Design of a trial to evaluate the impact of clinical pharmacists and community health promoters working with African-Americans and Latinos with diabetes

Patients' Expectations of Evidence-Based Service at the Pharmacy Regarding Information on Self-Care of the Feet for Persons with Diabetes at Risk of Developing Foot Ulcers - A Cross-Sectional Observational Study in Sweden

Purpose

Self-care of the feet is one of the cornerstones in the prevention of diabetic foot ulcers (DFU). Often, individuals with diabetes seek help at the pharmacy, but it is still unclear whether the service meets their expectations and needs. The aims were to explore patients' expectations of support from the pharmacy regarding self-care of their feet and explore how patients with diabetes felt that they managed the self-care of their feet.

Patients and Methods

The included participants (n = 17), aged 70 ± 9 years, answered surveys regarding their expectations of support from the pharmacy related to self-care of the feet and how they felt that they managed the self-care of their feet. By using software, MyFoot Diabetes, they assessed their risk of developing DFU (ranging from 1 = no risk to 4 = DFU). In addition, a healthcare professional assessed the risk grade.

Results

Sixteen patients had not received any information from the pharmacy regarding how to take care of their feet. Several suggestions for ways the pharmacy could help patients with diabetes to take care of their feet were registered. They included having the necessary skills and competence, giving advice regarding self-care, giving information regarding the products they market and have for sale and giving advice on ointments/creams. The participants gave several examples of how they self-managed their feet: by wearing shoes indoors and outdoors, wearing socks and compression stockings as often as possible, being physically active, inspecting their feet, being aware of the fact that their feet have no problems, washing, moisturising their feet, cutting their nails and finally seeking help to prevent DFU.

Conclusion

The participants thought that they should receive competent information from the personnel at the pharmacy to improve the self-care of their feet, eg, being given information about which ointments/creams to use.

Clinical Trial

NCT05692778.

Mobile Health Intervention in Patients With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Clinical pharmacists and health coaches using mobile health (mHealth) tools, such as telehealth and text messaging, may improve blood glucose levels in African American and Latinx populations with type 2 diabetes.

Objective

To determine whether clinical pharmacists and health coaches using mHealth tools can improve hemoglobin A1c (HbA1c) levels.

Design, Setting, and Participants

This randomized clinical trial included 221 African American or Latinx patients with type 2 diabetes and elevated HbA1c (≥8%) from an academic medical center in Chicago. Adult patients aged 21 to 75 years were enrolled and randomized from March 23, 2017, through January 8, 2020. Patients randomized to the intervention group received mHealth diabetes support for 1 year followed by monitored usual diabetes care during a second year (follow-up duration, 24 months). Those randomized to the waiting list control group received usual diabetes care for 1 year followed by the mHealth diabetes intervention during a second year.

Interventions

The mHealth diabetes intervention included remote support (eg, review of glucose levels and medication intensification) from clinical pharmacists via a video telehealth platform. Health coach activities (eg, addressing barriers to medication use and assisting pharmacists in medication reconciliation and telehealth) occurred in person at participant homes and via phone calls and text messaging. Usual diabetes care comprised routine health care from patients' primary care physicians, including medication reconciliation and adjustment.

Main Outcomes and Measures

Outcomes included HbA1c (primary outcome), blood pressure, cholesterol, body mass index, health-related quality of life, diabetes distress, diabetes self-efficacy, depressive symptoms, social support, medication-taking behavior, and diabetes self-care measured every 6 months.

Results

Among the 221 participants (mean [SD] age, 55.2 [9.5] years; 154 women [69.7%], 148 African American adults [67.0%], and 73 Latinx adults [33.0%]), the baseline mean (SD) HbA1c level was 9.23% (1.53%). Over the initial 12 months, HbA1c improved by a mean of -0.79 percentage points in the intervention group compared with -0.24 percentage points in the waiting list control group (treatment effect, -0.62; 95% CI, -1.04 to -0.19; P = .005). Over the subsequent 12 months, a significant change in HbA1c was observed in the waiting list control group after they received the same intervention (mean change, -0.57 percentage points; P = .002), while the intervention group maintained benefit (mean change, 0.17 percentage points; P = .35). No between-group differences were found in adjusted models for secondary outcomes.

