Receipt of recommended services among patients with selected disabling conditions and diabetes

Patients are unaware of clinical recommendations and resources

AIMS

The Emory Family Medicine Clinic (EFMC) sought to identify perceptions of recent patient-provider communications for patients with diabetes, factors influencing patient compliance with clinical recommendations, and patients' desire for additional resources to facilitate diabetes management.

METHODS

Four focus group discussions were held June-August 2018 (3-9 participants each, 21 total). EFMC patients with uncontrolled diabetes received a phone invitation. A template analytic strategy, characterized by an initial set of codes based on interview content and expected types of responses and inductive codes, was used to thematically code the data.

RESULTS

Most participants were single (62%), college educated (62%), had incomes less than $60,000 (76%), and were younger than 50 years old (62%). For themes related to barriers to compliance the participants mentioned the "business of medicine," convenience factors, food choices, accountability, feeling overwhelmed, costs, location/transportation, and miscommunications. Prevailing themes regarding facilitating compliance included a desire for help with self-accountability and prioritization of recommendations. The major desired patient resource was peer-support groups.

CONCLUSION

Patient understanding of the impact diabetes has on their life can affect adherence to treatment; hence patient education is critical. Payment policies should support innovative educational clinical visits with patients.

Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review

Background

Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications.

Methods

PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias.

Results

Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams.

Conclusion

Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.

Diabetes Standard of Care Among Individuals Who Have Diabetes With and Without Cognitive Limitation Disabilities

Purpose

The purpose of this study is to examine diabetes standard of care among individuals who have diabetes with and without cognitive limitation disabilities (CLDs). Individuals with CLDs are more likely to develop diabetes and less likely to participate in diabetes standard of care services compared to those without CLDs.

Methods

We used pooled cross-sectional data (2011-2016) from the Household Component of the Medical Expenditure Panel Survey (HC-MEPS). Dependent variables were utilization of dilated eye exams, foot checks, A1C blood tests, and engagement in moderate or vigorous physical exercise 5 times per week. Our independent variable was diabetes with CLDs vs diabetes without CLDs. We controlled for predisposing, enabling, and need factors.

Results

Findings suggest that individuals with diabetes and CLDs were less likely to engage in moderate or vigorous physical exercise 5 times per week compared to individuals without CLDs. For other diabetes care services, individuals with CLDs are as likely to participate in health services utilization as those without CLDs.

Conclusions

Our study supports research that indicates individuals with diabetes and CLDs were less likely to participate in physical exercise compared to individuals without CLDs. Conversely, individuals with diabetes and CLDs were just as likely to receive a dilated eye exam, have their feet checked, and have their A1C checked as individuals without CLDs, which is a very encouraging finding.

Disparities in diabetes management among medicaid recipients with intellectual and developmental disabilities (IDD): Evidence from five U.S. states

BACKGROUND

Diabetes is one of the most common chronic conditions among adults. Little is known about the quality of diabetes care received by adults with intellectual and developmental disabilities (IDD).

OBJECTIVE

To determine the extent to which the diabetes care needs are met for a population with both IDD and diabetes who are solely insured by Medicaid in five states (Iowa, Massachusetts, New York, Oregon and South Carolina).

METHODS

Medicaid administrative data in 2012 were used to identify Medicaid members (excluding dual eligibles) with diabetes and IDD in five states. Four diabetes care measures were compared between members with and without IDD using bivariate analyses. For those with diabetes and IDD, a logistic regression model was fitted for each state with the following predictors: age, sex, IDD subgroup, and occurrence of a specialist visit in the current or past year. A meta-analysis was then conducted to synthesize cross-state results.

RESULTS

Across the five states, 6229 (2%) of the 308,804 non-dual adult Medicaid members 18-64 years old with diabetes in 2012 also had IDD. Comparing those with IDD to their non-IDD peers on receipt of all four diabetes care measures showed differences by state, but state rates of overall adherence were very low, ranging from 16.6% to 28.5% of the population.

