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Manser ST, Sekar P, Bonilla Z, Ford B, Shippee N, Busch AM, Gelberg L, Rogers EA, Jennings-Dedina L, Montori VM, Vickery KD. Homelessness and Type 2 Diabetes: A Qualitative Study of Facilitators and Barriers to Self-Management and Medication Adherence. J Gen Intern Med 2024:10.1007/s11606-024-09030-z. [PMID: 39313666 DOI: 10.1007/s11606-024-09030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 09/10/2024] [Indexed: 09/25/2024]
Abstract
PURPOSE In this study, we explore the barriers and facilitators to diabetes medication adherence and self-management for people with type 2 diabetes who have experienced homelessness. METHODS We conducted five focus groups and two interviews with 26 participants. Our multi-disciplinary analysis team utilized principles of grounded theory and conducted thematic analysis with an inductive, iterative process to identify central themes. RESULTS The majority of participants identified as Black/African American and over half stayed in shelters or had no steady place to stay at enrollment. Three key themes emerged regarding medication adherence and diabetes self-management for people who have experienced homelessness: personal autonomy and security, predictability and stability, and supportive, knowledgeable relationships (both social and medical). We define personal autonomy and security as individual agency and choice when making decisions related to one's health and well-being as well as protection from risk or harm to one's physical or psychological well-being, belongings, or means of income. Predictability and stability take place through the development of a system of connections and routines built over time where individuals can reliably adopt and maintain diabetes self-management activities. Supportive, knowledgeable relationships include medical and social relationships that offer encouragement, information, and hands-on care promoting diabetes self-management and connection to clinical care and resources. Participants also highlighted a "domino effect" where a cascade of events negatively and consequently impacted their health and well-being. We describe the interactions of these themes, the intersection of structural vulnerability and individual social risks, and resulting impacts on medication adherence and diabetes self-management. CONCLUSIONS Our findings highlight the structural vulnerabilities impacting people experiencing homelessness and identify inflection points of opportunity at structural and individual levels to strengthen diabetes medication adherence and self-management. This understanding can inform policy change and future tailored diabetes interventions.
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Affiliation(s)
- Sarah Turcotte Manser
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Preethiya Sekar
- Health, Homelessness, and Criminal Justice Lab at the Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Zobeida Bonilla
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Becky Ford
- Health, Homelessness, and Criminal Justice Lab at the Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Nathan Shippee
- University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Andrew M Busch
- Behavioral Health Equity Research Group at the Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Lillian Gelberg
- Department of Family Medicine at the UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Elizabeth A Rogers
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Latasha Jennings-Dedina
- Health, Homelessness, and Criminal Justice Lab at the Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Minneapolis, MN, USA
| | - Katherine Diaz Vickery
- Health, Homelessness, and Criminal Justice Lab at the Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA.
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Wiens K, Bai L, Hwang SW, Ronksley PE, Austin PC, Booth GL, Spackman E, Campbell DJT. Disparities in diabetes processes of care among people experiencing homelessness: An opportunity for intervention. Diabetes Res Clin Pract 2024; 213:111748. [PMID: 38885743 DOI: 10.1016/j.diabres.2024.111748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/23/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
AIMS To compare processes of diabetes care by homeless status. METHODS A population-based propensity matched cohort study was conducted in Ontario, Canada. People with diabetes were identified in administrative healthcare data between April 2006 and March 2019. Those with a documented history of homelessness were matched to non-homeless controls. Data on processes of care measures included glucose monitoring tests, screening for microvascular complications, and physician follow-up. Differences in processes of care were compared by homeless status using proportions, risk ratios, and rate ratios. RESULTS Of the 1,076,437 people with diabetes, 5219 matched pairs were identified. Homelessness was associated with fewer tests for glycated hemoglobin (RR = 0.63; 95 %CI: 0.60-0.67), LDL cholesterol (RR = 0.80; 95 %CI: 0.78-0.82), serum creatinine (RR = 0.94; 95 %CI: 0.92-0.97), urine protein quantification (RR = 0.62; 95 %CI: 0.59-0.66), and eye examinations (RR = 0.74; 95 %CI: 0.71-0.77). People with a history of homelessness were less likely to use primary care for diabetes management (RR = 0.62; 95 %CI: 0.59-0.66) or specialist care (RR = 0.87; 95 %CI: 0.83-0.91) compared to non-homeless controls. CONCLUSIONS Disparities in diabetes care are evident for people with a history of homelessness and contribute to excess morbidity in this population. These data provide an impetus for investment in tailored interventions to improve healthcare equity and prevent long-term complications.
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Affiliation(s)
- Kathryn Wiens
- Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
| | - Li Bai
- ICES Central, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada.
| | - Stephen W Hwang
- Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada; ICES Central, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada.
| | - Peter C Austin
- ICES Central, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada.
| | - Gillian L Booth
- Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada; ICES Central, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.
| | - Eldon Spackman
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada.
| | - David J T Campbell
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada; Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive, NW, Calgary, AB T2N 4N1, Canada.
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Zenno A, Huang A, Roberts AJ, Pihoker C. Health-Care Utilization and Outcomes in Young Adults With Type 1 and Type 2 Diabetes. J Endocr Soc 2024; 8:bvae115. [PMID: 38939833 PMCID: PMC11210301 DOI: 10.1210/jendso/bvae115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Indexed: 06/29/2024] Open
Abstract
Young adulthood can be a challenging time for individuals with diabetes mellitus (DM) as they experience increasing independence and life transitions, which can make it difficult to engage in DM self care. Compared to older adults, young adults are more likely to have higher glycated hemoglobin A1c (HbA1c). They also often have lower adherence to standards of care in DM, and higher utilization of emergency department (ED) visits and hospitalizations for diabetic ketoacidosis. This review describes health-care utilization and explores factors that may contribute to high HbA1c among young adults with DM. In addition, it discusses the unique health-care needs of young adults with DM, examines the role of technology in their DM care, and analyzes the effects of social determinants of health on their health-care utilization.
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Affiliation(s)
- Anna Zenno
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
- Department of Medicine, University of Washington, Seattle, WA 98105, USA
| | - Alyssa Huang
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
| | - Alissa J Roberts
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
| | - Catherine Pihoker
- Department of Pediatrics, University of Washington, Seattle, WA 98105, USA
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Vickery KD, Gelberg L, Hyson AR, Strother E, Carter J, Oranday Perez O, Franco M, Kavistan S, Gust S, Adair E, Anderson-Campbell A, Brito L, Butler A, Robinson T, Connett J, Evans MD, Emmons KM, Comulada WS, Busch AM. Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless. Front Psychiatry 2024; 15:1329138. [PMID: 38487573 PMCID: PMC10937567 DOI: 10.3389/fpsyt.2024.1329138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
Introduction People living with type 2 diabetes who experience homelessness face a myriad of barriers to engaging in diabetes self-care behaviors that lead to premature complications and death. This is exacerbated by high rates of comorbid mental illness, substance use disorder, and other physical health problems. Despite strong evidence to support lay health coach and behavioral activation, little research has effectively engaged people living with type 2 diabetes who had experienced homelessness (DH). Methods We used community engaged research and incremental behavioral treatment development to design the Diabetes HOmeless MEdication Support (D-HOMES) program, a one-on-one, 3 month, coaching intervention to improve medication adherence and psychological wellness for DH. We present results of our pilot randomized trial (with baseline, 3 mo., 6 mo. assessments) comparing D-HOMES to enhanced usual care (EUC; brief diabetes education session and routine care; NCT05258630). Participants were English-speaking adults with type 2 diabetes, current/recent (<24 mo.) homelessness, and an HbA1c‗7.5%. We focused on feasibility (recruitment, retention, engagement) and acceptability (Client Satisfaction Questionnaire, CSQ-8). Our primary clinical outcome was glycemic control (HbA1c) and primary behavioral outcome was medication adherence. Secondary outcomes included psychological wellness and diabetes self-care. Results Thirty-six eligible participants enrolled, 18 in each arm. Most participants identified as Black males, had high rates of co-morbidities, and lived in subsidized housing. We retained 100% of participants at 3-months, and 94% at 6-months. Participants reported high satisfaction (mean CSQ-8 scores=28.64 [SD 3.94] of 32). HbA1c reduced to clinically significant levels in both groups, but we found no between group differences. Mean blood pressure improved more in D-HOMES than EUC between baseline and 6 mo. with between group mean differences of systolic -19.5 mmHg (p=0.030) and diastolic blood pressure -11.1 mmHg (p=0.049). We found no significant between group differences in other secondary outcomes. Conclusion We effectively recruited and retained DH over 6 months. Data support that the D-HOMES intervention was acceptable and feasible. We observe preliminary blood pressure improvement favoring D-HOMES that were statistically and clinically significant. D-HOMES warrants testing in a fully powered trial which could inform future high quality behavioral trials to promote health equity. Clinical trial registration https://clinicaltrials.gov/study/NCT05258630?term=D-HOMES&rank=1, identifier NCT05258630.
