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1.
Contemp Clin Trials Commun ; 25: 100878, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34977421

RESUMO

Background: Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin. Methods: The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin. Conclusion: The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

2.
JMIR Res Protoc ; 10(12): e29423, 2021 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-34855617

RESUMO

BACKGROUND: Peer narratives engage listeners through personally relevant content and have been shown to promote lifestyle change and effective self-management among patients with hypertension. Incorporating key quotations from these stories into follow-up text messages is a novel way to continue the conversation, providing reinforcement of health behaviors in the patients' daily lives. OBJECTIVE: In our previous work, we developed and tested videos in which African American Veterans shared stories of challenges and success strategies related to hypertension self-management. This study aims to describe our process for developing a text-messaging protocol intended for use after viewing videos that incorporate the voices of these Veterans. METHODS: We used a multistep process, transforming video-recorded story excerpts from 5 Veterans into 160-character texts. We then integrated these into comprehensive 6-month texting protocols. We began with an iterative review of story transcripts to identify vernacular features and key self-management concepts emphasized by each storyteller. We worked with 2 Veteran consultants who guided our narrative text message development in substantive ways, as we sought to craft culturally sensitive content for texts. Informed by Veteran input on timing and integration, supplementary educational and 2-way interactive assessment text messages were also developed. RESULTS: Within the Veterans Affairs texting system Annie, we programmed five 6-month text-messaging protocols that included cycles of 3 text message types: narrative messages, nonnarrative educational messages, and 2-way interactive messages assessing self-efficacy and behavior related to hypertension self-management. Each protocol corresponds to a single Veteran storyteller, allowing Veterans to choose the story that most resonates with their own life experiences. CONCLUSIONS: We crafted a culturally sensitive text-messaging protocol using narrative content referenced in Veteran stories to support effective hypertension self-management. Integrating narrative content into a mobile health texting intervention provides a low-cost way to support longitudinal behavior change. A randomized trial is underway to test its impact on the lifestyle changes and blood pressure of African American Veterans. TRIAL REGISTRATION: ClinicalTrials.gov NCT03970590; https://clinicaltrials.gov/ct2/show/NCT03970590. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29423.

4.
Healthc (Amst) ; 8 Suppl 1: 100485, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34175098

RESUMO

BACKGROUND: Compared to White patients in the United States, Black patients have a higher prevalence of hypertension and more severe forms of this condition. OBJECTIVE: To decrease racial disparities in blood pressure (BP) control among Black veterans with severe hypertension within a regional network of Veterans Affairs Medical Centers (VAMCs). METHODS: Health system leaders, clinicians, and health services researchers collaborated on a 12-month quality improvement (QI) project to: (1) examine project implementation and the QI strategies used to improve BP control and (2) assess the effect of the initiative on Black-White differences in BP control among veterans with severe hypertension. RESULTS: Within 9 participating VAMCs, the most frequently used QI strategies involved provider education (n=9), provider audit and feedback (n=8), and health care team change (n=7). Among 141,124 veterans with a diagnosis of hypertension, 9,913 had severe hypertension [2,533 (25.6%) Black and 7380 (74.4%) White]. Over the course of the project, the proportion of Black veterans with severe hypertension decreased from 7.5% to 6.6% (p=.002) and the racial difference in proportions for this condition decreased 0.9 percentage points, from 2.9% to 2.0% (p=.01). CONCLUSIONS: A multicenter, equity-focused QI project in VA reduced the proportion of Black veterans with severe hypertension and ameliorated observed racial disparities for this condition. Embedding health services researchers within a QI team facilitated an evaluation of the processes and effectiveness of our initiative, providing a successful model for QI within a learning health care system.


