Health behaviors and quality of care among Latinos with diabetes in managed care

"No sufro, estoy bien/I am not suffering, so I am doing OK": A mixed method exploration of individual and network-level factors and Type 2 Diabetes Mellitus (T2DM) among Mexican American adults in New York City

INTRODUCTION

The prevalence of type 2 Diabetes Mellitus (T2DM) is 2-3 times greater among Mexican Americans than non-Latino whites, and Mexican Americans are more likely to develop T2DM at younger ages and experience higher rates of complications. Social networks might play a crucial role in both T2DM etiology and management through social support, access to resources, social engagement, and health behavioral norms.

OBJECTIVE

To quantitatively identify the social network features associated with glycated hemoglobin (HbA1c) in a community sample of Mexican immigrants residing in New York City, and to explore the extent to which these quantitative findings converge with qualitative narratives of their lived experiences.

METHODS

This study used a convergent mixed methods design. To collect personal network data, we used EgoWeb, and obtained 1,400 personal network ties from 81 participants. HbA1c readings were collected using dried blood spots and categorized according to the laboratory criteria of the American Diabetes Association. Additional survey data were collected using Qualtrics software. To investigate the significance of the network-level factors after accounting for the socioeconomic and demographic individual-level factors that the literature indicates to be associated with T2DM, we used a multiple regression model on quantitative data sources. For the qualitative portion of the study, we selected a subset of individuals who participated in the quantitative portion, which represented 500 personal network ties from 25 participants. We conducted in-depth interviews guided by the visualization of these ties to explore who was helpful or difficult in managing their health and health behaviors.

RESULTS

Individual-level indicators associated with lower HbA1c scores were body mass index (β = -0.07, p<0.05), and healthy eating index scores (β = -0.03, p<0.02). The network-level predictor associated with higher HbA1c levels was the percentage of diabetic alters in the network (β = 0.08, p <0.001, with a 25% increase in the percentages associated 2.0 change in HbA1c levels. The qualitative data highlighted that most of the diabetes-related information diffused through the social networks of our participants was related to dietary practices, such as reducing sugar and red meat consumption, eating out less, and reducing portion sizes. Notably, even among those with elevated levels and diabetes-related health complications, HbA1c was not considered a part of the lay descriptions of good health since they were not "suffering." Participants regarded doctors as the ultimate authority in diabetes care, even if they had supportive members in their personal networks.

CONCLUSION

Our study provides quantitative evidence for the significant role of diabetic network members in the etiology and management of T2DM among Mexican Americans. Our qualitative findings suggest important ley terms for T2DM management and the importance of physicians, which could be included in in future social networks studies seeking to diffuse diabetes-related health information for T2DM prevention and management efforts in this population.

Assessment of Glycemic Control at St. Luke's Free Medical Clinic: Retrospective Chart Review

Background

A free clinic is a health care delivery model that provides primary care and pharmaceutical services exclusively to uninsured patients. With a multidisciplinary volunteer clinical staff, which includes physicians, social workers, dieticians, and osteopathic medical students, St. Luke’s Free Medical Clinic (SLFMC) cares for over 1700 patients annually in Spartanburg, South Carolina.

Objective

This study aims to measure the change, over time, in patient hemoglobin A_1c measurements at the SLFMC to quantify the success of the clinic’s diabetes treatment program.

Methods

A prospective-retrospective chart review of patients (n=140) enrolled at the SLFMC between January 1, 2018, and January 1, 2021, was performed. Patients were stratified as having controlled (hemoglobin A_1c<7.0, n=53) or uncontrolled (hemoglobin A_1c≥7.0, n=87) diabetes relative to a therapeutic hemoglobin A_1c target of 7.0, which is recommended by the American Diabetes Association. For both controlled and uncontrolled groups, baseline hemoglobin A_1c values were compared to subsequent readings using a Wilcoxon matched-pairs signed rank test. Results from the SLFMC population were compared to the published literature on hemoglobin A_1c from other free clinics.

Results

Patients with uncontrolled diabetes experienced significant reductions in median hemoglobin A_1c at both 6 months (P=.006) and 1 year (P=.002) from baseline. Patients with controlled diabetes showed no significant changes. Black and Hispanic patients with uncontrolled diabetes experienced a 1.0% mean improvement in hemoglobin A_1c over the study window. The SLFMC’s wholly uninsured patient population showed a population rate of controlled diabetes (42%), which was similar to recent nationwide averages for adults with diabetes (51% to 56%), as reported by the National Health and Nutrition Examination Survey. The clinic’s Hispanic population (n=47) showed the greatest average improvement in hemoglobin A_1c of any ethnic group from baseline. Additionally, 61% of the SLFMC’s Black population (n=33) achieved a hemoglobin A_1c of <7.0 by the end of the study window, which surpassed the nationwide averages for glycemic control.

Conclusions

We present free clinic hemoglobin A_1c outcomes obtained through a retrospective chart review. Uninsured patients treated for diabetes at the SLFMC show a reduction in hemoglobin A_1c, which is comparable to nationwide standards, although average hemoglobin A_1c levels in this study were higher than nationwide averages. Black and Hispanic patients with uncontrolled diabetes showed a mean 1% improvement in hemoglobin A_1c levels. These results represent some of the first in the literature emerging from a free clinic that is not affiliated with a major medical school.

Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada

Background

Patients with diabetes receiving chronic, in-center hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps.

Methods

We conducted a population-based, retrospective study between January 1, 2016 and January 1, 2018 in Ontario, Canada. We included adults with prevalent diabetes mellitus receiving in-center hemodialysis as of January 1, 2018 and examined the proportion with (1) insufficient or excessive glycemic monitoring, (2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), (3) hospital encounters for hypo- or hyperglycemia, and (4) hospital encounters for hypertension in the 2 years prior (January 1, 2016 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one care gap and used multivariable logistic regression to determine predictors. Further, we used geographic information systems to explore spatial variation in gaps.

Results

There were 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits, and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region.

Conclusions

There are opportunities to improve diabetes care in patients receiving in-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.

Evaluating the Impact of Mobile Phone Technology on Health Outcomes for Latinos with Type 2 Diabetes

OBJECTIVES

To assess whether a Spanish-language text messaging program helps Latinos with diabetes better manage their disease.

