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

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.

Outcomes of New York City Care Calls: A Prospective Randomized Controlled Effectiveness Trial of Telephone-Delivered Type 2 Diabetes Self-Management Support

PURPOSE

The purpose of the 12-month randomized controlled trial was to evaluate the effectiveness of a Telephonic Self-Management Support (T-SMS) program among adults with type 2 diabetes (T2D).

METHODS

Eight hundred twelve adults with T2D participated in NYC Care Calls (mean age = 59.2, SD = 10.8; female = 57%; mean A1C = 9.3, SD = 1.8; Latino = 86%) and were randomly assigned to T-SMS or enhanced usual care (EUC). A1C (primary outcome), blood pressure, and body mass index (secondary outcomes) were extracted from electronic medical records. Secondary patient-reported outcomes, including depressive symptoms, diabetes distress, medication adherence, and self-management activities, were assessed by telephone in English or Spanish. For T-SMS, the number of assigned phone calls was based on baseline A1C, depressive symptoms, and/or diabetes distress. Analyses were conducted under the intention-to-treat principle.

RESULTS

A1C decreased over 12 months in both T-SMS (0.72% percentage points; 95% CI, 0.53-0.91) and EUC (0.66% percentage points; 95% CI, 0.46-0.85; Ps < .001). Diabetes distress and self-management also improved over time in both arms (Ps < .05). Compared to EUC, participants in the T-SMS arm did not differ in outcomes.

CONCLUSIONS

The T-SMS and EUC groups were found not to have an appreciable outcome difference. It is unclear whether improvements in A1C across both conditions represent a secular trend or indicate that print-based educational intervention may have a positive impact on self-management and well-being.

Disparities in Acute and Chronic Complications of Diabetes Along the U.S. Rural-Urban Continuum

OBJECTIVE

To determine the relative hazards of acute and chronic diabetes complications among people with diabetes across the U.S. rural-urban continuum.

RESEARCH DESIGN AND METHODS

This retrospective cohort study used the OptumLabs Data Warehouse, a deidentified data set of U.S. commercial and Medicare Advantage beneficiaries, to follow 2,901,563 adults (age ≥18 years) with diabetes between 1 January 2012 and 31 December 2021. We compared adjusted hazard ratios (HRs) of diabetes complications in remote areas (population <2,500), small towns (population 2,500-50,000), and cities (population >50,000).

RESULTS

Compared with residents of cities, residents of remote areas had greater hazards of myocardial infarction (HR 1.06 [95% CI 1.02-1.10]) and revascularization (HR 1.04 [1.02-1.06]) but lower hazards of hyperglycemia (HR 0.90 [0.83-0.98]) and stroke (HR 0.91 [0.88-0.95]). Compared with cities, residents of small towns had greater hazards of hyperglycemia (HR 1.06 [1.02-1.10]), hypoglycemia (HR 1.15 [1.12-1.18]), end-stage kidney disease (HR 1.04 [1.03-1.06]), myocardial infarction (HR 1.10 [1.08-1.12]), heart failure (HR 1.05 [1.03-1.06]), amputation (HR 1.05 [1.02-1.09]), other lower-extremity complications (HR 1.02 [1.01-1.03]), and revascularization (HR 1.05 [1.04-1.06]) but a smaller hazard of stroke (HR 0.95 [0.94-0.97]). Compared with small towns, residents of remote areas had lower hazards of hyperglycemia (HR 0.85 [0.78-0.93]), hypoglycemia (HR 0.92 [0.87-0.97]), and heart failure (HR 0.94 [0.91-0.97]). Hazards of retinopathy and atrial fibrillation/flutter did not vary geographically.

CONCLUSIONS

Adults in small towns are disproportionately impacted by complications of diabetes. Future studies should probe for the reasons underlying these disparities.

The urban-rural disparities and factors associated with the utilization of public health services among diabetes patients in China

BACKGROUND

Basic public health services for diabetes play an essential role in controlling glycemia in patients with diabetes. This study was conducted to understand the urban-rural disparities in the utilization of basic public health services for people with diabetes and the factors influencing them.

METHODS

The data were obtained from the 2018 China Health and Retirement Longitudinal Study (CHARLS) with 2976 diabetes patients. Chi-square tests were used to examine the disparities in the utilization of diabetes physical examination and health education between urban and rural areas. Logistic regression was performed to explore the factors associated with the utilization of diabetes public health services.

