Low-income Minority Patients Research Articles

Understanding Type 2 Diabetes Self-Management in Racial/Ethnic Minorities: Application of the Extended Parallel Processing Model and Sensemaking Theory in a Qualitative Study.

The purpose of the study was to understand the role of perceived disease threat and self-efficacy in type 2 diabetes (T2DM) patients' self-management by using the extended parallel processing model (EPPM) and sensemaking theory. Semistructured interviews (n = 25) were conducted with T2DM patients from an urban safety-net hospital. Participants were 50% male/female median age was 55 years and 76% were Black. Participants were categorized by EPPM group based on validated questionnaires (high/low disease threat [HT/LT]; high/low self-efficacy [HE/LE]). Nine were HT/HE, 7 HT/LE, 6 LT/HE, and 3 LT/LE. Interviews were transcribed and analyzed using inductive and deductive coding. Sensemaking theory was applied to contextualize and analyze data. Those with HT indicated threat fluctuated throughout diagnosis but that certain triggers (eg, diabetic complications) drove changes in disease view. Those in the HT/HE group more frequently expressed disease acceptance, whereas the HT/LE group more often expressed anger or denial. HT/HE participants expressed having adequate social support and higher trust in health care providers. HT/LE participants reported limited problem-solving skills. In those with LT, the HE group took more ownership of self-management behaviors. The LT/LE group had heightened positive and negative emotional responses that appeared to limit their ability to perform self-care. They also less frequently described problem-solving skills, instead expressing reliance on medical guidance from their providers. EPPM and sensemaking theory are effective frameworks for understanding how perceived health threat and self-efficacy may impede T2DM self-care. A greater focus on these constructs is needed to improve care among low-income minority patients, especially those with low threat and self-efficacy.

Barriers to Healthy Eating and Diabetes Diet Education: Divergent Perspectives of Patients and Their Providers.

Patients report that adhering to diet is the most challenging aspect of diabetes management. Provision of diet education is often delegated to health care providers, despite a lack of nutrition education and training and limited awareness of environmental and cultural challenges faced by patients. Aim. We examined perceived barriers to diet self-management among low-income minority patients with type 2 diabetes and their health care providers within a single ecosystem, to test whether providers understood patient barriers. Method. We surveyed 149 members of a safety-net clinic (99 patients, 50 providers), using barriers derived from the literature. Binomial logistic regression was applied to investigate relationships between barriers and patients' sociodemographic variables and Pearson's χ2 was used to compare differences in perceived barriers between patients and providers. Results. Providers expressed divergent perceptions of patients' barriers to healthy eating, including more total barriers and little agreement with patients on their relative importance. Largest differences in providers' perceptions of patient barriers included poor motivation, high use of fast food, inadequate family support, and lack of cooking skills-all suggesting patient inadequacy. In contrast, patients showed evidence of high motivation-in rate of blood glucose measurement and desire for diet education. Patients identified primary care providers as a main source of nutrition education, yet providers indicated lack of time for diet discussion and preferred other staff do the teaching. Conclusion. The findings from this study strongly suggest that health systems need to consider patient, provider, and system barriers when implementing nutrition education and management programs.

548-P: Understanding T2D Self-Management in Racial/Ethnic Minorities: Application of the Extended Parallel Processing Model and Sensemaking Theory

Behavioral health interventions are needed to address disparities among low-income racial/ethnic minorities with type 2 diabetes (T2D). We aimed to gain a better understanding of the role of disease threat perception and self-efficacy using the Extended Parallel Processing Model (EPPM) as a guide in T2D self-management among Black and Hispanic patients. Semi-structured interviews were conducted with minority T2D patients who receive care in endocrinology, internal or family medicine practices in an urban safety-net hospital. Participants were placed in one of 4 EPPM groups based on validated questionnaires: High or low disease threat and high or low self-efficacy. The interviews were transcribed then analyzed using both inductive and deductive coding based on Sensemaking Theory. From this ongoing study, the current analysis includes 11 interviews. The cohort had a median age of 52 years, was 55% female, 82% were black and 18% were Hispanic. Participants in the high threat groups indicated disease threat fluctuated throughout their diabetes history and that certain triggers (e.g., diabetic complications) drove changes in disease view. Participants with high threat/high efficacy (n=4) expressed acceptance of T2D and reported adequate social support, whereas those with high threat/low efficacy (n=2) expressed anger or denial about T2D. Participants with low threat/high efficacy (n=2) reported poor social support, while those with low threat/low efficacy (n=3) had heightened positive and negative emotional responses. Both low efficacy groups reported less problem-solving skills than the high efficacy groups. Perceived health threat and low self-efficacy may impede T2D self-care, presenting barriers to achieving good diabetes control. A greater focus on the role of diabetes threat perception and self-efficacy is needed to improve T2D care among low-income minority patients. Disclosure D. J. Rubin: Research Support; Self; AstraZeneca. D. A. Swavely: None. J. Brajuha: None. P. J. Kelly: None. S. Allen: None. A. Hoadley: None. A. Iwamaye: None. Y. Zisman-ilani: None. S. B. Bass: None.

Developing Messaging Content for a Physical Activity Smartphone App Tailored to Low-Income Patients: User-Centered Design and Crowdsourcing Approach.

BackgroundText messaging interventions can be an effective and efficient way to improve health behavioral changes. However, most texting interventions are neither tested nor designed with diverse end users, which could reduce their impact, and there is limited evidence regarding the optimal design methodology of health text messages tailored to low-income, low–health literacy populations and non-English speakers.ObjectiveThis study aims to combine participant feedback, crowdsourced data, and researcher expertise to develop motivational text messages in English and Spanish that will be used in a smartphone app–based texting intervention that seeks to encourage physical activity in low-income minority patients with diabetes diagnoses and depression symptoms.MethodsThe design process consisted of 5 phases and was iterative in nature, given that the findings from each step informed the subsequent steps. First, we designed messages to increase physical activity based on the behavior change theory and knowledge from the available evidence. Second, using user-centered design methods, we refined these messages after a card sorting task and semistructured interviews (N=10) and evaluated their likeability during a usability testing phase of the app prototype (N=8). Third, the messages were tested by English- and Spanish-speaking participants on the Amazon Mechanical Turk (MTurk) crowdsourcing platform (N=134). Participants on MTurk were asked to categorize the messages into overarching theoretical categories based on the capability, opportunity, motivation, and behavior framework. Finally, each coauthor rated the messages for their overall quality from 1 to 5. All messages were written at a sixth-grade or lower reading level and culturally adapted and translated into neutral Spanish by bilingual research staff.ResultsA total of 200 messages were iteratively refined according to the feedback from target users gathered through user-centered design methods, crowdsourced results of a categorization test, and an expert review. User feedback was leveraged to discard unappealing messages and edit the thematic aspects of messages that did not resonate well with the target users. Overall, 54 messages were sorted into the correct theoretical categories at least 50% of the time in the MTurk categorization tasks and were rated 3.5 or higher by the research team members. These were included in the final text message bank, resulting in 18 messages per motivational category.ConclusionsBy using an iterative process of expert opinion, feedback from participants that were reflective of our target study population, crowdsourcing, and feedback from the research team, we were able to acquire valuable inputs for the design of motivational text messages developed in English and Spanish with a low literacy level to increase physical activity. We describe the design considerations and lessons learned for the text messaging development process and provide a novel, integrative framework for future developers of health text messaging interventions.

MHealth app using machine learning to increase physical activity in diabetes and depression: clinical trial protocol for the DIAMANTE Study

IntroductionDepression and diabetes are highly disabling diseases with a high prevalence and high rate of comorbidity, particularly in low-income ethnic minority patients. Though comorbidity increases the risk of adverse outcomes...

Costs and Utilization for Low Income Minority Patients with Depression in a Collaborative Care Model Implemented in a Community‐Based Academic Health System

Research ObjectiveThe collaborative care model (CoCM) is effective in treating patients with common behavioral health conditions in primary care settings and improving clinical outcomes. As health care reform efforts move toward model sustainability and scalability, more information is needed to assess its potential impact on costs and utilization. In a community‐based academic health system, serving primarily Medicare and Medicaid recipients with significant racial and ethnic diversity, we examined cost and major health care utilization metrics for depressed patients enrolled in CoCM compared to a group that did not receive CoCM treatment.Study DesignThe community‐based academic health system has 23 primary care practices in an urban setting offering colocated behavioral health care access to a psychiatrist and social worker as part of “usual care.” Seven of these sites implemented the CoCM to enhance care quality through care manager support, psychiatric consultation, measurement‐informed care, and a patient tracking registry. Two types of analyses were conducted to examine cost and utilization metrics; a site‐level intention to treat (ITT) model and an analysis comparing CoCM patients to a matched cohort at all usual care sites using propensity score matching. Two timeframes were considered; the first and second year following an initial positive PHQ‐9 (>10 indicating clinically significant depressive symptoms).Population StudiedIndividuals were eligible for inclusion if they sought care at one of the 23 primary care sites, scored positive on the PHQ‐9, and were enrolled in Medicaid for at least nine months out of the year for both the baseline and analysis year. The outcomes of interest were cost and selected health care utilization metrics including emergency room, admissions, and office visits.Principal FindingsIn the first year, the CoCM patients (n = 4,315) demonstrated a statistically significant decrease in emergency room visits (OR = .95; OR = .91) and non‐BH specialty office visits (OR =. 92; OR = .93), and an increase in PCP visits (OR = 1.03; OR = 1.03) and behavioral health (BH) office visits (OR = 1.03; OR = 1.08) compared to the usual care patients (n = 3,061) for both the ITT and cohort match analyses (n = 1,873 in both groups). The trend in year two continued, with statistically significant decreased emergency room visits (OR = .89; OR = .88) and non‐BH specialty office visits (OR = .87; OR = .92) for CoCM patients (n = 2,623) compared to those in usual care (n = 1,838) for the ITT and cohort match analyses (n = 1,193). Total costs for both years were not significantly different between groups.ConclusionsFindings demonstrate CoCM treatment is associated with potentially positive outcomes, including decreased emergency room visits and improved continuity of primary care. Results indicate these outcomes are sustained for at least 24 months.Implications for Policy or PracticeWhen comparing CoCM treatment of depression with colocation care in a 2‐year analysis, more effective health care utilization was found for decreasing emergency room utilization and other medical specialty utilization, and increasing primary care continuity for patients receiving CoCM. As organizations continue to seek new opportunities to integrate behavioral health into primary care, consideration of health care utilization and costs will be helpful in determining model selection for integration.Primary Funding SourceCenters for Medicare and Medicaid Services.

Automated Reminders Improve Retinal Screening Rates in Low Income, Minority Patients with Diabetes and Correct the African American Disparity.

Diabetic retinopathy (DR) is a major cause of blindness in the United States. Prevention relies on periodic DR screening, yet overall national screening rates are not optimal, especially in low-income, minority patients. We prospectively evaluated show rates for prescheduled teleretinal DR screening appointments in diabetic patients (n = 301) in a large safety-net clinic in South Central Los Angeles. Patients were predominately African American (n = 88) and Latino (n = 200). Patients received either usual care telephone reminders or automated reminder calls in addition to usual care. The overall mean (SEM) show rate for DR screening, irrespective of reminder method, was low: 54+1.03%. Show rates with usual care alone were 46.3+2.6%, and with automated reminders added, 59.9+1.47% (p = 0.036). Show rate with usual care amongst African Americans was 23.6+6.46% compared with 53.2+3.41% for Latinos (p = 0.025). When automated calling was added, the show rate doubled amongst African Americans, to 51.6+3.96% (p = 0.002) with a slightly higher, non-significant show rate in Latinos. In summary, show rates for pre-scheduled teleretinal DR screening appointments were low with usual care alone in a safety-net clinic, with evidence for a racial disparity amongst low-income, minority patients with diabetes. Addition of a pre-recorded automated reminder call improved show rates, and corrected much of the racial disparity observed. Greater focus on failed appointments as an explanation for low DR screening rates and racial disparities, and as a potentially remediable target with automated reminders, may improve DR screening rates and reduce blindness in low-income minority patients with diabetes.