METHODS

Spanish-speaking Latinos with type 2 diabetes and HbA1c ≥ 8% (N = 38) were recruited January 1, 2016-May 31, 2016, at a large integrated healthcare delivery system. Participants received 1-3 Spanish-language text messages about diabetes self-care per day for 3 months with an optional 3-month extension. The Wilcoxon signed-rank test for paired data was used to compare pre-post intervention HbA1c. The Wilcoxon-Mann-Whitney nonparametric test was used to compare changes in HbA1c across groups.

RESULTS

After 3 months, the median HbA1c reduction overall was 1.4 percentage points (IQR: 0.5-3.3, p < 0.01). Latinos having pre-intervention HbA1c > 10.0% had a greater reduction in median HbA1c (3.8, IQR: 0.5-5.3) compared with those having pre-intervention HbA1c ≤ 10.0% (0.9, IQR: 0.1-1.9, p < 0.05). This reduction in median HbA1c persisted after 6 months (1.3, IQR: 0.2-2.9, p < 0.01).

CONCLUSION

A Spanish-language text messaging program was an effective way to improve glycemic control for Latinos with type 2 diabetes.

POLICY IMPLICATIONS

Culturally and linguistically tailored text messaging programs for managing diabetes should be considered.

New research directions on disparities in obesity and type 2 diabetes

Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.

Associations Between Changes in Depressive Symptoms and Social Support and Diabetes Management Among Low-Income, Predominantly Hispanic Patients in Patient-Centered Care

OBJECTIVE

This study examined whether changes in depressive symptoms and social support prospectively predicted diabetes management among Hispanic patients with probable depression in patient-centered medical homes at safety-net clinics in East Los Angeles, CA.

RESEARCH DESIGN AND METHODS

Data were collected from 251 patients enrolled in a randomized clinical trial testing the effectiveness of a self-management intervention assisted by a promotora (Hispanic community health worker). Cross-lagged analyses examined associations between changes in depression symptoms and social support between baseline and 6-month follow-up and self-efficacy and adherence to diabetes management at the 6- and 12-month follow-ups.

RESULTS

Changes in depressive symptoms predicted self-efficacy and level of adherence at the 6- and 12-month follow-ups. Changes in total social support and emotional social support were correlated only with self-efficacy regarding diabetes management at 6-month follow-up.

CONCLUSIONS

Decline in depressive symptoms is a reliable predictor of improvement in self-efficacy and adherence to diabetes management. Further studies are recommended to study psychosocial mechanisms related to social relationships other than social support that affect diabetes management.

Diabetes Outcome and Process Measures Among Patients Who Require Language Interpreter Services in Minnesota Primary Care Practices

Immigrants and refugees are less likely to meet diabetes management goals than the general US population. Those with limited English proficiency (LEP) and who need interpreter services (IS) for health care encounters, maybe at higher risk for encountering barriers to optimal diabetes management, and while most receive diabetes care in primary care settings, little is known about the association between IS need and diabetes outcomes. This study aims to determine adherence with diabetes process and outcomes measures among LEP patients in primary care settings, and is a retrospective cohort study of patients with type II diabetes at two large primary care networks in Minnesota from January 1, 2012 through December 31, 2013. Diabetes outcome measure goals were defined as hemoglobin A1C <8%, LDL-C <100 mg/dL, and blood pressure <140/90 mmHg. Process measure goals were defined as hemoglobin A1C measured within the previous 6 months and LDL cholesterol (LDL-C) measured within the previous 12 months. Compared to non-IS patients (N = 11,970), IS patients (N = 1486) were more likely to meet guideline outcome recommendations for blood pressure (Adjusted odds ratio [OR] 2.02; 95% confidence interval [CI] 1.70, 2.40), hemoglobin A1C (OR 1.23; 95% CI 1.08, 1.40), and LDL-C (OR 1.40; 95% CI 1.2, 1.62). Older IS patients and male IS patients were less likely to meet recommendations for hemoglobin A1C (OR 0.70; 95% CI 0.48, 1.02; OR 0.66; CI 0.54, 0.79; respectively) and LDL-C (OR 0.81; 95% CI 0.55, 1.17; OR 0.47; CI 0.39, 0.57; respectively). Healthcare system solutions need to bridge gaps from process to outcomes among LEP patients who require IS in primary care settings.

Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers

OBJECTIVE

To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference.

STUDY SETTING/DATA COLLECTION

Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053).

STUDY DESIGN

We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups.

PRINCIPAL FINDINGS

After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients.

CONCLUSIONS

Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.

Migration, Health Care Behaviors, and Primary Care for Rural Latinos with Diabetes

Many US Latinos migrate or travel between the US and Mexico on a regular basis, defined as circular migration. Latinos with diabetes (n = 250) were surveyed about circular migration and their ability to use medications and perform recommended diabetes self-care activities. A review of medical charts was performed. Twenty-eight percent (n = 70) of patients traveled to Mexico during the last 12 months. Older Latinos were more likely to report traveling to Mexico and back into the US. Among those that traveled, 29 % reported use of less medication than they wanted to or were prescribed because of travel and 20 % ran out of medications. The rate of reported problem areas while traveling were 39 % (27/70) for following a diabetic diet, 31 % (21/70) for taking medication, and 37 % (26/70) for glucose self-monitoring. The results suggest that the structure of primary care and care coordination are important for this population to fully engage in diabetes self-care.

Policy dilemmas in Latino health care and implementation of the Affordable Care Act

The changing Latino demographic in the United States presents a number of challenges to health care policy makers, clinicians, organizations, and other stakeholders. Studies have demonstrated that Latinos tend to have worse patterns of access to, and utilization of, health care than other ethnic and racial groups. The implementation of the Affordable Care Act (ACA) of 2010 may ameliorate some of these disparities. However, even with the ACA, it is expected that Latinos will continue to have problems accessing and using high-quality health care, especially in states that are not expanding Medicaid eligibility as provided by the ACA. We identify four current policy dilemmas relevant to Latinos' health and ACA implementation: (a) the need to extend coverage to the undocumented; (b) the growth of Latino populations in states with limited insurance expansion;

The Impact of Hispanic Ethnicity on Knowledge and Behavior Among Patients With Diabetes

PURPOSE

The purpose of the study was to measure the current level of awareness of the American Heart Association's 7 risk/protective factors of cardiovascular health among adults with diabetes of Hispanic and non-Hispanic origin and to identify factors associated with knowledge deficits.