Conclusions and Relevance

In this randomized clinical trial, HbA1c levels improved among African American and Latinx adults with type 2 diabetes. These findings suggest that a clinical pharmacist and health coach-delivered mobile health intervention can improve blood glucose levels in African American and Latinx populations and may help reduce racial and ethnic disparities.

Trial Registration

ClinicalTrials.gov Identifier: NCT02990299.

Assessment of clinical inertia in people with diabetes within primary care

RATIONALE, AIMS AND OBJECTIVES

Clinical inertia, defined as a delay in treatment intensification, is prevalent in people with diabetes. Treatment intensification rates are as low as 37.1% in people with haemoglobin A1c (HbA1c) values >7%. Intensification by addition of medication therapy may take 1.6 to more than 7 years. Clinical inertia increases the risk of cardiovascular events. The primary objective was to evaluate rates of clinical inertia in people whose diabetes is managed by both pharmacists and primary care providers (PCPs). Secondary objectives included characterizing types of treatment intensification, HbA1c reduction, and time between treatment intensifications.

METHOD

Retrospective chart review of persons with diabetes managed by pharmacists at an academic, safety-net institution. Eligible subjects were referred to a pharmacist-managed cardiovascular risk reduction clinic while continuing to see their PCP between October 1, 2016 and June 30, 2018. All progress notes were evaluated for treatment intensification, HbA1c value, and type of medication intensification.

RESULTS

Three hundred sixty-three eligible patients were identified; baseline HbA1c 9.6% (7.9, 11.6) (median interquartile range [IQR]). One thousand one hundred ninety-two pharmacist and 1739 PCP visits were included in data analysis. Therapy was intensified at 60.5% (n = 721) pharmacist visits and 39.3% (n = 684) PCP visits (P < .001). The median (IQR) time between interventions was 49 (28, 92) days for pharmacists and 105 (38, 182) days for PCPs (P < .001). Pharmacists more frequently intensified treatment with glucagon-like peptide-1 agonists and sodium glucose cotransporter-2 inhibitors.

CONCLUSION

Pharmacist involvement in diabetes management may reduce the clinical inertia patients may otherwise experience in the primary care setting.

A New Case Manager for Diabetic Patients: A Pilot Observational Study of the Role of Community Pharmacists and Pharmacy Services in the Case Management of Diabetic Patients

The adherence of type 2 diabetes mellitus (DM2) patients with an individual care plan (ICP) is often not satisfactory, nor does it allow for a significant improvement in outcome, because of poor accessibility to services, poor integration of pathway articulations, poor reconciliation with the patient’s life, or the lack of a constant reference person. The purpose of this study was to evaluate the contribution of community pharmacists and pharmacy services in improving adherence with periodic controls in DM2. The study was conducted at a rural pharmacy. A sample of 40 patients was calculated with respect to a historical cohort and subsequently enrolled. Clinical and personal data were collected in an electronic case report form. Pharmacists acting as a case manager followed patients carrying out their ICP developed by an attending physician. Some of the activities foreseen by the ICP, such as electrocardiogram, fundus examination, and self-analysis of blood and urine, were carried out directly in the pharmacy by the pharmacist through the use of telemedicine services and point of care units. Activities that could not be performed in the pharmacy were booked by the pharmacist at the accredited units. Examination results were electronically reported by the pharmacist to the attending physician. The primary endpoint was the variation in patient adherence with the ICP compared to a historical cohort. Secondary endpoints were variation in waiting time for the examinations, mean percentage change in glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels and blood pressure, impact on healthcare-related costs, and perceived quality of care. Adherence to the ICP significantly increased. Waiting times were reduced and clinical outcomes improved with conceivable effects on costs. Patients appreciated the easier access to services. Community pharmacists and pharmacy services represent ideal actors and context that, integrated in the care network, can really favor ICP adherence and obtain daily morbidity reduction and cost savings through proper disease control and an early diagnosis of complications.

