Reducing racial/ethnic disparities in diabetes: the Coached Care (R2D2C2) project

Linguistic Disparities in Diabetes Care Quality in California Community Health Centers Before and During the COVID-19 Pandemic

BACKGROUND

Disparities in diabetes care quality may have increased for patients with limited English language proficiency (LEP) compared to non-LEP patients during the COVID-19 pandemic. Changes in diabetes care quality for adult LEP and non-LEP patients of community health centers (CHCs) were examined from 2019 to 2020.

METHODS

Adults with Type 2 diabetes (n = 15 965) of 88 CHC sites in California and with 1+ visit/year in 2019 and 2020 from OCHIN electronic health record data were included. Multivariable regression models estimated the association of LEP status and changes in diabetes care quality from 2019 to 2020, controlling for patient sociodemographic and clinical characteristics. Interaction terms (LEP × 2020) were used to estimate differential over time changes in (1) blood pressure screening, (2) blood pressure control (<140/90 mm Hg), and (3) hemoglobin A1c control (HbA1c <8%) for LEP versus non-LEP patients.

RESULTS

LEP and non-LEP patients with diabetes had comparable blood pressure screening and control in 2019 and in 2020. LEP patients were less likely than non-LEP patients to have their HbA1c under control in 2019 (OR = 0.85, 95% CI = 0.77, 0.96, P = .006) and 2020 (OR = 0.83, 95% CI = 0.75, 0.92, P = .001). There were no differential changes in HbA1c control over time for LEP and non-LEP patients.

DISCUSSION

Although LEP patients were less likely than non-LEP patients to have their HbA1c under control, CHCs maintained quality of care equally for LEP and non-LEP patients with diabetes during the early pandemic period.

Demographic Variables Associated With Diabetes Technology Awareness or Use in Adults With Type 2 Diabetes

Background

Studies in populations with type 1 diabetes highlight racial/ethnic disparities in the use of diabetes technology; however, little is known about disparities among those with type 2 diabetes. This project investigates the racial/ethnic and socioeconomic disparities in diabetes technology awareness and use in adults with type 2 diabetes in the ambulatory setting.

Methods

Adults ≥40 years of age with type 2 diabetes in ambulatory care were invited to participate via an e-mail link to a de-identified REDCap (Research Electronic Data Capture) questionnaire. Variables, including awareness and use of continuous glucose monitoring (CGM) and insulin pumps, were summarized descriptively using frequencies and percentages and were compared across racial/ethnic groups, education level, and income using Pearson χ2 or Fisher exact tests.

Results

The study included 116 participants, most of whom (62%) were White, elderly Medicare recipients. Compared with White participants, those of racially/ethnically minoritized groups were less likely to be aware of CGM (P = 0.013) or insulin pumps (P = 0.001). Participants with a high school education or less were also less likely to be aware of insulin pumps (P = 0.041). Interestingly, neither awareness nor use of CGM or insulin pumps was found to be associated with income.

Conclusion

This cross-sectional analysis suggests that racially/ethnically minoritized groups and individuals with lower education have less awareness of CGM or insulin pumps.

Food insecurity, diabetes, and perceived diabetes self-management among Latinos in California: Differences by nativity and duration of residence

