Early lessons from an initiative on Chicago's South Side to reduce disparities in diabetes care and outcomes

Socioeconomic status is associated with pediatric adenotonsillectomy outcomes: A single institution study

OBJECTIVE

Our institution serves a diverse patient population across a large metropolitan city. Literature has shown pediatric otolaryngology patients with lower socioeconomic status (SES) have higher rates of sleep-disordered breathing, delays in treatment time, and greater risks of complications post-tonsillectomy. This study aims to examine the effects of SES on adenotonsillectomy outcomes performed at our institution.

STUDY DESIGN

A retrospective chart review including 1560 pediatric patients (ages 0-18) who underwent adenotonsillectomy between January 2015 and December 2020.

SETTING

Large metropolitan hospital, level 1 trauma center.

METHODS

Outcome variables included postoperative hospital admission, phone calls, 30-day follow-up, and persistent obstructive sleep apnea (OSA). Descriptive statistics using Wilcoxon Signed Rank Tests and univariate and multivariate logistic regression modeling were used to determine statistically significant covariates at α = 0.05.

RESULTS

The cohort included Non-Hispanic White (n = 488, 31 %), Non-Hispanic Black (n = 801, 51 %), Hispanic (n = 210, 13 %), and other (n = 61, 4 %) groups. Using multivariate regression, privately insured patients were less likely to have moderate-to-severe OSA before surgery (0.65 95 % CI 0.45, 0.93 p = 0.017) and be admitted postoperatively (0.73, 0.55-0.96, p < 0.01), while more likely to have postoperative follow-up phone calls (1.57, 1.19-2.09, p < 0.01) and visits (1.53, 1.22-1.92, p < 0.01). Increased income was associated with decreased rehospitalizations within three months of surgery (0.98, 0.97-1.00, p < 0.01).

CONCLUSION

This study suggests SES significantly affects adenotonsillectomy outcomes. Further studies are warranted to provide better care for all pediatric patients.

Factors Associated with Health-Related Quality of Life in Lung Transplant Candidates and Recipients

OBJECTIVES

Health-related quality of life has been well studied across transplantation fields, but factors associated with lung transplant preoperative and postoperative quality of life remain unknown. Here, we determine factors associated with health-related quality of life in lung transplant candidates and recipients to identify patients at risk of lower health-related quality of life.

MATERIALS AND METHODS

From January 2021 to May 2022, health-related quality of life was measured in candidates and recipients using the RAND 36-Item Short Form Health Survey questionnaire. We reviewed demographic parameters and clinical information and scored frailty according to the modified 5-item frailty index. We performed Fisher exact test and the Pearson chi-square test and used linear regression models to determine covariate associations on physical component summary, mental component summary, and self-reported health scores (α = 0.05).

RESULTS

Eleven candidates and 17 recipients comp-leted the survey. Compared with candidates, transplant recipients reported significantly higher scores in 4 of the 8 health domains and in the physical component summary (P < .01), mental component summary (P = .05), and self-reported health score (P < .01). In candidates, higher body mass index and higher modified 5-item frailty index scores were negatively associated with the physical component summary and mental component summary, respec-tively (P < .05). In recipients, higher body mass index and higher lung allocation scores were associated with lower values for the physical component summary (-2.29; P < .05) and self-reported health score (-0.33; P < .05), respectively.

CONCLUSIONS

Body mass index, the modified 5-item frailty index, and the lung allocation score were significantly associated with health-related quality of life in lung transplant recipients. Future interventions should target these modifiable associations to maximize candidate and recipient health-related quality of life.

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.

"Everything in One Place": Stakeholder Perceptions of Integrated Medical and Social Care for Diabetes Patients in Western Maryland

BACKGROUND

Patients with type 2 diabetes frequently have both medical- and health-related social needs that must be addressed for optimal disease management. Growing evidence suggests that intersectoral partnerships between health systems and community-based organizations may effectively support improved health outcomes for patients with diabetes.

OBJECTIVE

The purpose of this study was to describe stakeholders' perceptions of the implementation factors associated with a diabetes management program, an intervention involving coordinated clinical and social services supports to address both medical- and health-related social needs. This intervention delivers proactive care alongside community partnerships, and leverages innovative financing mechanisms.

DESIGN

Qualitative study with semi-structured interviews.

PARTICIPANTS

Study participants included adults (18 years or older) who were patients with diabetes and essential staff (e.g., members of a diabetes care team, health care administrators) and leaders of community-based organizations.

APPROACH

We used the Consolidated Framework for Implementation Research (CFIR) to develop a semi-structured interview guide designed to elicit perspectives from patients and essential staff on their experiences within an outpatient center to support patients with chronic conditions (the CCR) as a part of an intervention to improve care for patients with diabetes.