METHODS

A cross-sectional survey measured demographic data, personal behaviors/health factors, cardiovascular disease (CVD) history, and knowledge of 7 components of ideal cardiovascular health (smoking, obesity, exercise, diet, cholesterol, blood pressure, and blood glucose). A subset of 331 Hispanic and white patients with diabetes was surveyed. Knowledge scores were dichotomized between full knowledge (7 components) and less than full knowledge and compared between ethnicities using multiple logistic regression.

RESULTS

Seventy-nine percent of surveys were returned; 50.5% of subjects were Hispanic. Median age was 64.5 years with 60.7% being female. Two-thirds of the sample completed high school and 26% reported comorbid CVD. Recognition of diabetes as a risk factor didn't differ by ethnicity. Thirty-five percent of respondents identified 7 American Heart Association risk factors. Hispanics were less likely to identify 7 components. After adjustment for education and English literacy, the difference disappeared. Better knowledge was positively associated with healthier behaviors for high cholesterol, hypertension, and exercise only among white patients.

CONCLUSIONS

Hispanic patients with diabetes exhibit less knowledge about CVD risk/protective factors due to lower education and English literacy. Educational interventions should be tailored to those with less education/limited English proficiency.

Baseline characteristics and Latino versus non-Latino contrasts among Bronx A1C study participants

We describe baseline demographic and psychosocial characteristics of low-income, diverse diabetes adults enrolled in a telephonic intervention trial. Environment for the study was New York City (NYC) A1C Registry program. Baseline data were analyzed from 941 participants randomized to either telephonic/print or print-only intervention to improve glycemic control. Summary statistics for key variables were calculated; we highlight baseline contrasts between Latino and non-Latino participants. There were high proportions of Latino (67.7%) and non-Latino Black (28.0%) participants from South Bronx. Mean age was 56.3 years, almost 70.0% were foreign born, and 55.8% preferred Spanish language. Mean A1C was 9.2% and mean body mass index (BMI) 32.1 kg/m(2). There were significant contrasts between Latino and non-Latino participants for behavioral and psychosocial variables. This telephonic intervention study succeeded in randomizing a large number of low-income, diverse participants with poor diabetes control who are under-represented in studies. Latino versus non-Latino differences at baseline were striking.

The association of English ability and glycemic control among Latinos with diabetes

OBJECTIVE

Language barriers may be significant contributors to diabetes disparities. We sought to assess the association of English speaking ability with glycemic control among Latinos with diabetes.

METHODS

We analyzed 167 Latinos from a cross-sectional survey of adults with type 2 diabetes. The main outcome was HbA1c > or =7.0%. The main predictor was self-reported English speaking ability. Adjusted analyses accounted for age, sex, education, annual income, health insurance status, duration of diabetes, birth in the United States, and years in the United States.

RESULTS

In unadjusted analyses, point estimates for the odds of having a high HbAlc revealed a U-shaped curve with English speaking ability. Those who spoke English very well (OR=2.32, 95% CI, 1.00-5.41) or not at all (OR=4.11, 95% CI 1.35-12.54) had higher odds of having an elevated HbA1c than those who spoke English well, although this was only statistically significant for those who spoke no English. In adjusted analyses, the U-shaped curve persisted with the highest odds among those who spoke English very well (OR=3.20, 95% CI 1.05-9.79) or not at all (OR 4.95, 95% CI 1.29-18.92).

CONCLUSIONS

The relationship between English speaking ability and diabetes management is more complex than previously described. Interventions aimed at improving diabetes outcomes may need to be tailored to specific subgroups within the Latino population.

Pathways to depression care: help-seeking experiences of low-income Latinos with diabetes and depression

This qualitative study examines help-seeking pathways to depression care of low-income Latinos with diabetes and major depression. A purposive sample (N = 19) of Spanish-speaking, immigrant, low-income Latinos was selected from a randomized clinical trial targeting Latinos with diabetes and major depression. Four focus groups followed by 10 in-depth qualitative interviews were conducted. Narratives were analyzed using the constant comparative method informed by grounded theory. Need for formal care was described in relation to acute somatic symptoms, functional impairment, and mood changes. Treatment initiation occurred through family members and primary care physicians who encouraged or inhibited help-seeking. Adherence to depression care focused on interpersonal aspects of care, evaluated symptom relief, and improved functioning. Help-seeking barriers included self-reliance, language barriers, stigma, competing health demands, and structural barriers. Findings from this study highlight potential points of intervention for developing culturally-appropriate collaborative care approaches for low-income Latinos with diabetes and major depression.

Diabetes self-management activities for Latinos living in non-metropolitan rural communities: a snapshot of an underserved rural state

The Latino community continues to grow in the rural Midwest, and diabetes is a pertinent disease for research in this demographic. Patient self-management is an important aspect of comprehensive care for diabetes and may mitigate complications. A cross-sectional survey assessed various activities including self-monitoring of blood glucose, personal foot inspection, diet adherence, and diabetes self-management education. Less than half of the sample performed self-monitoring of blood glucose daily (40 %), adhered strictly to special diabetes diet recommendations (44 %), or attended a diabetes self-management education class (48 %). Participants advised on personal foot inspection were three times more likely to perform the self-care activity. Improvements are indicated in these self-management activities. Further research is needed to discern disparities and barriers in self-monitoring of blood glucose among this target population. An increased emphasis on enrollment in diabetes self-management classes should target foreign-born Latinos with lower levels of education.

Ethnic differences in quality of life in insured older adults with diabetes mellitus in an integrated delivery system

OBJECTIVES

To explore racial and ethnic (ethnic hereafter) differences in health-related quality of life (HRQL) in older adults with diabetes mellitus in an integrated delivery system.

DESIGN

Observational cross-sectional study.

SETTING

Kaiser Permanente Northern California.

PARTICIPANTS

Ethnic-stratified, random sample of 6,096 adults with diabetes mellitus aged 60 to 75 who completed a HRQL questionnaire.

MEASUREMENTS

Physical and mental HRQL were measured based on the Medical Outcomes Study 8-item Short Form Survey (range 0-100, mean 50). Age- and sex-adjusted weighted linear regression models estimated associations between ethnicity and HRQL and evaluated potential mediators (socioeconomic status, acculturation, health behaviors, diabetes mellitus-related conditions). Differences in ethnic-specific, adjusted mean HRQL scores were tested (reference whites).