Clinical pharmacists in diabetes management: What do minority patients with uncontrolled diabetes have to say?

OBJECTIVE

Clinical pharmacist support for patients with type 2 diabetes mellitus (T2DM) can optimize patient outcomes and medication adherence. However, there is limited understanding of what pharmacist roles patients perceive as most helpful in T2DM management interventions. This study describes experiences of minority patients with uncontrolled T2DM in terms of perceived pharmacist helpfulness and specific roles found to be most helpful within diabetes management.

DESIGN

A secondary analysis of a 2-year randomized, crossover trial was conducted.

SETTING AND PARTICIPANTS

This study included 244 African American and Hispanic adults with uncontrolled T2DM who received clinical pharmacist support within a team-based model.

OUTCOME MEASURES

The patients completed a mixed-methods survey regarding their experience with the intervention that included a general helpfulness rating on a 10-point unipolar Likert scale and described the support qualitatively, including their perception of the pharmacist roles. Thematic analysis guided coding of the responses.

RESULTS

One hundred forty-seven (60%) patients completed the survey and had at least 1 encounter with a clinical pharmacist. Of these, 108 (74%) were African American, 39 (27%) were Hispanic, and 101 (69%) were women. The median rating of clinical pharmacist helpfulness was 10 (very helpful). Only 10 (7%) participants rated pharmacist helpfulness as 1 (not at all helpful). "Medication education and management" was the most frequently perceived supportive role of the clinical pharmacists, followed by "non-medication-related patient education," "social support," and "care coordination." Miscommunication related to scheduling was the most common reason cited for not meeting with the clinical pharmacist.

CONCLUSION

This sample of minority patients with uncontrolled T2DM recognized many roles outlined within the American Pharmacists Association Medication Therapy Management framework. Patient experiences with clinical pharmacist T2DM support are crucial for developing effective programs, maximizing patient engagement, satisfying patient needs, and ensuring that a program's intended purpose aligns with the patient perspective.

Correlates of low-adherence to oral hypoglycemic medications among Hispanic/Latinos of Mexican heritage with Type 2 Diabetes in the United States

AIMS

We examined psychosocial- and social/economic factors related to low medication adherence, and sex differences, among 279 adults of Mexican heritage with Type 2 Diabetes.

METHODS

Self-report and health record data were used for cross-sectional analyses. Bivariate analyses tested the association of demographic, psychosocial (depression, anxiety, stress) and social/economic factors (insurance type, health literacy, social support) and medication adherence measured by proportion of days covered. Hierarchical regression analyses examined associations between demographic, psychosocial- and social/economic- related factors and low medication adherence stratified by sex.

RESULTS

More males than females demonstrated low adherence to hypoglycemic medications (75.0.% vs. 70.3%) (p < 0.05). We found significant differences between levels social support and medication adherence (p < 0.05). In hierarchical models, being US born and higher levels of social support were associated with low adherence among males (p < 0.05, and p < 0.001).

CONCLUSIONS

Approximately 72% of Mexican heritage adults demonstrated low adherence (PDC ≤ 0.50) to their hypoglycemic regimen, and gender differences exist. Interventions should address gender differences in preferences for social support to improve medication-taking behaviors among Mexican heritage males.

The impact of a pharmacist-driven, collaborative practice on diabetes management in an Urban underserved population: a mixed method assessment

The objective of this manuscript is to describe the results of a pharmacist-driven, Type 2 diabetes targeted, collaborative practice within an urban, underserved federally qualified health center. Pharmacists within a primary care team managed patients with chronic illnesses utilizing a collaborative practice agreement. Pharmacists, pharmacy residents, and supervised students provided care for patients with Type 2 diabetes. The first visit incorporated past medical history, medication reconciliation, determination of adherence and patient knowledge of diabetes pathophysiology, care plan, including diet and exercise, medications, and possible complications. Pharmacists had the authority to optimize medications and order laboratory tests and referrals. Diabetes, hypertension, and medication use outcomes data were collected and analyzed to assess the impact of clinical pharmacy services. Patient and provider satisfaction were assessed via surveys and focus group interviews. Ninety-nine patients were included in the evaluation. The mean A1c level was 9.8% at baseline and 8.4% at follow-up (p< .05). There were significant improvements in patient attainment of A1c <9%, ACE Inhibitor/angiotensin receptor blocker and statin use, and tobacco cessation at follow-up (p< .05). Eleven providers who responded to the satisfaction survey answered 73% of the questions with strongly agree. The seven patients who participated in the satisfaction survey, and focus group were satisfied with the care they received from the pharmacists. The focus group highlighted similar personal goals, barriers, and interests in nutrition education. Working as part of a collaborative care team, pharmacists were able to have a significant impact on improving the health outcomes of patients with Type 2 diabetes and patient and provider perceptions of the vital role of pharmacists.

