Racial differences in patient perception of interactions with providers are associated with health outcomes in type II diabetes

In Pursuit of Person-Centered Medicine: How Do People with Type 2 Diabetes Choose Glucose-Lowering Medications? A Qualitative Study

BACKGROUND

Clinical guidelines recommend person-centered selection of glucose-lowering therapies that takes patient goals, preferences, and needs into consideration. However, there is limited understanding of how patients' preferences and experiences shape their medication choices.

OBJECTIVE

To explore how individuals with type 2 diabetes (T2D) choose glucose-lowering medications, focusing on their treatment goals, preferences, and alignment between patient and clinician priorities.

DESIGN

Qualitative study.

PARTICIPANTS

Forty adults with T2D at moderate cardiovascular disease risk, currently taking ≥ 1 glucose-lowering medication, recruited from two health systems in the Midwestern and Southern United States.

APPROACH

Semi-structured individual interviews were conducted to explore factors influencing medication choice, quality of communication with clinicians, and degree of patient-perceived alignment between patient and clinician treatment goals.

KEY RESULTS

Among the 40 participants, 55% were female with a mean age of 56.1 years (SD 13.6). The majority identified as White (50.0%) or Black (37.5%). Participants emphasized the importance of avoiding specific side effects and achieving efficacy in their T2D medication choices. While participants valued clear and comprehensive information about medications from clinicians, many described unmet needs and often supplemented clinical information with advice from peers and online sources. Perceptions around medication decision-making authority varied, with some participants preferring patient-led choices, others relying on clinician expertise, and many advocating for a collaborative or shared decision-making approach to selecting a T2D medication. Discrepancies were noted between clinical priorities and person-centered outcomes, with patients prioritizing quality of life and manageable treatment regimens over strict clinical targets.

CONCLUSIONS

Understanding patient preferences and experiences is crucial for achieving person-centeredness in T2D medication management. Participants described diverse approaches to evaluating glucose-lowering medications, prioritizing quality of life, ease of adherence, and minimizing side effects. Transparent and collaborative communication with clinicians was identified as crucial for aligning treatment plans with patient values.

Using normalisation process theory to understand implementation of effective early-onset type 2 diabetes treatment and care within England: a qualitative study

BACKGROUND

Despite increasing prevalence, early-onset type 2 diabetes (EOT2D) has received little clinical and qualitative research attention within England. This qualitative study aimed to explore and understand the unmet needs of people living with early-onset type 2 diabetes (PEOT2D) and their diabetes care within England.

METHODS

Using semi-structured interviews, data was collected, transcribed and analysed from 25 PEOT2D and 25 healthcare professionals (HCPs). Taking an abductive approach, data for both cohorts were analysed and interpreted according to four constructs of Normalisation Process Theory (NPT): coherence (sense-making), cognitive participation (engagement), collective action (enactment) and reflexive monitoring (formal and informal appraisal).

RESULTS

Our findings revealed several unmet needs in current treatment and care for PEOT2D. The main unmet need was access to specialist care. Having GP (general practitioner) practices as their main caregivers presented a significant barrier to this population successfully carrying out their diabetes self-care. HCPs in specialist roles expressed similar views and were keen to see PEOT2D receive access to holistic and specialist care via a multidisciplinary team. Data interpretation according to the four constructs of NPT found that implementation of this approach would involve fostering an environment of support that allowed HCPs across the primary and secondary interface to do the following: (1) provide consultations incorporating person-centred care, shared decision-making, and non-judgemental and non-stigmatising behaviours and (2) work in an integrated and synchronous manner using streamlined referrals, interprofessional collaborations and team-based learning. Provision of tailored financial, human (additional staffing) and learning resources was found to be integral to allow creation of tailored multidisciplinary teams, and individual and collective skill enhancement of both specialist and primary care providers.

CONCLUSION

Although both PEOT2D and specialist care providers are keen for young adults with EOT2D to receive access to specialist and holistic care, there are several resource barriers that must be addressed to allow implementation of their desired approach to treatment and care. Further qualitative research with primary care providers (for example, GPs and practice nurses) involved in EOT2D care is needed to understand if (and how) their views and experiences differ from those providing specialist care.

