183626 A Randomized Controlled Trial of Primary Care and Community-Based Interventions to Reduce Emergency Room Visits over 24 Months among African Americans with Type 2 Diabetes

Tuesday, October 28, 2008: 11:30 AM

Tiffany L. Gary, PhD , Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
Marian Batts-Turner, MSN, RN , The Johns Hopkins Medical Institutions, Baltimore, MD
Hsin-Chieh Yeh, PhD , Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins School of Public Health, Baltimore, MD
Lee Bone, MPH, RN , Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
Felicia Hill-Briggs, PhD , Johns Hopkins Medical Institutions, Baltimore, MD
Nae-Yuh Wang, PhD , Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins School of Medicine, Baltimore, MD
David Levine, MD, MPH, ScD , Department of Medicine, Johns Hopkins University, Baltimore, MD
Neil Powe, MD, MPH, MBA , San Francisco General Hospital, University of California San Francisco, San Francisco, CA
Christopher Saudek, MD , Department of Medicine, Johns Hopkins University, Baltimore, MD
Martha N. Hill, PhD, RN , School of Nursing, Johns Hopkins University, Baltimore, MD
Maura McGuire, MD , Department of Medicine, Johns Hopkins University, Baltimore, MD
Frederick Brancati, MD, MHS , Department of Medicine & Epidemiology, Johns Hopkins University, Baltimore, MD
     
Background:

While African Americans suffer disproportionately from complications of diabetes, few studies have tested culturally appropriate and comprehensive interventions to improve diabetes care and reduce ER visits.

Methods:

Therefore, we conducted a randomized controlled trial among 542 African Americans with type 2 diabetes enrolled in an urban managed care organization. Participants were randomized to either an Intensive Intervention Group (INT) or Minimal Intervention Group (MIN). The INT consisted of individualized, culturally-tailored care provided by a nurse-case manager (who assessed and reinforced medication adherence and medical issues in the clinic) and a community health worker (who provided health education and mobilized social support in the home), using evidence-based clinical algorithms with feedback to primary care providers. The MIN consisted of mailings and phone calls every 6 mo to remind participants about preventive screenings. Participants made data collection visits at baseline and 24 mo. Health care utilization was assessed every 6 mo using claims and encounter data.

Results:

At baseline, participants were 74% female, had a mean age of 58 years, and 35% had yearly household incomes <$500. Most (57%) had HbA1c ≥7%; 73% had blood pressure (BP) >130/80 mmHg; 77% had HDL cholesterol ≥40 mg/dl. At 24 months after adjustment for age, insurance status, and baseline values, compared to the MIN, the INT had fewer ER visits (rate ratio=0.77, 95% CI: 0.59-1.00, P=0.05). Furthermore, when the results were stratified by intervention intensity, those with more nurse-case manager and community health worker visits were significantly less likely to have ER visits (rate ratio =0.66, P=0.048) and had improvements in HbA1c (-0.68% decline) compared to the MIN. However, there was no significant improvement in control of BP or lipids.

Conclusions:

These data suggest that an intensive intervention conducted by a nurse-case manager/community health worker team reduces ER visits in urban African-Americans with diabetes; a benefit which may be partially mediated by improvement in glycemic control. Whether diabetes disease management by a nurse-case manager/community health worker team is cost-effective for urban minorities warrants further research.

Learning Objectives:
-To describe a nurse-case manager/community health worker team intervention to improve diabetes care among urban African Americans -To discuss the implications for applying this model in real world clinical practices and the community

Keywords: African American, Health Care Delivery

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Dr. Tiffany L. Gary is an Assistant Professor in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health. She also holds a joint appointment in the Division of General Internal Medicine at the Johns Hopkins School of Medicine and is a core faculty member in two research centers, the Welch Center for Prevention, Epidemiology, and Clinical Research and the Center for Health Disparities Solutions. Dr. Gary has a master’s and doctoral degree in clinical epidemiology from the Johns Hopkins Bloomberg School of Public Health, and has experience in epidemiological research, clinical trial design and conduct, and medical claims data analysis, mostly in the disease area of diabetes. She also has experience in applied epidemiology through working for the Centers for Disease Control and Prevention (CDC). Dr. Gary has a particular dedication toward improving the health of ethnic minorities and focuses her professional work around issues of minority health and social/environmental determinants of chronic disease. She’s been an active member of the APHA and the Epidemiology Section since 2002.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

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