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Diabetes process and outcome measures are common quality measures in payment reform models, including Alternative Payment Models (APMs) and value-based insurance design (VBID). In this commentary we review evidence from selected research to examine whether these payment models can improve the value of diabetes care. We found that higher-risk APMs yielded greater improvements in diabetes process measures than lower-risk APMs, and that VBID models appeared to improve medication adherence but not other quality measures. We argue that these models are promising first steps in redesigning the payment system to improve diabetes care. However, greater coordination and alignment across models is needed to enhance their impact on providers' behavior, diabetes care processes, and patient health outcomes.
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Diabetes Mellitus , Seguro de Salud Basado en Valor , Diabetes Mellitus/terapia , Humanos , Estados UnidosRESUMEN
Background: The Diabetes Prevention Program (DPP) showed that lifestyle change or metformin is equally efficacious in preventing diabetes in women who have had gestational diabetes mellitus (GDM). Few studies have investigated the relationship between education and willingness to engage in either intervention and between education and preferred decision-making style. Methods: Within a large health system, we surveyed insured women 18-64 years old with a history of GDM, identified through the electronic health record. We estimated preference for decision-making style and interest in DPP lifestyle change and/or metformin by educational level, using multivariate logistic regression models controlling for age, race, and ethnicity. Results: Our sample (n = 264) was 36% Latino, 29% Asian, 28% non-Latino white, and 5% African American, with a mean age of 37 years. In terms of education, 31% had a postgraduate degree, 41% were college graduates, and 29% did not graduate from college. In multivariate analyses, willingness to engage in either intervention did not vary by education. Women who did not graduate from college were more likely to leave medical decisions to their provider (p = 0.004) compared to women with a college or postgraduate degree. However, regardless of education, over 80% of women preferred to make medical decisions themselves or jointly with their provider. Conclusions: Most women prefer to play an active role in their own medical decisions and have an interest in both evidence-based diabetes prevention strategies. This suggests that shared decision-making is appropriate for many women with a history of GDM and different levels of educational attainment.
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BACKGROUND: Stakeholders (ie, patients, policymakers, clinicians, advocacy groups, health system leaders, payers, and others) offer critical input at various stages in the research continuum, and their contributions are increasingly recognized as an important component of effective translational research. Natural experiments, in particular, may benefit from stakeholder feedback in addressing real-world issues and providing insight into future policy decisions, though best practices for the engagement of stakeholders in observational studies are limited in the literature. METHODS: The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) network utilizes rigorous methods to evaluate natural experiments in health policy and program delivery with a focus on diabetes-related outcomes. Each of the 8 partnering institutions incorporates stakeholder engagement throughout multiple study phases to enhance the patient-centeredness of results. NEXT-D2 dedicates a committee to Engagement for resource sharing, enhancing engagement approaches, and advancing network-wide engagement activities. Key stakeholder engagement activities include Study Meetings, Proposal Development, Trainings & Educational Opportunities, Data Analysis, and Results Dissemination. Network-wide patient-centered resources and multimedia have also been developed through the broad expertise of each site's stakeholder group. CONCLUSIONS: This collaboration has created a continuous feedback loop wherein site-level engagement approaches are informed via the network and network-level engagement efforts are shaped by individual sites. Emerging best practices include: incorporating stakeholders in multiple ways throughout the research, building on previous relationships with stakeholders, enhancing capacity through stakeholder and investigator training, involving stakeholders in refining outcome choices and understanding the meaning of variables, and recognizing the power of stakeholders in maximizing dissemination.
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Investigación Biomédica/métodos , Investigación sobre Servicios de Salud/métodos , Participación de los Interesados , Investigación Biomédica/organización & administración , Diabetes Mellitus/terapia , Investigación sobre Servicios de Salud/organización & administración , Humanos , Difusión de la Información , Investigación Biomédica Traslacional/métodos , Investigación Biomédica Traslacional/organización & administraciónRESUMEN
African American neighborhoods have been historically targeted for urban renewal projects, which impact social composition and resident's health. The Hill District in Pittsburgh, PA is such a neighborhood. This research sought to investigate the extent to which social networks and perceived neighborhood social cohesion and safety were associated with psychological distress among residents in an African American neighborhood undergoing urban renewal, before the implementation of major neighborhood changes. Findings revealed a modest, significant inverse association between social network size and psychological distress (ß = -0.006, p < .01), even after controlling for age, employment, education, and income. Perceived neighborhood safety predicted decreased psychological distress (ß = -1.438, p < .01), but not social cohesion, which is consistent with past research. Findings suggest that social networks protect against psychological distress, but neighborhood perceptions are also paramount.