RESULTS

Physical HRQL was better for Filipinos (48.3, 95% confidence interval (CI) = 47.0-49.6, P < .001), Asians (48.1, 95% CI = 46.8-49.3, P < .001), Hispanics (45.1, 95% CI = 44.2-46.0, P < .001), and blacks (44.2, 95% CI = 43.3-45.1, P = .04) than whites (42.9, 95% CI = 42.6-43.2). Adjusting for potential mediators did not change these relationships. Mental HRQL was better only for Asians (52.7, 95% CI = 51.6-53.7, P = .01) than for whites (51.0, 95% CI = 50.7-51.3), but this difference was small and became nonsignificant after adjustment for socioeconomic status, acculturation, health behaviors, and diabetes mellitus-related conditions.

CONCLUSION

In older adults with diabetes mellitus in a well-established integrated healthcare delivery system, ethnic minorities had better physical HRQL than whites. Equal access to care in an integrated delivery system may hold promise for reducing health disparities in diabetes mellitus-related patient-reported outcomes.

A qualitative study on healthcare professionals' perceived barriers to insulin initiation in a multi-ethnic population

Background

Nationwide surveys have shown that the prevalence of diabetes rates in Malaysia have almost doubled in the past ten years; yet diabetes control remains poor and insulin therapy is underutilized. This study aimed to explore healthcare professionals’ views on barriers to starting insulin therapy in people with type 2 diabetes.

Methods

Healthcare professionals consisting of general practitioners (n = 11), family medicine specialists (n = 10), medical officers (n = 8), government policy makers (n = 4), diabetes educators (n = 3) and endocrinologists (n = 2) were interviewed. A semi-structured topic guide was used to guide the interviews by trained facilitators. The interviews were transcribed verbatim and analysed using a thematic analysis approach.

Results

Insulin initiation was found to be affected by patient, healthcare professional and system factors. Patients’ barriers include culture-specific barriers such as the religious purity of insulin, preferred use of complementary medication and perceived lethality of insulin therapy. Healthcare professionals’ barriers include negative attitudes towards insulin therapy and the ‘legacy effect’ of old insulin guidelines; whilst system barriers highlight the lack of resources, language and communication challenges.

Conclusions

Tackling the issue of insulin initiation should not only happen during clinical consultations. It requires health education to emphasise the progressive nature of diabetes and the eventuality of insulin therapy at early stage of the illness. Healthcare professionals should be trained how to initiate insulin and communicate effectively with patients from various cultural and religious backgrounds.

Diabetic nephropathy among Mexican Americans

The incidence of diabetic nephropathy (DN) is growing rapidly worldwide as a consequence of the rising prevalence of Type 2 diabetes mellitus (T2DM). Among U.S. ethnic groups, Mexican Americans have a disproportionately high incidence and prevalence of DN and associated end-stage renal disease (ESRD). In communities bordering Mexico, as many as 90% of Mexican American patients with ESRD also suffer from T2DM compared to only 50% of non-Hispanic Whites (NHW). Both socio-economic factors and genetic predisposition appear to have a strong influence on this association. In addition, certain pathogenetic and clinical features of T2DM and DN are different in Mexican Americans compared to NHW, raising questions as to whether the diagnostic and treatment strategies that are standard practice in the NHW patient population may not be applicable in Mexican Americans. This article reviews the epidemiology of DN in Mexican Americans, describes the pathophysiology and associated risk factors, and identifies gaps in our knowledge and understanding that needs to be addressed by future investigations.

HbA1c in pregnancy

During pregnancy, the glucose levels vary according to the hormonal changes and the metabolic needs necessary to maintain fetal nutrition but strict glycemic control is essential to minimize the maternal and fetal morbidity and mortality of pregnancies complicated by diabetes. Although considered the "gold standard" for diagnosis, measurement of glucose in the blood is subject to several limitations, many of which are not widely appreciated. Measurement of A1c for diagnosis is appealing as with one number, a total, integrated view of glycemia over time is derived though it has some inherent limitations. Thus, supplementation with HbA1c, as is common outside pregnancy, seems appropriate. Before pregnancy, the target for metabolic control in women with diabetes is HbA1c values near the normal range. However, the upper normal range of HbA1c during normal pregnancy is only sparsely investigated with different methods though recently a number of papers have been published regarding the determination of reference ranges for HbA1c in pregnancy. These changes may have clinical implications for the assessment and management of glycemic control in diabetic pregnancy and calls for establishment of separate reference limits of HbA1c levels in different trimesters as compared to general population.

Factors Affecting the Quality of Diabetic Care in Primary Care Settings in Oman: A qualitative study on patients' perspectives

OBJECTIVES

The quality of services delivered to type 2 diabetic patients in primary health care has an important impact on long-term outcomes. The aim of this study is to explore diabetic patients' views of factors affecting quality of diabetic services delivered in primary care in Oman, a developing country with a high burden of diabetes.

METHODS

Semi-structured face to face interviews were conducted with 19 type 2 diabetic patients recruited from four selected primary healthcare centres (PHCs) in Muscat region, the capital city of Oman. A framework approach was used to analyse the qualitative data.

RESULTS

PARTICIPANTS IDENTIFIED SEVERAL FACTORS WHICH COULD AFFECT THE QUALITY OF DIABETIC SERVICES PROVIDED IN PHCS: delays in the follow-up process; lack of continuity of care; diabetes educational materials unavailable in waiting areas; shortage of Omani nurses able to speak the patients' language; inadequate explanations from the attending primary care physician (PCP); under involvement of dieticians in patient management; delays in provision of laboratory results; inadequate supplies of diabetic medication between appointments, and long waits to see ophthalmologists.

CONCLUSION

Several factors were identified by diabetic patients that may influence the quality of diabetic services provided in the PHC setting in Oman. Health care professionals and decision makers in the Ministry of Health (MOH) and other health care sectors in Oman should consider patients' views and concerns in order to improve the quality of diabetic care services in primary health care.

Primary language, income and the intensification of anti-glycemic medications in managed care: the (TRIAD) study

BACKGROUND

Patients who speak Spanish and/or have low socioeconomic status are at greater risk of suboptimal glycemic control. Inadequate intensification of anti-glycemic medications may partially explain this disparity.

OBJECTIVE

To examine the associations between primary language, income, and medication intensification.

DESIGN

Cohort study with 18-month follow-up.

PARTICIPANTS

One thousand nine hundred and thirty-nine patients with Type 2 diabetes who were not using insulin enrolled in the Translating Research into Action for Diabetes Study (TRIAD), a study of diabetes care in managed care.