Therapeutic inertia in type 2 diabetes: prevalence, causes, consequences and methods to overcome inertia

Early glycaemic control leads to better outcomes, including a reduction in long-term macrovascular and microvascular complications. Despite good-quality evidence, glycaemic control has been shown to be inadequate globally. Therapeutic inertia has been shown present in all stages of treatment intensification, from the first oral antihyperglycaemic drug (OAD), all the way to the initiation of insulin. The causes and possible solutions to the problem of therapeutic inertia are complex but can be understood better when viewed from the perspective of the providers [healthcare professionals (HCPs)], patients and healthcare systems. In this review, we will discuss the possible aetiologies, consequences and solutions of therapeutic inertia, drawing upon evidence from published literature on the subject of type 2 diabetes.

Community Health Workers Supporting Clinical Pharmacists in Diabetes Management: A Randomized Controlled Trial

OBJECTIVES

To evaluate the effectiveness of clinical pharmacists and community health workers (CHWs) in improving glycemic control within a low-income ethnic minority population.

METHODS

In a two-arm 2-year crossover trial, 179 African-American and 65 Hispanic adult patients with uncontrolled diabetes mellitus (hemoglobin A_1c [HbA1C] of 8% or higher) were randomized to CHW support either during the first or second year of the study. All participants received clinical pharmacist support for both years of the study. The primary outcome was change in HbA1C over 1 and 2 years.

RESULTS

Similar HbA1C declines were noted after receiving the 1 year of CHW support: -0.45% (95% confidence interval [CI] -0.96 to 0.05) with CHW versus -0.42% (95% CI -0.93 to 0.08) without CHW support. In addition, no differences were noted in change on secondary outcome measures including body mass index, systolic blood pressure, high-density lipoprotein and low-density lipoprotein cholesterol, quality of life, and perceived social support. A difference in diastolic blood pressure change was noted: 0.80 mm Hg (95% CI -1.92 to 3.53) with CHW versus -1.85 mm Hg (95% CI -4.74 to 1.03) without CHW support (p=0.0078). Patients receiving CHW support had more lipid-lowering medication intensifications (0.39 [95% CI 0.27-0.52]) compared with those without CHW support (0.26 [95% CI 0.14-0.38], p<0.0001). However, no significant differences in intensification of antihyperglycemic and antihypertensive medications were observed between patients receiving CHW support and those without CHW support. Patients with low health literacy completed significantly more encounters with the pharmacist and CHW than those with high health literacy, although outcomes were comparable.

CONCLUSIONS

No significant differences were noted between a clinical pharmacist-CHW team and clinical pharmacist alone in improving glycemic control within a low-income ethnic minority population.

Measuring Health-related Transportation Barriers in Urban Settings

Access to reliable transportation is important for people with chronic diseases considering the need for frequent medical visits and for medications from the pharmacy. Understanding of the extent to which transportation barriers, including lack of transportation, contribute to poor health outcomes has been hindered by a lack of consistency in measuring or operationally defining "transportation barriers." The current study uses the Rasch measurement model to examine the psychometric properties of a new measure designed to capture types of transportation and associated barriers within an urban context. Two hundred forty-four adults with type 2 diabetes were recruited from within an academic medical center in Chicago and completed the newly developed transportation questions as part of a larger National Institutes of Health funded study (ClinicalTrials.gov identifier: NCT01498159). Results suggested a two subscale structure that reflected 1) general transportation barriers and 2) public transportation barriers.

