A randomized study of the impact of home health aides on diabetic control and utilization patterns

Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis

INTRODUCTION

This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene.

METHODS

We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality.

RESULTS

5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693).

CONCLUSIONS

LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

Impact of Community Health Workers on Use of Healthcare Services in the United States: A Systematic Review

BACKGROUND

As the US transitions to value-based healthcare, physicians and payers are incentivized to change healthcare delivery to improve quality of care while controlling costs. By assisting with the management of common chronic conditions, community health workers (CHWs) may improve healthcare quality, but physicians and payers who are making choices about care delivery also need to understand their effects on healthcare spending.

METHODS

We searched PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycINFO, Embase, and Web of Science from the inception of each database to 22 June 2015. We included US-based studies that evaluated a CHW intervention for patients with at least one chronic health condition and reported cost or healthcare utilization outcomes. We evaluated studies using tools specific to study design.

RESULTS

Our search yielded 2,941 studies after removing duplicates. Thirty-four met inclusion and methodological criteria. Sixteen studies (47%) were randomized controlled trials (RCTs). RCTs typically had less positive outcomes than other study designs. Of the 16 RCTs, 12 reported utilization outcomes, of which 5 showed a significant reduction in one or more of ED visits, hospitalizations and/or urgent care visits. Significant reductions reported in ED visits ranged from 23%-51% and in hospitalizations ranged from 21%-50%, and the one significant reduction in urgent care visits was recorded at 60% (p < 0.05 for all).

DISCUSSION

Our results suggest that CHW interventions have variable effects, but some may reduce costs and preventable utilization. These findings suggest that it is possible to achieve reductions in care utilization and cost savings by integrating CHWs into chronic care management. However, variations in cost and utilization outcomes suggest that CHWs alone do not make an intervention successful. The paucity of rigorous studies and heterogeneity of study designs limited conclusions about factors associated with reduced utilization.

The “In-Between People”: Participation of Community Health Representatives in Diabetes Prevention and Care in American Indian and Alaska Native Communities

Respected members of American Indian and Alaska Native communities are a critical resource in helping communities mobilize efforts in diabetes prevention and care. Possessing cultural and historical knowledge and training in health promotion and social support, community health representatives (CHRs) are uniquely equipped to broker the needed relationship between a world shaped by culture and history and the world of conventional scientific knowledge. Grounded in principles of social support and interpersonal communication, as well as an understanding of their community’s strengths and history in health protection, CHRs are bridges distinctively positioned to connect these two worlds. With additional training and mentoring in diabetes care and prevention, CHRs, in their self-described roles as “in-between people,” can serve both as caring and knowledgeable community members and valuable members of the health care team.

The role of peer support in diabetes care and self-management

In light of the growing prevalence and healthcare costs of diabetes mellitus, it is critically important for healthcare providers to improve the efficiency and effectiveness of their diabetes care. A key element of effective disease management for diabetes is support for patient self-management. Barriers to care exist for both patients and healthcare systems. As a result, many people with diabetes do not get the care and support needed to successfully manage their diabetes.Disease management approaches that incorporate peer support may be a promising way to help provide self-management support to patients with diabetes. Trained peers provide emotional support, instrumental (tangible or material) support, education, and skills training to those they serve, and outreach and care coordination for provider systems. They play a unique role that complements and supports clinical care.To describe how peers are currently supporting diabetes care, a number of databases were searched for studies describing the roles of peers using relevant key words. This paper reviews current literature that describes the roles and duties of peers in interventions to improve diabetes care, with a focus on their contributions to six essential elements of self-management support: (i) access to regular, high-quality clinical care; (ii) an individualized approach to assessment and treatment; (iii) patient-centered collaborative goal setting; (iv) education and skills training; (v) ongoing follow-up and support; and (vi) linkages to community resources.Peers worked under a variety of titles, which did not define their duties. The scope of their work ranged from assisting health professionals to playing a central role in care. Providing education and follow-up support were the two most common roles. In all but one study, these roles were carried out during face-to-face contact, most frequently in community sites.A growing body of literature supports the value of peer models for diabetes management. Additional research can answer remaining questions related to such issues as cost effectiveness, sustainability, integration of peers into health and social service delivery systems, and recruitment, training, and support of peers. Continuing to develop and evaluate innovative models for more effectively mobilizing and integrating peers into diabetes care has great potential for improving diabetes outcomes worldwide.