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Affiliation(s)
- Katherine Diaz Vickery
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Lillian Gelberg
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- UCLA Fielding School of Public Health, Los Angeles, CA, United States
| | - Audrey Rose Hyson
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Ella Strother
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Jill Carter
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Oscar Oranday Perez
- The Behavioral Health Equity Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Moncies Franco
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Silvio Kavistan
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Susan Gust
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Edward Adair
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | | | - Lelis Brito
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Annette Butler
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Tahiti Robinson
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - John Connett
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, United States
| | - Karen M. Emmons
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - W. Scott Comulada
- David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
- UCLA Fielding School of Public Health, Los Angeles, CA, United States
| | - Andrew M. Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- The Behavioral Health Equity Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
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Sekar P, Ward M, Gust S, Ford BR, Franco M, Adair E, Bryant A, Ngwu D, Cole JM, Brito L, Barnes M, Robinson T, Anderson-Campbell A'C, Gray J, Ouray E, Carr A, Vickery KD. Disseminating Community-Engaged Research Involving People Experiencing Homelessness and Diabetes Using Participatory Theater. Health Promot Pract 2024:15248399231221731. [PMID: 38264858 PMCID: PMC11266524 DOI: 10.1177/15248399231221731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
People experiencing homelessness balance competing priorities resulting in reduced capacity to meet the care demands of chronic conditions, including Type 2 Diabetes Mellitus (T2DM). Arts-based performances present an avenue to expose others to these challenges. This article describes the process of incorporating qualitative research findings in a community-based participatory theater production to expose audiences to the day-to-day realities of living with T2DM while simultaneously experiencing homelessness. We conducted five focus groups and two individual interviews with people living with T2DM who had experienced homelessness with guidance from a community-engaged research team. We then collaborated with a local theater company to present common themes from these focus groups in a co-created play about the experience of managing T2DM while being homeless. We performed a staged reading of the play and assessed audience members' perceived stigma through a pre- and post-survey to determine if audience engagement within our theatrical production could reduce stigma toward individuals living with diabetes and/or people experiencing homelessness. This theatrical production is titled "Life Heist: Stealing Hope While Surviving Diabetes and Homelessness." Our work illustrates the feasibility and effectiveness of using participatory theater to disseminate qualitative research findings.
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Affiliation(s)
- Preethiya Sekar
- Health, Homelessness, & Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maren Ward
- zAmya Theater Project, Minneapolis, MN, USA
| | - Susan Gust
- Partners Three Consulting, Minneapolis, MN, USA
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | - Becky R Ford
- Health, Homelessness, & Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Moncies Franco
- Health, Homelessness, & Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | - Edward Adair
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | - Annette Bryant
- zAmya Theater Project, Minneapolis, MN, USA
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | - Denita Ngwu
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
- Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Lelis Brito
- zAmya Theater Project, Minneapolis, MN, USA
- The Center for Moving Cultures, Minneapolis, MN, USA
| | - Marcia Barnes
- zAmya Theater Project, Minneapolis, MN, USA
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | - Tahiti Robinson
- zAmya Theater Project, Minneapolis, MN, USA
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | | | | | | | - Alphonse Carr
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
| | - Katherine Diaz Vickery
- Health, Homelessness, & Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Quorum for Community-Driven Wellness Research, Minneapolis, MN, USA
- Hennepin Healthcare, Minneapolis, MN, USA
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Vickery KD, Ford BR, Gelberg L, Bonilla Z, Strother E, Gust S, Adair E, Montori VM, Linzer M, Evans MD, Connett J, Heisler M, O'Connor PJ, Busch AM. The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness. Front Psychol 2023; 14:1225777. [PMID: 37794913 PMCID: PMC10546874 DOI: 10.3389/fpsyg.2023.1225777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/08/2023] [Indexed: 10/06/2023] Open
Abstract
Introduction Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH. Methods We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions). Results In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing. Discussion The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.
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Affiliation(s)
- Katherine Diaz Vickery
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Becky R. Ford
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, CA, United States
| | - Zobeida Bonilla
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Ella Strother
- The Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Susan Gust
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Edward Adair
- The Quorum for Community Engaged Wellness Research, Minneapolis, MN, United States
| | - Victor M. Montori
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine and the Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Mark Linzer
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, United States
| | - John Connett
- School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Michele Heisler
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Patrick J. O'Connor
- Center for Chronic Care Innovation, HealthPartners Institute, Bloomington, MN, United States
| | - Andrew M. Busch
- Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
- The Behavioral Health Equity Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
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Jones AL, Chu K, Rose DE, Gelberg L, Kertesz SG, Gordon AJ, Wells KB, Leung L. Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness. J Gen Intern Med 2023; 38:2436-2444. [PMID: 36810631 PMCID: PMC10465405 DOI: 10.1007/s11606-023-08077-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied. OBJECTIVE To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care. DESIGN Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019). PARTICIPANTS PEH diagnosed or treated for a depressive disorder. MAIN MEASURES The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings. KEY RESULTS Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004). CONCLUSIONS Homeless-tailored primary care approaches may improve depression care for PEH.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center and Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Lillian Gelberg
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Stefan G Kertesz
- Birmingham VA Health Care System, Birmingham, AL, USA
- Heersink University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center and Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kenneth B Wells
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UCLA Center for Health Services and Society, Los Angeles, CA, USA
| | - Lucinda Leung
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
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Sharan R, Wiens K, Ronksley PE, Hwang SW, Booth GL, Austin PC, Spackman E, Bai L, Campbell DJT. The Association of Homelessness With Rates of Diabetes Complications: A Population-Based Cohort Study. Diabetes Care 2023; 46:1469-1476. [PMID: 37276538 DOI: 10.2337/dc23-0211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/01/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects. RESEARCH DESIGN AND METHODS A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to nonhomeless control subjects with similar sociodemographic and clinical characteristics. Rate ratios (RRs) for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with negative binomial distribution and robust SEs. RESULTS Of 1,076,437 people who were eligible for inclusion in the study, 6,944 were identified as homeless. A suitable nonhomeless match was found for 5,219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared with nonhomeless control subjects (RR 1.85, 95% CI 1.64-2.07), as were rates of hospitalization for glycemia (RR 5.64, 95% CI 4.07-7.81) and skin/soft tissue infections (RR 3.78, 95% CI 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR 0.76, 95% CI 0.62-0.94). CONCLUSIONS These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.