RESULTS

Among all participants, 8.4% used diabetes physical examination in the past year, and 28.4% used diabetes health education services. A significant association with age (OR = 0.64, 95% CI:0.49-0.85; P < 0.05) was found between patients' use of health education services. Compared with diabetes patients living in an urban area, diabetes patients living in a rural area used less diabetes health education. (χ2= 92.39, P < 0.05). Patients' self-reported health status (OR = 2.04, CI:1.24-3.35; P < 0.05) and the use of glucose control (OR = 9.33, CI:6.61-13.16; P < 0.05) were significantly positively associated with the utilization of diabetes physical examination. Patients with higher education levels were more likely to use various kinds of health education services than their peers with lower education levels (OR = 1.64, CI:1.21-2.22; P < 0.05).

CONCLUSION

Overall, urban-rural disparities in the utilization of public health services existed. Vulnerable with diabetes, such as those in rural areas, are less available to use diabetes public health services. Providing convenient health service infrastructure facilitates the utilization of basic public health services for diabetes in older patients with diabetes, especially in rural areas.

Factors Associated With Receipt of Diabetes Self-Management Education and Support for Type 2 Diabetes: Potential for a Population Health Management Approach

BACKGROUND

Population health management approaches can help target diabetes resources like Diabetes Self-Management Education and Support (DSMES) to individuals at the highest risk of complications and poor outcomes. Little is known about patient characteristics associated with DSMES receipt since widespread uptake of telemedicine for diabetes care in 2020.

METHODS

In this retrospective cohort study, we used electronic medical record (EMR) data to assess patterns of DSMES delivery from May 2020 to May 2022 among adults who used telemedicine for type 2 diabetes (T2D) endocrinology care in a large integrated health system. Multilevel regression models were used to evaluate the association of key patient characteristics with DSMES receipt.

RESULTS

Of 3530 patients in the overall cohort, 401 patients (11%) received DSMES. In adjusted multivariable logistic regression, higher baseline HbA1c (odds ratios [OR] 3.10 [95% confidence interval 2.22-4.33] for HbA1c ≥9% vs <7%), insulin regimen complexity (OR 3.53 [2.59-4.80] for multiple daily injections vs no insulin), and number of noninsulin medications (OR 1.17 [1.05-1.30] per 1 additional medication) were significantly associated with receipt of DSMES, whereas rurality and area-level deprivation of patient residence were not.

CONCLUSIONS

Diabetes Self-Management Education and Support remains underutilized in this cohort of adults using telemedicine to access endocrinology care for T2D. Factors contributing to clinical complexity increased the odds of receiving DSMES. These results support a potential population health management approach using EMR data, which could target DSMES resources to those at higher risk of poor outcomes. This risk-stratified approach may be even more effective now that more people can access DSMES via telemedicine in addition to in-person care.

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.

Frequency of Follow-Up Attendance and Blood Glucose Monitoring in Type 2 Diabetic Patients at Moderate to High Cardiovascular Risk: A Cross-Sectional Study in Primary Care

Regular follow-up attendance in primary care and routine blood glucose monitoring are essential in diabetes management, particularly for patients at higher cardiovascular (CV) risk. We sought to examine the regularity of follow-up attendance and blood glucose monitoring in a primary care sample of type 2 diabetic patients at moderate-to-high CV risk, and to explore factors associated with poor engagement. Cross-sectional data were collected from 2130 patients enrolled in a diabetic retinopathy screening programme in Guangdong province, China. Approximately one-third of patients (35.9%) attended clinical follow-up <4 times in the past year. Over half of patients (56.9%) failed to have blood glucose monitored at least once per month. Multivariable logistic regression analysis showed that rural residents (adjusted odds ratio [aOR] = 0.420, 95% confidence interval [CI] = 0.338-0.522, p < 0.001, for follow-up attendance; aOR = 0.580, 95%CI: 0.472-0.712, p < 0.001, for blood glucose monitoring) and subjects with poor awareness of adverse consequences of diabetes complications (aOR = 0.648, 95%CI = 0.527-0.796, p < 0.001, for follow-up attendance; aOR = 0.770, 95%CI = 0.633-0.937, p = 0.009, for blood glucose monitoring) were both less likely to achieve active engagement. Our results revealed an urban-rural divide in patients' engagement in follow-up attendance and blood glucose monitoring, which suggested the need for different educational approaches tailored to the local context to enhance diabetes care.

