presentation - Women In Government

Addressing diabetes disparities in
underserved communities
Enrique Caballero MD
Endocrinologist/Clinical Investigator
Director, Medical Affairs, Professional Education
Director of the Latino Diabetes Initiative
Joslin Diabetes Center
Harvard Medical School
Boston, MA
Challenges
• Rapidly growing populations
• The prevalence of type 2 diabetes is at least twice as high as that
in the White population
• Diabetes care disparities – worse glycemic control, high rates of
chronic complications, high mortality rates
• Social and cultural barriers
• Limited cultural awareness and skills among providers
• Significant limitations in clinical practice – time, resources,
support
• Limited comprehensive culturally oriented programs that address
patient, provider and health system issues
Case
• Rosa is a 58 y/o Hispanic or Latino woman
who has lived in the US for 20 years.
• She is married. Her husband is also Latino.
They have two sons and two daughters and
6 grandchildren.
• She is a housewife. Her husband is a
construction worker.
• She completed 6 years of school education.
She speaks very little English.
Race and Ethnicity: Definitions
Race
• Usually biological
• White, Black,
American Indian
(Native American)/
Alaska Native
(Eskimo, Aleut),
Asian/Pacific Islander
• Often overlapping
Ethnicity
• Primarily social
• Independent of race
• Hispanic or Latino?
Caballero AE. Diabetes in minority populations.
In: Joslin’s Diabetes Mellitus. LW & W; 2005. 14th Ed. p 505-524.
The US Hispanic/Latino Population
Puerto Ricans 8.6%
Mexicans
66.9%
Central and South
Americans 14.3%
Cubans 3.7%
Others 6.5%
US Census Bureau. The Hispanic Population in the United States: March 2002. Available at:
www.census.gov. Accessed June 28, 2004.
Case
• Rosa has continuously gained weight over the last
20 years.
• Her father and maternal grandmother died of
diabetes related complications.
• Her husband, children and grandchildren are
overweight. Her meals are usually rich in CHOs
and fats and does not exercise.
• Since she has felt well and has no health
insurance, she has not had a medical visit in many
years.
• During the last 6 months, she has felt very tired,
with increasing polyuria and polydipsia.
Age-adjusted Prevalence of self-reported diabetes
among Hispanics and non-Hispanic Whites, aged > 18
years by area of residence
BRFSS –1998-2002
Area
California
Florida
Illinois
NY/NJ
Texas
Puerto Rico
Hispanic
10.9
7.2
10.5
8
10.5
10
White-Non-Hispanic
4.6
5.2
5.5
4.9
5.1
---
Centers for Disease Control and Prevention. MMWR; 53, Oct 2004:pp 7-10
Genes, Environment and Social/Cultural Factors in Type 2 Diabetes in
Racial/Ethnic Minorities
Appetite and Satiety ?
Insulin Resistance and
Abdominal Obesity
Thrifty Genes
+
Lifestyle
Beta and Alpha
Cell Dysfunction
Type 2
Diabetes
Incretin dysfunction?
Socio-economic and
Cultural factors
Frequent Chronic
Complications
Renal glucose handling ?
Increased Mortality rates
Caballero AE. Modified from Curr Diab and Endocrinology Reports 2007. 14:151-157
Case
• Rosa is diagnosed with type 2 diabetes, based
on a random plasma glucose level above 200
mg/dl and the classical symptoms of
hyperglycemia.
• She has dyslipidemia (elevated Tg, low HDL-C
and mildly elevated LDL-C ). Her BP is
normal.
• She is also found with moderate nonproliferative retinopathy, peripheral neuropathy
and microalbuminuria.
Type 2 Diabetes and its
Complications in Minorities
• Disparate and Disproportionate prevalence
of longterm complications of type 2
diabetes in minorities vs Whites
– lower leg amputations 2-4x
– retinopathy and blindness 2-4x
– stroke 2x
– ESRD 4-6x
Caballero AE. Diabetes in minority populations.
In: Joslin’s Diabetes Mellitus. LW & W; 2005. 14th Ed. p 505-524.
*Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
Institute of Medicine. The National Academies Press. Washington, D.C. 2004.
