representations of diabetes.

CONCLUSION

The TRIOS measure adapted to diabetes care explained variance in illness representations of diabetes, while African American ethnicity/black race was not able to explain variance in illness representations. Clinicians would benefit from considering the degree to which a patient identifies with particular cultural characteristics when tailoring interventions to manipulate illness representations that are not concordant with biomedical representations.

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.

Facilitators and Barriers to Self-management of Type 2 Diabetes Among Urban African American Adults

Purpose

The purpose of this study was to identify facilitators and barriers to self-management of type 2 diabetes mellitus (T2DM) among urban African American adults.

Methods

Thirty-eight African American adults with T2DM were recruited from 1 of 3 health care agencies in a midsized city in the southeastern United States. Qualitative data were obtained using focus groups, wherein each participant engaged in a 60- to 90-minute audio-recorded session. Focus group data were transcribed and analyzed using Atlas ti 6 ® data analysis software. Demographic and medical history information was also collected.

Results

Factors relating to external locus of control primarily facilitated adherence to T2DM self-management behaviors. Support from family, peers, and health care providers positively influenced adherence behaviors by providing cues to action, direct assistance, reinforcement, and knowledge. Internal factors were primarily described as barriers to self-management behaviors and included fears associated with glucose monitoring, lack of self-control over dietary habits, memory failure, and perceived lack of personal control over diabetes.

Conclusions

African Americans perceived external factors as facilitators of their T2DM management behaviors and internal factors as barriers to self-management. Further research is necessary to design and test interventions that capitalize on the external facilitators while helping African Americans to overcome perceived barriers identified in this study.

A simple and promising tool to improve self-monitoring of blood glucose in patients with diabetes

AIM

To examine patient formation of implementation plans, a volitional strategy, and its influence on self-monitoring of blood glucose (SMBG).

METHODS

A randomized experimental-control design over a 2-week time period was used. The study population was diabetes patients with HbA1c >7% and requiring insulin therapy. Patients were recruited from a southeastern Michigan healthcare system. A self-administered intervention was designed to assist patients to formulate plans to perform SMBG. The primary outcome measure was SMBG rates. Three control groups were used to control for testing effects. Hypotheses were tested using ANOVA at a significance level of 0.05. SMBG was measured using a 2-week diary and two recall measures.

RESULTS

There were 402 patients with diabetes recruited for the study. Analyses indicated that making implementation plans increased SMBG rates as assessed by a diary and two recall measures. The patients in the experimental group checked their blood sugar up to 7.77 times more than the control groups (sig<0.05) over a 2-week time period as measured by the diary.

CONCLUSIONS

Patient behavior can be impacted by using an implementation planning tool. This technique can help improve patient self-monitoring behavior.

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

Background

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

Methods

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

Results

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

Conclusion

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

Appointment adherence and disparities in outcomes among patients with diabetes

BACKGROUND

Successful control of diabetes mellitus requires lifelong adherence to multiple self-management activities in close collaboration with health professionals. We examined the association of such control with appointment keeping behavior in a rural health system.

METHODS

Among 4,253 predominantly lower socioeconomic status patients with diabetes, the association of metabolic control (most recent A1c <7% or >9% in two models of respectively 'good' and 'poor' control) with 'missed appointment rate' over a 3-year period was examined using multiple logistic regression.

MAIN RESULTS

For each 10% increment in missed appointment rate, the odds of good control decreased 1.12x (p < 0.001) and the odds of poor control increased 1.24x (p < 0.001). The missed appointment rate was substantially higher among African-American patients (15.9% vs. 9.3% for white patients, p < 0.001). Controlling for the missed appointment rate and insurance status in multivariate analysis attenuated the racial association with good control, and the racial association with poor control was no longer significant. Older, white patients with health insurance tended to have significantly better metabolic control. There was no independent association of metabolic control with patient income, gender, or number of primary care visits.

CONCLUSION

Adherence to appointments, independent of visit frequency, was a strong predictor of diabetes metabolic control. We hypothesize that missed appointment behavior may serve as an indicator for other diabetes adherence behaviors and associated barriers that serve to undermine successful diabetes self-management.

Medication adherence and racial differences in A1C control

OBJECTIVE

The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients.

RESEARCH DESIGN AND METHODS

We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged >/=18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up.

RESULTS

At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P < 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P < 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap.

CONCLUSIONS

We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention.