Geographic disparities and temporal changes of diabetes-related mortality risks in Florida: a retrospective study

Background

Over the last few decades, diabetes-related mortality risks (DRMR) have increased in Florida. Although there is evidence of geographic disparities in pre-diabetes and diabetes prevalence, little is known about disparities of DRMR in Florida. Understanding these disparities is important for guiding control programs and allocating health resources to communities most at need. Therefore, the objective of this study was to investigate geographic disparities and temporal changes of DRMR in Florida.

Methods

Retrospective mortality data for deaths that occurred from 2010 to 2019 were obtained from the Florida Department of Health. Tenth International Classification of Disease codes E10-E14 were used to identify diabetes-related deaths. County-level mortality risks were computed and presented as number of deaths per 100,000 persons. Spatial Empirical Bayesian (SEB) smoothing was performed to adjust for spatial autocorrelation and the small number problem. High-risk spatial clusters of DRMR were identified using Tango's flexible spatial scan statistics. Geographic distribution and high-risk mortality clusters were displayed using ArcGIS, whereas seasonal patterns were visually represented in Excel.

Results

A total of 54,684 deaths were reported during the study period. There was an increasing temporal trend as well as seasonal patterns in diabetes mortality risks with high risks occurring during the winter. The highest mortality risk (8.1 per 100,000 persons) was recorded during the winter of 2018, while the lowest (6.1 per 100,000 persons) was in the fall of 2010. County-level SEB smoothed mortality risks varied by geographic location, ranging from 12.6 to 81.1 deaths per 100,000 persons. Counties in the northern and central parts of the state tended to have high mortality risks, whereas southern counties consistently showed low mortality risks. Similar to the geographic distribution of DRMR, significant high-risk spatial clusters were also identified in the central and northern parts of Florida.

Conclusion

Geographic disparities of DRMR exist in Florida, with high-risk spatial clusters being observed in rural central and northern areas of the state. There is also evidence of both increasing temporal trends and Winter peaks of DRMR. These findings are helpful for guiding allocation of resources to control the disease, reduce disparities, and improve population health.

The role of health system penetration rate in estimating the prevalence of type 1 diabetes in children and adolescents using electronic health records

OBJECTIVE

Having sufficient population coverage from the electronic health records (EHRs)-connected health system is essential for building a comprehensive EHR-based diabetes surveillance system. This study aimed to establish an EHR-based type 1 diabetes (T1D) surveillance system for children and adolescents across racial and ethnic groups by identifying the minimum population coverage from EHR-connected health systems to accurately estimate T1D prevalence.

MATERIALS AND METHODS

We conducted a retrospective, cross-sectional analysis involving children and adolescents <20 years old identified from the OneFlorida+ Clinical Research Network (2018-2020). T1D cases were identified using a previously validated computable phenotyping algorithm. The T1D prevalence for each ZIP Code Tabulation Area (ZCTA, 5 digits), defined as the number of T1D cases divided by the total number of residents in the corresponding ZCTA, was calculated. Population coverage for each ZCTA was measured using observed health system penetration rates (HSPR), which was calculated as the ratio of residents in the corresponding ZTCA and captured by OneFlorida+ to the overall population in the same ZCTA reported by the Census. We used a recursive partitioning algorithm to identify the minimum required observed HSPR to estimate T1D prevalence and compare our estimate with the reported T1D prevalence from the SEARCH study.

RESULTS

Observed HSPRs of 55%, 55%, and 60% were identified as the minimum thresholds for the non-Hispanic White, non-Hispanic Black, and Hispanic populations. The estimated T1D prevalence for non-Hispanic White and non-Hispanic Black were 2.87 and 2.29 per 1000 youth, which are comparable to the reference study's estimation. The estimated prevalence of T1D for Hispanics (2.76 per 1000 youth) was higher than the reference study's estimation (1.48-1.64 per 1000 youth). The standardized T1D prevalence in the overall Florida population was 2.81 per 1000 youth in 2019.

CONCLUSION

Our study provides a method to estimate T1D prevalence in children and adolescents using EHRs and reports the estimated HSPRs and prevalence of T1D for different race and ethnicity groups to facilitate EHR-based diabetes surveillance.

Effectiveness of diabetes education interventions in rural America: a systematic review

The purpose of this systematic review is to summarize the characteristics of recent studies on diabetes education interventions in rural areas and identify the relative proportion of studies with characteristics of interest that showed a reduction in glycated hemoglobin (A1C). A systematic literature search was performed in Web of Science, PubMed and PsychInfo, using keywords and Medical Subject Heading terms. Articles conducted in rural areas of the United States tested an educational intervention for people with type 2 diabetes, and reported outcomes were identified. A total of 2762 articles were identified, of which 27 were included. Of the 27 articles, most were implemented in the Southeast (n = 13). Of the 21 interventions that measured A1C, 10 reported a statistically significant decrease in A1C. The proportion of studies with a significant A1C reduction was higher for the studies that used telehealth/online, delivered by a collaboration between health-care professionals and lay educators or included family or group components. Only three studies included their criteria in determining rurality. Future diabetes education interventions may consider including family members or group sessions, holding online sessions and partnering with local resources. Additionally, stronger research methods are needed to test practical and effective interventions to improve diabetes education in rural areas.

A Community Health Worker-Led mHealth-Enabled Diabetes Self-Management Education and Support Intervention in Rural Latino Adults: Single-Arm Feasibility Trial (Preprint)

Background

Latinos living in rural South Texas have a higher prevalence of diabetes, but their access to diabetes self-management education and support (DSMES) is limited.

Objective

We aimed to test the feasibility of a community health worker-led, mobile health (mHealth)-based DSMES intervention to reduce disparities in accessing DSMES in underserved rural Latino residents in South Texas.

Methods

This 12-week, single-arm, pre-post trial was delivered by trained community health workers to 15 adults with type 2 diabetes. The intervention consisted of digital diabetes education, self-monitoring, a cloud-based connected platform, and community health worker support. Feasibility was evaluated as retention, actual intervention use, program satisfaction, and barriers to implementation. We also explored the intervention’s effect on weight loss and hemoglobin A_1c (HbA_1c).

Results

All 15 participants were Latino (mean age 61.87 years, SD 10.67; 9/15 female, 60%). The retention rate at posttest was 14 of 15 (93%). On average, the participants completed 37 of 42 (88%) digital diabetes education lessons with 8 participants completing all lessons. Participants spent 81/91 days (89%) step tracking, 71/91 days (78%) food logging, 43/91 days (47%) blood glucose self-monitoring, and 74/91 days (81%) weight self-monitoring. The level of program satisfaction was high. On average, participants lost 3.5 (SD 3.2) kg of body weight (P=.001), while HbA_1c level remained unchanged from baseline (6.91%, SD 1.28%) to posttest (7.04%, SD 1.66%; P=.668).

Conclusions

A community health worker-led mHealth-based intervention was feasible and acceptable to improve access to DSMES services for Latino adults living in rural communities. Future randomized controlled trials are needed to test intervention efficacy on weight loss and glycemic control.

"Counting Carbs to Be in Charge": A Comparison of an Internet-Based Education Module With In-Class Education in Adolescents With Type 1 Diabetes

Carbohydrate counting is an essential component of type 1 diabetes education but can be difficult for adolescents to learn. Because adolescents are avid users of technology, an Internet-based education module was compared with an in-class education session in terms of carbohydrate counting accuracy in adolescents with type 1 diabetes. Adolescent participants displayed increased carbohydrate counting accuracy after attending an in-class education session compared with an Internet-based education module. These results suggest that online education is best reserved as an adjunctive therapy to in-class teaching in this population.

Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels (P < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team (P = .78). Physicians had a 1.082 (95% confidence interval 1.007-1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.

Investigation of geographic disparities of pre-diabetes and diabetes in Florida

BACKGROUND

Diabetes is a leading cause of death and disability in the United States, and its precursor, pre-diabetes, is estimated to occur in one-third of American adults. Understanding the geographic disparities in the distribution of these conditions and identifying high-prevalence areas is critical to guiding control and prevention programs. Therefore, the objective of this study was to investigate clusters of pre-diabetes and diabetes risk in Florida and identify significant predictors of the conditions.

METHODS

Data from the 2013 Behavioral Risk Factor Surveillance System were obtained from the Florida Department of Health. Spatial scan statistics were used to identify and locate significant high-prevalence local clusters. The county prevalence proportions of pre-diabetes and diabetes and the identified significant clusters were displayed in maps. Logistic regression was used to identify significant predictors of the two conditions for individuals living within and outside high-prevalence clusters.

RESULTS

The study included a total of 34,186 respondents. The overall prevalence of pre-diabetes and diabetes were 8.2 and 11.5%, respectively. Three significant (p < 0.05) local, high-prevalence spatial clusters were detected for pre-diabetes, while five were detected for diabetes. The counties within the high-prevalence clusters had prevalence ratios ranging from 1.29 to 1.85. There were differences in the predictors of the conditions based on whether respondents lived within or outside high-prevalence clusters. Predictors of both pre-diabetes and diabetes regardless of region or place of residence were obesity/overweight, hypertension, and hypercholesterolemia. Income and physical activity level were significant predictors of diabetes but not pre-diabetes. Arthritis, sex, and marital status were significant predictors of diabetes only among residents of high-prevalence clusters, while educational attainment and smoking were significant predictors of diabetes only among residents of non-cluster counties.

CONCLUSIONS

Geographic disparities of pre-diabetes and diabetes exist in Florida. Information from this study is useful for guiding resource allocation and targeting of intervention programs focusing on identified modifiable predictors of pre-diabetes and diabetes so as to reduce health disparities and improve the health of all Floridians.

Using Mobile Health Tools to Engage Rural Underserved Individuals in a Diabetes Education Program in South Texas: Feasibility Study

Background

Access to diabetes education and resources for diabetes self-management is limited in rural communities, despite higher rates of diabetes in rural populations compared with urban populations. Technology and mobile health (mHealth) interventions can reduce barriers and improve access to diabetes education in rural communities. Screening, Brief Intervention, and Referral to Treatment (SBIRT) and financial incentives can be used with mHealth interventions to increase the uptake of diabetes education; however, studies have not examined their combined use for diabetes self-management in rural settings.

Objective

This two-phase Stage 1 feasibility study aimed to use a mixed methods design to examine the feasibility and acceptability of an mHealth diabetes education program combining SBIRT and financial incentives to engage rural individuals.

Methods

In Phase 1, we aimed to develop, adapt, and refine the intervention protocol. In Phase 2, a 3-month quasi-experimental study was conducted with individuals from 2 rural communities in South Texas. Study participants were individuals who attended free diabetes screening events in their community. Those with low or medium risk received health education material, whereas those with high risk or those with a previous diagnosis of diabetes participated in motivational interviewing and enrolled in the 6-week mHealth Diabetes Self-Management Education Program under either an unconditional or aversion incentive contract. The participants returned for a 3-month follow-up. Feasibility and acceptability of the intervention were determined by the rate of participant recruitment and retention, the fidelity of program delivery and compliance, and the participant’s satisfaction with the intervention program.

Results

Of the 98 screened rural community members in South Texas, 72 individuals met the study eligibility and 62 individuals agreed to enroll in the study. The sample was predominately female and Hispanic, with an average age of 52.6 years. The feedback from study participants indicated high levels of satisfaction with the mHealth diabetes education program. In the poststudy survey, the participants reported high levels of confidence to continue lifestyle modifications, that is, weight loss, physical activity, and diet. The retention rate was 50% at the 3-month follow-up. Participation in the intervention was high at the beginning and dissipated in the later weeks regardless of the incentive contract type. Positive changes were observed in weight (mean -2.64, SD 6.01; P<.05) and glycemic control index (-.30; P<.05) in all participants from baseline to follow-up.