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Negro o Afroamericano/psicología , Poder Psicológico , Características de la Residencia , Percepción Social , Apoyo Social , Estrés Psicológico/psicología , Adolescente , Adulto , Anciano , Escolaridad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores Socioeconómicos , Adulto JovenRESUMEN
BACKGROUND: There is a paucity of evidence supporting the effectiveness of diabetes self-management education (DSME) in improving mental health-related quality of life (HRQoL) for African American and Latinos. Also, among studies supporting the favorable effects of DSME on mental HRQoL, the direct effect of DSME that is independent of improved glycemic control has never been investigated. The objectives of this study were to investigate the effect of community-based DSME intervention targeting empowerment on mental HRQoL and to determine whether the effect is direct or mediated by glycemic control. METHODS: We conducted secondary analyses of data from the Diabetes Self-Care Study, a randomized controlled trial of a community-based DSME intervention. Study participants (n = 516) were African Americans and Latinos 55 years or older with poorly controlled diabetes (HbA1c ≥ 8.0%) recruited from senior centers and churches in Los Angeles. The intervention group received six weekly small-group self-care sessions based on the empowerment model. The control group received six lectures on unrelated geriatrics topics. The primary outcome variable in this secondary analysis was the change in Mental Component Summary score (MCS-12) from the SF-12 Health Survey between baseline and six-month follow-up. We used the change in HbA1c during the study period as the main mediator of interest in our causal mediation analysis. Additionally, possible mediations via social support and perceived empowerment attributable to the program were examined. RESULTS: MCS-12 increased by 1.4 points on average in the intervention group and decreased by 0.2 points in the control group (difference-in-change: 1.6 points, 95% CI: 0.1 to 3.2). In the causal mediation analysis, the intervention had a direct effect on MCS-12 improvement (1.7 points, 95% CI: 0.2 to 3.2) with no indirect effects mediated via HbA1c change (-0.1 points, 95% CI: -0.4 to 0.1), social support (0.1 points), and perception of empowerment (0.1 points). CONCLUSIONS: This Diabetes Self-Care Study empowerment intervention had a modest positive impact on mental HRQoL not mediated by the improvement in glycemic control, as well as social support and perception of empowerment. This favorable effect on mental HRQoL may be a separate clinical advantage of this DSME intervention. TRIAL REGISTRATION: ClinicalTrial.gov NCT00263835.
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Enfermería en Salud Comunitaria/organización & administración , Diabetes Mellitus/terapia , Educación en Salud/métodos , Educación del Paciente como Asunto/métodos , Poder Psicológico , Autocuidado/métodos , Apoyo Social , Negro o Afroamericano/educación , Anciano , Anciano de 80 o más Años , Femenino , Hispánicos o Latinos/educación , Humanos , Los Angeles , Masculino , Persona de Mediana Edad , Calidad de VidaRESUMEN
BACKGROUND: The association between the Medicare Part D low-income subsidy (LIS), gap coverage, and outcomes such as medical expenditures, prescription fills, and medication adherence is not well understood. The purpose of this study was to examine the relationship between the LIS and these measures for patients within a large, national Part D plan in the United States. METHODS: In this cross-sectional, retrospective analysis, we compared total and plan expenditures, out-of-pocket costs, and medication fills and adherence for three categories of Medicare beneficiaries: non-LIS beneficiaries without gap coverage (non-LIS/non-GC), non-LIS beneficiaries with gap coverage (non-LIS/GC), and LIS beneficiaries (LIS). RESULTS: LIS beneficiaries, relative to non-LIS/non-GC and non-LIS/GC beneficiaries, had higher total expenditures ($1,887 vs. $1,360 vs. $1,341); lower out-of-pocket costs ($148 vs. $546 vs. $570); more expenditures exceeding the gap threshold (27.6% vs. 18.4% vs. 16.9%); and slightly higher adherence to blood pressure (65.6% vs. 64.2% vs. 62.4%); diabetes (62.5% vs. 57.7 vs. 57.4%); and lipid-lowering (59.6% vs. 57.0 vs. 55.6%) medications. CONCLUSION: LIS beneficiaries had higher total expenditures, lower out-of-pocket costs, and modestly better adherence to diabetes medications than non-LIS/non-GC and non-LIS/GC beneficiaries.
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Financiación Personal/economía , Cobertura del Seguro/economía , Medicare Part D/economía , Cumplimiento de la Medicación , Pobreza , Medicamentos bajo Prescripción/economía , Anciano , Anciano de 80 o más Años , Estudios Transversales , Diabetes Mellitus/tratamiento farmacológico , Femenino , Gastos en Salud , Humanos , Masculino , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND: African American men with chronic kidney disease (CKD) progress to end-stage renal disease more rapidly than African American women or whites. Uncontrolled hypertension worsens CKD, and disparities in hypertension control may contribute to disparities in CKD progression. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: 10,827 individuals with CKD and self-reported hypertension screened in the Kidney Early Evaluation Program. PREDICTORS: African American race, sex. OUTCOMES: Hypertension control (blood pressure <130 mm Hg systolic and/or <80 mm Hg diastolic). MEASUREMENTS: Self-report, physical examination (blood pressure), laboratory data (serum creatinine, microalbuminuria by urine dipstick). We calculated estimated glomerular filtration rates by using the 4-variable isotope dilution mass spectrometry Modification of Diet in Renal Disease Study equation. We classified CKD as early (stages 1 to 2) or late (stages 3 to 5) based on estimated glomerular filtration rate and microalbuminuria. RESULTS: In individuals with early CKD, African American women (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.14 to 1.88), white men (OR, 1.85; 95% CI, 1.39 to 2.46), and white women (OR, 1.69; 95% CI, 1.28 to 2.22) had greater odds of hypertension control (blood pressure <130/80 mm Hg) than African American men. In individuals with late CKD, white men (OR, 1.66; 95% CI, 1.10 to 2.52) and white women (OR, 1.67; 95% CI, 1.13 to 2.46) had greater odds of hypertension control than African American men. No differences were seen between African American men and women with late CKD. LIMITATIONS: No information for medication regimens. CONCLUSIONS: African American men with CKD have poorly controlled hypertension compared with African American women and whites, particularly in the early stages of disease. Efforts to aggressively treat hypertension in this population may help narrow the race and sex disparities in progression to end-stage renal disease.