Implementing health reform: improved data collection and the monitoring of health disparities.

The relative lack of standards for collecting data on population subgroups has not only limited our understanding of health disparities, but also impaired our ability to develop policies to eliminate them. This article provides background about past challenges to collecting data by race/ethnicity, primary language, sex, and disability status. It then discusses how passage of the Affordable Care Act has provided new opportunities to improve data-collection standards for the demographic variables of interest and, as such, a better understanding of the characteristics of populations served by the U.S. Department of Health and Human Services (HHS). The new standards have been formally adopted by the Secretary of HHS for application in all HHS-sponsored population health surveys involving self-reporting. The new data-collection standards will not only promote the uniform collection and utilization of demographic data, but also help the country shape future programs and policies to advance public health and to reduce disparities.

Lifestyle behaviors and physician advice for change among overweight and obese adults with prediabetes and diabetes in the United States, 2006.

INTRODUCTION: The objective of this study was to examine the lifestyle behaviors of overweight and obese people with prediabetes or diabetes and to determine whether an association exists between reported behaviors and physician advice for behavior change. METHODS: This investigation included overweight and obese people (body mass index ≥25.0 kg/m(2)) with prediabetes and diabetes aged 40 years or older identified from the 2006 National Health Interview Survey. Respondents reported attempts to control or lose weight, reduce the amount of fat or calories in their diet, and increase physical activity. Respondents also reported receipt of a physician recommendation for behavioral change in 1 or more of these areas. Data analysis included use of logistic regression stratified by sex and prediabetes/diabetes status to model odds of behavior by physician advice. RESULTS: Most people reported trying to control or lose weight (prediabetes, 82%; diabetes, 75%). Fewer identified efforts to reduce the amount of fat or calories in their diet (prediabetes, 62%; diabetes, 71%) or increase physical activity (prediabetes, 53%; diabetes, 57%). Approximately one-third reported not receiving physician advice for each of these behavior changes. In logistic regression, physician advice for reducing the amount of fat or calories in the diet and increasing physical activity was generally associated with the reported corresponding behavior. CONCLUSION: Many respondents reported trying to control or lose weight, but fewer reported actually reducing fat or calories in their diet or increasing physical activity. Physician advice may influence attempts at behavior change among overweight and obese patients with prediabetes and diabetes.

Racial and ethnic differences in weight management behavior by weight perception status.

OBJECTIVE: To examine racial/ethnic differences in the relationship between weight perception and weight management behaviors among overweight and obese adults. PARTICIPANTS: The study examined a nationally representative sample of 11,319 non-Hispanic White, non-Hispanic Black and Mexican American overweight and obese adults aged > or = 20 years from the 1999-2006 National Health and Nutrition Examination Survey. DESIGN: Body mass index (BMI, defined as weight in kilograms divided by height in meters squared) was used to categorize overweight (25 < or = BMI < 30) and obesity (BMI > or = 30). Measured height and weight were used to calculate BMI. Subjects reported self-perception of weight status (correct perception and misperception) and weight management behaviors over the previous 12 months (trying to lose weight, trying not to gain weight, and having a desired weight goal). Weight perception stratified logistic regression was used to model odds of weight management behavior by race/ethnicity. RESULTS: Among overweight and obese non-Hispanic White, non-Hispanic Black, and Mexican American adults, correct weight perception was positively associated with weight management behavior. In multiple logistic regression models, overweight non-Hispanic Blacks with a weight misperception were less likely to have tried to lose weight (adjusted odds ratio [aOR] = .7; 95% confidence interval [Cl] = .5,1.0) or to have tried not to gain weight (aOR = .7; 95% CI = .5,1.0) compared to overweight non-Hispanic Whites with a weight misperception. Among the obese with a misperception, non-Hispanic Blacks were less likely to desire to weigh less compared to non-Hispanic Whites (aOR = .5; 95% CI = .3,.9). CONCLUSIONS: Weight perception was associated with weight management behaviors, and this relationship varied by race/ethnicity. Weight perception may need to be addressed among overweight and obese individuals to increase appropriate weight management behaviors, particularly among minority communities.

Control of risk factors among people with diagnosed diabetes, by lower extremity disease status.

