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Redmond ML, Nollen N, Okut H, Collins TC, Chaparro B, Mayes P, Knapp K, Perkins A, Hill-Briggs F. eDECIDE a web-based problem-solving interventions for diabetes self-management: Protocol for a pilot clinical trial. Contemp Clin Trials Commun 2023; 32:101087. [PMID: 36844972 PMCID: PMC9946845 DOI: 10.1016/j.conctc.2023.101087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/29/2023] [Accepted: 02/03/2023] [Indexed: 02/05/2023] Open
Abstract
Background In the US, diabetes affects 13.2% of African Americans, compared to 7.6% of Caucasians. Behavioral factors, such as poor diet, low physical activity, and general lack of good self-management skills and self-care knowledge are associated with poor glucose control among African Americans. African Americans are 77% more likely to develop diabetes and its associated health complications compared to non-Hispanic whites. A higher disease burden and lower adherence to self-management among this populations calls for innovative approaches to self-management training. Problem solving is a reliable tool for the behavior change necessary to improve self-management. The American Association of Diabetes Educators identifies problem-solving as one of seven core diabetes self-management behaviors. Methods We are using a randomized control trial design. Participants are randomized to either traditional DECIDE or eDECIDE intervention. Both interventions run bi-weekly over 18 weeks. Participant recruitment will take place through community health clinics, University health system registry, and through private clinics. The eDECIDE is an 18-week intervention designed to deliver problem-solving skills, goal setting, and education on the link between diabetes and cardiovascular disease. Conclusion This study will provide feasibility and acceptability of the eDECIDE intervention in community populations. This pilot trial will help inform a powered full-scale study using the eDECIDE design.
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Affiliation(s)
- Michelle L. Redmond
- University of Kansas School of Medicine-Wichita, 1010 N. Kansas, Wichita, KS, USA
- Corresponding author.
| | | | | | - Tracie C. Collins
- University of New Mexico Health Sciences, College of Population Health, USA
| | | | | | - Kara Knapp
- University of Kansas Medical Center, USA
| | | | - Felicia Hill-Briggs
- Northwell Health, Institute of Health System Science, Feinstein Institutes for Medical Research, USA
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Heisler M, Kullgren J, Richardson C, Stoll S, Alvarado Nieves C, Wiley D, Sedgwick T, Adams A, Hedderson M, Kim E, Rao M, Schmittdiel JA. Study protocol: Using peer support to aid in prevention and treatment in prediabetes (UPSTART). Contemp Clin Trials 2020; 95:106048. [PMID: 32497783 PMCID: PMC8059966 DOI: 10.1016/j.cct.2020.106048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is an urgent need to develop and evaluate effective and scalable interventions to prevent or delay the onset of type 2 diabetes mellitus (T2DM). METHODS In this randomized controlled pragmatic trial, 296 adults with prediabetes will be randomized to either a peer support arm or enhanced usual care. Participants in the peer support arm meet face-to-face initially with a trained peer coach who also is a patient at the same health center to receive information on locally available wellness and diabetes prevention programs, discuss behavioral goals related to diabetes prevention, and develop an action plan for the next week to meet their goals. Over six months, peer coaches call their assigned participants weekly to provide support for weekly action steps. In the final 6 months, coaches call participants at least once monthly. Participants in the enhanced usual care arm receive information on local resources and periodic updates on available diabetes prevention programs and resources. Changes in A1c, weight, waist circumference and other patient-centered outcomes and mediators and moderators of intervention effects will be assessed. RESULTS At least 296 participants and approximately 75 peer supporters will be enrolled. DISCUSSION Despite evidence that healthy lifestyle interventions can improve health behaviors and reduce risk for T2DM, engagement in recommended behavior change is low. This is especially true among racial and ethnic minority and low-income adults. Regular outreach and ongoing support from a peer coach may help participants to initiate and sustain healthy behavior changes to reduce their risk of diabetes. TRIAL REGISTRATION The ClinicalTrials.gov registration number is NCT03689530.
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Affiliation(s)
- Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America.
| | - Jeffrey Kullgren
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States of America; University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, United States of America.
| | - Caroline Richardson
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Shelley Stoll
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States of America.
| | - Cristina Alvarado Nieves
- University of Michigan, Department of Internal Medicine- Metabolism, Endocrinology and Diabetes, United States of America.
| | - Deanne Wiley
- Kaiser Permanente Northern California, United States of America.
| | - Tali Sedgwick
- Kaiser Permanente Northern California Division of Research, United States of America.
| | - Alyce Adams
- Kaiser Permanente Northern California, United States of America.
| | | | - Eileen Kim
- The Permanente Medical Group (Kaiser Permanente, Northern California), United States of America.
| | - Megan Rao
- The Permanente Medical Group (Kaiser Permanente, Northern California), United States of America.
| | - Julie A Schmittdiel
- Kaiser Permanente Northern California Division of Research, United States of America.
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Chao MT, Schillinger D, Nguyen U, Santana T, Liu R, Gregorich S, Hecht FM. A Randomized Clinical Trial of Group Acupuncture for Painful Diabetic Neuropathy Among Diverse Safety Net Patients. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:2292-2302. [PMID: 31127837 PMCID: PMC7963203 DOI: 10.1093/pm/pnz117] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Existing pharmacologic approaches for painful diabetic neuropathy (PDN) are limited in efficacy and have side effects. We examined the feasibility, acceptability, and effects of group acupuncture for PDN. DESIGN AND SETTING We randomized patients with PDN from a public safety net hospital to 1) usual care, 2) usual care plus 12 weeks of group acupuncture once weekly, or 3) usual care plus 12 weeks of group acupuncture twice weekly. METHODS The primary outcome was change in weekly pain intensity (daily 0-10 numerical rating scale [NRS] averaged over seven days) from baseline to week 12. We also assessed health-related quality of life and related symptoms at baseline and weeks 6, 12, and 18. RESULTS We enrolled 40 patients with PDN (baseline pain = 5.3). Among participants randomized to acupuncture, 92% attended at least one treatment (mean treatments = 10.1). We observed no significant differences between once- vs twice-weekly acupuncture and combined those groups for the main analyses. Compared with usual care, participants randomized to acupuncture experienced greater decreases in pain during the 12-week intervention period (between-group differences from baseline = -2.06, 95% confidence interval [CI] = -3.01 to -1.10), but benefits were not maintained after acupuncture ended (baseline to week 18 = -0.61, 95% CI = -1.46 to 0.24). Quality of life improved for acupuncture participants (baseline to week 12 difference = 11.79, 95% CI = 1.92 to 21.66), but group differences were not significant compared with usual care (25.58, 95% CI = -3.90 to 55.06). CONCLUSIONS Group acupuncture is feasible and acceptable among linguistically and racially diverse safety net patients. Findings suggest clinically relevant reduction in pain from PDN and quality of life improvements associated with acupuncture, with no differences based on frequency.
