Clinical outcomes and incremental costs from a medication adherence pilot intervention targeting low-income patients with diabetes at risk of cost-related medication nonadherence.

PURPOSE: The extent to which reducing cost-related barriers affects diabetes outcomes and medication adherence among uninsured patients is not known. The purpose of these analyses was to understand the clinical impact and cost considerations of a prescription assistance program targeting low-income, minority patients with diabetes and at high risk for cost-related medication nonadherence. METHODS: Patients received diabetes medications without copayments for 12 months. Change in diabetes control was calculated by using glycosylated hemoglobin (HbA1c) level at follow-up compared with baseline. Clinical data were collected from the electronic health record. Medication adherence for diabetes medications was estimated by using proportion of days covered (PDC). Incremental acquisition and per-patient costs, based on actual hospital medication costs, were calculated for different baseline HbA1c levels. FINDINGS: Patients with baseline HbA1c levels ≥7%, ≥8%, and ≥9% experienced mean HbA1c reductions of 0.82% (P = 0.008), 1.02% (P = 0.010), and 1.47% (P = 0.010), respectively, during the 12-month period. The average PDC was 70.55%; 45.24% had a PDC ≥80%, indicating an adequate level of medication adherence. Medication adherence ≥80% was associated with ethnicity (P = 0.015), whereas mean PDC was associated with number of diabetes medication classes used (P = 0.031). Acquisition cost for 1242 prescriptions filled by 103 patients was $13,365.82, representing per-patient costs of $132.39; however, as baseline targets increased, acquisition costs decreased and per-patient costs increased from $10,682.59 and $169.56 to $6509.91 and $192.27, respectively. IMPLICATIONS: Clinically significant reductions in HbA1c levels were achieved for all patients, although greater reductions were achieved with modest per-patient cost increases when considering patients with uncontrolled diabetes. Incorporating a multifactorial intervention to address cost-related medication nonadherence with a behavior change component may yield greater reductions in HbA1c with improved diabetes outcomes and meaningful hospital-based cost savings.

Participation in and impact of a depression care management program targeting low-income minority patients in an urban community-based clinic.

BACKGROUND: African 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. OBJECTIVE: To address this disparity in our primary care clinic, we introduced a validated framework for detecting and managing depression. METHODS: Over 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. RESULTS: The 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. CONCLUSIONS: Most 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.

Short and long-term outcomes from a multisession diabetes education program targeting low-income minority patients: a six-month follow up.

BACKGROUND: A diabetes self-management education (DSME) program was offered to patients at a primary care clinic serving low-income people. OBJECTIVES: The purpose of the analyses presented here was to understand the feasibility of the program and effectiveness of the intervention. METHODS: The 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 (HbA(1c)), 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, χ(2) and t tests, and repeated measures t tests were used to analyze data. RESULTS: Patients were mostly non-Hispanic black or Hispanic (93.1%); mean BMI was 34.89 kg/m(2). 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 HbA(1c) was significantly reduced (0.82%), from 8.60% to 7.78% (P = 0.007), with 26.67% of patients reducing HbA(1c) 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). CONCLUSIONS: Outcomes 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.

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.

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: The intervention produced good outcomes; however, an alternative platform may be a less expensive approach.