KEY RESULTS

Interviews illuminated three key takeaways: (1) team-based care held an important role in promoting accountability across stakeholders motivating patient engagement and positive perceptions, (2) mission-driven alignment across the health care and community sectors was needed to synergize a broad range of efforts, and (3) global payment models allowing for flexible resource allocation can invaluably support the appropriate care being directed where it is needed the most whether medical or social services.

CONCLUSIONS

The views and experiences of patient and essential staff stakeholder groups reported here thematically according to CFIR domains may inform the development of other chronic disease interventions that address medical- and health-related social needs in additional settings.

Goals of cure: Perspectives on the concept of cure in type 2 diabetes

RATIONALE, AIMS AND OBJECTIVES: Type 2 diabetes (T2D) is an archetypical chronic condition of significant prevalence. Yet the concept of cure in the context of T2D reveals an interplay between the medical imagination and clinical realities that can shift the course of a patient's care. There are two domains in which cure is sociologically constructed: the professional domain occupied by clinicians treating people with T2D, and the lay domain occupied by T2D patients. Lay epistemologies of cure tend to be focused on modifying the experience of having T2D, while professional epistemologies tend to focus on modifying the disease through medical treatment. The objective of this study is to explore the role of the concept of cure in the context of type 2 diabetes, a model for chronic disease.

METHODS

Through surveys and interviews of T2D patients, providers and researchers at an urban academic medical centre, I explore the perspectives and attitudes each group have towards the concept of cure in T2D. Semi-structured interviews of T2D professionals and patient surveys consisting of free response questions and Likert scale items were thematically analysed for perspectives on cure in T2D.

RESULTS

Sixteen T2D patients met inclusion criteria and consented to the survey and ten T2D professionals were interviewed. Cure is conceived of heterogeneously both within and between epistemologies. Patients carry hopes of cure predicated on eliminating the unpleasant experiences of T2D and its treatments, while T2D professionals tend to avoid invoking the concept of cure, at least to patients, on grounds of clinical uncertainty. However, the concept of cure is a significant motivator of treatment in both lay and professional epistemologies.

CONCLUSION

Different viewpoints on cure in T2D present an opportunity for shared meaning and decision making between patients and their providers that can frame the best possible outcome for patient care.

Healthcare disparities in vascular surgery: A critical review

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White. Persons categorized as Black, Latino, Latina, or Latinx, and women are less likely to undergo carotid endarterectomy for symptomatic carotid stenosis and repair of abdominal aortic aneurysms. New approaches are needed to address these disparities. We suggest surgeons use data to identify groups that would most benefit from medical care and then partner with community organizations or individuals to create lasting health benefits. Surgeons alone cannot rectify the structural inequalities present in American society. However, all surgeons should contribute to ensuring that all people have access to high-quality vascular surgical care.

Diabetes Management in Community Health Centers: a Review of Policies and Programs

PURPOSE OF REVIEW

Community health centers (CHCs) provide care to millions of vulnerable patients in the USA, including a disproportionate number with diabetes. Policies affecting diabetes management in CHCs therefore have broad implications for clinical practice and patient outcomes nationwide. We describe prior policies that have influenced diabetes management in CHCs, discuss current policies and programs, as well as present emerging innovations and future directions for diabetes care in this setting.

RECENT FINDINGS

Domains for current diabetes policies and programs in CHCs include coverage requirements, quality reporting and incentives, prescription discounts, healthy behavior incentives, and team-based care. Policies in these areas affect the management of diabetes at multiple levels, from organizations that support CHCs to individual health centers, and the providers and patients based there. Several domains of interrelated policies and programs impact CHC diabetes management at multiple levels. Stakeholders' understanding of these policies and programs may identify opportunities to improve diabetes care.

New research directions on disparities in obesity and type 2 diabetes

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

How patient and community involvement in diabetes research influences health outcomes: A realist review

Background

Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes.

Objective

This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self‐management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type.

Data extraction and synthesis

Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis.

Main results

Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co‐design and co‐deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes.

Discussion and Conclusions

Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Diabetes and the Built Environment: Evidence and Policies

PURPOSE OF REVIEW

To explore the relationship between the built environment and type 2 diabetes, considering both risk factors and policies to reduce risk. The built environment refers to the physical characteristics of the areas in which people live including buildings, streets, open spaces, and infrastructure.

RECENT FINDINGS

A review of current literature suggests an association between the built environment and type 2 diabetes, likely driven by two key pathways-physical activity and the food environment. Other hypothesized mechanisms linking the built environment and type 2 diabetes include housing policy, but evidence in these areas is underdeveloped. Policies designed to enhance the built environment for diabetes risk reduction are mechanistically plausible, but as of yet, little direct evidence supports their effectiveness in reducing in type 2 diabetes risk. Future work should rigorously evaluate policies meant to reduce type 2 diabetes via the built environment.

