What are the barriers to medical care for patients with newly diagnosed diabetes mellitus?

A Scoping Review of Possible Solutions for Decreasing Socioeconomic Inequalities in Type 2 Diabetes Mellitus

Background

As socioeconomic inequalities are key factors in access and utilization of type 2 diabetes (T2D) services, the purpose of this scoping review was to identify solutions for decreasing socioeconomic inequalities in T2D.

Methods

A scoping review of scientific articles from 2000 and later was conducted using PubMed, Web of Science (WOS), Scopus, Embase, and ProQuest databases. Using the Arksey and O'Malley framework for scoping review, articles were extracted, meticulously read, and thematically analyzed.

Results

A total of 7204 articles were identified from the reviewed databases. After removing duplicate and nonrelevant articles, 117 articles were finally included and analyzed. A number of solutions and passways were extracted from the final articles. Solutions for decreasing socioeconomic inequalities in T2D were categorized into 12 main solutions and 63 passways.

Conclusions

Applying identified solutions in diabetes policies and interventions would be recommended for decreasing socioeconomic inequalities in T2D. Also, the passways could be addressed as entry points to help better implementation of diabetic policies.

Self-Management Barriers Perceived by Patients with Type 2 Diabetes: A Confirmatory Factor Analysis

Background:

Self-management remains poor among most of the diabetic patients due to various individual and environmental barriers which affect it. These barriers should be identified and intervened promptly. The current study aimed to determine self-management barriers perceived by patients with type 2 diabetes.

Methods:

A cross-sectional study carried out on 681 patients with type 2 diabetes who referred to the diabetes center which is affiliated to Kerman University of Medical Sciences, Kerman, Iran during 2018. Through a structured interview, demographic and disease-related data were recorded and the Persian version of the modified Personal Diabetes Questionnaire (PDQ) was used to assess self-management barriers. The tool has four subscales including diet, medication, monitoring, and exercise barriers. The higher score in each subscale indicates a higher level of barriers in that section. Data analyzed by SPSS 20 using T-test, ANOVA, and multiple linear regressions.

Results:

The majority of the patients (62.8%) were female, married (78.3%) with monthly income 10 to 20 million IRRLs (78.4%) and the mean age of 55.65 ± 14.65 years. Body Mass Index, marital status, monthly income, and HbA1C significantly predicted the barriers' score. The instrument had excellent reliability (α = 0.95). In confirmatory factor analysis, the fit indices had approximately acceptable levels.

Conclusions:

The Persian version of modified PDQ had good psychometric properties and can be used as a valid and reliable instrument in the primary health care setting. The significant perceived barriers should be identified and intervened by health care providers through the comprehensive management of diabetic patients.

A multi-site exploration of barriers faced by vulnerable patient populations: a qualitative analysis exploring the needs of patients for targeted interventions in new models of care delivery

AIM

To investigate which populations of patients are considered 'vulnerable' across varying clinical sites, and to identify the barriers encountered by these patient populations limiting optimal health.

BACKGROUND

Vulnerable patient populations encounter diverse barriers that limit their ability to successfully navigate the health system, potentially resulting in poor health outcomes. Little current-day work has described types of barriers encountered by vulnerable patient populations across numerous clinical sites and settings, which is necessary to ensure health systems can begin to improve quality and disparities for all patient populations.

METHODS

An inductive content analysis was performed based on field-site notes and digitally recorded telephone interviews with providers/leadership at clinics/programs related to patient- and clinic-needs from January 2014 through May 2015. Using thematic analysis with grounded theory techniques, authors identified categories and themes. In total, 30 diverse clinical sites/programs including inpatient- and outpatient-based clinics providing medicine and surgery-based services were assessed through both site visits and follow-up telephone interviews. Follow-up interviews were conducted with one individual in various positions within sites/programs, including physicians (n=15), registered nurses (n=8), clinic managers/coordinators (n=2), clinical program coordinator (n=1), and care coordinator (n=1); one participant represented three clinical sites.

FINDINGS

In total, 30 sites/programs (n=30) received both a site visit and follow-up interview. Commonly reported vulnerable patient populations included those with multiple chronic conditions, lower socioeconomic status, patients in a specific stage in the continuum of care, and patients with over- and under-utilization of resources without a clear etiology. Themes related to barriers included systems barriers (eg, insufficiencies of care processes), clinic barriers (eg, lack of resources), patient-related barriers (eg, housing, transportation), and provider-related barriers (eg, inadequate time and knowledge).