INTRODUCTION: We examined the control of modifiable risk factors among a national sample of diabetic people with and without lower extremity disease (LED). METHODS: The sample from the 1999-2004 National Health and Nutrition Examination Survey consisted of 948 adults aged 40 years or older with diagnosed diabetes and who had been assessed for LED. LED was defined as peripheral arterial disease (ankle-brachial index <0.9), peripheral neuropathy (> or = 1 insensate area), or presence of foot ulcer. Good control of modifiable risk factors, based on American Diabetes Association recommendations, included being a nonsmoker and having the following measurements: hemoglobin A1c (HbA1c) less than 7%, systolic blood pressure less than or equal to 130 mm Hg, diastolic blood pressure less than or equal to 80 mm Hg, high-density lipoprotein (HDL) cholesterol greater than 50 mg/dL, and body mass index (BMI) between 18.5 kg/m(2) and 24.9 kg/m(2). RESULTS: Diabetic people with LED were less likely than were people without LED to have recommended levels of HbA1c (39.3% vs 53.5%) and HDL cholesterol (29.7% vs 41.1%), but there were no differences in systolic or diastolic blood pressure, BMI classification, or smoking status between people with and without LED. Control of some risk factors differed among population subgroups. Notably, among diabetic people with LED, non-Hispanic blacks were more likely to have improper control of HbA1c (adjusted odds ratio [AOR] = 2.0; 95% confidence interval [CI], 1.1-3.9), systolic blood pressure (AOR = 1.9; 95% CI, 1.1-3.2), and diastolic blood pressure (AOR = 2.6; 95% CI, 1.1-5.8), compared with non-Hispanic whites. CONCLUSION: Control of 2 of 6 modifiable risk factors was worse in diabetic adults with LED compared with diabetic adults without LED. Among diabetic people with LED, non-Hispanic blacks had worse control of 3 of 6 risk factors compared with non-Hispanic whites.

Influences on screening for chronic diabetes complications in type 1 diabetes.

Screening for the long-term complications of diabetes is a critical component of diabetes management; however, evidence demonstrates that screening rates in diabetes populations are suboptimal. Our objective was to determine the use and predictors of optimal screening behavior, defined as receiving a fasting lipid test, dilated eye exam, spot urine test, foot examination, blood pressure reading, and hemoglobin A1c (HbA1c) in the previous year in a representative cohort of subjects with type 1 diabetes. Data are from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective cohort study of subjects with childhood onset type 1 diabetes. Data from 325 participants who responded to a survey during 1999-2001 were included in analyses. Reported screening rates were as follows: 87.9% had at least one HbA1c measurement in the past year, 63% had a foot exam, 73.3% had a spot urine test, 81.9% had a dilated eye exam, 93.5% had a blood pressure reading and 68.7% received a fasting lipid profile. Within this group, 37.7% of subjects reported undergoing all five tests (optimal screening). Independent correlates of optimal screening were receiving care from a specialist provider (odds ratio [OR] = 2.4; 95% confidence interval [CI]: 1.4-4.1) and blood glucose monitoring at least weekly (OR = 2.6; 95% CI: 1.1-6.2). These findings indicate that a large proportion of persons with type 1 diabetes are not being screened at the optimal level. Our data indicate that efforts to rectify this should focus on men and those who do not monitor blood glucose, and should involve primary care practitioners.

High risk characteristics for motor vehicle crashes in persons with diabetes by age.

Studies highlight a higher involvement of drivers with diabetes in motor vehicle accidents. Extensive debate, though, exists over the most appropriate approach to license these drivers. Risk factors for crashes in persons with diabetes are not well defined. In this report, motor vehicle crash involvement was identified in two cohorts of persons with type 1 diabetes to identify if crash patterns and characteristics differ by age. Overall, reported crashes decline with age in persons with and without diabetes, but the crash risk remained higher for persons with diabetes throughout the age span. No relationship was observed between diabetes complications, blood glucose control, and diabetes treatment patterns and motor vehicle crashes. Severe hypoglycemia, though, was consistently and strongly related to crashes at all ages. The findings suggest that the crash risk related to hypoglycemia does not diminish markedly in persons with Type 1 diabetes, despite changes in health and age. Several reports highlight the involvement of drivers with diabetes in motor vehicle crashes [Charlton, 2004]. Extensive debate exists, though, over the role of diabetes in these crashes and licensing policy differs, worldwide, for these drivers. The natural history of type 1 diabetes (worsening health outcomes over time) indicates that factors influencing crashes in persons with diabetes may change over time. Few reports, though, have examined the factors related to crashes in persons with diabetes by age.

Reducing Ex-offender Health Disparities through the Affordable Care Act: Fostering Improved Health Care Access and Linkages to Integrated Care.