Conclusions

The finding showed strong feasibility and acceptability of study recruitment and enrollment. The participants’ participation and retention were reasonable given the unforeseen events that impacted the study communities during the study period. Combining mHealth with SBIRT has the potential to reach individuals with need to participate in diabetes education in rural communities.

The Changing Landscape of Diabetes Mortality in the United States Across Region and Rurality, 1999-2016

PURPOSE

This brief report examines place-based differences in diabetes mortality in order to understand whether disparities in diabetes mortality have changed across United States Census regions and levels of rurality over time.

METHODS

We use data from the National Center for Health Statistics from 1999 to 2016 to analyze changes in diabetes mortality over time and across geographical regions of the United States.

FINDINGS

We find evidence that diabetes mortality has declined in the United States over the past 2 decades, but that improvements in mortality vary considerably by place. Improvements are observed in urban America and in the Northeast and Midwest while diabetes mortality has remained largely unchanged in rural areas, particularly in the rural South.

CONCLUSIONS

Diabetes is one of the leading causes of death in the United States, but important differences have emerged in the burden of this disease. Reductions in diabetes mortality are lagging in rural areas, and the rural South in particular, relative to other areas of the country. Continued innovations in care and targeted interventions in rural areas are warranted.

ACOs' Impact on Hospitalization Rates of Rural Older Adults With Diabetes: Early Indications

The purpose of this study was to examine the impact of Medicare Shared Savings Program Accountable Care Organizations (SSP ACOs), along with other factors, on diabetes-related hospitalization rates for rural older adults. Using an early year of the SSP ACO program, we conducted multiple linear regressions to examine the effect of ACO participation on African American and white older adults. In neither model was ACO affiliation found to have a statistically significant impact on diabetes-related hospitalization rates. This study provides baseline measures for patient outcomes during the initial years of ACO formation.

One potato, two potato,… assessing carbohydrate counting accuracy in adolescents with type 1 diabetes

BACKGROUND/OBJECTIVE

Carbohydrate (CHO) counting is a recommended daily practice to help manage blood glucose levels in type 1 diabetes. Evidence suggests that CHO estimates should be within 10 to 15 g of the actual meal for optimal postprandial blood glucose control. The objective of this study was to assess accuracy of CHO counting in adolescents with type 1 diabetes.

METHODS

Adolescents (aged 12-18 years) with type 1 diabetes who self-identified as regular CHO counters were recruited from the SickKids Diabetes Clinic, Toronto, Canada. Adolescents completed the PedsCarbQuiz (PCQ) and estimated CHO content of test trays (three meals and three snack trays) that were randomly assigned. Analyses were conducted to identify factors associated with accuracy of counting and CHO counting knowledge (PCQ score).

RESULTS

A total of 140 adolescents (78 females, mean age 14.7, SD = 1.8) participated. The average PCQ score was 81 ± 10%. Forty-two percent of adolescents were accurate in estimating meal trays (ie, within 10 g of the actual CHO content), 44% estimated inaccurately (within 10-20 g), while 14% were significantly inaccurate counters (>20 g variation). PCQ scores were higher in teens who CHO counted accurately than in those with significant inaccuracy (>20 g) (P < 0.05), and a longer duration of diabetes corresponded significantly with a lower PCQ score. No demographics correlated significantly with CHO counting accuracy.

CONCLUSIONS

Less than half of the teens in our study were accurate CHO counters. These results indicate the need for regular clinical accuracy check and reeducation.