Assuntos
Hipertensão , Veteranos , Pressão Sanguínea , Humanos , Hipertensão/terapia , Estados Unidos , United States Department of Veterans Affairs
5.
Diabetes Technol Ther ; 23(9): 616-622, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33761284

RESUMO

Background: Racial-ethnic disparities in diabetes technology use are well documented in young adults (YA) with type 1 diabetes (T1D), but modifiable targets for intervention still need to be identified. Our objective was to explore YA perspectives on technology access and support in routine clinical care. Materials and Methods: Participants were YA with T1D of Hispanic or non-Hispanic Black race-ethnicity from pediatric and adult endocrinology clinics in the Bronx, NY. We conducted semistructured individual interviews to explore how health care and personal experiences affected technology use. Interviews were audio-recorded and transcribed for analysis. We used a modified inductive coding approach with two independent coders and iterative coding processes to improve data reliability and validity. Results: We interviewed 40 YA with T1D: mean age 22 years; 62% female; 72% Medicaid insured; 72% Hispanic; 28% non-Hispanic Black; and mean hemoglobin A1C 10.3%. Themes were categorized into potentially exacerbating and alleviating factors of racial-ethnic disparities in technology use. Exacerbating factors included perceptions that providers were gatekeepers of information and prescription access to technology, providers did not employ shared decision making for use, and YA biases against technology were left unaddressed. Alleviating factors included provider optimism and tailoring of technology benefits to YA needs, and adequate Medicaid insurance coverage. Conclusions: Our results reveal potential intervention targets at the provider level to increase technology uptake among underrepresented YA with T1D. Diabetes health care providers need to be aware of inadvertent withholding of information and prescription access to technology. Provider approaches that address YA technology concerns and promote shared decision making help to mitigate racial/ethnic disparities in technology use.

6.
Diabetes Technol Ther ; 23(4): 306-313, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33155826

RESUMO

Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.


Assuntos
Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 1/tratamento farmacológico , Hemoglobina A Glicada/análise , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde , Humanos , Sistemas de Infusão de Insulina , Tecnologia , Estados Unidos , Adulto Jovem
7.
J Gen Intern Med ; 35(Suppl 2): 808-814, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33107002

RESUMO

BACKGROUND: Patient engagement is a key tenet of patient-centered care and is associated with many positive health outcomes. To improve resources for patient engagement, we created a web-based, interactive patient engagement toolkit to improve patient engagement in primary care across the Veterans Health Administration (VHA). OBJECTIVE: To use the knowledge translation (KT) framework to evaluate the dissemination and implementation of a patient engagement toolkit at facilities across one region in the VHA. DESIGN: Using a mixed-methods approach, this process evaluation involved phone monitoring via semi-structured interviews and group meetings, during which we explored barriers and facilitators to KT. Outcomes were assessed using a structured rubric and existing patient satisfaction measures. PARTICIPANTS: We enlisted implementers at 40 VHA facilities primarily serving Pennsylvania, New Jersey, and Delaware to implement patient engagement practices at their sites. Sites were randomly assigned into a high or low coaching group to assess whether external support influenced implementation. KEY RESULTS: Sites with high rubric scores employed and possessed several elements across the KT trajectory from identification of the problem to sustainment of knowledge use. Key factors for successful implementation and dissemination included implementer engagement, organizational support, and strong collaborators. The most frequently cited barriers included short staffing, time availability, lack of buy-in, and issues with leadership. Successful implementers experienced just as many barriers, but leveraged facilitators to overcome obstacles. While sites that received more coaching did not have different outcomes, they were more likely to revisit the toolkit and indicated that they felt more accountable to local personnel. CONCLUSIONS: Because leveraging available resources is a key component of successful implementation, future toolkits should highlight the type of facilitators necessary for successful implementation of toolkit content in healthcare settings. The ability to tailor interventions to local context is critical for overcoming barriers faced in most healthcare settings.