We examined associations between food security (FS) status and type 2 diabetes (T2D) prevalence and perceived T2D self-management by nativity and US duration of residence among Latinos living in California. We used the California Health Interview Survey (2012-2017) and included Latinos who lived below 200% of the federal poverty line (n = 16,254) and for our management outcome, those with T2D (n = 2284). Latinos with low FS (OR = 1.44, 95% CI 1.14-1.83) or very low FS (OR = 1.87, 95% CI 1.33-2.61) had a higher odds of T2D compared to their food-secure counterparts. When stratified by nativity/duration in the US, US-born Latinos and Latino immigrants with >10 years duration had a higher odds of T2D if they reported low FS (US-born: OR = 1.60, 95% CI 1.02-2.52; >10 yrs: OR = 1.48, 95% CI 1.12-1.97) or very low FS (US-born: OR = 2.37, 95% CI 1.45-3.86; >10 yrs: OR = 1.78, 95% CI 1.15-2.76) compared to their food-secure counterparts. There was no association among immigrants with <10 years duration. For perceived T2D self-management, those with low or very low FS had lower odds of reporting proper management (OR = 0.56, 95% CI 0.36-0.86; OR = 0.46, 95% CI 0.26-0.83) compared to their food-secure counterparts. When stratified by nativity, the US-born did not differ in their perceived self-management by FS status, while immigrants with low or very FS had lower odds of perceived self-management (OR = 0.54, 95% CI 0.34-0.86; OR = 0.36, 95% CI 0.17-0.74), compared to their food-secure counterparts. Food insecurity may be an important contributor to T2D prevalence and perceived T2D self-management for Latino immigrants.

Perceived Risk of Diabetes Among Vietnamese Americans with Prediabetes: A Mixed Methods Study (Preprint)

BACKGROUND

Vietnamese Americans have a relatively high risk of developing diabetes at younger ages, yet there are no published studies exploring their risk perceptions.

OBJECTIVE

This mixed methods study describes perceived diabetes risk in the context of an underserved population.

METHODS

This study was guided by the Common-Sense Model of Self-Regulation. Snowball sampling was used to recruit 10 Vietnamese Americans with prediabetes and achieve data saturation. Qualitative and quantitative descriptive methodologies with data transformation were used to analyze data from semistructured interviews and questionnaires to explore the dimensions of perceived diabetes risk.

RESULTS

Participants were between the ages of 30 and 75 years with diversity also noted in diabetes risk factors. The 3 risk perception domains from qualitative data were risk factors, disease severity, and preventing diabetes. The main perceived diabetes risk factors were eating habits (including cultural influences), sedentary lifestyle, and family history of diabetes. Quantitative data supported qualitative findings of a low-to-moderate level of perceived diabetes risk. Despite the lower levels of perceived diabetes risk, Vietnamese Americans do believe that the severity of diabetes is a "big concern."

CONCLUSIONS

Vietnamese Americans with prediabetes have a low-to-moderate level of perceived diabetes risk. Understanding the perceived diabetes risk in this population provides a foundation for diabetes prevention interventions that consider cultural influences on diet and exercise.

Feasibility and Acceptability of a Digital Patient-Reported Outcome Tool in Routine Outpatient Diabetes Care: Mixed Methods Formative Pilot Study

Background

Improvements in the digital capabilities of health systems provide new opportunities for the integration of patient-reported outcome (PRO) solutions in routine care, which can facilitate the delivery of person-centered diabetes care. We undertook this study as part of our development of a new digital PRO diabetes questionnaire and clinical dialog support tool for use by people with diabetes and their health care professionals (HCPs) to improve person-centered diabetes care quality and outcomes.

Objective

This study evaluates the feasibility, acceptability, and perceived benefits and impacts of using a digital PRO diabetes tool, DiaProfil, in routine outpatient diabetes care.

Methods

Overall, 12 people with diabetes scheduled for routine medical diabetes visits at the outpatient clinic were recruited. Purposive sampling was used to optimize heterogeneity regarding age, gender, duration, type of diabetes, treatment modality, and disease severity. Participants filled out a PRO diabetes questionnaire 2 to 5 days before their visit. During the visit, HCPs used a digital PRO tool to review PRO data with the person with diabetes for collaborative care planning. Participants completed evaluation forms before and after the visit and were interviewed for 30 to 45 minutes after the visit. HCPs completed the evaluation questionnaires after each visit. All visits were audio-recorded and transcribed for analysis. Data were analyzed using quantitative, qualitative, and mixed methods analyses.