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Affiliation(s)
- Maria T Chao
- Osher Center for Integrative Medicine
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Dean Schillinger
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | | | | | | | - Steve Gregorich
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Frederick M Hecht
- Osher Center for Integrative Medicine
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
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Shiyanbola OO, Brown CM, Ward EC. "I did not want to take that medicine": African-Americans' reasons for diabetes medication nonadherence and perceived solutions for enhancing adherence. Patient Prefer Adherence 2018; 12:409-421. [PMID: 29593383 PMCID: PMC5865580 DOI: 10.2147/ppa.s152146] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Diabetes is disproportionally burdensome among African-Americans (AAs) and medication adherence is important for optimal outcomes. Limited studies have qualitatively examined reasons for nonadherence among AAs with type 2 diabetes, though AAs are less adherent to prescribed medications compared to whites. This study explored the reasons for medication nonadherence and adherence among AAs with type 2 diabetes and examined AAs' perceived solutions for enhancing adherence. METHODS Forty AAs, age 45-60 years with type 2 diabetes for at least 1 year prior, taking at least one prescribed diabetes medication, participated in six semistructured 90-minute focus groups. Using a phenomenology qualitative approach, reasons for nonadherence and adherence, as well as participants' perceived solutions for increasing adherence were explored. Qualitative content analysis was conducted. RESULTS AAs' reasons for intentional nonadherence were associated with 1) their perception of medicines including concerns about medication side effects, as well as fear and frustration associated with taking medicines; 2) their perception of illness (disbelief of diabetes diagnosis); and 3) access to medicines and information resources. Participants reported taking their medicines because they valued being alive to perform their social and family roles, and their belief in the doctor's recommendation and medication helpfulness. Participants provided solutions for enhancing adherence by focusing on the roles of health care providers, patients, and the church. AAs wanted provider counseling on the necessity of taking medicines and the consequences of not taking them, indicating the need for the AA community to support and teach self-advocacy in diabetes self-management, and the church to act as an advocate in ensuring medication use. CONCLUSION Intentional reasons of AAs with type 2 diabetes for not taking their medicines were related to their perception of medicines and illness. Solutions for enhancing diabetes medication adherence among AAs should focus on the roles of providers, patients, and the church.
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Affiliation(s)
- Olayinka O Shiyanbola
- Division of Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
- Correspondence: Olayinka O Shiyanbola, Division of Social and Administrative Sciences, School of Pharmacy, University of Wisconsin-Madison, 777 Highland Avenue, Madison, WI 53705, USA, Tel +1 608 890 2091, Fax +1 608 262 5262, Email
| | - Carolyn M Brown
- Division of Health Outcomes and Pharmacy Practice, College of Pharmacy, University of Texas at Austin, Austin, TX, USA
| | - Earlise C Ward
- School of Nursing, University of Wisconsin-Madison, Madison, WI, USA
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McEwan P, Bennett H, Qin L, Bergenheim K, Gordon J, Evans M. An alternative approach to modelling HbA1c trajectories in patients with type 2 diabetes mellitus. Diabetes Obes Metab 2017; 19:628-634. [PMID: 28026908 DOI: 10.1111/dom.12865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 11/30/2022]
Abstract
AIMS Time-dependent HbA1c trajectories in health economic models of type 2 diabetes mellitus (T2DM) are typically informed by the UK Prospective Diabetes Study (UKPDS). However, this approach may not accurately predict HbA1c progression in patients who do not conform to the demographic profile of the original UKPDS cohort. This study aimed to develop an alternative mathematical model (MM) to simulate HbA1c progression in T2DM. MATERIALS AND METHODS A systematic literature review identified studies, published between 2005 and 2015, that reported HbA1c in adult T2DM patients over a minimum duration of 18 months. Pooled data from eligible studies were used to develop an alternative MM equation for HbA1c progression, which was then contrasted with the UKPDS 68 progression equation in illustrative scenarios. RESULTS A total of 68 studies were eligible for data extraction (mean follow-up time 4.1 years). HbA1c progression was highly heterogeneous across studies, varying with baseline HbA1c, treatment group and patient age. The MM equation was fitted with parameters for mean baseline HbA1c (8.3%), initial change in HbA1c (-0.62%) and upper quartile of maximum observed HbA1c (9.3%). Differences in HbA1c trajectories between the MM and UKPDS approaches altered the timing of therapy escalation in illustrative scenarios. CONCLUSIONS The MM represents an alternative approach to simulate HbA1c trajectories in T2DM models, as UKPDS data may not adequately reflect the heterogeneity of HbA1c profiles observed in clinical studies. However, the choice of approach should ultimately be determined by the characteristics of individual patients under consideration and the clinical face validity of the modelled trajectories.
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Affiliation(s)
- Phil McEwan
- Health Economics and Outcomes Research Ltd, Cardiff, UK
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | - Lei Qin
- Global Health Economics and Payer Analytics, AstraZeneca, Gaithersburg, Maryland
| | - Klas Bergenheim
- Global Health Economics and Payer Analytics, AstraZeneca, Gothenburg, Sweden
| | - Jason Gordon
- Health Economics and Outcomes Research Ltd, Cardiff, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
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Patel I, Erickson SR, Caldwell CH, Woolford SJ, Bagozzi RP, Chang J, Balkrishnan R. Predictors of medication adherence and persistence in Medicaid enrollees with developmental disabilities and type 2 diabetes. Res Social Adm Pharm 2015; 12:592-603. [PMID: 26522400 DOI: 10.1016/j.sapharm.2015.09.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 09/17/2015] [Accepted: 09/18/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND The prevalence of diabetes mellitus is high among patients with developmental disabilities (cerebral palsy, autism, Down's syndrome and cognitive disabilities). OBJECTIVES The purpose of this study was to examine the racial health disparities in medication adherence and medication persistence in developmentally disabled adults with type 2 diabetes enrolled in Medicaid. METHODS This was a retrospective cohort study using the MarketScan(®) Multi-State Medicaid Database. Adults aged 18-64 years with a prior diagnosis of a developmental disability (cerebral palsy/autism/down's/cognitive disabilities) and a new diagnosis of type 2 diabetes enrolled in Medicaid from January 1, 2004 and December 31, 2006, were included. Adults were included if they had a continuous enrollment for at least 12 months and were excluded if they were dual eligible. Anti-diabetes medication adherence and diabetes medication persistence were measured using multivariate logistic regression and the Cox-proportional hazard regression, respectively. RESULTS The study population comprised of 1529 patients. Although overall diabetes medication adherence in this population was optimal, African Americans had significantly lower odds (25%) of adhering to anti-diabetes medications compared to Caucasians (OR = 0.75, 95% CI = 0.58-0.97, P < 0.05). Also, after controlling for other covariates, the rate of discontinuation was higher in African Americans compared to Caucasians (hazard ratio = 1.03, 95% CI = 0.91-1.18, P < 0.629). CONCLUSION In this study, racial disparities were found in anti-diabetes medication adherence among Medicaid enrollees with developmental disabilities (DD). Studies conducted in the future should examine predictors that impact access to care, availability of primary and specialized care, social support as well as beliefs of racial minority populations with developmental disabilities and chronic conditions like diabetes to optimize medication use outcomes in this especially vulnerable population.