Adapting the NIMHD Research Framework for Type 2 Diabetes-Related Disparities

PURPOSE OF REVIEW

Type 2 diabetes (T2D) disproportionately impacts minority populations. The National Institute on Minority Health and Health Disparities (NIMHD) developed a research framework to encourage health disparities research that considers a multi-level, multi-domain perspective. The purpose of this review was to describe evidence on the levels and domains that influence T2D disparities among minority populations and use this information to adapt the NIMHD Research Framework for T2D.

RECENT FINDINGS

Screening identified 108 articles published between 2017 and 2023 covering 74,354,597 participants. Articles were classified under the following domains, Biological (18), Behavioral (22), Physical/Built Environment (19), Sociocultural Environment (42), and Health Care System (31). Article levels of influence included Individual (73), Interpersonal (18), Community (36), and Societal (10). Findings were used to adapt the NIMHD Research Framework with an eye towards advancing T2D-related health equity. The results of this review confirm the complex nature of T2D-related disparities and support the notion that drivers operate within and between multiple levels and multiple domains to influence T2D-related outcomes across the lifespan.

Instruments evaluating the duration and pace of clinical encounters: A scoping review

OBJECTIVE

Hurried encounters in clinical settings contribute to dissatisfaction among both patients and clinicians and may indicate and contribute to low-quality care. We sought to identify patient- or clinician-reported instruments concerning this experience of time in clinical encounters.

METHODS

We searched multiple databases from inception through July 2023. Working in duplicate without restrictions by language or clinical context, we identified published instruments or single items measuring perceptions of time adequacy in clinical encounters. We characterized these by time domain (perceived duration or pace of the encounter), responder (patient or clinician), and reference (experience of care in general or of a particular encounter).

RESULTS

Of the 96 instruments found, none focused exclusively on perception of time adequacy in clinical encounters. Nonetheless, these instruments contained 107 time-related items. Of these, 81 items (77 %) measured the perception of the encounter duration, assessing whether there was adequate consultation time overall or for specific tasks (e.g., listening to the patient, exploring psychosocial issues, formulating the care plan). Another 19 (18 %) assessed encounter pace, and 7 (7 %) assessed both duration and pace. Pace items captured actions perceived as rushed or hurried or the perception that patients and clinicians felt pressed for time or rushed. Patients were the respondents for 76 (71 %) and clinicians for 24 (22 %) items. Most patient-reported items (48 of 76) referred to the patient's general care experience.

CONCLUSION

There are existing items to capture patient and clinician perceptions of the duration and/or pace of clinical encounters. Further work should ascertain their ability to identify hurried consultations and to detect the effect of interventions to foster unhurried encounters.

PRACTICE IMPLICATIONS

The available items assessing patient and clinician perceptions of duration and pace can illuminate the experience of time adequacy in clinical encounters as a target for quality improvement interventions. These items may capture unintended consequences on perceived time for care of interventions to improve healthcare access and efficiency.

A Systematic Review of the Relationship Between Discrimination, Racism, and Type 2 Diabetes Healthcare Outcomes for Black Americans

BACKGROUND

Disparities in type 2 diabetes (T2DM) risk, care, and complications impact Black Americans more than that of their White counterparts. This study aims to examine the association between discrimination, racism, and T2DM care and outcomes in Black Americans.

METHOD

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

A total of six original research articles met the inclusion criteria, comprising three quantitative and three qualitative studies. Overall, the systematic review findings revealed that among Black Americans, perceived interpersonal discrimination and racism by healthcare professionals are associated with patients' behaviors that impact T2DM outcomes. The findings also revealed that provider-level factors such as communication, provider assumptions and attitudes, information sharing, shared decision-making, and disease management behaviors might influence T2DM outcomes in this population.