Racial/ethnic differences in healthcare use among patients with uncontrolled and controlled diabetes

OBJECTIVES

To examine racial/ethnic differences in healthcare use among patients classified as having controlled and uncontrolled diabetes.

DESIGN

Data from the Carolinas HealthCare System electronic data warehouse were used. Glycemic control was defined as glycosylated hemoglobin (HbA1c) < 8% (64 mmol/mol) in 2012 (n = 9996). Patients with HbA1c ≥ 8% (64 mmol/mol) in 2012 were classified as uncontrolled (n = 2576). Race and ethnicity were jointly classified as non-Hispanic Black, non-Hispanic White or Other. Separate mixed effects negative binomial models estimated the independent effect of race/ethnicity on the number of emergency department (ED) visits, hospitalizations and physician office visits in 2013, in each patient group, adjusting for significant confounding variables.

RESULTS

Rates of diabetes-related ED visits were two to three times higher for non-Hispanic Blacks compared to non-Hispanic Whites (uncontrolled rate ratio [RR]: 3.41 95% CI: 1.41-8.22; controlled RR: 2.95; 95% CI: 1.78-4.91). Similar differences were observed for all-cause ED visits (uncontrolled RR: 1.83, 95% CI: 1.50-2.24; controlled RR: 2.45, 95% CI: 2.17-2.77). Non-Hispanic Blacks with controlled and uncontrolled diabetes also had lower rates of all-cause physician office visits when compared to non-Hispanic Whites (uncontrolled RR: 0.84, 95% CI: 0.77-0.91; controlled RR: 0.81, 95% CI: 0.78-0.84).

CONCLUSION

Notable racial/ethnic disparities exist in the use of emergency services and physician offices for diabetes care. Strategies such as patient education and care delivery changes that address healthcare access issues in racial/ethnic minorities should be considered to offer better diabetes management and address diabetes disparities.

Cross-Sector Collaboration in the High-Poverty Setting: Qualitative Results from a Community-Based Diabetes Intervention

OBJECTIVE

To characterize the motivations of stakeholders from diverse sectors who engaged in cross-sector collaboration with an academic medical center.

DATA SOURCE

Primary qualitative data (2014-2015) were collected from 22 organizations involved in a cross-sector diabetes intervention on the South Side of Chicago.

STUDY DESIGN

In-depth, semistructured interviews; participants included leaders from all stakeholder organization types (e.g., businesses, community development, faith-based) involved in the intervention.

DATA COLLECTION METHODS

Data were transcribed verbatim from audio and video recordings. Analysis was conducted using the constant comparison method, derived from grounded theory.

PRINCIPAL FINDINGS

All stakeholders described collaboration as an opportunity to promote community health in vulnerable populations. Among diverse motivations across organization types, stakeholders described collaboration as an opportunity for: financial support, brand enhancement, access to specialized skills or knowledge, professional networking, and health care system involvement in community-based efforts. Based on our findings, we propose a framework for implementing a working knowledge of stakeholder motivations to facilitate effective cross-sector collaboration.

CONCLUSIONS

We identified several factors that motivated collaboration across diverse sectors with health care systems to promote health in a high-poverty, urban setting. Understanding these motivations will be foundational to optimizing meaningful cross-sector collaboration and improving diabetes outcomes in the nation's most vulnerable communities.

Comprehensive Diabetes Self-Management Support From Food Banks: A Randomized Controlled Trial

OBJECTIVES

To determine whether food bank provision of self-management support and diabetes-appropriate food improves glycemic control among clients with diabetes.

METHODS

We screened 5329 adults for diabetes at food pantries (n = 27) affiliated with food banks in Oakland, California; Detroit, Michigan; and Houston, Texas, between October 2015 and September 2016. We individually randomized 568 participants with hemoglobin A1c (HbA1c) 7.5% or greater to waitlist control or 6-month intervention including food, diabetes education, health care referral, and glucose monitoring. The primary outcome was HbA1c at 6 months.

RESULTS

Food security (relative risk [RR] = 0.85; 95% confidence interval [CI] = 0.73, 0.98), food stability (RR = 0.77; 95% CI = 0.64, 0.93), and fruit and vegetable intake (risk difference [RD] = 0.34; 95% CI = 0.34, 0.34) significantly improved among intervention participants. There were no differences in self-management (depressive symptoms, diabetes distress, self-care, hypoglycemia, self-efficacy) or HbA1c (RD = 0.24; 95% CI = -0.09, 0.58).