MEASUREMENTS

Using administrative pharmacy data, we compared the odds of medication intensification for patients with baseline A1c ≥ 8%, by primary language and annual income. Covariates included age, sex, race/ethnicity, education, Charlson score, diabetes duration, baseline A1c, type of diabetes treatment, and health plan.

RESULTS

Overall, 42.4% of patients were taking intensified regimens at the time of follow-up. We found no difference in the odds of intensification for English speakers versus Spanish speakers. However, compared to patients with incomes <$15,000, patients with incomes of $15,000-$39,999 (OR 1.43, 1.07-1.92), $40,000-$74,999 (OR 1.62, 1.16-2.26) or >$75,000 (OR 2.22, 1.53-3.24) had increased odds of intensification. This latter pattern did not differ statistically by race.

CONCLUSIONS

Low-income patients were less likely to receive medication intensification compared to higher-income patients, but primary language (Spanish vs. English) was not associated with differences in intensification in a managed care setting. Future studies are needed to explain the reduced rate of intensification among low income patients in managed care.

Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the Diabetes Study of Northern California (DISTANCE)

BACKGROUND

A significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown.

OBJECTIVE

To assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician.

DESIGN

Cross-sectional, observational study using data from the 2005-2006 Diabetes Study of Northern California (DISTANCE). Patients received care in a managed care setting with interpreter services and self-reported their English language ability and the Spanish language ability of their physician. Outcome was poor glycemic control (glycosylated hemoglobin A1c > 9%).

KEY RESULTS

The unadjusted percentage of patients with poor glycemic control was similar among Latino patients with LEP (n = 510) and Latino English-speakers (n = 2,683), and higher in both groups than in whites (n = 3,545) (21% vs 18% vs. 10%, p < 0.005). This relationship differed significantly by patient-provider language concordance (p < 0.01 for interaction). LEP patients with language-discordant physicians (n = 115) were more likely than LEP patients with language-concordant physicians (n = 137) to have poor glycemic control (27.8% vs 16.1% p = 0.02). After controlling for potential demographic and clinical confounders, LEP Latinos with language-concordant physicians had similar odds of poor glycemic control as Latino English speakers (OR 0.89; CI 0.53-1.49), whereas LEP Latinos with language-discordant physicians had greater odds of poor control than Latino English speakers (OR 1.76; CI 1.04-2.97). Among LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03-3.80).

CONCLUSIONS

Language barriers contribute to health disparities among Latinos with diabetes. Limited English proficiency is an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association not observed when care is provided by language-concordant physicians. Future research should determine if strategies to increase language-concordant care improve glycemic control among US Latinos with LEP.

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: the DISTANCE study

OBJECTIVE

To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions.

METHODS

Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination.

RESULTS

Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients.

CONCLUSIONS

Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians.

PRACTICE IMPLICATIONS

Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.

Race/ethnicity, social support, and associations with diabetes self-care and clinical outcomes in NHANES

PURPOSE

The purpose of this study was to evaluate how social support and race/ethnicity were associated with diabetes self-care behaviors and clinical outcomes.

METHODS

Using the cross-sectional 2005-2006 National Health and Nutrition Examination Survey (NHANES), the authors examined white, black, and Latino respondents who self-reported a diabetes diagnosis (n = 450), estimating the associations of social support on diabetes outcomes. The primary exposure was a social support index (0-5), which assessed the number of sources of support in one's life. Outcomes were self-care behaviors (controlling weight, exercising, controlling fat/caloric intake, checking feet, and self-monitoring blood glucose) and intermediate clinical outcomes (hemoglobin A1C, diastolic blood pressure, and low-density lipoprotein [LDL]).

RESULTS

There were no differences in social support by race/ethnicity. The authors observed several significant race/ethnicity by social support interactions in adjusted models, controlling for age, gender, education, self-reported health, depression, functional disability, insurance status, and insulin use. Among blacks, social support was associated with controlling weight (odds ratio [OR] = 1.55, P = .03), exercising (OR = 1.38, P = .03), controlling fat/calories (OR = 1.84, P = .03), and lower diastolic blood pressure (beta = -3.07, P = .02). Among whites, social support was associated with lower LDL (beta = -9.45, P = .01). No significant effects were noted for Latinos.

CONCLUSIONS

The relationship of social support with diabetes management differed by race/ethnicity, with the strongest findings among blacks. Social support may be influential for maintaining self-care behaviors among blacks and controlling lipid levels among whites.

A culturally focused exercise program in Hispanic adults with type 2 diabetes: a pilot study

PURPOSE

The purpose of this pilot study was to examine the feasibility and effectiveness of a community-based, culturally focused, exercise program for adults in the Hispanic community with type 2 diabetes.

METHODS

A pretest/posttest design using a culturally designed exercise program through dance was used. A total of 19 Mexican American men and women (39 to 64 years of age) with type 2 diabetes were recruited. Mean preprogram and postprogram differences were examined in hemoglobin A1C, lipid panel, body mass index (BMI), and psychological well-being.

RESULTS

Feasibility was demonstrated by exceeding our recruitment goal and achieving an 84% completion rate and 75% attendance rate for the exercise sessions. Mean hemoglobin A1C, lipids, and psychological well-being demonstrated trends toward improvement from the beginning of the program to the end. BMI remained unchanged. Physical activity increased and all participants met the physical activity goals from the national physical activity guidelines for Americans by the end of the program.

CONCLUSIONS

The culturally focused exercise program detailed here is effective in promoting regular physical activity among Hispanic adults with type 2 diabetes.

The Limits of Self-Management: Community and Health Care System Barriers Among Latinos With Diabetes

Although numerous studies examine diabetes self-care, few regard ecological framework correlates such as community and institutional level factors as fundamental for understanding diabetes management for Latinos. This article addresses the dearth of research that exists regarding social contextual forces and diabetes management for Latinos. Given the scarcity of research on this topic, studies of non-Latino groups were reviewed to illustrate the importance of community and institutional influences on diabetes care. Consideration of fundamental correlates within the ecological framework may better discern the underlying rationale for inadequate diabetes self-management for individuals who live in impoverished communities.

