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Lee SY, Hayes LW, Ozaydin B, Howard S, Garretson AM, Bradley HM, Land AM, DeLaney EW, Pritchett AO, Furr AL, Allgood A, Wyatt MC, Hall AG, Banaszak-Holl JC. Integrating Social Determinants of Health in Machine Learning-Driven Decision Support for Diabetes Case Management: Protocol for a Sequential Mixed Methods Study. JMIR Res Protoc 2024; 13:e56049. [PMID: 39321449 DOI: 10.2196/56049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 06/23/2024] [Accepted: 06/27/2024] [Indexed: 09/27/2024] Open
Abstract
BACKGROUND The use of both clinical factors and social determinants of health (SDoH) in referral decision-making for case management may improve optimal use of resources and reduce outcome disparities among patients with diabetes. OBJECTIVE This study proposes the development of a data-driven decision-support system incorporating interactions between clinical factors and SDoH into an algorithm for prioritizing who receives case management services. The paper presents a design for prediction validation and preimplementation assessment that uses a mixed methods approach to guide the implementation of the system. METHODS Our study setting is a large, tertiary care academic medical center in the Deep South of the United States, where SDoH contribute to disparities in diabetes-specific hospitalizations and emergency department (ED) visits. This project will develop an interpretable artificial intelligence model for a population with diabetes using SDoH and clinical data to identify which posthospitalization cases have a higher likelihood of subsequent ED use. The electronic health record data collected for the study include demographics, SDoH, comorbidities, hospitalization-related factors, laboratory test results, and medication use to predict posthospitalization ED visits. Subsequently, a mixed methods approach will be used to validate prediction outcomes and develop an implementation strategy from insights into patient outcomes from case managers, clinicians, and quality and patient safety experts. RESULTS As of December 2023, we had abstracted data on 174,871 inpatient encounters between January 2018 and September 2023, involving 89,355 unique inpatients meeting inclusion criteria. Both clinical and SDoH data items were included for these patient encounters. In total, 85% of the inpatient visits (N=148,640) will be used for training (learning from the data) and the remaining 26,231 inpatient visits will be used for mixed-methods validation (testing). CONCLUSIONS By integrating a critical suite of SDoH with clinical data related to diabetes, the proposed data-driven risk stratification model can enable individualized risk estimation and inform health professionals (eg, case managers) about the risk of patients' upcoming ED use. The prediction outcome could potentially automate case management referrals, helping to better prioritize services. By taking a mixed methods approach, we aim to align the model with the hospital's specific quality and patient safety considerations for the quality of patient care and the optimization of case management resource allocation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/56049.
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Affiliation(s)
- Seung-Yup Lee
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Leslie W Hayes
- Department of Quality and Patient Safety, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Bunyamin Ozaydin
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Steven Howard
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Alison M Garretson
- Department of Care Transitions, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Heather M Bradley
- Cooper Green Mercy Health Service Authority, Birmingham, AL, United States
| | - Andrew M Land
- Primary Care Line, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Erin W DeLaney
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Amy O Pritchett
- Department of Quality and Patient Safety, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Amanda L Furr
- Cardiovascular Institute, University of Alabama at Birmingham Medicine, Birmingham, AL, United States
| | - Ashleigh Allgood
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew C Wyatt
- Informatics Institute, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Allyson G Hall
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jane C Banaszak-Holl
- School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
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Choi JY, Choi D, Mehta NK, Ali MK, Patel SA. Diabetes Disparities in the United States: Trends by Educational Attainment from 2001 to 2020. Am J Prev Med 2024; 67:319-327. [PMID: 38615980 PMCID: PMC11338700 DOI: 10.1016/j.amepre.2024.04.006] [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: 11/09/2023] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Tracking changes in socioeconomic disparities in diabetes in the U.S. is important to evaluate progress in health equity and guide prevention efforts. Disparities in diabetes prevalence by educational attainment from 2001 to 2020 were investigated. METHODS Using a serial cross-sectional design, data from 33,220 adults aged 30-79 assessed in nine rounds of the National Health and Nutrition Examination Surveys between 2001 and 2020 were analyzed in 2023-2024. Diabetes was defined as self-reported prior diagnosis, elevated glycated hemoglobin (HbA1c≥6.5%), or use of diabetes medications. Marginalized age- and covariate-adjusted prevalence differences (PD) and prevalence ratios (PR) of diabetes by educational attainment (less than high school graduation, high school graduation, some college education or associate degree, or college graduation [reference]) by calendar period (2001-2004, 2005-2008, 2009-2012, 2013-2016, 2017-2020) were derived from logistic regression models. RESULTS From 2001 to 2020, age-adjusted diabetes prevalence was consistently higher among adults without a college degree. Adults without a high school diploma exhibited the largest disparities in both 2001-2004 (PD 8.0%; 95%CI 5.6-10.5 and PR 2.1; 95%CI 1.5-2.6) and 2017-20 (PD 11.0%; 95%CI 6.7-15.2 and PR 2.1; 95%CI 1.5-2.7). Between 2001-2004 and 2017-2020, the absolute disparity in diabetes changed only among adults with a high school diploma (increase from PD 1.7%; 95%CI -0.5- 3.9 to PD 8.8% 95%CI 4.1-13.4, respectively), while the PR did not change in any group. Education-related disparities in diabetes were attenuated after accounting for socio-demographic factors and BMI. CONCLUSIONS From 2001 to 2020, national education-related disparities in diabetes prevalence have shown no signs of narrowing.
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Affiliation(s)
- Ji Young Choi
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Daesung Choi
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Neil K Mehta
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, Texas
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia; Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Shivani A Patel
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.
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Doré A, Grammes J, Egri E, Priesterroth L, Frenzel SB, Spörkel O, Kubiak T. Identification with Characters of a National Narrative Health Communication Campaign Targeting Type 2 Diabetes. HEALTH COMMUNICATION 2024:1-8. [PMID: 39014879 DOI: 10.1080/10410236.2024.2378256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
Type 2 diabetes mellitus (T2DM) has a high prevalence in Germany. Tailored health communication campaigns are part of preventing T2DM at a societal level, with narrative approaches as a promising communication strategy. The aim of this study was to qualitatively examine identification with characters as a potential narrative effect mechanism within a national T2DM communication campaign (Slogan: "Diabetes - not only a question of type"). In doing so, characters' liking and perceived similarity were explored as antecedents of identification. For this purpose, nine focus groups comprising a total of 76 participants diagnosed with T2DM were conducted. Two of these focus groups consisted entirely of participants of Turkish descent. An assessment was developed to measure the extent to which participants liked, perceived themselves to be similar to, and identified with different characters presented via three videoclip formats (live action, animated cartoons, and celebrity testimonials) from a national diabetes communication campaign. Live action and celebrity testimonial characters were mostly perceived as likeable. However, level of identification was low, and participants felt an overall lack of similarity regarding both personal and disease-related characteristics as compared to these characters. Animated cartoons were perceived as less stigmatizing, but also as less engaging. The study indicates that liking without a feeling of similarity to a character is not sufficient to elicit identification. Further, the reinforcement of harmful T2DM stereotypes should be avoided in health communications to prevent reactance and to increase generalizability.