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Affiliation(s)
- Ruchi Sharan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn Wiens
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Stephen W Hwang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Gillian L Booth
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Peter C Austin
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Eldon Spackman
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - David J T Campbell
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
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9
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Hassan S, Gujral UP, Quarells RC, Rhodes EC, Shah MK, Obi J, Lee WH, Shamambo L, Weber MB, Narayan KMV. Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward. Lancet Diabetes Endocrinol 2023; 11:509-524. [PMID: 37356445 PMCID: PMC11070656 DOI: 10.1016/s2213-8587(23)00129-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 06/27/2023]
Abstract
Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.
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Affiliation(s)
- Saria Hassan
- Department of Medicine, Emory University, Atlanta, GA, USA; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA.
| | - Unjali P Gujral
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA
| | - Rakale C Quarells
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - Elizabeth C Rhodes
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA
| | - Megha K Shah
- Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA
| | - Jane Obi
- Emory School of Medicine, and the Nutrition and Health Sciences Doctoral Program, Laney Graduate School, Emory University, Atlanta, GA, USA; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA
| | - Wei-Hsuan Lee
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Luwi Shamambo
- Department of Medicine, Emory University, Atlanta, GA, USA
| | - Mary Beth Weber
- Emory School of Medicine, and the Nutrition and Health Sciences Doctoral Program, Laney Graduate School, Emory University, Atlanta, GA, USA; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA
| | - K M Venkat Narayan
- Department of Medicine, Emory University, Atlanta, GA, USA; Emory School of Medicine, and the Nutrition and Health Sciences Doctoral Program, Laney Graduate School, Emory University, Atlanta, GA, USA; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Atlanta, GA, USA
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10
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Flores-Ortiz R, Fiaccone RL, Leyland A, Millett C, Hone T, Schmidt MI, Ferreira AJF, Ichihara MY, Teixeira C, Sanchez MN, Pescarini J, Aquino EML, Malta DC, Velasquez-Melendez G, de Oliveira JF, Craig P, Ribeiro-Silva RC, Barreto ML, Katikireddi SV. Subsidised housing and diabetes mortality: a retrospective cohort study of 10 million low-income adults in Brazil. BMJ Open Diabetes Res Care 2023; 11:e003224. [PMID: 37349106 PMCID: PMC10314413 DOI: 10.1136/bmjdrc-2022-003224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/29/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION Housing-related factors can be predictors of health, including of diabetes outcomes. We analysed the association between subsidised housing residency and diabetes mortality among a large cohort of low-income adults in Brazil. RESEARCH DESIGN AND METHODS A cohort of 9 961 271 low-income adults, observed from January 2010 to December 2015, was created from Brazilian administrative records of social programmes and death certificates. We analysed the association between subsidised housing residency and time to diabetes mortality using a Cox model with inverse probability of treatment weighting and regression adjustment. We assessed inequalities in this association by groups of municipality Human Development Index. Diabetes mortality included diabetes both as the underlying or a contributory cause of death. RESULTS At baseline, the mean age of the cohort was 40.3 years (SD 15.6 years), with a majority of women (58.4%). During 29 238 920 person-years of follow-up, there were 18 775 deaths with diabetes as the underlying or a contributory cause. 340 683 participants (3.4% of the cohort) received subsidised housing. Subsidised housing residents had a higher hazard of diabetes mortality compared with non-residents (HR 1.17; 95% CI 1.05 to 1.31). The magnitude of this association was more pronounced among participants living in municipalities with lower Human Development Index (HR 1.30; 95% CI 1.04 to 1.62). CONCLUSIONS Subsidised housing residents had a greater risk of diabetes mortality, particularly those living in low socioeconomic status municipalities. This finding suggests the need to intensify diabetes prevention and control actions and prompt treatment of the diabetes complications among subsidised housing residents, particularly among those living in low socioeconomic status municipalities.
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Affiliation(s)
- Renzo Flores-Ortiz
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
| | - Rosemeire L Fiaccone
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
- Institute of Mathematics, Federal University of Bahia, Salvador, Brazil
| | | | - Christopher Millett
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Thomas Hone
- Public Health Policy Evaluation Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Maria Inês Schmidt
- Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrêa J F Ferreira
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
| | - Maria Y Ichihara
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
| | - Camila Teixeira
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
| | - Mauro N Sanchez
- Tropical Medicine Center, University of Brasilia, Brasília, Brazil
| | - Julia Pescarini
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
| | - Estela M L Aquino
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - Deborah C Malta
- Escola de Enfermagem, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Juliane Fonseca de Oliveira
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
- Center of Mathematics of University of Porto (CMUP), University of Porto, Porto, Portugal
| | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Rita C Ribeiro-Silva
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
- School of Nutrition, Federal University of Bahia, Salvador, Brazil
| | - Mauricio L Barreto
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Bahia, Brazil
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
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11
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Gu KD, Faulkner KC, Thorndike AN. Housing instability and cardiometabolic health in the United States: a narrative review of the literature. BMC Public Health 2023; 23:931. [PMID: 37221492 PMCID: PMC10203673 DOI: 10.1186/s12889-023-15875-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/11/2023] [Indexed: 05/25/2023] Open
Abstract
Housing instability is variably defined but generally encompasses difficulty paying rent, living in poor or overcrowded conditions, moving frequently, or spending the majority of household income on housing costs. While there is strong evidence that people experiencing homelessness (i.e., lack of regular housing) are at increased risk for cardiovascular disease, obesity, and diabetes, less is known about housing instability and health. We synthesized evidence from 42 original research studies conducted in the United States examining the association of housing instability and cardiometabolic health conditions of overweight/obesity, hypertension, diabetes, and cardiovascular disease. The included studies varied widely in their definitions and methods of measuring housing instability, but all exposure variables were related to housing cost burden, frequency of moves, living in poor or overcrowded conditions, or experiencing eviction or foreclosure, measured at either the individual household level or at a population level. We also included studies examining the impact of receipt of government rental assistance, which serves as a marker of housing instability given that its purpose is to provide affordable housing for low-income households. Overall, we found mixed but generally adverse associations between housing instability and cardiometabolic health, including higher prevalence of overweight/obesity, hypertension, diabetes, and cardiovascular disease; worse hypertension and diabetes control; and higher acute health care utilization among those with diabetes and cardiovascular disease. We propose a conceptual framework for pathways linking housing instability and cardiometabolic disease that could be targeted in future research and housing policies or programs.