A1c levels by ethnicity/race
NHANES 1999-2000
8.2
8.1
8
%
7.9
NH White
NH Black
Hispanics
7.8
7.7
7.6
7.5
7.4
7.3
NH White
NH Black
Hispanics
Boltri JM, et al. Ethn Dis 2005; 15 (4): 562-7
Percentage of participants with diagnosed diabetes with an A1c
≥11% by ethnicity/race
NHANES 1999-2000
11.1
12
10.4
10
%
8
NH White
NH Black
Hispanics
6
4
2
0
1.7
NH White
NH Black
Hispanics
Boltri JM, et al. Ethn Dis 2005; 15 (4): 562-7
What Causes Disparities in Healthcare?
Socio-economic status
Patient
Education/Health literacy
Health seeking behavior
Cultural factors
Mistrust
Lack of cultural awareness
Provider
Stereotyping or biases
Language barrier
Lack of resources
System
Lack of culturally oriented programs
Inadequate interpreter services
Time pressures and resource constraints
Lack of adequate training
Limited Access
Case
• Rosa is followed by a non-Spanish speaking physician. Most of the
time, a professional interpreter is present in the clinical encounter, but
sometimes, it is one of Rosa’s children who helps with translation.
• Rosa usually forgets to take her oral medications well and has not
made significant changes in her meal plan and physical activity.
• Her family income is limited and has missed several medical
appointments due to financial issues
• She frequently receives patient education brochures in Spanish. Most
of these materials have been translated from an original English
version.
Health Insurance Coverage
Non-Latino White
African American
All Latino
U.S. Born
Mexican American
Foreign Born
Mexican American
0
20
40
60
80
Percentage with health insurance
U.S. Census Bureau. Health Insurance Coverage: 2000. September, 2001.
Harris MI. Diabetes Care. 2001;24:454-459.
100
Socioeconomic Considerations
•
20% or more of non-Hispanic blacks and Hispanics
cite cost as a barrier to healthcare
(8% for non-Hispanic whites)1
•
From a study of African American women, following a
program on medical nutrition in diabetes care:
– “I wish I had more money to make more choices
– income makes a big difference in the types of food
one can afford.”2
1Gary
TL, et al. Ethn Dis. 2003;13:47-54.
P, et al. Diabetes Educator. 2005;31:719-725.
2Galasso
The Latino Diabetes Initiative at Joslin
A comprehensive strategy that involves
clinical care, patient education, community outreach,
research and provider education
www.joslin.org/latino
Current structure of LDI
Clinical
Program
Ecological
Model
Community and policy
System, group,
culture
Family,
friends, small
group
Individual
The health of individuals is inseparable from the health of communities
(Healthy People 2010)
Patient Flow in the Latino Initiative
General intake form - Laboratory - Joslin Vision Network (eye evaluation)
Research protocol: evaluation of medical, socio-economic and cultural aspects. Health Literacy Level
New Patient Visit (MD Visit)
Clinical Care
(MD and NP)
Group Medical
Visits:
Individual
6-8 Patients
Follow-up Visit
90 minute sessions
Include Education
Referrals to Specialty
Clinics:
BI Latino Mental Team
Betham Eye Institute
Pregnancy Clinic
Cardiology
Podiatry
Nephrology
Neurology, etc…
Patient Flow in the Latino Initiative
General intake form - Laboratory - Joslin Vision Network (eye evaluation)
Research protocol: evaluation of medical, socio-economic and cultural aspects. Health Literacy Level
New Patient Visit (MD Visit)
Patient
Education
Clinical Care
(MD and NP)
Monday Classes
Group Medical
Visits:
Diabetes Today Series in Spanish
Full day activity
1.
First Steps
2.
What can I eat
3.
Monitoring Matters
4.
Foods that fit/exercise
5.
Diabetes Medications
Rosa’s Story
Individual
6-8 Patients
Follow-up Visit
90 minute sessions
Include Education
Follow-up
Referrals to Specialty
Clinics:
with CDE
BI Latino Mental Team
Betham Eye Institute
Low Health
Literacy
Medium-high
Health Literacy
The Plate
Method
Carb Counting
for Beginners
Pregnancy Clinic
Cardiology
Podiatry
Nephrology
Neurology, etc…
Follow-up
With CDE
Language Barrier
A true story:
64 y/o Hispanic woman
Patient does not speak English
Treated for Hypertension
Received a prescription for :
Lisinopril 10 mg.
Once/d.
