Michele Heisler

The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management

AbstractOBJECTIVE: Patients’ self-management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient-physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient-physician interaction styles on patients’ diabetes self-management. This study assessed the influence of patients’ evaluation of their physicians’ participatory decision-making style, rating of physician communication, and reported understanding of diabetes self-care on their self-reported diabetes management. DESIGN: We surveyed 2,000 patients receiving diabetes care across 25 Veterans’ Affairs facilities. We measured patients’ evaluation of provider participatory decision making with a 4-item scale (Provider Participatory Decision-making Style [PDMstyle]; α=0.96), rating of providers’ communication with a 5-item scale (Provider Communication [PCOM]; α=0.93), understanding of diabetes self-care with an 8-item scale (α=0.90), and patients’ completion of diabetes self-care activities (self-management) in 5 domains (α=0.68). Using multivariable linear regression, we examined self-management with the independent associations of PDMstyle, PCOM, and Understanding. RESULTS: Sixty-six percent of the sample completed the surveys (N=1,314). Higher ratings in PDMstyle and PCOM were each associated with higher self-management assessments (P<.01 in all models). When modeled together, PCOM remained a significant independent predictor of self-management (standardized β: 0.18; P<.001), but PDMstyle became nonsignificant. Adding Understanding to the model diminished the unique effect of PCOM in predicting self-management (standardized β: 0.10; P=.004). Understanding was strongly and independently associated with self-management (standardized β: 0.25; P<.001). CONCLUSION: For these patients, ratings of providers’ communication effectiveness were more important than a participatory decision-making style in predicting diabetes self-management. Reported understanding of self-care behaviors was highly predictive of and attenuated the effect of both PDMstyle and PCOM on self-management, raising the possibility that both provider styles enhance self-management through increased patient understanding or self-confidence.

Food Insufficiency Is Associated with High-Risk Sexual Behavior among Women in Botswana and Swaziland

Background Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behavior has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behavior. Methods and Findings We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a nonprimary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men. Conclusions Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance womens legal and social rights may play an important role in decreasing HIV transmission risk for women.

The Health Effects of Restricting Prescription Medication Use Because of Cost

Background:High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known. Methods:We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995–1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression. Results:In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27–2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09–2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02–2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort. Conclusions:Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

Cost-Related Medication Underuse Among Chronically III Adults: the Treatments People Forgo, How Often, and Who Is at Risk

OBJECTIVES We sought information about the cost-related underuse of medications-which medications are underused, by whom, and how often. METHODS Chronically ill adults were asked to identify how often they underused prescription medication for 16 health conditions because of the cost. RESULTS Eighteen percent of respondents cut back on medication use owing to cost in the previous year, and 14% used less medication at least monthly. Although rates of underuse varied substantially across treatments, prescription coverage and out-of-pocket costs were determinants of underuse across medication types. CONCLUSIONS Many chronically ill adults frequently cut back on medications owing to cost. Patients are selective about the treatments they forgo. Out-of-pocket costs and inadequate prescription coverage may lead to adherence problems for many important medication types.

Routine HIV testing in Botswana: a population-based study on attitudes, practices, and human rights concerns.

Background The Botswana government recently implemented a policy of routine or “opt-out” HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults. Methods and Findings We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1–1.9), higher education (AOR = 2.0, 95% CI = 1.5–2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3–2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1–2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2–2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5–0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45–0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning ones status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%). Conclusions Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

When Do Patients and Their Physicians Agree on Diabetes Treatment Goals and Strategies, and What Difference Does It Make?

BACKGROUND: For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians.OBJECTIVE: To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes.DESIGN: One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management.RESULTS: Overall, agreement on top treatment goals and strategies was low (all κ were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management.CONCLUSION: Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.

