Health Disparities/ Diabetes Care

1. Health Disparities/ Diabetes Care Sheldon Greenfield, MD Orange County Diabetes Education Collaborative Conference January 31, 2009

2. Optimizing the ‘Physician Effect’ on HbA1c levels

3. Coached Care Team • Quyen Ngo-Metzger, MD, MPH • Israel De Alba, MD, MPH • Dara Sorkin, PhD • John Billimek, PhD • Dana Mukamel, PhD • Community-based Coaches

4. Background: Disparities in Diabetes Care in the U.S. • More ethnic minorities fail to meet diabetes quality benchmarks than non-minority patients • Rates of diabetes complications are higher among many ethnic minorities • All cause mortality rates are higher among African Americans and Hispanic patients

5. 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 community-based patients with diabetes

6. Study Designs • Diabetes Registry (population definition) • Cross-sectional DAWN Minority Survey (measures development; comparison ethnic groups) • Randomized controlled trial (intervention test)

7. 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

9. Optimizing the ‘Physician Effect’ on HbA1c levels

10. 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

11. Tailored Algorithm Information: Example, Patient on Insulin both Using insulin alone yes Adherence as instructed Problems with insulin regimen OPTIONS Change insulin to rapid acting qd Use insulin Pen for administration Stop or reduce insulin; add oral agent Improve diet, exercises yes no no

13. Control Group • Matched for session length • Same venue, same staff • Content = state of the art patient education materials for each disease

14. 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

15. 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

16. Features of Coached Carefor 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

17. Coached Care for Diabetes Program:DAWN Minority Survey Results

18. Characteristics of Patient Sample

19. Baseline HbA1c by Ethnicity F-value = 63.1, p<.001

20. % HbA1c <7 by Ethnicity Chi Square = 49.7, p<.001

21. DAWN Minority Survey Measures • 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

22. 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 DAWN Minority Survey Measures

23. 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…..

24. 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?....

25. 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?....

26. 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) • Our finances in general?.... • Our finances due to the cost of my medications?….

27. Ethnic Differences: Survey Measures

28. Ethnic Differences: Survey Measures

29. Correlation Health Status Measures with HbA1c ***p<.001

30. Coached Care for Diabetes Program:DAWN Minority Trial Results

31. Mean HbA1c Preliminary Results *p<.05

32. HbA1c >8% Preliminary Results **p<.01

33. 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