The Diabetes Management Education Program in South Texas: An Economic and Clinical Impact Analysis

Introduction

Diabetes is a major chronic disease that can lead to serious health problems and high healthcare costs without appropriate disease management and treatment. In the United States, the number of people diagnosed with diabetes and the cost for diabetes treatment has dramatically increased over time. To improve patients' self-management skills and clinical outcomes, diabetes management education (DME) programs have been developed and operated in various regions.

Objective

This community case study explores and calculates the economic and clinical impacts of expanding a model DME program into 26 counties located in South Texas.

Methods

The study sample includes 355 patients with type 2 diabetes and a follow-up hemoglobin A1c level measurement among 1,275 individuals who participated in the DME program between September 2012 and August 2013. We used the Gilmer's cost differentials model and the United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine methodology to predict 3-year healthcare cost savings and 10-year clinical benefits of implementing a DME program in the selected 26 Texas counties.

Results

Changes in estimated 3-year cost and the estimated treatment effect were based on baseline hemoglobin A1c level. An average 3-year reduction in medical treatment costs per program participant was $2,033 (in 2016 dollars). The total healthcare cost savings for the 26 targeted counties increases as the program participation rate increases. The total projected cost saving ranges from $12 million with 5% participation rate to $185 million with 75% participation rate. A 10-year outlook on additional clinical benefits associated with the implementation and expansion of the DME program at 60% participation is estimated to result in approximately 4,838 avoided coronary heart disease cases and another 392 cases of avoided strokes.

Conclusion

The implementation of this model DME program in the selected 26 counties would contribute to substantial healthcare cost savings and clinical benefits. Organizations that provide DME services may benefit from reduction in medical treatment costs and improvement in clinical outcomes for populations with diabetes.

Primary health care teams put to the test a cross-sectional study from Austria within the QUALICOPC project

BACKGROUND

Multidisciplinary Primary Health Care Teams (PHCT) provide a comprehensive approach to address the social and health needs of communities. It was the aim of this analysis to assess the number of PHCT in Austria, a country with a weak PHC system, and to compare preventive activities, psychosocial care, and work satisfaction between GPs who work and those who do not work in PHCT.

METHOD

Within the QUALICOPC study, data collection was performed between November 2011 and May 2012, utilizing a standardized questionnaire for GPs. A stratified sample of GPs from across Austria was invited. Statistical analyses included descriptive statistics and tests.

RESULTS

Data from 171 GPs questionnaires were used for this analysis. Of these, 61.1 % (n = 113) had a mono-disciplinary office, 26.3 % (n = 45) worked in an office consisting of GP, receptionist and one additional primary care profession, and 7.6 % (n = 13) worked in a larger PHCT. GPs that worked in larger PHCT were younger and more involved in psychosocial and preventive care. No differences were found with regard to work satisfaction or workload.

CONCLUSIONS

This study gives insight into the structures of PHC in Austria. The results indicate a low number of PHCT; however, the overall return rate in our sample was low with more male GPs, more GPs from urban areas and more GPs working in offices together with other physicians than the national average. Younger GPs demonstrate a greater tendency to implement this primary care practice model in their practices, which seems to be associated with an emphasis in psychosocial and preventive care. If Austria is to increase the number of PHC teams, the country should embrace the work of young GPs and should offer relevant support for PHCT. Future developments could be guided by considering effective models of good practice and governmental support as in other countries.

Improving diabetes care in rural areas: a systematic review and meta-analysis of quality improvement interventions in OECD countries

BACKGROUND AND AIMS

Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.

METHODS

We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.

RESULTS

Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).

CONCLUSIONS

This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.

"Another day in paradise": a photovoice journey of rural older adults living with diabetes

This article provides the results of a photovoice project conducted with older adults affected by diabetes living in three rural counties in the southern region of the United States. Photovoice is a community-based participatory action methodology that puts the tools of research in the hands of participants. This project was an initial community engagement activity that promoted trust-building and formed part of a larger comprehensive community needs assessment. The process revealed themes of personal and community resilience focused on the daily living with diabetes, formal and informal supports, barriers to taking care of their diabetes, accessibility to fruits and vegetables, changes to food preparation and consumption, and exercise supports and barriers. The impact of the photovoice project on the participants and the implications for practice are discussed.