Results

People with diabetes found the PRO diabetes questionnaire to be relevant, acceptable, and feasible to complete from home. People with diabetes and HCPs found the digital PRO tool to be feasible and acceptable for use during the diabetes visit and would like to continue using it. HCPs were able to use the tool in a person-centered manner, as intended. For several people with diabetes, completion of the questionnaire facilitated positive reflection and better preparation for the visit. The use of the PRO tool primarily improved the quality of the dialog by improving the identification and focus on the issues most important to the person with diabetes. People with diabetes did not report any negative aspects of the PRO tool, whereas HCPs highlighted that it was demanding when the person with diabetes had many PRO issues that required attention within the predefined time allocated for a visit.

Conclusions

The Danish PRO diabetes questionnaire and the digital tool, DiaProfil, are feasible and acceptable solutions for routine diabetes visits, and this tool may generate important benefits related to advancement of person-centered care. Further research is now required to corroborate and expand these formative insights on a larger scale and in diverse health care settings. The results of this study are therefore being used to define research hypotheses and finalize real-world PRO evaluation tools for a forthcoming large-scale multisector implementation study in Denmark.

Patient Activation and Glycemic Control Among Filipino Americans

Purpose: Increasing patient activation facilitates self-management of health, improves health outcomes, and lowers health care expenditures. Extant research notes mixed findings in patient activation by race/ethnicity. The purpose of the study was to examine the relationships among patient activation, select patient characteristics, and glycemic control among Filipino Americans.

Methods: A cross-sectional study was conducted with a convenience sample of Filipino Americans (n=191), with a diagnosis of diabetes mellitus type 1 or type 2, recruited from a southern California adult primary care clinic between December 2017 and March 2018. Patient activation, select characteristics, and hemoglobin A1c (HbA1c) levels were assessed. Bivariate and logistic regression analyses were used to identify correlates of glycemic control. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist was used to develop the study.

Results: Participants with HgbA₁C≤7.0% reported statistically higher patient activation measure (13 items) (PAM-13) natural log score (mean [M]=60.32, standard deviation [SD]=13.50) compared to those with an HgbA₁C>7.0%, M=52.58, SD=10.19, F(1)=11.05, p<0.001. Multivariate logistic regression using age, low-density lipoprotein, and PAM-13 natural log was statistically reliable distinguishing between A₁C≤7.0 and A₁C>7.0, −2 LogLikehood=1183.23, χ²(3)=15.44, p<0.001.

Conclusions: Patient activation is an important factor in supporting glycemic control. Findings support interventions to target patient activation. Providers are encouraged to use racial/ethnic-centered engagement strategies in resolving health disparity with racial and ethnic minorities to facilitate patient activation and improve health outcomes in patients with diabetes.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review

Background

Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients.

Methods

The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed.

Results

Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies.

Conclusions

Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01209-w.

Can the Routine Use of Patient-Reported Outcome Measures Improve the Delivery of Person-Centered Diabetes Care? A Review of Recent Developments and a Case Study

PURPOSE OF REVIEW

In recent years, the recommendation for and use of patient-reported outcome measures (PROMs) in routine diabetes care has significantly increased. We review recent evidence and highlight key opportunities and challenges related to the active clinical use of PROMs to support person-centered diabetes care and focus areas for future research in the area.

RECENT FINDINGS

Recent pragmatic studies support that integration of multi-dimensional PROMs for diabetes in clinical care as part of a care improvement strategy can be acceptable for and valued by people with diabetes (PWD) and healthcare professionals (HCPs) and may improve multiple aspects of quality of care, including screening, medical care monitoring and decision support, individualization of self-management support and goal-setting, and broader benefits related to active patient participation and person-centred diabetes care. We identify multiple intervention, individual, and care setting characteristics, which influence acceptability, feasibility, implementation, and effectiveness of PROMs in routine care. Recent clinical PROM studies highlight the value of mixed methods research and systematic involvement of PWD, clinicians, and other stakeholders in the design and implementation of questionnaires for patient input in routine diabetes care. We identified a new significant trend towards participatory development of multi-dimensional PROMs with the aim of IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes. While results from large-scale randomized controlled studies are still limited, a growing number of pragmatic implementation studies support that user-centric PROM interventions have the potential to facilitate significant improvements in care for PWD.