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Affiliation(s)
- Kristine D. Gu
- Division of Endocrinology, Massachusetts General Hospital, 50 Staniford Street, Suite 340, Boston, MA 02114 USA
- Harvard Medical School, Boston, MA USA
| | - Katherine C. Faulkner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Anne N. Thorndike
- Harvard Medical School, Boston, MA USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA USA
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12
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Wiens K, Bai L, Austin PC, Ronksley PE, Hwang SW, Spackman E, Booth GL, Campbell DJT. Long-term association between homelessness and mortality among people with diabetes. Lancet Diabetes Endocrinol 2023; 11:229-231. [PMID: 36958867 DOI: 10.1016/s2213-8587(22)00358-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/15/2022] [Accepted: 11/29/2022] [Indexed: 03/25/2023]
Affiliation(s)
- Kathryn Wiens
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; MAP Centre for Urban Health Solutions, St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Li Bai
- ICES, Toronto, ON, Canada
| | - Peter C Austin
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Eldon Spackman
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Gillian L Booth
- MAP Centre for Urban Health Solutions, St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - David J T Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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13
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Carlozzi NE, Kallen MA, Troost JP, Miner JA, Bragg A, Martin-Howard J, De La Cruz B, Moldovan I, Jack BW, Mitchell S. Development of a New Measure of Housing Security: The REDD-CAT Housing Security Measure. J Gen Intern Med 2023:10.1007/s11606-023-08147-x. [PMID: 36964423 PMCID: PMC10038379 DOI: 10.1007/s11606-023-08147-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/09/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Housing security is a key social determinant of behavior related to health outcomes. OBJECTIVE The purpose of this study was to develop a new patient-reported outcome measure that evaluates aspects of housing security for use in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system. DESIGN Qualitative data, literature reviews, and cross-sectional survey study. PARTICIPANTS A total of 225 people with T2DM provided responses to the items in this item pool. MAIN MEASURES A new item pool that evaluates important aspects of housing security was developed using stakeholder data from focus groups of persons with T2DM. KEY RESULTS For the Housing Affordability scale, factor analysis (both exploratory and confirmatory) supported the retention of six items. Of these items, none exhibited sparse cells or problems with monotonicity; no items were deleted due to low item-adjusted total score correlations. For the six affordability items, a constrained graded response model indicated no items exhibited misfit; thus, all were retained. No items indicated differential item functioning (examined for age, sex, education, race, and socioeconomic status). Thus, the final Affordability item bank comprised six items. A Housing Safety index (three items) and a Home Features index (eight items) were also developed. Reliability (i.e., internal consistency and test-retest reliability) and validity (i.e., convergent, discriminant, and known-groups) of the new measures were also supported. CONCLUSIONS The REDD-CAT Housing Security Measure provides a reliable and valid assessment of housing affordability, safety, and home features in people with type 2 diabetes mellitus. Future work is needed to establish the clinical utility of this measure in other clinical populations.
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Affiliation(s)
- Noelle E Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA.
- Center for Clinical Outcomes Development and Application (CODA), Department of Physical Medicine & Rehabilitation, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building NCRC B14, Room G216, Ann Arbor, MI, 48109-2800, USA.
| | - Michael A Kallen
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer A Miner
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Alexa Bragg
- Department of Family Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jessica Martin-Howard
- Department of Family Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Ioana Moldovan
- Department of Family Medicine, Boston Medical Center, Boston, MA, USA
| | - Brian W Jack
- Department of Family Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Family Medicine, Boston Medical Center, Boston, MA, USA
| | - Suzanne Mitchell
- Department of Family Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Family Medicine, Boston Medical Center, Boston, MA, USA
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14
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SMS texting for uncontrolled diabetes among persons experiencing homelessness: Study protocol for a randomized trial. Contemp Clin Trials 2023; 128:107149. [PMID: 36918092 DOI: 10.1016/j.cct.2023.107149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/20/2023] [Accepted: 03/09/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes. METHODS AND ANALYSIS This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10). DISCUSSION DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.
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15
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Schillinger D, Bullock A, Powell C, Fukagawa NK, Greenlee MC, Towne J, Gonzalvo JD, Lopata AM, Cook JW, Herman WH. The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission. Diabetes Care 2023; 46:e24-e38. [PMID: 36701595 PMCID: PMC9887620 DOI: 10.2337/dc22-0619] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 10/04/2022] [Indexed: 01/27/2023]
Abstract
The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.
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Affiliation(s)
- Dean Schillinger
- Division of General Internal Medicine, Center for Vulnerable Populations, San Francisco General Hospital, University of California San Francisco School of Medicine, San Francisco, CA
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Clydette Powell
- Division of Neurology, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Naomi K. Fukagawa
- Beltsville Human Nutrition Research Center, U.S. Department of Agriculture Agricultural Research Service, Beltsville, MD
| | | | - Jana Towne
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | - Jasmine D. Gonzalvo
- Center for Health Equity and Innovation, Purdue University/Eskenazi Health, Indianapolis, IN
| | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | | | - William H. Herman
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Epidemiology, University of Michigan, Ann Arbor, MI
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16
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Herman WH, Bullock A, Boltri JM, Conlin PR, Greenlee MC, Lopata AM, Powell C, Tracer H, Schillinger D. The National Clinical Care Commission Report to Congress: Background, Methods, and Foundational Recommendations. Diabetes Care 2023; 46:e14-e23. [PMID: 36701594 PMCID: PMC9887619 DOI: 10.2337/dc22-0611] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
Since the first Federal Commission on Diabetes issued its report in 1975, the diabetes epidemic in the U.S. has accelerated, and efforts to translate advances in diabetes treatment into routine clinical practice have stalled. In 2021, the National Clinical Care Commission (NCCC) delivered a report to Congress that provided recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. In the five articles in this series, we present the NCCC's evidence-based recommendations to 1) reduce diabetes-related risks, prevent type 2 diabetes, and avert diabetes complications through changes in federal policies and programs affecting the general population; 2) prevent type 2 diabetes in at-risk individuals through targeted lifestyle and medication interventions; and 3) improve the treatment of diabetes and its complications to improve the health outcomes of people with diabetes. In this first article, we review the successes and limitations of previous federal efforts to combat diabetes. We then describe the establishment of and charge to the NCCC. We discuss the development of a hybrid conceptual model that guided the NCCC's novel all-of-government approach to address diabetes as both a societal and medical problem. We then review the procedures used by the NCCC to gather information from federal agencies, stakeholders, key informants, and the public and to conduct literature reviews. Finally, we review the NCCC's three foundational recommendations: 1) improve the coordination of non-health-related and health-related federal agencies to address the social and environmental conditions that are accelerating the diabetes epidemic; 2) ensure that all Americans at risk for and with diabetes have health insurance and access to health care; and 3) ensure that all federal policies and programs promote health equity in diabetes.
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Affiliation(s)
| | - Ann Bullock
- Division of Diabetes Treatment and Prevention, Indian Health Service, Rockville, MD
| | | | - Paul R. Conlin
- Department of Veterans Affairs Boston Healthcare System, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Aaron M. Lopata
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD
| | - Clydette Powell
- School of Medicine and Health Services, George Washington University, Washington, DC
| | - Howard Tracer
- Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD
| | - Dean Schillinger
- University of California San Francisco School of Medicine and San Francisco General Hospital, San Francisco, CA
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17
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Howell CR, Harada CN, Fontaine KR, Mugavero MJ, Cherrington AL. Perspective: Acknowledging a Hierarchy of Social Needs in Diabetes Clinical Care and Prevention. Diabetes Metab Syndr Obes 2023; 16:161-166. [PMID: 36760578 PMCID: PMC9869784 DOI: 10.2147/dmso.s389182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/22/2022] [Indexed: 04/20/2023] Open
Abstract
The evidence of suboptimal social determinants of health (SDoH) on poor health outcomes has resulted in widespread calls for research to identify ways to measure and address social needs to improve health outcomes and reduce disparities. While assessing SDoH has become increasingly important in diabetes care and prevention research, little guidance has been offered on how to address suboptimal determinants in diabetes-related clinical care, prevention efforts, medical education and research. Not surprisingly, many patients experience multiple social needs - some that are more urgent (housing) than others (transportation/resources), therefore the order in which these needs are addressed needs to be considered in the context of diabetes care/outcomes. Here we discuss how conceptualizing diabetes related health through the lens of Maslow's hierarchy of needs has potential to help prioritize individual social needs that should be addressed to improve outcomes in the context of population-level determinants in the communities where people live.
