Diabetes Self Management in a Community Health Center

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Diabetes Self Management in a Community Health
Center Daren R. Anderson, MD Assistant Professor
of Medicine Yale University School of
Medicine Director of Primary Care VA Connecticut
Healthcare System
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Diabetes in Underserved Populations

• Age-adjusted prevalence is nearly double in
  Hispanic/Latino and African American patients
• Co-morbid depression rates are higher
• Complication rates are higher
• Lack of effective strategies to teach self
  management in underserved settings

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Challenges to Diabetes SM in Underserved
Populations

• SM is action-oriented. Underserved populations
  may have lower self efficacy
• High rates of depression
• Low literacy
• Language/cultural differences
• Unpredictability

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Largest FQHC in CT
50,000 pts
150,000 encounters/yr
43 Hispanic
13 African American
88 below 200 poverty
Community Health Center, Inc
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CHC Services
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Patient-centered Diabetes Care

• Our Program Goals
• Provide patient-centered self management support
  to all patients with diabetes
• Flexibility
• Cultural and linguistic competence
• Incorporate depression screening and treatment
• Promote self efficacy through goal attainment

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Program Description

• Eligibility All patients with type 2 DM
• Bilingual CDEs
• Intake session/6 follow up sessions
• Depression screening
• Integrated care Primary care, diabetes SM, and
  mental health
• Group sessions
• You Can Do It SM goal handouts/posters

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Data Collection

• Demographics
• Language
• Education level
• Health History
• Smoking, alcohol, drug use
• Intake PHQ9 scores
• Laboratory
• A1C
• Lipids
• Self management goals

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Self management attainment scores

• SM builds self efficacy through stepwise goal
  setting and attainment
• Our goal was to measure whether pts were
  attaining their specific goals
• Each visit previous SM goals reviewed
• CDE assigned an attainment score
• 1 not attained
• 2attempted but limited success
• 3partial success
• 4fully successful

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Baseline characteristics
Age (N488) 51.5 10.8 Sex (N488)
male 37.7 female 62.3 Hispanic
(N483) yes 64.4 no 35.6 Primary
language (N322) Spanish 52.5 English 4
1.6 bilingual 5.9 Education completed
(grade) (N462) 9.0 3.9 Employment status
(N358) employed 20.4 unemployed 79.6 Cu
rrent smoker (N482) yes 26.3 no 73.7 H
istory of smoking (N313) yes 56.5 no 43
.5 Depression Hx, Sx, or Dx (N488)
yes 61.9
no 38.1 Time since diabetes diagnosis (years)
(N441) 6.3 7.5 Baseline HbA1C
(N487) 8.4 2.2
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2,133 SM Goals
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Predictors of successful goal attainment

• Associated with higher attainment rates
• Age
• depression
• No association with lower education, Hispanic
  ethnicity, gender, baseline A1C, time since Dx

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Mean HbA1C change 0.9/yr

• Change in the annual rate
• of change of HbA1C 95
  CI
• Characteristic
• Age (per 10 years older) 0.02 -0.34, 0.38
• Education (per grade) -0.09 -0.20, 0.02
• Male gender -0.25 -0.95, 0.44
• Hispanic ethnicity 0.39 -0.47, 1.24
• Depression 0.51 -0.21, 1.24
• Time since diabetes diagnosis (per year)
  0.08 0.04, 0.13
• Baseline HbA1C lt 7.0 (reference group) 0
• gt7.0 lt9.0 -1.22
  -2.05, -0.39
• gt9.0 -3.69 -4.57, -2.80
• __________________________________________________
  ________________________
• A negative effect indicates faster improvement in
  HbA1C levels.
• N233
• Adjusted by multiple linear regression for all
  other variables in the table.
• Probability lt0.005 (under null hypothesis
  that change 0)

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A1C change in risk category
Final HbA1C category

• HbA1C7.0
  7.0ltHbA1Clt9.0 HbA1C9.0 TOTAL
• HbA1C7 5 13 5 77
• 7ltHbA1Clt9 39 48 18 105
• HbA1C9 18 35 28
  81
• TOTAL 116 96
  51 263

Baseline HbA1C
Low risk Moderate risk High risk
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Adjusted odds ratios for good outcome
(maintenance of A1Clt7 or improvement in risk
category) (N233)

• Characteristic Odds Ratio 95 CI
• Age 20-29 (reference group) 1
• 30-39 0.73 0.12, 4.50
• 40-49 0.94 0.18, 4.85
• 50-59 1.45 0.27, 7.76
• 60 2.89 0.50, 16.59
• Education (per grade) 1.04 0.96, 1.13
• Male gender 1.11 0.60, 2.03
• Depression 1.11 0.59, 2.07
• Time since diabetes diagnosis (per year) 0.92
  0.88, 0.96
• Baseline HbA1C lt 7.0 (reference group) 1
• gt7.0 lt9.0 0.19
  0.09, 0.41
• gt9.0 0.80 0.36, 1.78
• Number of SMGs attained (per goal) 1.17 1.03,
  1.34
• __________________________________________________
  _______________
• Adjusted in multiple logistic regression for all
  other variables in the table.
• Probabilitylt0.05 (under null hypothesis that
  odds ratio1.0)
• Probabilitylt0.001

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Summary Key Finding

• 1) Patients set nutrition goals preferentially
• 2) Patients were more successful with nutrition
  goals than physical activity goals
• 3) Depression did not impact goal attainment
• 4) Lower education level, depression and Hispanic
  ethnicity were NOT associated with worse outcomes
• 5) Goal attainment was associated with good
  glycemic outcomes

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Implications

• A culturally tailored diabetes SM program focused
  on goals and goal attainment can improve glycemic
  control in underserved, largely Hispanic patients
• Underserved patients can successfully set and
  attain diabetes self management goals
• Depressed patients can successfully participate
  in goal setting, can attain goals, and improve
  their HgA1C
• Goal attainment is associated with improved
  glycemic control