Alliance to Reduce Disparities in Diabetes

Evaluation: Camden Citywide Diabetes Collaborative

Research Questions and Measures

Which has a more lasting impact on patient outcomes: community or practice-based interventions? Clinical measures including HDL, LDL, total cholesterol, triglycerides, and HbA1c collected for 200 patients at baseline through 2 years post-intervention
Does Diabetes Self-Management Education improve patients’ HbA1c levels? HbA1c collected at baseline through 2 years post-intervention
Does Diabetes Self-Management Education (DSME) improve patients’ self-care related to their diabetes? Surveys assessing patients’ self-care administered at the first and last DSME classes, and then at 3, 6, 12, 18, and 24 months post-intervention:
  • Veterans RAND 12 Item Health Survey¹
  • Resources and Supports for Self- Management Survey²
  • Summary of Diabetes Self-Care Activities Measure ³
Does coordination of care improve health care utilization and reduce health care costs? Billing data from 2002-2012 for all 3 hospitals in Camden contained in the Camden Health Database, which provides information on:
  • Hospital utilization (ER and inpatient), charges, and receipts
  • Referrals to specialty care, mental health services, and primary care (if needed)


  1. Kazis, L.E., Miller, D.R., Skinner, K.M., Lee, A., Ren, X.S., Clark, J.A., Rogers, W.H., Spiro III, A., Selim, A., Linzer, M., Payne, S.M., Mansell, D., & Fincke, B.G. (2006). Applications of methodologies of the Veterans Health Study in the VA Health Care System: Conclusions and summary. Ambulatory Care Management, 29, 2182-2188.
  2. McCormack, L.A., Williams-Piehota, P.A., Bann, C.M., Burton, J., Kamerow, D.B., Squire, C., et al. (2008). Development and validation of an instrument to measure resources and support for chronic illness self-management: a model using diabetes. Diabetes Educator, 34(4), 707-718.
  3. Toobert, D.J., Hampson, S.E., & Glasgow, R.E. (2000). The Summary of Diabetes Self-Care Activities Measure: Results from 7 studies and a revised scale. Diabetes Care, 23(7), 943-950.


Presentations and Publications

2014 Publications

Kaufman, S., Brenner, J., DeFiglio, V., Craig, K., & Ali, N. (2014). Early efforts to target and enroll high-risk diabetic patients into urban community-based programsHealth Promotion Practice, 15(2S), 62S-70S.

2013 Presentations

Carter, A. & Cormier, P. (2013, August). Helping hospital super-utilizers: The case study of an Army veteran. Poster presented at the National Association of Community Health Centers' Community Health Institute and Expo, Chicago, IL.

Kaufman, S., Grabowski, F., Ali, N., & Katz, A. (2013). Group diabetes visits to support self-management goals: A model for care in an urban, resource-poor community. Poster presented at the American Diabetes Association's 73rd Scientific Sessions, Chicago, IL.

2012 Presentations

Grabowski, F., Kaufman, S., Ali, N., Kratz, A. (2012, October). An innovative analysis of a citywide approach to diabetes self-management education in Camden, NJ. Poster presented at the American Diabetes Association's 5th Disparities Partnership Forum, Washington, DC.

Kaufman, S., Ali, N., DeFiglio, V., Turi, J., Lluz, M. (2012, October). Improving diabetes outcomes for high-utilizing patients in Camden. Poster presented at the American Diabetes Association's 5th Disparities Partnership Forum, Washington, DC.

In the News

Robert Wood Johnson Foundation. (2012, March 29). Expanding "Hot Spotting" to New Communities.
Dr. Jeffrey Brenner discusses his work identifying "hot spots" in and beyond New Jersey at the Robert Wood Johnson's Health Care Group's Meeting in March 2012 (Video Link).

Zakaria, Fareed. (2012, March 15). 5% of U.S. patients account for 50% of health care costs. CNN.
Fareed Zakaria speaks with Dr. Jeffrey Brenner regarding the Collaborative's work in using medical records to identify that just 1% of patients accounted for 30% of health care costs in Camden in "The GPS Road Map for Saving Health Care" (Video Link).

Moss-Coane, Marty. (2011, February 4). Controlling health care costs among Camden's 'super-users'. Radio Times.
Interview with Marty Moss-Coane for RadioTimes, in which Dr. Jeffrey Brenner and other Collaborative members discuss the program's successes and challenges of the program, which identifies the most frequent users of Camden's health care systems, and how best to treat these patients.  Marty Moss-Coane.

Gawande, Atul. (2011, January 24). The Hot Spotters: Can we lower medical costs by giving the neediest patients better care? The New Yorker.
New Yorker article and interview with Atul Gawande, in which Dr. Jeffrey Brenner discusses his work identifying "hot spots" and frequent users of health care services in Camden, and how providing assistance and management of care for these users can actually lower medical costs.