A Systematic Review of Community Health Center Based Interventions for People with Diabetes.

Community health centers (CHCs) focus on serving socioeconomically disadvantaged populations with heightened chronic disease burden, making CHCs an ideal setting for implementing diabetes care programs that target vulnerable populations. We aimed to synthesize evidence concerning the effects of CHC interventions in people with diabetes. To do this, four electronic databases were searched, including PubMed, EMBASE, CINAHL, and Scopus, and hand searches of reference collections were undertaken to identify intervention trials published in English. We screened 892 unique titles and abstracts. Two reviewers then independently evaluated 221 full-text articles. We discovered 29 articles met our eligibility criteria for inclusion. We found 27 unique studies with two companion articles. Seventeen studies were randomized controlled trials and the majority had a higher proportion of female and racial/ethnic minorities in the study sample. CHC interventions often involved either one-on-one or group education sessions supplemented by a phone follow-up that were delivered by health providers, nutritionists, or community health workers. CHC interventions using education sessions combined with follow up via phone generally resulted in significant improvements in hemoglobin A1C, while sole telephone-based education studies showed no significant improvements. CHC interventions had no significant effects on physical activity in all six studies that examined the outcome. Overall, we found that CHC interventions were in general effective in improving glucose control when using face-to-face interactions in low-income, underserved, and racial and ethnic minority patients with diabetes. Evidence was limited, however, in regards to other outcomes which suggests the need for continued evaluations of CHC intervention models.

The Role of Text Messages in Patient-Physician Communication about the Influenza Vaccine.

Racial and ethnic minorities face disparities in receiving the influenza vaccination. A text message intervention could deliver personalized and timely messages to counsel patients on asking their physician for the vaccination. We assessed whether patients would be receptive to influenza vaccination text messages. Participants were recruited from a sample of low-income, racial and ethnic minority primary care patients. Participants completed a self-administered survey. Descriptive statistics were used to analyze the data. There were 274 patients who participated and answered the questions of interest, of whom 70% were racial and ethnic minorities and 85% owned a cell phone. Thirty-six percent reported they had never received an influenza vaccination recommendation from their physician. However, 84% would be comfortable asking their physician for the influenza vaccination. Of cell phone-owning participants who would be comfortable asking their physician about the influenza vaccination, 80% would also be comfortable receiving a text message reminder. Text messages may be an acceptable channel to prompt patients to discuss the annual influenza vaccination with their physicians. Text messaging is a feasible tool to engage patients in their health and improve annual influenza vaccination rates among low-income, racial and ethnic minority patients.

Patient Navigation to Improve Cancer Screening in Underserved Populations: Reported Experiences, Opportunities, and Challenges

Our goal is to define patient navigation for an imaging audience, present a focused selection of published experiences with navigation programs for breast and colorectal cancer screening, and expose principal barriers to the success of such programs. Despite numerous advances in the early detection of cancers, many patients still present with advanced disease. A disproportionate number are low-income minority patients who experience worse health outcomes than their white or more financially stable counterparts. Patient navigation, which aims to assist the medically underserved by overcoming specific barriers to care, may represent one solution to narrowing disparities. Related research suggests that in general, patient navigation programs that have addressed breast or colorectal cancer screening have been successful in improving screening rates and timeliness of follow-up care. However, although beneficial, navigation is expensive and may present an unmanageable financial burden for many health care centers. To overcome this challenge, navigation efforts will likely need to target those patients that are most likely to benefit. Further research to identify such patients will be critically important for improving the sustainability of navigation programs, and, in turn, for realizing the benefits of such programs in reducing cancer disparities.