Cost-effectiveness of multicomponent interventions in type 2 diabetes mellitus in a cluster randomised controlled trial: the INDICA study

OBJECTIVE

To analyse the cost-effectiveness of multicomponent interventions designed to improve outcomes in type 2 diabetes mellitus (T2DM) in primary care in the Canary Islands, Spain, within the INDICA randomised clinical trial, from the public health system perspective.

DESIGN

An economic evaluation was conducted for the within-trial period (2 years) comparing the four arms of the INDICA study.

SETTING

Primary care in the Canary Islands, Spain.

PARTICIPANTS

2334 patients with T2DM without complications were included.

INTERVENTIONS

Interventions for patients (PTI), for primary care professionals (PFI), for both (combined intervention arm for patients and professionals, CBI) and usual care (UC) as a control group.

OUTCOMES

The main outcome was the incremental cost per quality-adjusted life-years (QALY). Only the intervention and the healthcare costs were included.

ANALYSIS

Multilevel models were used to estimate results, and to measure the size and significance of incremental changes. Missed values were treated by means of multiple imputations procedure.

RESULTS

There were no differences between arms in terms of costs (p=0.093), while some differences were observed in terms of QALYs after 2 years of follow-up (p=0.028). PFI and CBI arms were dominated by the other two arms, PTI and UC. The differences between the PTI and the UC arms were very small in terms of QALYs, but significant in terms of healthcare costs (p=0.045). The total cost of the PTI arm (€2571, 95% CI €2317 to €2826) was lower than the cost in the UC arm (€2750, 95% CI €2506 to €2995), but this difference did not reach statistical significance. Base case estimates of the incremental cost per QALY indicate that the PTI strategy was the cost-effective option.

CONCLUSIONS

The INDICA intervention designed for patients with T2DM and families is likely to be cost-effective from the public healthcare perspective. A cost-effectiveness model should explore this in the long term.

TRIAL REGISTRATION NUMBER

NCT01657227.

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.

Trends and Rural-Urban Differences in Participation in Diabetes Self-management Education Among Adults in North Carolina: 2012-2017

PURPOSE

This study aimed to report recent trends in self-reported diabetes self-management education (DSME) participation rates among adults in North Carolina and to compare these rates between rural and urban residents.

METHODS

Data for this analysis were obtained from the NC Behavioral Risk Factor Surveillance System (BRFSS) for the years 2012, 2013, 2015, and 2017, when the survey included the diabetes module. Respondents were classified as having participated in DSME if they answered "Yes" to the question, "Have you ever taken a course or class in how to manage your diabetes yourself?" We used the Rural Urban Continuum Code to classify urban and rural residence. The study sample included 4368 adults 18 years or older with self-reported diabetes. We assessed the changes in DSME participation from 2012 to 2017. We used multiple logistic regression modeling to assess the association between rural residence and DSME participation. All analyses were conducted in Stata 14 and accounted for the survey design of the BRFSS. Statistical significance was set at P < .01.

RESULTS

Overall, the DSME participation rates decreased slightly in the study period, from 55.8% in 2012 to 55.6% in 2013 to 56.5% in 2015 to 52.1% in 2017. By rural-urban residence, the rates were 52.3% versus 57.8% in 2012, 54.0% versus 56.5% in 2013, 48.8% versus 62.0% in 2015, and 46.7% versus 56.1% in 2017. The multiple logistic regression model results showed that rural residents were less likely to have participated in DSME (adjusted odds ratio = 0.78; 95% confidence interval, 0.64-0.94) than urban residents. Adults with higher income and education levels were also more likely to have participated in DSME (P < .01).

CONCLUSIONS

The recent BRFSS data showed that the DSME participation rate declined slightly in North Carolina. There were persistent rural-urban disparities in DSME participation, with rural residents showing lower rates, and the gaps seemed to be widening.

IMPLICATIONS FOR POLICY OR PRACTICE

Continuous efforts are needed to bring more American Diabetes Association/American Association of Diabetes Educators programs to rural communities and assist persons with diabetes to participate in DSME training to reduce the burden of diabetes. Furthermore, those in rural areas may need additional support.

