Objective

To examine self-reported financial strain in relation to pharmacy utilization adherence data.

Data sources/study setting

Survey, administrative, and electronic medical data from Kaiser Permanente Northern California.

Study design

Retrospective cohort design (2006, n = 7,773).

Data collection/extraction methods

We compared survey self-reports of general and medication-specific financial strain to three adherence outcomes from pharmacy records, specifying adjusted generalized linear regression models.

Principal findings

Eight percent and 9 percent reported general and medication-specific financial strain. In adjusted models, general strain was significantly associated with primary nonadherence (RR = 1.37; 95 percent CI: 1.04-1.81) and refilling late (RR = 1.34; 95 percent CI: 1.07-1.66); and medication-specific strain was associated with primary nonadherence (RR = 1.42, 95 percent CI: 1.09-1.84).

Conclusions

Simple, minimally intrusive questions could be used to identify patients at risk of poor adherence due to financial barriers.

Background

In chronic illness self-care, social support may influence some health behaviors more than others.

Purpose

Examine social support's association with seven individual chronic illness self-management behaviors: two healthy "lifestyle" behaviors (physical activity, diet) and five more highly skilled and diabetes-specific (medical) behaviors (checking feet, oral medication adherence, insulin adherence, self-monitored blood glucose, primary care appointment attendance).

Methods

Using cross-sectional administrative and survey data from 13,366 patients with type 2 diabetes, Poisson regression models estimated the adjusted relative risks (ARR) of practicing each behavior at higher vs lower levels of social support.

Results

Higher emotional support and social network scores were significantly associated with increased ARR of both lifestyle behaviors. Both social support measures were also associated with increased ARR for checking feet. Neither measure was significantly associated with other medical behaviors.

Conclusions

Findings suggest that social support diminished in importance as self-care progresses from lifestyle to more skilled "medical" behaviors.

Background

No studies have compared care in the Department of Veterans Affairs (VA) with that delivered in commercial managed care organizations, nor have studies focused in depth on care comparisons for chronic, outpatient conditions.

Objective

To compare the quality of diabetes care between patients in the VA system and those enrolled in commercial managed care organizations by using equivalent sampling and measurement methods.

Design

Cross-sectional patient survey with retrospective review of medical records.

Setting

5 VA medical centers and 8 commercial managed care organizations in 5 matched geographic regions.

Participants

8205 diabetic patients: 1285 in the VA system and 6920 in commercial managed care.

Measurements

We compared scores on identically specified quality measures for 7 diabetes care processes and 3 diabetes intermediate outcomes and on 4 dimensions of satisfaction. Scores were expressed as the percentage of patients receiving indicated care and were adjusted for patients' demographic and health characteristics.

Results

Patients in the VA system had better scores than patients in commercial managed care on all process measures (for example, 93% vs. 83% for annual hemoglobin A1c; P = 0.006; 91% vs. 75% for annual eye examination; P < 0.001). Blood pressure control was poor in both groups (52% to 53% of persons had blood pressure < 140/90 mm Hg), but patients in the VA system had better control of low-density lipoprotein cholesterol and hemoglobin A1c (for example, 86% vs. 72% for low-density lipoprotein cholesterol level < 3.37 mmol/L [<130 mg/dL]; P = 0.002). Satisfaction was similar in the 2 groups.

Limitations

Our results may not be generalizable to all regions or health plans, and some of the differences in performance could reflect differences in documentation.

Conclusions

Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care. However, both VA and commercial managed care had room for improvement, especially for blood pressure control.

Objective

The aim of this study was to evaluate ethnic differences in burden of prevalent geriatric conditions and diabetic complications among older, insured adults with diabetes.

Method

An observational study was conducted among 115,538 diabetes patients, aged ≥60, in an integrated health care system with uniform access to care.

Results

Compared with Whites, Asians and Filipinos were more likely to be underweight but had substantively lower prevalence of falls, urinary incontinence, polypharmacy, depression, and chronic pain, and were least likely of all groups to have at least one geriatric condition. African Americans had significantly lower prevalence of incontinence and falls, but higher prevalence of dementia; Latinos had a lower prevalence of falls. Except for end-stage renal disease (ESRD), Whites tended to have the highest rates of prevalent diabetic complications.