DISCUSSION

Better T2DM-related outcomes depend on optimal disease control through adequate disease management. Building a therapeutic and culturally appropriate relationship free of discrimination and racism is vital for optimal disease management and decreasing health disparities in this patient population.

CONCLUSION

Perceived interpersonal racism and discrimination by healthcare providers, among other sociocultural factors, play a crucial role in influencing some patient behaviors that affect T2DM health outcomes in this population. Efforts to decrease health disparities in this specific community should also focus on interventions addressing provider-level factors and behaviors perceived as racist or discriminatory.

Impact of Negative or Stigmatizing Messages on Diabetes Outcomes: An Integrative Review

PURPOSE

The purpose was to determine if negative or stigmatizing language and messaging have an impact on diabetes distress, outcomes, or care behaviors in people with diabetes. Since 2012, when the first language position statement was published, the way health care professionals talk to people with diabetes has been an ongoing topic of discussion. However, there have been no recent literature reviews evaluating the impact of problem language on outcomes among people with type 1 and type 2 diabetes.

METHODS

An integrative review was conducted using 4 electronic databases: CINAHL, Embase, Web of Science, and Medline (Ovid). Studies reporting on diabetes, language, stigma, diabetes distress, glycemic outcomes, and self-care behaviors were included.

RESULTS

The review included 9 studies, all of which were of high quality. The impact of negative or stigmatizing language on self-care behaviors was the most commonly addressed outcome. Whereas some studies revealed no change, others reported a decrease in self-care behaviors by people with diabetes who had negative perceptions of provider messages. Actual or perceived use of negative or stigmatizing language is linked to higher A1C. Four studies reported an association between messages and diabetes distress.

CONCLUSIONS

Negative/stigmatizing language has both an immediate and long-term effect on people with diabetes. The inconsistent approaches to studying language in diabetes makes it challenging to compare outcomes and identify themes. Future research is needed to identify effective interventions to change the messages in diabetes.

Perspective: Nutrition Health Disparities Framework: A Model to Advance Health Equity

Disparities in nutrition, such as poor diet quality and inadequate nutrient intake, arise from multiple factors and are related to adverse health outcomes such as obesity, diabetes, cardiovascular disease, and some cancers. The aim of the current perspective is to present a nutrition-centric socioecological framework that delineates determinants and factors that contribute to diet and nutrition-related disparities among disadvantaged populations. The Nutrition Health Disparities Framework (NHDF) describes the domains (biological, behavioral, physical/built environment, sociocultural environment, and healthcare system) that influence nutrition-related health disparities through the lens of each level of influence (that is, individual, interpersonal, community, and societal). On the basis of the scientific literature, the authors engaged in consensus decision making in selecting nutrition-related determinants of health within each domain and socioecological level when creating the NHDF. The framework identifies how neighborhood food availability and access (individual/built environment) intersect with cultural norms and practices (interpersonal/sociocultural environment) to influence dietary behaviors, exposures, and risk of diet-related diseases. In addition, the NHDF shows how factors such as genetic predisposition (individual/biology), family dietary practices (interpersonal/behavioral), and food marketing policies (societal) may impact the consumption of unhealthy foods and beverages and increase chronic disease risk. Family and peer norms (interpersonal/behavior) related to breastfeeding and early childhood nutrition interact with resource-poor environments such as lack of access to preventive healthcare settings (societal/healthcare system) and low usage of federal nutrition programs (societal/behavioral), which may increase risk of poor nutrition during childhood and food insecurity. The NHDF describes the synergistic interrelationships among factors at different levels of the socioecological model that influence nutrition-related outcomes and exacerbate health disparities. The framework is a useful resource for nutrition researchers, practitioners, food industry leaders, and policymakers interested in improving diet-related health outcomes and promoting health equity in diverse populations.

Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report

In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.