Assuntos
Participação do Paciente , Atenção Primária à Saúde , Humanos , New Jersey , Assistência Centrada no Paciente , Pennsylvania , Pesquisa Qualitativa
8.
JAMA Netw Open ; 3(9): e2016369, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32915236

RESUMO

Importance: Diabetes is a substantial public health issue. Peer mentoring is a low-cost intervention for improving glycemic control in patients with diabetes. However, long-term effects of peer mentoring and creation of sustainable models are not well studied. Objective: Assess the effects of a peer support intervention for improving glycemic control in patients with diabetes and evaluate a model in which former mentees serve as mentors. Design, Setting, and Participants: A randomized clinical trial was conducted from September 27, 2012, to March 21, 2018, at the Corporal Michael J. Crescenz Medical Center. US veterans with type 2 diabetes aged 30 to 75 years with hemoglobin A1C (HbA1c) greater than 8% received support over 6 months from peers with prior poor glycemic control but who had achieved HbA1c less than or equal to 7.5% (phase 1). Phase 1 mentees were then randomized to become a mentor or not to new randomly assigned participants in phase 2. Outcomes were assessed at 6 and 12 months. Data were analyzed from October 5, 2016, to September 4, 2018. Interventions: Mentors who received an initial training session and monthly reinforcement training were assigned 1 mentee and given $20 for each month they contacted their mentee at least weekly. Main Outcomes and Measures: Primary outcome was HbA1c change at 6 months. Secondary outcomes included HbA1c change at 12 months and change in low-density lipoprotein, blood pressure, diabetes quality of life, and depression symptoms at 6 and 12 months. Results: The study enrolled 365 participants into phase 1 and 122 participants into phase 2. Most participants were Black (341 [66%]) and male (454 [96%]), with a mean (SD) age of 60 (7.5) years. Mean phase 1 HbA1c change at 6 months for usual care was -0.20% (95% CI, -0.46% to 0.06%) vs -0.52% (95% CI, -0.76% to -0.29%) for mentees (P = .06). Mean phase 2 HbA1c change at 6 months for usual care was -0.46% (95% CI, -1.02% to 0.10%) vs 0.08% (95% CI, -0.42% to 0.57%) for mentees (P = .16). There were no differences in secondary outcomes or HbA1c levels at 12 months. There was no benefit to past mentees who became mentors. Conclusions and Relevance: In this randomized clinical trial, a peer mentor intervention did not improve 6-month HbA1c levels and did not have sustained benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT01651117.


Assuntos
Diabetes Mellitus Tipo 2/terapia , Mentores/estatística & dados numéricos , Infuência dos Pares , Autogestão/métodos , Veteranos/psicologia , Adulto , Idoso , Diabetes Mellitus Tipo 2/psicologia , Feminino , Hemoglobina A Glicada/análise , Humanos , Masculino , Pessoa de Meia-Idade , Autogestão/psicologia , Autogestão/estatística & dados numéricos , Estados Unidos , Veteranos/estatística & dados numéricos
9.
Health Serv Res ; 55 Suppl 2: 894-901, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32643163

RESUMO

OBJECTIVE: To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. DATA SOURCES/STUDY SETTING: Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. STUDY DESIGN: The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. DATA COLLECTION/EXTRACTION METHODS: The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. PRINCIPAL FINDINGS: Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023). CONCLUSIONS: Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.


Assuntos
Agentes Comunitários de Saúde/organização & administração , Hospitalização/estatística & dados numéricos , Múltiplas Afecções Crônicas/terapia , Pobreza/estatística & dados numéricos , Adulto , Idoso , Feminino , Nível de Saúde , Humanos , Masculino , Medicaid/estatística & dados numéricos , Saúde Mental , Pessoa de Meia-Idade , Philadelphia , Método Simples-Cego , Fatores Socioeconômicos , Estados Unidos , Populações Vulneráveis
10.
J Clin Endocrinol Metab ; 105(8)2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32382736