Diabetes Control With Reciprocal Peer Support Versus Nurse Care Management: A Randomized Trial

BACKGROUND Resource barriers complicate diabetes care management. Support from peers may help patients manage their diabetes. OBJECTIVE To compare a reciprocal peer-support (RPS) program with nurse care management (NCM). DESIGN Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00320112) SETTING 2 U.S. Department of Veterans Affairs health care facilities. PATIENTS 244 men with hemoglobin A(1c) (HbA(1c)) levels greater than 7.5% during the previous 6 months. MEASUREMENTS The primary outcome was 6-month change in HbA(1c) level. Secondary outcomes were changes in insulin therapy; blood pressure; and patient reports of medication adherence, diabetes-related support, and emotional distress. INTERVENTION Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals, receive peer communication skills training, and be paired with another age-matched peer patient. Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact. These patients could also participate in optional group sessions at 1, 3, and 6 months. Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager. RESULTS Of the 244 patients enrolled, 216 (89%) completed the HbA(1c) assessments and 231 (95%) completed the survey assessments at 6 months. Mean HbA(1c) level decreased from 8.02% to 7.73% (change, -0.29%) in the RPS group and increased from 7.93% to 8.22% (change, 0.29%) in the NCM group. The difference in HbA(1c) change between groups was 0.58% (P = 0.004). Among patients with a baseline HbA(1c) level greater than 8.0%, those in the RPS group had a mean decrease of 0.88%, compared with a 0.07% decrease among those in the NCM group (between-group difference, 0.81%; P < 0.001). Eight patients in the RPS group started insulin therapy, compared with 1 patient in the NCM group (P = 0.020). Groups did not differ in blood pressure, self-reported medication adherence, or diabetes-specific distress, but the RPS group reported improvement in diabetes social support. LIMITATION The study included only male veterans and lasted only 6 months. CONCLUSION Reciprocal peer support holds promise as a method for diabetes care management.

Effectiveness of a Community Health Worker Intervention Among African American and Latino Adults With Type 2 Diabetes: A Randomized Controlled Trial

OBJECTIVES We tested the effectiveness of a culturally tailored, behavioral theory-based community health worker intervention for improving glycemic control. METHODS We used a randomized, 6-month delayed control group design among 164 African American and Latino adult participants recruited from 2 health systems in Detroit, Michigan. Our study was guided by the principles of community-based participatory research. Hemoglobin A1c (HbA1c) level was the primary outcome measure. Using an empowerment-based approach, community health workers provided participants with diabetes self-management education and regular home visits, and accompanied them to a clinic visit during the 6-month intervention period. RESULTS Participants in the intervention group had a mean HbA1c value of 8.6% at baseline, which improved to a value of 7.8% at 6 months, for an adjusted change of -0.8 percentage points (P < .01). There was no change in mean HbA1c among the control group (8.5%). Intervention participants also had significantly greater improvements in self-reported diabetes understanding compared with the control group. CONCLUSIONS This study contributes to the growing evidence for the effectiveness of community health workers and their role in multidisciplinary teams engaged in culturally appropriate health care delivery.

Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population.

AbstractBACKGROUND: Patient-provider communication is essential for effective care of diabetes and other chronic illnesses. However, the relative impact of general versus disease-specific communication on self-management is poorly understood, as are the determinants of these 2 communication dimensions. DESIGN: Cross-sectional survey. SETTING: Three VA heath care systems, 1 county health care system, and 1 university-based health care system. PATIENTS: Seven hundred fifty-two diabetes patients were enrolled. Fifty-two percent were nonwhite, 18% had less than a high-school education, and 8% were primarily Spanish-speaking. MEASUREMENTS AND MAIN RESULTS: Patients’ assessments of providers’ general and diabetes-specific communication were measured using validated scales. Self-reported foot care; and adherence to hypoglycemic medications, dietary recommendations, and exercise were measured using standard items. General and diabetes-specific communication reports were only moderately correlated (r=.35) and had differing predictors. In multivariate probit analyses, both dimensions of communication were independently associated with self-care in each of the 4 areas examined. Sociodemographically vulnerable patients (racial and language minorities and those with less education) reported communication that was as good or better than that reported by other patients. Patients receiving most of their diabetes care from their primary provider and patients with a longer primary care relationship reported better general communication. VA and county clinic patients reported better diabetes-specific communication than did university clinic patients. CONCLUSIONS: General and diabetes-specific communication are related but unique facets of patient-provider interactions, and improving either one may improve self-management. Providers in these sites are communicating successfully with vulnerable patients. These findings reinforce the potential importance of continuity and differences among VA, county, and university health care systems as determinants of patient-provider communication.

Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?

BACKGROUNDThe majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.OBJECTIVEWe sought to understand how the number, type, and severity of comorbidities influence diabetes patients’ self-management and treatment priorities.DESIGNCross-sectional observation study.PATIENTSA total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.MEASUREMENTSWe constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).RESULTS40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.CONCLUSIONSThe type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients’ self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.