A Systematic Review of Barriers to Access-to-Care in Hispanics With Type 2 Diabetes

INTRODUCTION

A systematic review was conducted to highlight current barriers to access-to-care for Hispanics with type 2 diabetes (T2D).

METHOD

PubMed and CINAHL databases (2010-2015) using PRISMA guidelines. 84 studies were identified, 12 quantitative studies were selected for review remained based on inclusion/exclusion criteria. There were five research questions: (1) What samples/settings were included? (2) What theories guided each study? (3) What were the study aims and (4) designs? (5) What barriers of access-to-care were identified? Barriers were placed into three categories set a priori.

RESULTS

The word "barrier" was in one study aim. Barriers of self (92%), provider (50%), and environment (25%) were identified. Self-care behaviors (diet and exercise), individual resources (cost factors), lack of providers specializing in T2D, and environmental factors affect Hispanics with T2D access-to-care.

DISCUSSION

These barriers to access underscore current importance to Hispanics with T2D. A follow-up review should be conducted as new barriers are expected to emerge.

Clinical inertia in the pharmacological management of hypertension: A systematic review and meta-analysis

BACKGROUND

Clinical Inertia is defined as "failure of health care providers to initiate or intensify therapy according to current guidelines". This phenomenon is gaining increasing attention as a major cause of clinicians' failure to adequately manage hypertension, thus leading to an increased incidence of cardiovascular events. We performed a systematic review and meta-analysis of randomized controlled trials to determine whether interventions aimed at reducing clinical inertia in the pharmacological treatment of hypertension improve blood pressure (BP) control.

METHODS

MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched from the start of their database until October 3, 2017 for the MESH terms "Hypertension" or "Blood Pressure", their subheadings, and the keywords "Therapeutic Inertia" or "Clinical Inertia". Studies were included if they addressed pharmacologic hypertension management, clinical inertia, were randomized controlled trials, reported an outcome describing prescriber behavior, and were available in English. Data for the included studies was extracted by two independent observers. Quality of studies was analyzed using the Cochrane Risk of Bias Assessment. Data was pooled for statistical analysis using both fixed- and random-effects models. The primary study outcome was the percentage of patients achieving blood pressure control as defined by the Joint National Committee guidelines or study authors.

RESULTS

Of 474 citations identified, ten met inclusion criteria comprising a total of 26,871 patients, and eight were selected for meta-analysis. Interventions included Physician Education, Physician Reminders, Patient Education, Patient Reminders, Ambulatory BP Monitoring, Digital Medication Offerings, Physician Peer Visits, and Pharmacist-led Counselling. Pooled event rates revealed more patients with controlled BP in the intervention group versus control (55%, 95% CI 46-63% versus 45%, 95% CI 37-53%) and interventions significantly improved the odds of BP control (OR = 1.19, 95% CI = 1.12-1.27, P < .001). Heterogeneity in the quantitative analysis was moderate.

CONCLUSIONS & RELEVANCE

Addressing clinical inertia through physician reminders, ambulatory BP monitoring, and educational interventions for primary care providers was associated with an improvement in blood pressure control. Our findings encourage further research to investigate strategies at reducing clinical inertia in the management of hypertension.

Disease factors associated with spousal influence on diabetic diet: An exploratory comparison of Vietnamese American and White older adults

This study examined whether disease-specific factors were important for how and how often White versus Vietnamese American spouses influenced their partners’ diabetic diet. Results from a cross-sectional survey of 145 older adult spouses whose partners had type 2 diabetes revealed that Vietnamese American spouses used more frequent spousal influence (positive and negative) than White spouses. In addition, most of the factors associated with spousal influence differed for Vietnamese American and White spouses. Findings from this study highlight the importance of proximal and sociocultural factors in understanding older spouses’ influence on their partners’ diabetic diet.