Racial and ethnic group variations in service use in a national sample of Medicare home health care patients with type 2 diabetes mellitus

Type 2 diabetes mellitus is known to affect adults in racial and ethnic minority groups disproportionately. When diabetes mellitus-related symptoms lead to the need for skilled care in the community-dwelling Medicare population, physicians can order the Medicare home health care (HHC) benefit, and Medicare-certified home health agencies can deliver it. Little is known about the extent to which racial and ethnic disparities exist in types and patterns of HHC services delivered to Medicare beneficiaries with diabetes mellitus when they are approved for the Medicare HHC benefit. This was examined by comparing racial and ethnic groups in terms of measures of HHC service use in a nationally representative sample of Medicare HHC beneficiaries with a primary diagnosis of type 2 diabetes mellitus. Uniform clinical data from the Outcome and Assessment Information Set were linked with Medicare HHC claims for beneficiaries who received a complete episode of HHC in 2002. In the study sample (n=9,838), 62% of participants self-identified as white, 22% African American, 12% Hispanic, and 3% Asian. Nearly all (99%) participants in all racial and ethnic groups received skilled nursing services. Controlling for numerous sociodemographic and health-related covariates and geographic region of the country, African-American participants received fewer nurse visits per week and fewer visits per week from all clinical disciplines combined than whites (both P<.001), and Hispanic participants were less likely than whites to receive physical therapy (adjusted odds ratio (AOR)=0.640, 95% confidence interval (CI)=0.543-0.754, P<.001) or home health aide (AOR=0.716, 95% CI=0.582-0.880, P=.002) services. Lower use of skilled nursing and rehabilitation services by African Americans and of rehabilitation services by Hispanics warrant further clinical and research attention.

The effect of home visits on the quality of life of children and adolescents with type 1 diabetes mellitus

OBJECTIVE

The aim of the study was to analyze the impact of home and school visits and to strengthen the knowledge on diabetes education on the quality of care and life of children and adolescents with diabetes.

METHODOLOGY AND RESULTS

This was a descriptive cross-sectional study of all children and adolescents (n = 16, seven males and nine females), attending a pediatric diabetes center (mean age: 11.25 yr ± 4.82, range: 5-17 yr), mean duration of diabetes being 4.6 ± 3.9 yr, range 0.5-8.4 yr. Ten patients were visited by the medical social worker at home and school, their knowledge ondiabetes education was strengthened, and intervention effect was evaluated 4 months later. Positive effects observed were that clinic visits became regular, there was notification by school of clinical status, a reduction in number of hypoglycemic episodes at school, increased acquisition of glucometers, and daily and regular (100%) self home blood glucose (BG) monitoring. The mean center HbA1c was reduced from 12.86 ± 2.5% to 9.41 ± 1.56%, the change from previsit was 3.45%. The mean center morning BG dropped from 181.60 ± 71.96 to 127.54 ± 27.54 mg/dL reflecting change from previsit BG of 54.19 mg/dL. However, these visitations had little effect on checking of BG at school.

CONCLUSION

This study stressed the importance of home and school visits and diabetes education on the quality of care and life of the children and adolescents with diabetes in our region.

The Impact of Home Care on Recently Discharged Elderly Hospital Patients in an Ontario Community

Hospital and long-term care facility utilization, mortality and functional status over a 12-month follow-up period are described for elderly home care recipients who had been discharged from an acute care hospital. Of those eligible for receipt of services from the Program, 356 (92%) patients 65 years of age and older agreed to participate in the study at the time of discharge from an acute care hospital. Of these, 82.2 per cent survived during the subsequent 12 months, 44 per cent were readmitted to hospital, and 5 per cent were admitted to a nursing home or home for the aged. After adjusting for socio-demographic and health variables using regression analyses, the total number of home care services received was significantly associated with physical function and social function at 12 months. Similarly, the analyses revealed home care “social services” (social worker visits, meals on wheels, visiting home maker visits and volunteer visits) received were significantly associated with morale at 12 months. The clinical significance of these findings for case-management and home care program management and monitoring are discussed.

Implementing the community health worker model within diabetes management: challenges and lessons learned from programs across the United States

PURPOSE

The purpose of this qualitative study was to examine methods of implementation of the community health worker (CHW) model within diabetes programs, as well as related challenges and lessons learned.