RESUMO

CONTEXT: Minority young adults (YA) currently represent the largest growing population with type 1 diabetes (T1D) and experience very poor outcomes. Modifiable drivers of disparities need to be identified, but are not well-studied. OBJECTIVE: To describe racial-ethnic disparities among YA with T1D and identify drivers of glycemic disparity other than socioeconomic status (SES). DESIGN: Cross-sectional multicenter collection of patient and chart-reported variables, including SES, social determinants of health, and diabetes-specific factors, with comparison between non-Hispanic White, non-Hispanic Black, and Hispanic YA and multilevel modeling to identify variables that account for glycemic disparity apart from SES. SETTING: Six diabetes centers across the United States. PARTICIPANTS: A total of 300 YA with T1D (18-28 years: 33% non-Hispanic White, 32% non-Hispanic Black, and 34% Hispanic). MAIN OUTCOME: Racial-ethnic disparity in HbA1c levels. RESULTS: Non-Hispanic Black and Hispanic YA had lower SES, higher HbA1c levels, and much lower diabetes technology use than non-Hispanic White YA (P < 0.001). Non-Hispanic Black YA differed from Hispanic, reporting higher diabetes distress and lower self-management (P < 0.001). After accounting for SES, differences in HbA1c levels disappeared between non-Hispanic White and Hispanic YA, whereas they remained for non-Hispanic Black YA (+ 2.26% [24 mmol/mol], P < 0.001). Diabetes technology use, diabetes distress, and disease self-management accounted for a significant portion of the remaining non-Hispanic Black-White glycemic disparity. CONCLUSION: This study demonstrated large racial-ethnic inequity in YA with T1D, especially among non-Hispanic Black participants. Our findings reveal key opportunities for clinicians to potentially mitigate glycemic disparity in minority YA by promoting diabetes technology use, connecting with social programs, and tailoring support for disease self-management and diabetes distress to account for social contextual factors.


Assuntos
Diabetes Mellitus Tipo 1/epidemiologia , Disparidades nos Níveis de Saúde , Grupos Minoritários/estatística & dados numéricos , Autogestão/estatística & dados numéricos , Classe Social , Automonitorização da Glicemia/instrumentação , Automonitorização da Glicemia/estatística & dados numéricos , Estudos Transversais , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/terapia , Feminino , Hemoglobina A Glicada/análise , Humanos , Masculino , Cooperação do Paciente/estatística & dados numéricos , Determinantes Sociais da Saúde/estatística & dados numéricos , Estados Unidos , Adulto Jovem
11.
Diabetes Spectr ; 33(1): 74-81, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32116457

RESUMO

A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.

12.
Health Aff (Millwood) ; 39(2): 207-213, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32011942

RESUMO

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.


Assuntos
Agentes Comunitários de Saúde , Medicaid , Atenção à Saúde , Humanos , Investimentos em Saúde , Fatores Socioeconômicos , Estados Unidos
13.
Res Gerontol Nurs ; 13(3): 138-145, 2020 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-31834415

RESUMO

The current study investigated the feasibility of telehealth-delivered diabetes self-management education and support (DSMES) for older adults with type 2 diabetes mellitus following hospital discharge. The intervention included one in-person home visit and follow-up weekly virtual DSMES for 4 additional weeks. Diabetes knowledge was measured at baseline and completion of the program. The Telehealth Usability Questionnaire was completed following the final session. Hemoglobin A1C (A1C) level was abstracted from the electronic health record at baseline and 3 months post hospital discharge. Hospital re-admissions were measured at 30 days post index hospital stay. Of the 20 patients enrolled, 12 completed the intervention. The most common reason for attrition was discharge to a skilled nursing facility (3/20). Participants who completed the intervention increased their diabetes knowledge scores. A1C values decreased by 1.1%, and there were no hospital readmissions for any patient who completed the program. Participants described the program as useful and were satisfied with the program. These results suggest that it is feasible to identify and enroll patients in a telehealth education program for diabetes during hospital admission. [Research in Gerontological Nursing, 13(3), 138-145.].


