Abstract
Keywords
Introduction
Type 2 diabetes mellitus (DM) is a major cause of morbidity and death; it disproportionately affects low-income and minority populations in the United State. Diabetes complications include blindness, heart attack, stroke, tooth loss, amputation, and dialysis.1-5 Proper diabetes management requires consistent and multidisciplinary medical care to facilitate proper glycemic control.
Federally qualified community health centers (CHCs) care for under- and uninsured patients, many of whom have multiple chronic conditions such as diabetes.6,7 In Pennsylvania, more than 700 000 patients receive care and services during 2.3 million visits from more than 200 urban and rural clinic sites. In general, CHCs are cost-effective, reduce health disparities, and improve clinical outcomes for patients with chronic diseases. 1 However, those with higher proportions of uninsured patients have poorer outcomes compared with national averages. 8
Uninsured diabetic patients have a higher risk of developing diabetes complications compared with their insured counterparts 8 and are often less likely to receive hemoglobin A1c (HbA1c) screening.9-11 CHCs that make use of multidisciplinary techniques, such as intensive patient education and engagement, case management, and clinical pharmacy programs in community clinics, have been shown to be successful in improving glycemic control in low-income and underserved diabetic patients.12-14 The purpose of this pilot study was to evaluate the effectiveness of a diabetes management program called the Diabetes Healthy Outcomes Program (DHOP). DHOP is designed to provide multidisciplinary services for uninsured diabetic patients at a CHC, Hamilton Health Center (HHC).
Methods
Setting
In December 2007, a 2-year, $250 000 grant was awarded to HHC by the Highmark Foundation to provide a high-quality program for uninsured diabetic patients at no additional cost. DHOP is a comprehensive diabetes management program for uninsured patients that made diabetes care accessible to those previously without care. DHOP delivered coordinated, multidisciplinary, and supportive services such as dietary, exercise, and diabetes counseling; podiatry; ophthalmology; dental; prescriptions; and HbA1c measurements. Participants were offered up to 4 office visits per year that were coordinated such that all necessary care occurred during a single visit. This decreased transportation and other barriers for completing treatment and follow-up of diabetes. The primary endpoint over the course of the 2-year intervention was to lower HbA1c levels at least 5% from baseline and ultimately bring participants within HbA1c target of <7.0%.
Patients and Recruitment
Patients were recruited in 2008 by HHC providers. HHC patients who were determined to be uninsured for at least 20 months and have DM were referred to the DHOP coordinator. Eligible participants were then invited to an evening workshop at which they were invited to join the study. During this workshop, all DHOP services and benefits were described to each potential participant, including how each service would help the participant to improve his or her diabetes management. More than 90% of patients who attended the workshop participated in DHOP.
Intervention and Measures
Participant age at entry into the program, gender, and race were self-reported. All participants were offered HbA1c measurements during visits. All DHOP data were tracked using the Patient Electronic Care System. The Patient Electronic Care System is a form-driven, access-based system that is accessible to all HHC providers. DHOP data were entered by the HHC data specialist from paper charts completed by HHC providers.
Health Services Utilization Measures
Participants were offered basic dental (cleaning and basic exam only), podiatry (foot examination only), and nutrition services (basic review of the diabetic diet) at no cost at HHC. Up to 4 yearly primary care visits were provided by the grant. Free or discounted prescriptions were provided by the HHC on site pharmacy. Lab services and diabetes education sessions were contracted at a discounted rate by HHC through a local hospital/health center. Diabetes educators were made available through HHC on the day of visit for individualized sessions. Participants were referred for diabetes education for up to 2 visits yearly. The content of diabetes education sessions was tailored to individual patient needs. HHC partnered with local exercise facilities, including the YMCA, to offer free memberships and opportunities to exercise; however, exercise was not monitored. Vision services were supplied by a local provider. Participants were provided an initial visit for eyeglasses. However, there was no specialized diabetic eye care.
Primary Outcome Measure
HbA1c of 7% or less is indicative of diabetes control. 4 Participants were categorized as to whether they were able to maintain or obtain controlled HbA1c over the course of the program. Other clinical measures included systolic and diastolic blood pressures, which were assessed during each clinic visit.
Assessment of Participant Satisfaction
To assess participants’ experience in DHOP, the conducted semistructured interviews. Participants who provided written consent to be interviewed were contacted up to 5 times. After verbal consent to conduct and record the interview, participants were asked several questions, including the following:
How has DHOP helped you in managing your diabetes?
Do you need anything else to help you manage your diabetes right now?
Interviews were audio recorded, transcribed verbatim, and analyzed via content analysis. 15
Analysis
Descriptive statistics were used to assess demographic and health service utilization variables. T tests were conducted to assess relationships between HbA1c and service utilization.
Results
Participants
The Hamilton Health Center enrolled 189 participants total. Forty-four (23%) participants were treated by HHC for diabetes prior to enrollment in DHOP. The mean age was 51 and 50% were female. More than half of the sample was African American (55%), approximately 22% was white, 9% was Latino, and the rest was Asian American, mixed race, other or refused. Eighty-eight participants (47%) became inactive (ceased medical visits) during DHOP. Of these 88 participants, 50 (57%) were lost to follow-up; however, 38 (43%) participants left the intervention because they were able to obtain health insurance as a result of counseling by HHC staff. Seven (18%) participants obtained Medicare, 30 (34%) participants received Medicaid, and 1 (1%) participant obtained private insurance.
Health Service Utilization
Twenty-seven participants (14%) received dental services, 52 (27%) received podiatry services, and 43(22%) received nutrition services. Overall, 116 (62%) participants received eye care services, 121 (64%) received prescription drugs, and 28 (15%) engaged in an exercise program. Additionally, 89 (47%) participants set a self-management goal such as completing regular foot examinations or changing their diet to improve blood sugar control (Table 1).