Patient rushed to the ER due to severe hypotension
Culturally Appropriate Translations
Rosa’s Story
Provider
Manual
English
Patient
Booklet
Spanish
Patient Flow in the Latino Initiative
General intake form - Laboratory - Joslin Vision Network (eye evaluation)
Research protocol: evaluation of medical, socio-economic and cultural aspects. Health Literacy Level
New Patient Visit (MD Visit)
Patient
Education
Clinical Care
(MD and NP)
Monday Classes
Group Medical
Visits:
Diabetes Today Series in Spanish
Full day activity
1.
First Steps
2.
What can I eat
3.
Monitoring Matters
4.
Foods that fit/exercise
5.
Diabetes Medications
Rosa’s Story
Individual
6-8 Patients
Follow-up Visit
90 minute sessions
Include Education
Follow-up
Referrals to Specialty
Clinics:
with CDE
BI Latino Mental Team
Betham Eye Institute
Low Health
Literacy
Medium-high
Health Literacy
The Plate
Method
Carb Counting
for Beginners
Pregnancy Clinic
Cardiology
Podiatry
Nephrology
Neurology, etc…
Follow-up
With CDE
Emotional
and social
support
Individual
Session
Support
Groups
6-8 patients
General Characteristics of LDI Patients
with Type 2 Diabetes
•
•
•
•
•
•
•
Age: 56 yrs (SD± 11.3)
DM duration: 11.7 yrs (SD±9.3)
Gender (F/M) 95/65
Married: 44%
Unemployed: 50%
High School Education: 48.5%
Insurance type:
– Commercial: 27 %
– Free-care: 9 %
– Government: 64 %
•
Language:
•
– None to Basic English: 64%
– Bilingual: 25%
Miles traveled: 9.7 miles (SD+ 10.66)
N:160
Laboratory results:







A1c at baseline: 9.0 % (IQR 2.5)
Weight: 83 kg (IQR 22)
BMI: 32 (IQR 8.4)
Total Cholesterol: 182 (SD± 43)
LDL Cholesterol: 108.5 (SD± 36)
HDL Cholesterol: 39 (IQR 12)
Triglycerides: 149 (IQR 126)
Median A1C Level of Patients with Type 2 DM
in the Latino Program
Median A1C
N= 160 pts
9.2
9
8.8
8.6
8.4
8.2
8
7.8
7.6
7.4
*
*
**
**
*
**
A1C
**
**
0
3
6
9
12
15
18
21
24
Months after enrollment
**p<0.0001 *p<0.05 for paired t-test comparisons
Median A1C Level of Patients with Type 2 DM
in the Latino Program
Median A1C
N= 129 pts
11
10.5
10
9.5
9
8.5
8
7.5
7
6.5
6
*
**
**
**
*
**
Improved
Worsened
0
3
6
9
12
15
18
21
Months after enrollment
**p<0.0001 *p<0.05 for paired t-test comparisons
24
General Characteristics by Glycemic Control
Improved control
(n:96)
Worsened control
(n:33)
P-value
55.9 (± SD: 11.0)
55.5 ± (SD: 10.8)
0.85
61/35
21/12
0.99
9.1 ± 2.8
9.0 ± 1.4
0.16
Less than High School Education
58 %
48 %
0.3
Not Married
53 %
76 %
0.02
Unemployment
48 %
59 %
0.28
JVN at baseline
41 %
24 %
0.09
Education minutes 1st yr (median ± IQR)
420 (IQR: 165)
390 (IQR: 60)
0.7
Education minutes 2nd yr (median ± IQR)
0 (IQR: 90)
60 (IQR: 90)
0.06
2 (IQR: 2.5)
6 (IQR: 6)
<0.0001
Rx Advancements (dose increases) 1st yr
2.18 ± 2.79
0.87 ± 1.1
0.01
Rx Advancements (dose increases) 2nd yr
1.57 ± 2.22
0.95 ± 1.1
0.53
Variable
Age (yrs)
Gender (F/M))
A1c (%) (median ± IQR)
# of No Show visits during RX
Improvement: A1c reduction ≥0.4% or Goal achievement at 1 year.
Worsening: A1c increase ≥0.4% at 1 year.