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Affiliation(s)
- Anastasia Doré
- Health Psychology, Institute of Psychology, Johannes Gutenberg University Mainz
| | - Jennifer Grammes
- Health Psychology, Institute of Psychology, Johannes Gutenberg University Mainz
| | - Esra Egri
- Health Psychology, Institute of Psychology, Johannes Gutenberg University Mainz
| | - Lilli Priesterroth
- Health Psychology, Institute of Psychology, Johannes Gutenberg University Mainz
| | - Svenja B Frenzel
- Health Psychology, Institute of Psychology, Johannes Gutenberg University Mainz
- Social Psychology, Institute of Psychology, Goethe University Frankfurt am Main
| | - Olaf Spörkel
- National Diabetes Information Center, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf
| | - Thomas Kubiak
- Health Psychology, Institute of Psychology, Johannes Gutenberg University Mainz
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Fleming J, Nguyen K, Winston J, Allen JO, Smith J, Thornton W, Mejia Ruiz MJ, Mezuk B. Promoting sustained diabetes management: Identifying challenges and opportunities in developing an alumni peer support component of the YMCA Diabetes Control Program. PATIENT EDUCATION AND COUNSELING 2022; 105:1322-1328. [PMID: 34544624 DOI: 10.1016/j.pec.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/27/2021] [Accepted: 09/06/2021] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To explore the perspectives of coaches and participant alumni of the YMCA Diabetes Control Program (DCP) to inform the development of a peer support component of the DCP for sustained diabetes self-management. METHODS Coaches (n = 2) and alumni (n = 38) participated in semi-structured interviews and focus groups regarding their experiences with the DCP and anticipated challenges and strengths of incorporating alumni peer support into the program. Transcripts were analyzed using content analysis to identify topics related to peer support. RESULTS Six topics emerged related to strengths and weaknesses of the coach and peer roles, including how those roles influenced motivation and accountability in self-management. Both roles provide encouragement for sustained behavior change, particularly in the face of setbacks. Interest in becoming an alumni peer supporter was strongly related to a sense of reciprocity and potential for mutual benefit, while concerns centered on unclear expectations and a desire for formal training. CONCLUSION Program alumni saw value in continued formal contact not only with their coaches, but with fellow peers, as part of their sustained diabetes self-management and anticipated reciprocal benefits. PRACTICE IMPLICATIONS Findings illustrate opportunities for, and the value of, incorporating alumni peer support into hierarchical coach-led diabetes self-management programs.
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Affiliation(s)
- Jacinda Fleming
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Kim Nguyen
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jason Winston
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Julie Ober Allen
- Research Center for Group Dynamics, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA; Department of Health and Exercise Science, University of Oklahoma, Norman, OK, USA
| | - Jana Smith
- YMCA of Greater Richmond, Richmond, VA, USA
| | | | | | - Briana Mezuk
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Research Center for Group Dynamics, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.
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Telehealth Interventions to Improve Diabetes Management Among Black and Hispanic Patients: a Systematic Review and Meta-Analysis. J Racial Ethn Health Disparities 2022; 9:2375-2386. [PMID: 35000144 PMCID: PMC8742712 DOI: 10.1007/s40615-021-01174-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/17/2021] [Accepted: 10/19/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Previous systematic reviews have found that telehealth is an effective strategy for implementing interventions to improve glycemic control and other clinical outcomes for diabetes patients. However, these reviews have not meaningfully focused on Black and Hispanic patients-partly because of the lack of adequate representation of people from racial and ethnic minority groups in clinical trials. It is unclear whether telehealth interventions are effective at improving glycemic control among Black and Hispanic patients given the disproportionate number of barriers they face accessing health care. OBJECTIVES A systematic review and meta-analysis of randomized control trials that used telehealth interventions for improving glycemic control among Black and Hispanic diabetes patients. METHODS We reviewed PubMed, Embase, Web of Science, CINAHL, PsycINFO, and clinicalTrials.gov from inception to March 2021. We used a narrative summary approach to describe key study characteristics and graded the quality of studies using two reviewers. The pooled net change in HbA1c values was estimated across studies using a random-effects model. RESULTS We identified 10 studies that met our inclusion and exclusion criteria. Nine studies were included in the meta-analysis. Only one study was rated as having low bias. Telehealth interventions were primarily delivered by telephone calls, text messages, web-based portals, and virtual visits. Most interventions involved delivering diabetes self-management education. Telehealth intervention pooled across studies with a mix of Black and Hispanic participants (> 50% sample) was associated with a - 0.465 ([CI: - 0.648 to - 0.282], p = 0.000) reduction in HbA1c. CONCLUSIONS Our findings suggest telehealth interventions are effective at improving glycemic control among Black and Hispanic diabetes patients.
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Chin MH. New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care. J Clin Endocrinol Metab 2021; 106:e4887-e4902. [PMID: 33837415 PMCID: PMC8083316 DOI: 10.1210/clinem/dgab229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 02/06/2023]
Abstract
Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.
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Affiliation(s)
- Marshall H Chin
- Section of General Internal Medicine, Department of Medicine, University of Chicago
- Corresponding author contact information: Marshall H. Chin, MD, MPH, University of Chicago, Section of General Internal Medicine, 5841 South Maryland Avenue, MC2007, Chicago, Illinois 60637 USA, (773) 702-4769 (telephone), (773) 834-2238 (fax), (e-mail)
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A Resilience Intervention for Adults with Type 2 Diabetes: Proof-of-Concept in Community Health Centers. Int J Behav Med 2020; 27:565-575. [DOI: 10.1007/s12529-020-09894-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Allen JO, Concha JB, Mejía Ruiz MJ, Rapp A, Montgomery J, Smith J, Wolfson JA, Thornton W, Mezuk B. Engaging Underserved Community Members in Diabetes Self-Management: Evidence From the YMCA of Greater Richmond Diabetes Control Program. THE DIABETES EDUCATOR 2020; 46:169-180. [PMID: 32129157 PMCID: PMC7813155 DOI: 10.1177/0145721720907059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to identify factors influencing participant engagement in a community-based diabetes self-management program (DSMP), with a focus on the needs of underserved groups (eg, racial/ethnic minorities, low income). METHODS Focus groups were conducted with participants (n = 22) from the YMCA of Greater Richmond's Diabetes Control Program, who were recruited using a purposeful sampling frame to capture a range of experiences. In-depth interviews were conducted with lay health coaches (n = 3). The RADaR qualitative analysis technique was used to identify themes related to factors across the continuum of engagement. RESULTS Fear affected program enrollment and retention in complex ways. Peers and coaches were important for social support and accountability. The length of the program (12 weeks), accessible information, practical skill building, and emphasis on making small, feasible improvements in pursuit of larger goals were identified as critical for engagement and improving diabetes self-management. Health and outside obligations were the major barriers to program attendance. CONCLUSIONS Participant and coach perspectives provide important insight into existing strengths of community-based DSMPs that can be expanded on to promote engagement as well as potential opportunities for improvement. Actionable recommendations for increasing engagement of underserved groups in community-based DSMPs are provided.
