Addressing diabetes disparities in underserved communities

Transcription

1 Addressing diabetes disparities in underserved communities Enrique Caballero MD Endocrinologist/Clinical Investigator Director, Medical Affairs, Professional Education Director of the Latino Diabetes Initiative Joslin Diabetes Center Harvard Medical School Boston, MA

2 Challenges Rapidly growing populations The prevalence of type 2 diabetes is at least twice as high as that in the White population Diabetes care disparities worse glycemic control, high rates of chronic complications, high mortality rates Social and cultural barriers Limited cultural awareness and skills among providers Significant limitations in clinical practice time, resources, support Limited comprehensive culturally oriented programs that address patient, provider and health system issues

3 Case Rosa is a 58 y/o Hispanic or Latino woman who has lived in the US for 20 years. She is married. Her husband is also Latino. They have two sons and two daughters and 6 grandchildren. She is a housewife. Her husband is a construction worker. She completed 6 years of school education. She speaks very little English.

4 Race and Ethnicity: Definitions Race Usually biological White, Black, American Indian (Native American)/ Alaska Native (Eskimo, Aleut), Asian/Pacific Islander Often overlapping Ethnicity Primarily social Independent of race Hispanic or Latino? Caballero AE. Diabetes in minority populations. In: Joslin s Diabetes Mellitus. LW & W; th Ed. p

5 The US Hispanic/Latino Population Puerto Ricans 8.6% Mexicans 66.9% Central and South Americans 14.3% Cubans 3.7% Others 6.5% US Census Bureau. The Hispanic Population in the United States: March Available at: Accessed June 28, 2004.

6 Case Rosa has continuously gained weight over the last 20 years. Her father and maternal grandmother died of diabetes related complications. Her husband, children and grandchildren are overweight. Her meals are usually rich in CHOs and fats and does not exercise. Since she has felt well and has no health insurance, she has not had a medical visit in many years. During the last 6 months, she has felt very tired, with increasing polyuria and polydipsia.

7 Age-adjusted Prevalence of self-reported diabetes among Hispanics and non-hispanic Whites, aged > 18 years by area of residence BRFSS Area Hispanic White-Non-Hispanic California Florida Illinois NY/NJ Texas Puerto Rico Centers for Disease Control and Prevention. MMWR; 53, Oct 2004:pp 7-10

8 Genes, Environment and Social/Cultural Factors in Type 2 Diabetes in Racial/Ethnic Minorities Appetite and Satiety? Thrifty Genes + Lifestyle Insulin Resistance and Abdominal Obesity Beta and Alpha Cell Dysfunction Type 2 Diabetes Incretin dysfunction? Socio-economic and Cultural factors Renal glucose handling? Frequent Chronic Complications Increased Mortality rates Caballero AE. Modified from Curr Diab and Endocrinology Reports :

9 Case Rosa is diagnosed with type 2 diabetes, based on a random plasma glucose level above 200 mg/dl and the classical symptoms of hyperglycemia. She has dyslipidemia (elevated Tg, low HDL-C and mildly elevated LDL-C ). Her BP is normal. She is also found with moderate nonproliferative retinopathy, peripheral neuropathy and microalbuminuria.

10 Type 2 Diabetes and its Complications in Minorities Disparate and Disproportionate prevalence of longterm complications of type 2 diabetes in minorities vs Whites lower leg amputations 2-4x retinopathy and blindness 2-4x stroke 2x ESRD 4-6x Caballero AE. Diabetes in minority populations. In: Joslin s Diabetes Mellitus. LW & W; th Ed. p

11 *Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine. The National Academies Press. Washington, D.C

12 Boltri JM, et al. Ethn Dis 2005; 15 (4): A1c levels by ethnicity/race NHANES % NH White NH Black Hispanics NH White NH Black Hispanics

13 Boltri JM, et al. Ethn Dis 2005; 15 (4): Percentage of participants with diagnosed diabetes with an A1c 11% by ethnicity/race NHANES % NH White NH Black Hispanics 0 NH White NH Black Hispanics

14 What Causes Disparities in Healthcare? Patient Socio-economic status Education/Health literacy Health seeking behavior Cultural factors Mistrust Provider System Lack of cultural awareness Stereotyping or biases Language barrier Lack of resources Lack of culturally oriented programs Inadequate interpreter services Time pressures and resource constraints Lack of adequate training Limited Access

15 Case Rosa is followed by a non-spanish speaking physician. Most of the time, a professional interpreter is present in the clinical encounter, but sometimes, it is one of Rosa s children who helps with translation. Rosa usually forgets to take her oral medications well and has not made significant changes in her meal plan and physical activity. Her family income is limited and has missed several medical appointments due to financial issues She frequently receives patient education brochures in Spanish. Most of these materials have been translated from an original English version.