Current structure of LDI
Clinical Program
Research Program
The Latino Diabetes Initiative
Endothelial Function in
Hispanic Children
Endothelial Function in
Hispanic Adults
Research
Body Image in Latino Women
with Diabetes
Adherence to Treatment
Genetics of Cardiovascular
Disease
Characterization
of Retinopathy
The Impact of Rosa’s Story on
Diabetes Knowledge and Self-Care
Behavior in Hispanics with Diabetes
Assessing the impact of Rosa’s
Story as a DM educational tool
Research Highlights
1. Identification of social and cultural factors that
influence diabetes care
2. The benefit of culturally oriented patient
education strategies and community based
activities
3. The presence of advanced stages of retinopathy
in this population
4. Severe vascular and metabolic abnormalities in
Latinos with family history of type 2 diabetes
and in overweight children and adolescents
1. Caballero AE. Curr Opin Endocrinol Diabetes Obesity 2007; 14: 151-157
2. Millan-Ferro A. Current Diabetes Reports 2007; 7: 391-97
3. Sanchez C. ARVO meeting 2010
4. Caballero AE. Diabetes Care 2008; 31:576-82
Impaired Endothelium-Dependent Vasodilation in
People at Risk for Type 2 Diabetes
16
% Increase over baseline of
brachial artery diameter
13.7
*
12
10.5
9.8
8.4
8
4
0
Control
Relatives**
IGT
Diabetes
*C vs R, IGT, D
**1 or both parents
Caballero AE et al. Diabetes. 1999; 48: 1856-1862.
Diabetes Incidence Rates by Ethnicity
Cases/100 person-yr
Lifestyle
Metformin
Placebo
12
8
4
0
Caucasian African
(n=1768) American
(n=645)
Hispanic
(n=508)
American
Indian
(n=171)
Asian
(n=142)
Weight Change Over Time
DPP Research Group. Lancet . On line – Oct 29, 2009
DPP vs. DPPOS Diabetes Rates
DPP Research Group. Lancet . On line – Oct 29, 2009
Obesity and Endothelial Dysfunction in Hispanic Children
Variable
Controls
(n=17)
At risk
(n=21)
P value
Age
14.18+2.3
13.33+2.7
0.31
Waist/hip ratio
0.79+0.08
0.88+0.11
0.003
Total % fat
24+6
42+9
<0.0001
Trunk fat
19+5
42+9
<0.0001
Systolic BP
101.5+7
116.6+12
<0.0001
Diastolic BP
68.6+6
70.9+6
0.23
Total cholesterol
142.06
149.76
0.318
Triglycerides
58.82
108.29
0.004
HDL
42.00
37.52
0.162
LDL
89.24
93.50
0.484
Demographic and clinical characteristics between both groups, comparisons were
Done with t test in case of continuous variables and x2 in case of dichotomous variables
Obesity and Endothelial Dysfunction in Hispanic Children
Caballero AE. Diabetes Care. 2008; 31:576-82
Obesity and Endothelial Dysfunction
in Hispanic Children
8
6
4
2
0
-2
20
15
10
5
0
10
8
6
4
2
0
PAI-1
*
White Blood Cell Count
*
White Cells
(zx10-3)
mg/mL
hs-CRP
100
80
60
40
20
0
*
μg/mL
*
sICAM
ng/mL
ng/mL
TNF-α
400
300
200
100
0
Overweight Group
*P<0.05.
Caballero AE. Diabetes Care. 2008;31:576-582.