Association of depressive symptoms and lifestyle behaviors among Latinos at risk of type 2 diabetes

Little is known about depression among Latinos at risk for type 2 diabetes. The purpose of this cross-sectional study was to determine the rate of depression in Latinos at risk for type 2 diabetes and to examine the associations between depressive symptoms, diet, physical activity, and body mass index (BMI; calculated as kg/m(2)). Latinos at risk for type 2 diabetes (n=210) were surveyed from July 2007 to August 2008. Depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CES-D). Three 24-hour recalls were used to assess diet and physical activity. Linear regression analyses were used to examine the association between depression, BMI, and lifestyle factors. The sample (78% female) was largely of Caribbean origin (83%) and mean age was 52 years (standard deviation [SD]=11 years). Mean BMI was 34.2 (SD=5.9) and 77% were obese. Average CES-D score was 16.3 (SD=11.3; range=0-45) and 50% had CES-D score > or =16, suggesting clinical depression. Higher CES-D scores were associated with lower diet quality (P<0.05), but were not associated with BMI or physical activity. Depression and lower dietary quality can contribute to risk for type 2 diabetes among Latinos.

Do race and ethnicity impact hemoglobin A1c independent of glycemia?

Hemoglobin A1c (HbA1c) is widely used as an index of mean glycemia, a measure of risk for the development of diabetes complications, and a measure of the quality of diabetes care. Emerging literature suggests that, although HbA1c levels change little over time within persons without diabetes, they vary considerably among individuals, suggesting that factors other than glycemia may impact HbA1c. Racial and ethnic differences in HbA1c have been described that do not appear to be explained by differences in glycemia. It is imperative that the nonglycemic factors that affect HbA1c be more clearly defined. Even more important, it must be determined whether differences among individuals or groups correlate with susceptibility to complications or merely reflect variation in hemoglobin glycation.

Language interpreting as social justice work: perspectives of formal and informal healthcare interpreters

The assurance that limited-English-proficient individuals have access to quality healthcare depends on the availability of competent healthcare interpreters. To further understand the complex work of interpreting, we conducted in-depth interviews with 27 formal and informal healthcare interpreters. Participants identified the technical conduit role as the professional standard. Yet they experienced considerable role dissonance and blurring. From their position "in the middle," they witnessed discrimination and bias. Having a social justice perspective encouraged expanding their role to include advocacy and cultural brokering. Implications for nursing include a shared commitment to language access and social justice.

Ethnic and gender differences in psychosocial factors, glycemic control, and quality of life among adult type 2 diabetic patients

OBJECTIVE

To examine ethnic and gender differences in psychosocial factors, e.g., social support and acceptance of the disease, knowledge levels, perceived difficulty in adherence behaviors, and diabetes outcome (glycemic control and quality of life) in Type 2 diabetic patients.

METHODS

Data were collected via telephone interviews from 180 diabetic subjects (34% Hispanics, 27% Non-Hispanic whites, 18% African-Americans, and 20% Asian-Indians; 52% females) from 2 clinics. Hemoglobin A1c levels were obtained from patient charts.

RESULTS

Significant ethnic and gender differences existed in acceptance of the disease, in receiving social support, disease knowledge, perceived difficulty in self-management behaviors, glycemic control, and quality of life among Type 2 diabetic patients; differences were more pronounced by gender than by ethnicity. In general, social support and acceptance of the disease were high. However, perceived difficulty in self-management behaviors varied by racial/ethnic groups with self-monitoring of blood glucose perceived as most difficult by Hispanic respondents, dietary management was most difficult for non-Hispanic whites, while physical activity was the most difficult for African-Americans. Hispanic respondents had greatest severity of the disease (poorest metabolic control).

CONCLUSIONS

Ethnic and gender variations exist in social support, acceptance of diabetes, quality of life, and adherence behaviors. The outcomes of diabetes care can be improved if practitioners factor these differences in tailoring diabetes education and supportive care for individuals with Type 2 diabetes.

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

BACKGROUND

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

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: a systematic literature review

OBJECTIVE

This systematic review assesses the impact of peer education/counseling on nutrition and health outcomes among Latinos and identifies future research needs.

DESIGN

A systematic literature search was conducted by: (1) searching Internet databases; (2) conducting backward searches from reference lists of articles of interest; (3) manually reviewing the archives of the Center for Eliminating Health Disparities among Latinos; (4) searching the Journal of Nutrition Education and Behavior; and (5) directly contacting researchers in the field. The authors reviewed 22 articles derived from experimental or quasi-experimental studies.

OUTCOME MEASURES

Type 2 diabetes behavioral and metabolic outcomes, breastfeeding, nutrition knowledge, attitudes and behaviors.

RESULTS

Peer nutrition education has a positive influence on diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos.

CONCLUSIONS AND IMPLICATIONS

There is a need for longitudinal randomized trials testing the impact of peer nutrition education interventions grounded on goal setting and culturally appropriate behavioral change theories. Inclusion of reliable scales and the construct of acculturation are needed to further advance knowledge in this promising field. Operational research is also needed to identify the optimal peer educator characteristics, the type of training that they should receive, the client loads and dosage (ie, frequency and amount of contact needed between peer educator and client), and the best educational approaches and delivery settings.

Texas-Mexico Border Intervention by Promotores for Patients With Type 2 Diabetes

Purpose The purpose of this study is to evaluate the impact of a promotores-led diabetes self-management program by comparing the outcomes (knowledge, beliefs, and HbA1c level) of Mexican American patients with type 2 diabetes who received usual diabetic care in a wait-list control group to those who received self-management education and follow-up by promotores in consultation with clinic providers and staff.

Methods This randomized control study compared the results of 63 patients who attended a promotores-led culturally sensitive diabetes self-management course at a commu- nity clinic with 68 patients in a wait-list, usual-care control group. Participants were Mexican Americans with type 2 diabetes who were patients at the clinic and at least 18 years of age. At baseline, 3 months, and 6 months, the Diabetes Knowledge Questionnaire (DKQ), Health Beliefs Questionnaire (HBQ), and HbA1c levels (drawn by the clinic laboratory) were collected.

Results There was a significant improvement in the intervention group's DKQ scores over time and in treatment by time. The baseline HbA1c level was 7.49 and did not change over time in either group. The DKQ, HBQ, and HbA1c results were significantly affected by age; the DKQ and HbA1c were affected by years with diabetes.

Conclusions The promotores-led diabetes self-management course improved the knowledge of patients with diabetes. Participant baseline HbA1c level was close to therapeutic level (much lower than reported in previous studies), suggesting participants received good medical care within the community clinic.