Assuntos
Diabetes Mellitus Tipo 2/terapia , Hemoglobina A Glicada/análise , Comportamentos Relacionados com a Saúde , Autogestão/educação , Telemedicina , Idoso , Estudos de Viabilidade , Feminino , Visita Domiciliar , Humanos , Masculino , Alta do Paciente
14.
Diabetes Educ ; 45(6): 607-615, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31596174

RESUMO

PURPOSE: The purpose of this study was to explore the mentor-mentee relationship in veterans with type 2 diabetes and gain insight into successful pairings. METHODS: Qualitative semistructured interviews were conducted as part of a peer mentoring randomized controlled trial to understand participants' experiences, their relationship with their partner, and how the intervention affected self-care behaviors. Purposive sampling was done to ensure adequate representation of mentees who made large strides in reaching their glycemic targets, those who made marginal improvements toward their glycemic goals, and those who got worse. All interviews were audio-recorded, transcribed, and analyzed for salient themes. RESULTS: The intervention was well received, with most participants describing it as valuable. Participants perceived the intervention to have a number of benefits, including accessible support, enhanced self-confidence, increased accountability, better self-efficacy, improved glycemic management, and a fulfilled sense of altruism. Participants did encounter barriers, including logistical, interpersonal, and individual obstacles. The more successful mentees tended to be more effusive in their description of their mentors, endorsed a stronger sense of connection to their mentor, described a more structured interaction with their mentor, and tended to be more complimentary of the intervention. CONCLUSIONS: Large peer support programs are appealing and well received. These programs can be optimized by selecting naturally inclined mentors, providing additional training to introduce more structure into mentorship interactions, and targeting mentees who are not struggling with overwhelming comorbidities.


Assuntos
Diabetes Mellitus Tipo 2/psicologia , Mentores/psicologia , Autogestão/psicologia , Apoio Social , Veteranos/psicologia , Diabetes Mellitus Tipo 2/terapia , Feminino , Humanos , Masculino , Tutoria/métodos , Pessoa de Meia-Idade , Grupo Associado , Avaliação de Programas e Projetos de Saúde , Pesquisa Qualitativa , Autogestão/métodos
16.
Diabetes Educ ; 45(3): 260-271, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31027477

RESUMO

PURPOSE: The purpose of the study was to examine whether a peer coaching intervention is more effective in improving clinical outcomes in diabetes when enhanced with e-health educational tools than peer coaching alone. METHODS: The effectiveness of peer coaches who used an individually tailored, interactive, web-based tool (iDecide) was compared with peer coaches with no access to the tool. Two hundred and ninety Veterans Affairs patients with A1C ≥8.0% received a 6-month intervention with an initial session with a fellow patient trained to be a peer coach, followed by weekly phone calls to discuss behavioral goals. Participants were randomized to coaches who used iDecide or coaches who used nontailored educational materials at the initial session. Outcomes were A1C (primary), blood pressure, and diabetes social support (secondary) at 6 and 12 months. RESULTS: Two hundred and fifty-five participants (88%) completed 6-month and 237 (82%) 12-month follow-up. Ninety-eight percent were men, and 63% were African American. Participants in both groups improved A1C values (>-0.6%, P < .001) at 6 months and maintained these gains at 12-month follow-up ( >-0.5%, P < .005). Diabetes social support was improved at both 6 and 12 months ( P < .01). There were no changes in blood pressure. CONCLUSIONS: Clinical gains achieved through a volunteer peer coach program were not increased by the addition of a tailored e-health educational tool.


Assuntos
Afro-Americanos/estatística & dados numéricos , Diabetes Mellitus Tipo 2/terapia , Tutoria/métodos , Educação de Pacientes como Assunto/métodos , Pobreza/estatística & dados numéricos , Telemedicina/métodos , Afro-Americanos/psicologia , Idoso , Pressão Sanguínea , Diabetes Mellitus Tipo 2/etnologia , Diabetes Mellitus Tipo 2/psicologia , Feminino , Hemoglobina A Glicada/análise , Humanos , Masculino , Pessoa de Meia-Idade , Grupo Associado , Pobreza/etnologia , Pobreza/psicologia , Autocuidado/métodos , Autocuidado/psicologia , Apoio Social , Resultado do Tratamento
17.
Perspect Sex Reprod Health ; 51(1): 35-41, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30645011