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Affiliation(s)
- Carrie R Howell
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Caroline N Harada
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kevin R Fontaine
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, Al, USA
| | - Michael J Mugavero
- Department of Medicine, Division of General Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrea L Cherrington
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Developing and evaluating a SAFER model to screen for diabetes complications among people experiencing homelessness: a pilot study protocol. Pilot Feasibility Stud 2022; 8:211. [PMID: 36114586 PMCID: PMC9479401 DOI: 10.1186/s40814-022-01165-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/25/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Diabetes management combined with housing instability intersects, forcing individuals to triage competing needs and critical stressors, such as safety and shelter, with fundamental diabetes self-management tasks like attending healthcare appointments to screen for the complications of diabetes, leaving individuals overwhelmed and overburdened. We aim to address this disjuncture found within our current healthcare delivery system by providing point-of-care screening opportunities in a more patient-centered approach.
Method
We describe a pilot study of a novel clinical intervention which provides timely, comprehensive, and accessible screening for diabetes complications to people experiencing homelessness. We will assess the reach, effectiveness, adoption, implementation, and maintenance, as per the RE-AIM framework, of a SAFER model of care (i.e., screening for A1C, feet, eyes, and renal function). A trained nurse will provide this screening within a homeless shelter. During these encounters, eligible participants will be screened for microvascular complications (neuropathy, nephropathy, retinopathy) and have their A1C measured, all at the point of care, using bedside tools and novel technology. Effectiveness, our primary objective, will be evaluated using a pre-post design, by comparing the rate of completion of full microvascular screening during the study period with individuals’ own historical screening in the 2-year period prior to enrollment. The other domains of the RE-AIM framework will be assessed using process data, chart reviews, patient surveys, and qualitative semi-structured interviews with service providers and participants. This study will be conducted in a large inner-city homeless shelter within a major urban Canadian city (Calgary, Canada).
Discussion
Currently, screening for diabetes complications is often inaccessible for individuals experiencing homelessness, which places heavy burdens on individuals and, ultimately, on already strained emergency and acute care services when complications go undetected at earlier stages. The SAFER intervention will modify the current standard of care for this population in a way that is less fragmented, more person-focused, and timely, with the goal of ultimately improving the rate of screening in an acceptable fashion to identify those requiring specialist referral at earlier stages.
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Flike K, Foust JB, Hayman LL, Aronowitz T. Homelessness and Vulnerably-Housed Defined: A Synthesis of the Literature. Nurs Sci Q 2022; 35:350-367. [PMID: 35762065 DOI: 10.1177/08943184221092445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is no single accepted definition used in policy or research for the concepts of homelessness and vulnerably housed. Neuman's systems model (NSM) was the framework for this mixed-studies review, with the client system defined as these social issues and categorized as environmental stressors. Eighteen unique definitions of the concepts were identified in 30 studies. Extrapersonal stressors included housing history, interpersonal stressors included dependence on others for housing, and intrapersonal stressors included self-identification. Each level of stressor should be considered when defining these populations for inclusion in future research. Proposed definitions were formulated from the analysis of the results.
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Affiliation(s)
- Kimberlee Flike
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Janice B Foust
- Robert and Donna Manning College of Nursing & Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Laura L Hayman
- Robert and Donna Manning College of Nursing & Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Teri Aronowitz
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
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Asgary R, Beideck E, Naderi R. Diabetes care and its predictors among persons experiencing homelessness compared with domiciled adults with diabetes in New York City; An observational study. EClinicalMedicine 2022; 48:101418. [PMID: 35516444 PMCID: PMC9062666 DOI: 10.1016/j.eclinm.2022.101418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is a dearth of data regarding diabetes control among patients experiencing homelessness. METHODS We retrospectively collected type 2 diabetes-related measurements, sociodemographic, and clinical indicators from medical records of all incoming adults with diabetes (n = 418; homeless: 356 and domiciled: 58) seen in shelter-clinics in New York City in 2019. The outcomes were the rates of inadequately managed diabetes and associated factors. FINDINGS Bivariate analysis showed that patients experiencing homelessness (63% Black; 32% Hispanic) 134/304 (43⋅9%) were more likely than domiciled patients 13/57 (22·8%) to have inadequately managed diabetes (OR 2⋅67, CI 1·38-5·16, p = 0⋅003). The average HbA1c among homeless (8·4%, SD± 2·6) was higher than that of domiciled persons (7·3%, SD± 1·8, p = 0·002). In logistic regression, domiciled status (OR 0⋅ 42, CI 0·21 - 0·84, p = 0·013), older age (OR 0·97, CI 0·95 - 0·99, p = 0·004), and non-Hispanic/Latino ethnicity were associated with well-managed diabetes. Among persons experiencing homelessness, non-Hispanic/Latino (OR 0·61, CI 0·37-0·99, p = 0·047) and older age (0·96, CI 0·94-0·99, p = 0·003) were associated with well-managed diabetes. In linear regression, mental illness (-0·11, p = 0·048) and older age (-0·15, p = 0·010) were associated with lower HbA1c, suggesting better support in respective shelters. There was no statistically significant association between inadequately managed diabetes with several traditional risk factors including substance or alcohol use disorder, health insurance, or other chronic diseases. INTERPRETATION Interventions at shelters or shelter-clinics should target subgroups in addition to addressing traditional risk factors to improve diabetes control. mHealth strategies could be considered to improve engagement, care delivery, and medication taking. Ultimately, homelessness itself needs to be addressed. FUNDING There are no funding sources to declare.
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Key Words
- BMI, body mass index
- BP, blood pressure
- CAD, coronary artery disease
- CKD, chronic kidney disease
- DM, diabetes mellitus
- Diabetes mellitus
- GFR, glomerular filtration rate
- HTN, hypertension
- HbA1c, hemoglobin A1c
- Health disparities
- Homeless
- LDL, low density lipoprotein
- PCP, primary care physician
- Primary care
- Quality care
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Affiliation(s)
- Ramin Asgary
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave NW, Washington, D.C. 20052, USA
- Weill Cornell Medical College of Cornell University, 525 East 68th Street, New York, NY 10065, USA
- Corresponding author.
| | - Elena Beideck
- Weill Cornell Medical College of Cornell University, 525 East 68th Street, New York, NY 10065, USA
| | - Rosanna Naderi
- Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave NW, Washington, D.C. 20052, USA
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Mosley-Johnson E, Walker RJ, Thakkar M, Campbell JA, Hawks L, Pyzyk S, Egede LE. Relationship between housing insecurity, diabetes processes of care, and self-care behaviors. BMC Health Serv Res 2022; 22:61. [PMID: 35022049 PMCID: PMC8756650 DOI: 10.1186/s12913-022-07468-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 01/04/2022] [Indexed: 11/17/2022] Open
Abstract
Background The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity. Methods Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count. Results 38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99). Conclusions Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.