Provider attitudes and practice of recommended guidelines to reduce readmissions among low income minority patients

Abstract In recognition of the contributory role of patient, provider, and systems related factors to failure in transitions of care, recommendations have been made by healthcare organizations regarding best practices to improve transitions of care and reduce readmissions. The role of provider attitudes and adherence to recommended practice guidelines in care transitions has not been studied. The present study sought to determine provider attitudes and actual practice of recommended best practice strategies aimed at promoting optimal transitions of care. A cross-sectional survey was conducted among key healthcare providers involved in the discharge process at the Grady Memorial Hospital, a 953 bed academically affiliated urban safety net hospital. Of these, 131 participants completed the surveys including 73 internal medicine residents, 7 social workers, 51 nurses (5 nurse case managers, 6 inpatient unit nursing directors and charge nurses and 40 bedside nurses). There was a variation as to consideration of importance of best practices across healthcare disciplines consistent with the practice focus of each discipline. Medication reconciliation however seemed to be considered equally important across disciplines. Coordination of care, use of a multidisciplinary team and discussion of goals of care were practices considered to be least important. There was a significant discrepancy between consideration of importance of best practices and actual practice of these. This study has shown areas where key providers involved in the discharge process are not adhering to guidelines recommended to reduce readmissions. Future studies to determine barriers to guideline adherence are needed along with targeted interventions to promote provider adherence.

Misdiagnosing adult appendicitis: clinical, cost, and socioeconomic implications of negative appendectomy

BackgroundThe aim of this study was to evaluate the clinical, financial, and socioeconomic factors associated with negative appendectomy (NA). MethodsData were obtained from the California State Inpatient Database (2005 to 2011). Patients (≥18 years) who underwent nonincidental appendectomies (n = 180,958) were evaluated with multivariate regression analyses. ResultsNA rates decreased from 4.5% in 2005 to 2.8% in 2011 (P < .01). Compared with patients with nonperforated appendicitis, NA was associated with longer length of stay, higher morbidity, and higher hospital costs. Multivariate regression demonstrated that African Americans, younger age (18 to 29 years), and females were predictors of NA. Hispanics and patients with public or no insurance were associated with a lower NA rate; however, perforation rates were higher. ConclusionsNA was associated with higher cost, longer length of stay, and higher morbidity compared with nonperforated appendicitis. Lower NA rates but higher perforation rates in some populations suggest a delay in presentation. Further research is needed to understand these disparities and to improve quality of care among low-income minority patients.

Do Socioeconomic Factors and Race Determine the Likelihood of Breast-Conserving Surgery?

BackgroundRacial disparities in the use of breast-conserving surgery (BCS) have been reported and may be due to advanced stage at diagnosis. Our hypothesis was that low-income and ethnic minority patients have an increased tumor size at diagnosis and decreased likelihood of BCS. Patients and MethodsA retrospective review was conducted of early stage breast cancer patients from 10 hospitals in Harris County, Texas, between 2004 and 2011. Clinical stage was calculated on the basis of data from the institutional tumor registries and electronic medical records. Zip code–based socioeconomic factors were downloaded from the US Census Bureau (http://www.census.gov/). Linear regression was used to identify predictors of tumor size, and logistic regression was used to identify predictors of BCS. ResultsThe cohort included 3937 patients, comprising 2546 (65%) whites, 535 (14%) African Americans, 482 (11%) Hispanics, and 374 (10%) Asian/others. Multivariate linear regression demonstrated socioeconomic status (SES), younger age, African American, Hispanic race, and hormone receptor–negative tumors to be associated with increased tumor size at diagnosis (P < .05). Hispanic and Asian/other race, larger tumor size, combined estrogen receptor–negative/progesterone receptor–negative tumors were associated with not receiving BCS. ConclusionRace and SES were both associated with larger tumor size at diagnosis. Larger tumor size, negative hormone receptor status, and Hispanic and Asian race were associated with lack of receipt of BCS. Breast cancer screening programs should target both minority and low SES groups. Rates of BCS should be interpreted cautiously when used as a quality metric because of the multiple factors, including tumor size and biology, contributing to its use.