Despite steadily declining incarceration rates overall, racial and ethnic minorities, namely African Americans, Latinos, and American Indians and Alaska Natives, continue to be disproportionately represented in the justice system. Ex-offenders commonly reenter communities with pressing health conditions but encounter obstacles to accessing care and remaining in care. The lack of health insurance coverage and medical treatment emerge as the some of the most reported reentry health needs and may contribute to observed health disparities. Linking ex-offenders to care and services upon release increases the likelihood that they will remain in care and practice successful disease management. The Affordable Care Act (ACA) offers opportunities to address health disparities experienced by the reentry population that places them at risk for negative health outcomes and recidivism. Coordinated efforts to link ex-offenders with these newly available opportunities may result in a trajectory for positive health and overall well-being as they reintegrate into society.

Monitoring in diabetes self-management: issues and recommendations for improvement.

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care. The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework. People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring.

Racial/ethnic differences in weight perception.

The objective of this research was to estimate the prevalence of weight misperception among adults using the most recent nationally representative data, according to measured weight category and to assess the relationship between weight misperception and race/ethnicity. Height and weight were measured as part of the 1999-2006 National Health and Nutrition Examination Survey. The study sample consisted of 17,270 adults aged >or=20 years. BMI was categorized as underweight (BMI < 18.5), healthy weight (18.5 or= 30). Subjects reported self-perception of weight status. Among study subjects, 31.7% of healthy weight adults, 38.1% of overweight adults, and 8.1% of obese adults incorrectly perceived their weight category. Among obese men, the odds of weight misperception were higher for non-Hispanic blacks (odds ratio (OR) = 3.0; 95% confidence interval (CI) = 2.0-4.5) compared to non-Hispanic whites and for persons with less than a high school education (OR = 2.1; 95% CI = 1.3-2.1), compared to those with some college education. Among obese women, the odds of weight misperception were higher for non-Hispanic blacks (OR = 3.4; 95% CI = 1.4, 3.1) and Mexican Americans (OR = 1.9; 95% CI = 1.2, 3.2) compared to non-Hispanic whites and for persons with less than high school education compared to those with some college education (OR = 5.5; 95% CI = 3.3-9.3). Weight misperception is highly prevalent in the US population, and more frequent in racial/ethnic minorities, males, and in persons with lower educational levels. Addressing the issue of weight misperception may help address the problem of obesity in the United States by increasing awareness of healthy weight levels, which may subsequently have an impact on weight-related behavior change.

Does patient behavior or access factors have the largest influence on screening in type 1 diabetes?

OBJECTIVE: Successful disease management is heavily influenced by access to care issues and patient behavior. Screening tests to detect chronic complications are part of diabetes management and may be influenced by access to care or patient decisions. The objective of this research was to examine how strongly access to care and patient behavior predict screening practices. RESEARCH DESIGN AND METHODS: Information on screening practices, access to care, and diabetes management were identified from the Pittsburgh Epidemiology of Diabetes Complications Study at two time points: 1998-2001 and 2002-2006. Information on access to care and patient behavior identified in 1998-2001 were examined relative to screening practices observed in 2002-2006. RESULTS: Access-to-care issues positively predicted subsequent screening practices. Specifically, specialist care visits, number of doctor visits, and intensive insulin therapy were all strong predictors for screening use. Receipt of the recommended level of screening tests was also positively associated with the patient behavior of daily blood glucose testing. CONCLUSIONS: The findings of this study show that access to care, in general, and access to quality diabetes care, in specific, play a key role in the use of recommended screening tests in type 1 diabetic patients. These data suggest that future efforts to improve screening practices in the type 1 diabetic population should address issues related to access to care.

Health-related quality of life and support group attendance for patients with systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with variable symptoms. Severity of disease has been associated with mental and physical health-related quality of life (HRQoL). The potential effects of support groups have not been examined. We examined the possible improvement in mental and physical HRQoL of women with SLE who attended support groups. Thirty-four women who attended support groups and 71 comparison women with SLE were recruited. Self-administered surveys included the Medical Outcomes Study Short-Form 36 (SF-36) and a 3-level rating of disease activity.Mean SF-36 Mental Health Summary Scale scores (MCS) were significantly lower for women attending groups (31.5) compared with nonattending SLE women (39.8). MCS scores were lower for blacks compared with whites (33.7 vs. 39.2, P <0.05). Women with high and moderate disease activity had lower MCS scores compared with those with low activity (28.6 or 35.6 vs. 42.7, P <0.05). In linear regression, 27% of the variation in MCS was explained by support group attendance, disease activity, race, and age.Overall, women with SLE reported lower MCS and physical health summary scales (PCS) scores than published population values, indicating markedly reduced quality of life. Any potential positive effects of support groups will need to be tested in a prospective random design to assess improvements in HRQoL.