16 Health Insurance Coverage Non-Latino White African American All Latino U.S. Born Mexican American Foreign Born Mexican American U.S. Census Bureau. Health Insurance Coverage: September, Harris MI. Diabetes Care. 2001;24: Percentage with health insurance

17 Socioeconomic Considerations 20% or more of non-hispanic blacks and Hispanics cite cost as a barrier to healthcare (8% for non-hispanic whites) 1 From a study of African American women, following a program on medical nutrition in diabetes care: I wish I had more money to make more choices income makes a big difference in the types of food one can afford. 2 1 Gary TL, et al. Ethn Dis. 2003;13: Galasso P, et al. Diabetes Educator. 2005;31:

18 The Latino Diabetes Initiative at Joslin A comprehensive strategy that involves clinical care, patient education, community outreach, research and provider education

19 Current structure of LDI Clinical Program

20 Ecological Model Community and policy System, group, culture Family, friends, small group Individual The health of individuals is inseparable from the health of communities (Healthy People 2010)

21 Patient Flow in the Latino Initiative General intake form - Laboratory - Joslin Vision Network (eye evaluation) Research protocol: evaluation of medical, socio-economic and cultural aspects. Health Literacy Level New Patient Visit (MD Visit) Clinical Care (MD and NP) Individual Follow-up Visit Group Medical Visits: 6-8 Patients 90 minute sessions Include Education Referrals to Specialty Clinics: BI Latino Mental Team Betham Eye Institute Pregnancy Clinic Cardiology Podiatry Nephrology Neurology, etc

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23 Patient Flow in the Latino Initiative General intake form - Laboratory - Joslin Vision Network (eye evaluation) Research protocol: evaluation of medical, socio-economic and cultural aspects. Health Literacy Level New Patient Visit (MD Visit) Patient Education Clinical Care (MD and NP) Monday Classes Diabetes Today Series in Spanish Full day activity 1. First Steps 2. What can I eat 3. Monitoring Matters 4. Foods that fit/exercise 5. Diabetes Medications Individual Follow-up Visit Group Medical Visits: 6-8 Patients 90 minute sessions Include Education Rosa s Story Low Health Literacy The Plate Method Follow-up With CDE Follow-up with CDE Medium-high Health Literacy Carb Counting for Beginners Referrals to Specialty Clinics: BI Latino Mental Team Betham Eye Institute Pregnancy Clinic Cardiology Podiatry Nephrology Neurology, etc

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25 Language Barrier A true story: 64 y/o Hispanic woman Patient does not speak English Treated for Hypertension Received a prescription for : Lisinopril 10 mg. Once/d. Patient rushed to the ER due to severe hypotension

26 Culturally Appropriate Translations

27 Rosa s Story Provider Manual English Patient Booklet Spanish

28 Patient Flow in the Latino Initiative General intake form - Laboratory - Joslin Vision Network (eye evaluation) Research protocol: evaluation of medical, socio-economic and cultural aspects. Health Literacy Level New Patient Visit (MD Visit) Patient Education Clinical Care (MD and NP) Emotional and social support Monday Classes Diabetes Today Series in Spanish Full day activity 1. First Steps 2. What can I eat 3. Monitoring Matters 4. Foods that fit/exercise Individual Follow-up Visit Group Medical Visits: 6-8 Patients 90 minute sessions Include Education Individual Session Support Groups 6-8 patients 5. Diabetes Medications Rosa s Story Low Health Literacy The Plate Method Follow-up With CDE Follow-up with CDE Medium-high Health Literacy Carb Counting for Beginners Referrals to Specialty Clinics: BI Latino Mental Team Betham Eye Institute Pregnancy Clinic Cardiology Podiatry Nephrology Neurology, etc

