Transcript Sheldon Greenfield - OC Diabetes Conference

Health Disparities/ Diabetes Care
Sheldon Greenfield, MD
Orange County Diabetes Education
Collaborative Conference
January 31, 2009
Optimizing the ‘Physician
Effect’ on HbA1c levels
Coached Care Team
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Quyen Ngo-Metzger, MD, MPH
Israel De Alba, MD, MPH
Dara Sorkin, PhD
John Billimek, PhD
Dana Mukamel, PhD
Community-based Coaches
Background: Disparities in Diabetes
Care in the U.S.
• More ethnic minorities fail to meet
diabetes quality benchmarks than nonminority patients
• Rates of diabetes complications are
higher among many ethnic minorities
• All cause mortality rates are higher
among African Americans and Hispanic
patients
Purposes of Study
• Document disparities in diabetes care
among three ethnic groups (Mexicans,
Vietnamese, Non-Hispanic Whites) in
defined population
• Reduce disparities through Coached
Care program for improving patients’
participation in care using communitybased patients with diabetes
Study Designs
• Diabetes Registry (population
definition)
• Cross-sectional DAWN Minority
Survey (measures development;
comparison ethnic groups)
• Randomized controlled trial
(intervention test)
Sampling
• Diabetes Registry:
– All patients seen for diabetes at UCI Medical
Center clinics
• Cross-sectional DAWN Minority Survey:
– Random sample 300 patients each ethnic
group
• Randomized controlled trial:
– Balanced design, n=100 exp/cont by ethnic
group
Optimizing the ‘Physician
Effect’ on HbA1c levels
Features of Coached Care
• Algorithm mapping decisions, treatment
options; detailed explanations
• Patient’s medical record; tailored,
personalized information
• Reviewed immediately before office visit
• ‘Coaching’ for more effective participation
during visit
Tailored Algorithm Information:
Example, Patient on Insulin
Using insulin
alone
yes
Adherence as
instructed
Problems with
insulin regimen
no
no
both
OPTIONS
yes
Change insulin to
rapid acting qd
Use insulin Pen for
administration
Stop or reduce
insulin; add oral
agent
Improve diet,
exercises
Control Group
• Matched for session length
• Same venue, same staff
• Content = state of the art patient
education materials for each disease
PRIOR RESULTS FROM THE
COACHED CARE PROGRAM:
Health Outcomes
• Compared to controls, patients in
experimental group had:
– 1.5% reduction in HbA1c
– 10 mm Hg reduction in diastolic BP
– 25% reduction in symptoms
– 30% improvement in functional status
PRIOR RESULTS FROM THE
COACHED CARE PROGRAM:
Communication
• Compared to controls, patients in
experimental group (based on audiotapes):
– 3 times more queries, ‘controlling’
conversational behaviors
– 2 times more effective in information seeking
– 30% increase in emotional response from
physicians
Features of Coached Care
for Diabetes Program
• Use of community-based ethnic
minority coaches
• Training program for, quality
monitoring of coaches
• Use of diabetes registry at UC Irvine to
ensure representativeness of patient
sampling, assignment
Coached Care for Diabetes
Program:
DAWN Minority
Survey Results
Characteristics of Patient Sample
Characteristics
Mean HbA1c
Mean LDL
Registry
(n=3,894)
7.6 [1.5]
96.1 [28.6]
Survey Sample
(n=1001)
8.3 [1.8]
103.2 [33.0]
Baseline HbA1c by Ethnicity
Ethnic Group
White
Hispanic
Vietnamese
F-value = 63.1, p<.001
Mean HbA1c
7.3 [1.5]
8.2 [2.0]
6.8 [0.9]
% HbA1c <7 by Ethnicity
Ethnic Group
% HbA1c <7
White
Hispanic
Vietnamese
Chi Square = 49.7, p<.001
54.8
32.4
55.6
DAWN Minority Survey Measures
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•
•
•
General health status
Diabetes specific health status
Adherence to diabetes regimen
Disease management/health enhancing
behaviors
• Quality of interpersonal care
• Access to care
• Total Illness Burden
DAWN Minority Survey Measures
• General health status
–
–
–
–
–
–
–
SF-36
General health distress
WHO
EuroQual
CESD
Quality of life
Stress level
• Diabetes specific
health status
– Diabetes
management hassles
– Diabetes frustration
– Diabetes distress
– Diabetes
worry/concern
– Diabetes burden
– Stress managing
diabetes
Sample Questions: Diabetes
Management Hassles
“During the past 4 weeks, how much of a
problem or hassle has each of the following
been for you in your everyday life?”
(A major hassle
No hassle at all)
h. Having to keep your schedule (eating,
drugs, exercise) in mind all the time…..
Sample Questions: Diabetes
Frustrations
“Sometimes diabetes can be a source of
frustration to those who have it. During the
past 4 weeks, how often:
(All of the time
None of the time)
a. Were you frustrated about diabetes?....
Sample Questions: Diabetes
Worries or Concern
“Sometimes people with diabetes have
concerns about complications that may
develop. How much are you worried or
concerned about each of the following?”
(Extremely worried
Not worried at all)
a. Losing my eyesight from diabetes?....
Sample Questions: Diabetes Burden
“Overall, how much of a burden is your
having diabetes on you and your family in
each of the following areas?”
(Very great burden
No burden at all)
a. Our finances in general?....
b. Our finances due to the cost of my
medications?….
Ethnic Differences: Survey Measures
Whites
Hispanic
Vietnamese
General health
(n=216)
(n=502)
(n=283)
Mean
Diff
P-value
SF-36 PFI10
65.4
65.1
57.3
<.01
SF-36 Role
Physical
67.1
69.9
53.9
<.01
WHO
55.8
57.1
54.4
.331
EuroQual
2.1
2.1
2.7
.381
CESD
10.7
12.2
13.9
<.01
Measure:
Ethnic Differences: Survey Measures
Whites
Hispanic
Vietnamese
(n=216)
(n=502)
(n=283)
Mean
Diff
P-value
Hassles
35.6
36.3
30.5
<.01
Frustrations
33.9
43.3
44.4
<.01
Worry/concern
48.9
68.8
46.6
<.01
Burden
31.0
50.5
32.7
<.01
Management
stress
36.1
47.8
37.2
<.01
Measure:
Diabetes health
Correlation Health Status Measures with HbA1c
Health status measures
SF-36 PFI10
SF-36 Role physical
WHO
EuroQual
Diabetes Hassles
Diabetes Frustration
Diabetes Worry/Concern
Diabetes Burden
DM Management Stress
***p<.001
HbA1c
.01
.04
-.03
-.03
.17***
.18***
.25***
.27***
.21***
Coached Care for Diabetes
Program:
DAWN Minority
Trial Results
Mean HbA1c Preliminary Results
Study
Period
Control
N
Coached
Care
Mean
Diff
Baseline
244
8.2
8.4
0.2
6 months
159
8.1
8.3
0.1
12 months
112
7.7
8.3
0.6*
*p<.05
HbA1c >8% Preliminary Results
Study
Period
Control
N
Coached
Care
Mean
Diff
Baseline
125
9.4
9.4
0.0
6 months
64
9.0
8.9
-0.1
12 months
38
7.9
9.4
1.6*
**p<.01
Conclusions
• Coached Care may improve diabetes
outcomes among poor and ethnic
minorities
• Despite disparities in diabetes care at
baseline, Coached Care improved
HbA1c, diabetes health status across
ethnic groups
• Community-based coaches of same
culture can be trained; less expensive