CONCLUSIONS

Food banks are ideally situated to provide diabetes-appropriate food to food-insecure households. Effective strategies for food banks to support improvements in diabetes clinical outcomes require additional study. Public Health Implications. Moving chronic disease support from clinics into communities expands reach into vulnerable populations. However, it is unclear how community interventions should be integrated with clinical care to improve disease outcomes.

TRIAL REGISTRATION NUMBER

NCT02569060.

Evaluating an organization-wide disparity reduction program: Understanding what works for whom and why

Background

Disparity-reduction programs have been shown to vary in the degree to which they achieve their goal; yet the causes of these variations is rarely studied. We investigated a broad-scale program in Israel’s largest health plan, aimed at reducing disparities in socially disadvantaged groups using a composite measure of seven health and health care indicators.

Methods

A realistic evaluation was conducted to evaluate the program in 26 clinics and their associated managerial levels. First, we performed interviews with key stakeholders and an ethnographic observation of a regional meeting to derive the underlying program theory. Next, semi-structured interviews with 109 clinic teams, subregional headquarters, and regional headquarters personnel were conducted. Social network analysis was performed to derive measures of team interrelations. Perceived team effectiveness (TE) and clinic characteristics were assessed to elicit contextual characteristics. Interventions implemented by clinics were identified from interviews and coded according to the mechanisms each clinic employed. Assessment of each clinic’s performance on the seven-indicator composite measure was conducted at baseline and after 3 years. Finally, we reviewed different context-mechanism-outcome (CMO) configurations to understand what works to reduce disparity, and under what circumstances.

Results

Clinics’ inner contextual characteristics varied in both network density and perceived TE. Successful CMO configurations included 1) highly dense clinic teams having high perceived TE, only a small gap to minimize, and employing a wide range of interventions; (2) clinics with a large gap to minimize with high clinic density and high perceived TE, focusing efforts on tailoring services to their enrollees; and (3) clinics having medium to low density and perceived TE, and strong middle-management support.

Conclusions

Clinics that achieved disparity reduction had high clinic density, close ties with middle management, and tailored interventions to the unique needs of the populations they serve.

Culturally Tailoring a Patient Empowerment and Diabetes Education Curriculum for the African American Church

Purpose The African American church has long been recognized as a valuable partner for health interventions in the community. While an extensive literature exists documenting the potential efficacy of diabetes education programs in church settings, there has yet to be an effort to leverage spiritual beliefs and practices to promote diabetes self-management and shared decision making within a faith-based framework that is culturally tailored to the African American church. The purpose of this article is to describe the translation of a clinic-based diabetes education program into faith-based education curriculum tailored for use in the African American church. Conclusions Themes extracted from focus groups and input from a faith-based community partner provided a methodical and patient-informed foundation for culturally tailoring and piloting a diabetes self-management curriculum for the African American church setting. This study illustrates how spirituality can be incorporated into interventions to enhance health promotion and behavioral change among African Americans with diabetes. Participants in our study described how religious beliefs play an active role in many aspects of diabetes care, including self-management behaviors, coping strategies, and patient/provider communication. In addition, this intervention can serve as a model for the development of patient-centered health interventions.

The Monthly Cycle of Hypoglycemia: An Observational Claims-based Study of Emergency Room Visits, Hospital Admissions, and Costs in a Commercially Insured Population

Supplemental Digital Content is available in the text.

Background:

Multipayer initiatives have sought to address social determinants of health, such as food insecurity, by linking primary care patients to social services. It remains unclear whether such social determinants contribute to avoidable short-term health care costs.

Objectives:

We sought to quantify costs and mitigating factors for the increased risk of hypoglycemia at the end of each month among low-income Americans, a phenomenon related to exhaustion of food budgets.

Research Design:

We used claims data on 595,770 commercially insured American adults aged 19 through 64 years old from 2004 through 2015 to estimate the risks and costs of emergency room visits and inpatient hospitalizations for hypoglycemia during the last week of each month versus prior weeks.

Results:

Although persons with household incomes greater than the national median did not experience a monthly cycle of hypoglycemia, those with incomes less than the national median had an odds ratio of 1.07 (95% confidence interval, 1.02–1.12; P=0.005) for emergency room visits or inpatient hospitalizations for hypoglycemia during the last week of each month, compared with earlier weeks. The risk of end-of-the-month hypoglycemia was mitigated to statistical insignificance during a period of increased federal nutrition program benefits from 2009 through 2013. Eliminating the monthly cycle of hypoglycemia among commercially insured nonelderly adults would be expected to avert $54.1 million per year (95% confidence interval, $0.8–$204.0) in emergency department and inpatient hospitalization costs.