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Affiliation(s)
- Julie Ober Allen
- Population Studies Center, University of Michigan Institute for Social Research, Ann Arbor, Michigan
| | - Jeannie B Concha
- Department of Public Health Sciences, University of Texas, El Paso, Texas
| | | | - Ashley Rapp
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Joshua Montgomery
- Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Washington, District of Columbia
| | - Jana Smith
- YMCA of Greater Richmond, Richmond, Virginia
| | - Julia A Wolfson
- Departments of Health Management and Policy and Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan
| | | | - Briana Mezuk
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
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Vitale M, Dorado L, Pais V, Sidani S, Gucciardi E. Food Insecurity Screening Among Families of Children With Diabetes. Diabetes Spectr 2019; 32:338-348. [PMID: 31798292 PMCID: PMC6858075 DOI: 10.2337/ds18-0083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Little is known about screening in clinical settings for food insecurity (FI) among households of children with diabetes. This study evaluated the acceptability and feasibility of an FI screening initiative in a pediatric diabetes clinic that was implemented to help diabetes dietitian educators tailor management plans for families of children with type 1 or type 2 diabetes facing FI. The initiative comprised three validated screening questions, a care algorithm, a community resource handout, and a poster. In total, 50 families of children and adolescents aged 0-18 years with type 1 or type 2 diabetes were screened for FI. In-person semi-structured interviews combining open-ended and Likert-scale questions were conducted with 37 of the screened families and the three diabetes dietitian educators who conducted the screening. Perceived barriers and facilitators of the screening initiative were identified using content analysis, and Likert-scale questionnaires rated interviewees' comfort level with the screening questions. A reflective journal kept by an onsite research interviewer also facilitated the data interpretation process. Most families felt comfortable answering the screening questions. Families with FI appreciated the opportunity to express their concerns and learn about affordable food resources. However, ∼20% of these families described stigma and fear of judgment by clinicians if they screened positive for FI. Diabetes educators also felt comfortable with the screening questions but reported lack of time to screen all families and to follow-up with resources after a positive screen. A self-reported intake form was recommended to ensure that everyone is systematically screened. A standardized and respectful method of assessing FI could help clinicians better tailor treatment plans and support for families of children with diabetes who face FI. Based on these findings, similar FI screening initiatives should be implemented in other clinical settings as part of routine clinical practice.
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Affiliation(s)
- Michele Vitale
- School of Nutrition, Ryerson University, Toronto, Ontario, Canada
| | | | | | - Souraya Sidani
- School of Nursing, Ryerson University, Toronto, Ontario, Canada
| | - Enza Gucciardi
- School of Nutrition, Ryerson University, Toronto, Ontario, Canada
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Johnson PJ, O’Brien M, Orionzi D, Trahan L, Rockwood T. Pilot of Community-Based Diabetes Self-Management Support for Patients at an Urban Primary Care Clinic. Diabetes Spectr 2019; 32:157-163. [PMID: 31168288 PMCID: PMC6528400 DOI: 10.2337/ds18-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Pamela Jo Johnson
- Division of Health Policy & Management, University of Minnesota, Minneapolis, MN
| | - Mollie O’Brien
- Division of Applied Research, Allina Health, Minneapolis, MN
| | - Dimpho Orionzi
- Division of Applied Research, Allina Health, Minneapolis, MN
| | - Lovel Trahan
- Division of Applied Research, Allina Health, Minneapolis, MN
| | - Todd Rockwood
- Division of Health Policy & Management, University of Minnesota, Minneapolis, MN
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Taylor YJ, Spencer MD, Mahabaleshwarkar R, Ludden T. Racial/ethnic differences in healthcare use among patients with uncontrolled and controlled diabetes. ETHNICITY & HEALTH 2019; 24:245-256. [PMID: 28393538 DOI: 10.1080/13557858.2017.1315372] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 03/20/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To examine racial/ethnic differences in healthcare use among patients classified as having controlled and uncontrolled diabetes. DESIGN Data from the Carolinas HealthCare System electronic data warehouse were used. Glycemic control was defined as glycosylated hemoglobin (HbA1c) < 8% (64 mmol/mol) in 2012 (n = 9996). Patients with HbA1c ≥ 8% (64 mmol/mol) in 2012 were classified as uncontrolled (n = 2576). Race and ethnicity were jointly classified as non-Hispanic Black, non-Hispanic White or Other. Separate mixed effects negative binomial models estimated the independent effect of race/ethnicity on the number of emergency department (ED) visits, hospitalizations and physician office visits in 2013, in each patient group, adjusting for significant confounding variables. RESULTS Rates of diabetes-related ED visits were two to three times higher for non-Hispanic Blacks compared to non-Hispanic Whites (uncontrolled rate ratio [RR]: 3.41 95% CI: 1.41-8.22; controlled RR: 2.95; 95% CI: 1.78-4.91). Similar differences were observed for all-cause ED visits (uncontrolled RR: 1.83, 95% CI: 1.50-2.24; controlled RR: 2.45, 95% CI: 2.17-2.77). Non-Hispanic Blacks with controlled and uncontrolled diabetes also had lower rates of all-cause physician office visits when compared to non-Hispanic Whites (uncontrolled RR: 0.84, 95% CI: 0.77-0.91; controlled RR: 0.81, 95% CI: 0.78-0.84). CONCLUSION Notable racial/ethnic disparities exist in the use of emergency services and physician offices for diabetes care. Strategies such as patient education and care delivery changes that address healthcare access issues in racial/ethnic minorities should be considered to offer better diabetes management and address diabetes disparities.
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Affiliation(s)
- Yhenneko J Taylor
- a Center for Outcomes Research and Evaluation , Carolinas HealthCare System , Charlotte , USA
| | - Melanie D Spencer
- a Center for Outcomes Research and Evaluation , Carolinas HealthCare System , Charlotte , USA
| | - Rohan Mahabaleshwarkar
- a Center for Outcomes Research and Evaluation , Carolinas HealthCare System , Charlotte , USA
| | - Thomas Ludden
- b Department of Family Medicine , Carolinas HealthCare System , Charlotte , USA
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Taylor YJ, Davis ME, Mohanan S, Robertson S, Robinson MD. Awareness of Racial Disparities in Diabetes Among Primary Care Residents and Preparedness to Discuss Disparities with Patients. J Racial Ethn Health Disparities 2019; 6:237-244. [PMID: 30039500 PMCID: PMC6997468 DOI: 10.1007/s40615-018-0518-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 01/15/2023]
Abstract
Many healthcare providers lack the awareness of health disparities among their patients that precedes action to improve outcomes. Limited health disparities training is a probable contributor. We assessed primary care residents' awareness of racial and ethnic disparities in diabetes, their perceived preparedness to discuss health disparities with patients, and their preferences for training and resources to improve their preparedness. Primary care residents (n = 98) affiliated with two teaching hospitals in North Carolina were invited to complete a 20-question health disparities survey. Fifty-two residents completed the survey (response rate = 53%). Most were non-Hispanic White (54%) and had ≤ 50% African American patients in their panel (65%). Although 83% were aware of higher diabetes prevalence among African Americans, only 31% felt prepared to discuss diabetes health disparities with patients. Their primary concerns included not having information for the discussion (58%) and being unsure how to share information in a way that is easy for patients to understand (48%). Perceived preparedness to discuss health disparities did not differ significantly by primary care resident race or percentage of African American patients in their panel. Residents indicated that having information regarding how to discuss and address health disparities would make them feel more prepared. Cultural competency training and experiential learning were the most preferred methods to learn how to identify and address health disparities. Future health disparities training should focus on improving residents' preparedness to address health disparities in their clinical practice using culturally relevant communication tools and experiential learning opportunities.