Health competence as predictor of access to care among Latinos in Baltimore

The goal of this study is to identify the underlying structure of Health Competence and its value as a predictor of access to care among the Latino population in Baltimore, Maryland. Data on a cross-sectional urban probability sample were collected from 330 foreign-born Latino men and women aged 21-75 years residing in Baltimore at the time of the survey. Principal components analysis yielded a two-component solution: the first component comprised "factors enabling" access to care; the second, "perceived barriers". When testing the predictive power of the Health Competence construct using model building and the log likelihood criteria the "enabling factors" added significantly (P < .005) to the power of the socio-demographic variables to predict access to care, making it an important tool for programs aiming to improve US Latinos' health.

Differences in A1C by race and ethnicity among patients with impaired glucose tolerance in the Diabetes Prevention Program

OBJECTIVE

We sought to examine racial and ethnic differences in A1C in individuals with impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

We studied 3,819 individuals aged > or = 25 years with IGT who were found to be eligible to participant in the Diabetes Prevention Program. A1C was compared among five racial and ethnic groups before and after adjustment for factors that differed among groups or might affect glycemia including age, sex, education, marital status, blood pressure, adiposity (BMI and waist circumference), hematocrit, fasting and post-glucose load glucose levels, glucose area under the curve (AUC), beta-cell function, and insulin resistance.

RESULTS

Mean +/- SD A1C was 5.91 +/- 0.50%. Among whites, A1C was 5.80 +/- 0.44%, among Hispanics 5.89 +/- 0.46%, among Asian 5.96 +/- 0.45%, among American Indians 5.96 +/- 0.46%, and among blacks 6.19 +/- 0.59%. Age, sex, systolic blood pressure, diastolic blood pressure, BMI, fasting glucose, glucose AUC, corrected insulin response, and insulin resistance were each independent predictors of A1C. Adjusting for these and other factors, mean A1C levels were 5.78% for whites, 5.93% for Hispanics, 6.00% for Asians, 6.12% for American Indians, and 6.18% for blacks (P < 0.001).

CONCLUSIONS

A1C levels are higher among U.S. racial and ethnic minority groups with IGT after adjustment for factors likely to affect glycemia. Among patients with IGT, A1C may not be valid for assessing and comparing glycemic control across racial and ethnic groups or as an indicator of health care disparities.

Hispanic adults? beliefs about type 2 diabetes: Clinical implications

PURPOSE

This integrative literature review focused on Hispanic adults' beliefs about type 2 diabetes. Type 2 diabetes is a progressive, chronic illness with the potential for debilitating complications that disproportionately affect Hispanic adults. By understanding Hispanic adults' beliefs about type 2 diabetes, health professionals will be able to offer more culturally competent health care.

DATA SOURCES

Published research reports on Hispanic adults' beliefs about type 2 diabetes were obtained using multiple computerized databases and by searching reference lists of published reports. A total of 15 research reports comprised this review.

CONCLUSION

While there was some variance among Hispanic subgroups, in general, Hispanic adults' understanding of the etiology of diabetes was an integration of biomedical causes such as heredity and traditional or folk beliefs such as susto, which is the concept of strong emotions. Hispanic adults believed that diabetes is a serious illness and that they could identify many of the symptoms of diabetes. They identified both biomedical and herbal treatments for diabetes. Negative attitudes toward insulin were common. Religious beliefs also factored into Hispanic adult's explanatory models of type 2 diabetes.

IMPLICATIONS FOR PRACTICE

Hispanic adults have a fairly cohesive explanatory model of diabetes. Healthcare professionals can use this information as a starting point to discuss each individual patient's explanatory model of illness, clarify misconceptions, and develop an individualized plan of care.

Addressing cultural barriers to the successful use of insulin in Hispanics with type 2 diabetes

Hispanics experience a higher rate of diabetes than non-Hispanic whites and tend to have worse glycemic control and a greater risk of diabetes-related complications. Once oral antidiabetic agents become insufficient, insulin plays an important role in achieving glycemic goals. However, many Hispanic patients are resistant to initiating insulin therapy or hesitant to increase doses, as necessary, to control their glucose levels. Barriers to insulin therapy include socioeconomic issues (eg, cost, insurance status), language difficulties, poor health literacy, and cultural beliefs that impact the patient-provider relationship and negatively affect patients' perceptions of diabetes and insulin. Healthcare providers can help overcome these issues and improve patient-provider communication by practicing culturally competent care. Implementation of a simple titration regimen using once-daily basal insulin may enable Hispanic patients to maintain glycemic control and improve outcomes.

Teaching how, not what: the contributions of community health workers to diabetes self-management

PURPOSE

The purpose of this study is to describe ways in which community health workers (CHWs) are used in various clinic and community settings to support diabetes self-management.

METHODS

Descriptive quantitative data were collected from logs completed by CHWs. Logs described mode, place, type, duration, and focus of individual contact between the CHW and the patient. Qualitative data were collected from semistructured interviews with patients. Interviews were conducted on site from June to August 2006. Interviewees included a purposeful sample of 47 patients who perceived being helped by CHWs.

RESULTS

CHWs reported providing assistance and teaching or practicing skills as the focus of most of the 1859 individual contacts. The assistance CHWs reported providing was most often in the form of encouragement/motivation. During interviews, patients shared that CHWs were helpful in demonstrating how to incorporate diabetes self-management (DSM) into their daily lives. The information patients shared also provided insight into what they perceived as encouragement/motivation from the CHWs. Quotes from interviews provide specific examples of how support from CHWs was different from that received from family and health care team members.

CONCLUSIONS

Both CHWs and patients perceived assistance being provided in similar ways, with consistent emphasis on encouragement/motivation. Interviews with the patients revealed that a personal connection along with availability and provision of key resources and supports for self-management made the CHW-patient interaction successful for DSM. Examples provide insight into the valuable contributions of CHWs to DSM. This insight should encourage guidelines that make CHWs a routine, standard part of the diabetes care team.

Identifying newly diagnosed Hispanic cancer patients who use a physician with a Spanish-language practice, for studies of quality of cancer treatment

BACKGROUND

Language barriers may affect cancer treatment choices among U.S. Hispanic-Latino patients newly diagnosed with cancer. This study examined use of a physician with a Spanish-language practice (SLP) by Hispanic patients diagnosed with a cancer reported to a population-based cancer registry.