Access to Transportation and Health Care Visits for Medicaid Enrollees With Diabetes

PURPOSE

Diabetes is a chronic condition that requires frequent health care visits for its management. Individuals without nonemergency medical transportation often miss appointments and do not receive optimal care. This study aims to evaluate the association between Medicaid-provided nonemergency medical transportation and diabetes care visits.

METHODS

A retrospective analysis was conducted of demographic and claims data obtained from the Oklahoma Medicaid program. Participants consisted of Medicaid enrollees with diabetes who made at least 1 visit for diabetes care in a year. The sample was predominantly female and white, with an average age of 46.38 years. Two zero-truncated Poisson regression models were estimated to assess the independent effect of transportation use on number of diabetes care visits.

FINDINGS

Use of nonemergency medical transportation is a significant predictor of diabetes care visits. Zero-truncated Poisson regression coefficients showed a positive association between the use of transportation and number of visits (0.6563, P < .001). Age, gender, race/ethnicity, area of residence, and presence of additional chronic conditions had independent associations with number of visits. Older enrollees were likely to make more visits than younger enrollees with diabetes (0.02382); controlling for all other factors in the model, rural residents made more visits than urban; women made fewer visits than men (-0.09312; P < .001); and minorities made fewer visits than whites, with pronounced differences for Hispanics and Asians compared to whites.

CONCLUSIONS

Findings underscore the importance of ensuring transportation to Medicaid populations with diabetes, particularly in the rural areas where the prevalence of diabetes and complications are higher and the availability of medical resources lower than in the urban areas.

Contributors to Patients' Ratings of Quality of Care Among Ethnically Diverse Patients with Type 2 Diabetes

We examined racial/ethnic differences in patients' ratings of components of interpersonal quality [participatory decision making (PDM) style, being treated as an equal partner, and feelings of trust], and evaluated the association between each of these components and patients' ratings of overall healthcare quality among non-Hispanic white (NHW), Vietnamese American, and Mexican American patients with type 2 diabetes. The findings indicated that although all three components were significantly associated with ratings of overall healthcare quality, the significant interactions between race/ethnicity and both PDM style (β = -0.09, p < 0.01) and equal partner (β = -0.06, p < 0.05) for the Vietnamese American patients suggested that the relationship between these components and patients' ratings of healthcare quality were less strong among Vietnamese American patients than among the NHW patients. Understanding racial/ethnic differences in the components of interpersonal quality that are associated with patients' ratings of overall healthcare quality is an important step for improving patients' experiences of their own care.

Evaluating the Validity and Reliability of the Beliefs About Medicines Questionnaire in Low-Income, Spanish-Speaking Patients With Diabetes in the United States

Purpose The purpose of this study was to examine the reliability and validity of a Spanish version of the Beliefs about Medicines Questionnaire (BMQ) as a measure to evaluate beliefs about medications and to differentiate adherent from nonadherent patients among low-income Latino patients with diabetes in the United States. Methods Seventy-three patients were administered the BMQ and surveyed for evidence of medication nonadherence. Internal consistency of the BMQ was assessed by Cronbach's alpha along with performing a confirmatory factor analysis. Criterion validity was assessed by comparing mean scores on 3 subscales of the BMQ (General Overuse, General Harm, and Specific Necessity-Concerns difference score) between adherent patients and patients reporting nonadherence for 3 different reasons (unintentional nonadherence, cost-related nonadherence, and nonadherence due to reasons other than cost) using independent samples t tests. Results The BMQ is a reliable instrument to examine beliefs about medications in this Spanish-speaking population. Construct validity testing shows nearly identical factor loading as the original construct map. General Overuse scores were significantly more negative for patients reporting each reason for nonadherence compared with their adherent counterparts. Necessity-Concerns difference scores were significantly more negative for patients reporting nonadherence for reasons other than cost compared with those who did not report this reason for nonadherence. Conclusion The Spanish version of the BMQ is appropriate to assess beliefs about medications in Latino patients with type 2 diabetes in the United States and may help identify patients who become nonadherent to medications for reasons other than out-of-pocket costs.

