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Health Disparities/ Diabetes Care. Sheldon Greenfield, MD Orange County Diabetes Education Collaborative Conference January 31, 2009. Optimizing the ‘Physician Effect’ on HbA1c levels. Coached Care Team. Quyen Ngo-Metzger, MD, MPH Israel De Alba, MD, MPH Dara Sorkin, PhD

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Health Disparities/ Diabetes Care

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Health Disparities/ Diabetes Care

Sheldon Greenfield, MD

Orange County Diabetes Education Collaborative Conference

January 31, 2009

Optimizing the ‘Physician Effect’ on HbA1c levels

Coached Care Team

  • Quyen Ngo-Metzger, MD, MPH

  • Israel De Alba, MD, MPH

  • Dara Sorkin, PhD

  • John Billimek, PhD

  • Dana Mukamel, PhD

  • Community-based Coaches

Background: Disparities in Diabetes Care in the U.S.

  • More ethnic minorities fail to meet diabetes quality benchmarks than non-minority patients

  • Rates of diabetes complications are higher among many ethnic minorities

  • All cause mortality rates are higher among African Americans and Hispanic patients

Purposes of Study

  • Document disparities in diabetes care among three ethnic groups (Mexicans, Vietnamese, Non-Hispanic Whites) in defined population

  • Reduce disparities through Coached Care program for improving patients’ participation in care using community-based patients with diabetes

Study Designs

  • Diabetes Registry (population definition)

  • Cross-sectional DAWN Minority Survey (measures development; comparison ethnic groups)

  • Randomized controlled trial (intervention test)


  • Diabetes Registry:

    • All patients seen for diabetes at UCI Medical Center clinics

  • Cross-sectional DAWN Minority Survey:

    • Random sample 300 patients each ethnic group

  • Randomized controlled trial:

    • Balanced design, n=100 exp/cont by ethnic group

Optimizing the ‘Physician Effect’ on HbA1c levels

Features of Coached Care

  • Algorithm mapping decisions, treatment options; detailed explanations

  • Patient’s medical record; tailored, personalized information

  • Reviewed immediately before office visit

  • ‘Coaching’ for more effective participation during visit

Tailored Algorithm Information: Example, Patient on Insulin


Using insulin alone


Adherence as instructed

Problems with insulin regimen


Change insulin to rapid acting qd

Use insulin Pen for administration

Stop or reduce insulin; add oral agent

Improve diet, exercises




Control Group

  • Matched for session length

  • Same venue, same staff

  • Content = state of the art patient education materials for each disease


  • Compared to controls, patients in experimental group had:

    • 1.5% reduction in HbA1c

    • 10 mm Hg reduction in diastolic BP

    • 25% reduction in symptoms

    • 30% improvement in functional status


  • Compared to controls, patients in experimental group (based on audiotapes):

    • 3 times more queries, ‘controlling’ conversational behaviors

    • 2 times more effective in information seeking

    • 30% increase in emotional response from physicians

Features of Coached Carefor Diabetes Program

  • Use of community-based ethnic minority coaches

  • Training program for, quality monitoring of coaches

  • Use of diabetes registry at UC Irvine to ensure representativeness of patient sampling, assignment

Coached Care for Diabetes Program:DAWN Minority Survey Results

Characteristics of Patient Sample

Baseline HbA1c by Ethnicity

F-value = 63.1, p<.001

% HbA1c <7 by Ethnicity

Chi Square = 49.7, p<.001

DAWN Minority Survey Measures

  • General health status

  • Diabetes specific health status

  • Adherence to diabetes regimen

  • Disease management/health enhancing behaviors

  • Quality of interpersonal care

  • Access to care

  • Total Illness Burden

General health status


General health distress




Quality of life

Stress level

Diabetes specific health status

Diabetes management hassles

Diabetes frustration

Diabetes distress

Diabetes worry/concern

Diabetes burden

Stress managing diabetes

DAWN Minority Survey Measures

Sample Questions: Diabetes Management Hassles

“During the past 4 weeks, how much of a problem or hassle has each of the following been for you in your everyday life?”

(A major hassle No hassle at all)

h. Having to keep your schedule (eating, drugs, exercise) in mind all the time…..

Sample Questions: Diabetes Frustrations

“Sometimes diabetes can be a source of frustration to those who have it. During the past 4 weeks, how often:

(All of the time None of the time) a. Were you frustrated about diabetes?....

Sample Questions: Diabetes Worries or Concern

“Sometimes people with diabetes have concerns about complications that may develop. How much are you worried or concerned about each of the following?”

(Extremely worried Not worried at all) a. Losing my eyesight from diabetes?....

Sample Questions: Diabetes Burden

“Overall, how much of a burden is your having diabetes on you and your family in each of the following areas?”

(Very great burden No burden at all)

  • Our finances in general?....

  • Our finances due to the cost of my medications?….

Ethnic Differences: Survey Measures

Ethnic Differences: Survey Measures

Correlation Health Status Measures with HbA1c


Coached Care for Diabetes Program:DAWN Minority Trial Results

Mean HbA1c Preliminary Results


HbA1c >8% Preliminary Results



  • Coached Care may improve diabetes outcomes among poor and ethnic minorities

  • Despite disparities in diabetes care at baseline, Coached Care improved HbA1c, diabetes health status across ethnic groups

  • Community-based coaches of same culture can be trained; less expensive

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