Conclusions:

Addressing the end-of-the-month increase in hypoglycemia risk among lower-income populations may avert substantial costs from emergency department visits and inpatient hospitalizations.

Using feedback to change primary care physician behavior

Recognizing the gap between high-quality care and the care actually provided, health care providers across the country are under increasing institutional and payer pressures to move toward more high-quality care. This pressure is often leveraged through data feedback on provider performance; however, feedback has been shown to have only a variable effect on provider behavior. This study examines the cognitive behavioral factors that influence providers to participate in feedback interventions, and how feedback interventions should be implemented to encourage more provider engagement and participation.

Adaptation of the Grasha Riechman Student Learning Style Survey and Teaching Style Inventory to assess individual teaching and learning styles in a quality improvement collaborative

BACKGROUND

NIATx200, a quality improvement collaborative, involved 201 substance abuse clinics. Each clinic was randomized to one of four implementation strategies: (a) interest circle calls, (b) learning sessions, (c) coach only or (d) a combination of all three. Each strategy was led by NIATx200 coaches who provided direct coaching or facilitated the interest circle and learning session interventions.

METHODS

Eligibility was limited to NIATx200 coaches (N = 18), and the executive sponsor/change leader of participating clinics (N = 389). Participants were invited to complete a modified Grasha Riechmann Student Learning Style Survey and Teaching Style Inventory. Principal components analysis determined participants' preferred learning and teaching styles.

RESULTS

Responses were received from 17 (94.4 %) of the coaches. Seventy-two individuals were excluded from the initial sample of change leaders and executive sponsors (N = 389). Responses were received from 80 persons (25.2 %) of the contactable individuals. Six learning profiles for the executive sponsors and change leaders were identified: Collaborative/Competitive (N = 28, 36.4 %); Collaborative/Participatory (N = 19, 24.7 %); Collaborative only (N = 17, 22.1 %); Collaborative/Dependent (N = 6, 7.8 %); Independent (N = 3, 5.2 %); and Avoidant/Dependent (N = 3, 3.9 %). NIATx200 coaches relied primarily on one of four coaching profiles: Facilitator (N = 7, 41.2 %), Facilitator/Delegator (N = 6, 35.3 %), Facilitator/Personal Model (N = 3, 17.6 %) and Delegator (N = 1, 5.9 %). Coaches also supported their primary coaching profiles with one of eight different secondary coaching profiles.

CONCLUSIONS

The study is one of the first to assess teaching and learning styles within a QIC. Results indicate that individual learners (change leaders and executive sponsors) and coaches utilize multiple approaches in the teaching and practice-based learning of quality improvement (QI) processes. Identification teaching profiles could be used to tailor the collaborative structure and content delivery. Efforts to accommodate learning styles would facilitate knowledge acquisition enhancing the effectiveness of a QI collaborative to improve organizational processes and outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00934141 Registered July 6, 2009. Retrospectively registered.

The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics

BACKGROUND

Quality improvement collaboratives (QICs) support rapid testing and implementation of interventions through the collective experience of participating organizations to improve care quality and reduce costs. Although QICs have been societally cost-effective in improving the care of chronic diseases, they may not be adopted by outpatient clinics if their costs are high. Diabetes QICs warrant reexamination as secular trends in the quality of diabetes care, new care guidelines for diabetes, and evolving strategies for quality improvement may have altered implementation costs.

METHODS

The costs over the first four years-from June 2009 through May 2013-of an ongoing diabetes QIC were characterized by activities and over time. The QIC, linking six clinics on Chicago's South Side, tailored interventions to minority populations and built community partnerships. Costs were calculated from clinic surveys regarding activities, labor, and purchases.

RESULTS

Data were obtained from five of the six participating clinics. Cost/diabetic patient/year ranged across clinic sites from $6 (largest clinic) to $68 (smallest clinic). Clinics spent 62%-88% of their total QIC costs on labor. The cost/diabetic patient/year changed over time from Year 1 (range across clinics, $5-$51), Year 2 ($11-$84), Year 3 ($4-$57), to Year 4 ($4-$80), with costs peaking at Year 2 for all clinics except Clinic 4, where costs peaked at Year 4.

DISCUSSION

Cost experiences of QICs in clinics were di- verse over time and setting. High per-patient costs may stem from small clinic size, a sicker patient population, and variation in personnel type used. Cost decreases over time may represent increasing organizational learning and efficiency. Sharing resources may have achieved additional cost savings. This practical information can help administrators and policy makers predict, manage, and support costs of QICs as payers increasingly seek high-value health care.