Gender Disparities in Anti-dementia Medication Use among Older Adults: Health Equity Considerations and Management of Alzheimer's Disease and Related Dementias

Objective: The prevalence of Alzheimer's disease and related dementias (ADRD) in women is higher than men. However, the knowledge of gender disparity in ADRD treatment is limited. Therefore, this study aimed to determine the gender disparities in the receipt of anti-dementia medications among Medicare beneficiaries with ADRD in the U.S. Methods: We used data from the Medicare Current Beneficiary Survey 2016. Anti-dementia medications included cholinesterase inhibitors (ChEIs; including rivastigmine, donepezil, and galantamine) and N-methyl-D-aspartate (NMDA) receptor antagonists (including memantine). Descriptive analysis and multivariate logistic regression models were implemented to determine the possible gender disparities in the receipt of anti-dementia medications. Subgroup analyses were conducted to identify gender disparities among beneficiaries with Alzheimer's disease (AD) and those with only AD-related dementias. Results: Descriptive analyses showed there were statistically significant differences in age, marital status, and Charlson comorbidities index (CCI) between Medicare beneficiaries who received and who did not receive anti-dementia medications. After controlling for covariates, we found that female Medicare beneficiaries with ADRD were 1.7 times more likely to receive anti-dementia medications compared to their male counterparts (odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.19-2.45). Specifically, among Medicare beneficiaries with AD, females were 1.2 times more likely to receive anti-dementia medications (Odds Radio: 1.20; 95% confidence interval: 0.58-2.47), and among the Medicare beneficiaries with only AD-related dementias, females were 1.9 times more likely to receive anti-dementia medications (OR: 1.90; 95% CI: 1.23-2.95). Conclusion: Healthcare providers should be aware of gender disparities in receiving anti-dementia medications among patients with ADRD, and the need to plan programs of care to support both women and men. Future approaches to finding barriers of prescribing, receiving and, adhering to anti-dementia medications by gender should include differences in longevity, biology, cognition, social roles, and environment.

Burden and management of type 2 diabetes in rural United States

In the United States, rural areas have a higher burden of type 2 diabetes (T2DM) compared to urban areas. However, there is limited information on risk factors and interventions that improve the primary prevention and management of T2DM in rural areas. To synthesize current knowledge on T2DM in rural areas and to guide healthcare providers and policy makers, we reviewed five scientific databases and the grey literature over the last decade (2010-2020). We described classification systems for rurality and the T2DM burden based on rurality and region (West, South, Midwest, and Northeast). We highlighted risk factors for T2DM in rural compared to urban areas, and summarized interventions to screen and manage T2DM based on opportunistic screening, T2DM self-management, community-based initiatives, as well as interventions targeting comorbidities and T2DM. Several studies identified the co-existence of T2DM and depression/psychological symptoms, which could reduce adherence to non-pharmacologic and pharmacologic management of T2DM. We highlighted the role of technology in education and counselling of patients with geographic and financial barriers to accessing care, which is exacerbated by the SARS-CoV-2 coronavirus disease-19 pandemic. We identified knowledge gaps and next steps in improving T2DM care in rural areas. There is an urgent need for interventions tailored to rural areas given that rural Americans currently experience a disproportionate burden of T2DM and are encumbered by its associated morbidity, mortality, and loss in economic productivity.

Rural-urban differences in uptake of diabetes self-management education among Medicare beneficiaries: Results from the 2016 to 2018 Medicare Current Beneficiary Survey

PURPOSE

To assess rural-urban differences in participation rates of diabetes self-management education and associated factors among Medicare beneficiaries with type 2 diabetes (T2DM).

METHODS

Data were from the 2016 to 2018 Medicare Current Beneficiary Survey (MCBS). Participation in diabetes self-management education was self-reported. The study sample included 3,799 beneficiaries aged 65 years and older with self-reported T2DM. Logistic regression was used to assess the association of participation in diabetes self-management education and residential location. Sampling weights embedded in the MCBS were incorporated into all analyses.