The Impact of Disasters on Populations With Health and Health Care Disparities

Context:A disaster is indiscriminate in whom it affects. Limited research has shown that the poor and medically underserved, especially in rural areas, bear an inequitable amount of the burden.

Objective:To review the literature on the combined effects of a disaster and living in an area with existing health or health care disparities on a community's health, access to health resources, and quality of life.

Methods:We performed a systematic literature review using the following search terms: disaster, health disparities, health care disparities, medically underserved, and rural. Our inclusion criteria were peer-reviewed, US studies that discussed the delayed or persistent health effects of disasters in medically underserved areas.

Results:There has been extensive research published on disasters, health disparities, health care disparities, and medically underserved populations individually, but not collectively.

Conclusions:The current literature does not capture the strain of health and health care disparities before and after a disaster in medically underserved communities. Future disaster studies and policies should account for differences in health profiles and access to care before and after a disaster.

(Disaster Med Public Health Preparedness. 2010;4:30-38)

Racial/ethnic, regional, and rural/urban differences in receipt of diabetes education

PURPOSE

The objective of this study is to examine the differences in receipt of diabetes education according to risk factors that are associated with the disease, including race/ ethnicity, region, and rural/urban location.

METHODS

National data from the 2007 Medical Expenditure Panel Survey (MEPS) were analyzed to examine likelihood of receipt of diabetes education in terms of race, urban/rural location, and region.

RESULTS

Of 1747 adults with type 2 diabetes, 65.6% were white, 15% black, and 19.4% other. In addition, 49.3% were male, 50.6% female; 46.9% were under age 64; 39.8% had more than high school; 34.1% were from low-income households, 35.1% middle income, and 30.8% high income; 39.5% lived in the South while other regions were equally represented; 80.6% lived in rural areas; 63.7% did not receive any type 2 diabetes education. Patients in the South were least likely to receive education (67.5% did not). Logistic regression demonstrated that being black (odds ratio [OR] = 1.38, 95% confidence interval [CI], 1.03-1.84) and living in an urban area (OR = 1.40, 95% CI, 1.00-1.97) were associated with a higher likelihood of receiving diabetes education. By contrast, being 65 or older was associated with lower probability of receiving education (OR = 0.59, 95% CI, 0.40-0.87), as was lack of insurance (OR = 0.54, 95% CI, 0.33-0.88) CONCLUSIONS: Being black independently increased likelihood of receiving diabetes education, but living in rural areas, being uninsured, and living in the South reduced chances one would receive this helpful information. Therefore, further research should examine benefits of leveraging technology such as telemedicine to improve delivery of diabetes education to those living in rural areas.

Quality of diabetes mellitus care by rural primary care physicians

PURPOSE

To explore the relationship between degree of rurality and glucose (hemoglobin A1c), blood pressure (BP), and lipid (LDL) control among patients with diabetes.

METHODS

Descriptive study; 1,649 patients in 205 rural practices in the United States. Patients' residence ZIP codes defined degree of rurality (Rural-Urban Commuting Areas codes). Outcomes were measures of acceptable control (A1c < = 9%, BP < 140/90 mmHg, LDL < 130 mg/dL) and optimal control (A1c < 7%, BP < 130/80 mmHg, LDL < 100 mg/dL). Statistical significance was set at P < .008 (Bonferroni's correction).