Abstract 156: Assessing the readiness and interest towards electronic means of communication among patients at Federally Qualified Health Centers.

Background: Some research has been done into using mobile phones as a means of communication with patients. It has been shown to improve medication adherence among chronically ill patients. As of December 2012 , more than 89% of the US inhabitants have mobile broadband subscriptions .This opens up the potential for Smartphone applications and also patient portals, above and beyond text messaging for patient communication. Objectives: To assess the readiness, interest and barriers of low income minority patients with diabetes mellitus (DM) and cardiovascular disease (CVD) towards adopting 1) Text messaging , Smartphone applications , Patient portals as means of communication with providers. 2)Compare technology adoption in immigrant versus non-immigrant populations. Methods: This study is part of the Office- Guidelines Applied to Practice (Office-GAP) project, designed to improve secondary prevention of heart disease for DM and CVD patients in FQHCs (Federally Qualified Health Centers) in Michigan. We analyzed 119 out of the 242 patients that participated in Office-GAP group visits (June 2013-January 2014) and completed the questionnaire. The questionnaire evaluated their readiness , interest and barriers towards electronic means of communication . Chart abstraction was performed for relevant data by trained research assistants. Descriptive analysis was performed on the cross sectional data thus obtained. Results: Study population is 53 % (63 of 119) non-immigrant , 47% (56 of 119) immigrant. Mean age is 53.69 (33.07% males) and 57.1% (68 of 119) of our patient population has a cellphone with non-immigrants having higher access (74.6 vs 37.5%) compared to immigrants. Text messages can be sent and received by 37.8% (45 of 119) with 21.1% (25 of 118) having to pay extra charges for texts and 25.7% (30 of 117) want texts from the doctors office. A landline is available to 54% (64 of 119) and 48.2% (56 of 116) want voicemails. Out of our population with both a landline and cellphone 57 %(60 of 106) prefer landline. Only 10 % (12 of 119) of our population can use a computer very well and 55% (65 of 119) cannot use a computer at all , 35%(42 of 119) have access to internet and email and 52.3%(22 of 42) want emails from their doctors office. Seven percent (4 of 58) would like to have access to their medical information online by means of a patient portal. Three percent (2 of 58) have a smartphone and 1.7% (1 of 58) would like a Smartphone application for accessing their medical records. Conclusion: Minority and low-income patients with DM and CVD may eventually be ready for adopting more technology as a means of communication with their provider as technology gets cheaper and trivialized . Current readiness and interest to adoption is lower among immigrant compared to non immigrant population. More research is needed to determine the barriers to adopting technology for secondary prevention of heart disease.

Participation in and Impact of a Depression Care Management Program Targeting Low-Income Minority Patients in an Urban Community-Based Clinic

BackgroundAfrican American people experience disproportionately higher rates of chronic depression, and among those affected, the condition is less likely to be detected and treated than in non-Hispanic white people. ObjectiveTo address this disparity in our primary care clinic, we introduced a validated framework for detecting and managing depression. MethodsOver a 5-year period, there were 146 patients diagnosed as having depression and enrolled in a depression care management program. We evaluated the feasibility and effectiveness of that program using baseline and follow-up screening data from the Patient Health Questionnaire-9. ResultsThe mean baseline severity score of 20.60 was reduced to 15.89 at 6 months (P < 0.001) and to 16.62 at 12 months. Patients achieved their best score, a mean of 12.93, 10.14 months after baseline (P < 0.001). The last mean severity score, after 15.47 months, was 14.60, a significant difference compared with baseline (P < 0.001). Although baseline severity scores for both groups were similar (P = 0.534), patients who remained engaged with the program demonstrated better scores and achieved greater severity score reductions from baseline to the last measure (P < 0.001). This study did not find any differences between the sexes when comparing PHQ-9 scores at baseline (P = 0.074), 6 months (P = 0.303), and 12 months (P = 0.429) and best (P = 0.875) and last (P = 0.640) scores. ConclusionsMost of the improvement was witnessed in the first 10 months of treatment. Patients with more medical comorbidities participated longer in the study than patients with fewer comorbidities. Further research could elicit the relationship between improvement in mental health and medical conditions.