FINDINGS

Overall, the participation rate of diabetes self-management education was 46.8% (95% CI: 44.4%-49.2%). The rate was 40.3% for beneficiaries in rural areas, 48.0% for suburban areas, and 47.3% for urban areas. About 31% of beneficiaries newly diagnosed with diabetes did not participate within the past year. Controlling for other covariates, beneficiaries in rural areas were less likely to have participated in diabetes self-management education (AOR = 0.73, 95% CI: 0.55-0.95) than those living in urban areas. Asian Americans were less likely to have participated (AOR = 0.49, 95% CI: 0.28-0.84) than Whites. Those who were older, with lower education, and lower income levels were less likely to have participated (P < .05).

CONCLUSIONS

Recent MCBS data indicate that more than half of Medicare beneficiaries with T2DM did not participate in diabetes self-management education, and the participation rate in rural areas was 7 percentage points lower than that ​in urban areas. The study findings highlight challenges to maximize the benefits of participating in diabetes self-management education, particularly in rural areas.

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.

Effectiveness of Internet-Based Multicomponent Interventions for Patients and Health Care Professionals to Improve Clinical Outcomes in Type 2 Diabetes Evaluated Through the INDICA Study: Multiarm Cluster Randomized Controlled Trial

Background

Type 2 diabetes mellitus (T2DM) is a chronic disease in which health outcomes are related to decision making by patients and health care professionals.

Objective

This study aims to assess the effectiveness of internet-based multicomponent interventions to support decision making of all actors involved in the care of patients with T2DM in primary care.

Methods

The INDICA study is an open, community-based, multicenter trial with random allocation to usual care or the intervention for patients, the intervention for health care professionals in primary care, or the combined intervention for both. In the intervention for patients, participants received an educational group program and were monitored and supported by logs, a web-based platform, and automated SMS. Those in the intervention for professionals also received an educational program, a decision support tool embedded in the electronic clinical record, and periodic feedback about patients’ results. A total of 2334 people with T2DM, regardless of glycated hemoglobin (HbA_1c) levels and without diabetes-related complications, were included. The primary end point was change in HbA_1c level. The main analysis was performed using multilevel mixed models.

Results

For the overall sample, the intervention for patients attained a significant mean reduction in HbA_1c levels of ‒0.27 (95% CI ‒0.45 to ‒0.10) at month 3 and ‒0.26 (95% CI ‒0.44 to ‒0.08) at month 6 compared with usual care, which remained marginally significant at month 12. A clinically relevant reduction in HbA_1c level was observed in 35.6% (191/537) of patients in the intervention for patients and 26.0% (152/586) of those in usual care at month 12 (P=.006). In the combined intervention, HbA_1c reduction was significant until month 18 (181/557, 32.6% vs 140/586, 23.9%; P=.009). Considering the subgroup of patients uncontrolled at baseline, all interventions produced significant reductions in HbA_1c levels across the entire study period: ‒0.49 (95% CI ‒0.70 to ‒0.27) for the intervention for patients, ‒0.35 (95% CI ‒0.59 to ‒0.14) for the intervention for professionals, and ‒0.35 (95% CI ‒0.57 to ‒0.13) for the combined intervention. Differences in HbA_1c for the area under the curve considering the entire period were significant for the intervention for patients and the combined intervention compared with usual care (P=.03 for both). Compared with usual care, the intervention for professionals and the combined intervention had significant longer-term reductions in systolic and diastolic blood pressure.

Conclusions

In uncontrolled patients, the intervention for patients at baseline provided clinically relevant and significant longer-term reductions of HbA_1c levels. The intervention for professionals and combined intervention also improved the cardiovascular risk profile of patients.

Trial Registration

ClinicalTrials.gov NCT01657227; https://clinicaltrials.gov/ct2/show/NCT01657227

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.

Difference in frequency and outcome of geriatric emergency department utilization between urban and rural areas

BACKGROUND

Elderly people are susceptible to develop multiple chronic diseases and are thus likely to utilize the emergency department (ED). Access to health care and health outcomes may differ between rural and urban areas. This study aims to compare the frequency and outcome of geriatric ED utilization between urban and rural areas.

METHODS

This population-based study obtained information from the health insurance database. The frequency and outcome of ED utilization in 2013 were compared among people aged ≥65 years living in urban and rural areas. The independent effect of various characteristics on the frequency and outcome of ED utilization was evaluated using multivariate logistic regression analysis.

