Improvement in Diabetes Care of Underinsured Patients Enrolled in Project Dulce

Abstract

OBJECTIVE -To improve clinical diabetes care, patient knowledge, and treatment satisfaction and to reduce health-adverse culture-based beliefs in underserved and underinsured populations with diabetes. RESEARCH DESIGN AND METHODS-A total of 153 high-risk patients with diabetes recruited from six community clinic sites in San Diego County, California were enrolled in a nurse case management (NCM) and peer education/empowerment group. Baseline and 1-year levels of HbA 1c , lipid parameters, systolic and diastolic blood pressure, knowledge of diabetes, culture-based beliefs in ineffective remedies, and treatment satisfaction were prospectively measured. The NCM and peer education/empowerment group was compared with 76 individuals in a matched control group (CG) derived from patients referred but not enrolled in Project Dulce. RESULTS-After 1 year in Project Dulce, the NCM and peer education/empowerment group had significant improvements in HbA 1c (12.0 -8.3%, P Ͻ 0.0001), total cholesterol (5.82-4.86 mmol/l, P Ͻ 0.0001), LDL cholesterol (3.39 -2.79 mmol/l, P Ͻ 0.0001), and diastolic blood pressure (80 -76 mmHg, P Ͻ 0.009), which were significantly better than in the CG, in which no significant changes were noted. Accepted American Diabetes Association standards of diabetes care, knowledge of diabetes (P ϭ 0.024), treatment satisfaction (P ϭ 0.001), and culturebased beliefs (P ϭ 0.001) were also improved.CONCLUSIONS -A novel, culturally appropriate, community-based, nurse case management/peer education diabetes care model leads to significant improvement in clinical diabetes care, self-awareness, and understanding of diabetes in underinsured populations. Diabetes Care 27:110 -115, 2004T he incidence of diabetes is rapidly increasing in Western societies. Specific racial and ethnic groups, such as Mexican Americans, African Americans, Asian Americans, and Native Americans, are disproportionately affected by diabetes (1,2). The adverse impact on health of uncontrolled diabetes in these groups is compounded by lack of access to traditional primary care and preventive health care services (3-5).In response to this lack of adequate care for the uninsured, there is an increasing impetus for defining and implementing additional methods of improving diabetes care. The Centers for Disease Control and Prevention's national health objectives for year 2010 include increasing the percentage of individuals with diabetes who achieve specific standards of diabetes care (6). Diabetes management and education programs have been shown to have a significant impact on improving health outcomes (7-10). However, there remains a significant gap in translating and implementing effective approaches in the treatment of diabetes, particularly in underserved racial and ethnic groups (11-13). There is limited experience and available data assessing nontraditional approaches to diabetes self-management and empowerment models in diverse ethnic groups and none testing a comprehensive management approach (14 -17). Project Dulce was designed to test ...

Health Care and Patient-Reported Outcomes

“…Our finding that measures of team care were not associated with better diabetes control contrasts with reports of improvements in blood glucose control attributed to intensive nurse-directed diabetes interventions in recent controlled trails (43)(44)(45). On the other hand, our findings are consistent with those of a health care system-wide randomized trial of team diabetes care (2) that showed an increase in the utilization of preventive services (and less use of emergency room and specialty care services) but no greater change in HbA 1c (A1C) level in team care patients compared with those receiving usual care.…”

Gender Differences in Medical Advice and Health Behavior of Obese African Americans With and Without Type 2 Diabetes

“…Several studies have reported patients receiving medical advice were more likely to follow the recommendations, independent of race, gender, and other social factors (Deakin, Cade, Williams, & Greenwood, 2006;Phili-Tsimikas et al, 2004;Tang et al, 2005;Tang, Funnell, Brown, & Kurlander, 2010). Therefore, we hypothesize that gender will not be a factor in level of following advice.…”

Dulce Mothers: an intervention to reduce diabetes and cardiovascular risk in Latinas after gestational diabetes

“…For the current study, items were modified to address beliefs about diabetes onset (rather than cancer). A 10-item (true/false) measure, previously validated in English and Spanish in this population, assessed the participants' diabetes-specific cultural beliefs (e.g., urine is a cure for diabetes) [35]. Items were summed to reflect the number of (erroneous) beliefs endorsed out of 10.…”