EXPANSION of diabetes education in a United States-Mexico border community (Expanding Services for Patients to Acquire New Skills, Set Goals, and Improve Overall Knowledge)

OBJECTIVES

To describe the process used by a pharmacy team at a community health center to coordinate and expand diabetes education services (English and Spanish) for a predominantly Hispanic, Spanish-speaking population.

SETTING

The project was implemented at 2 clinics in a federally qualified community health center system based in a low-income southwest U.S.-Mexico border community.

PRACTICE INNOVATION

This project enhanced accessibility to diabetes education to improve knowledge, skills, and goal setting through existing pharmacy services at the primary clinic and 1 rural satellite clinic.

EVALUATION

The success of the project was evaluated quantitatively. Metrics used to evaluate enhancement of existing practices included enrollment and completion rates, number of sessions, and diabetes leadership meetings.

RESULTS

Over the 5-month project period assessed, 7 interdisciplinary professionals were certified as Diabetes Empowerment Education Program educators. Four sessions were conducted at both clinics. A total of 31 participants completed the diabetes classes. An educational attainment of 8th grade or less was reported in 91% of the rural participants compared with 50% of the urban participants. Ten interdisciplinary leadership meetings centered on recruitment, progress toward goals, and action items to ensure quality of classes. A nurse practitioner and pharmacist piloted a shared-visit model with 5 patients during a 45-minute time period.

CONCLUSION

Successful diabetes education services occurred by implementing an evidence-based curriculum, identifying provider champions, increasing patient enrollment through provider referrals, and generating reports. Patient accountability was facilitated by setting patient-centered goals for knowledge and skills. Last, support groups provided ongoing support once patients graduated from a structured diabetes program.

Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus

Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.

Pharmacists' perspectives of the current status of pediatric asthma management in the U.S. community pharmacy setting

Objective To explore community pharmacists' continuing education, counseling and communication practices, attitudes and barriers in relation to pediatric asthma management. Setting Community pharmacies in Michigan, United States. Methods Between July and September 2015 a convenience sample of community pharmacists was recruited from southeastern Michigan and asked to complete a structured, self-reported questionnaire. The questionnaire elucidated information on 4 general domains relating to pharmacists' pediatric asthma management including: (1) guidelines and continuing education (CE); (2) counseling and medicines; (3) communication and self-management practices; (4) attitudes and barriers to practice. Regression analyses were conducted to determine predictors towards pharmacists' confidence/frequency of use of communication/counseling strategies. Main outcome measure Confidence in counseling skills around asthma. Results 105 pharmacists completed the study questionnaire. Fifty-four percent of pharmacists reported participating in asthma related CE in the past year. Over 70% of pharmacists reported confidence in general communication skills, while a lower portion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen (58%), decision-making (50%) and setting short-term (47%) and long-term goals (47%) with the patient and caregiver for managing asthma at home. Pharmacists who reported greater use of recommended communication/self-management strategies were more likely to report confidence in implementing these communication/self-management strategies when counseling caregivers and children with asthma [Beta (B) Estimate 0.58 SE (0.08), p < 0.001]. Female pharmacists [B Estimate -2.23 SE (1.01), p < 0.05] and those who reported beliefs around doctors being the sole provider of asthma education [B Estimate -1.00 SE (0.32), p < 0.01] were less likely to report confidence in implementing communication/self-management strategies. Conclusion A pharmacists' confidence may influence their ability to implement recommended self-management counseling strategies. This study showed that community pharmacists are confident in general communication. However pharmacists are reporting lower confidence levels in counseling on higher order self-management strategies with patients. More appropriate and targeted continuing education programs for pharmacists around asthma self-management education are recommended.

Who is a community health worker? - a systematic review of definitions

BACKGROUND

Community health workers (CHWs) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWs that will aid common understanding among policy makers, programme planners, and researchers.

OBJECTIVE

To identify the common themes in the definitions and descriptions of CHWs that will aid delineation within this cadre and distinguish CHWs from other healthcare providers.