Diabetes Healthy Outcomes Program Patient Service Utilization.
Primary Outcome, HbA1c
Adequate glycemic control is assessed by whether patients have an HbA1c of 7% or less. 88 participants had at least 2 HbA1c measures. For these 88, the baseline HbA1c value was 8.3 (SD = 3.2) and post value was 8.2 (SD = 2.8); P = .12. Although the overall HbA1c decreased slightly during the DHOP program, 38% of participants started with glycemic control but only 28% ended with glycemic control. Specifically, of the 34 participants who had HbA1c ≤7% at study entry, 19 maintained glycemic control and 15 lost control. Among the 54 participants who had HbA1c >7% at study entry, 6 achieved glycemic control and 48 continued to have elevated HbA1c levels (Figure 1). Participants who achieved or maintained glycemic control had more often used DHOP services (mean = 4.7, SD = 2.3) to achieve control compared with other DHOP participants who used fewer or no services (mean = 3.2 services, SD = 1.1; P < .01; Figure 2 and Table 2).
Mean HbA1c and percentage with glycemic control at baseline and post–Diabetes Healthy Outcomes Program.
Mean number of services used by glycemic control status.
Diabetes Healthy Outcomes Program Glycemic Control Status at End of Participation (N = 88).
P < .05 according to t test.
Blood Pressure Control
According to the American Diabetes Association guidelines (at the time of the study) blood pressure is considered controlled if systolic blood pressure is <130 mm Hg and diastolic blood pressure is <80 mm Hg. Ninety-eight participants (89%) had 2 blood pressure measurements. Ten participants (11%) entered the study with uncontrolled blood pressure and ended with blood pressure less than 130/80 mm Hg. Eighty percent (of 98) had blood pressure control at entry and maintained control. The remaining 10% (of 98) had uncontrolled blood pressure throughout the program.
Participant Satisfaction
Eighty participants (of 101) consented, and 35 (39%) completed semistructured interviews. Participants appreciated and were satisfied with DHOP. Several participants considered DHOP life saving. Some examples include the folowing:
If it wasn’t for the Hamilton Diabetes program, I would be dead. I didn’t have any way to get my diabetes medicine before the DHOP program.
However, participants reported difficulty obtaining medications due to personal responsibilities, lack of social support, and/or transportation limitations.
I can’t get to my prescription because I babysit my grand-daughter while my daughter is in beauty school. I don’t have a ride to the clinic.
Participants who revealed medical need during the interview were referred to the DHOP management team for prompt support. For example, the team could mail prescriptions to participant homes or arrange a follow-up appointment.
Discussion
Although participants reported that DHOP was helpful, they also reported multiple remaining challenges. Many of the participants required more than the 4 primary care visits covered by the program because of their uncontrolled diabetes or new diagnosis. Participants with long-standing, poorly controlled diabetes required dental services that were not covered by the program (ie, extractions or dentures). Eye exams were limited to one screening and one pair of eyeglasses without any retinal screening. Many people required services that were not covered by the program, including cataract removal, glaucoma, and retinal surgery. Point-of-care HbA1c and cholesterol were not available and delayed providers’ decisions on medication starts and changes.
We were not able to evaluate whether participants who left the program had better HbA1c control than those who remained. However, participants who dropped out of the study for more permanent insurance might have been less complex than those who remained uninsured. Those retained participants might have been more difficult to manage or required more services to obtain DM control than provided in the intervention. In addition, possible confounding factors in measurement include participant transience or lack of follow-up (only 88 of 195 had repeated measurements), low use of services (28% to 86% depending on service), and the type of services provided. Given the pre–post measurement design, whether having services available increased the intention to change or whether the use of services led to more DM control is unclear. The most powerful intervention for diabetes control, regular physical activity, was only accessed by 25% of the sample. Of note, participants were only offered opportunities for physical activity. No intervention encouraged or monitored the frequency of exercise. Last, we cannot ascertain whether changes in HbA1c resulted from actual services or the attention of being part of a formal intervention.
Our intervention failed to improve DM control in the majority of participants as measured by HbA1c. Several factors likely contributed, including the needs and the relative geographic transience of low socioeconomic status individuals. Based on study observations, additional services could contribute to better outcomes in future pilot studies: (1) More sustained physical activity and a model for motivating and monitoring the occurrence and extent of participation in exercise. Physical activity, along with changes in diet, has been shown to increase the likelihood of diabetes control.16,17 (2) Retinal screening and treatment and more inclusive dental procedures. Screening for retinopathy both predicts blindness and can motivate patients to control their blood glucose to avoid blindness. Poor dental health or dental pain may inhibit the ability to eat a healthy diet.
Multidisciplinary teams, including patient educators, case managers, physical activity coaches, and clinical pharmacies, have been shown to reduce HbA1c. 17 However, for a positive result, additional supportive services, such as transportation to needed services and social support for diet (eg, resources for finding healthy food on a fixed income) and exercise (provide motivation for sustained physical activity), will likely be needed in this lower socioeconomic status population to address long-term diabetes complications and improve patient quality of life.18,19
Footnotes
Acknowledgements
We would like to acknowledge all Diabetes Healthy Outcomes Program (DHOP) providers and Hamilton Health Center data management and information technology staff for their help with the providing treatment for the DHOP participants and for managing the data for this pilot study. We would like to thank the Highmark Foundation for providing funding for the pilot study.
Declaration of Conflicts of Interests
The author(s) declare no potential conflicts of interest related to this research or authorship of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This pilot study was funded by the Highmark Foundation.