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Affiliation(s)
- Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, 1540 Garden Terrace, Suite 405, Charlotte, NC, 28203, USA.
| | - Marion E Davis
- Center for Outcomes Research and Evaluation, Atrium Health, 1540 Garden Terrace, Suite 408, Charlotte, NC, 28203, USA
| | - Sveta Mohanan
- Department of Family Medicine, Atrium Health, 2001 Vail Ave., Suite 400, Charlotte, NC, 28207, USA
| | - Sandy Robertson
- Cabarrus Family Medicine Residency, Atrium Health, 270 Copperfield Blvd NE #102, Concord, NC, 28025, USA
| | - Mark D Robinson
- Cabarrus Family Medicine Residency, Atrium Health, 270 Copperfield Blvd NE #102, Concord, NC, 28025, USA
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Nelson LA, Wallston KA, Kripalani S, Greevy RA, Elasy TA, Bergner EM, Gentry CK, Mayberry LS. Mobile Phone Support for Diabetes Self-Care Among Diverse Adults: Protocol for a Three-Arm Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e92. [PMID: 29636319 PMCID: PMC5915673 DOI: 10.2196/resprot.9443] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/19/2018] [Accepted: 02/08/2018] [Indexed: 01/03/2023] Open
Abstract
Background Nonadherence to self-care is common among patients with type 2 diabetes (T2D) and often leads to severe complications. Moreover, patients with T2D who have low socioeconomic status and are racial/ethnic minorities disproportionately experience barriers to adherence and poor outcomes. Basic phone technology (text messages and phone calls) provides a practical medium for delivering content to address patients’ barriers to adherence; however, trials are needed to explore long-term and sustainable effects of mobile phone interventions among diverse patients. Objective The aim of this study is to evaluate the effects of mobile phone–based diabetes support interventions on self-care and hemoglobin A1c (HbA1c) among adults with T2D using a 3-arm, 15-month randomized controlled trial with a Type 1 hybrid effectiveness-implementation approach. The intervention arms are (1) Rapid Encouragement/Education And Communications for Health (REACH) and (2) REACH + Family-focused Add-on for Motivating Self-care (FAMS). Methods We recruited primary care patients with T2D (N=512) from Federally Qualified Health Centers and an academic medical center, prioritizing recruitment of publicly insured and minority patients from the latter. Eligible patients were prescribed daily diabetes medication and owned a cell phone with text messaging capability. We excluded patients whose most recent HbA1c result within 12 months was <6.8% to support detection of intervention effects on HbA1c. Participants were randomly assigned to REACH only, REACH + FAMS, or the control condition. REACH provides text messages tailored to address patient-specific barriers to medication adherence based on the Information-Motivation-Behavioral skills model, whereas FAMS provides monthly phone coaching with related text message content focused on family and friend barriers to diet and exercise adherence. We collect HbA1c and self-reported survey data at baseline and at 3, 6, and 12 months, and again at 15 months to assess sustained changes. We will use generalized estimating equation models to test the effects of REACH (either intervention arm) on HbA1c relative to the control group, the potential additive effects of FAMS, and effects of either intervention on adherence to self-care behaviors and diabetes self-efficacy. Results The trial is ongoing; recruitment closed December 2017. We plan to perform analyses on 6-month outcomes for FAMS in July 2018, and project to have 15-month data for REACH analyses in April 2019. Conclusions Our study will be one of the first to evaluate a long-term, theory-based text messaging intervention to promote self-care adherence among racially/ethnically and socioeconomically diverse adults with T2D. Moreover, our study will assess the feasibility of a family-focused intervention delivered via mobile phones and compare the effects of text messaging alone versus text messaging plus phone coaching. Findings will advance our understanding of how interventions delivered by phone can benefit diverse patients with chronic conditions. Trial Registration ClinicalTrials.gov NCT02409329; https://clinicaltrials.gov/ct2/show/NCT02409329 (Archived by WebCite at http://www.webcitation.org/6yHkg9SSl); NCT02481596; https://clinicaltrials.gov/ct2/show/NCT02481596 (Archived by WebCite at http://www.webcitation.org/6yHkj9XD4)
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Affiliation(s)
- Lyndsay A Nelson
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kenneth A Wallston
- Center for Diabetes Translation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,School of Nursing, Vanderbilt University, Nashville, TN, United States.,Center for Effective Health Communication, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sunil Kripalani
- Center for Effective Health Communication, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Clinical Quality and Implementation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Tom A Elasy
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Diabetes Translation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Erin M Bergner
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Chad K Gentry
- Department of Pharmacy, College of Pharmacy and Health Sciences, Lipscomb University, Nashville, TN, United States
| | - Lindsay S Mayberry
- Center for Health Behavior and Health Education, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Diabetes Translation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Effective Health Communication, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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14
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Michaud TL, Siahpush M, Schwab RJ, Eiland LA, DeVany M, Hansen G, Slachetka TS, Boilesen E, Tak HJ, Wilson FA, Wang H, Pagán JA, Su D. Remote Patient Monitoring and Clinical Outcomes for Postdischarge Patients with Type 2 Diabetes. Popul Health Manag 2018; 21:387-394. [PMID: 29583057 DOI: 10.1089/pop.2017.0175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The objective of this study was to evaluate changes in clinical outcomes for patients with type 2 diabetes (T2D) after a 3-month remote patient monitoring (RPM) program, and examine the relationship between hemoglobin A1c (HbA1c) outcomes and participant characteristics. The study sample included 955 patients with T2D who were admitted to an urban Midwestern medical center for any reason from 2014 to 2017, and used RPM for 3 months after discharge. Clinical outcomes included HbA1c, weight, body mass index (BMI), and patient activation scores. Logistic regression was used to estimate the likelihood of having a postintervention HbA1c <9% by patient characteristics, among those who had baseline HbA1c >9%. Most patients experienced decreases in HbA1c (67%) and BMI (58%), and increases in patient activation scores (67%) (P < 0.001 in all 3 cases) at the end of RPM. Logistic regression analyses revealed that among patients who had HbA1c >9% at baseline, men (odds ratio [OR] = 3.72; 95% confidence interval [CI], 1.43-9.64), those who had increased patient activation scores after intervention (OR = 1.05; 95% CI, 1.01-1.09), those who had higher baseline patient activation scores, and those who had a greater number of biometric data uploads during the intervention (OR = 1.02; 95% CI, 1.00-1.04) were more likely to have reduced their HbA1c to <9% at the end of RPM. RPM for postdischarge patients with T2D might be a promising approach for HbA1c control with increased patient engagement. Future studies with study designs that include a control group should provide more robust evidence.