DESIGN

A systematic review of peer-reviewed papers and grey literature.

RESULTS

We identified 119 papers that provided definitions of CHWs in 25 countries across 7 regions. The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWs can be categorised into three groups by education and pre-service training. These are lay health workers (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionals (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionals (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workers tend to provide basic health services as unpaid volunteers while level 1 paraprofessionals often receive an allowance and level 2 paraprofessionals tend to be salaried.

CONCLUSIONS

This review provides a categorisation of CHWs that may be useful for health policy formulation, programme planning, and research.

Community Health Workers Versus Nurses as Counselors or Case Managers in a Self-Help Diabetes Management Program

OBJECTIVES

To confirm the effectiveness of community health workers' involvement as counselors or case managers in a self-help diabetes management program in 2009 to 2014.

METHODS

Our open-label, randomized controlled trial determined the effectiveness of a self-help intervention among Korean Americans aged 35 to 80 years in the Baltimore-Washington metropolitan area with uncontrolled type 2 diabetes. We measured and analyzed physiological and psychobehavioral health outcomes of the community health worker-counseled (n = 54) and registered nurse (RN)-counseled (n = 51) intervention groups in comparison with the control group (n = 104).

RESULTS

The community health workers' performance was comparable to that of the RNs for both psychobehavioral outcomes (e.g., self-efficacy, quality of life) and physiological outcomes. The community health worker-counseled group showed hemoglobin A1C reductions from baseline (-1.2%, -1.5%, -1.3%, and -1.6%, at months 3, 6, 9, and 12, respectively), all of which were greater than reductions in the RN-counseled (-0.7%, -0.9%, -0.9%, and -1.0%) or the control (-0.5%, -0.5%, -0.6%, and -0.7%) groups.

CONCLUSIONS

Community health workers performed as well as or better than nurses as counselors or case managers in a self-help diabetes management program in a Korean American community.

Pharmacists' perspectives on collaborating with community health workers in diabetes care

OBJECTIVES

To qualitatively assess pharmacists' perspectives on the barriers and facilitators of collaborating with community health workers (CHWs) when caring for patients with diabetes.

METHODS

Eight pharmacists were invited to participate in a focus group. All pharmacists had worked with CHWs for 12 months as part of a larger study. Seven pharmacists participated in a single focus group while one pharmacist participated in an individual interview. Data were analyzed by two investigators to identify common themes.

RESULTS

Perceived barriers included issues associated with maintaining patient confidentiality, pharmacists' level of comfort with CHWs, uncertainty about CHW roles, and inconsistent communication between pharmacists and CHWs. However, pharmacists reported that the care model fostered improvement in patient-pharmacist communication, patient adherence to medication, and assessment of patients' overall condition.

CONCLUSION

Pharmacists expressed positive attitudes and experiences in working with CHWs caring for a minority patient population with poorly controlled diabetes. Most believed that CHWs acted as facilitators and aided them in producing positive clinical outcomes by addressing the multiple psychosocial and contextual dimensions of patient health. Developing approaches for more frequent and effective communication between pharmacists and CHWs was the primary perceived challenge.

Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus

BACKGROUND

Ethnic minority groups in upper-middle-income and high-income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus.

SEARCH METHODS

A systematic literature search was performed of the following databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper-middle-income or high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta-analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education.Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) -0.4% (95% confidence interval (CI) -0.5 to -0.2); 14 trials; 1442 participants; high-quality evidence) and at six months (MD -0.5% (95% CI -0.7 to -0.4); 14 trials; 1972 participants; high-quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD -0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at 24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268 participants; moderate-quality evidence) post intervention. Neutral effects on health-related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies - the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low-density lipoprotein (LDL) cholesterol or high-density lipoprotein (HDL) cholesterol were reported at any follow-up point. Other outcome measures (blood pressure, body mass index, self-efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient.Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self-reported via questionnaires, leading to high bias in subjective outcome assessment.

AUTHORS' CONCLUSIONS

Culturally appropriate health education has short- to medium-term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long-term trials, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long-term, standardised, multi-centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium-term effects could lead to clinically important health outcomes, if sustained.