29 General Characteristics of LDI Patients with Type 2 Diabetes Age: 56 yrs (SD± 11.3) DM duration: 11.7 yrs (SD±9.3) Gender (F/M) 95/65 Married: 44% Unemployed: 50% High School Education: 48.5% Insurance type: Commercial: 27 % Free-care: 9 % Government: 64 % Language: None to Basic English: 64% Bilingual: 25% Miles traveled: 9.7 miles (SD ) N:160 Laboratory results: A1c at baseline: 9.0 % (IQR 2.5) Weight: 83 kg (IQR 22) BMI: 32 (IQR 8.4) Total Cholesterol: 182 (SD± 43) LDL Cholesterol: (SD± 36) HDL Cholesterol: 39 (IQR 12) Triglycerides: 149 (IQR 126)

30 Median A1C Median A1C Level of Patients with Type 2 DM in the Latino Program N= 160 pts ** ** * ** * * ** ** A1C Months after enrollment **p< *p<0.05 for paired t-test comparisons

31 Median A1C Median A1C Level of Patients with Type 2 DM in the Latino Program N= 129 pts * ** ** ** * ** Improved Worsened Months after enrollment **p< *p<0.05 for paired t-test comparisons

32 General Characteristics by Glycemic Control Variable Improved control (n:96) Worsened control (n:33) P-value Age (yrs) 55.9 (± SD: 11.0) 55.5 ± (SD: 10.8) 0.85 Gender (F/M)) 61/35 21/ A1c (%) (median ± IQR) 9.1 ± ± Less than High School Education 58 % 48 % 0.3 Not Married 53 % 76 % 0.02 Unemployment 48 % 59 % 0.28 JVN at baseline 41 % 24 % 0.09 Education minutes 1 st yr (median ± IQR) 420 (IQR: 165) 390 (IQR: 60) 0.7 Education minutes 2 nd yr (median ± IQR) 0 (IQR: 90) 60 (IQR: 90) 0.06 # of No Show visits during RX 2 (IQR: 2.5) 6 (IQR: 6) < Rx Advancements (dose increases) 1 st yr 2.18 ± ± Rx Advancements (dose increases) 2 nd yr 1.57 ± ± Improvement: A1c reduction 0.4% or Goal achievement at 1 year. Worsening: A1c increase 0.4% at 1 year.

33 Current structure of LDI Clinical Program Research Program

34 The Latino Diabetes Initiative Endothelial Function in Hispanic Children Endothelial Function in Hispanic Adults Research Body Image in Latino Women with Diabetes Genetics of Cardiovascular Disease Characterization of Retinopathy Adherence to Treatment The Impact of Rosa s Story on Diabetes Knowledge and Self-Care Behavior in Hispanics with Diabetes Assessing the impact of Rosa s Story as a DM educational tool

35 Research Highlights 1. Identification of social and cultural factors that influence diabetes care 2. The benefit of culturally oriented patient education strategies and community based activities 3. The presence of advanced stages of retinopathy in this population 4. Severe vascular and metabolic abnormalities in Latinos with family history of type 2 diabetes and in overweight children and adolescents 1. Caballero AE. Curr Opin Endocrinol Diabetes Obesity 2007; 14: Millan-Ferro A. Current Diabetes Reports 2007; 7: Sanchez C. ARVO meeting Caballero AE. Diabetes Care 2008; 31:576-82

36 Impaired Endothelium-Dependent Vasodilation in People at Risk for Type 2 Diabetes % Increase over baseline of brachial artery diameter * Control Relatives** IGT Diabetes *C vs R, IGT, D **1 or both parents Caballero AE et al. Diabetes. 1999; 48:

37 Diabetes Incidence Rates by Ethnicity Lifestyle Metformin Placebo 12 Cases/100 person-yr Caucasian (n=1768) African American (n=645) Hispanic (n=508) American Indian (n=171) Asian (n=142)

38 Weight Change Over Time DPP Research Group. Lancet. On line Oct 29, 2009

39 DPP vs. DPPOS Diabetes Rates DPP Research Group. Lancet. On line Oct 29, 2009

40 Obesity and Endothelial Dysfunction in Hispanic Children Variable Controls At risk P value (n=17) (n=21) Age Waist/hip ratio Total % fat < Trunk fat < Systolic BP < Diastolic BP Total cholesterol Triglycerides HDL LDL Demographic and clinical characteristics between both groups, comparisons were Done with t test in case of continuous variables and x 2 in case of dichotomous variables

41 Obesity and Endothelial Dysfunction in Hispanic Children Caballero AE. Diabetes Care. 2008; 31:576-82

42 Obesity and Endothelial Dysfunction in Hispanic Children Control Group Overweight Group ng/ml svcam ng/ml sicam * μg/ml Adiponectin * pg/ml TNF-α * ng/ml PAI-1 * ng/ml tpa * *P<0.05. mg/ml hs-crp * White Cells (zx10-3) White Blood Cell Count * pg/ml IL-6 Caballero AE. Diabetes Care. 2008;31:

43 Current structure of LDI Clinical Program Research Program Community Based Activities

44 Main factors that may influence diabetes development and care in Culturally Diverse Populations Acculturation Body Image Cultural Competence Depression Educational Level Fears General Family Integration and Support Health Literacy Individual and Social Interaction Judgment about disease Caballero AE. Insulin. 2007; 80-91

45 Main factors that may influence diabetes development and care in Culturally Diverse Populations Knowledge about the disease Language Myths Nutritional Preferences Other forms of Medicine ( Alternative ) Physical Activity Preferences Quality of Life Religion Socio-economic status Caballero AE. Insulin. 2007; 80-91

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47 Esto es mejor: Improving food purchasing selection among low-income Spanish-speaking Latinos through social marketing messages Baseline Evaluation: Analysis of the Grocery Receipt: 930 Calories per dollar 29 gr of Fat per dollar 150 gr of Carbs per dollar 5 gr of Fiber per dollar 21 gr of Protein per dollar cal 50 USD Other activities: Home Visits Supermarket tours Photovoice Rosa s Story Salud America - RWJ Foundation

48 Research Project in the Community Collaboration with the South End Community Health Center Aim : Test the hypothesis that A1c testing at home by patients along with more regular communication between patients and providers improves glycemic control better and faster than current standards Investigator Initiated Trial supported by Bayer Health Care

49 Collaboration with Multiple Organizations Harvard Medical School and affiliated institutions Mauricio Gaston Institute U Mass Boston Massachusetts Department of Public Health Massachusetts League of CHC Community Health Centers Community Based Organizations Hispanic American Chamber of Commerce Individuals and Latino owned businesses Media Health Care Plans Pharmaceutical and Diagnostics Industry ADA, CDC, NHMA, AACE, LADA NMQF

50 Men Said That Computers Are Like Women Because: Only their creator understands their internal logic. The language that they use to communicate among themselves is incomprehensible to others. Even the smallest mistakes are stored in long-term memory to be retrieved later on. As soon as you commit to one, you have to spend most of your salary in accessories.

51 Women Said That Computers Are Like Men Because: In order to get their attention, you have to turn them on. They have a lot of information but they are clueless. They are supposed to help you solve problems, but most of the time they ARE the problem. When you need them the most, their system fails. As soon as you commit to one, you realize that if you had waited a little longer, you could have gotten a better model.

52 Current structure of LDI Clinical Program Research Program Community Based Activities Professional Education

53 Health Care Professionals Education Medical Education Programs Community Health Centers Medical Students Visitors Program National and International Meetings Publications

54 What is Cultural Competence? The knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences; self-awareness; knowledge of patient s culture; and adaptation of skills. American Medical Association

55 MENTAL PHYSICAL SPIRITUAL EMOTIONAL

56 Purnell s s Model: Cultural Competence Person, Family, Community, Society Unconsciously incompetent Consciously incompetent Consciously competent Unconsciously competent

57 Model for Cross-Cultural Care: A Patient-Based Approach Awareness of Cultural and Social Factors Elicit Factors Negotiate Models Implement Management Strategies Tools and skills necessary to provide quality care to any patient we see, regardless of race, ethnicity, culture, class or language proficiency.

58 The ESFT Model Explanatory Model Social Barriers Fears/Concerns about Medication Therapeutic Contracting/Playback

59 POLICY DISTRIBUTION POLICY AVAILABILITY POLICY EFFECTIVENESS EFFICIENCY Supply Diffusion of interventions BASIC SCIENCE EFFICACY Biggest effect on most people Real world settings Ideal settings Molecular/ physiological

60 Recommendations Recognize the need to improve diabetes prevention and care for all groups Develop and support clinical and research programs that aim at understanding and addressing diabetes care in minority populations Develop specific strategies for underserved populations considering their social and cultural context Implement programs that address patient, health care provider and health care system issues Emphasize diabetes prevention and community based activities Consider strategies that may favorably impact provider and patient interaction as well as cross cultural interaction at all levels

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62 The Latino Diabetes Initiative at Joslin A comprehensive strategy that involves clinical care, patient education, community outreach, research and provider education enrique.caballero@joslin.harvard.edu

63 THANK YOU