Food Rx: a community-university partnership to prescribe healthy eating on the South Side of Chicago

Patients living with diabetes in underserved communities face significant challenges to healthy eating. To support them, we need interventions that integrate community resources into the healthcare setting. A "prescription" for healthy food may be a promising platform for such a community-linked intervention: it can promote behavior change, provide nutrition education, include financial incentives, and connect patients to local resources. We describe Food Rx, a food prescription collaboratively developed by a university research team, Walgreens, a local farmers market, and six health centers on the South Side of Chicago. We share preliminary lessons learned from implementation, highlighting how each stakeholder (university, community partners, and clinics) contributed to this multifaceted effort while meeting research standards, organizational priorities, and clinic workflow demands. Although implementation is in early stages, Food Rx shows promise as a model for integrating community and healthcare resources to support the health of underserved patients.

National Strategies to Decrease the Burden of Diabetes and Its Complications

Comparative results from national strategies for diabetes care and prevention are needed to understand the impact and barriers encountered during the implementation process. Long-term outcomes are limited, but results on intermediate outcomes and processes of diabetes care measures are available from translational research studies. In this narrative review, we highlight programs with nationwide reach, targeting various ethnic, racial, and socioeconomic populations with diabetes. We describe the implementation strategies, the impact on clinical outcomes, specific barriers, and cost-effectiveness results of national efforts aimed at improving diabetes care and prevention in the USA.

A story of change: The influence of narrative on African-Americans with diabetes

OBJECTIVE

To understand if narratives can be effective tools for diabetes empowerment, from the perspective of African-American participants in a program that improved diabetes self-efficacy and self-management.

METHODS

In-depth interviews and focus groups were conducted with program graduates. Participants were asked to comment on the program's film, storytelling, and role-play, and whether those narratives had contributed to their diabetes behavior change. An iterative process of coding, analyzing, and summarizing transcripts was completed using the framework approach.

RESULTS

African-American adults (n=36) with diabetes reported that narratives positively influenced the diabetes behavior change they had experienced by improving their attitudes/beliefs while increasing their knowledge/skills. The social proliferation of narrative - discussing stories, rehearsing their messages with role-play, and building social support through storytelling - was reported as especially influential.

CONCLUSION

Utilizing narratives in group settings may facilitate health behavior change, particularly in minority communities with traditions of storytelling. Theoretical models explaining narrative's effect on behavior change should consider the social context of narratives.

PRACTICE IMPLICATIONS

Narratives may be promising tools to promote diabetes empowerment. Interventions using narratives may be more effective if they include group time to discuss and rehearse the stories presented, and if they foster an environment conducive to social support among participants.

Putting theory into practice: a case study of diabetes-related behavioral change interventions on Chicago's South Side

Diabetes self-management is central to diabetes care overall, and much of self-management entails individual behavior change, particularly around dietary patterns and physical activity. Yet individual-level behavior change remains a challenge for many persons with diabetes, particularly for racial/ethnic minorities who disproportionately face barriers to diabetes-related behavioral changes. Through the South Side Diabetes Project, officially known as "Improving Diabetes Care and Outcomes on the South Side of Chicago," our team sought to improve health outcomes and reduce disparities among residents in the largely working-class African American communities that comprise Chicago's South Side. In this article, we describe several aspects of the South Side Diabetes Project that are directly linked to patient behavioral change, and discuss the theoretical frameworks we used to design and implement our programs. We also briefly discuss more downstream program elements (e.g., health systems change) that provide additional support for patient-level behavioral change.

Expanding and sustaining integrated health care-community efforts to reduce diabetes disparities

To reduce racial and ethnic disparities in diabetes care and outcomes, it is critical to integrate health care and community approaches. However, little work describes how to expand and sustain such partnerships and initiatives. We outline our experience creating and growing an initiative to improve diabetes care and outcomes in the predominantly African American South Side of Chicago. Our project involves patient education and activation, a quality improvement collaborative with six clinics, provider education, and community partnerships. We aligned our project with the needs and goals of community residents and organizations, the mission and strategic plan of our academic medical center, various strengths and resources in Chicago, and the changing health care marketplace. We use the Robert Wood Johnson Foundation Finding Answers: Disparities Research for Change conceptual model and the Consolidated Framework for Implementation Research to elucidate how we expanded and sustained our project within a shifting environment. We recommend taking action to integrate health care with community projects, being inclusive, building partnerships, working with the media, and understanding vital historical, political, and economic contexts.

Outside the exam room: policies for connecting clinic to community in diabetes prevention and treatment

The public health burden and racial/ethnic, sex, and socioeconomic disparities in obesity and in diabetes require a population-level approach that goes beyond provision of high-quality clinical care. The Robert Wood Johnson Foundation’s Commission to Build a Healthier America recommended 3 strategies for improving the nation’s health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children; 2) create communities that foster health-promoting behaviors; and 3) broaden health care to promote health outside the medical system. We present an overview of evidence supporting these approaches in the context of diabetes and suggest policies to increase investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management.