Self-Care Disparities Among Adults with Type 2 Diabetes in the USA

Suboptimal glycemic control is more common among non-Hispanic Blacks (NHBs) and Hispanics than non-Hispanic Whites (NHWs). Disparities in the performance of self-care behaviors may contribute to this. To synthesize knowledge on current self-care disparities, we reviewed studies from January 2011-March 2016 that included NHWs, NHBs, and Hispanics with type 2 diabetes in the USA. Self-care behaviors included diet, exercise, medications, self-monitoring of blood glucose (SMBG), self-foot exams, and not smoking. Of 1241 articles identified in PubMed, 25 met our inclusion criteria. These studies report consistent disparities in medication adherence. Surprisingly, we found consistent evidence of no disparities in exercise and some evidence of reverse disparities: compared to NHWs, Hispanics had healthier diets and NHBs had more regular SMBG. Consistent use of validated measures could further inform disparities in diet and exercise. Additional research is needed to test for disparities in self-foot exams, not smoking, and diabetes-specific problem solving and coping.

Complementary and alternative medicine (CAM) use among non-Hispanic white, Mexican American, and Vietnamese American patients with type 2 diabetes

PURPOSE

This study examines the use of complementary and alternative medicine (CAM) by ethnicity/race among patients with type 2 diabetes.

SUBJECTS AND METHODS

Four hundred and ten (410) patients with type 2 diabetes recruited from an academic-medical center completed a survey assessing CAM use, diabetes status, and sociodemographic characteristics.

RESULTS

Several significant ethnic/racial differences were observed in CAM use (both in the types of providers seen as well as in the herbs and dietary supplements used). Although White patients reported using CAM in addition to their diabetes medication (mean [SD] 4.9 [0.4] on a scale from 1=never to 5=always) more frequently than Mexican American patients (3.1 [1.6], p<.05), Mexican American patients (1.4 [1.1]) used CAM instead of their diabetes medications more frequently than non-Hispanic White patients (1.0 [0.1], p<.05). More Mexican American (66.7%) and Vietnamese American patients (73.7%) than non-Hispanic Whites (11.8%, p=.002) described CAM practitioners as being closer to their cultural traditions than Western practitioners, whereas Vietnamese [End Page 1941] patients were more likely to describe use of herbs and supplements as closer to their cultural traditions (84.5% versus 15.3% for White and 30.9% for Mexican American patients, p <.001).

CONCLUSIONS

Considering the variability and perceptions in CAM use, providers should discuss with their patients how their CAM use may influence diabetes management behaviors.

Geographic clustering of diabetic lower-extremity amputations in low-income regions of California

For patients suffering from diabetes and other chronic conditions, a large body of work demonstrates income-related disparities in access to coordinated preventive care. Much less is known about associations between poverty and consequential negative health outcomes. Few studies have assessed geographic patterns that link household incomes to major preventable complications of chronic diseases. Using statewide facility discharge data for California in 2009, we identified 7,973 lower-extremity amputations in 6,828 adults with diabetes. We mapped amputations based on residential ZIP codes and used data from the Census Bureau to produce corresponding maps of poverty rates. Comparisons of the maps show amputation "hot spots" in lower-income urban and rural regions of California. Prevalence-adjusted amputation rates varied tenfold between high-income and low-income regions. Our analysis does not support detailed causal inferences. However, our method for mapping complication hot spots using public data sources may help target interventions to the communities most in need.

Racial and Economic Disparities in Diabetes in a Large Primary Care Patient Population

OBJECTIVE

We sought to determine if, after adjusting for economic status, race is an independent risk factor for glycemic control among diabetic patients in a large primary care patient population.

DESIGN SETTING PARTICIPANTS

We performed a retrospective chart review of 264,000 primary care patients at our large, urban academic medical center to identify patients with a diagnosis of diabetes (n=25,123). Zip code was used to derive median income levels using US Census Bureau demographic information. Self-reported race was extracted from registration data.

