Transcript Peter Dews MD, MS

Providing Diabetes Care For
The Uninsured
DPAC Full Membership Meeting
April 27, 2009
Kellogg Conference Center, East Lansing, MI
Peter Dews M.D., M.S.
What are Health Disparities?
Health disparities are differences in the incidence, prevalence,
mortality, burden of diseases and other
adverse health conditions or outcomes that exist among specific
population groups in the United States.
In Michigan, as in the United States, racial and ethnic minority
populations carry a disproportionately
heavy burden from health disparities. This burden is manifested in
increased risk for disease, delayed
diagnosis, inaccessible and inadequate care, poor health outcomes
and premature death, much of which
is preventable.
MDCH, Health Disparities Report, 2008, 2.16.09
Breaking News…………………
Insurance Coverage May Reduce Disparities in
Cardiovascular Disease and Diabetes Management
April 21, 2009 - A Commonwealth Fundsupported study in the Annals of Internal
Medicine found that Medicare coverage
reduces racial, ethnic, and socioeconomic
disparities in heart disease and diabetes
outcomes. The authors suggested that
providing health coverage to those under age
65 may reduce such disparities among all
adults.
Insurance Coverage May Reduce Disparities in Cardiovascular
Disease and Diabetes Management
Contribution
To measure changes in chronic disease control, the
authors used blood pressure, hemoglobin A1c, and total
cholesterol measurements that were obtained from
participants in the 1999 to 2006 National Health and
Nutrition Examination Survey. Disease control improved
over 8 years, but gaps between white and nonwhite patients
did not change. The gaps were smaller after age 65 years,
when universal Medicare insurance begins.
21 April 2009 Annals of Internal Medicine Volume 150 • Number 8 515
Insurance Coverage May Reduce Disparities in Cardiovascular
Disease and Diabetes Management
Context
Acquiring health insurance and getting
better quality of care could reduce health
care disparities. The relative importance of
these 2 factors is unknown.
21 April 2009 Annals of Internal Medicine Volume 150 • Number 8 515
Meanwhile, down here on the ground…………..
It’s all about spin!!!!!!!!
Brightmoor
From Wikipedia, the free encyclopedia
'Brightmoor' is a neighborhood in Detroit, Michigan, United States.
Composed of mostly low-grade housing, Brightmoor was first
populated by poor whites from Appalachia. The area is still home to a
remnant population of extremely few poor whites. Brightmoor is one of
the most desolate and poorest neighborhoods in Detroit.
Brightmoor was created in the early 1900s by Henry Ford as a
neighborhood for his factory workers. The area has been affected
economically by the overall reduction in automotive industry jobs in the
region. Consequently, the poverty rate is 44% in the neighborhood,
compared to a 32% average for the rest of Detroit.
It’s all about spin!!!!!!!!
Welcome to the Brightmoor community web
site. We are a neighborhood in the North-West of
Detroit and are proud to have been chosen as a
"Good Neighborhood" by the Skillman
Foundation.
Brightmoor is a community of 19,837 residents in Northwest Detroit and is
bordered on the west by Telegraph Road, Eliza Howell Park and the Rouge
River and on the East roughly by Evergreen Road with a Southern section
between Evergreen and Southfield Roads. It is situated entirely within the
48223 zip code area.
Development of Brightmoor began in the early 1920s when B.E. Taylor bought
160 acres of land in 1921, one mile from the Detroit city limits. He opened the
Brightmoor Subdivision in 1922. Brightmoor grew quickly with an additional
2,913 acres added from 1923 to 1924. In 1926 it was annexed by the city of
Detroit. The population of Brightmoor was primarily working class families that
supported the auto industry.
Income and Poverty
2008 UDS Data Summary by Health Center
Health
Center
Encounters
# of
Patients
Uninsured
Medicaid
Medicare
Other
Public
Private
Insurance
Homeless
Patients
AFHC
9,176
2,690
58%
16%
4.2%
5%
17%
40
TBHC
11,294
3,823
47%
29.4%
5.3%
7.7%
10.4%
57
Waller
Universal
Report
8,656
3,309
85%
5%
2%
4.7%
2.8%
3,078
30,042
9,877
70%
17%
3.7%
N/A
9.4%
3,425
Challenges to Quality (Diabetes) Care



Staff Turnover (providers,
managers, staff)
‘Specialty’ Care, & Services
(Opinions easier to come by, than
‘stuff’)
‘Environment’ (opportunity to ‘redesign’ Fenkell street & surrounding
area)
Responses to Challenges to Quality
(Diabetes) Care

Staff Turnover


‘Specialty’ Care, & Services


(learning environment)
(Broadened professional scope, Physicians Who
Care, network)
‘Environment’

(community partnerships, like Skillman
foundation)
‘Process, Structure, Outcomes’

Structure




(social worker, processes Patient Assistance
Program forms for medications, 10-15% unretrieved). Estimated 10-12 hours a week on
forms alone. (www.needymeds.com).
340 B Pharmacy, but emphasize $4 Rx programs
(Dietician / CDE from city health department
rotates across sites. Estimates return follow up
rates < 50%)
Establishing group visits, 30% ‘open access’
scheduling. Planned visits
‘Process, Structure, Outcomes’

Process




(‘Low Tech’ chronic condition charting)
Attention to consensus guidelines
Align staff incentives with those of
Physicians, NP’s.
Selective on site HbA1c determination
There was a difference (improvement) of .3 mg / % between the means of the ‘oldest’ and ‘newest’
HBA1C values. While this observed improvement was encouraging, and we believe indicative of a
trend and evidence of intervention effects, it was not statistically significant. We anticipate that at the
next review, a larger sample size or larger effect will allow us to demonstrate statistical significance.
Figure 5 HBA1C_60_1 (oldest) vs. HBA1C_60_3 (newest)
Table 4 change in systolic blood pressure
A comparison of these two means suggests a trend toward lower (improved) systolic blood pressure
control. While this observed improvement was encouraging, and we believe indicative of intervention
effects, it was not statistically significant (two sample t test p-value =.100). We anticipate that at the
next review, a larger sample size or larger effect will allow us to demonstrate statistical significance.
Figure 6 SBP_1 (oldest) vs. SBP_3 (newest)
‘Racial and ethnic minorities and adults of lower
socioeconomic status are much more likely to be
uninsured and uninsured adults are much less likely to
receive basic clinical services for these (chronic)
conditions’
‘evidence suggests that quality of care has
improved in the past decade, however quality
improvement may not necessarily lead to more
equitable care especially if improvements occur
among providers who serve fewer disadvantaged
patients’
Now I know what it does!