RESUMO

CONTEXT: Advancing gestational age can increase the cost of an abortion and is a significant risk factor for complications. While obesity is not associated with increased risks, anecdotal evidence suggests that obese women seeking services at freestanding abortion clinics are often referred for hospital-based care, which can lead to delays. METHODS: In 2016, a cross-sectional survey collected data on the experiences of 201 women who had obtained abortions at a hospital-based clinic in Philadelphia; rates of medical complications were determined from hospital records. Multivariable logistic regression analysis was used to assess if obesity was associated with whether patients had been referred from freestanding abortion clinics or reported other paths to care. Differences in wait time and up-front out-of-pocket costs were examined by women's referral status. RESULTS: No difference in rates of abortion complications was found between patient groups. Women who were severely obese (body mass index of at least 40 kg/m2 ) were more likely than normal-weight individuals to have been referred from a freestanding abortion clinic (odds ratio, 7.5). The median wait time to get an abortion was 28 days for referred patients and 12 days for others. Multivariable analysis confirmed that referred patients waited twice as long as other patients (rate ratio, 2.0) and paid 66% more in up-front costs. CONCLUSIONS: Future research is needed to determine whether obese women seeking abortions are being referred despite evidence that they do not require hospital-based care. If obese women are suffering delays because of referral, strategies to help overcome delay should also be explored.


Assuntos
Aborto Induzido/estatística & dados numéricos , Obesidade/epidemiologia , Ambulatório Hospitalar/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Aborto Induzido/economia , Adulto , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Índice de Massa Corporal , Estudos Transversais , Feminino , Idade Gestacional , Gastos em Saúde , Humanos , Modelos Logísticos , Análise Multivariada , Razão de Chances , Philadelphia/epidemiologia , Gravidez , Salários e Benefícios , Centros de Atenção Terciária , Tempo para o Tratamento/economia , Transportes
18.
JAMA Intern Med ; 178(12): 1635-1643, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30422224

RESUMO

Importance: Addressing the social determinants of health has been difficult for health systems to operationalize. Objective: To assess a standardized intervention, Individualized Management for Patient-Centered Targets (IMPaCT), delivered by community health workers (CHWs) across 3 health systems. Design, Setting, and Participants: This 2-armed, single-blind, multicenter randomized clinical trial recruited patients from 3 primary care facilities in Philadelphia, Pennsylvania, between January 28, 2015, and March 28, 2016. Patients who resided in a high-poverty zip code, were uninsured or publicly insured, and who had a diagnosis for 2 or more chronic diseases were recruited, and patients were randomized to either the CHW intervention or the control arm (goal setting only). Follow-up assessments were conducted at 6 and 9 months after enrollment. Data were analyzed using an intention-to-treat approach from June 2017 to March 2018. Intervention: Participants set a chronic disease management goal with their primary care physician; those randomized to the CHW intervention received 6 months of tailored support. Main Outcomes and Measures: The primary outcome was change in self-rated physical health. The secondary outcomes were self-rated mental health, chronic disease control, patient activation, patient-reported quality of primary care, and all-cause hospitalization. Results: Of the 592 participants, 370 (62.5%) were female, with a mean (SD) age of 52.6 (11.1) years. Participants in both arms had similar improvements in self-rated physical health (mean [SD], 1.8 [11.2] vs 1.6 [9.9]; P = .89). Patients in the intervention group were more likely to report the highest quality of care (odds ratio [OR], 1.8; 95% CI, 1.4-2.4; risk difference [RD], 0.12; P < .001) and spent fewer total days in the hospital at 6 months (155 days vs 345 days; absolute event rate reduction, 69%) and 9 months (300 days vs 471 days; absolute event rate reduction, 65%). This reduction was driven by a shorter average length of stay (difference, -3.1 days; 95% CI, -6.33 to 0.22; P = .06) and a lower mean number of hospitalizations (difference, -0.3; 95% CI, -0.6 to 0.0; P = .07) among patients who were hospitalized. Patients in the intervention group had a lower odds of repeat hospitalizations (OR, 0.4; 95% CI, 0.2-0.9; RD, -0.24; P = .02), including 30-day readmissions (OR, 0.3; 95% CI, 0.1-0.9; RD, -0.17; P = .04). Conclusions and Relevance: A standardized intervention did not improve self-rated health but did improve the patient-perceived quality of care while reducing hospitalizations, suggesting that health systems may use a standardized intervention to address the social determinants of health. Trial Registration: ClinicalTrials.gov identifier: NCT02347787.