MAIN OUTCOME MEASURES

The prevalence of diabetes, average glycated hemoglobin (A1c), and prevalence of uncontrolled diabetes of White and Black patients at all income levels were determined.

RESULTS

White patients had a lower average A1c level and a lower prevalence of diabetes than Black patients in all income quartiles (P<.001). Among White patients, the prevalence of diabetes (P<.001), uncontrolled diabetes (P<.001), and A1c level (P=.014) were inversely proportional to income level. No significant difference in the prevalence of diabetes (P=.214), A1c level (P=.282), or uncontrolled diabetes related to income was seen in Black patients (P=.094).

CONCLUSIONS

Race had an independent association with diabetes prevalence and glycemic control. Our study does not support two prominent theories that economic and insurance status are the main factors in diabetes disparities, as we attempted to control for economic status and nearly every patient had insurance. It will be important for future analysis to explore how health care system factors affect these observed gaps in quality.

Effectiveness and feasibility of a software tool to help patients communicate with doctors about problems they face with their medication regimen (EMPATHy): study protocol for a randomized controlled trial

Background

Low-income, Mexican-American patients with diabetes exhibit high rates of medication nonadherence, poor blood sugar control and serious complications, and often have difficulty communicating their concerns about the medication regimen to physicians. Interventions led by community health workers, non-professional community members who are trained to work with patients to improve engagement and communication during the medical visit, have had mixed success in improving outcomes. The primary objective of this project is to pilot test a prototype software toolkit called “EMPATHy” that a community health worker can administer to help patients identify the most important barriers to adherence that they face and discuss these barriers with their doctor.

Methods/Design

The EMPATHy toolkit will be piloted in an ongoing intervention (Coached Care) in which community health workers are trained to be “coaches” to meet with patients before the medical visit and help them prepare a list of important questions for the doctor. A total of 190 Mexican-American patients with poorly controlled type 2 diabetes will be recruited from December 2014 through June 2015 and will be randomly assigned to complete either a single Coached Care intervention visit with no software tools or a Coached Care visit incorporating the EMPATHy software toolkit. The primary endpoints are (1) the development of a “contextualized plan of care” (i.e., a plan of care that addresses a barrier to medication adherence in the patient’s daily life) with the doctor, determined from an audio recording of the medical visit, and (2) attainment of a concrete behavioral goal set during the intervention session, assessed in a 2-week follow-up phone call to the patient. The statistical analysis will include logistic regression models and is powered to detect a 50% increase in the primary endpoints.

Discussion

The study will provide evidence regarding the effectiveness and feasibility of a software tool to help patients communicate with doctors about problems they face with their medications.

Trial registration

ClinicalTrials.gov NCT02324036 Registered 16 December 2014.

Effectiveness and feasibility of a software tool to help patients communicate with doctors about problems they face with their medication regimen (EMPATHy): study protocol for a randomized controlled trial

BACKGROUND

Low-income, Mexican-American patients with diabetes exhibit high rates of medication nonadherence, poor blood sugar control and serious complications, and often have difficulty communicating their concerns about the medication regimen to physicians. Interventions led by community health workers, non-professional community members who are trained to work with patients to improve engagement and communication during the medical visit, have had mixed success in improving outcomes. The primary objective of this project is to pilot test a prototype software toolkit called "EMPATHy" that a community health worker can administer to help patients identify the most important barriers to adherence that they face and discuss these barriers with their doctor.