Higher blood pressure control rate in a real life management program provided by the community health service center in China

BACKGROUND

Community health service center (CHSC) in China is always regarded as a good facility of primary care, which plays an important role in chronic non-communicable disease management. This study aimed to investigate the blood pressure (BP) control rate in a real life CHSC-based management program and its determinants.

METHODS

The study enrolled 3191 patients (mean age of 70 ± 10 years, 43% males) in a hypertension management program provided by the Yulin CHSC (Chengdu, China), which had been running for 9 years. Uncontrolled BP was defined as the systolic BP of ≥140 mmHg and/or the diastolic BP of ≥90 mmHg, and its associated factors were analyzed by using logistic regression.

RESULTS

The duration of stay in the program was 33 ± 25 months. When compared with the BP at entry, the recent BP was significantly lowered (147 ± 17 vs. 133 ± 8 mmHg; 83 ± 11 vs. 75 ± 6 mmHg) and the BP control rate was dramatically increased (32 vs. 85%) (all p < 0.001). The age of >70 years [1.40 (odds ratio), 1.15-1.71 (95% confidence interval)], female gender (0.76, 0.63-0.93), longer stay of >33 months (0.77, 0.63-0.94), doctor in charge (0.97, 0.95-0.99), and the use of calcium channel blocker (1.35, 1.09-1.67) were significantly related to uncontrolled BP at the recent follow up (all p < 0.05).

CONCLUSIONS

This CHSC-run hypertension program provides an ideal platform of multi-intervention management, which is effective in achieving higher BP control rate in community patient population. However, the BP control status could be affected by age, gender and adherence of the patients, as well as practice behavior of the doctors.

Integrated community-healthcare diabetes interventions to reduce disparities

Racial and ethnic minorities suffer disproportionately from diabetes-related morbidity and mortality. With the creation of Accountable Care Organizations (ACOs) under the Affordable Care Act, healthcare organizations may have an increased motivation to implement interventions that collaborate with community resources and organizations. As a result, there will be an increasing need for evidence-based strategies that integrate healthcare and community components to reduce diabetes disparities. This paper summarizes the types of community/health system partnerships that have been implemented over the past several years to improve minority health and reduce disparities among racial/ethnic minorities and describes the components that are most commonly integrated. In addition, we provide our recommendations for creating stronger healthcare and community partnerships through enhanced community support.

Adjustments to Diabetes Medications in Response to Increases in Hemoglobin A1c

Objective: The primary objective was to assess associations between increases in glycated hemoglobin (HbA1c) levels and medication adjustments among patients with diabetes. A secondary objective was to measure the effect of adjustments on subsequent HbA1c levels. Methods: A retrospective analysis of administrative data from a large health insurer in Hawaii of 7654 patients with diabetes mellitus type II, HbA1c levels greater than 7%, and who were taking oral diabetic medications. Patients were eligible if they had an HbA1c measurement in 2009, a prior measure 30 or more days previously, and at least 30 days of follow-up to identify medication adjustments. Patients were classified into 3 groups based on their extent of change in HbA1c levels. Patients were followed to determine the frequency of medication adjustments and to observe the possible benefit of making adjustments on subsequent HbA1c levels. Results: Medication adjustments were the exception, occurring among less than a fourth of patients. Compared with patients without HbA1c increases, patients with <1% HbA1c increases made adjustments 20% more frequently, and patients with increased HbA1c levels of 1% or more made adjustments 60% more frequently. Patients with similar HbA1c increases were more likely to adjust their medications if they had higher baseline HbA1c levels. Medication adjustments were mostly for oral diabetes medications; insulin use was seldom initiated, and then primarily by patients with HbA1c levels of 9% or higher. Patients with medication adjustments averaged about 0.40% lower HbA1c levels when reassessed after 120 days or more. Conclusion: The results show limited responsiveness to increases in HbA1c levels and a low initiation rate of insulin use. Patients adjusting their medications, however, had clinically significant improvements in their HbA1c levels. Clinical inertia and patient concerns are discussed as factors possibly limiting the frequency of medication adjustments.