Material need support interventions for diabetes prevention and control: a systematic review

Unmet material needs, such as food insecurity and housing instability, are associated with increased risk of diabetes and worse outcomes among diabetes patients. Healthcare delivery organizations are increasingly held accountable for health outcomes that may be related to these "social determinants," which are outside the scope of traditional medical intervention. This review summarizes the current literature regarding interventions that provide material support for income, food, housing, and other basic needs. In addition, we propose a conceptual model of the relationship between unmet needs and diabetes outcomes and provide recommendations for future interventional research.

Medical assistant coaching to support diabetes self-care among low-income racial/ethnic minority populations: randomized controlled trial

Innovative, culturally tailored strategies are needed to extend diabetes education and support efforts in lower-resourced primary care practices serving racial/ethnic minority groups. A randomized controlled trial (RCT) examined the effect of a diabetes self-care coaching intervention delivered by medical assistants and the joint effect of intervention and ethnicity over time. The randomized repeated-measures design included 270 low-income African American and Hispanic/Latino patients with type 2 diabetes. The 1-year clinic- and telephone-based medical assistant coaching intervention was culturally tailored and guided by theoretical frameworks. A1C was obtained, and a self-care measure was completed at baseline, 6 months, and 12 months. Data were analyzed using mixed-effects models with and without adjustment for covariates. There was a significant overall improvement in mean self-care scores across time, but no intervention effect. Results revealed differences in self-care patterns across racial/ethnic subgroups. No differences were found for A1C levels across time or group.

Food-insecure dietary patterns are associated with poor longitudinal glycemic control in diabetes: results from the Boston Puerto Rican Health study

OBJECTIVE

To determine whether dietary patterns associated with food insecurity are associated with poor longitudinal glycemic control.

RESEARCH DESIGN AND METHODS

In a prospective, population-based, longitudinal cohort study, we ascertained food security (Food Security Survey Module), dietary pattern (Healthy Eating Index-2005 [HEI 2005]), and hemoglobin A1c (HbA1c) in Puerto Rican adults aged 45-75 years with diabetes at baseline (2004-2009) and HbA1c at ∼2 years follow-up (2006-2012). We determined associations between food insecurity and dietary pattern and assessed whether those dietary patterns were associated with poorer HbA1c concentration over time, using multivariable-adjusted repeated subjects mixed-effects models.

RESULTS

There were 584 participants with diabetes at baseline and 516 at follow-up. Food-insecure participants reported lower overall dietary quality and lower intake of fruit and vegetables. A food insecurity*HEI 2005 interaction (P < 0.001) suggested that better diet quality was more strongly associated with lower HbA1c in food-insecure than food-secure participants. In adjusted models, lower follow-up HbA1c was associated with greater HEI 2005 score (β = -0.01 HbA1c % per HEI 2005 point, per year, P = 0.003) and with subscores of total vegetables (β = -0.09, P = 0.04) and dark green and orange vegetables and legumes (β = -0.06, P = 0.048). Compared with the minimum total vegetable score, a participant with the maximum score showed relative improvements of HbA1c of 0.5% per year.

CONCLUSIONS

Food insecurity was associated with lower overall dietary quality and lower consumption of plant-based foods, which was associated with poor longitudinal glycemic control.

Integrated community-healthcare diabetes interventions to reduce disparities

Racial and ethnic minorities suffer disproportionately from diabetes-related morbidity and mortality. With the creation of Accountable Care Organizations (ACOs) under the Affordable Care Act, healthcare organizations may have an increased motivation to implement interventions that collaborate with community resources and organizations. As a result, there will be an increasing need for evidence-based strategies that integrate healthcare and community components to reduce diabetes disparities. This paper summarizes the types of community/health system partnerships that have been implemented over the past several years to improve minority health and reduce disparities among racial/ethnic minorities and describes the components that are most commonly integrated. In addition, we provide our recommendations for creating stronger healthcare and community partnerships through enhanced community support.

Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care?

BACKGROUND

A systematic scan of the disparities intervention literature will allow researchers, providers, and policymakers to understand which interventions are being evaluated to improve minority health and which areas require further research.

METHODS

We systematically categorized 391 disparities intervention articles published between 1979 and 2011, covering 11 diseases. We developed a taxonomy of disparities interventions using qualitative theme analysis. We identified the tactic, or what was done to intervene; the strategy, or a group of tactics with common characteristics; and the level, or who was targeted by the effort.