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Affiliation(s)
- Isha Patel
- Bernard Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
| | | | | | | | | | - Jongwha Chang
- McWhorter College of Pharmacy, Samford University, Birmingham, AL, USA
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Goonesekera SD, Yang MH, Hall SA, Fang SC, Piccolo RS, McKinlay JB. Racial ethnic differences in type 2 diabetes treatment patterns and glycaemic control in the Boston Area Community Health Survey. BMJ Open 2015; 5:e007375. [PMID: 25967997 PMCID: PMC4431069 DOI: 10.1136/bmjopen-2014-007375] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/17/2015] [Accepted: 03/27/2015] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Numerous studies continue to report poorer glycaemic control, and a higher incidence of diabetes-related complications among African-Americans and Hispanic-Americans as compared with non-Hispanic Caucasians with type 2 diabetes. We examined racial/ethnic differences in receipt of hypoglycaemic medications and glycaemic control in a highly insured Massachusetts community sample of individuals with type 2 diabetes. SETTING Community-based sample from Boston, Massachusetts, USA. PARTICIPANTS 682 patients with physician-diagnosed diabetes from the third wave of the Boston Area Community Health Survey (2010-2012). The study included approximately equal proportions of African-Americans, Hispanics and Caucasians. METHODS We examined racial/ethnic disparities in diabetes treatment by comparing proportions of individuals on mutually exclusive diabetes treatment regimens across racial/ethnic subgroups. Using multivariable linear and logistic regression, we also examined associations between race/ethnicity and glycaemic control in the overall population, and within treatment regimens, adjusting for age, gender, income, education, health insurance, health literacy, disease duration, diet and physical activity. RESULTS Among those treated (82%), the most commonly prescribed antidiabetic regimens were biguanides only (31%), insulin only (23%), and biguanides and insulin (16%). No overall racial/ethnic differences in treatment or glycaemic control (per cent difference for African-Americans: 6.18, 95% CI -1.00 to 13.88; for Hispanic-Americans: 1.01, 95% CI -10.42 to 12.75) were observed. Within regimens, we did not observe poorer glycaemic control for African-Americans prescribed biguanides only, insulin only or biguanides combined with insulin/sulfonylureas. However, African-Americans prescribed miscellaneous regimens had higher risk of poorer glycaemic control (per cent difference=23.37, 95% CI 7.25 to 43.33). There were no associations between glycaemic levels and Hispanic ethnicity overall, or within treatment regimens. CONCLUSIONS Findings suggest a lack of racial/ethnic disparities in diabetes treatment patterns and glycaemic control in this highly insured Massachusetts study population. Future studies are needed to understand impacts of increasing insurance coverage on racial/ethnic disparities in treatment patterns and related outcomes.
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Affiliation(s)
| | - May H Yang
- New England Research Institutes, Watertown, Massachusetts, USA
| | - Susan A Hall
- New England Research Institutes, Watertown, Massachusetts, USA
| | - Shona C Fang
- New England Research Institutes, Watertown, Massachusetts, USA
| | | | - John B McKinlay
- New England Research Institutes, Watertown, Massachusetts, USA
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Meigs JB, Grant RW, Piccolo R, López L, Florez JC, Porneala B, Marceau L, McKinlay JB. Association of African genetic ancestry with fasting glucose and HbA1c levels in non-diabetic individuals: the Boston Area Community Health (BACH) Prediabetes Study. Diabetologia 2014; 57:1850-8. [PMID: 24942103 PMCID: PMC5424892 DOI: 10.1007/s00125-014-3301-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 05/20/2014] [Indexed: 12/16/2022]
Abstract
AIMS/HYPOTHESIS To test among diabetes-free urban community-dwelling adults the hypothesis that the proportion of African genetic ancestry is positively associated with glycaemia, after accounting for other continental ancestry proportions, BMI and socioeconomic status (SES). METHODS The Boston Area Community Health cohort is a multi-stage 1:1:1 stratified random sample of self-identified African-American, Hispanic and white adults from three Boston inner city areas. We measured 62 ancestry informative markers, fasting glucose (FG), HbA1c, BMI and SES (income, education, occupation and insurance status) and analysed 1,387 eligible individuals (379 African-American, 411 Hispanic, 597 white) without clinical or biochemical evidence of diabetes. We used three-heritage multinomial linear regression models to test the association of FG or HbA1c with genetic ancestry proportion adjusted for: (1) age and sex; (2) age, sex and BMI; and (3) age, sex, BMI and SES. RESULTS Mean age- and sex-adjusted FG levels were 5.73 and 5.54 mmol/l among those with 100% African or European ancestry, respectively. Using per cent European ancestry as the referent, each 1% increase in African ancestry proportion was associated with an age- and sex-adjusted FG increase of 0.0019 mmol/l (p = 0.01). In the BMI- and SES-adjusted model the slope was 0.0019 (p = 0.02). Analysis of HbA1c gave similar results. CONCLUSIONS/INTERPRETATION A greater proportion of African genetic ancestry is independently associated with higher FG levels in a non-diabetic community-based cohort, even accounting for other ancestry proportions, obesity and SES. The results suggest that differences between African-Americans and whites in type 2 diabetes risk may include genetically mediated differences in glucose homeostasis.