RESULTS

Of the 6695 people living in urban areas, 1879 (28.07%) utilized the ED and accounted for 3859 ED visits. Meanwhile, 908 (29.75%) of the 3052 people living in rural areas utilized the ED and accounted for 1820 ED visits. No difference in the prevalence of ED utilization was found between the urban and rural areas. Urbanization did not affect the risk of frequent ED utilization among ED users. People living in rural areas had an increased risk of ED visits with a high acuity (adjusted odds ratio: 1.40, 95% CI: 1.12-1.75). Urbanization did not affect the risk of hospitalization or immediate death after ED visits.

CONCLUSION

The frequency of ED utilization showed no urban-rural difference. Elderly people living in rural areas had an increased risk of visiting the ED with a high acuity.

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.

Diabetes Self-management Training in a Virtual Environment

Diabetes self-management training (DSMT) improves diabetes health outcomes. However, low numbers of patients receive DSMT. Using virtual environments (VEs) for DSMT is an innovative approach to removing barriers for patients. The purpose of this paper is to describe the experience of health professionals and diabetes educators establishing and teaching DSMT in a VE, Diabetes LIVE© (Learning in Virtual Environments), and the implications for future use of VEs in DSMT. It was found that providing DSMT in a VE preserves real-time interaction between patients and educators. To facilitate ongoing patient learning and engagement, the DSMT curriculum was expanded beyond the core content as “Above and Beyond” topics. Using a VE for DSMT presents challenges and opportunities. Challenges include overcoming technological barriers and improving comfort levels to orient educators and patients to the functionality of the VE. Opportunities include overcoming barriers to reaching patients, particularly given the diabetes epidemic and relatively small number of diabetes educators. Using a VE also affords a simulated community for experiential learning. VEs may become powerful tools for diabetes and other health educators to reach patients. Ongoing education and support are vital to successful self-management of chronic disease.

Identification, prevalence, and treatment of painful diabetic neuropathy in patients from a rural area in South Carolina

Diabetic peripheral neuropathy (DPN) represents significant burdens to many patients and the public health-care system. Patients with diabetes in rural areas have higher risk of developing complications and having less access to proper treatment. We studied a rural population of patients with diabetes who attended a pharmacist-led free clinic for a diabetic education program. Our objectives were to 1) determine the prevalence of DPN and painful diabetic neuropathy (p-DN) in patients with type 2 diabetes; 2) assess the proportion of patients with DPN and p-DN left undocumented upon physician referral to a pharmacist-led free clinic; and 3) determine the appropriateness of pain medication regimen. We performed a retrospective analysis of clinical records of patients from the Presbyterian College School of Pharmacy (PCSP) Wellness Center located in Clinton, SC. Diagnoses of DPN and/or p-DN were obtained from referral notes in the clinical records and compared with results from foot examinations performed in the free clinic and clinical features. Medication regimens were also obtained and compared using American Academy of Neurology (AAN) treatment guidelines. Within our study population (n=111), the prevalence of DPN was 62.2% (national average of 28%–45%) and that of p-DN was 23.4% (national average of 11%–24%). In p-DN patients (n=26), 53.8% (n=14) had a documented diagnosis of p-DN by the referring physician, and 46.2% (n=12) were identified by the pharmacists. A total of 95% (19 of 20) of the patients treated for p-DN received adequate pharmacological agents, though suboptimal as per clinical guidelines. More than 50% of the patients used subtherapeutic doses of their medications. Gabapentin was the most frequently used medication in our population (65.4%). Patients in rural South Carolina had a higher prevalence of DPN and p-DN with >60% undocumented cases of p-DN. More than 95% of treated patients did not receive optimum therapy according to AAN guidelines.

The empirical evidence for the telemedicine intervention in diabetes management

OBJECTIVE

The research presented here assesses the scientific evidence for the telemedicine intervention in the management of diabetes (telediabetes), gestational diabetes, and diabetic retinopathy. The impetus derives from the confluence of high prevalence of these diseases, increasing incidence, and rising costs, while telemedicine promises to ameliorate, if not prevent, type 2 diabetes and its complications.