METHODS/DESIGN

The EMPATHy toolkit will be piloted in an ongoing intervention (Coached Care) in which community health workers are trained to be "coaches" to meet with patients before the medical visit and help them prepare a list of important questions for the doctor. A total of 190 Mexican-American patients with poorly controlled type 2 diabetes will be recruited from December 2014 through June 2015 and will be randomly assigned to complete either a single Coached Care intervention visit with no software tools or a Coached Care visit incorporating the EMPATHy software toolkit. The primary endpoints are (1) the development of a "contextualized plan of care" (i.e., a plan of care that addresses a barrier to medication adherence in the patient's daily life) with the doctor, determined from an audio recording of the medical visit, and (2) attainment of a concrete behavioral goal set during the intervention session, assessed in a 2-week follow-up phone call to the patient. The statistical analysis will include logistic regression models and is powered to detect a 50% increase in the primary endpoints.

DISCUSSION

The study will provide evidence regarding the effectiveness and feasibility of a software tool to help patients communicate with doctors about problems they face with their medications.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02324036 Registered 16 December 2014.

Understanding disparities in lipid management among patients with type 2 diabetes: gender differences in medication nonadherence after treatment intensification

BACKGROUND

Gender differences in dyslipidemia are widely documented, but the contributors to these differences are not well understood. This study examines whether differences in quality of care, intensity of lipid-lowering medication regimen, and medication adherence can explain this disparity.

METHODS

Secondary analysis of medical records data and questionnaires collected from adult patients with type 2 diabetes (n = 1,369) from seven outpatient clinics affiliated with an academic medical center as part of the Reducing Racial Disparities in Diabetes: Coached Care (R2D2C2) study. Primary outcome was low-density lipoprotein (LDL) cholesterol.

FINDINGS

Women had higher LDL cholesterol levels than men (mean [SD], 101.2 [35.2] vs. 92.3 [33.0] mg/dL; p < .001), but were no less likely to receive recommended processes of diabetes care, to attain targets for glycemic control and blood pressure, or to be on intensive medication regimens. More women than men reported medication nonadherence related to cost (32.7% vs. 24.2%; p = .040) and related to side effects (47.2% vs. 36.8%; p = .024). For all patients, regimen intensity (p < .05) and nonadherence related to side effects (p < .01) were each associated with higher LDL cholesterol levels. The addition of a new lipid-lowering agent was associated with subsequent nonadherence related to side effects for women (p < .001), but not for men (p = .45; test for interaction p = .048).

CONCLUSIONS

Despite comparable quality of diabetes care and regimen intensity for lipid management, women with diabetes experienced poorer lipid control than men. Medication nonadherence seemed to be a major contributor to dyslipidemia, particularly for women because of side effects associated with intensifying the lipid-lowering regimen.

Costs and beliefs: understanding individual- and neighborhood-level correlates of medication nonadherence among Mexican Americans with type 2 diabetes

OBJECTIVE

High rates of medication nonadherence observed in disadvantaged populations are often attributed to socioeconomic factors. Little is known, however, about how a person's neighborhood environment may contribute to nonadherence beyond what can be explained by a lack of individual resources to pay for medications. This study considered the reasons patients reported for deviating from their medication regimens to understand how individual-level and neighborhood-level indicators of socioeconomic status (SES) may each influence adherence behavior.

METHOD

Cross-sectional data were collected between 2006 and 2011 from a sample of Mexican American patients with type 2 diabetes (N = 749) treated at university-affiliated clinics in Southern California. Measures included individual-level SES (years of education, health insurance type, and household income), neighborhood deprivation, and medication nonadherence (for reasons related to cost and reasons related to beliefs about medications). Neighborhood deprivation was assessed using the Neighborhood Socioeconomic Status Index (Dubowitz et al., 2011), a validated aggregate of census tract-level indicators linked to each participant's home address.

RESULTS

RESULTS from multilevel logistic regression models revealed that individual-level SES was associated with nonadherence related to cost (annual household income < $20,000 vs. > $40,000, p = .001; Medicare vs. commercial health insurance, p < .001), whereas neighborhood deprivation was associated with nonadherence related to beliefs about medications (p = .011).

CONCLUSION

Findings from this study suggest that an individual's lack of resources may contribute to nonadherence related to cost, whereas elements of the broader social environment may promote nonadherence related to negative beliefs about medications.