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Affiliation(s)
- Tzeyu L Michaud
- 1 Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska.,2 Department of Health Promotion, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
| | - Mohammad Siahpush
- 2 Department of Health Promotion, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
| | - Robert J Schwab
- 3 Division of General Internal Medicine, Department of Internal Medicine, University of Nebraska Medical Center , Omaha, Nebraska
| | - Leslie A Eiland
- 4 Division of Diabetes, Endocrine & Metabolism, Department of Internal Medicine, University of Nebraska Medical Center , Omaha, Nebraska
| | - Mary DeVany
- 5 TeleHealth Team, Nebraska Medicine , Omaha, Nebraska
| | - Geri Hansen
- 5 TeleHealth Team, Nebraska Medicine , Omaha, Nebraska
| | | | - Eugene Boilesen
- 6 Center for Collaboration on Research Design and Analysis, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
| | - Hyo Jung Tak
- 7 Department of Health Services Research & Administration, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
| | - Fernando A Wilson
- 7 Department of Health Services Research & Administration, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
| | - Hongmei Wang
- 7 Department of Health Services Research & Administration, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
| | - José A Pagán
- 8 Department of Public Health Policy and Management, College of Global Public Health, New York University , New York, New York.,9 Center for Health Innovation , The New York Academy of Medicine, New York, New York.,10 Leonard Davis Institute of Health Economics, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Dejun Su
- 1 Center for Reducing Health Disparities, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska.,2 Department of Health Promotion, College of Public Health, University of Nebraska Medical Center , Omaha, Nebraska
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15
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Bohorquez Robles R, Compeán Ortiz LG, González Quirarte NH, Berry DC, Aguilera Pérez P, Piñones Martínez S. Knowledge and Practices of Diabetes Foot Care and Risk of Developing Foot Ulcers in México May Have Implications for Patients of Méxican Heritage Living in the US. DIABETES EDUCATOR 2017; 43:297-303. [PMID: 28459176 DOI: 10.1177/0145721717706417] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose The purpose of the study was to examine the relationship between knowledge and foot care practices among adults with type 2 diabetes. Methods A descriptive correlational study examined 200 patients with type 2 diabetes in México. Data collected included the Knowledge and Practices Self-Care Questionnaire and a Podiatry Examination Questionnaire. Data analysis included Pearson’s correlations and chi-square tests. Results More than half of the participants had poor knowledge and poor foot care practices. A significant negative correlation between knowledge and practices of foot care and risk of developing diabetes foot ulcers was found. There was no relationship between sociodemographic variables and the risk of developing diabetes foot ulcers. Conclusions Patients with type 2 diabetes served in an outpatient clinic had poor knowledge and practices of foot care. They demonstrated decreased knowledge and practice of foot care and therefore showed a greater risk of developing diabetes foot, which may predispose patients to early complications.
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Affiliation(s)
- Rosa Bohorquez Robles
- Clínic of Family Medicine of Surgical Specialties “ISSSTE,” Tampico Tamaulipas, México (Ms Bohorquez Robles)
- Universidad Autónoma de Tamaulipas School of Nursing, Tampico Tamaulipas, México (Dr Compeán Ortiz, Dr González Quirarte, Ms Aguilera Pérez, Dr Piñones Martínez)
- The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina (Dr Berry)
| | - Lidia G. Compeán Ortiz
- Clínic of Family Medicine of Surgical Specialties “ISSSTE,” Tampico Tamaulipas, México (Ms Bohorquez Robles)
- Universidad Autónoma de Tamaulipas School of Nursing, Tampico Tamaulipas, México (Dr Compeán Ortiz, Dr González Quirarte, Ms Aguilera Pérez, Dr Piñones Martínez)
- The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina (Dr Berry)
| | - Nora H. González Quirarte
- Clínic of Family Medicine of Surgical Specialties “ISSSTE,” Tampico Tamaulipas, México (Ms Bohorquez Robles)
- Universidad Autónoma de Tamaulipas School of Nursing, Tampico Tamaulipas, México (Dr Compeán Ortiz, Dr González Quirarte, Ms Aguilera Pérez, Dr Piñones Martínez)
- The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina (Dr Berry)
| | - Diane C. Berry
- Clínic of Family Medicine of Surgical Specialties “ISSSTE,” Tampico Tamaulipas, México (Ms Bohorquez Robles)
- Universidad Autónoma de Tamaulipas School of Nursing, Tampico Tamaulipas, México (Dr Compeán Ortiz, Dr González Quirarte, Ms Aguilera Pérez, Dr Piñones Martínez)
- The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina (Dr Berry)
| | - Paulina Aguilera Pérez
- Clínic of Family Medicine of Surgical Specialties “ISSSTE,” Tampico Tamaulipas, México (Ms Bohorquez Robles)
- Universidad Autónoma de Tamaulipas School of Nursing, Tampico Tamaulipas, México (Dr Compeán Ortiz, Dr González Quirarte, Ms Aguilera Pérez, Dr Piñones Martínez)
- The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina (Dr Berry)
| | - Socorro Piñones Martínez
- Clínic of Family Medicine of Surgical Specialties “ISSSTE,” Tampico Tamaulipas, México (Ms Bohorquez Robles)
- Universidad Autónoma de Tamaulipas School of Nursing, Tampico Tamaulipas, México (Dr Compeán Ortiz, Dr González Quirarte, Ms Aguilera Pérez, Dr Piñones Martínez)
- The University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina (Dr Berry)
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16
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Hofer R, Choi H, Mase R, Fagerlin A, Spencer M, Heisler M. Mediators and Moderators of Improvements in Medication Adherence. HEALTH EDUCATION & BEHAVIOR 2016; 44:285-296. [PMID: 27417502 DOI: 10.1177/1090198116656331] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In a randomized controlled trial we compared two models of community health worker-led diabetes medication decision support for low-income Latino and African American adults with diabetes. Most outcomes were improved when community health workers used either an interactive e-Health tool or print materials. This article investigates mediators and moderators of improved medication adherence in these two models. METHOD Because both programs significantly improved satisfaction with medication information, medication knowledge, and decisional conflict, we examined whether improvements in each of these outcomes in turn were associated with improvements in self-reported medication adherence, and if so, whether these improvements were mediated by improvements in diabetes self-efficacy or diabetes distress. Potential moderators of improvement included gender, race/ethnicity, age, education, insulin use, health literacy, and baseline self-efficacy, diabetes distress, and A1c. RESULTS A total of 176 participants (94%) completed all assessments. After adjusting for potential confounders, only increased satisfaction with medication information was correlated with improved medication adherence ( p = .024). Improved self-efficacy, but not diabetes distress, was associated with improvements in both satisfaction with medication information and medication adherence. However, the Sobel-Goodman Mediation test did not support improvements in self-efficacy as a mechanism by which improved satisfaction led to better adherence. None of the examined variables achieved statistical significance as moderators. CONCLUSIONS Improvements in satisfaction with medication information but not in medication knowledge or decision conflict were associated with improvements in medication adherence. Interventions that target low-income ethnic and racial minorities may need to focus on increasing participants' satisfaction with information provided on diabetes medications and not just improving their knowledge about medications. Future research should explore in more depth other possible mediators and moderators of improvements in medication adherence in low-income minority populations.
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Affiliation(s)
| | | | - Rebecca Mase
- 1 University of Michigan, Ann Arbor, MI, USA.,2 Ann Arbor Veterans' Affairs Healthcare System, Ann Arbor, MI, USA
| | - Angela Fagerlin
- 1 University of Michigan, Ann Arbor, MI, USA.,2 Ann Arbor Veterans' Affairs Healthcare System, Ann Arbor, MI, USA.,3 Center for Bioethics and Social Sciences in Medicine, Ann Arbor, MI, USA
| | | | - Michele Heisler
- 1 University of Michigan, Ann Arbor, MI, USA.,2 Ann Arbor Veterans' Affairs Healthcare System, Ann Arbor, MI, USA
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17
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Roy B, Stanojevich J, Stange P, Jiwani N, King R, Koo D. Development of the Community Health Improvement Navigator Database of Interventions. MMWR Suppl 2016; 65:1-9. [PMID: 26917110 DOI: 10.15585/mmwr.su6502a1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
With the passage of the Patient Protection and Affordable Care Act, the requirements for hospitals to achieve tax-exempt status include performing a triennial community health needs assessment and developing a plan to address identified needs. To address community health needs, multisector collaborative efforts to improve both health care and non-health care determinants of health outcomes have been the most effective and sustainable. In 2015, CDC released the Community Health Improvement Navigator to facilitate the development of these efforts. This report describes the development of the database of interventions included in the Community Health Improvement Navigator. The database of interventions allows the user to easily search for multisector, collaborative, evidence-based interventions to address the underlying causes of the greatest morbidity and mortality in the United States: tobacco use and exposure, physical inactivity, unhealthy diet, high cholesterol, high blood pressure, diabetes, and obesity.
