Primary health care for urban African Americans with type 2 diabetes mellitus: Current practices and behavioral interventions aimed at improvement.

摘要

Type 2 diabetes and its complications poses a considerable public health burden, which affects African Americans disproportionately. Reasons for this substantial burden may be related to inadequate health behaviors and health care. Therefore, characterizing the current state of healthcare practices in diabetes to identify factors that could be intervened on, as well as tackling individual patient behaviors, are essential strategies to help prevent the development of diabetes-related complications in African Americans. We conducted 3 studies related to the common theme of Primary Health Care for Urban African Americans with Type 2 Diabetes Mellitus: Current Practices and Behavioral Interventions Aimed at Improvement.; The first study was set within an urban managed care setting and examined practice behaviors related to preventive diabetes care as recommended by the American Diabetes Association (ADA). Individuals were followed for 1 year, using a retrospective design, to determine the association between practice patterns and increased hospitalizations and emergency room (ER) visits. Results showed that in this predominately African American, clinic-based population, only 3% of individuals had preventive screenings as recommended by the ADA (4 primary care visits, 4 HbA_1c screenings, 1 total cholesterol screening, and 1 specialty visit). Protective odds ratios were seen for those who had 2–4 primary care visits compared to those without primary care visits. After 5 or more visits, the odds of having a hospitalization were increased compared to those with no visits, possibly indicating increased utilization due to illness. Receiving any number of primary care visits was protective for having an ER visit.; The second study was a meta-analysis that evaluated randomized educational/behavioral intervention trials in diabetes care. Results suggested that several qualitative aspects of study designs did not improve with year of publication, including sample size and study quality. In addition, very few studies reported that they included African Americans or other ethnic minority populations. Further quantitative analyses showed that overall, educational/behavioral interventions in patients with type 2 diabetes produced small declines (non-significant) in fasting blood sugar and weight, and moderate declines (non-significant) in glycohemoglobin. Effects of the interventions on glycohemoglobin were similar to the effects seen in previous meta-analyses.; The third study, Project Sugar 1, was a randomized controlled trial with 4 parallel arms. The purpose was to determine whether a multifaceted practice-based strategy implemented by a Nurse Case-Manager (NCM) in the clinic, a Community Health Worker (CHW) in the home, or both, could improve metabolic control and diabetes-related health behaviors (vs. usual care alone) over 2 years. The population consisted of 186 African Americans with type 2 diabetes recruited from 2 primary care clinics in East Baltimore. Compared to the usual care group, the NCM group and the CHW group had modest declines in HbA _1c (0.3% and 0.3%, respectively) over 2 years, and the combined NCM+CHW group had a greater decline (0.8%).; Results from these studies suggest that practice patterns in a predominately African-American population were poor compared to the ADA recommendations for diabetes care, and previous studies have not included many African Americans in intervention studies designed to improve care. Furthermore, these results suggest that an interactive clinic and community-based intervention may be essential to address the complex diabetes-related needs in this population.