CONCLUSIONS

Meta-analysis results identified specialist visits as a strong predictor of adults with diabetes and IDD receiving all four components of diabetes care. This important information should be considered in efforts to improve quality care for this population.

Physical Mobility Impairment and Risk for Cardiovascular Disease

Background: People with disabilities (PWD) often self-report reduced access to preventive health services and poorer health than people without disability. Risk factors for chronic disease are more prevalent in PWD, increasing risk for secondary conditions including cardiovascular disease (CVD). Methods: Logistic regression was used to analyze data from the 2016 Behavioral Risk Factor Surveillance Survey to explore the relationship between disability with mobility impairment and CVD. Results: Difficulty walking and climbing stairs significantly predicted concomitant CVD and diabetes in logistic regression models. Conclusion: Information from this study may be useful in addressing CVD risk for adults with mobility impairments.

A Call for Better Data on Prevalence and Health Surveillance of People With Intellectual and Developmental Disabilities

The U.S. approach to the health of people with intellectual and developmental disabilities (IDD) is fraught with paradox. The health of this population has been of longstanding concern, yet we understand their health less well than many other groups. The U.S. spends much more per person on the well-being of people with IDD compared to the general population, yet the outcomes of those expenditures are disappointing and include significant preventable health disparities. Even as expectations for people with IDD have changed to include better health and greater participation in their communities, eligibility for services that support these outcomes is rooted in expectations of dependence and poverty. This article is a call for better data that considers a series of questions to provide context for understanding the need and directions for better health surveillance of people with IDD.

A Patient-Facing Diabetes Dashboard Embedded in a Patient Web Portal: Design Sprint and Usability Testing

Background

Health apps and Web-based interventions designed for patients with diabetes offer novel and scalable approaches to engage patients and improve outcomes. However, careful attention to the design and usability of these apps and Web-based interventions is essential to reduce the barriers to engagement and maximize use.

Objective

The aim of this study was to apply design sprint methodology paired with mixed-methods, task-based usability testing to design and evaluate an innovative, patient-facing diabetes dashboard embedded in an existing patient portal and integrated into an electronic health record.

Methods

We applied a 5-day design sprint methodology developed by Google Ventures (Alphabet Inc, Mountain View, CA) to create our initial dashboard prototype. We identified recommended strategies from the literature for using patient-facing technologies to enhance patient activation and designed a dashboard functionality to match each strategy. We then conducted a mixed-methods, task-based usability assessment of dashboard prototypes with individual patients. Measures included validated metrics of task performance on 5 common and standardized tasks, semistructured interviews, and a validated usability satisfaction questionnaire. After each round of usability testing, we revised the dashboard prototype in response to usability findings before the next round of testing until the majority of participants successfully completed tasks, expressed high satisfaction, and identified no new usability concerns (ie, stop criterion was met).

Results

The sample (N=14) comprised 5 patients in round 1, 3 patients in round 2, and 6 patients in round 3, at which point we reached our stop criterion. The participants’ mean age was 63 years (range 45-78 years), 57% (8/14) were female, and 50% (7/14) were white. Our design sprint yielded an initial patient-facing diabetes dashboard prototype that displayed and summarized 5 measures of patients’ diabetes health status (eg, hemoglobin A_1c). The dashboard used graphics to visualize and summarize health data and reinforce understanding, incorporated motivational strategies (eg, social comparisons and gamification), and provided educational resources and secure-messaging capability. More than 80% of participants were able to successfully complete all 5 tasks using the final prototype. Interviews revealed usability concerns with design, the efficiency of use, and content and terminology, which led to improvements. Overall satisfaction (0=worst and 7=best) improved from the initial to the final prototype (mean 5.8, SD 0.4 vs mean 6.7, SD 0.5).

Conclusions

Our results demonstrate the utility of the design sprint methodology paired with mixed-methods, task-based usability testing to efficiently and effectively design a patient-facing, Web-based diabetes dashboard that is satisfying for patients to use.