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Affiliation(s)
- James B Meigs
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA, 02114, USA,
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Forjuoh SN, Bolin JN, Huber Jr JC, Vuong AM, Adepoju OE, Helduser JW, Begaye DS, Robertson A, Moudouni DM, Bonner TJ, McLeroy KR, Ory MG. Behavioral and technological interventions targeting glycemic control in a racially/ethnically diverse population: a randomized controlled trial. BMC Public Health 2014; 14:71. [PMID: 24450992 PMCID: PMC3909304 DOI: 10.1186/1471-2458-14-71] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 12/09/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Diabetes self-care by patients has been shown to assist in the reduction of disease severity and associated medical costs. We compared the effectiveness of two different diabetes self-care interventions on glycemic control in a racially/ethnically diverse population. We also explored whether reductions in glycated hemoglobin (HbA1c) will be more marked in minority persons. METHODS We conducted an open-label randomized controlled trial of 376 patients with type 2 diabetes aged ≥18 years and whose last measured HbA1c was ≥7.5% (≥58 mmol/mol). Participants were randomized to: 1) a Chronic Disease Self-Management Program (CDSMP; n = 101); 2) a diabetes self-care software on a personal digital assistant (PDA; n = 81); 3) a combination of interventions (CDSMP + PDA; n = 99); or 4) usual care (control; n = 95). Enrollment occurred January 2009-June 2011 at seven regional clinics of a university-affiliated multi-specialty group practice. The primary outcome was change in HbA1c from randomization to 12 months. Data were analyzed using a multilevel statistical model. RESULTS Average baseline HbA1c in the CDSMP, PDA, CDSMP + PDA, and control arms were 9.4%, 9.3%, 9.2%, and 9.2%, respectively. HbA1c reductions at 12 months for the groups averaged 1.1%, 0.7%, 1.1%, and 0.7%, respectively and did not differ significantly from baseline based on the model (P = .771). Besides the participants in the PDA group reporting eating more high-fat foods compared to their counterparts (P < .004), no other significant differences were observed in participants' diabetes self-care activities. Exploratory sub-analysis did not reveal any marked reductions in HbA1c for minority persons but rather modest reductions for all racial/ethnic groups. CONCLUSIONS Although behavioral and technological interventions can result in some modest improvements in glycemic control, these interventions did not fare significantly better than usual care in achieving glycemic control. More research is needed to understand how these interventions can be most effective in clinical practice. The reduction in HbA1c levels found in our control group that received usual care also suggests that good routine care in an integrated healthcare system can lead to better glycemic control. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01221090.
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Affiliation(s)
- Samuel N Forjuoh
- Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, TX, USA
- Department of Epidemiology & Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
- Department of Health Promotion & Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Jane N Bolin
- Department of Health Policy & Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - John C Huber Jr
- Department of Epidemiology & Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Ann M Vuong
- Department of Epidemiology & Biostatistics, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Omolola E Adepoju
- Department of Health Policy & Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Janet W Helduser
- Department of Health Policy & Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Dawn S Begaye
- Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, TX, USA
| | - Anne Robertson
- Department of Family & Community Medicine, Scott & White Healthcare, College of Medicine, Texas A&M Health Science Center, Temple, TX, USA
| | - Darcy M Moudouni
- Department of Health Policy & Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Timethia J Bonner
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
| | - Kenneth R McLeroy
- Department of Health Promotion & Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
| | - Marcia G Ory
- Department of Health Promotion & Community Health Sciences, School of Rural Public Health, Texas A&M Health Science Center, College Station, TX, USA
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Abstract
HbA1c has become the gold standard for monitoring glycemic control in patients with diabetes mellitus. The use of this test has been expanded to diagnose and screen for diabetes mellitus with the endorsement of influential diabetes societies and the World Health Organization. The literature on the use of HbA1c for the diagnosis and screening of diabetes mellitus was critically examined. There is substantial recent literature on this topic with strong advocates for the use of HbA1c to diagnose and screen for diabetes and equally strong detractors for its use. Advocates of the use of HbA1c cite challenges in respect of patient compliance and the analysis of glucose and inconsistency of diagnosis with glucose-based diabetes diagnosis with the elimination or reduction in these challenges in HbA1c-based diagnosis. Detractors of its use cite increased cost, concerns about the availability of HbA1c testing, and the influence of demographic and clinical factors on HbA1c results that make the use of a single-threshold values questionable for different ethnic and age groups. Despite the recommendation of many international diabetes societies that HbA1c be used for screening and diagnosis of diabetes mellitus, there is a wide divergence of opinion on this use.
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Affiliation(s)
- Trefor Higgins
- DynaLIFEDx, #200, 10150 102 St, Edmonton, AB, T6L 1X2, Canada.
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11
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Campbell JA, Walker RJ, Smalls BL, Egede LE. Glucose control in diabetes: the impact of racial differences on monitoring and outcomes. Endocrine 2012; 42:471-82. [PMID: 22815042 PMCID: PMC3779599 DOI: 10.1007/s12020-012-9744-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 07/05/2012] [Indexed: 11/30/2022]
Abstract
Type 2 diabetes is the seventh leading cause of death in the US and is projected to increase in prevalence globally. Minorities are disproportionately affected by diabetes and data suggest that clinical outcomes consistently fall below American Diabetes Association recommendations. The purpose of this systematic review was to examine ethnic differences in self-monitoring and outcomes in adults with type 2 diabetes. Medline was searched for articles published between January 1990 and January 2012 by means of a reproducible strategy. Inclusion criteria included (1) published in English, (2) targeted African Americans, Hispanic, or Asian adults, ages 18+ years with type 2 diabetes, (3) cross-sectional, cohort, or intervention study, and (4) measured change in glycemic control, BP, lipids, or quality of life by race. Twenty-two papers met the inclusion criteria and were reviewed. Overall, significant racial differences and barriers were found in published studies in diabetes management as it pertains to self-monitoring and outcomes. African Americans tend to consistently exhibit worse outcomes and control when compared to other minority populations and non-Hispanic Whites. In conclusion, significant racial differences and barriers exist in diabetes management as it pertains to self-monitoring and outcomes when compared to non-Hispanic Whites. Explanatory and intervention studies are needed to determine the mechanisms and mediators of these differences and strategies to reduce these disparities. In addition, more research is needed to investigate the impact of racial differences in self-monitoring and outcomes on quality of life.