12
10
8
6
4
2
*
Adiponectin
*
tPA
*
IL-6
pg/mL
4
3
2
1
0
sVCAM
ng/mL
1000
800
600
400
200
0
pg/mL
ng/mL
Control Group
4.5
3.5
2.5
1.5
0.5
0
Current structure of LDI
Clinical Program
Community Based
Activities
Research Program
Main factors that may influence diabetes development
and care in Culturally Diverse Populations
•
•
•
•
•
•
•
•
•
•
Acculturation
Body Image
Cultural Competence
Depression
Educational Level
Fears
General Family Integration and Support
Health Literacy
Individual and Social Interaction
Judgment about disease
Caballero AE. Insulin. 2007; 80-91
Main factors that may influence diabetes development
and care in Culturally Diverse Populations
•
•
•
•
•
•
•
•
•
Knowledge about the disease
Language
Myths
Nutritional Preferences
Other forms of Medicine ( Alternative )
Physical Activity Preferences
Quality of Life
Religion
Socio-economic status
Caballero AE. Insulin. 2007; 80-91
Esto es mejor: Improving food purchasing selection among
low-income Spanish-speaking Latinos through social
marketing messages
Baseline Evaluation:
Analysis of the Grocery
Receipt:
930 Calories per dollar
29 gr of Fat per dollar
150 gr of Carbs per dollar
5 gr of Fiber per dollar
Other activities:
21 gr of Protein per dollar
• Home Visits
• Supermarket tours
46500 cal – 50 USD
• Photovoice
• Rosa’s Story
Salud America - RWJ Foundation
Research Project in the Community
• Collaboration with the South End Community
Health Center
• Aim : Test the hypothesis that A1c testing at
home by patients along with more regular
communication between patients and providers
improves glycemic control better and faster than
current standards
• Investigator Initiated Trial supported by Bayer
Health Care
Collaboration with Multiple Organizations
•
•
•
•
•
•
•
•
•
•
•
•
•
Harvard Medical School and affiliated institutions
Mauricio Gaston Institute – U Mass Boston
Massachusetts Department of Public Health
Massachusetts League of CHC
Community Health Centers
Community Based Organizations
Hispanic American Chamber of Commerce
Individuals and Latino owned businesses
Media
Health Care Plans
Pharmaceutical and Diagnostics Industry
ADA, CDC, NHMA, AACE, LADA
NMQF
Men Said That Computers Are Like
Women Because:
Only their creator understands their internal logic.
The language that they use to communicate among
themselves is incomprehensible to others.
Even the smallest mistakes are stored in long-term
memory to be retrieved later on.
As soon as you commit to one, you have to spend most
of your salary in accessories.
Women Said That Computers Are Like
Men Because:
In order to get their attention, you have to turn them on.
They have a lot of information but they are clueless.
They are supposed to help you solve problems, but most
of the time they ARE the problem.
When you need them the most, their system fails.
As soon as you commit to one, you realize that if you
had waited a little longer, you could have gotten a
better model.
Current structure of LDI
Clinical Program
Community Based
Activities
Research Program
Professional
Education
Health Care Professionals Education
•
•
•
•
•
•
Medical Education Programs
Community Health Centers
Medical Students
Visitors Program
National and International Meetings
Publications
What is Cultural Competence?
The knowledge and interpersonal skills
that allow providers to understand,
appreciate, and work with individuals
from cultures other than their own. It
involves an awareness and acceptance
of cultural differences; self-awareness;
knowledge of patient’s culture; and
adaptation of skills.
– American Medical Association
MENTAL
PHYSICAL
SPIRITUAL
EMOTIONAL
Cultural Competence
Purnell’s Model:
Person, Family, Community, Society
•Unconsciously incompetent
•Consciously incompetent
•Consciously competent
•Unconsciously competent
Model for Cross-Cultural Care:
A Patient-Based Approach
Awareness
of Cultural
and Social
Factors
Elicit
Factors
Negotiate
Models
Implement
Management
Strategies
Tools and skills necessary to provide quality care to
any patient we see, regardless of race, ethnicity,
culture, class or language proficiency.
The ESFT Model
• Explanatory Model
• Social Barriers
• Fears/Concerns about Medication
• Therapeutic Contracting/Playback
POLICY DISTRIBUTION
POLICY AVAILABILITY
Diffusion
Diffusion of
of
interventions
interventions
POLICY EFFICIENCY
Supply
Supply
EFFECTIVENESS
EFFICACY
Real
Real world
world
settings
settings
BASIC SCIENCE
Ideal
Ideal
settings
settings
Molecular/
Molecular/
physiological
physiological
Biggest
Biggest effect
effect on
on
most
most people
people
Recommendations
• Recognize the need to improve diabetes prevention and care
for all groups
• Develop and support clinical and research programs that aim
at understanding and addressing diabetes care in minority
populations
• Develop specific strategies for underserved populations
considering their social and cultural context
• Implement programs that address patient, health care provider
and health care system issues
• Emphasize diabetes prevention and community based
activities
• Consider strategies that may favorably impact provider and
patient interaction as well as cross cultural interaction at all
levels
The Latino Diabetes Initiative at Joslin
A comprehensive strategy that involves
clinical care, patient education, community outreach,
research and provider education
www.joslin.org/latino
enrique.caballero@joslin.harvard.edu
THANK YOU