CONCLUSIONS

These results provide a framework to identify systems- and clinic-related barriers that can be used in population health management strategies aimed at improving health disparities within clinically diverse sites.

Assessing the influence of health systems on Type 2 Diabetes Mellitus awareness, treatment, adherence, and control: A systematic review

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is reported to affect one in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries. Health systems play an integral role in responding to this increasing global prevalence, and are key to ensuring effective diabetes management. We conducted a systematic review to examine the health system-level factors influencing T2DM awareness, treatment, adherence, and control.

METHODS AND FINDINGS

A protocol for this study was published on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016048185). Studies included in this review reported the effects of health systems factors, interventions, policies, or programmes on T2DM control, awareness, treatment, and adherence. The following databases were searched on 22 February 2017: Medline, Embase, Global health, LILACS, Africa-Wide, IMSEAR, IMEMR, and WPRIM. There were no restrictions on date, language, or study designs. Two reviewers independently screened studies for eligibility, extracted the data, and screened for risk of bias. Thereafter, we performed a narrative synthesis. A meta-analysis was not conducted due to methodological heterogeneity across different aspects of included studies. 93 studies were included for qualitative synthesis; 7 were conducted in LMICs. Through this review, we found two key health system barriers to effective T2DM care and management: financial constraints faced by the patient and limited access to health services and medication. We also found three health system factors that facilitate effective T2DM care and management: the use of innovative care models, increased pharmacist involvement in care delivery, and education programmes led by healthcare professionals.

CONCLUSIONS

This review points to the importance of reducing, or possibly eliminating, out-of-pocket costs for diabetes medication and self-monitoring supplies. It also points to the potential of adopting more innovative and integrated models of care, and the value of task-sharing of care with pharmacists. More studies which identify the effect of health system arrangements on various outcomes, particularly awareness, are needed.

Work-related psychosocial stress and glycemic control among working adults with diabetes mellitus

OBJECTIVE

To examine the association between glycosylated hemoglobin (HbA1c) and four subscales of work-related psychosocial stress at study baseline and over time.

MATERIALS AND METHODS

We used survey data from a major HMO located in the Southeastern part of the US on health and healthy behaviors linked with patients' clinical, pharmacy and laboratory records for the period between 2005 and 2009. Study participants (n=537) consisted of working adults aged 25-59 years, diagnosed with diabetes mellitus (DM) but without advanced micro or macrovascular complications at the time of the survey. We estimated the baseline (2005) association between HbA1c and work-related psychosocial stress and their interactions using linear regression analysis. Using individual growth model approach, we estimated the association between HbA1c over time and work-related psychosocial stress. Each of the models controlled for socio-demographic variables, diet and physical activity factor, laboratory factor, physical examinations variables and medication use in a hierarchical fashion.

RESULTS

After adjusting for all study covariates, we did not find a significant association between work-related psychosocial stress and glycemic control either at baseline or over time.

CONCLUSION

Among fairly healthy middle aged working adults with DM, work-related psychosocial stress was not directly associated with glycemic control.

Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement

OBJECTIVE

The aim was to provide a scholarly review of the published literature on biological, clinical, and nonclinical contributors to race/ethnic and sex disparities in endocrine disorders and to identify current gaps in knowledge as a focus for future research needs. PARTICIPANTS IN DEVELOPMENT OF SCIENTIFIC STATEMENT: The Endocrine Society's Scientific Statement Task Force (SSTF) selected the leader of the statement development group (S.H.G.). She selected an eight-member writing group with expertise in endocrinology and health disparities, which was approved by the Society. All discussions regarding the scientific statement content occurred via teleconference or written correspondence. No funding was provided to any expert or peer reviewer, and all participants volunteered their time to prepare this Scientific Statement.