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Affiliation(s)
- Jennifer A. Campbell
- Center for Health Disparities Research, Medical University of South
Carolina Charleston, South Carolina
| | - Rebekah J. Walker
- Center for Health Disparities Research, Medical University of South
Carolina Charleston, South Carolina
- Division of General Internal Medicine and Geriatrics, Department of
Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Brittany L. Smalls
- Center for Health Disparities Research, Medical University of South
Carolina Charleston, South Carolina
| | - Leonard E. Egede
- Center for Health Disparities Research, Medical University of South
Carolina Charleston, South Carolina
- Division of General Internal Medicine and Geriatrics, Department of
Medicine, Medical University of South Carolina, Charleston, South Carolina
- Center for Disease Prevention and Health Interventions for Diverse
Populations, Charleston VA REAP, Ralph H. Johnson VA Medical Center, Charleston,
South Carolina
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Higgins T. HbA1c — An analyte of increasing importance. Clin Biochem 2012; 45:1038-45. [DOI: 10.1016/j.clinbiochem.2012.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 06/04/2012] [Accepted: 06/06/2012] [Indexed: 11/29/2022]
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Melia MT, Muir AJ, McCone J, Shiffman ML, King JW, Herrine SK, Galler GW, Bloomer JR, Nunes FA, Brown KA, Mullen KD, Ravendhran N, Ghalib RH, Boparai N, Jiang R, Noviello S, Brass CA, Albrecht JK, McHutchison JG, Sulkowski MS. Racial differences in hepatitis C treatment eligibility. Hepatology 2011; 54:70-8. [PMID: 21488082 PMCID: PMC3736356 DOI: 10.1002/hep.24358] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
UNLABELLED Black Americans are disproportionally infected with hepatitis C virus (HCV) and are less likely than whites to respond to treatment with peginterferon (PEG-IFN) plus ribavirin (RBV). The impact of race on HCV treatment eligibility is unknown. We therefore performed a retrospective analysis of a phase 3B multicenter clinical trial conducted at 118 United States community and academic medical centers to evaluate the rates of and reasons for HCV treatment ineligibility according to self-reported race. In all, 4,469 patients were screened, of whom 1,038 (23.2%) were treatment ineligible. Although blacks represented 19% of treated patients, they were more likely not to be treated due to ineligibility and/or failure to complete required evaluations (40.2%) than were nonblack patients (28.5%; P < 0.001). After the exclusion of persons not treated due to undetectable HCV RNA or nongenotype 1 infection, blacks were 65% less likely than nonblacks to be eligible for treatment (28.1% > 17.0%; relative risk, 1.65; 95% confidence interval, 1.46-1.87; P < 0.001). Blacks were more likely to be ineligible due to neutropenia (14% versus 3%, P < 0.001), anemia (7% versus 4%, P = 0.02), elevated glucose (8% versus 3%, P < 0.001), and elevated creatinine (5% versus 1%, P < 0.001). CONCLUSION Largely due to a higher prevalence of neutropenia and uncontrolled medical conditions, blacks were significantly less likely to be eligible for HCV treatment. Increased access to treatment may be facilitated by less conservative neutrophil requirements and more effective care for chronic diseases, namely, diabetes and renal insufficiency.
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Affiliation(s)
- Michael T Melia
- Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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14
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Comparative Performance of Comorbidity Indices in Discriminating Health-related Behaviors and Outcomes. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.ehrm.2011.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Determinants of glycaemic control in type 2 diabetes African patients monitored by physicians from 1991 to 2004 in Cote d’Ivoire. Trans R Soc Trop Med Hyg 2010; 104:298-303. [DOI: 10.1016/j.trstmh.2009.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 10/20/2009] [Accepted: 10/20/2009] [Indexed: 11/22/2022] Open
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Winston GJ, Barr RG, Carrasquillo O, Bertoni AG, Shea S. Sex and racial/ethnic differences in cardiovascular disease risk factor treatment and control among individuals with diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA). Diabetes Care 2009; 32:1467-9. [PMID: 19435957 PMCID: PMC2713610 DOI: 10.2337/dc09-0260] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 04/22/2009] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine sex and racial/ethnic differences in cardiovascular risk factor treatment and control among individuals with diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA). RESEARCH DESIGN AND METHODS This study was an observational study examining mean levels of cardiovascular risk factors and proportion of subjects achieving treatment goals. RESULTS The sample included 926 individuals with diabetes. Compared with men, women were 9% less likely to achieve LDL cholesterol <130 mg/dl (adjusted prevalence ratio 0.91 [0.83-0.99]) and systolic blood pressure (SBP) <130 mmHg (adjusted prevalence ratio 0.91 [0.85-0.98]). These differences diminished over time. A lower percentage of women used aspirin (23 vs. 33%; P < 0.001). African American and Hispanic women had higher mean levels of SBP and lower prevalence of aspirin use than non-Hispanic white women. CONCLUSIONS Women with diabetes had unfavorable cardiovascular risk factor profiles compared with men. African American and Hispanic women had less favorable profiles than non-Hispanic white women.
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Affiliation(s)
- Ginger J. Winston
- Division of General Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - R. Graham Barr
- Division of General Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Olveen Carrasquillo
- Division of General Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Alain G. Bertoni
- Division of Public Health Sciences and Maya Angelou Center for Health Equity, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Steven Shea
- Division of General Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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Higgins T, Cembrowski G, Tran D, Lim E, Chan J. Influence of variables on hemoglobin A1c values and nonheterogeneity of hemoglobin A1c reference ranges. J Diabetes Sci Technol 2009; 3:644-8. [PMID: 20144306 PMCID: PMC2769978 DOI: 10.1177/193229680900300404] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Hemoglobin A1c (HbA1c) values are influenced by analytical interferences such as HbF and hemoglobin variants and clinical factors such as increased red cell turnover. Although less well-known, demographic factors such as race, age, and sex also influence HbA1c values. The HbA1c reference range should be homogenous in the United States based on the use of National Glycohemoglobin Standardization Program certified methods and the recommendations in the National Academy of Clinical Biochemistry guidelines. METHODS Data on age, race, sex, HbA1c, and glucose values were extracted from the National Health and Nutrition Examination study for a 3 year period. A search for reference range data for laboratories in the United States was performed using the Google search engine. RESULTS Extracted data agree with published data on the influence of age, sex, and smoking status on HbA1c values. There is substantial heterogeneity in HbA1c reference ranges in laboratories in the United States. CONCLUSION Age, sex, and smoking status influence HbA1c values. Despite standardization of HbA1c methods and published recommendations, there is wide heterogeneity in HbA1c reference ranges in the United States.
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Trinacty CM, Adams AS, Soumerai SB, Zhang F, Meigs JB, Piette JD, Ross-Degnan D. Racial differences in long-term adherence to oral antidiabetic drug therapy: a longitudinal cohort study. BMC Health Serv Res 2009; 9:24. [PMID: 19200387 PMCID: PMC2645384 DOI: 10.1186/1472-6963-9-24] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 02/07/2009] [Indexed: 11/12/2022] Open
Abstract
Background Adherence to oral antidiabetic medications is often suboptimal. Adherence differences may contribute to health disparities for black diabetes patients, including higher microvascular event rates, greater complication-related disability, and earlier mortality. Methods In this longitudinal retrospective cohort study, we used 10 years of patient-level claims and electronic medical record data (1/1/1992–12/31/2001) to assess differences in short- and long-term adherence to oral antidiabetic medication among 1906 newly diagnosed adults with diabetes (26% black, 74% white) in a managed care setting in which all members have prescription drug coverage. Four main outcome measures included: (1) time from diabetes diagnosis until first prescription of oral antidiabetic medication; (2) primary adherence (time from first prescription to prescription fill); (3) time until discontinuation of oral antidiabetic medication from first prescription; and (4) long-term adherence (amount dispensed versus amount prescribed) over a 24-month follow-up from first oral antidiabetic medication prescription. Results Black patients were as likely as whites to initiate oral therapy and fill their first prescription, but experienced higher rates of medication discontinuation (HR: 1.8, 95% CI: 1.2, 2.7) and were less adherent over time. These black-white differences increased over the first six months of therapy but stabilized thereafter for patients who initiated on sulfonylureas. Significant black-white differences in adherence levels were constant throughout follow-up for patients initiated on metformin therapy. Conclusion Racial differences in adherence to oral antidiabetic drug therapy persist even with equal access to medication. Early and continued emphasis on adherence from initiation of therapy may reduce persistent racial differences in medication use and clinical outcomes.