METHODS

Semi-structured interviews were conducted with program managers. Four databases (PubMed, CINAHL, ISI Web of Knowledge, PsycInfo), the CDC's 1998 directory of CHW programs, and Google Search Engine were used to identify CHW programs. Criteria for inclusion were: DM program; used CHW strategy; occurred in United States. Two independent reviewers performed content analyses to identify major themes and findings. Sixteen programs were assessed, all but 3 focused on minority populations. Most CHWs were recruited informally; 6 programs required CHWs to have diabetes.

RESULTS

CHW roles and responsibilities varied across programs; educator was the most commonly identified role. Training also varied in terms of both content and intensity. All programs gave CHWs remuneration for their work. Common challenges included difficulties with CHW retention, intervention fidelity and issues related to sustainability. Cultural and gender issues also emerged. Examples of lessons learned included the need for community buy-in and the need to anticipate nondiabetes related issues.

CONCLUSIONS

Lessons learned from these programs may be useful to others as they apply the CHW model to diabetes management within their own communities. Further research is needed to elucidate the specific features of this model necessary to positively impact health outcomes.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus

BACKGROUND

Research suggests adherence to treatment recommendations is low. In type 2 diabetes, which is a chronic condition slowly leading to serious vascular, nephrologic, neurologic and ophthalmological complications, it can be assumed that enhancing adherence to treatment recommendations may lead to a reduction of complications. Treatment regimens in type 2 diabetes are complicated, encompassing life-style adaptations and medication intake.

OBJECTIVES

To assess the effects of interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus.

SEARCH STRATEGY

Studies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references. Date of last search: November 2002.

SELECTION CRITERIA

Randomised controlled and controlled clinical trials, before-after studies and epidemiological studies, assessing changes in adherence to treatment recommendations, as defined in the objectives section, were included.

DATA COLLECTION AND ANALYSIS

Two teams of reviewers independently assessed the trials identified for inclusion. Three teams of two reviewers assessed trial quality and extracted data. The analysis for the narrative part was performed by one reviewer (EV), the meta-analysis by two reviewers (EV, JW).

MAIN RESULTS

Twentyone studies assessing interventions aiming at improving adherence to treatment recommendations, not to diet or exercise recommendations, in people living with type 2 diabetes in primary care, outpatient settings, community and hospital settings, were included. Outcomes evaluated in these studies were heterogeneous, there was a variety of adherence measurement instruments. Nurse led interventions, home aids, diabetes education, pharmacy led interventions, adaptation of dosing and frequency of medication taking showed a small effect on a variety of outcomes including HbA1c. No data on mortality and morbidity, nor on quality of life could be found.

AUTHORS' CONCLUSIONS

Current efforts to improve or to facilitate adherence of people with type 2 diabetes to treatment recommendations do not show significant effects nor harms. The question whether any intervention enhances adherence to treatment recommendations in type 2 diabetes effectively, thus still remains unanswered.

Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans

BACKGROUND

African Americans suffer disproportionately from diabetes complications, but little research has focused on how to improve diabetic control in this population. There are also few or no data on a combined primary care and community-based intervention approach.

METHODS

We randomly assigned 186 urban African Americans with type 2 diabetes (76% female, mean A SD age 59 A 9 years) to 1 of 4 parallel arms: (1) usual care only; (2) usual care + nurse case manager (NCM); (3) usual care + community health worker (CHW); (4) usual care + nurse case manager/community health worker team. Using the framework of the Precede-Proceed behavioral model, interventions included patient counseling regarding self-care practices and physician reminders.

RESULTS

The 2-year follow-up visit was completed by 149 individuals (84%). Compared to the Usual care group, the NCM group and the CHW group had modest declines in HbA(1c) over 2 years (0.3 and 0.3%, respectively), and the combined NCM/CHW group had a greater decline in HbA(1c) (0.8%. P = 0.137). After adjustment for baseline differences and/or follow-up time, the combined NCM/CHW group showed improvements in triglycerides (-35.5 mg/dl; P = 0.041) and diastolic blood pressure, compared to the usual care group (-5.6 mmHg; P = 0.042).

CONCLUSIONS

Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes. Although results were clinically important, they did not reach statistical significance. This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans.

Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes

PURPOSE

This meta-analysis was conducted to assess the effect of educational and behavioral interventions on body weight and glycemic control in type 2 diabetes.

METHODS

Studies selected for analysis were published randomized controlled trials that evaluated educational and behavioral interventions (no drug interventions) in type 2 diabetes (sample size > or = 10). These criteria were applied to searches of electronic databases and relevant bibliographies. Data were independently abstracted by 2 reviewers and adjudicated by consensus.