RESULTS

The taxonomy included 44 tactics, 9 strategies, and 6 levels. Delivering education and training was the most common strategy (37%). Within education and training, the most common tactics were education about disease (14%) and self-management (11%), whereas communication skills training (3%) and decision-making aids (1%) were less frequent. The strategy of actively engaging the community through tactics such as community health workers and outreach efforts accounted for 6.5% of tactics. Interventions most commonly targeted patients (50%) and community members who were not established patients of the intervening organization (32%). Interventions targeting providers (7%), the microsystem (immediate care team) (9%), organizations (3%), and policies (0.1%) were less common.

CONCLUSIONS

Disparities researchers have predominantly focused on the patient as the target for change; future research should also investigate how to improve the system that serves minority patients. Areas for further study include interventions that engage the community, educational interventions that address communication barriers, and the impact of policy reform on disparities in care.

Food insecurity and metabolic control among U.S. adults with diabetes

OBJECTIVE

We sought to determine whether food insecurity is associated with worse glycemic, cholesterol, and blood pressure control in adults with diabetes.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional analysis of data from participants of the 1999-2008 National Health and Nutrition Examination Survey. All adults with diabetes (type 1 or type 2) by self-report or diabetes medication use were included. Food insecurity was measured by the Adult Food Security Survey Module. The outcomes of interest were proportion of patients with HbA1c>9.0% (75 mmol/mol), LDL cholesterol>100 mg/dL, and systolic blood pressure>140 mmHg or diastolic blood pressure>90 mmHg. We used multivariable logistic regression for analysis.

RESULTS

Among the 2,557 adults with diabetes in our sample, a higher proportion of those with food insecurity (27.0 vs. 13.3%, P<0.001) had an HbA1c>9.0% (75 mmol/mol). After adjustment for age, sex, educational attainment, household income, insurance status and type, smoking status, BMI, duration of diabetes, diabetes medication use and type, and presence of a usual source of care, food insecurity remained significantly associated with poor glycemic control (odds ratio [OR] 1.53 [95% CI 1.07-2.19]). Food insecurity was also associated with poor LDL control before (68.8 vs. 49.8, P=0.002) and after (1.86 [1.01-3.44]) adjustment. Food insecurity was not associated with blood pressure control.

CONCLUSIONS

Food insecurity is significantly associated with poor metabolic control in adults with diabetes. Interventions that address food security as well as clinical factors may be needed to successfully manage chronic disease in vulnerable adults.

Using mobile health to support the chronic care model: developing an institutional initiative

Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a "human face" to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.

Strategies to reduce diabetes disparities: an update

Racial and ethnic minorities in the US have a higher prevalence, as well as suffer from more complications, lower quality care, and poorer outcomes for diabetes than their counterparts. Given the US health care system is in the midst of drastic transformation, with the passage of health care reform, and efforts in payment reform, and value-based purchasing, there is now support to provide more intensive, team-based care for those conditions that are complex, costly, and highly prevalent. Addressing and improving diabetes disparities, given they are prevalent and costly, will be an important area of focus in the years to come. The latest research demonstrates that community-based efforts, multifactorial approaches, and the deployment of health information technology can be successful in addressing diabetes disparities, and require support, attention, resources, and continued evaluation. Ultimately, these efforts should improve the quality of care for all persons with diabetes, especially those who are most vulnerable.

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.

Culturally tailoring patient education and communication skills training to empower African-Americans with diabetes

New translational strategies are needed to improve diabetes outcomes among low-income African-Americans. Our goal was to develop/pilot test a patient intervention combining culturally tailored diabetes education with shared decision-making training. This was an observational cohort study. Surveys and clinical data were collected at baseline, program completion, and 3 and 6 months. There were 21 participants; the mean age was 61 years. Eighty-six percent of participants attended >70 % of classes. There were improvements in diabetes self-efficacy, self-care behaviors (i.e., following a "healthful eating plan" (mean score at baseline 3.4 vs. 5.2 at program's end; p = 0.002), self glucose monitoring (mean score at baseline 4.3 vs. 6.2 at program's end; p = 0.04), and foot care (mean score at baseline 4.1 vs. 6.0 at program's end; p = 0.001)), hemoglobin A1c (8.24 at baseline vs. 7.33 at 3-month follow-up, p = 0.02), and HDL cholesterol (51.2 at baseline vs. 61.8 at 6-month follow-up, p = 0.01). Combining tailored education with shared decision-making may be a promising strategy for empowering low-income African-Americans and improving health outcomes.

A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care

Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care. Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities. Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care. The roadmap outlines a dynamic process in which individual interventions are just one part. It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts. Additionally, we summarize the major lessons learned through the Finding Answers program. We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature. Our research shows that promising interventions frequently are culturally tailored to meet patients' needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient's pathway of care. Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches. Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients. We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care.