FINDINGS

Although the proportion of patients with reasonable A1c control worsened by increasing degree of rurality, the differences were not statistically significant (urban 90%, large rural 88%, small rural 85%, isolated rural 83%; P = .10); mean A1c values also increased by degree of rurality, although not statistically significant (urban 7.2 [SD 1.6], large rural 7.3 [SD 1.7], small rural 7.5 [SD 1.8], isolated rural 7.5 [SD 1.9]; P = .16). We observed no differences between degree of rural and reasonable BP or LDL control (P = .42, P = .23, respectively) or optimal A1c or BP control (P = .52, P = .65, respectively). Optimal and mean LDL values worsened as rurality increased (P = .08, P = .029, respectively).

CONCLUSIONS

In patients with diabetes who seek care in the rural Southern United States, we observed no relationship between degree of rurality of patients' residence and traditional measures of quality of care. Further examination of the trends and explanatory factors for relative worsening of metabolic control by increasing degree of rurality is warranted.

Diabetes Implementation of a Self-management Program in Resource Poor and Rural Community Clinics

PURPOSE

To evaluate the implementation of a brief diabetes self-management support intervention designed for resource-poor community clinics.

METHODS

The authors conducted a pilot study among patients with type 2 diabetes in 3 community clinics. The intervention consisted of research assistants introducing and reviewing a diabetes self-management guide, helping patients set an achievable behavioral action plan, and following up with 2 telephone sessions. The primary outcome was patients' success setting and achieving behavioral goals.

RESULTS

All participants set an action plan (N = 247); most focused on physical activity or diet (97%). The initial session took an average of 15 minutes. At 2 to 4 weeks, 200 participants were contacted; 68% recalled their action plan; and 84% of these achieved it. At 6 to 9 weeks, approximately half of those who completed the first call were reached for the second call. Of those who remained in the intervention, 79% recalled their action plan, and 80% of these achieved it. At the end of the study, 62% of those initially enrolled reported behavior change. Most participants who did not complete the intervention could not be reached for telephone follow-up.

CONCLUSIONS

Although only about a third of patients remained engaged through the 2 follow-up calls, most of those who did reported they had achieved their action plan. This pilot study provides insight into initiating brief diabetes self-management strategies in resource-poor community clinics. Although telephone follow-up was challenging, using the self-management guide and action plan framework, particularly during the initial clinic visit, helped focus patients on behavior change.

Using telehealth to provide diabetes care to patients in rural Montana: findings from the promoting realistic individual self-management program

OBJECTIVE

The objectives of this study were to demonstrate the feasibility of telehealth technology to provide a team approach to diabetes care for rural patients and determine its effect on patient outcomes when compared with face-to-face diabetes visits.

MATERIALS AND METHODS

An evaluation of a patient-centered interdisciplinary team approach to diabetes management compared telehealth with face-to-face visits on receipt of recommended preventive guidelines, vascular risk factor control, patient satisfaction, and diabetes self-management at baseline and 1, 2, and 3 years postintervention.

RESULTS

One-year postintervention the receipt of recommended dilated eye exams increased 31% and 43% among telehealth and face-to-face patients, respectively (p=0.28). Control of two or more risk factors increased 37% and 69% (p=0.21). Patient diabetes care satisfaction rates increased 191% and 131% among telehealth and face-to-face patients, respectively (p=0.51). A comparison of telehealth with face-to-face patients resulted in increased self-reported blood glucose monitoring as instructed (97% vs. 89%; p=0.63) and increased dietary adherence (244% vs. 159%; p=0.86), respectively. Receipt of a monofilament foot test showed a significantly greater improvement among face-to-face patients (17% vs. 35%; p=0.01) at 1 year postintervention, but this difference disappeared in years 2 and 3.

CONCLUSIONS

Telehealth proved to be an effective mode for the provision of diabetes care to rural patients. Few differences were detected in the delivery of a team approach to diabetes management via telehealth compared with face-to-face visits on receipt of preventive care services, vascular risk factor control, patient satisfaction, and patient self-management. A team approach using telehealth may be a viable strategy for addressing the unique challenges faced by patients living in rural communities.

