Alliance to Reduce Disparities in Diabetes

Memphis Team at IHA Health Literacy Conference 2014

Assessing the Impact of Health Literacy of Health Professionals Engaged in a Diabetes Self-Management Program: The Diabetes for Life Project

Institute for Healthcare Advancement 13th Annual Health Literacy Conference
May 7-9 in Irvine, CA 

Presenters biography:
Patria Johnson, MSSW served as the Project Manager and Co-Principal Investigator for Diabetes for Life, a partnership between Healthy Memphis Common Table and Memphis Healthy Churches.  Belinda W. Nelson, PhD served as a member of the National Program Office for the Alliance to Reduce Disparities in Diabetes, providing technical assistance to the projects. Her research and practice focuses on health and well-being among the African Americans.  

Project Description:
Background: Diabetes for Life (DFL) is a self-management program aimed at reducing health disparities among African Americans with Type II diabetes in Memphis and Shelby County. This program is one of five national sites that constitute The Alliance to Reduce Disparities in Diabetes; a five-year grant funded initiative of The Merck Foundation.1 Each site is charged with developing a multilevel intervention with provider training as a central component of the strategy.  DFL delivered interventions focused on three core components: patient, clinician, and system.

Objective:
To improve communication between provider and patient; thereby impacting patient outcomes.

Research Question:  
What is the impact of intensive provider training on the interaction between patient and provider?

Approach:
Target Population:  Medical Providers of African American adults 18 years of age and older diagnosed with Type II diabetes for less than 10 years.  Six independent physician medical practice sites collaborated with the DFL program. These practices signed cooperative agreements that ensured their commitment to 1) refer patients to the program, 2) participate in provider training and 3) quality improvement activities.  

The Diabetes for Life Program convened Quarterly Provider Practice Learning Collaborative training sessions from January 2012 through August 2013.  Those in attendance in these trainings included physicians, nurse practitioners, nurses, and front office staff from each of the practice sites. The topics covered during the training sessions included: 1) Multicultural Awareness and Competency, 2) Patient Centered Medical Home, 3) the Chronic Care Model, 4) Public Reporting and the Value of Data, 5) Measuring and Improving Performance in Your Practice, and,  6) Incorporating Cultural Awareness into Shared Decision Making.
Participants completed a pretest prior to the training session to assess the current level of knowledge (1= no knowledge of concept, 4=knowledgeable and concept regularly applied in practice); and an immediate post-test after each session to assess for changes in knowledge (1= no change in knowledge of concept; 4= gained a great deal of knowledge).  

Patients referred to the DFL project by the participating medical practice sites also completed a  comprehensive baseline and follow up survey that covered several domains of behavioral and situational factors related to diabetes self-management, such as: health care utilization, trust in health care provider, self-efficacy and perceived competence for diabetes self-management.  The patient’s baseline clinical lab values such as Hemoglobin A1C and Total Cholesterol were shared with formal consent to the DFL project. At 12 months post enrollment in DFL, patient survey and clinical values were measured to asses change.  Patients referred to DFL participated in diabetes self- management education classes and received regular case management support for behavioral change.  

Target Population:
Health Professionals treating patients with Type 2 diabetes

Provider Outcomes:
Many of the providers from the practice sites demonstrated a relatively high level of multicultural awareness at the onset of the training sessions (69%) and there was no gain in knowledge for this topic.  Similarly, 84% of participants were knowledgeable about incorporating cultural awareness into shared decision making in diabetes care and this increased slightly to 87%.  More salient findings were demonstrated in change in knowledge for the topics of Patient Centered Medical Home (15% vs. 94%), the Chronic Care Model (46% vs. 73%), and the Value of data for improving performance (21% vs. 59%).  

Patient-Doctor Relationship:
Patients seen by providers who participated in DFL training sessions relative to the comparison group:

  • reported a higher level of trust in their doctors’ judgments about their medical care (4.87. vs. 4.00; p<.001)
  • more frequently asked their doctors questions about things they wanted to know and things they didn’t understand about their treatment (4.41 vs. 2.92; p<.001)
  • reported they felt comfortable discussing personal problems related to illness with their healthcare provider (3.67 vs. 2.11; p<.05).
  • more frequently received information they needed from their diabetes care team (2.03 vs. 1.66; p<05).  

The significant outcomes observed in the patient-doctor relationship and the patients’ improved perception of diabetes care was also accompanied by significant clinical outcomes and behavioral changes among patients.  

Clinical Outcomes: 
Participants showed statistically significant decreases in average A1C, the gold standard for assessing diabetes management, in systolic pressure.  Decreases in cholesterol were identified but did not meet statistical significance.

 Clinical Measure

Intake Mean

Follow-Up Mean

A1C

7.9

7.4*

Systolic Pressure

135.3

134.8*

Cholesterol

183.0

178.4

* Difference is statistically significant at α <.05, α ** <.01

Behavioral Outcomes:
Patients in the DFL intervention group (N=120), relative to the comparison group reported:

  • significant improvement in seven of eight self-care activities (e.g. healthy eating plan, testing blood sugar, engaging in physical activity)
  • significant improvement in area Diabetes Self-Efficacy based on the Stanford Self-efficacy2  (6.33 vs. 9.12; p<..001), and
  • improvement in Perceived Competence in Diabetes Self-care Scale3 (4.63 vs. 6.64; p<001)

Implications for Policy, Delivery or Practice:

  1. Physicians who participate in training on the Chronic Care Model, patient centered care and cultural awareness have patients with improved diabetes self-efficacy scores, a higher level of trust by their providers, better self-care activities and improvement in clinical outcomes.
  2.  Provider training that is implemented in tandem with patient education has the potential to significantly improve overall outcomes for patients with Type 2 diabetes.


References:
1.    Clark, N. M., Brenner, J., Johnson, P., Peek, M., Spoonhunter, H., Walton, J., Dodge, J. & Nelson, B. (2011). Reducing Disparities in Diabetes: The Alliance Model for Health Care Improvements. Diabetes Spectrum, 24(4), 226-230
2.    Diabetes Self-Efficacy Scale. Stanford Patient Education Research Center. Stanford University School of Medicine. 2013. http://patienteducation.stanford.edu/research/sediabetes.htm
3.    Toobert DJ, Hampson SE, Glasgow RE. The Summary of Diabetes Self-Care Activities Measure: results from 7 studies and a revised scale. Diabetes Care. 2000 Jul;23(7):943-950
4.    Glasgow RE, Wagner EH, Schaefer J, Mahoney LD, Reid RJ, Greene SM. Development and Validation of the Patient Assessment of Chronic Illness Care (PACIC). Medical Care. 2005; 43(5):436-444



 Clinical Measure

Intake Mean

Follow-Up Mean

A1C

7.9

7.4*

Systolic Pressure

135.3

134.8*

Cholesterol

183.0

178.4