Assuntos
Agentes Comunitários de Saúde , Atenção à Saúde/organização & administração , Pobreza , Atenção Primária à Saúde/organização & administração , Adulto , Idoso , Doença Crônica , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Método Simples-Cego
19.
Med Care ; 56(12): 1009-1017, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30383571

RESUMO

BACKGROUND: While patient engagement can be beneficial for patient care, there are barriers to engaging patients. These barriers exist for health care organizations, for health care personnel, and for the patients themselves. Solutions to barriers are not well documented. OBJECTIVES: Our objective was to explore barriers to patient engagement efforts and their corresponding solutions. RESEARCH DESIGN: Qualitative interviews and site visits from a national sample of primary care facilities within the Veterans Health Administration were analyzed to understand patient engagement barriers and solutions. SAMPLING: We conducted a total of 155 phone and in-person semistructured interviews with primary care providers, mental health staff, social workers, pharmacists, patient advocates, health behavior coaches, and administrative staff at 27 Veterans Health Administration sites. Participants were asked to describe the obstacles they had to overcome in their efforts to improve patient engagement at their site. RESULTS: Barriers to patient engagement are overcome by strategically updating data analytics; enhancing organization-wide processes and procedures; being creative with space design, staff hiring, and time commitments; cultivating staff collaborations; and addressing patient care issues such as access, customer service, and patient education. A key component of successful implementation is to create a culture, supported by leadership that promotes patient engagement. CONCLUSIONS: Participants understood the patient centered approach, despite experiencing a lack of resources and training and could push through solutions to patient engagement barriers while working within the limits of their settings.


Assuntos
Pessoal de Saúde/organização & administração , Liderança , Cultura Organizacional , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Comportamento Cooperativo , Pessoal de Saúde/psicologia , Humanos , Entrevistas como Assunto , Participação do Paciente/psicologia , Assistência Centrada no Paciente/métodos , Pesquisa Qualitativa , Estados Unidos , United States Department of Veterans Affairs/organização & administração , Saúde dos Veteranos
20.
Med Care ; 56(8): 719-726, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29939912

RESUMO

BACKGROUND: Half of all Americans have a chronic disease. Promoting healthy behaviors to decrease this burden is a national priority. A number of behavioral interventions have proven efficacy; yet even the most effective of these has high levels of nonresponse. OBJECTIVES: In this study, we explore variation in response to an evidence-based community health worker (CHW) intervention for chronic disease management. RESEARCH DESIGN: We used a convergent parallel design that combined a randomized controlled trial with a qualitative process evaluation that triangulated chart abstraction, in-depth interviews and participant observation. SUBJECTS: Eligible patients lived in a high-poverty region and were diagnosed with 2 or more of the following chronic diseases: diabetes, obesity, hypertension or tobacco dependence. There were 302 patients in the trial, 150 of whom were randomly assigned to the CHW intervention. Twenty patients and their CHWs were included in the qualitative evaluation. RESULTS: We found minimal differences between responders and nonresponders by sociodemographic or clinical characteristics. A qualitative process evaluation revealed that health behavior change was challenging for all patients and most experienced failure (ie, gaining weight or relapsing with cigarettes) along the way. Responders seemed to increase their resolve after failed attempts at health behavior change, while nonresponders became discouraged and "shut down." CONCLUSIONS: Failure is a common and consequential aspect of health behavior change; a deeper understanding of failure should inform chronic disease interventions.


Assuntos
Doença Crônica/terapia , Agentes Comunitários de Saúde/organização & administração , Comportamentos Relacionados com a Saúde , Cooperação do Paciente/estatística & dados numéricos , Adulto , Serviços de Saúde Comunitária/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pobreza , Resultado do Tratamento
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