Goal setting using telemedicine in rural underserved older adults with diabetes: experiences from the informatics for diabetes education and telemedicine project

OBJECTIVE

To describe the use of telemedicine for setting goals for behavior change and examine the success in achieving these goals in rural underserved older adults with diabetes.

MATERIALS AND METHODS

Medicare beneficiaries with diabetes living in rural upstate New York who were enrolled in the telemedicine intervention of the Informatics for Diabetes Education and Telemedicine (IDEATel) project (n = 610) participated in home televisits with nurse and dietitian educators every 4-6 weeks for 2-6 years. Behavior change goals related to nutrition, physical activity, monitoring, diabetes health maintenance, and/or use of the home telemedicine unit were established at the conclusion of each televisit and assessed at the next visit.

RESULTS

Collaborative goal setting was employed during 18,355 televisits (mean of 33 goal-setting televisits/participant). The most common goals were related to monitoring, followed by diabetes health maintenance, nutrition, exercise, and use of the telemedicine equipment. Overall, 68% of behavioral goals were rated as "improved" or "met." The greatest success was achieved for goals related to proper insulin injection technique and daily foot care. These elderly participants had the most difficulty achieving goals related to use of the computer. No gender differences in goal achievement were observed.

CONCLUSION

Televisits can be successfully used to collaboratively establish behavior change goals to help improve diabetes self-management in underserved elderly rural adults.

Recruitment of rural physicians in a diabetes internet intervention study: overcoming challenges and barriers

PURPOSE

This paper highlights a descriptive study of the challenges and lessons learned in the recruitment of rural primary care physicians into a randomized clinical trial using an Internet-based approach.

METHODS

A multidisciplinary/multi-institutional research team used a multilayered recruitment approach, including generalized mailings and personalized strategies such as personal office visits, letters, and faxes to specific contacts. Continuous assessment of recruitment strategies was used throughout study in order to readjust strategies that were not successful.

RESULTS

We recruited 205 primary care physicians from 11 states. The 205 lead physicians who enrolled in the study were randomized, and the overall recruitment yield was 1.8% (205/11231). In addition, 8 physicians from the same practices participated and 12 nonphysicians participated. The earlier participants logged on to the study Web site, the greater yield of participation. Most of the study participants had logged on within 10 weeks of the study.

CONCLUSION

Despite successful recruitment, the 2 major challenges in recruitment in this study included defining a standardized definition of rurality and the high cost of chart abstractions. Because many of the patients of study recruits were African American, the potential implications of this study on the field of health disparities in diabetes are important.

The role of insulin analogs in type 2 diabetes in the rural community

OBJECTIVE

Type 2 diabetes is a progressive disease requiring constant monitoring of patients to ensure maintenance of glycemic goals and advancement of therapy when necessary. The challenges of treatment in rural areas may be different from those in urban areas. This review article will evaluate the barriers to treatment of type 2 diabetes and the role of insulin analogs in overcoming such barriers and in treating the disease, particularly with respect to rural communities.

RESEARCH DESIGN AND METHODS

A literature review of English language articles in the Medline Database was conducted to identify published articles through April 2008. Search terms included rural, diabetes, insulin, treatment, and treatment challenges/barriers and were used either alone or in various combinations with one another. Articles were included if they pertained to rural communities in the United States. Barriers related to treatment of type 2 diabetes and the role of insulin analogs in treatment and in overcoming such barriers, were examined.

RESULTS

Health-care providers and patients in rural areas face barriers both common to the general population and unique to the rural setting. Challenges include limited access to health care, lack of health-care resources, and lack of multidisciplinary staff.

CONCLUSIONS

A number of strategies exist, including simple, stepwise treatment algorithms for insulin therapy, to manage type 2 diabetes in rural populations effectively. Because this article focused on rural communities in the United States, barriers in other rural communities may not have been identified. Additionally, although Medline is one of the largest and most comprehensive databases of published medical literature, publications not in the Medline database have not been included in this analysis.