Disparities in diabetes prevalence and management by race and ethnicity in the USA: defining a path forward

Type 2 diabetes disparities in the USA persist in both the prevalence of disease and diabetes-related complications. We conducted a literature review related to diabetes prevention, management, and complications across racial and ethnic groups in the USA. The objective of this review is to summarise the current understanding of diabetes disparities by examining differences between and within racial and ethnic groups and among young people (aged <18 years). We also examine the pathophysiology of diabetes as it relates to race and ethnic differences. We use a conceptual framework built on the socioecological model to categorise the causes of diabetes disparities across the lifespan looking at factors in five domains of health behaviours and social norms, public awareness, structural racism, economic development, and access to high-quality care. The range of disparities in diabetes prevalence and management in the USA calls for a community-engaged and multidisciplinary approach that must involve community partners, researchers, practitioners, health system administrators, and policy makers. We offer recommendations for each of these groups to help to promote equity in diabetes prevention and care in the USA.

Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations

Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield.

Patient Experience with Their Health Care Provider Among Non-Pregnant Women of Childbearing Age with Diabetes Mellitus by Race and Ethnicity in the United States

Objectives

The study objective was to investigate differences in patient experiences with health care providers among non-pregnant women of childbearing age with diabetes mellitus (DM) by race/ethnicity.

Design

This study used cross-sectional data from the 2012-2018 Medical Expenditure Panel Survey. The sample was limited to women of childbearing age (18-45 years) who have ever been told they had diabetes (n = 763; weighted n = 903,670). The key independent variable was race/ethnicity. The variables of interest included patient experiences with health care in the past 12 months: patient-provider communication (PPC); patient-provider racial/ethnic concordance; patient-provider gender concordance; and satisfaction.

Results

After adjusting for age, marital status, education, poverty level, health insurance, and perceived health status, non-Hispanic (NH) Black women had lower odds (adjusted odds ratio [aOR] = 0.04; 95% confidence interval [CI] = 0.01-0.11) of receiving care from a health care provider of the same race compared with NH white women. Similar results were found among Hispanic and NH women of other or multiple races. Hispanic women had lower odds (aOR = 0.18; 95% CI = 0.06-0.50) of seeing a health care provider of the same race/ethnicity compared with NH white women in adjusted models. There were no statistically significant differences in PPC, patient-provider gender concordance, and satisfaction with their health care provider among Hispanic, NH Black, or NH women of other or multiple races in comparison to NH White women.

Conclusion

There is a need to improve PPC quality and satisfaction in this patient population. Patient-provider racial/ethnic discordance among women of color with DM is concerning given the existing diabetes-related disparities. More research on women with DM is needed to inform and improve patient experience and health outcomes.

Association of Provider Perspectives on Race and Racial Health Care Disparities with Patient Perceptions of Care and Health Outcomes

Purpose: Research suggests that providers contribute to racial disparities in health outcomes. Identifying modifiable provider perspectives that are associated with decreased racial disparities will help in the design of effective educational interventions for providers. Methods: This cross-sectional study investigated the association between primary care provider (PCP) perspectives on race and racial disparities with patient outcomes. Results: Study participants included 40 PCPs (70% White, 30% racial minority) caring for 55 patients (45% White, 55% Black) with type 2 diabetes mellitus. Associations of provider perspectives on race and racial disparities with patient variables (Interpersonal Processes of Care [IPC] Survey, which measures patient's ratings of their provider's interpersonal skills; medication adherence; glycemic control) were measured using Spearman correlation coefficients. Results suggest that Black patients of providers who reported greater skill in caring for Black patients had more positive perceptions of care in three of four IPC subdomains (Spearman correlation coefficients of -0.43, 0.44, 0.46, all with p<0.05); however, Black patients of providers who believe that racial disparities are highly prevalent had more negative perceptions of care in three of four IPC subdomains (Spearman correlation coefficients of 0.38, -0.53, -0.51, all with p<0.05). These same provider characteristics had no correlation with outcomes of medication adherence and hemoglobin A1c (HbA1c) or among White patients. Conclusion: Findings suggest that Black patients of providers who felt better equipped to take care of Black patients had a better experience. Therefore, educational interventions for providers may be most effective if they focus on skill development rather than increasing awareness about racial disparities alone.