Feasibility of an Internet-Based Intervention for Improving Diabetes Outcomes Among Low-Income Patients With a High Risk for Poor Diabetes Outcomes Followed in a Community Clinic

The purpose of this study was to determine the feasibility of an Internet-based intervention, targeting very low-income minority patients with a high risk for not engaging in diabetes self-management, to increase diabetes self-management and improve diabetes outcomes. Patients with diabetes followed in a community clinic were enrolled in the 13-month trial. Participants were requested to test blood sugar and upload glucometer data every day and login to the program at least once every second day. Feasibility data included process measures; diabetes outcomes consisted of changes from baseline to follow-up for levels of glycosylated hemoglobin (A1C), LDL, HDL, triglyceride and total cholesterol, and health-related quality of life using the SF-36. Only 22% of participants had health insurance. Participants had an average of 4.39 comorbidities and 7.06 prescriptions. Participants uploaded glucometer data at least twice each week and logged into the application at least once each week. Participants demonstrated reductions statistically or clinically important changes in A1C, LDL cholesterol, total cholesterol, and triglyceride levels. Participants engaging in more frequent chat messages and interactive activities demonstrated greater reductions in LDL cholesterol levels; however, engaging in more frequent chat messages also was associated with increased triglyceride levels. Participants rated fewer role limitations from physical health problems at follow-up. The intervention produced good outcomes; however, an alternative platform may be a less expensive approach.

Adverse Childhood Experiences and Diabetes in Adulthood: Support for a Collaborative Approach to Primary Care

Prior studies have demonstrated an association between retrospective reports of experiencing trauma in childhood and the current incidence of type 2 diabetes in adulthood. Much less is known about this association among low-income minority patients in primary care settings. We replicated the adverse childhood experiences (ACEs) Centers for disease control and prevention (CDC) study with a low-income minority sample of primary care patients (N = 801) at a community-based healthcare center. We conducted a cross-sectional retrospective quantitative survey study to examine the association between participants’ reports of past childhood trauma and their current health care outcomes. Data were analyzed using binary logistic regression to evaluate the hypothesis that low income minority patients who reported more childhood trauma (abuse, neglect, household dysfunction, cumulative adverse childhood experiences [ACEs]) would more likely be diagnosed with type 2 diabetes. Results suggest that the number of ACEs in our sample were considerably higher than the original CDC ACEs study, as almost 50 % of patients surveyed at our clinic reported 4 or more ACEs, confirming that trauma is central in our urban primary care setting. The results of the cumulative ACEs score was in the expected direction and was significant, suggesting that participants who cumulatively reported experiencing more childhood trauma were more likely to be diagnosed with type 2 diabetes in adulthood. These findings have implications for family therapists, primary care providers, researchers, and policy makers to develop more collaborative approaches to primary care that better target the negative sequelae of ACEs.

Self-Rated Health and Association with ACEs

Background: Prior studies have demonstrated an association between experiencing trauma in childhood and poorer self-rated health in adulthood. Much less is known about this association among low-income minority patients in primary care settings. Methods: We replicated the Adverse Childhood Experiences (ACE) Study, a collaborative venture between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, with a low-income minority sample of primary care patients (N = 801) at a community-based healthcare center. We conducted a cross-sectional retrospective quantitative survey study. Data were analyzed using binary logistic regression to evaluate the hypothesis that low-income minority patients who reported more childhood trauma (abuse, neglect, household dysfunction, cumulative adverse childhood experiences [ACEs]) would more likely have reported poorer health in adulthood. Results: The number of ACEs in our sample was considerably higher than the original CDC ACE Study, as almost 50% of patients surveyed at our clinic reported 4 or more ACEs, confirming that trauma is central among individuals served in many urban primary care settings. The results of the ACE abuse, neglect, and cumulative ACEs score were in the expected direction and statistically significant suggesting that participants who reported more childhood abuse and neglect and who reported more childhood trauma (cumulative/total ACEs) were more likely to report poorer health in adulthood. Conclusion: These findings have implications for providers, researchers, and policy makers to develop more collaborative approaches to primary care that better target the negative sequelae of ACEs.