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Huggett TD, Tung EL, Cunningham M, Ghinai I, Duncan HL, McCauley ME, Detmer WM. Assessment of a Hotel-Based Protective Housing Program for Incidence of SARS-CoV-2 Infection and Management of Chronic Illness Among Persons Experiencing Homelessness. JAMA Netw Open 2021; 4:e2138464. [PMID: 34902035 PMCID: PMC8669521 DOI: 10.1001/jamanetworkopen.2021.38464] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Persons experiencing homelessness (PEH) are at higher risk for SARS-CoV-2 infection and severe illness due to COVID-19 because of a limited ability to physically distance and a higher burden of underlying health conditions. OBJECTIVE To describe and assess a hotel-based protective housing intervention to reduce incidence of SARS-CoV-2 infection among PEH in Chicago, Illinois, with increased risk of severe illness due to COVID-19. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study analyzed PEH who were provided protective housing in individual hotel rooms in downtown Chicago during the COVID-19 pandemic from April 2 through September 3, 2020. Participants were PEH at increased risk for severe COVID-19, defined as (1) aged at least 60 years regardless of health conditions, (2) aged at least 55 years with any underlying health condition posing increased risk, or (3) aged less than 55 years with any underlying health condition posing substantially increased risk (eg, HIV/AIDS). EXPOSURES Participants were housed in individual hotel rooms to reduce the risk of SARS-CoV-2 infection; on-site health care workers provided daily symptom monitoring, regular SARS-CoV-2 testing, and care for chronic health conditions. Additional on-site services included treatment of mental health and substance use disorders and social services. MAIN OUTCOMES AND MEASURES The main outcome measured was SARS-CoV-2 incidence, with SARS-Cov2 infection defined as a positive upper respiratory specimen using any polymerase chain reaction diagnostic assay authorized for emergency use by the Food and Drug Administration. Secondary outcomes were blood pressure control, glycemic control as measured by hemoglobin A1c, and housing placements at departure. RESULTS Of 259 participants from 16 homeless shelters in Chicago, 104 (40.2%) were aged at least 65 years, 190 (73.4%) were male, 185 (71.4%) were non-Hispanic Black, and 49 (18.9%) were non-Hispanic White. There was an observed reduction in SARS-CoV-2 incidence during the study period among the protective housing cohort (54.7 per 1000 people [95% CI, 22.4-87.1 per 1000 people]) compared with citywide rates for PEH residing in shelters (137.1 per 1000 people [95% CI, 125.1-149.1 per 1000 people]; P = .001). There was also an adjusted change in systolic blood pressure at a rate of -5.7 mm Hg (95% CI, -9.3 to -2.1 mm Hg) and hemoglobin A1c at a rate of -1.4% (95% CI, -2.4% to -0.4%) compared with baseline. More than half of participants (51% [n = 132]) departed from the intervention to housing of some kind (eg, supportive housing). CONCLUSIONS AND RELEVANCE This cohort study found that protective housing was associated with a reduction in SARS-CoV-2 infection among high-risk PEH during the first wave of the COVID-19 pandemic in Chicago. These findings suggest that with appropriate wraparound supports (ie, multisector services to address complex needs), such housing interventions may reduce the risk of SARS-CoV-2 infection, improve noncommunicable disease control, and provide a pathway to permanent housing.
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Affiliation(s)
| | - Elizabeth L. Tung
- Section of General Internal Medicine and Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois
| | | | - Isaac Ghinai
- Chicago Department of Public Health, Chicago, Illinois
| | - Heather L. Duncan
- Lawndale Christian Health Center, Chicago, Illinois
- Department of Nursing, North Park University, Chicago, Illinois
| | - Maura E. McCauley
- Chicago Department of Family and Support Services, Chicago, Illinois
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Campbell RB, Larsen M, DiGiandomenico A, Davidson MA, Booth GL, Hwang SW, McBrien KA, Campbell DJT. Les défis de la gestion du diabète chez les personnes itinérantes : étude qualitative avec la méthode photovoix. CMAJ 2021; 193:E1184-E1192. [PMID: 34344778 PMCID: PMC8354642 DOI: 10.1503/cmaj.202537-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/03/2022] Open
Abstract
CONTEXTE: La recherche sur les défis de la prise en charge du diabète chez les personnes itinérantes qui en sont atteintes n’a pas tendance à prendre en considération le point de vue des personnes touchées. Nous avons utilisé une approche de recherche participative avec la communauté pour explorer ces défis. MÉTHODES: Nous avons recruté des cochercheurs ayant une connaissance expérientielle de l’itinérance et du diabète. Les chercheurs principaux leur ont offert une formation en recherche et ont préparé le terrain avec eux pour ce projet. Les cochercheurs ont collectivement choisi d’utiliser la méthode photovoix pour illustrer la difficulté de bien s’alimenter quand on est en situation d’itinérance et explorer en quoi cet écueil affecte plus largement la gestion du diabète. Après une formation en photographie et en éthique, les cochercheurs ont pris des photos en lien avec les objectifs du projet et rédigé des récits connexes au moyen de techniques de rédaction inspirée par des photos. Les chercheurs principaux ont analysé les photos et les récits, et ils en ont dégagé des thèmes qui se sont précisés lors de discussions de groupe. RÉSULTATS: Les 8 cochercheurs étaient atteints de diabète de type 2 (diagnostiqué de 18 mois à 23 ans auparavant) et avaient vécu en situation d’itinérance pendant des périodes allant de 8 mois à 12 ans. Nous avons dégagé 4 thèmes à partir de 17 photos et récits produits. L’itinérance affecte grandement la santé émotionnelle et mentale des personnes, ce qui nuit à leur capacité de bien gérer leur diabète. Les aliments servis dans les refuges sont rarement nutritifs ou appétissants. L’obtention d’une forme de logement peut faciliter la prise en charge du diabète en créant un environnement stable qui favorise l’autonomie, mais les coûts et le manque de connaissances sont des obstacles à la préparation de repas sains. L’itinérance complique aussi l’accès aux professionnels de la prise en charge du diabète et aux médicaments d’ordonnance. INTERPRÉTATION: Les images et les récits associés permettent de dresser un tableau frappant, complet et fidèle des défis auxquels sont confrontées les personnes en situation d’itinérance qui essaient de gérer leur diabète. Comprendre ces défis est la première étape qui permettra aux intervenants et aux décideurs de répondre aux besoins de cette population.
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Affiliation(s)
- Rachel B Campbell
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - Matthew Larsen
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - Anna DiGiandomenico
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - Marleane A Davidson
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - Gillian L Booth
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - Stephen W Hwang
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - Kerry A McBrien
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb
| | - David J T Campbell
- Département de médecine (R.B. Campbell, D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.; Clients with Diabetes Action Committee, MAP Centre for Urban Health Solutions (Larsen, DiGiandomenico, Davidson), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; MAP Centre for Urban Health Solutions (Booth, Hwang), Institut du savoir Li Ka Shing, Hôpital St. Michael, Unity Health Toronto; Département de médecine, Faculté de médecine (Booth, Hwang), Université de Toronto, Toronto, Ont.; Départements des sciences de la santé communautaire (McBrien, D.J.T. Campbell), de médecine familiale (McBrien) et de cardiologie (D.J.T. Campbell), Faculté de médecine Cumming de l'Université de Calgary, Calgary, Alb.