MATERIALS AND METHODS

A purposeful review of the literature identified relevant publications from January 2005 to December 2013. These were culled to retain only credible research articles for detailed review and analysis. The search yielded approximately 17,000 articles with no date constraints. Of these, 770 appeared to be research articles within our time frame. A review of the abstracts yielded 73 articles that met the criteria for inclusion in the final analysis. Evidence is organized by research findings regarding feasibility/acceptance, intermediate outcomes (e.g., use of service, and screening compliance), and health outcomes (control of glycemic level, lipids, body weight, and physical activity.)

RESULTS

Definitions of telediabetes varied from study to study vis-à-vis diabetes subtype, setting, technology, staffing, duration, frequency, and target population. Outcome measures also varied. Despite these vagaries, sufficient evidence was obtained from a wide variety of research studies, consistently pointing to positive effects of telemonitoring and telescreening in terms of glycemic control, reduced body weight, and increased physical exercise. The major contributions point to telemedicine's potential for changing behaviors important to diabetes control and prevention, especially type 2 and gestational diabetes. Similarly, screening and monitoring for retinopathy can detect symptoms early that may be controlled or treated.

CONCLUSIONS

Overall, there is strong and consistent evidence of improved glycemic control among persons with type 2 and gestational diabetes as well as effective screening and monitoring of diabetic retinopathy.

Race and referral to diabetes education in primary care patients with prediabetes and diabetes

PURPOSE

The purpose of the study was to determine whether there are any race-related disparities in the prevalence of provisions for diabetes education in primary care clinics for patients with diabetes and prediabetes.

METHODS

A retrospective cross-sectional study of 3967 patients aged 14 to >89 years with prediabetes and diabetes. Medical record data from patient encounters within primary care clinics at a large academic medical health system between July 1, 2008, and July 31, 2013, were used to determine rates of referral for diabetes education by race. Multivariate logistic regression models were used to assess associations between race and referral to diabetes education. Separate regression models were computed for patients who were prediabetic and diabetic. Adjusted models included age, sex, A1C, health care utilization, smoking, and diagnosis for depression, hyperlipidemia, hypertension, vascular disease, and obesity.

RESULTS

Compared to that of white patients, a significantly higher prevalence of African American patients with prediabetes were referred to diabetes education, and this association was also observed in patients with diabetes. In fully adjusted models, white patients with prediabetes were significantly less likely to be referred.

CONCLUSIONS

Being African American independently increased the likelihood of referral for diabetes education in patients with prediabetes and patients with diabetes. After adjusting for patient comorbidities and risk factors, this association remained significant for patients with prediabetes. Additional research is needed to determine if provider beliefs and attitudes regarding race and diabetes education account for this association.

Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

OBJECTIVE

To assess differences in psychological outcomes as well as risk and protective factors for these outcomes among several USA ethnic groups and identify correlates of these psychological outcomes among adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2 * ) study.

RESEARCH DESIGN AND METHODS

The core USA DAWN2 sample was supplemented by independent samples of specific ethnic minority groups, yielding a total of 447 White non-Hispanics, 241 African Americans, 194 Hispanics, and 173 Chinese Americans (n = 1055). Multivariate analysis examined ethnic differences in psychological outcomes and risk/protective factors (disease, demographic and socioeconomic factors, health status and healthcare access/utilization, subjective burden of diabetes and social support/burden). Separate analyses were performed on each group to determine whether risk/protective factors differed across ethnic groups.

MAIN OUTCOME MEASURES

Psychological outcomes include well-being, quality of life, impact of diabetes on life domains, diabetes distress, and diabetes empowerment.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

Ethnic minorities tended to have better psychological outcomes than White non-Hispanics, although their diabetes distress was higher. Levels of most risk and protective factors differed significantly across ethnic groups; adjustment for these factors reduced ethnic group differences in psychological outcomes. Health status and modifiable diabetes-specific risk/protective factors (healthcare access/utilization, subjective diabetes burden, social support/burden) had strong associations with psychological outcomes, especially diabetes distress and empowerment. Numerous interactions between ethnicity and other correlates of psychological outcomes suggest that ethnic groups are differentially sensitive to various risk/protective factors. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Ethnic groups differ in their psychological outcomes. The risk/protective factors for psychological outcomes differ across ethnic groups and different ethnic groups are more/less sensitive to their influence. These findings can aid the development of strategies to overcome the most prominent and influential psychosocial barriers to optimal diabetes care within each ethnic group.