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Affiliation(s)
- Brita Roy
- Yale University School of Medicine, New Haven, Connecticut
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18
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Krieger N, Waterman PD, Spasojevic J, Li W, Maduro G, Van Wye G. Public Health Monitoring of Privilege and Deprivation With the Index of Concentration at the Extremes. Am J Public Health 2016; 106:256-63. [PMID: 26691119 PMCID: PMC4815605 DOI: 10.2105/ajph.2015.302955] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated use of the Index of Concentration at the Extremes (ICE) for public health monitoring. METHODS We used New York City data centered around 2010 to assess cross-sectional associations at the census tract and community district levels, for (1) diverse ICE measures plus the US poverty rate, with (2) infant mortality, premature mortality (before age 65 years), and diabetes mortality. RESULTS Point estimates for rate ratios were consistently greatest for the novel ICE that jointly measured extreme concentrations of income and race/ethnicity. For example, the census tract-level rate ratio for infant mortality comparing the bottom versus top quintile for an ICE contrasting low-income Black versus high-income White equaled 2.93 (95% confidence interval [CI] = 2.11, 4.09), but was 2.19 (95% CI = 1.59, 3.02) for low versus high income, 2.77 (95% CI = 2.02, 3.81) for Black versus White, and 1.56 (95% CI = 1.19, 2.04) for census tracts with greater than or equal to 30% versus less than 10% below poverty. CONCLUSIONS The ICE may be a useful metric for public health monitoring, as it simultaneously captures extremes of privilege and deprivation and can jointly measure economic and racial/ethnic segregation.
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Affiliation(s)
- Nancy Krieger
- Nancy Krieger and Pamela D. Waterman are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Jasmina Spasojevic, Wenhui Li, Gil Maduro, and Gretchen Van Wye are with the Bureau of Vital Statistics, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
| | - Pamela D Waterman
- Nancy Krieger and Pamela D. Waterman are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Jasmina Spasojevic, Wenhui Li, Gil Maduro, and Gretchen Van Wye are with the Bureau of Vital Statistics, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
| | - Jasmina Spasojevic
- Nancy Krieger and Pamela D. Waterman are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Jasmina Spasojevic, Wenhui Li, Gil Maduro, and Gretchen Van Wye are with the Bureau of Vital Statistics, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
| | - Wenhui Li
- Nancy Krieger and Pamela D. Waterman are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Jasmina Spasojevic, Wenhui Li, Gil Maduro, and Gretchen Van Wye are with the Bureau of Vital Statistics, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
| | - Gil Maduro
- Nancy Krieger and Pamela D. Waterman are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Jasmina Spasojevic, Wenhui Li, Gil Maduro, and Gretchen Van Wye are with the Bureau of Vital Statistics, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
| | - Gretchen Van Wye
- Nancy Krieger and Pamela D. Waterman are with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA. Jasmina Spasojevic, Wenhui Li, Gil Maduro, and Gretchen Van Wye are with the Bureau of Vital Statistics, Division of Epidemiology, New York City Department of Health and Mental Hygiene, New York, NY
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Eliminating Health Care Disparities With Mandatory Clinical Decision Support: The Venous Thromboembolism (VTE) Example. Med Care 2015; 53:18-24. [PMID: 25373403 DOI: 10.1097/mlr.0000000000000251] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND All hospitalized patients should be assessed for venous thromboembolism (VTE) risk factors and prescribed appropriate prophylaxis. To improve best-practice VTE prophylaxis prescription for all hospitalized patients, we implemented a mandatory computerized clinical decision support (CCDS) tool. The tool requires completion of checklists to evaluate VTE risk factors and contraindications to pharmacological prophylaxis, and then recommends the risk-appropriate VTE prophylaxis regimen. OBJECTIVES The objective of the study was to examine the effect of a quality improvement intervention on race-based and sex-based health care disparities across 2 distinct clinical services. RESEARCH DESIGN This was a retrospective cohort study of a quality improvement intervention. SUBJECTS The study included 1942 hospitalized medical patients and 1599 hospitalized adult trauma patients. MEASURES In this study, the proportion of patients prescribed risk-appropriate, best-practice VTE prophylaxis was evaluated. RESULTS Racial disparities existed in prescription of best-practice VTE prophylaxis in the preimplementation period between black and white patients on both the trauma (70.1% vs. 56.6%, P=0.025) and medicine (69.5% vs. 61.7%, P=0.015) services. After implementation of the CCDS tool, compliance improved for all patients, and disparities in best-practice prophylaxis prescription between black and white patients were eliminated on both services: trauma (84.5% vs. 85.5%, P=0.99) and medicine (91.8% vs. 88.0%, P=0.082). Similar findings were noted for sex disparities in the trauma cohort. CONCLUSIONS Despite the fact that risk-appropriate prophylaxis should be prescribed equally to all hospitalized patients regardless of race and sex, practice varied widely before our quality improvement intervention. Our CCDS tool eliminated racial disparities in VTE prophylaxis prescription across 2 distinct clinical services. Health information technology approaches to care standardization are effective to eliminate health care disparities.
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20
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Kim MT, Kim KB, Huh B, Nguyen T, Han HR, Bone LR, Levine D. The Effect of a Community-Based Self-Help Intervention: Korean Americans With Type 2 Diabetes. Am J Prev Med 2015; 49:726-737. [PMID: 26184986 PMCID: PMC4615366 DOI: 10.1016/j.amepre.2015.04.033] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 03/27/2015] [Accepted: 04/24/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Korean Americans are one of the most underserved ethnic/linguistic minority groups owing to cultural and institutional barriers; there is an urgent need for culturally competent diabetes management programs in the Korean American community for those with type 2 diabetes. The purpose of this study was to test the effectiveness of a community-based, culturally tailored, multimodal behavioral intervention program in an ethnic/linguistic minority group with type 2 diabetes. DESIGN An RCT with waitlist comparison based on the Predisposing, Reinforcing, and Enabling Constructs in Education/environmental Diagnosis and Evaluation (PRECEDE)-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PROCEED) and self-help models. Data were collected between September 2010 and June 2013 and were analyzed in August-December 2014. Statistical significance was set at p<0.05. SETTING/PARTICIPANTS In a naturally occurring community setting, a total of 250 Korean Americans with type 2 diabetes were randomized into an intervention group (n=120) or a control group (n=130). INTERVENTION The intervention consisted of key self-management skill-building activities through 12 hours of group education sessions, followed by integrated counseling and behavioral coaching by a team of RNs and community health workers. MAIN OUTCOME MEASURES Primary (clinical) outcomes were hemoglobin A1c, glucose, total cholesterol, and low-density lipoprotein at baseline and at 3, 6, 9, and 12 months. Secondary (psychosocial and behavioral) outcomes included diabetes-related quality of life, self-efficacy, adherence to diabetes management regimen, and health literacy. RESULTS During the 12-month project, the intervention group demonstrated 1.0%-1.3% (10.9-14.2 mmol/mol) reductions in hemoglobin A1c, whereas the control group achieved reductions of 0.5%-0.7% (5.5-7.7 mmol/mol). The differences between the two groups were statistically significant. The intervention group showed statistically significant improvement in diabetes-related self-efficacy and quality of life when compared with the control group. CONCLUSIONS RN/community health worker teams equipped with culturally tailored training can be effective in helping an ethnic/linguistic minority group manage diabetes in the community.