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24
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Wiens K, Nisenbaum R, Sucha E, Aubry T, Farrell S, Palepu A, Duhoux A, Gadermann A, Hwang SW. Does Housing Improve Health Care Utilization and Costs? A Longitudinal Analysis of Health Administrative Data Linked to a Cohort of Individuals With a History of Homelessness. Med Care 2021; 59:S110-S116. [PMID: 33710082 DOI: 10.1097/mlr.0000000000001379] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Individuals who are homeless have complex health care needs, which contribute to the frequent use of health services. In this study, we investigated the relationship between housing and health care utilization among adults with a history of homelessness in Ontario. METHODS Survey data from a 4-year prospective cohort study were linked with administrative health records in Ontario. Annual rates of health encounters and mean costs were compared across housing categories (homeless, inconsistently housed, housed), which were based on the percentage of time an individual was housed. Generalized estimating equations were applied to estimate the average annual effect of housing status on health care utilization and costs. RESULTS Over the study period, the proportion of individuals who were housed increased from 37% to 69%. The unadjusted rates of ambulatory care visits, prescription medications, and laboratory tests were highest during person-years spent housed or inconsistently housed and the rate of emergency department visits was lowest during person-years spent housed. Following adjustment, the rate of prescription claims remained higher during person-years spent housed or inconsistently housed compared with the homeless. Rate ratios for other health care encounters were not significant (P>0.05). An interaction between time and housing status was observed for total health care costs; as the percentage of days housed increased, the average costs increased in year 1 and decreased in years 2-4. CONCLUSIONS These findings highlight the effects of housing on health care encounters and costs over a 4-year study period. The rate of prescription medications was higher during person-years spent housed or inconsistently housed compared with the homeless. The cost analysis suggests that housing may reduce health care costs over time; however, future work is needed to confirm the reason for the reduction in total costs observed in later years.
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Affiliation(s)
- Kathryn Wiens
- Dalla Lana School of Public Health, University of Toronto
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
| | - Rosane Nisenbaum
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
| | - Ewa Sucha
- Institute for Clinical Evaluative Sciences
| | - Tim Aubry
- School of Psychology
- Centre for Research on Educational and Community Services, University of Ottawa
| | | | - Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
- Division of General Internal Medicine, University of British Colombia, Vancouver, BC
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC
| | - Anne Gadermann
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
- School of Population and Public Health, University of British Colombia, Vancouver, BC
| | - Stephen W Hwang
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto
- Division of General Internal Medicine, University of Toronto, Toronto, ON, Canada
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25
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Racial Differences in Prevalence of Cardiometabolic Morbidities Among Homeless Men. J Racial Ethn Health Disparities 2021; 9:456-461. [PMID: 33543445 DOI: 10.1007/s40615-021-00976-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Homelessness is associated with an increased risk of cardiometabolic morbidities. However, few studies have been performed to evaluate the racial differences on these morbidities commonly seen in the homeless. METHODS A retrospective chart review was conducted to examine the racial differences in the prevalence of cardiometabolic morbidities among the homeless men served at a local health care screening clinic. Medical information was extracted and collated into a single Excel spreadsheet. Racial differences in cardiometabolic morbidities were evaluated using multivariable binary or ordinal logistic regression analyses, adjusting for age, body mass index, and smoking status. RESULTS Of the 551 homeless men, 377 (68.4%) were Black, and 174 (31.6%) were White. The mean age (47.8±11.9 years) of Black homeless men was significantly older than that (45.4±13.0 years) of White homeless men (p=0.03). Blacks were 2.7 (95% CI = 1.75, 4.16) times more likely to be in the less desirable HbA1c categories than Whites. By contrast, Blacks were less likely to have non-desirable lipid profile than Whites. Blacks were 0.42 (95% CI = 0.29, 0.62) times and 0.51 (95% CI = 0.28, 0.94) times likely to be in the non-desirable high-density lipoprotein (HDL) and low-density lipoprotein (LDL) categories than Whites, respectively. CONCLUSION Black homeless men are more likely to have pre-diabetes or diabetes than White counterparts. On the other hand, Black homeless men have better lipid profiles of HDL or LDL than their White counterparts. Our findings reveal the health challenges of the homeless men and can provide guidance on policy changes related to diet and nutrition of meal programs provided by homeless shelters and congregate meal program to address the health disparities by race in this population.
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Henry ML, Lichtman JH, Hanlon K, Keene DE. Clinical management of Type II Diabetes among the unstably housed: a qualitative study of primary care physicians. Fam Pract 2020; 37:418-423. [PMID: 31781768 PMCID: PMC7377290 DOI: 10.1093/fampra/cmz085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Housing is a growing challenge for US adults in an increasingly unaffordable housing market. These housing challenges can create barriers to effective management and control of Type II Diabetes. However, little is known about how housing challenges are perceived and navigated by clinicians who care for patients with Type II Diabetes. OBJECTIVE To examine how primary care clinicians perceive and navigate their patients' housing challenges in the context of Type II Diabetes management. METHODS We conducted semi-structured interviews with 18 primary care clinicians practising in four clinical settings in New Haven, Connecticut. Two investigators systematically coded the interviews. Analysis of coded data was used to determine themes. RESULTS Participants considered housing as significant to their patients' health and a potential barrier to optimal diabetes management. Participants sought to improve their patients' housing through advocacy, referrals and interdisciplinary collaborations. They also adjusted clinical decisions to adapt to patients' housing challenges. In making clinical adjustments, participants struggled to find a balance between what they perceived to be feasible for unstably housed patients and maintaining a standard of care. Some participants navigated this balanced by employing creative strategies and individualized care. CONCLUSION In highlighting the challenges that clinicians face in maintaining a standard of care for unstably housed diabetes patients, our findings speak to the need for more guidance, resources and support to address housing in a clinical setting.
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Affiliation(s)
- Mariana L Henry
- Department of Chronic Disease Epidemiology, New Haven, CT, USA
| | | | - Kendra Hanlon
- Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, CT, USA
| | - Danya E Keene
- Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, CT, USA
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Religious Faith and Diabetes Health Beliefs in a Homeless Population: A Qualitative Study. J Christ Nurs 2019; 36:228-235. [PMID: 31490877 DOI: 10.1097/cnj.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This participatory action research project explored the perspectives and challenges of homeless persons living with, or at risk for, type 2 diabetes. Because these persons were sheltered in and served by a church, their perspectives provide understanding about how religious faith may influence diabetes self-management.
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Baggett TP, Liauw SS, Hwang SW. Cardiovascular Disease and Homelessness. J Am Coll Cardiol 2019; 71:2585-2597. [PMID: 29852981 DOI: 10.1016/j.jacc.2018.02.077] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/09/2018] [Accepted: 02/11/2018] [Indexed: 01/14/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Samantha S Liauw
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
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Lim S, Miller-Archie SA, Singh TP, Wu WY, Walters SC, Gould LH. Supportive Housing and Its Relationship With Diabetes Diagnosis and Management Among Homeless Persons in New York City. Am J Epidemiol 2019; 188:1120-1129. [PMID: 30834432 DOI: 10.1093/aje/kwz057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/26/2019] [Accepted: 02/26/2019] [Indexed: 12/17/2022] Open
Abstract
Supportive housing addresses a fundamental survival need among homeless persons, which can lead to reduced risk of diabetes mellitus and improved diabetes care. We tested the association between supportive housing and diabetes outcomes among homeless adults who were eligible for New York City's supportive housing program in 2007-2012. We used multiple administrative data sources, identifying 7,525 Medicaid-eligible adults. The outcomes included receiving medical evaluation and management services, hemoglobin A1C and lipid testing (n = 1,489 persons with baseline diabetes), and incidence of new diabetes diagnoses (n = 6,036 persons without baseline diabetes) in the 2 years postbaseline. Differences in these outcomes by placement were estimated using inverse-probability-of-treatment weighting. Placed persons were more likely to receive evaluation and management services (relative risk (RR) = 1.03, 95% confidence interval (CI): 1.01, 1.04) than unplaced persons. For those with baseline diabetes, placed persons were more likely to receive hemoglobin A1C tests (RR = 1.10, 95% CI: 1.02, 1.19) and lipid tests (RR = 1.09, 95% CI: 1.02, 1.17). For those without baseline diabetes, placement was also associated with lower risk of new diabetes diagnoses (RR = 0.87, 95% CI: 0.76, 0.99). These findings show that benefits of supportive housing may be extended to diabetes care and prevention.