EVIDENCE

The primary sources of data on global disease prevalence are from the World Health Organization. A comprehensive literature search of PubMed identified U.S. population-based studies. Search strategies combining Medical Subject Headings terms and keyword terms and phrases defined two concepts: 1) racial, ethnic, and sex differences including specific populations; and 2) the specific endocrine disorder or condition. The search identified systematic reviews, meta-analyses, large cohort and population-based studies, and original studies focusing on the prevalence and determinants of disparities in endocrine disorders. consensus process: The writing group focused on population differences in the highly prevalent endocrine diseases of type 2 diabetes mellitus and related conditions (prediabetes and diabetic complications), gestational diabetes, metabolic syndrome with a focus on obesity and dyslipidemia, thyroid disorders, osteoporosis, and vitamin D deficiency. Authors reviewed and synthesized evidence in their areas of expertise. The final statement incorporated responses to several levels of review: 1) comments of the SSTF and the Advocacy and Public Outreach Core Committee; and 2) suggestions offered by the Council and members of The Endocrine Society.

CONCLUSIONS

Several themes emerged in the statement, including a need for basic science, population-based, translational and health services studies to explore underlying mechanisms contributing to endocrine health disparities. Compared to non-Hispanic whites, non-Hispanic blacks have worse outcomes and higher mortality from certain disorders despite having a lower (e.g. macrovascular complications of diabetes mellitus and osteoporotic fractures) or similar (e.g. thyroid cancer) incidence of these disorders. Obesity is an important contributor to diabetes risk in minority populations and to sex disparities in thyroid cancer, suggesting that population interventions targeting weight loss may favorably impact a number of endocrine disorders. There are important implications regarding the definition of obesity in different race/ethnic groups, including potential underestimation of disease risk in Asian-Americans and overestimation in non-Hispanic black women. Ethnic-specific cut-points for central obesity should be determined so that clinicians can adequately assess metabolic risk. There is little evidence that genetic differences contribute significantly to race/ethnic disparities in the endocrine disorders examined. Multilevel interventions have reduced disparities in diabetes care, and these successes can be modeled to design similar interventions for other endocrine diseases.

Barriers to diabetes management: patient and provider factors

Despite significant advances in diagnosis and treatment, the persistence of inadequate metabolic control continues. Poor glycemic control may be reflected by both the failure of diabetes self-management by patients as well as inadequate intervention strategies by clinicians. The purpose of this systematic review is to summarize existing knowledge regarding various barriers of diabetes management from the perspectives of both patients and clinicians. A search of PubMed, CINAHL, ERIC, and PsycINFO identified 1454 articles in English published between 1990 and 2009, addressing type 2 diabetes, patient's barriers, clinician's barriers, and self-management. Patients' adherence, attitude, beliefs, and knowledge about diabetes may affect diabetes self-management. Culture and language capabilities influence the patient's health beliefs, attitudes, health literacy, thereby affecting diabetes self-management. Other influential factors include the patient's financial resources, co-morbidities, and social support. Clinician's attitude, beliefs and knowledge about diabetes also influence diabetes management. Clinicians may further influence the patient's perception through effective communication skills and by having a well-integrated health care system. Identifying barriers to diabetes management is necessary to improve the quality of diabetes care, including the improvement of metabolic control, and diabetes self-management. Further research that considers these barriers is necessary for developing interventions for individuals with type 2 diabetes.

Difficulties or mistakes in diagnosing type 1 diabetes in children?--demographic factors influencing delayed diagnosis

BACKGROUND

Diabetic ketoacidosis (DKA) development in children with new-onset type 1 diabetes (T1DM) is often the main consequence of delayed diagnosis. The aim of the study was to estimate the frequency of difficulties in T1DM diagnosis and to investigate if and how the demographic factors (gender, patient's age at presentation, family history of T1DM, level of maternal education, place of residence, and health service unit the patient called at) have any influence on diagnostic delays.

SUBJECTS AND METHODS

Retrospective analysis of 474 children (243 boys-51.27% and 231 girls -48.73%) with new-onset T1DM aged below 17 yr and living in the Pomeranian region of Poland was carried out. The delay in diagnosis was recognized if the patient was not diagnosed on the first visit because of omission, wrong interpretation of main diabetic symptoms, exclusive treatment of additional signs, or concomitant diseases.

RESULTS

Difficulties in diagnosing T1DM were found in 67 cases (14.13%) and they are the main cause of DKA development in these children (p = 0.00). Among the examined demographic factors, mainly the patient's age at presentation has a significant influence on diagnostic delays (p = 0.01), especially in children below 2 yr (p = 0.00). Most frequently family doctors were responsible for wrong preliminary diagnosis.