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Affiliation(s)
- Connie M Trinacty
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA.
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19
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Rhee MK, Ziemer DC, Caudle J, Kolm P, Phillips LS. Use of a uniform treatment algorithm abolishes racial disparities in glycemic control. DIABETES EDUCATOR 2008; 34:655-63. [PMID: 18669807 DOI: 10.1177/0145721708320903] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study is to compare glycemic control between blacks and whites in a setting where patient and provider behavior is assessed, and where a uniform treatment algorithm is used to guide care. METHODS This observational cohort study was conducted in 3542 patients (3324 blacks, 218 whites) with type 2 diabetes with first and 1-year follow-up visits to a municipal diabetes clinic; a subset had 2-year follow-up. Patient adherence and provider management were determined. The primary endpoint was A1c. RESULTS At presentation, A1c was higher in blacks than whites (8.9% vs 8.3%; P < .001), even after adjusting for demographic and clinical characteristics. During 1 year of follow-up, patient adherence to scheduled visits and medications was comparable in both groups, and providers intensified medications with comparable frequency and amount. After 1 year, A1c differences decreased but remained significant (7.7% vs 7.3%; P = .029), even in multivariable analysis (P = .003). However, after 2 years, A1c differences were no longer observed by univariate (7.6% vs 7.5%; P = .51) or multi-variable analysis (P = .18). CONCLUSIONS Blacks have higher A1c than whites at presentation, but differences narrow after 1 year and disappear after 2 years of care in a setting where patient and provider behavior are comparable and that emphasizes uniform intensification of therapy. Presumably, racial disparities at presentation reflected prior inequalities in management. Use of uniform care algorithms nationwide should help to reduce disparities in diabetes outcomes.
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Affiliation(s)
- Mary K Rhee
- The Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Rhee, Dr Ziemer, Ms Caudle, Dr Phillips)
| | - David C Ziemer
- The Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Rhee, Dr Ziemer, Ms Caudle, Dr Phillips)
| | - Jane Caudle
- The Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Rhee, Dr Ziemer, Ms Caudle, Dr Phillips)
| | - Paul Kolm
- The Christiana Care Center for Outcomes Research, Newark, Deleware (Dr Kolm)
| | - Lawrence S Phillips
- The Division of Endocrinology and Metabolism, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia (Dr Rhee, Dr Ziemer, Ms Caudle, Dr Phillips)
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Adams AS, Trinacty CM, Zhang F, Kleinman K, Grant RW, Meigs JB, Soumerai SB, Ross-Degnan D. Medication adherence and racial differences in A1C control. Diabetes Care 2008; 31:916-21. [PMID: 18235050 PMCID: PMC2563955 DOI: 10.2337/dc07-1924] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this study was to examine medication adherence and other self-management practices as potential determinants of higher glycemic risk among black relative to white patients. RESEARCH DESIGN AND METHODS We used a retrospective, longitudinal repeated-measures design to model the contribution of medication adherence to black-white differences in A1C among type 2 diabetic patients at a large multispecialty group practice. We identified 1,806 adult (aged >/=18 at diagnosis) patients (467 black and 1,339 white) with newly initiated oral hypoglycemic therapy between 1 December 1994 and 31 December 2000. Race was identified using an electronic medical record and patient self-report. Baseline was defined as the 13 months preceding and included the month of therapy initiation. All patients were required to have at least 12 months of follow-up. RESULTS At initiation of therapy, black patients had higher average A1C values compared with whites (9.8 vs. 8.9, a difference of 0.88; P < 0.0001). Blacks had lower average medication adherence during the first year of therapy (72 vs. 78%; P < 0.0001). Although more frequent medication refills were associated with lower average A1C values, adjustment for adherence did not eliminate the black-white gap. CONCLUSIONS We found persistent racial differences in A1C that were not explained by differences in medication adherence. Our findings suggest that targeting medication adherence alone is unlikely to reduce disparities in glycemic control in this setting. Further research is needed to explore possible genetic and environmental determinants of higher A1C among blacks at diagnosis, which may represent a critical period for more intensive intervention.
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Affiliation(s)
- Alyce S Adams
- Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts, USA.
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Abstract
PURPOSE OF REVIEW Ethnic disparities in disease management have been clearly documented across the medical field, but appear to be an even greater issue with regards to chronic disease. While various gaps in the provision of quality care persist, there have been some improvements in addressing some of those challenges. The purpose of this review is to highlight some of the persistent gaps in the provision of healthcare, with a focus on disparities seen in vulnerable populations, as well as opportunities to address those disparities. RECENT FINDINGS Disparities in the provision of health persist, especially in vulnerable populations. There is a growing awareness to actively address these issues. A number of projects have been undertaken to assess their impact on the provision of quality healthcare and consequent outcomes, with mixed results. For vulnerable populations, it appears that individualized, repeated, culturally sensitive interventions that involve the community from their inception have had the greatest positive impact. SUMMARY A growing body of data is emerging to not only highlight the disparities in healthcare we still confront in the USA, but to also implement strategies to successfully address and resolve those challenges.
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Affiliation(s)
- Luigi Meneghini
- Diabetes Research Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida 33136, USA.
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Understanding the Gap Between Good Processes of Diabetes Care and Poor Intermediate Outcomes. Med Care 2007; 45:1144-53. [DOI: 10.1097/mlr.0b013e3181468e79] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Trinacty CM, Adams AS, Soumerai SB, Zhang F, Meigs JB, Piette JD, Ross-Degnan D. Racial differences in long-term self-monitoring practice among newly drug-treated diabetes patients in an HMO. J Gen Intern Med 2007; 22:1506-13. [PMID: 17763913 PMCID: PMC2219792 DOI: 10.1007/s11606-007-0339-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 06/27/2007] [Accepted: 07/05/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND One approach to improving outcomes for minority diabetics may be through better self-care. However, minority patients may encounter barriers to better self-care even within settings where variations in quality of care and insurance are minimized. OBJECTIVE The objective of the study was to evaluate racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring. DESIGN Retrospective cohort study using 10 years (1/1/1993-12/31/2002) of electronic medical record data was used. PATIENTS Patients were 1,732 insured adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large multi-specialty care group practice. MEASUREMENTS Outcomes include incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards. RESULTS We found no evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients, but found lower rates of initiation among black patients living in low-income areas. Intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up [IRR for insulin = 0.41 (0.27-0.62); IRR for oral hypoglycemic = 0.75 (0.63, 0.90)], with both groups monitoring well below recommended standards. Among insulin-treated patients, <1% of blacks and <10% of whites were self-monitoring 3 times per day; 36% of whites and 10% of blacks were self-monitoring at least once per day. CONCLUSIONS Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a health system providing equal access to services for diabetes patients. Early and continued emphasis on adherence among black diabetics may be necessary to reduce racial differences in long-term glucose self-monitoring.