METHODS

Data on all 1,874 Connecticut Hispanic patients diagnosed with cancer in 1999-2002 were obtained from the Connecticut Tumor Registry, including the follow-up physician (FUP) responsible for the patient's medical care around the time of cancer diagnosis. FUPs were compared to a list of Spanish surnames (SS) to identify potential Hispanic ethnicity. A statewide database from a survey of licensed physicians was used to identify SLPs. For the two most common cancers (breast and prostate), SLP was examined in relation to radiotherapy after breast-conserving surgery (202 patients) and for prostate cancer (207 patients).

RESULTS

The 1,874 patients had 829 different FUPs, of whom 783 had information on SLP; only 37 FUPs had a SS but 269 had a SLP. Of the 1,727 Hispanic patients with known FUP, only 3.5% had a SS FUP, while 36.8% had a FUP with a SLP. Having a FUP with a SLP was statistically significantly associated with receipt of radiotherapy for breast cancer but not for prostate cancer.

CONCLUSION

This methodology should be explored in states with larger Hispanic populations, and future efforts should include efforts to obtain data on other cancer treatments (e.g., chemotherapy and hormone therapy).

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE

We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care.

RESEARCH DESIGN AND METHODS

Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry.

RESULTS

Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes.

CONCLUSIONS

For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

A Diabetes Outcome Progression Trial (ADOPT): baseline characteristics of Type 2 diabetic patients in North America and Europe

AIMS

To examine baseline characteristics of patients recruited into ADOPT, a multinational trial comparing three oral glucose-lowering monotherapies.

METHODS

Between April 2000 and June 2002, 4360 patients aged 30-75 years with Type 2 diabetes diagnosed for < 3 years and remaining on diet therapy alone with fasting plasma glucose levels (FPG) between 7.0 and 10.0 mmol/l were enrolled by 488 North American and European centres. Medical histories, anthropometric data and laboratory measurements were determined using common methodologies.

RESULTS

The mean (SD) age of the patients was 57 (10) years, body mass index 32.2 (6.4) kg/m(2), HbA(1c) 7.4 (0.9)%; 58% were male, 88% Caucasian and 15% smoked. North American Caucasians (NAC) were younger, more obese, and more insulin resistant than European Caucasians (EUC), but had better pancreatic B-cell function. NAC had lower total, low-density lipoprotein- and high-density liporpotein-cholesterol concentrations with higher triglyceride concentrations and were more often on lipid-lowering treatment. They had lower blood pressure levels but were equally likely to be on antihypertensive treatment. Metabolic syndrome was more frequent and microalbuminuria less frequent in NAC. Within North America, NAC had lower HbA(1c) concentrations than Blacks, Hispanics and Asians despite similar or higher FPG and 30-min postchallenge glucose concentrations.

CONCLUSIONS

Caucasian North American and European ADOPT patients differ with respect to adiposity, insulin resistance and metabolic syndrome prevalence. North American Blacks, Hispanics and Asians had lower HbA(1c) concentrations than NAC despite similar or higher glucose concentrations. These phenotypic differences may influence the progression of Type 2 diabetes and the response to initial oral glucose-lowering monotherapy.

Effect of switching medically vulnerable patients with uncontrolled diabetes from isophane insulin human to insulin glargine

PURPOSE

The purpose of this observational study was to determine if switching from isophane insulin human (NPH) to insulin glargine would improve glycemic control in a medically vulnerable population with uncontrolled diabetes.

METHODS

A retrospective cohort review of patients' medical records was performed that recorded events occurring between January 1, 2001, and December 31, 2003. The cohort consisted of patients with diabetes in an adult medicine clinic at a county hospital. Patients were included if they were receiving NPH insulin for a minimum of six months and subsequently switched to insulin glargine for a minimum of six months.

RESULTS

The study included 43 patients. There was no significant difference in mean glycosylated hemoglobin (HbA(1c)) between NPH insulin (9.6%) and insulin glargine (9.7%) regimens (p = 0.78, 95% confidence interval, -0.62%, 0.82%). Neither was there a significant difference in the frequency or severity of hypoglycemic episodes between the two treatments. Patients experienced significantly fewer diabetes-associated visits over six months while on insulin glargine. Refill frequency did not differ significantly when patients were receiving NPH insulin versus insulin glargine. When analyzing patient characteristics, those of Hispanic ethnicity experienced HbA(1c) values significantly higher than white patients. Several characteristics were associated with refill frequency.

CONCLUSION

The results of our study indicate that both NPH- and glargine-based basal insulin regimens result in similar levels of glycemic control in a medically vulnerable population with diabetes, without significant differences in the number or severity of hypoglycemic episodes or in refill frequency.

Diabetes, hypertension, and dyslipidemia in Mexican Americans and non-Hispanic whites

BACKGROUND

Ethnic disparities in healthcare quality have been documented, but knowledge of differences in cardiovascular risk factor prevalence, awareness, treatment, and control between Mexican Americans and non-Hispanic whites remains incomplete.

METHODS

Cross-sectional analysis in 2005 of nationally representative data collected from 2256 Mexican-American and 4624 non-Hispanic white adults aged 20 years and over who participated in the 1999-2002 National Health and Nutrition Examination Survey.

RESULTS

Type 2 diabetes is significantly more prevalent in Mexican Americans (13% age and gender adjusted) than in non-Hispanic whites (8%); however, Mexican Americans are more likely to be both diagnosed (77% vs 65%) and treated (63% vs 47%). There is no significant difference in the adjusted prevalence of hypertension, at 28% for non-Hispanic whites compared to 26% for Mexican Americans. Mexican Americans have a slightly lower adjusted prevalence of dyslipidemia, at 31% versus 35%. Awareness of hypertension and dyslipidemia are significantly lower in Mexican Americans (57% vs 71% for hypertension, and 33% vs 56% for dyslipidemia). Treatment rates for hypertension and dyslipidemia are also significantly lower in Mexican Americans (42% vs 61% for hypertension; 14% vs 30% for dyslipidemia). Multivariate logistic regression controlling for age, gender, education, and access to care indicate that Mexican Americans are significantly more likely than non-Hispanic whites to be aware and treated for their diabetes, but significantly less likely to be aware and treated for their hypertension or dyslipidemia.

CONCLUSIONS

The significantly higher prevalence of diabetes in Mexican Americans, in contrast to hypertension and dyslipidemia, may sensitize healthcare providers to its detection and treatment. Communicating the importance of hypertension and dyslipidemia is essential for eliminating disparities.