CONCLUSIONS

Difficulties in diagnosing T1DM are a significant cause of DKA development in children with new-onset disease. Patient's age at presentation is the main risk factor of delayed diagnosis, especially in children below 2 yr. The increase in awareness among pediatricians concerning the possibility of T1DM development in children is needed.

Pharmacy- and community-based screenings for diabetes and cardiovascular conditions in high-risk individuals

OBJECTIVE

To assess a model to screen minority, elderly, and at-risk individuals for diabetes, hypertension, and dyslipidemia in pharmacy and non-health care settings.

DESIGN

Multicenter, prospective, observational trial.

SETTING

26 pharmacies and 4 non-health care settings.

PARTICIPANTS

888 individuals with one or more of the following risk factors: first-degree relative with diabetes, age 55 years or older, obesity, previous diagnosis of hypertension, or a previous diagnosis of dyslipidemia.

INTERVENTION

Measurement of plasma glucose, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and blood pressure; risk assessment using a risk factor tool; referral of participants with abnormalities to physicians.

MAIN OUTCOME MEASURES

Adherence with follow-up, physician recommendations, and new diagnoses of diabetes, hypertension, and dyslipidemia.

RESULTS

Pharmacists screened 888 participants in pharmacies and non-health care settings; 794 scored at least 10 on the risk factor tool and received further screenings. Of these, 81% were referred for follow-up for at least one abnormality: 15% glucose, 68% blood pressure, 66% total cholesterol, and 26% HDL-C. For those referred, the mean (+/- SD) fasting plasma glucose concentration was 179 +/- 87 mg/dL, and the random glucose concentration was 234 +/- 90 mg/dL. Of participants completing follow-up, 16% received one or more new diagnoses as follows: diabetes, 8; hypertension, 9; and dyslipidemia, 29. Therapy changed for 42% of participants. Participants who were elderly, of African American and Hispanic race/ethnicity, or those with elevated cholesterol values were at significantly greater risk for elevated glucose levels. Screenings in community pharmacy settings had improved follow-up rates with physicians compared with screenings conducted in non-health care settings.

CONCLUSION

Pharmacists identified individuals with elevated glucose, cholesterol, and blood pressure values through community-based screenings. Pharmacists also identified individuals who could benefit from further control of previously diagnosed hypertension and hyperlipidemia.

Explaining disparities in treatment seeking: the case of infertility

OBJECTIVE

To present an integrated model of help-seeking, review empirical work in its support, and show its application to the explanation of racial and ethnic disparities in infertility help-seeking.

DESIGN

Review.

SETTING

None.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

None.

CONCLUSION(S)

A help-seeking model provides a plausible explanation of observed disparities in infertility help-seeking. In addition to being related to income, race and ethnicity is related to prior experience with doctors, marital status, parity, knowledge and attitudes toward reproductive technology, and attitudes supporting spiritual rather than technological solutions to health problems.

Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus

OBJECTIVES

(a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM).

RESEARCH DESIGN AND METHODS

Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained.

RESULTS

Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old.

CONCLUSIONS

At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.

Work-related factors associated with visiting a doctor for a medical diagnosis after a worksite screening for diabetes mellitus in Japanese male employees

This paper aims to investigate the work-related factors that affect whether Japanese male employees will seek a medical diagnosis after being screened for diabetes mellitus. Participants in this study received a questionnaire two months after receiving the results of their physical checkup. The analysis focused on 213 regular employees of small and medium-sized companies who were aged 35-64 and who had tested positive for diabetes in a screening. Only 42% of the subjects visited a doctor for medical diagnosis during an average follow-up period of 47.5 d. Cox's proportional hazard regression was used to analyze the length of time between the employees' receipt of the results and their first visit to a doctor's office. The employees who could comfortably take a day off, compared to those who found it difficult to do so, were more likely to visit a doctor (hazard ratio (HR) 1.94; 95% confidence interval (CI) 0.85, 4.42; p for trend 0.05). In addition, employees with a high level of psychological job control, compared to those with low level of job control, were more likely to visit a doctor (HR 1.80; 95%CI 0.94, 3.45; p for trend 0.08). Employees who worked the longest (61 h per week or more) were less likely to visit a doctor than those working from 41 to 60 h weekly (HR 0.41; 95%CI 0.17, 0.98). The findings suggest that a flexible work schedule, autonomy at work, and no excessive working hours tend to improve the chance of visiting a doctor after screening for diabetes mellitus.