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Affiliation(s)
- Connie Mah Trinacty
- Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA 02215, USA.
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Soljak MA, Majeed A, Eliahoo J, Dornhorst A. Ethnic inequalities in the treatment and outcome of diabetes in three English Primary Care Trusts. Int J Equity Health 2007; 6:8. [PMID: 17678547 PMCID: PMC1995195 DOI: 10.1186/1475-9276-6-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 08/02/2007] [Indexed: 11/29/2022] Open
Abstract
Background Although the prevalence of diabetes is three to five times higher in UK South Asians than Whites, there are no reports of the extent of ethnicity recording in routine general practice, and few population-based published studies of the association between ethnicity and quality of diabetes care and outcomes. We aimed to determine the association between ethnicity and healthcare factors in an English population. Methods Data was obtained in 2002 on all 21,343 diabetic patients registered in 99% of all computerised general practitioner (GP) practices in three NW London Primary Care Trusts (PCTs), covering a total registered population of 720,000. Previously practices had been provided with training, data entry support and feedback. Treatment and outcome measures included drug treatment and blood pressure (BP), total cholesterol and haemoglobin A1c (HbA1c) levels. Results Seventy per cent of diabetic patients had a valid ethnicity code. In the relatively older White population, we expected a smaller proportion with a normal BP, but BP differences between the groups were small and suggested poorer control in non-White ethnic groups. There were also significant differences between ethnic groups in the proportions of insulin-treated patients, with a smaller proportion of South Asians – 4.7% compared to 7.1% of Whites – receiving insulin, although the proportion with a satisfactory HbA1c was smaller- 25.6% compared to 37.9%. Conclusion Recording the ethnicity of existing primary care patients is feasible, beginning with patients with established diseases such as diabetes. We have shown that the lower proportion of South Asian patients with good diabetes control, and who are receiving insulin, is at least partly due to poorer standards of care in South Asians, although biological and cultural factors could also contribute. This study highlights the need to capture ethnicity data in clinical trials and in routine care, to specifically investigate the reasons for these ethnic differences, and to consider more intensive management of diabetes and education about the disease in South Asian patients.
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Affiliation(s)
- Michael A Soljak
- NHS London, Victory House, 170 Tottenham Court Road, London, W1T 7HA, UK
| | - Azeem Majeed
- Department of Primary Care and Social Medicine, Imperial College London,, London, SW7 2AZ, UK
| | - Joseph Eliahoo
- Statistical Advisory Service, Imperial College, South Kensington Campus, London, SW7 2AZ, UK
| | - Anne Dornhorst
- Division of Investigative Science, Imperial College, Charing Cross Campus, St. Dunstan's Road, London, W6 8RP, UK
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Millett C, Gray J, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth Prospective Diabetes Study. PLoS Med 2007; 4:e191. [PMID: 17564486 PMCID: PMC1891316 DOI: 10.1371/journal.pmed.0040191] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Accepted: 04/11/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004. METHODS AND FINDINGS We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005. CONCLUSIONS Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.
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MESH Headings
- Adult
- Africa/ethnology
- Aged
- Aged, 80 and over
- Bangladesh/ethnology
- Blood Pressure
- Caribbean Region/ethnology
- Cholesterol/blood
- Contracts
- Diabetes Mellitus/blood
- Diabetes Mellitus/economics
- Diabetes Mellitus/ethnology
- Diabetes Mellitus/therapy
- Disease Management
- Ethnicity
- Family Practice/economics
- Family Practice/organization & administration
- Female
- Glycated Hemoglobin/analysis
- Goals
- Health Policy
- Humans
- India/ethnology
- London
- Male
- Medical Records Systems, Computerized/statistics & numerical data
- Middle Aged
- National Health Programs/economics
- National Health Programs/standards
- Outcome Assessment, Health Care/economics
- Outcome Assessment, Health Care/standards
- Pakistan/ethnology
- Physician Incentive Plans/economics
- Physicians, Family/economics
- Practice Management, Medical/economics
- Prejudice
- Prospective Studies
- Quality Indicators, Health Care/economics
- Quality Indicators, Health Care/standards
- Reimbursement, Incentive/economics
- Reimbursement, Incentive/organization & administration
- Treatment Outcome
- United Kingdom/epidemiology
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Affiliation(s)
- Christopher Millett
- Wandsworth Primary Care Research Centre, Wandsworth Primary Care Trust, London, United Kingdom.
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Coberley CR, Puckrein GA, Dobbs AC, McGinnis MA, Coberley SS, Shurney DW. Effectiveness of Disease Management Programs on Improving Diabetes Care for Individuals in Health-Disparate Areas. ACTA ACUST UNITED AC 2007; 10:147-55. [PMID: 17590145 DOI: 10.1089/dis.2007.641] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In addition to race and ethnicity, specific geographic regions are associated with poorer outcomes of care. Individuals with diabetes experiencing health disparities typically have worse long-term outcomes, such as increased diabetes complications and mortality. Zip code mapping, or geocoding, was utilized in this study to identify regions of the United States with high diabetes prevalence rates and to identify areas with high densities of minority populations. Use of this methodology to examine the effect of disease management on a large, diverse diabetes population revealed greater improvement in clinical testing rates in health disparity zones compared with members living outside of these areas. In particular, significant improvement was achieved by members living in minority zip codes and by members aged 65 years or older. These findings demonstrate that members living in areas of health disparity obtain even greater benefit from diabetes disease management program participation, helping to reduce gaps in care.