Discussion

Among these insured older adults, ethnic health patterns varied substantially; differences were frequently small and rates were often better among select minority groups, suggesting progress toward the Healthy People 2020 objective to reduce health disparities.

Objective

Various models of peer support may be implemented in mental health settings. This randomized trial assessed the effectiveness of a telephone-delivered mutual peer support intervention.

Methods

A total of 443 patients receiving ongoing depression treatment from the U.S. Department of Veterans Affairs were enrolled in either enhanced usual care (N=243) or the peer support intervention (N=200). Intent-to-treat analyses assessed outcomes at six months postenrollment, excluding 56 patients who experienced an unplanned telephone platform shutdown.

Results

At baseline, patients had substantial depressive symptoms, functional limitations, and low quality of life. Both groups showed significant clinical improvements at six months, with no significant differences by group.

Conclusions

Telephone-delivered mutual peer support for patients with depression did not improve outcomes beyond those observed with enhanced usual care. Other peer support models, with more "professionalized" peers delivering a structured curriculum, may be more effective.

Objective

To examine racial/ethnic and economic variation in cost-related medication underuse among insured adults with diabetes.

Research design and methods

We surveyed 5,086 participants from the multicenter Translating Research Into Action for Diabetes Study. Respondents reported whether they used less medication because of cost in the past 12 months. We examined unadjusted and adjusted rates of cost-related medication underuse, using hierarchical regression, to determine whether race/ethnicity differences still existed after accounting for economic, health, and other demographic variables.

Results

Participants were 48% white, 14% African American, 14% Latino, 15% Asian/Pacific Islander, and 8% other. Overall, 14% reported cost-related medication underuse. Unadjusted rates were highest for Latinos (23%) and African Americans (17%) compared with whites (13%), Asian/Pacific Islanders (11%), and others (15%). In multivariate analyses, race/ethnicity significantly predicted cost-related medication underuse (P = 0.048). However, adjusted rates were only slightly higher for Latinos (14%) than whites (10%) (P = 0.026) and were not significantly different for African Americans (11%), Asian/Pacific Islanders (7%), and others (11%). Income and out-of-pocket drug costs showed the greatest differences in adjusted rates of cost-related medication underuse (15 vs. 5% for participants with income $50,000 and 24 vs. 7% for participants with out-of-pocket costs >$150 per month vs. ConclusionsOne in seven participants reported cost-related medication underuse. Rates were highest among African Americans and Latinos but were related to lower incomes and higher out-of-pocket drug costs in these groups. Interventions to decrease racial/ethnic disparities in cost-related medication underuse should focus on decreasing financial barriers to medications.

Background

Our understanding of social disparities in diabetes-related health behaviors is incomplete. The purpose of this study was to determine if having less education is associated with poorer diabetes-related health behaviors.

Methods

This observational study was based on a cohort of 8,763 survey respondents drawn from ~180,000 patients with diabetes receiving care from 68 provider groups in ten managed care health plans across the United States. Self-reported survey data included individual educational attainment ("education") and five diabetes self-care behaviors among individuals for whom the behavior would clearly be indicated: foot exams (among those with symptoms of peripheral neuropathy or a history of foot ulcers); self-monitoring of blood glucose (SMBG; among insulin users only); smoking; exercise; and certain diabetes-related health seeking behaviors (use of diabetes health education, website, or support group in last 12 months). Predicted probabilities were modeled at each level of self-reported educational attainment using hierarchical logistic regression models with random effects for clustering within health plans.

Results

Patients with less education had significantly lower predicted probabilities of being a non-smoker and engaging in regular exercise and health-seeking behaviors, while SMBG and foot self-examination did not vary by education. Extensive adjustment for patient factors revealed no discernable confounding effect on the estimates or their significance, and most education-behavior relationships were similar across sex, race and other patient characteristics. The relationship between education and smoking varied significantly across age, with a strong inverse relationship in those aged 25-44, modest for those ages 45-64, but non-evident for those over 65. Intensity of disease management by the health plan and provider communication did not alter the examined education-behavior relationships. Other measures of socioeconomic position yielded similar findings.

Conclusion

The relationship between educational attainment and health behaviors was modest in strength for most behaviors. Over the life course, the cumulative effect of reduced practice of multiple self-care behaviors among less educated patients may play an important part in shaping the social health gradient.