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Affiliation(s)
- Miyong T Kim
- School of Nursing, University of Texas at Austin, Austin, Texas.
| | - Kim B Kim
- Korean Resource Center, Ellicott City, Maryland
| | - Boyun Huh
- School of Nursing, University of California at San Francisco, San Francisco, California
| | - Tam Nguyen
- Connell School of Nursing, Boston College, Boston, Massachusetts
| | - Hae-Ra Han
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Lee R Bone
- School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - David Levine
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
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Moreo K, Sapir T, Greene L. Applying Quality Improvement into Systems-based Learning to Improve Diabetes Outcomes in Primary Care. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:bmjquality_uu208829.w3999. [PMID: 26734436 PMCID: PMC4693094 DOI: 10.1136/bmjquality.u208829.w3999] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/09/2015] [Indexed: 12/18/2022]
Abstract
In the U.S., where the prevalence of type 2 diabetes has reached epidemic proportions, many patients with this disease are treated by primary care physicians in community-based systems, including accountable care organisations (ACOs). To address gaps in the quality of diabetes care, national quality measures have been established, including patient-centered measures adopted by the Centers for Medicare and Medicaid Services for its Shared Savings Program for ACOs. From a patient-centered perspective, high-quality diabetes care depends on effective communication between clinicians and patients, along with patient education and counseling about medications and lifestyle. We designed and implemented a quality improvement (QI) program for 30 primary care physicians treating patients with type 2 diabetes in three structurally similar but geographically diverse ACOs. Retrospective chart audits were conducted before (n = 300) and after (n = 300) each physician participated in accredited continuing medical education (CME) courses that focused on QI strategies. Randomly selected charts were audited to measurably assess essential interventions for improved outcomes in type 2 diabetes including the physicians’ documentation of patient counseling and assessment of side effects, and patients’ medication adherence status and changes in hemoglobin A1C (A1C) and body mass index (BMI). Paced educational interventions included a private performance improvement Internet live course conducted for each physician, small-group Internet live courses involving peer discussion, and a set of enduring materials, which were also multi-accredited for all clinicians in the physician's practice. Continual improvement cycles were guided by analysis of the baseline chart audits, quantitative survey data, and qualitative feedback offered by participants. To extend the benefit of the education, the enduring materials were offered to the interprofessional team of clinicians throughout the U.S. who did not participate in the QI program. For brevity, this article presents outcomes of the 30 primary care physicians. Baseline to post-education improvements were observed for percentages of charts with documented assessment of medication side effects (+11%) and counseling about medication risks/benefits (+28%), medication adherence (+13%), and lifestyle modifications (+8%). Improvements were also observed for documented adherence to diabetes medications (+24%) and first-to-last visit changes in A1C (−0.16%) and BMI (−2.1). The findings indicate a positive influence of QI education on primary care physicians’ performance of patient-centered quality measures and patient outcomes.
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Clark NM, Quinn M, Dodge JA, Nelson BW. Alliance system and policy change: necessary ingredients for improvement in diabetes care and reduction of disparities. Health Promot Pract 2015; 15:11S-22S. [PMID: 25359245 DOI: 10.1177/1524839914543829] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reducing diabetes inequities requires system and policy changes based on real-life experiences of vulnerable individuals living with the condition. While introducing innovative interventions for African American, Native American, and Latino low-income people, the five community-based sites of the Alliance to Reduce Disparities in Diabetes recognized that policy changes were essential to sustain their efforts. Data regarding change efforts were collected from site leaders and examined against documents provided routinely to the National Program Office at the University of Michigan. A policy expert refined the original lists to include only confirmed policy changes, scope of change (organizational to national), and stage of accomplishment (1, beginning; 2, adoption; 3, implementation; and 4, full maintenance). Changes were again verified through site visits and telephone interviews. In 3 years, Alliance teams achieved 53 system and policy change accomplishments. Efforts were implemented at the organizational (33), citywide (13), state (5), and national (2) levels, and forces helping and hindering success were identified. Three types of changes were deemed especially significant for diabetes control: data sharing across care-providing organizations, embedding community health workers into the clinical care team, and linking clinic services with community assets and resources in support of self-management.
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Black Men's Perceptions and Knowledge of Diabetes: A Church-Affiliated Barbershop Focus Group Study. J Racial Ethn Health Disparities 2015; 2:465-72. [PMID: 26594612 DOI: 10.1007/s40615-015-0094-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Diabetes is the seventh leading cause of death in the United States and disproportionately affects racial and ethnic minorities. These disparities persist despite educational efforts to reduce the prevalence of diabetes. Receptiveness of educational efforts for Black men needs to be studied. OBJECTIVE This study assesses Black men's receptiveness to a barbershop-based program focused on diabetes prevention and awareness in a church-affiliated barbershop in Rochester, Minnesota. METHODS The pastor and barber of a church-affiliated barbershop and academic medical researchers designed a community-engaged research study to determine Black men's perception of diabetes. Recruitment for the 90-minute focus group included flyers (n=60), email, and in-person. Units of analysis included focus-group audio recording, transcripts, and field notes. Using traditional content analysis, we categorized data into themes and sub-themes. RESULTS Thirteen Black men participated (Group 1, n=6; Group 2, n=7) having a mean age of 40.3 years (range 19 to 65), and employed full-time (77%). Themes included diabetes prevention, treatment, prevalence, risks, and health education. Participants identified diet and exercise as essential components of diabetes prevention. Additionally, participants mentioned that family history contributes to diabetes. Participants agreed that barbershops are an appropriate setting for data collection and health education on diabetes for Black men. DISCUSSION/CONCLUSION Findings indicate that Black men are generally aware of diabetes. The community-engaged research process allowed for development of a culturally appropriate research study on diabetes. This study is the foundation for developing a culturally appropriate health education program on diabetes for Black men.
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White RO, Eden S, Wallston KA, Kripalani S, Barto S, Shintani A, Rothman RL. Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting. PATIENT EDUCATION AND COUNSELING 2015; 98:144-9. [PMID: 25468393 PMCID: PMC4282939 DOI: 10.1016/j.pec.2014.10.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 10/14/2014] [Accepted: 10/20/2014] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients. METHODS Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations. RESULTS Participants (N=411) were 49.7±9.5 years, 61% female, uninsured (96%), with A1C 9.6±2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40-0.68, all p<0.05), higher treatment satisfaction (OR 1.76-1.96, all p<0.01), portion size reduction (OR 1.43, p<0.05), diabetes self-efficacy (OR 1.41, p<0.05), and lower A1C (β=-0.06, p<0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39-0.68, all p<0.05), and higher treatment satisfaction (AOR 1.90-2.21, all p<0.001). CONCLUSIONS Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction. PRACTICE IMPLICATIONS Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations.