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Grant R, Adams AS, Trinacty CM, Zhang F, Kleinman K, Soumerai SB, Meigs JB, Ross-Degnan D. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care 2007; 30:807-12. [PMID: 17259469 DOI: 10.2337/dc06-2170] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Clinical inertia has been identified as a critical barrier to glycemic control in type 2 diabetes. We assessed the relationship between patients' initial medication adherence and subsequent regimen intensification among patients with persistently elevated A1C levels. RESEARCH DESIGN AND METHODS We analyzed an inception cohort of 2,065 insured patients with type 2 diabetes who were newly started on hypoglycemic therapy and were followed for at least 3 years between 1992 and 2001. Medication adherence was assessed by taking the ratio of medication days dispensed (from pharmacy records) to medication days prescribed (as documented in the medical record) for the first prescribed hypoglycemic drug. Adherence was measured for the period between medication initiation and the next elevated A1C result measured at least 3 months later; intensification was defined as a dose increase or the addition of a second hypoglycemic agent. RESULTS Patients were aged (mean +/- SD) 55.4 +/- 12.2 years; 53% were men, and 19% were black. Baseline medication adherence was 79.8 +/- 19.3%. Patients in the lowest quartile of adherence were significantly less likely to have their regimens increased within 12 months of their first elevated A1C compared with patients in the highest quartile (27 vs. 37%, respectively, with increased regimens if A1C is elevated, P < 0.001). In multivariate models adjusting for patient demographic and treatment factors, patients in the highest adherence quartile had 53% greater odds of medication intensification after an elevated A1C (95% CI 1.11-1.93, P = 0.01). CONCLUSIONS Among insured diabetic patients with elevated A1C, level of medication adherence predicted subsequent medication intensification. Poor patient self-management behavior increases therapeutic clinical inertia.
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Affiliation(s)
- Richard Grant
- General Medicine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Tseng CL, Sambamoorthi U, Tiwari A, Rajan M, Findley P, Pogach L. Diabetes care among veteran women with disability. Womens Health Issues 2007; 16:361-71. [PMID: 17188219 PMCID: PMC1950593 DOI: 10.1016/j.whi.2006.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 07/12/2006] [Accepted: 07/13/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The primary objective of this study was to analyze predictors of diabetes care consistent with performance standards among women Veterans Health Administration (VHA) clinic users with disability enrollment status. METHODS This is a retrospective cohort study using VHA and Medicare files of VHA clinic users with diabetes. Diabetes care measures consisted of annual testing for hemoglobin A(1c) (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and poor HbA(1c) (>9%) and LDL-C (> or =130 mg/dL) control in fiscal year 2000. Chi-square tests and logistic regressions were used to assess subgroup differences in diabetes care. Independent variables included demographic characteristics and physical and psychiatric comorbidities. POPULATION Study population was based on veteran women <65 years of age who used VHA clinics; we identified 2,344 women as having coexisting disability and diabetes and 2,766 women with diabetes and without disability. FINDINGS Among veteran women with diabetes and disability, 65% received > or =1 HbA(1c) test, and 54% received a LDL-C test; 25% and 30% had poor HbA(1c) and LDL-C control, respectively. In logistic regressions, none of the independent variables had significant effects on poor HbA(1c) or LDL-C control, except that African Americans were more likely to have poor HbA(1c) control than whites. Significant age effects were noted in rates of HbA(1c) and LDL testing. Comparison of diabetes care measures between women with and without disability indicated that those with disability were more likely to receive HbA(1c) and LDL-C tests; no significant differences in HbA(1c) and LDL-C control were noted. CONCLUSIONS Disability status of women veterans was not a barrier to diabetes care consistent with performance standards. Our findings suggest that to improve diabetes care, subgroup-specific interventions, rather than a global approach, are warranted.
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Affiliation(s)
- Chin-Lin Tseng
- Center for Healthcare Knowledge and Management, Veterans Administration New Jersey Health Care System, East Orange, New Jersey 07018, USA.
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Yeo KK, Tai BC, Heng D, Lee JMJ, Ma S, Hughes K, Chew SK, Chia KS, Tai ES. Ethnicity modifies the association between diabetes mellitus and ischaemic heart disease in Chinese, Malays and Asian Indians living in Singapore. Diabetologia 2006; 49:2866-73. [PMID: 17021918 DOI: 10.1007/s00125-006-0469-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 08/14/2006] [Indexed: 01/23/2023]
Abstract
AIMS/HYPOTHESIS The aim of the study was to determine whether the risk of ischaemic heart disease (IHD) associated with diabetes mellitus differs between ethnic groups. METHODS Registry linkage was used to identify IHD events in 5707 Chinese, Malay and Asian Indian participants from three cross-sectional studies conducted in Singapore between the years 1984 and 1995. The study provided a median of 10.2 years of follow-up with 240 IHD events experienced. We assessed the interaction between diabetes mellitus and ethnicity in relation to the risk of IHD events using Cox proportional hazards regression. RESULTS Diabetes mellitus was more common in Asian Indians. Furthermore, diabetes mellitus was associated with a greater risk of IHD in Asian Indians. The hazard ratio when comparing diabetes mellitus with non-diabetes mellitus was 6.41 (95% CI 5.77-7.12) in Asian Indians and 3.07 (95% CI 1.86-5.06) in Chinese (p = 0.009 for interaction). Differences in the levels of established IHD risk factors among diabetics from the three ethnic groups did not appear to explain the differences in IHD risk. CONCLUSIONS/INTERPRETATION Asian Indians are more susceptible to the development of diabetes mellitus than Chinese and Malays. When Asian Indians do develop diabetes mellitus, the risk of IHD is higher than for Chinese and Malays. Consequently, the prevention of diabetes mellitus amongst this ethnic group is particularly important for the prevention of IHD in Asia, especially given the size of the population at risk. Elucidation of the reasons for these ethnic differences may help us understand the pathogenesis of IHD in those with diabetes mellitus.
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Affiliation(s)
- K K Yeo
- Department of Endocrinology, Singapore General Hospital, Block 6 level 6, Room B35, Outram Road, Singapore, Singapore
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Dave JK, Kamdar VV. Ethnicity and diabetic heart disease. Endocrinol Metab Clin North Am 2006; 35:633-49, x. [PMID: 16959590 DOI: 10.1016/j.ecl.2006.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Ethnicity is a complex yet important construct and an independent risk factor for diabetic heart disease (DHD) with paramount clinical significance. Clinicians should try to better understand the role of ethnicity through more questions. The risk of DHD is modified by ethnicity through more questions. The risk of DHD is modified by ethnicity, and its management may require a culturally sensitive individualized approach. Findings from Caucasian populations cannot be fully extrapolated to other ethnic groups, thereby emphasizing the importance of future research with ethnicity-based threshold for obesity. Available limited data support the interaction between genetic predisposition, environmental risk, and lifestyle choices and disparities based on ethnicity as the likely cause for ethnic variations in DHD.
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Affiliation(s)
- Jatin K Dave
- Harvard Medical School, Division of Aging, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
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Hart CB. Race differences in long-term diabetes management in an HMO: response to Adams et al. Diabetes Care 2006; 29:1461-2; author reply 1462. [PMID: 16732052 DOI: 10.2337/dc06-0262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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