Short and Long-Term Outcomes from a Multisession Diabetes Education Program Targeting Low-Income Minority Patients: A Six-Month Follow Up

BackgroundA diabetes self-management education (DSME) program was offered to patients at a primary care clinic serving low-income people. ObjectivesThe purpose of the analyses presented here was to understand the feasibility of the program and effectiveness of the intervention. MethodsThe program was facilitated by a nurse and licensed dietician. Data were collected at baseline, after each class, and after 6 months. Patients were interviewed to identify diabetes self-care behaviors before the first class, after the fourth class, and at 6 months. Knowledge related to content areas was measured before and after each class. Glycosylated hemoglobin (HbA1c), blood pressure, weight, and body mass index (BMI) were collected at baseline and after 6 months. Medical records were reviewed for LDL levels, co-morbidity, and diabetes management. Frequencies, χ2 and t tests, and repeated measures t tests were used to analyze data. ResultsPatients were mostly non-Hispanic black or Hispanic (93.1%); mean BMI was 34.89 kg/m2. About one-half (41.95%) completed the program. Significant improvements were observed for knowledge related to each of the 4 content areas: diet (P < 0.001), diabetes management (P = 0.003), monitoring blood glucose (P < 0.001), and preventing complications (P = 0.001). Among long-term outcomes, mean HbA1c was significantly reduced (0.82%), from 8.60% to 7.78% (P = 0.007), with 26.67% of patients reducing HbA1c from ≥7.0% at baseline to <7% at follow up (P < 0.001). Patients demonstrated a significant improvement in readiness to improve dietary behaviors (P = 0.016). ConclusionsOutcomes suggested that minority patients with a high risk for poor diabetes outcomes might be retained in a multisession DSME program and benefit from increasing knowledge of diabetes content. Further evaluation is necessary to determine the cost-effectiveness of this intervention.

Design of a prostate cancer patient navigation intervention for a Veterans Affairs hospital

BackgroundPatient navigation programs have been launched nationwide in an attempt to reduce racial/ethnic and socio-demographic disparities in cancer care, but few have evaluated outcomes in the prostate cancer setting. The National Cancer Institute-funded Chicago Patient Navigation Research Program (C-PNRP) aims to implement and evaluate the efficacy of a patient navigation intervention for predominantly low-income minority patients with an abnormal prostate cancer screening test at a Veterans Affairs (VA) hospital in Chicago.Methods/DesignFrom 2006 through 2010, C-PNRP implemented a quasi-experimental intervention whereby trained social worker and lay health navigators worked with veterans with an abnormal prostate screen to proactively identify and resolve personal and systems barriers to care. Men were enrolled at a VA urology clinic and were selected to receive navigated versus usual care based on clinic day. Patient navigators performed activities to facilitate timely follow-up such as appointment reminders, transportation coordination, cancer education, scheduling assistance, and social support as needed. Primary outcome measures included time (days) from abnormal screening to diagnosis and time from diagnosis to treatment initiation. Secondary outcomes included psychosocial and demographic predictors of non-compliance and patient satisfaction. Dates of screening, follow-up visits, and treatment were obtained through chart audit, and questionnaires were administered at baseline, after diagnosis, and after treatment initiation. At the VA, 546 patients were enrolled in the study (245 in the navigated arm, 245 in the records-based control arm, and 56 in a subsample of surveyed control subjects).DiscussionGiven increasing concerns about balancing better health outcomes with lower costs, careful examination of interventions aimed at reducing healthcare disparities attain critical importance. While analysis of the C-PNRP data is underway, the design of this patient navigation intervention will inform other patient navigation programs addressing strategies to improve prostate cancer outcomes among vulnerable populations.