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Affiliation(s)
- Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, USA; Department of Family Medicine, Mayo Clinic, Jacksonville, USA.
| | - Svetlana Eden
- Department of Biostatistics, Vanderbilt University, Nashville, USA
| | | | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Institute for Medicine and Public Health, Vanderbilt University, Nashville, USA
| | - Shari Barto
- Institute for Medicine and Public Health, Vanderbilt University, Nashville, USA
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University, Nashville, USA
| | - Russell L Rothman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, USA; Institute for Medicine and Public Health, Vanderbilt University, Nashville, USA
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Moore K, Jiang L, Manson SM, Beals J, Henderson W, Pratte K, Acton KJ, Roubideaux Y. Case management to reduce cardiovascular disease risk in American Indians and Alaska Natives with diabetes: results from the Special Diabetes Program for Indians Healthy Heart Demonstration Project. Am J Public Health 2014; 104:e158-64. [PMID: 25211728 DOI: 10.2105/ajph.2014.302108] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated cardiovascular disease (CVD) risk factors in American Indians/Alaska Natives (AI/ANs) with diabetes in the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project. METHODS Multidisciplinary teams implemented an intensive case management intervention among 30 health care programs serving 138 tribes. The project recruited 3373 participants, with and without current CVD, between 2006 and 2009. We examined data collected at baseline and 1 year later to determine whether improvements occurred in CVD risk factors and in Framingham coronary heart disease (CHD) risk scores, aspirin use, and smoking status. RESULTS A1c levels decreased an average of 0.2% (P < .001). Systolic and diastolic blood pressure, low-density lipoprotein (LDL) cholesterol, and triglyceride levels decreased, with the largest significant reduction in LDL cholesterol (∆ = -5.29 mg/dL; P < .001). Average Framingham CHD risk scores also decreased significantly. Aspirin therapy increased significantly, and smoking decreased. Participants with more case management visits had significantly greater reductions in LDL cholesterol and A1c values. CONCLUSIONS SDPI-HH successfully translated an intensive case management intervention. Creative retention strategies and an improved understanding of organizational challenges are needed for future Indian health translational efforts.
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Affiliation(s)
- Kelly Moore
- Kelly Moore, Spero M. Manson, Janette Beals, William Henderson, and Katherine Pratte are with the Centers for American Indian and Alaska Native Health, School of Public Health, University of Colorado Denver, Aurora. Luohua Jiang is with the Department of Epidemiology and Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station. Kelly J. Acton is with the Office of the Assistant Secretary of Health, US Department of Health and Human Services, San Francisco, CA. Yvette Roubideaux is with the Office of the Director, Indian Health Service (IHS), Rockville, MD
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Gawron AJ, Yadlapati R. Disparities in endoscopy use for colorectal cancer screening in the United States. Dig Dis Sci 2014; 59:530-7. [PMID: 24248417 DOI: 10.1007/s10620-013-2937-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 10/28/2013] [Indexed: 01/10/2023]
Abstract
It is well established that disparities exist for colorectal cancer (CRC) incidence rates and death. With screening, death from CRC may be considered a preventable occurrence. Endoscopy (flexible sigmoidoscopy and colonoscopy) is the only modality with therapeutic benefit of removal of pre-cancerous polyps. The Patient Protection and Affordable Care Act mandated that preventive screening services be covered, which includes endoscopy for colon cancer screening. Recent federal rules have eliminated cost sharing for polyp removal during screening colonoscopy in privately insured patients; however, this has not been mandated for Medicare patients. Understanding the current state of disparities in endoscopy use is important, as these policy changes will affect millions of patients. The purpose of this literature review was to summarize the known research on disparities in endoscopy use for colon cancer screening in the United States and highlight areas for future research.
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Affiliation(s)
- Andrew J Gawron
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive, 10th Floor, Chicago, IL, USA,
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Peek ME, Ferguson M, Bergeron N, Maltby D, Chin MH. Integrated community-healthcare diabetes interventions to reduce disparities. Curr Diab Rep 2014; 14:467. [PMID: 24464339 PMCID: PMC3956046 DOI: 10.1007/s11892-013-0467-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Racial and ethnic minorities suffer disproportionately from diabetes-related morbidity and mortality. With the creation of Accountable Care Organizations (ACOs) under the Affordable Care Act, healthcare organizations may have an increased motivation to implement interventions that collaborate with community resources and organizations. As a result, there will be an increasing need for evidence-based strategies that integrate healthcare and community components to reduce diabetes disparities. This paper summarizes the types of community/health system partnerships that have been implemented over the past several years to improve minority health and reduce disparities among racial/ethnic minorities and describes the components that are most commonly integrated. In addition, we provide our recommendations for creating stronger healthcare and community partnerships through enhanced community support.
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Mitchell JA, Hawkins J. Current approaches to support the psychosocial care of African American adults with diabetes: a brief review. SOCIAL WORK IN PUBLIC HEALTH 2014; 29:518-527. [PMID: 25144694 PMCID: PMC4145410 DOI: 10.1080/19371918.2014.888533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 01/24/2014] [Indexed: 06/03/2023]
Abstract
African Americans are disproportionately affected by Type 2 diabetes and experience significantly higher age-adjusted prevalence of the disease. Psychosocial support, material resources, and education can have a significant impact on successful diabetes management, particularly among populations with diabetes-related psychological distress such as African Americans. This brief review of the literature identifies and synthesizes current evidence on faith-based, community-based, empowerment-based, strength-based, and culturally competent strategies that may be particularly relevant for social work practitioners supporting African American adults at risk for or diagnosed with Type 2 diabetes. Discussion focuses on multiple influences on the self-determination of clients working to manage their condition.
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Affiliation(s)
- Jamie Ann Mitchell
- School of Social Work, Wayne State University, 337 Thompson Home, 4756 Cass Avenue, Detroit, MI 48202
| | - Jaclynn Hawkins
- School of Social Work, University of Michigan, 1080 S. University Avenue, Ann Arbor, MI 48109-1106
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Minority trauma patients tend to cluster at trauma centers with worse-than-expected mortality: can this phenomenon help explain racial disparities in trauma outcomes? Ann Surg 2013; 258:572-9; discussion 579-81. [PMID: 23979271 DOI: 10.1097/sla.0b013e3182a50148] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To determine whether minority trauma patients are more commonly treated at trauma centers (TCs) with worse observed-to-expected (O/E) survival. BACKGROUND Racial disparities in survival after traumatic injury have been described. However, the mechanisms that lead to these inequities are not well understood. METHODS Analysis of level I/II TCs included in the National Trauma Data Bank 2007-2010. White, Black, and Hispanic patients 16 years or older sustaining blunt/penetrating injuries with an Injury Severity Score of 9 or more were included. TCs with 50% or more Hispanic or Black patients were classified as predominantly minority TCs. Multivariate logistic regression adjusting for several patient/injury characteristics was used to predict the expected number of deaths for each TC. O/E mortality ratios were then generated and used to rank individual TCs as low (O/E <1), intermediate, or high mortality (O/E >1). RESULTS A total of 556,720 patients from 181 TCs were analyzed; 86 TCs (48%) were classified as low mortality, 6 (3%) intermediate, and 89 (49%) as high mortality. More of the predominantly minority TCs [(82% (22/27) vs 44% (67/154)] were classified as high mortality (P < 0.001). Approximately 64% of Black patients (55,673/87,575) were treated at high-mortality TCs compared with 54% Hispanics (32,677/60,761) and 41% Whites (165,494/408,384) (P < 0.001). CONCLUSIONS Minority trauma patients are clustered at hospitals with significantly higher-than-expected mortality. Black and Hispanic patients treated at low-mortality hospitals have a significantly lower odds of death than similar patients treated at high-mortality hospitals. Differences in TC outcomes and quality of care may partially explain trauma outcomes disparities.
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