RESULTS

Of the 63 articles that met the inclusion criteria, 18 provided enough information for pooled estimates of glycohemoglobin (total Ghb, HbA1, or HbA1C). These 18 studies yielded 2720 participants (sample sizes of 18 to 749). Interventions ranged from 1 to 19 months; follow-up ranged from 1 to 26 months. Glycohemoglobin was reduced by a mean of 0.43%. When results were stratified by quality score, glycohemoglobin was -0.50% and -0.38% for studies with high and low quality scores, respectively. When weighting studies by sample size, fasting blood glucose was reduced by 24 mg/dL and weight by 3 lbs.

CONCLUSIONS

Previous educational and behavioral interventions in type 2 diabetes have produced modest improvements in glycemic control. Future research should refine such interventions and improve methodology.

Patient priorities and needs for diabetes care among urban African American adults

PURPOSE

This study was conducted to determine diabetes care priorities and needs in a group of urban African American adults with type 2 diabetes mellitus.

METHODS

One hundred nineteen African American adults with type 2 diabetes, aged 35 to 75, received behavioral/educational interventions from a nurse case manager, a community health worker, or both. Priorities and needs were assessed during 3 intervention visits.

RESULTS

The most frequently reported priorities for diabetes care were glucose self-monitoring (61%), medication adherence (47%), and healthy eating (36%). The most frequently addressed diabetes needs were glucose self-monitoring and medication adherence. Most of the intervention visits (77%) addressed non-diabetes-related health issues such as cardiovascular disease (36%) and social issues such as family responsibilities (30%).

CONCLUSIONS

Participants' self-reported priorities for diabetes care directly reflected the diabetes needs addressed. Needs beyond the focus of traditional diabetes care (social issues and insurance) are important to address in urban African Americans with type 2 diabetes. Interventions designed to address comprehensive health and social needs should be included in treatment and educational plans for this population.

The ethnic minority linkworker: a key member of the primary health care team?

We present an evaluation of the role of a link-worker trained in health promotion and aspects of chronic disease management. A shift in workload occurred from the practice nurse to link-worker, and there were improvements in asthma and diabetes care. A link-worker can be successfully trained to do traditional nursing tasks, which permits a change of role for the practice nurse and can have a beneficial effect on the processes of chronic disease management.

Measurement of actions of care-providers in long-term care

While measurement of the actions of providers (process) are a vital part of assessing the quality of care in long-term care settings, instruments that are appropriate to such measurement in program evaluation, auditing staff performance, and evaluation of continuing education programs are often unavailable. Long-term care providers are therefore faced with the challenge of either selecting an instrument from the few available or constructing a new one. This article describes several scientifically acceptable measurement properties for instruments measuring the actions of long-term care providers and their application to instruments reported in the long-term care literature. Only five of the 23 instruments reviewed met four or more of the seven measurement properties.

Factor associated with diabetic control and utilization patterns in a low-income, older adult population

The importance to health educators of identification of factors associated with diabetic control is underscored by the prevalence of the disease and its physical, psychological and economic impacts, all of which appear greatest for the poor. An investigation of social, attitudinal, and physical characteristics of 161 low income, predominantly black and female diabetic clinic patients was conducted. Results indicate that the factors associated with poor control (higher mean fasting blood glucose) include being older, lack of belief in control over health, lack of belief in the efficacy of treatment, a belief that diabetes is less serious than three curable illnesses, reported lack of social support in a crisis with diabetes, reported low satisfaction with the clinic, and finally, higher levels of reported problems with the self-care regimen, particularly diet. Moreover, poor control was also significantly associated with an increase in the number of emergency room visits and clinic visits. Increased clinic visits were also significantly associated with younger age, a higher number of prescribed medications and the requirement for insulin therapy, higher knowledge scores, and two health beliefs, the belief that diabetes is more serious than curable illnesses, and the belief that the treatment is likely to help. More frequent emergency room visits were also associated with being white, a higher number of complications of the disease, and more reported problems with self care. A higher number of days hospitalized was significantly associated with more complications, lower satisfaction with the clinic, and lack of belief in control over health. The results suggest the potential usefulness of a number of activities by health educators to positively influence diabetes control and decrease negative utilization patterns, such as hospitalizations. These include education aimed at refocusing health beliefs to emphasize the individual's control outcomes as well as the efficacy of treatment, and behavioral training to increase practical dietary skills. Finally, altering structural characteristics of clinics to better meet patient needs, such as decreasing waiting times, may encourage patient efforts towards diabetic control.