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Affiliation(s)
- Sungwoo Lim
- Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York
| | - Sara A Miller-Archie
- Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York
| | - Tejinder P Singh
- Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York
| | - Winfred Y Wu
- Bureau of Primary Care Information Project, Division of Prevention and Primary Care, New York City Department of Health and Mental Hygiene, New York, New York
- Hackensack Meridian Health, Edison, New Jersey
| | - Sarah C Walters
- Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York
| | - L Hannah Gould
- Bureau of Epidemiology Services, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, New York
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Brooks LK, Kalyanaraman N, Malek R. Diabetes Care for Patients Experiencing Homelessness: Beyond Metformin and Sulfonylureas. Am J Med 2019; 132:408-412. [PMID: 30472322 DOI: 10.1016/j.amjmed.2018.10.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/12/2022]
Abstract
On any given night in the United States, an estimated 553,742 people are homeless. Applying a broader definition of homelessness that includes unstably housed people, an estimated 1.5% of Americans experience homelessness in a given year. Rates of diabetes are increasing among individuals experiencing homelessness. The social, psychological, and physical challenges of homelessness not only contribute to the rate of diabetes, but also complicate management. Unstable housing, limited medical resources, food insecurity, and competing priorities are barriers to diabetes care among patients experiencing homelessness. Homeless patients with diabetes more frequently develop specific comorbidities that require special attention, such as cardiovascular disease, substance abuse, depression, and foot wounds. The Affordable Care Act gave states the option to expand Medicaid to those earning up to 138% of the federal poverty level. This addressed a gap in coverage for low-income individuals not eligible for Medicaid or employer-sponsored insurance. With increased insurance coverage, this has increased the variety of medications available to treat hyperglycemia from type 2 diabetes beyond metformin, sulfonylureas, and insulin. Several of the newer classes of medications have advantages for patients experiencing homelessness, but also have special considerations in this vulnerable patient population. This narrative review will provide a review of dipeptidyl peptidase-4 inhibitors, glucagon-like peptide agonists, sodium glucose cotransporter-2 inhibitors, and thiazolidinediones in individuals experiencing homelessness.
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Affiliation(s)
- Lauren K Brooks
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore
| | | | - Rana Malek
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore.
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Corey Williams J, Lo E, Iheanacho T. A Novel Resident Experience in a Veteran's Homeless Center. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2018; 42:538-541. [PMID: 29094290 DOI: 10.1007/s40596-017-0842-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/15/2017] [Indexed: 06/07/2023]
Affiliation(s)
| | - Emma Lo
- Yale University, New Haven, CT, USA
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Berkowitz SA, Kalkhoran S, Edwards ST, Essien UR, Baggett TP. Unstable Housing and Diabetes-Related Emergency Department Visits and Hospitalization: A Nationally Representative Study of Safety-Net Clinic Patients. Diabetes Care 2018; 41:933-939. [PMID: 29301822 PMCID: PMC5911783 DOI: 10.2337/dc17-1812] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/08/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Homelessness is associated with worse diabetes outcomes, but the relationship between other forms of unstable housing and diabetes is not well studied. We assessed whether unstable housing was associated with increased risk for diabetes-related emergency department use or hospitalization. RESEARCH DESIGN AND METHODS We used data from the 2014 Health Center Patient Survey (HCPS), a cross-sectional, nationally representative survey of patients who receive care at federally funded safety-net health centers. We included nonhomeless adults (aged ≥18 years) with self-reported diabetes. Unstable housing was defined as not having enough money to pay rent or mortgage, moving two or more times in the past 12 months, or staying at a place one does not own or rent. The primary outcome was self-report of diabetes-related emergency department visit or inpatient hospitalization in the last 12 months. We also examined use of housing assistance. RESULTS Of 1,087 participants, representing 3,277,165 adults with diabetes, 37% were unstably housed. Overall, 13.7% of participants reported a diabetes-related emergency department visit or hospitalization in the past year. In logistic regression analyses adjusted for multiple potential confounders, unstable housing was associated with greater odds of diabetes-related emergency department use or hospitalization (adjusted odds ratio 5.17 [95% CI 2.08-12.87]). Only 0.9% of unstably housed individuals reported receiving help with housing through their clinic. CONCLUSIONS Unstable housing is common and associated with increased risk of diabetes-related emergency department and inpatient use. Addressing unstable housing in clinical settings may help improve health care utilization for vulnerable individuals with diabetes.
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Affiliation(s)
- Seth A Berkowitz
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA .,Diabetes Population Health Research Center, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sara Kalkhoran
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Samuel T Edwards
- Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, OR.,Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR
| | - Utibe R Essien
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA.,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA
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Impact of Glycemic Control on Morbidity and Mortality in Adult Idiopathic Scoliosis Patients Undergoing Spinal Fusion. Clin Spine Surg 2017; 30:E974-E980. [PMID: 27764054 DOI: 10.1097/bsd.0000000000000447] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This is a retrospective analysis of administrative database. OBJECTIVE To elucidate the effect of glycemic control on surgical outcomes of middle-aged and elderly idiopathic scoliosis patients undergoing spinal fusion surgery. SUMMARY OF BACKGROUND DATA Diabetes mellitus (DM) is a condition thought to adversely affect outcomes of spine surgery. However, no study has stratified glycemic control levels and their impact on outcome for idiopathic scoliosis patients receiving a spinal fusion surgery. Previous studies may have reported higher than true rates of complications for controlled diabetic patients, who are the majority of diabetic patients. MATERIALS AND METHODS The Nationwide Inpatient Sample was queried from years 2002 to 2011. We extracted idiopathic scoliosis patients older than 45 years of age that received spinal fusion and analyzed complications and outcomes variables among 3 cohorts: nondiabetic patients, controlled diabetics, and uncontrolled diabetics. Multivariate analyses were used to assess whether glycemic control was a risk factor for adverse postoperative outcomes. RESULTS Controlled diabetics had significantly increased rates of acute renal failure (ARF), while uncontrolled diabetics had significantly increased rates of acute postoperative hemorrhage. In multivariate analyses controlling for patient factors and comorbidities, controlled DM was found to be an independent predictor of ARF [odds ratio (OR), 1.863; 95% confidence interval (CI), 1.346-2.579; P=0.0002), and uncontrolled DM was found to be a significant risk factor for acute postoperative hemorrhage (OR, 2.182; 95% CI, 1.192-3.997; P=0.0115), ARF (OR, 4.839; 95% CI, 1.748-13.392; P=0.0024), deep vein thrombosis (OR, 5.825; 95% CI, 1.329-25.522, P=0.0194) and in-patient mortality (OR, 8.889; 95% CI, 1.001-78.945; P=0.0499). CONCLUSIONS Controlled DM was found to be a risk factor for ARF in adult idiopathic scoliosis patients undergoing spinal fusion surgery, while uncontrolled DM was shown to be a risk factor for postoperative hemorrhage, ARF, deep vein thrombosis, and mortality. The present study provides valuable data for better informed consent for patients with diabetes considering surgery for idiopathic scoliosis. LEVEL OF EVIDENCE Level III.
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Crowley MJ. Capsule Commentary on Axon et al., Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus. J Gen Intern Med 2016; 31:1357. [PMID: 27503433 PMCID: PMC5071298 DOI: 10.1007/s11606-016-3819-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Matthew J Crowley
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA.
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